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research-article2013

VAW19910.1177/1077801213501898Violence Against WomenStephenson et al.

Article

Frequency of Intimate Partner Violence and Rural Women’s Mental Health in Four Indian States

Violence Against Women 19(9) 1133­–1150 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1077801213501898 vaw.sagepub.com

Rob Stephenson1, Amy Winter1, and Michelle Hindin2

Abstract This study examines the association between self-reported frequency of verbal, physical, and sexual intimate partner violence (IPV) and mental health among 6,303 rural married women (age 15-49), in four Indian states: Bihar, Jharkhand, Maharashtra, and Tamil Nadu. Data are taken from the 2002-2003 National Family Health Survey-2 Follow-Up Survey. The results indicate that experiencing physical, verbal, or sexual IPV is associated with an increased risk of adverse mental health outcomes. Our results provide support for the importance of screening for IPV in mental health settings, especially in resource-poor settings where both IPV and mental health are often overlooked. Keywords domestic violence, India, intimate partner violence, mental health, rural, women

Introduction The global magnitude of intimate partner violence (IPV) and its negative health effects on women is an increasingly recognized and important public health topic (Heise, Ellsberg, & Gottmoeller, 2002; Krug, Mercy, Dahlberg, & Zwi, 2002; World Health Organization [WHO], 1996). The World Health Organization (2005) reported that IPV was the most common form of violence in women’s lives. The prevalence of IPV, in a review of 48 population-based studies from around the world, ranged from 10% to 69% among women who reported being physically assaulted by an intimate partner

1Emory 2Johns

University, Atlanta, GA, USA Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

Corresponding Author: Rob Stephenson, Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd., NE, #722, Atlanta, GA 30322, USA. Email: [email protected]

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(Krug et al., 2002). In addition to physical violence, IPV also includes sexual coercion, verbal and physical threats, psychological abuse, controlling actions, deprivation, and neglect (Krug et al., 2002; WHO, 1996). Substantial evidence has suggested that high levels of IPV exist in South Asia, and specifically India, where cultural norms surrounding the value and treatment of women have acted to increase the tolerance of IPV in these settings (Jeyaseelan et al., 2007; Kaur & Garg, 2008; Koenig, Stephenson, Ahmed, Jejeebhoy, & Campbell, 2006; Martin et al., 2002; Martin, Tsui, Maitra, & Marinshaw, 1999; Stephenson, Koenig, & Ahmed, 2006). Recently, there has been a global recognition of the burden of mental health disorders and the need to scale-up coverage and services, especially in low resource countries (Lancet Global Mental Health Group, 2007; P. T. Lee, Henderson, & Patel, 2010). A systematic review of epidemiological literature (1990-2008) indicated that social and economic conditions of poverty are associated with common mental disorders in low- and middle-income countries (Lund et al., 2010). The review stated that factors often associated with persons of low- and middle-income countries, such as lack of education, food insecurity, poor housing, low socioeconomic status, low income, financial stress, and unemployment, exhibited associations with common mental disorders (Lund et al., 2010). In addition, there was a large resource and treatment inequity, in which more than 75% of those identified with mental disorders in the World Mental Health Survey in low- and middle-income countries received no care at all (Demyttenaere et al., 2004; Patel & Prince, 2010; Saxena, Thornicroft, Knapp, & Whiteford, 2007). There is a strong link between intimate partner violence and adverse mental health outcomes (Heise et al., 2002). Evidence, however, comes largely from studies conducted in developed country settings. In addition, most studies in developed regions look at clinical rather than population-based samples (Ellsberg, Jansen, Heise, Watts, & Garcia-Moreno, 2008). In the current analysis we examine the association between physical, sexual, and verbal IPV and mental health in a resource-poor region, specifically rural areas of four Indian states (Bihar, Jharkhand, Maharashtra, and Tamil Nadu). In addition, the study will use population-based data from a survey of married women of reproductive age (15-49 years). An understanding of the associations between IPV and mental health in this setting has the potential to inform how mental health is significantly associated with population in rural India and illuminate a topic that is largely overlooked in resource-poor settings.

