Prevalence, pattern, and predictors of formal help-seeking for intimate partner violence against women: findings from India’s cross-sectional National Family Health Surveys-3 (2005–2006) and 4 (2015–2016)

Violations of women’s rights, such as violence against women (VAW), are a priority for the United Nations (UN) Sustainable Development Goals (SDGs) [1]. Male intimate partner violence (IPV) against women is the most common form of VAW [2]. Worldwide in 2018, 27% of ever-partnered women aged 15–49 years were estimated to have experienced physical or sexual IPV worldwide during their lifetime, 13% of them in the past year [3]. Help-seeking by survivors of violence—whether ongoing or in the past—is described as disclosure of violence to obtain some sort of assistance or support [4, 5]. It can be classified into two categories in the context of IPV: (i) formal help from authorities such as health, legal, or police services, shelters, women’s non-governmental organisations (NGOs), or local or religious leaders, and (ii) informal help, which may include but is not limited to, assistance from family, friends, and neighbours [2]. Both formal and informal social support have been found to improve survivors’ mental health, reduce adverse post-traumatic outcomes, reduce the likelihood of future violence, and increase survivors’ willingness and ability to seek formal assistance and subsequent capacity to stay safe [6‐10]. For many reasons, however, IPV is globally under-reported [11], and this has limited survivors’ help-seeking [12]. The low proportion of women seeking help for IPV is a major source of concern for policymakers, service providers, and programmes [6].

Help-seeking for IPV is limited in Low and Middle-Income Countries (LMICs) — 40% in Tanzania, Jordan, and Nigeria, 35% in Pakistan, 33% in Bangladesh, 27% in South Sudan, 24% in India, and 20% in Afghanistan and Ethiopia [12‐22]. Between 22% and 66% of women who had ever been physically abused told no one about it prior to a World Health Organization (WHO) multi-country survey interview, and 34–59% of survivors of physical violence claimed that no one had attempted to help them, even on request [2]. Informal support was preferred over formal support. Sources of informal support included family (28–63%), friends (18–56%), and neighbours (2–25%); 55–95% of women did not seek help from formal sources [2]. A little over 1% of women survivors of IPV have approached formal sources in India. A relatively large body of work has been carried out, but our collective understanding of the prevalence, pattern, and impact of sociodemographic and socioeconomic factors on formal help-seeking remain understudied.

Several theories or models have been applied to help-seeking behaviour, such as the theory of planned behaviour, Andersen’s behavioural model, and help-seeking and change [10, 23, 24]. Researchers have also identified two internal criteria for help-seeking: survivors perceiving IPV as intolerable and their belief that it is unlikely to resolve without assistance from others [25]. Numerous additional factors influence the decision to seek help and the source of assistance. These include the form of IPV, an increase in severity and frequency of violence, survivors’ fear for their lives, their sociodemographic and socioeconomic status, interpersonal factors, insufficient support systems, and societal norms [2, 26‐28].

Another dimension that affects decisional balance for help-seeking is the effectiveness or responsiveness of legislation. In theory at least, legal acts to protect women against domestic violence can help foster an environment that enables survivors to resist, disclose, testify, or seek help [29]. Effectiveness might manifest as, among others, a decrease or increase in reported crimes or an increase in service utilisation, with increased disclosure and access to sources of help [30]. India’s Protection of Women from Domestic Violence Act of 2005 (PWDVA 2005) is the most progressive measure against domestic abuse in Indian history. It is a civil law enacted to address inadequacies in India’s existing domestic violence statutes, specifically Section 498A of 1983 and 304B of 1986 of the Indian Penal Code, which focused on dowry-related assault. The PWDVA 2005 describes physical, sexual, emotional, and economic abuse based on the UN Declaration on VAW [31]. The definition of domestic violence extends to the threat of abuse, including harassment in the form of unlawful dowry demands. It applies to daughters, sisters, widows, mothers, and women in partnerships that resemble marriage and is seen as the first piece of legislation to grant legal recognition and protection for non-marital partnerships. Rather than solely punishing the husband, the PWDVA 2005 is civil legislation intended primarily for the enforcement of protection orders, rather than criminal law. It grants women certain rights: (i) to apply for a protection order, an order for monetary relief, a custody order, a residence order, or a compensation order; (ii) to receive free legal services under the Legal Services Authorities Act of 1987; and (iii) to file a complaint under section 498A of the Indian Penal Code [32]. Through the PWDVA, vulnerable women are also entitled to protection, residence, monetary relief and maintenance, compensation, custody, and legal service.

