Violence Against Women

Violence against women (VaW) is an important issue of concern worldwide. The issue is particularly significant in the Indian context as we fare poorly in women's security overall. The Women Peace and Security Index 2023 has ranked India very low — 128 out of 177 countries — in terms of women's inclusion, justice, and security.

Women's safety includes their safety within their own homes. Specifically, violence against women within their homes is pervasive worldwide but more so in India. The World Health Organization (WHO) states that nearly 1 in 3 women worldwide (840 million women) have experienced violence within their homes.

For tackling violence against women in their homes, India has enacted the Protection of Women from Domestic Violence Act (PWDA) in 2005, but domestic violence (DV) figures in the country continue to remain high. In 2022, the National Crime Records Bureau (NCRB) recorded more than 365,000 overall acts of violence against women, of which 38% were cases of cruelty by a husband or relative. These figures demonstrate the high likelihood of women facing violence within their own homes from spouses and relatives.

DV in the Rural Context

Rural women in India are even more vulnerable to facing violence within their homes due to factors which include entrenched patriarchy, geographical remoteness, and lower educational levels in rural parts. Evidence from the National Family Health Survey (NFHS)-5 (2020–21) indicates that women in rural areas of India experience a higher prevalence of DV compared to women in urban areas, raising critical concerns about the ability of rural women to access timely and appropriate support.

Primary Healthcare Centres (PHCs) and Sub-Centres serve as the first point of care for women survivors of violence in remote rural settings. In addition to the health system, other institutional support services have been established in the form of One-Stop Centres for shelter, Bharosa Cells for counselling, and legal aid and Protection Officer services — all of which can be accessed via referral through health-care facilities.

Survivors of DV in rural settings face multiple barriers in accessing the available services. Since the health system serves as the first link in the chain for addressing DV against women, it is imperative that the system is strengthened in terms of readiness so that existing barriers that survivors face can be overcome.

Apart from geographical distance and connectivity, limited awareness, restricted mobility, and social and familial restraints, an important barrier which survivors encounter relates to patriarchal attitudes in society in general and among health-care providers (HCPs) as well.

Udaan Project

MASUM's Udaan project in partnership with research partner CEHAT is an effort to remove the above-mentioned barriers by strengthening the readiness and ability of the health system to address and prevent DV against women. Implemented in two intervention blocks — Gangapur and Paithan — in collaboration with the District Health Department, Chhatrapati Sambhajinagar, Udaan seeks to improve women survivors' access to health and support services by improving the readiness of health-care facilities (HCFs) in the intervention blocks through training and capacity building.

Under Udaan, training was conducted for all levels of HCPs and community-level workers (ASHAs). The training aimed at skill building and positive attitudinal changes among HCPs such that they can provide effective response in addressing and preventing DV faced by women.

The training covered:

• Understanding VaW and DV as public health issues
• Addressing existing biases and understanding patriarchy and gender stereotyping
• Exploring the different types of violence — physical, verbal, sexual, psychological, economic
• Understanding multi-sectoral coordination and referral pathways
• Orientation on issues like DV-related documentation, communication skills, and techniques including LIVES (Listen, Inquire, Validate, Ensure Safety) and SOLER (Sit squarely, Open posture, Lean slightly, Eye contact, Relax) for non-judgemental support

To ensure that readiness of facilities to help DV survivors is strengthened, the project also engages in continued hand-holding of HCPs to bolster their confidence in preventing and addressing DV. At the community level, ASHAs are constantly given support and inputs in order to empower them to address DV issues in their villages.

Outcome of Udaan Interventions at Health-Care Facility Level

Interacting with different cadres of HCPs at the HCFs in the intervention blocks, we sought to discover if the training had brought about positive attitudinal changes among them. And if so, did such attitudinal changes translate into improved responses and practices to address and prevent DV? Have HCFs improved in terms of readiness as a result?

HCPs are now aware about patriarchy, gender roles, and women's rights

In one PHC in Gangapur block, the ANM is herself a DV survivor and has been actively identifying DV survivors at her facility. Someone who tolerated physical abuse by her husband for several years, she is now back at her parental home with her two children and supported by her brother's family. The training taught her that DV comes in several forms. But most important, she learned that "women have the right to not tolerate abuse of any kind." Had she received the same training earlier, she would have left her marital home years ago, she says.