Background There is substantial evidence from developed countries documenting a relationship between IPV (including physical, sexual, and verbal) and poor mental health (Chen, Rovi, Vega, Jacobs, & Johnson, 2009; Coker, Davis et al., 2002; Duran et al., 2009; Edwards, Black, Dhingra, McKnight-Eily, & Perry, 2009; Golding, 1999; Martin et al., 2008; Roberts, Williams, Lawrence, & Raphael, 1998; Sato-DiLorenzo & Sharps, 2007). A range of mental health outcomes associated with IPV includes depression, sleep problems, anxiety, mental distress, posttraumatic stress disorder (PTSD), and

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suicidal thoughts and attempts (Duran et al., 2009; Edwards et al., 2009; Ellsberg et al., 2008; Hathaway et al., 2000; Hurwitz, Gupta, Liu, Silverman, & Raj, 2006). While many of these studies have used cross-sectional data to indentify a relationship between IPV and poor mental health, Roberts et al.’s (1998) longitudinal study in Australia among women who visit emergency departments found a relationship between IPV and poor mental health, specifically finding that one third of the psychiatric diagnoses were attributable to IPV among hospital emergency department patients. Other studies have looked at the associations between multiple forms of violence and poor mental health. For example, among African Americans who visited emergency departments, Houry, Kemball, Rhodes, and Kaslow (2006) found an association between physical, sexual, and emotional abuse and depression, PTSD, and suicidality. Similarly, Leithner and colleagues (Leithner, Assem-Hilger, Naderer, Umek, & Springer-Kemser, 2009) found an association between physical, sexual, and psychological violence and depressive disorders among Austrian women who attended a psychosomatic-gynecological outpatient clinic. Hicks and Li (2003) discussed their finding that a dose–response relationship between physical violence and severity of major depressive episodes existed among Chinese Americans. Similarly, Campbell and Soeken (1999) showed that as the number of incidents of sexual assault increases, so does risk of depression among women in the midwestern United States. However, the pathways of influence between IPV and poor mental health are not well understood, and direct and indirect pathways of influence exist. Directly, the psychological effects of experiencing IPV have ranged from shock, fear, anxiety, fatigue, stress, and humiliation to sleeping and eating disturbances, PTSD, and suicide (Heise, Raikes, Watts, & Zwi, 1994). The experience of violence or even fear of violence is stressful, and it is well known that stress has been associated with poor mental health (Kessler, Price, & Wortman, 1985; Walker & Browne, 1985). Poor body image and low self-esteem are both related to shame as a result of sexual assault (Campbell & Soeken, 1999; Herman, 1992). In addition, women who have experienced abuse may become isolated and withdraw from social life as they try to hide the evidence of violence from others, or they may have been forcibly isolated by their partners (Heise et al., 1994; Nicolaidis, Curry, McFarland, & Gerrity, 2004). Isolation (whether voluntary or forced) has decreased access to social capital and has increased risk of depression (Nicolaidis et al., 2004). In fact, Coker, Smith et al. (2002) found that abused women with a higher level of social support were less likely to report poor mental health than abused women with lower social support. Indirectly, there are several factors that may mediate the relationship between IPV and mental health. For example, stress-related factors, including a couple living in poverty, were positively associated with increased risks of IPV (Martin et al., 1999). Stress has also been linked to increased alcohol consumption, which has been known to be directly associated with IPV perpetration (Rao, 1997). In addition, low levels of education among women have been associated with an increased risk of experiencing IPV (Boyle, Georgiades, Cullen, & Racine, 2009; Kumar, Jeyaseelan, Suresh, & Ahuja, 2005). Women who are illiterate or have low levels of education have depended on their husbands for information and news, and other important needs, which may result in anxiety or stress (Patel, Araya, de Lima, Ludermir, & Todd, 1999).

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Evidence from resource-poor countries on the links between IPV and mental health remain scarce. Vizcarra et al., (2004) found an association between IPV and poor mental health in India, Egypt, and the Philippines, but only considered the roles of physical and psychological IPV on mental health. Kumar et al., (2005) also found an association between IPV and poor mental health in India, but only examined the impact of physical IPV on anxiety and depression. In a qualitative study in rural Maharashtra, India, women respondents related poor mental health with conflict with their husband and domestic violence (Kermode et al., 2007). Chandra, Satyanarayana, & Carey (2009) showed that Indian women reporting IPV (sexual, physical, verbal) had higher scores on PTSD and depression; however, the respondents were recruited only from psychiatry outpatient units. A recent study in north Goa, India, found that physical or sexual partner violence partially mediated the association between the partner’s excessive alcohol use and the female’s common mental disorders, defined as nonpsychotic affective disorders, such as depression or anxiety (Nayak, Patel, Bond, & Greenfield, 2010). India exhibits significant levels of IPV against women; in fact, based on the NFHS3, 35.49% of married Indian women reported experiencing physical IPV with or without sexual violence, 7.68% reported both physical and sexual IPV, and 27.8% reported experiencing physical IPV only (Silverman, Decker, Saggurti, Balaiah, & Raj, 2008). However, few studies have explored the mental health consequences of IPV in a resource-poor context, such as rural India where IPV is often tolerated and socially sanctioned (Satish, Gupta, & Abraham, 2002). This study seeks to build upon the minimal work on IPV and mental health in India by exploring the associations between self-reported mental health and frequency of physical, sexual, and verbal intimate partner violence among rural Indian women from four states: Bihar, Jharkhand, Maharashtra, and Tamil Nadu.