The PWDVA stipulates that central government and state government officials, including police officers, healthcare providers, and members of the judicial services, must receive “periodic sensitization and awareness training” on the topics addressed by the Act [33]. The Act also authorises the state to issue protective orders (which must be enforced by the police) and to employ Protection Officers to help survivors of domestic violence access medical care and submit domestic abuse reports [33]. Although some newspapers and web commentaries covered the PWDVA, the Act itself did not prescribe how public awareness could be encouraged. Its socialisation among policy implementers, survivors and the public remains an obstacle. National Crime Records Bureau (NCRB) data from 2006 to 2014 suggest that reporting of domestic violence increased in 16 states and remained relatively stable in the other nine [29]. According to an NCRB report, 89,097 cases of crimes against women were filed across India in 2018. The figures indicate that little progress has been made in comparison to the 86,001 instances filed under this heading in 2017. Out of the total crimes against women registered under the Indian Penal Code (IPC), the majority (31.9%) were filed under the ‘cruelty by spouse or his family’ category. At 27.6%, ‘attack against women with the goal to offend her modesty’ came in second. Women’s kidnapping and abduction accounted for 22.5% of all crime, while rape accounted for 10.3% of all crime [34]. The NCRB report compiles crime information from all states. It defines the crime rate as the number of instances reported by the female population in 100,000 s under Section 498A of the IPC. India’s National Family Health Survey (NFHS) is a nationally representative data source that collects self-reported responses about marital violence. NFHS survey rounds are comparable due to compatible designs, including sampling, questionnaire content, and field staff training. We compared two rounds of NFHS data obtained before and after implementing the PWDVA-2005—NHFS-3 (2005–2006) and NFHS-4 (2015–2016)—to see if there was an increase in reported help-seeking from formal resources when women disclosed IPV in the preceding 12 months. We examined (i) the prevalence and pattern of help-seeking by form of IPV, (ii) sociodemographic and socioeconomic factors associated with help-seeking, and (iii) associations between sources of help and forms of IPV.

Between the NFHS-3 and NFHS-4, reported physical, sexual, and emotional IPV in the past 12 months increased among ever-married women aged 15–49 years. In both surveys, a small proportion of women sought any help for any form of IPV. This proportion declined from NFHS-3 to NFHS-4 for both formal and informal sources. More women continued to seek help from informal than from formal sources, and the odds of help-seeking varied with the form of IPV (greatest for emotional or sexual IPV or spousal coercive control) and sociodemographic position. The odds of help-seeking from formal sources remained similar for sexual IPV and increased a little for emotional IPV and spousal control. Age is an important predictor of the experience of violence as well as help-seeking, but a separate analysis of help-seeking by age did not change the findings.

The PWDVA was implemented in 2006, between the two rounds of the NFHS. The Act is a reforming piece of legislation aimed at reducing domestic violence in India and includes specific provisions. The NFHS-4 of 2015–2016 was collected a decade after implementation and one would expect a consequent reduction in reported IPV, or at least an increase in help-seeking from formal sources. However, the proportion of women who reported IPV increased over the decade between surveys and the proportion of women who sought help was similar or perhaps a little less.

