Community interventions to prevent violence against women and girls in informal settlements in Mumbai: the SNEHA-TARA pragmatic cluster randomised controlled trial

The Convention on the Elimination of All Forms of Discrimination Against Women was signed by 189 countries, including India, in 1980 [1]. The United Nations declared a response to violence against women and girls imperative in 2006 [2], and it was identified as a health priority in World Health Organization (WHO) guidelines of 2013 [3]. Elimination of violence against women and girls in public and private is a target for the fifth Sustainable Development Goal.

Globally, 30% (95% confidence interval [CI] 28, 32) of women have experienced physical or sexual violence by an intimate partner or sexual violence by a non-partner [4]. The question of how to achieve substantial reductions in violence against women in low- and middle-income countries is central to current debate [5]. The response needs to be multisectoral and to include both prevention and response, supported by research on the effects, costs, and potential scalability of promising interventions [6]. About 40% of survivors disclose violence—usually to a friend or relative—but only 7% to a formal source of support, making disclosure an early priority in a theory of change [7]. A recent systematic review of studies in India suggested that 29% of women had survived physical abuse in the past year, 22% had suffered psychological abuse, 7% sexual abuse, and 30% multiple forms of violence [8].

Violence causes non-fatal or fatal injuries: 21% of homicides in Southeast Asia are committed by an intimate partner, constituting 60% of all female homicides (the figure for male homicides is 1%) [9]. Other harms to health include sexually transmitted infections, miscarriage, induced abortion, stillbirth, low birth weight, preterm delivery, harmful drug and alcohol use, anxiety and depression, self-harm, suicide, and trans-generational recapitulation of violence [4, 10, 11]. Physical and psychological trauma and fear lead to mental health problems, limited sexual and reproductive control, somatoform conditions [4], difficulties in seeking healthcare, and lost economic productivity [12]. Violence is associated with male authority over female behaviour, justification of wife beating, and women’s economic disadvantage [13], all of which are manifest in India. Intimate partner violence is endemic, domestic violence extends beyond the WHO definition [14], to culturally sanctioned household maltreatment [15], and non-partner sexual violence is reported regularly in the media [16].

The latest National Family Health Survey (NFHS-4) suggests that 21% of ever-married women in Maharashtra state—the location of our work—have experienced intimate partner violence [17]. Risk factors for both physical and sexual violence include poverty, exposure to parental violence, childhood maltreatment, limited education, unemployment, young adulthood, mental disorder, substance use, individual acceptance of violence, weak community and legal sanctions, and gender and social norms supportive of violence [10]. These risk factors meet in Mumbai’s urban informal settlements, along with population density and stressful living conditions, and their toll in terms of violence is the reason for our activities. More than 377 million people live in urban India [18, 19]. Two-thirds of cities and towns include informal settlements [20], characterized by overcrowding, insubstantial housing, insufficient water and sanitation, lack of tenure, and hazardous location [21, 22]. There were an estimated ~ 105 million people in such settlements as of 2017 [19], and they currently include 41% of Mumbai’s households [20]. Women and girls in these communities lack both financial and social resources and also an understanding of the possibility of relief from endemic violence.

The SNEHA (Society for Nutrition, Education and Health Action) programme on Prevention of Violence against Women and Children began in 2000 and now includes ten counselling centres across Mumbai, linked with community mobilisation, health services, police, and legal support. The programme history follows global developments. The emphasis of a first wave of interventions, driven largely by feminist activism, was support for survivors of violence, reduction in secondary perpetration, strengthening legal recourse, and advocacy [23]. This led to the consolidation of services such as women’s shelters, counselling, legal advice, and laws such as India’s Protection of Women from Domestic Violence Act (PWDVA) 2005. A second wave of interventions, led by groups such as SNEHA, emphasises primary prevention and community activism and takes a public health position: population-based, interdisciplinary, and intersectoral [10].

The objectives of current efforts are both to respond to the burden of violence and to prevent it from happening [23, 24]. The underlying socio-ecological model locates individual personal histories within families, located in turn within communities, and in turn within societies [25]. There is broad agreement that interventions should operate at multiple levels, from individual to societal [26]. Interventional discourse has also moved from a concentration on the needs of survivors to an acknowledgment that intervention should aim to “transform the relations, norms, and systems that sustain gender inequality and violence” [27]. Of particular interest are interventions that aim to change norms that privilege controlling and aggressive masculine behaviour [27, 28]. Such interventions are usually termed ‘gender transformative’ [29], involve women, men, and young people [11], and aim to develop critical mass among community members, leaders, and institutions to change discriminatory social norms, promote gender equality, and reduce violence [24].