Data and Method In 1998-1999, the National Family Health Survey–2 (NFHS-2) was conducted by the International Institute for Population Sciences (IIPS) (Government of India, 20052006). The NFHS-2 was the Indian equivalent of the Demographic and Health Survey, and was India’s second national survey. The NFHS-2 sampling system covered 99% of India’s population, and was made up of three questionnaires: household, village, and women’s questionnaires. Following the NFHS-2, IIPS and Johns Hopkins Bloomberg School of Public Health partnered to implement a prospective follow-up survey. The NFHS-2 Follow-Up Survey (2002-2003) consisted of all the original rural respondents to NFHS-2 from four Indian states: Bihar, Jharkhand, Maharashtra, and Tamil Nadu. These four states were chosen to represent differing economic, cultural, and demographic contexts in India (Arokiasamy & Gautam, 2008; Dyson & Moore, 1983; Griffiths, Hinde, & Matthews, 2001). This analysis used the NFHS-2 Follow-Up Survey data (2002-2003) and analyzed data from 6,303 married rural women (aged 15-46) in four states of India: Bihar, Jharkhand, Maharashtra, and Tamil Nadu. The NFHS-2 Follow-Up Survey was administered by trained female interviewers. The survey included the 12-item General

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Health Questionnaire (GHQ-12) to measure the current mental health status of the respondents (Goldberg, 1978). Each of the 12 questions was accompanied by two possible responses (yes, no). For positive items, where agreement indicated health, the scoring was 0 = yes and 1 = no; for negative items, where agreement indicated poor health, the scoring was 1 = yes and 0 = no. Therefore, reported symptoms ranged from 0 to 12 (higher number indicating poorer mental health symptoms). The GHQ was chosen because of its high validity scores, its ease of use, and because it is one of the most widely used screening questionnaires for the detection of common mental disorders in primary care and community settings (Goldberg et al., 1997; Jackson, 2007). In addition, the 60-item and 12-item GHQ have been field tested and used in India (Bagadia, Ayyar, Lakdawala, Susainathan, & Pradhan, 1985; Gautam, Nijhawan, & Kamal, 1987; John, Vijaykumar, Jayaseelan, & Jacob, 2006; Kermode, Bowen, Arole, Joag, & Jorm, 2009; Patel et al., 2008; Patel, Pereira, & Mann, 1998). The GHQ score was analyzed as two outcomes: the first outcome was binary, with a cut-off of three fourths (0-9, 10-12); the second outcome was binary, with one as the cut-off (0, 1-12). The three fourths cut-off of the GHQ-12 provided an optimal balance between sensitivity and specificity in a recent validation study in India and was used to define a mental health problem (Patel & Oomman, 1998). From this point forward, the binary outcome with three fourths as the cut-off will be referred to as a mental health problem; and the binary outcome with one as the cut-off will be referred to as any mental health symptom. The survey also covered many other issues related to IPV, demographics, fertility behavior, media exposure, decision-making, financial situation, marriage, and husband’s alcohol use. Multiple variables were used to assess the presence and number of reported incidents of physical, verbal, and sexual IPV among the respondents. To assess physical IPV, respondents were asked whether their husbands had ever pushed, pulled, or held them down; hit with fist; kicked or dragged them; tried to strangle them; or attacked them with a knife or weapon. Sexual IPV was assessed by asking the respondents whether their husband had used physical force to have sex with them. And verbal IPV was assessed by asking if their husband had verbally abused them (defined as verbal insults). For each type of IPV (physical, verbal, sexual), the respondents were asked if they had experienced that type of IPV in the past 12 months, and if so, how often in the last 12 months.