We can see three possible explanations for the findings. First, little may have changed in the wake of the Act. Women continued to experience similar or higher levels of IPV and were as reticent to seek help as previously. One of the reasons for low help-seeking may have been lack of awareness of the PWDVA. Second, willingness to disclose IPV may have increased, leading to higher reported prevalence. Third, the actual prevalence of IPV may have declined, compensated for by this higher reporting and similar levels of help-seeking. Another possible reason for declines in help-seeking may be that the PWDVA had the paradoxical effect of increasing women’s fear of negative consequences if they were to seek help. It is possible that women hesitated to seek help for fear of threats to their safety, as the involvement of law enforcement, paired with poor implementation of the protective aspects of the PWDVA, might further strain their relationships with intimate partners. There is a need to better implement protection procedures for women who use the Act. According to the Lawyers Collective Women’s Rights Initiative (LCWRI), 2013, there have been numerous loopholes in the Act’s implementation. For example, despite the provision of periodic training in the Act for police, health personnel, protection officers, lawyers, and judges, not many states have taken measures for training. Another gap exists in the recruitment of protection officers [42]. Many states have not appointed enough protection officers and many have additional duties [43]. Several states lack a plan for PWDVA implementation and many have not allocated a budget for implementation. There is a lack of periodic or annual aggregated national data from 2006 to 2015 on the appointment of protection officers compared with the actual requirement, training on the PWDVA, or the number of cases filed in each state under the Act [43]. Socialisation of the act needs more attention, particularly with respect to implementation guidelines and monitoring strategy.

Ghosh and Choudhuri (2011) suggest that the promise made by the PWDVA of addressing a case within 60 days from the first date of hearing could not be fulfilled. For many survivors, sluggish implementation of court orders and lengthy legal battles are discouraging. The ambivalent position of the police in upholding survivors’ experience and enforcing judicial orders may have been an impediment to affording women timely and necessary justice. The PWDVA proposes a new emancipatory role for police. However, the perception of police as having power to punish clashes with this role. Police officers can also file cases and take action on their own under the PWDVA. Despite this, the police often do not file a domestic case, but refer the matter to a protection officer [44]. The other barriers to disclosure and help-seeking for IPV are well understood: normalization and minimization, fear of reprisal or escalation of violence, and lack of awareness of or belief in potential support. Many survivors believe that IPV is a burden that must be tolerated so long as it is not perceived as severe, that a husband has the right to use violence against his wife, that violence is the consequence of failings in themselves, or that their partner’s behaviour will change. Often, survivors are reluctant to disclose violence or seek help because of their traumatic experiences. They fear that they will be blamed or not believed. Many justifiably fear for their safety or the safety of their family if they disclose IPV. Some do not disclose to maintain family honour or hope that things can get better. Escalation or reprisal might include increased violence, the onset of physical IPV where it was not already a feature of their abuse, and the loss of their children, home, and financial support. Many survivors have limited awareness of available support services or lack conviction of their effectiveness [2, 12, 19, 20, 45‐49]. Legal recourse is often a last resort for survivors generally take because most often, their priorities are met by other mechanisms, such as taking help from informal sources such as family or friends whenever required and violence reduces or stops in her life. However, we did not see an increase in informal help-seeking from NFHS-3 to NFHS-4.

Education, awareness, and mandatory training for the police will provide more effective responses in dealing with cases of domestic violence. As in other countries, primary healthcare providers can and do offer more effective help when they are trained and supported so that the healthcare system is fully engaged to do better. There needs to be a focus on the abilities of police, lawyers, protection officers, and health and social care professionals who are first responders to domestic violence to respond effectively to domestic violence, ensuring the safety of survivors while holding abusers accountable.

To break the cycle of domestic abuse, a concerted community response is essential. The police, lawyers, protection officers, health professionals, social service organizations, and communities must be familiar with national legislation relating to domestic violence. It is the government’s responsibility to prevent and control domestic violence in order to provide its citizens with a life free of violence and characterised by dignity. Local authorities, the health sector, the social services sector, the education sector, the judicial sector, and the law enforcement sector, as well as groups such as women’s unions and the media also need to be involved in raising awareness of the laws intended to prevent and control domestic violence.