To achieve these aims, our preventive activities—the complex intervention that the trial will test—involve two kinds of community outreach: group education and enablement, and individual voluntarism. Group education involves women, men, and adolescents. It aims to develop awareness and understanding of violence, knowledge of rights and recourse, individual and collective local strategies for primary and secondary prevention, and increased confidence and leadership, and to reduce community tolerance and increase bystander action. Individual intervention involves women volunteers, sanginis, who identify survivors of violence, provide support, connect them with crisis intervention and counselling services, and facilitate police and health service consultation. Sangini response is supported by an innovative mobile electronic platform, Little Sister, which integrates real-time field reports of violence and their interventions with programme services. Our processes increase the social standing and agency of group members and sanginis, digital literacy, employability, and supportive social networks.

Secondary interventions for survivors—the background activities that will be available to both intervention and control groups in the trial—include counselling, liaison with the police, medical attention, mental health intervention, family interventions, and legal recourse. Our centres offer support from trained counsellors, clinical psychologists, municipal clinicians, visiting psychiatrists, and lawyers. SNEHA is a service provider under the PWDVA and runs women’s outpatient departments in three tertiary and one peripheral municipal hospital. We work with the police in five zones, training cadets and officers, and co-developing, piloting, and introducing guidelines for response to violence against women and girls into police practice. Components of our model have been adapted and replicated in collaborations with Ekjut in Jharkhand state and with Swasti in five states.

We aim to help people understand the gendered nature of violence, so that survivors make decisions, potential perpetrators think again, and others believe that action is possible. As a result of this, people will stand up against violence, individually and collectively, and community members will act to help survivors, will stop accepting violence, and will strengthen community structures that support a conviction that it is unacceptable. Our hypotheses are that women and girls will be more likely to disclose violence, that communities will become less tolerant of it, and that the prevalences of intimate partner and domestic violence will diminish.

A recent set of systematic reviews of interventions to prevent violence against women and girls developed a typology of effectiveness and the quality of evidence for it. Community mobilisation was rated as a promising population-based intervention [45], and included participatory projects and community-driven development engaging multiple stakeholders and addressing gender norms. Group-based training or workshops for prevention of violence against women and girls included empowerment training (rated as promising), work with men and boys on norms (rated as conflicting), and community workshops to promote changes in norms and behaviour (rated as promising) [23].

We lack adequately powered trials of clearly defined interventions of sufficient duration to have meaningful effects. We have identified 13 randomised trials of interventions to reduce domestic violence against women and girls in low- and middle-income countries. Six had urban components [46‐51], 11 were in Africa [46‐50, 52‐57], and one in South Asia [51]. Seven of the trials combined violence prevention activities with HIV prevention [46‐48, 50, 52, 56, 58], and four with enterprise and microfinance [52, 53, 55, 58]. In South Africa, the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) study added to microfinance Sisters for Life, a 10-session programme followed by community mobilisation to engage adolescents and adult males. In a sample of 538 from eight clusters, reported past-year intimate partner violence was halved (adjusted risk ratio 0.45; 0.23, 0.91) [58]. In Uganda, the Safe Homes and Respect for Everyone (SHARE) study added community mobilisation to HIV prevention activities. The intervention involved efforts to change attitudes, social norms, and behaviours related to intimate partner violence. After 3 years, in a sample of 7842 in four intervention and seven control clusters, reported past-year physical (adjusted prevalence rate ratio 0.79; 95% CI 0.67, 0.92) and sexual (0.80; 0.67, 0.7) intimate partner violence were reduced [50]. Also in Uganda, the SASA! intervention recruited community activists to encourage change in norms, attitudes, and behaviours. After about 3 years, in a sample of 2532 in eight clusters, reported past-year physical (odds ratio 0.48; 0.16, 1.39) and sexual (0.76; 0.33, 1.72) intimate partner violence were substantially, but non-significantly, reduced [48, 59]. A couples intervention in Rwanda reduced physical and sexual intimate partner violence in the preceding 12 months [57], and a combination of community mobilisation, group work, and service provision has been trialled in urban Bangladesh [51].

We aim to address known deficiencies in evaluation and partnership. Research on violence against women and girls has been limited, given its ubiquity and health burden, and has favoured description of prevalence and risk factors [5]. Interventional evaluations have tended to focus on high-income countries and on response rather than prevention [23]. Evaluation of the effects of programmes is a priority, particularly through theory-informed testing of interventions to address gender inequality and social norms that legitimise violence [24, 26]. Competent evaluation remains a challenge, non-governmental organisations (NGOs) need to improve their evaluative capacity, and researchers need to partner with implementors [11, 12]. Backed by public engagement, advocacy, and open publication, our vision is of a replicable community-led intervention to address the public health burden of violence against women and girls.

The protocol is version 9 of 20th March 2019. The protocol was reviewed by the Trial Steering Committee: Seema Sahay (chair), Chris Bonell, Anthony Costello, and Sunita Krishnan. Recruitment began to the baseline survey in early December 2017. Recruitment will be complete for the post-intervention survey in early March 2022. The Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist is provided as Additional file 4.