Data Analysis Regression models were fitted to each of the outcomes. Logistic regression models were fitted to the data, mental health problem (binary variable: 0, 1), and any mental health symptom (binary variable: 0, 1). The key exposures of interest in each model were the experience of physical, sexual, and verbal IPV; the analysis considered the self-reported frequency of each of the types of IPV. Physical IPV and verbal IPV were categorized as zero, one, two to four, and five or more episodes in the last 12 months. Sexual IPV was categorized as zero, one, and two or more episodes in the last 12 months because there were fewer instances of sexual violence. The models control

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for several factors that have been shown to be associated with poor mental health in previous studies: state, education, age, total children born, the number of children who have died, and whether the respondent has had an abortion since the baseline survey. Experience of abortion is included to control for recent events that may also have contributed to poor mental health status. Two indices measuring decision-making and no permission needed were also controlled for and both ranged from 0 to 18. Decision-making asked six questions: Who decides what to cook, who decides on obtaining health care, who decides to purchase jewelry, who decides about the respondent staying with family, who decides how money will be spent, who manages the account. Each of the six questions was accompanied by three answer choices and received the corresponding score per answer: husband or someone else (1), jointly with respondent (2), and respondent only (3). The no permission needed index was created from nine questions: does the respondent need permission to go to the market, to visit relatives and friends, to visit relatives and friends outside the village, to take a sick child to the health center, to purchase household items, to purchase clothing items, to purchase a piece of jewelry, to purchase a gift for a relative, and to purchase medicine. Similarly, each of the questions was accompanied by two answer choices and received the corresponding score per answer: yes, permission is needed or not allowed at all (1); and no, permission is not needed (2). Thus, a higher score on the decision-making or no permission needed index indicated a woman’s greater freedom to make decisions or to undertake tasks without permission. Previous studies suggest that low levels of autonomy in decision-making are associated with poorer mental health (Patel et al., 2006). Additional control variables included economic situation over the past 4 years (same, better, worse); witnessed physical parental violence (yes, no); currently working (yes, no); financial autonomy (has own bank account and allowed to set money aside, no); media exposure (reads a newspaper, listens to the radio, and watches TV at least once a week; no); contribution to family earning (none or almost none, less than half to all); the number of years the respondent has been married (0-5, 6-10, 11+); age at current union (≤20, >20); husband consumes any alcohol (yes; no); and husbands’ age (≤25, >25).

Results Table 1 shows the frequency distributions of reported poor mental health status. The most commonly reported problems across all states were feeling constantly under strain (39.83%), depressed or unhappy (38.48%), and lost sleep over worry (36.57%). Only 6.07% of the respondents felt they had not played a useful part in things. Figure 1 shows the frequencies of the two outcomes analyzed in this study: mental health problem, and any mental health symptom. The overall percentage of respondents with a mental health problem was 3.0%, again with Jharkhand at the highest percentage of respondents at 12.91%. The overall percentage of respondents who reported any mental health symptom was 66.90%, with Maharashtra with the highest at 76.86%.

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Table 1.  Reported Mental Health Status of Respondents, Aged 15 to 49 years From Rural India (n = 6,290). Self-reported mental health symptoms (General Health Questionnaire-12) Ability to concentrate Lost sleep over worry Played a useful part in things Capable of making decisions Constantly under strain Could overcome difficulties Able to enjoy day-to-day activities Able to face up to problems Unhappy or depressed Losing confidence in oneself Thinking of oneself as worthless Feeling reasonably happy, all things considered

Bihar

Jharkhand

Maharashtra

Tamil Nadu

Total

n (%)

n (%)

n (%)

n (%)

n (%)

394 (13.84) 1,121 (39.43) 217 (7.64) 452 (15.90) 1,236 (43.49) 521 (18.33) 419 (14.75) 453 (15.94) 1,214 (42.72) 382 (13.44) 404 (14.21) 387 (13.62)

195 (23.69) 308 (37.42) 125 (15.19) 197 (23.94) 321 (39.05) 262 (31.83) 201 (24.42) 238 (28.92) 293 (35.60) 127 (15.43) 102 (12.41) 239 (29.04)

131 (11.73) 459 (41.09) 75 (6.71) 272 (24.35) 448 (40.14) 292 (26.16) 202 (18.08) 253 (22.65) 422 (37.78) 339 (30.35) 221 (19.79) 146 (13.07)

273 (17.96) 417 (27.43) 22 (1.45) 111 (7.30) 504 (33.16) 49 (3.22) 423 (27.83) 84 (5.53) 496 (32.63) 71 (4.67) 93 (6.12) 690 (45.39)

993 (15.75) 2,305 (36.57) 439 (6.97) 1,032 (16.38) 2,509 (39.83) 1,124 (17.84) 1,245 (19.76) 1,028 (16.31) 2,425 (38.48) 919 (14.58) 820 (13.01) 1,462 (23.20)

Figure 1.  Frequencies of the two mental health outcomes, respondents aged 15-49 years from rural India (n = 6,290).