One PHC in Gangapur has 5 Sub-Centres. Here, the Medical Officer (MO) expresses that the training changed his attitude and that of his staff when they learned about patriarchy and gender discrimination. After the training, he and his staff regularly identify DV survivors among patients attending the facility. They also provide the required assistance to such survivors. For example, in one crisis situation, the survivor was directly sent in an ambulance to a larger health-care facility to which the survivor's parents were simultaneously called. This way, the survivor did not have to return to her marital home which she no longer found safe. In other instances, they provide individual and family counselling. Many families have responded positively to family counselling interventions which have served as a preventive measure against DV.

HCPs realise that DV is not a private matter but a public-health issue

A male Staff Nurse from a facility in Gangapur confessed, "I used to consider domestic violence as a personal issue. In the past, I did not want to interfere if I noticed any such case." After the training, he realised that DV is a public-health issue and he can help DV survivors during the course of his work. He has worked in the health sector for over 30 years and he looks at his own role as a nurse in a new light. Now, when he notices a possible survivor, he makes it a point to interact and win her trust by being empathetic. "Showing kindness and empathy is often the key to making a survivor open up and disclose her situation," he says. He now feels happy that he gets to help so many women survivors by just being sympathetic and sensitive during the course of his regular work!

The male Staff Nurse from a facility in Paithan block who works in the ANC Department similarly imbibed the fact that DV is not a private matter. Previously, he was conditioned to not interfere or pay much attention, but after the training he has learned to look closely at women attending the ANC, especially those suffering from anaemia or those going through multiple pregnancies. In many such cases, he has counselled the accompanying husbands or family members regarding harmful health effects of multiple pregnancies. "I have also told some husbands to not discriminate between the girl and boy child. Multiple pregnancies are often caused as the birth of sons is awaited," he says.

HCPs now grasp that their role extends beyond medical treatment to include preventing and addressing DV

"The training taught me that my role includes more than only treating symptoms of women who come with bodily injuries. I must also address their concerns and fears and provide them whatever support they need to ensure their well-being and safety," says the ANM at a facility in Gangapur block. At the training, she also learned about women's rights for the first time and realised that DV can cause women's health problems. Problems like stress, frequent headaches and body aches, anaemia and many other health problems can be a product of facing DV. Becoming aware of this, she began to observe women visiting the facility to check for stress-related issues. She makes it a point to initiate a conversation with women who appear to be facing some mental or emotional problem.

The MO at a PHC in Gangapur block says, "The training taught me about the crucial role that the health system can play in helping DV survivors." He and the Pharmacist at the facility have been identifying survivors based on non-obvious signs. Before the training, the MO considered his role to be limited to treating the physical injuries. Now, he counsels, gives LIVES, and provides referral to survivors as per the requirement. The training also taught him about the additional services that survivors can avail of including that of a Protection Officer.

HCPs now actively apply a changed mindset to DV survivor identification

Most HCPs have a changed mindset after the MASUM training. As one lady MO at a PHC in Gangapur block said: "As a doctor, I had attended trainings which addressed gender issues. For example, the training on POCSO. However, we became sensitised to the issue of DV, only after the MASUM training, as have all levels of our staff." The change in mindset has made these HCPs into "catalysts" who actively apply this to their work and identify DV survivors regularly. She says that even at the community level, the ASHAs have gained the confidence to intervene in DV-related issues.

In one of Paithan block's larger health facilities, the changed attitudes have driven many of the HCPs — a male Staff Nurse, lady MO, and the Lab Assistant — to actively identify DV survivors based on many non-obvious signs and not just bodily injuries.

In Conclusion

The interaction with HCPs showed that the DV training has made a significant contribution to the knowledge, attitude, and preparation/practice of these HCPs in the context of preventing and addressing DV. It was also observed that in these facilities, the identified DV cases are called for follow-up check-ups to determine the situation. At these facilities, there remain some trained HCPs who have yet to actively identify DV survivors but their superiors feel assured that these HCPs are gaining in confidence to be active in the process.

Udaan's DV training has helped make inroads into providing HCPs the expertise to deal with DV issues. This in turn is helping HCFs improve in readiness for DV survivor identification and prevention. The training has provided insights to HCPs that will go a long way. As one lady MO at a PHC in Gangapur block says:

"I recently graduated from medical school and this is my first placement. The training on DV was conducted within a month of my joining here as MO. I am happy that I got the opportunity to attend the training at the beginning of my career as it has given me new insights on how to view women survivors of violence. I will be able to use this new insight lifelong while serving at any health facility."