Figure 2 shows the prevalence of IPV in the past 12 months. The prevalence of IPV in the previous 12 months among the respondents was high, with 37.43% respondents who reported verbal violence, 20.93% who reported physical violence, and 10.60% who reported sexual violence, across all four states. Tamil Nadu had the highest

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Figure 2.  Percentage of respondents reporting 1, 2-4, or 5+ number of incidents of verbal and physical IPV in the past 12 months, and 1, or 2+ number of incidents of sexual violence in the past 12 months, aged 15-49 years from rural India (n = 6,303).

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reported number of respondents who have had at least one incident of verbal and physical violence in the past 12 months: 61.59% and 27.01%, respectively. Bihar had the highest reported five or more incidents of physical violence in the past 12 months at 3.38%. In addition, Bihar had the highest reported number of respondents (13.84%) who had at least one incident of sexual violence. Table 2 shows the distribution of all independent variables. Overall, 69.55% of the respondents were illiterate, 25.33% had a worse economic condition over the past 4 years (rather than same or better), 31.03% of women respondents had at least one child who has died, and 20.4% witnessed their father physically beating their mother. In addition, 40.12% of the respondents’ partners consume alcohol. Table 3 shows the results of the logistic regression models for each mental health outcome. Of particular interest is the association between IPV and mental health, after controlling for all other variables in the model. Relative to women who had not experienced verbal violence, women who reported two to four or five or more recent acts of verbal violence were significantly more likely to report a mental health problem (two to four episodes of verbal violence 1.65 [1.01, 2.72], and five or more episodes 4.19 [2.60, 6.75]); women who reported one or more than five recent episodes of verbal IPV were also more likely to report any mental health symptom (one episode of verbal violence 1.88 [1.16, 3.04], five or more episodes 1.81 [1.46, 2.24]). However, the experience of physical IPV was less significantly associated with the reporting of a mental health problem, and only women with two to four episodes of physical IPV were significantly more likely to report any mental health symptom. Finally, women who reported any sexual IPV were more likely to report any mental health symptom (one episode of sexual violence 3.92 [1.16, 13.24], and two or more episodes 1.50 [1.17, 1.92]), but were not more likely to report a mental health problem. Relative to women who were from Bihar, women from Jharkhand were significantly more likely to report a mental health problem 5.57 (3.79, 8.20); however, they were less likely to report any mental health symptom 0.66 (0.55, 0.79). Women from Maharashtra were more likely report any mental health symptom 2.17 (1.79, 2.62), but were not significantly more likely to report a mental health problem. Finally, respondents from Tamil Nadu were less likely to report any mental health symptom 0.51 (0.42, 0.62) or a mental health problem 0.28 (0.13, 0.62) compared with women from Bihar. As the number of children ever born increases, the risk of a mental health problem decreases (one to three children 0.23 [0.13, 0.42], four to six children 0.19 [0.10, 0.37], and seven or more children 0.13 [0.05, 0.31]). In addition, respondents who report more children ever born are also less likely to report any mental health symptoms (one to three children 0.25 [0.16, 0.39], four to six children 0.25 [0.16, 0.39], and seven or more children 0.27 [0.16, 0.46]). Respondents over the age of 30 years were more likely to report poor mental health, compared with women under the age of 30 years, as measured by each mental health outcome variable. Respondents who reported a worse economic condition over the past 4 years, were significantly more likely to report any mental health symptom, 1.94 (1.66, 2.28), compared with respondents who reported the same economic condition over the past 4 years. However, reporting a worse economic condition was not significantly associated with a mental health problem. Also, a respondent with a partner who

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Table 2.  Distribution of Independent Variables Considered in Analysis of Mental Health Among Women, Aged 15 to 49 years From Rural India (n = 6,303).

 

Bihar

Jharkhand

Maharashtra

Tamil Nadu

Overall

n (%)

n (%)

n (%)

n (%)

n (%)

827 (80.60) 23 (2.24) 53 (5.17) 123 (11.99)

567 (38.41) 51 (3.46) 483 (32.72) 375 (25.41)

3,540 (62.57) 127 (2.24) 1,023 (18.08) 968 (17.11)

911 (88.88) 29 (2.83) 69 (6.73) 16 (1.56)

1,078 (72.99) 134 (9.07) 244 (16.52) 21 (1.42)

4,481 (79.07) 293 (5.17) 758 (13.38) 135 (2.38)

973 (94.83) 6 (0.58) 47 (4.58)

1,392 (94.37) 1 (0.07) 85 (5.56)

5,054 (89.40) 38 (0.67) 561 (9.92)

639 (57.21) 273 (24.44) 102 (9.13) 103 (9.22)

887 (58.36) 279 (18.36) 190 (12.50) 164 (10.79)

4,384 (69.55) 1,025 (16.26) 397 (6.30) 497 (7.89)

497 (44.49) 620 (55.51)

650 (42.76) 870 (57.24)

3,051 (48.41) 3,252 (51.59)

634 (56.81) 107 (9.59) 375 (33.60)

587 (38.62) 669 (44.01) 264 (17.37)

2,994 (47.61) 1,593 (25.33) 1,702 (27.06)

25 (2.24) 682 (61.06) 376 (33.66) 34 (3.04)

64 (4.21) 1,137 (74.80) 308 (20.26) 11 (0.72)

214 (3.40) 3,380 (53.63) 2,178 (34.55) 531 (8.42)

925 (82.81) 192 (17.19)

951 (62.57) 569 (37.43)

5,017 (79.60) 1,286 (20.40)

834 (74.73) 282 (25.27) 1,117

758 (49.87) 762 (50.13) 1,520

3,771 (59.88) 2,527 (40.12) 6,303

Verbal violence: the number of incidents in the past 12 months  0 1,726 (72.37) 420 (54.47)  1 50 (2.10) 3 (0.39)  2-4 289 (12.12) 198 (25.68)  5+ 320 (13.42) 150 (19.46) Physical violence: the number of incidents in the past 12 months  0 1,914 (79.78) 578 (75.48)  1 98 (4.09) 32 (4.18)  2-4 306 (12.76) 139 (18.15)  5+ 81 (3.38) 17 (2.22) Sexual violence the number of incidents in the past 12 months  0 2,061 (86.16) 628 (82.63)  1 21 (0.88) 10 (1.32)  2+ 310 (12.96) 122 (16.05) Education  Illiterate 2,211 (77.77) 647 (78.61)   Literate < mid complete 348 (12.24) 125 (15.19)   Mid complete 86 (3.02) 19 (2.31)   High school + 198 (6.96) 32 (3.89) Age (years)   ≤30 1,467 (51.60) 437 (53.10)   ≥31 1,376 (48.40) 386 (46.90) Economic situation over the past 4 years  Same 1,344 (47.34) 429 (52.70)  Worse 712 (25.08) 105 (12.90)  Better 783 (27.58) 280 (34.40) Total children ever born  0 89 (3.13) 36 (4.37)  1-3 1,180 (41.51) 381 (46.29)  4-6 1,166 (41.01) 328 (39.85)  7+ 408 (14.35) 78 (9.48) Witnessed parental violence  No 2,475 (87.06) 666 (80.92)  Yes 368 (12.94) 157 (19.08) Husband consumes alcohol  No 1,776 (62.56) 403 (48.97)  Yes 1,063 (37.44) 420 (51.03) Total 2,843 823

consumed alcohol is more likely to have a mental health problem 1.55 (1.08, 2.21), and have any mental health symptom 1.30 (1.14, 1.48).

Discussion One interesting finding among IPV prevalence rates by state is that Tamil Nadu has the largest proportion of women who experience any verbal violence or any physical violence compared with the other three states; however, women in Tamil Nadu are the

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Table 3.  Logistic Regression Models: Analysis of Mental Health Among Women, Aged 15 to 49 years, Rural India (n = 6,303). Mental health problem OR (95% CI) Number of verbal IPV incidents in the past 12 months (0) 1 2.19 [0.65, 7.42] 2-4 1.65 [1.01, 2.72]† 5+ 4.19 [2.60, 6.75]† Number of physical IPV incidents in the past 12 months (0) 1 1.27 [0.65, 2.50] 24 0.94 [0.59, 1.52] 5+ 0.58 [0.23, 1.45] Number of sexual IPV incidents in the past 12 months (0) 1 1.60 [0.45, 5.77] 2+ 1.19 [0.77, 1.84] State (Bihar) Jharkhand 5.57 [3.79, 8.20]† Maharashtra 0.61 [0.31, 1.21] Tamil Nadu 0.28 [0.13, 0.62]† Education(illiterate) Literate < middle complete 0.70 [0.40, 1.23] Middle school complete 1.15 [0.44, 3.01] High school or more 0.72 [0.23, 2.21] Respondents Age (≤30) ≥31 1.60 [1.03, 2.48]† Economic situation, past 4 years (same) Worse 1.33 [0.87, 2.02] Better 0.77 [0.51, 1.17] Total children ever born (0) 13 0.23 [0.13, 0.42]† 4-6 0.19 [0.10, 0.37]† 7+ 0.13 [0.05, 0.31]† Witnessed parental physical violence (no) Yes 0.92 [0.61, 1.38] Partner’s alcohol consumption (no) Yes 1.55 [1.08, 2.21]†

Any mental health symptom OR (95% CI) 1.88 [1.16, 3.04]† 1.18 [0.98, 1.42] 1.81 [1.46, 2.24]† 1.23 [0.91, 1.66] 1.49 [1.18, 1.88]† 1.53 [0.89, 2.63] 3.92 [1.16, 13.24]† 1.50 [1.17, 1.92]† 0.66 [0.55, 0.79]† 2.17 [1.79, 2.62]† 0.51 [0.42, 0.62]† 1.05 [0.88, 1.26] 0.69 [0.53, 0.89]† 0.82 [0.63, 1.06] 1.31 [1.12, 1.53]† 1.94 [1.66, 2.28]† 0.94 [0.82, 1.10] 0.25 [0.16, 0.39]† 0.25 [0.16, 0.39]† 0.27 [0.16, 0.46]† 1.26 [1.08, 1.47]† 1.30 [1.14, 1.48]†

Note. The model also controlled for experiencing the death of a child, terminating a previous pregnancy, decision-making score, no permission needed score, media exposure, financial autonomy, contribution to family earnings, age at marriage, years of marriage, and partner’s age. †Significant at alpha level 0.05.

most educated and reported the highest decision-making ability and needed the least permission. According to Simister & Mehta (2010), there is evidence in India that gender-based violence is a male response to an increase in “modern” attitudes of women. In addition, women of northern India, including Bihar and Jharkhand, have

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less autonomy than southern India, and also have the highest prevalence of sexual IPV. More studies are needed to explore this region-specific finding (Jejeebhoy, 2002). The results reported in this study largely corroborate findings from previous studies from developed and developing countries concerning risk factors for self-reported mental health. Of central interest was this study’s demonstration of associations between verbal, physical, and sexual forms of IPV and mental health. Our results demonstrated that after controlling for a number of other demographic, socioeconomic, and partnership factors, significant associations between IPV and poor mental health remained, confirming results of previous studies (Chandra, Satyanarayana, & Carey, 2009; Chen et al., 2009; Coker, Davis, et al., 2002; Duran et al., 2009; Edwards et al., 2009; Ellsberg et al., 2008; Golding, 1999; Kumar et al., 2005; Martin et al., 2008; Roberts et al., 1998; Sato-DiLorenzo & Sharps, 2007; Vizcarra et al., 2004). However, this study went further by using a population-based study among women in rural resource-poor regions of India, and by examining the association between poor mental health and three types of IPV (verbal, physical, sexual), and the frequency of each of these forms of IPV. Interestingly, there was a very strong association between five or more incidents of verbal violence and a mental health problem. This supported Heise et al.’s (1994) assessment that for many women, psychological abuse was more difficult to endure than physical abuse. Also interesting, respondents who experienced sexual violence one time in the past 12 months were more likely to report any mental health symptom than respondents who experienced sexual violence two or more times in the past 12 months. This finding has not been reported in other studies. It is possible that the one sexual episode was also associated with shock and resulted in worse mental health as compared with women who had experienced two or more sexual violence incidents. Further research focusing on sexual IPV and specific mental health outcomes is needed to fully explain this association. Surprisingly, physical violence was not highly associated with poor mental health. Only women who experienced two to four episodes of physical violence were significantly more likely to report any mental health symptom than women who did not report any physical IPV. This association was insignificant when measured by mental health problem, therefore suggesting that physical violence is associated with any mental health symptom, but not with a mental health problem. Several other risk factors for mental health identified here support findings from other studies. For example, this study’s finding of increased risk of poor mental health among respondents in the presence of the partner’s alcohol consumption measured by both outcomes has been reported in at least one other study (Varma, Chandra, Thomas, & Carey, 2007). Fikree and Bhatti’s (1999) finding that low monthly income was associated with poor mental health among Pakistani women was similar to this study’s finding that a reported worse economic situation in the past 4 years is associated with any mental health symptom. There are many mechanisms through which poverty may affect Indian women’s mental health, including issues such as powerlessness, being the sole caretaker, and unequal power relations (Kuruvilla & Jacob, 2007; Lund et al., 2010). Further, there are a number of reasons why poverty increases the risk of violence, including marital disagreements over lack of funds, overcrowding,

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hopelessness, or because it is more difficult for women to leave violent relationships (WHO, 2002). This study also confirmed the results of previous studies with regard to the harmful role of witnessing parental violence on IPV. The relationship between IPV and poor mental health may be partially explained by a history of abuse. Jeyaseelan et al., (2007) argued that women who experience severe physical punishment as a child, or viewed their father beating their mother, were more likely to experience IPV as an adult. Similarly, this study’s finding that respondents’ childhood exposure to parental violence was associated with any mental health symptom was supported by at least two other studies (Jeyaseelan et al., 2007; Widom & Maxfield, 2001). Therefore, firstgeneration to second-generation violence was a trend among the abused women, possibly resulting in increased anxiety and poor mental health at an early age, which can be exacerbated by further abuse as an adult for the woman. However, unlike some studies, this analysis did not find a significant association between poor education and poor mental health (Hicks & Li, 2003; Kumar et al., 2005; Y. S. Lee & Hadeed, 2009; Patel et al., 1999). The only significant difference found was that respondents who had completed middle school education (but not high school education) were less likely to report any mental health symptom than respondents who were illiterate. Further, poor education of both the female and male has been associated with increased risk of IPV, possibly because less education may result in poor communication, which is associated with IPV (Dutton & Strachan, 1987; Jeyaseelan et al., 2007; Koenig, Ahmed, Hossain, & Khorshed Alam Mozumder, 2003; Koenig et al., 2006). It is possible that through the inclusion of other covariates in the model, we are explaining the relationship between education and IPV; however, further research is needed to understand this context-specific finding. This analysis shows a protective relationship between respondents who had one or more children ever born and poor mental health, significantly measured by both mental health outcomes. Husain, Gater, Tomenson, & Creed (2004) in Pakistan found a relationship between poor mental health and having four or more children. By using zero children as the reference, this analysis was more able to clearly illustrate the positive effect of any children born on the mental health of the mother, or rather, the poor mental health status created by being childless in a society that places a strong emphasis on childbearing. This analysis has several limitations. First, the data were based on self-reported IPV; therefore, the survey may potentially underestimate the level of IPV. In addition, respondents may be socially pressurized to accept IPV as part of their marriage to their husbands and, therefore, may be less likely to identify having experienced IPV (Kaur & Garg, 2009). Previous studies suggest that strong normative support for male-tofemale violence exists in this setting, possibly reducing the stigma attached to domestic violence and, therefore, social desirability bias, which would lead to underreporting (Jejeebhoy, 1998; Koenig et al., 2006). Second, data on mental health were also selfreported; however, numerous studies have illustrated the validity of the GHQ-12 for collecting mental health data in India (Bagadia et al., 1985; Gautam et al., 1987; John et al., 2006; Kermode et al., 2009; Patel et al., 2008; Patel et al., 1998).

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Conclusion This study contributes to a better understanding of how experiencing verbal, physical, or sexual IPV is associated with women’s mental health. In addition, this analysis fills a gap in the literature by demonstrating the relationship between IPV frequency and mental health in a resource-poor setting by using a population-based study. There is a need to incorporate IPV screening and services in mental health settings, especially in research-poor settings such as rural India where both IPV and mental health are often overlooked. Moreover, this finding may add to the argument to integrate mental health into primary care in resource-poor settings by emphasizing the association between IPV and mental health of women as demonstrated here (World Health Organization & Wonca, 2008). Finally, community awareness of the harmful consequences of IPV needs to be increased to reduce the community’s tolerance of IPV in India (Kumar et al., 2005). Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies Rob Stephenson, MSc, PhD, is an associate professor, Hubert Department of Global Health, Rollins School of Public Health, Emory University. Amy Winter, MPH, is currently a PhD candidate in the Office of Population Research at Princeton University. Michelle Hindin, MHS, PhD, is an associate professor, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University.

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