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Intimate partner violence (IPV) is frequently experienced by women of low socioeconomic status in India. It is a human rights violation and associated with negative effects on physical and mental well-being, underscoring the need for effective prevention strategies.
This study aimed to develop a dyadic intervention for the primary prevention of IPV among newly married couples residing in slum communities in India.
The intervention was developed using a community-based, mixed-methods design rooted in couple-interdependence theory and guided by the intervention mapping (IM) framework. It used the six critical IM steps to inform the content and delivery of the intervention: (1) needs assessment, (2) preparation of matrices of change objectives, (3) selection of theory-based methods and practical applications, (4) production of intervention components and materials, (5) intervention adoption and implementation, and (6) evaluation planning.
The resulting
Ghya Bharari Ekatra is evidence-based, grounded in intervention-mapping, and developed and iteratively refined using a community-based participatory research approach, suggesting it has great potential to be an acceptable and effective solution to preventing IPV among newly married couples.
ClinicalTrials.gov NCT03332134; https://clinicaltrials.gov/ct2/show/NCT03332134
Intimate partner violence (IPV), defined by the World Health Organization as “behavior by an intimate partner or ex-partner that causes physical, sexual or psychological harm, including physical aggression, sexual coercion, psychological abuse and controlling behaviors,” is experienced by approximately one-third (30%) of women worldwide during their lifetime [
To date, the majority of IPV prevention efforts by the government sector, nongovernmental organizations, and research-based organizations in India has focused on secondary and tertiary IPV prevention [
The international literature suggests that most evidence-based IPV prevention interventions engage women alone [
The intervention,
The methods used to develop the intervention include (1) cross-sectional surveys with newly married men and women residing in slums to identify correlates of IPV to inform intervention change objectives, (2) 21 key informant interviews (with individuals who bring expertise in IPV, gender equality, marital health, sexual and reproductive health, or work with slum communities) to inform the content and delivery of the intervention, (3) feedback from gender-based violence (GBV) experts and the Indian Council of Medical Research-National AIDS Research Institute (ICMR-NARI, Pune, India) community advisory board (CAB) on the intervention protocol, and (4) 3 focus group discussions with married men, married women, and parents-in-law (each of 7-10 participants) to assess acceptance of some of the more controversial topics included in the intervention.
The intervention was developed in Pune, India, the second largest city in the western state of Maharashtra. It has a population of 3.1 million, a female:male sex ratio of 0.948, and significant religious diversity (79% [2,449,000/3,100,000] Hindu; 11% [341,000/3,100,000] Muslim; 4% [124,000/3,100,000] Buddhist; 2% [62,000/3,100,000] Jain; and 2% [62,000/3,100,000] Christian). Approximately, a quarter (22% or 690,545 individuals) of Pune resides in slums [
The study was approved by the Ethics Committee of ICMR-NARI and the institutional review board of Emory University (Atlanta, USA) and registered at ClinicalTrials.gov (NCT03332134) and the Clinical Trials Registry-India (CTRI/2018/01/011596).
First, we conducted a systematic review of the literature to assess the breadth and depth of IPV in India and to identify high-risk groups (ie, women of low SES) [
Afterward, an analysis of IPV causation in Pune slums was undertaken to inform the development of the PRECEDE logic model (
We then assessed the community capacity by exploring services provided by local community-based organizations (CBOs); engaging in informal discussions with community leaders and individuals working in the intervention communities (ie, from
To develop matrices of change objectives (
Together with the research field team (that brought working knowledge of the needs and interests of individuals residing in Pune slums through years of field experience), we brainstormed ideas for the intervention that would accomplish each of the change objectives. We narrowed the list of applications based on the extent to which we felt they could appeal to and meet the needs of the intervention population and whether the application was justified by a theory-based behavior change method. The selected intervention applications were individually again examined by ASK, SS, and RS to ensure they addressed the respective change objectives.
A logic model of the needs assessment.
The phase II key informant interview data were used to inform the production of the application content and materials. Specifically, we extracted case stories and common marital conflict scenarios, and key informant suggestions about information content, delivery methods (including language considerations), order of module delivery, and duration. We then reviewed and revised the content and delivery for the 6-intervention modules exercise-by-exercise until team consensus was achieved about the material being relevant, stimulating, clear, and appropriate in addressing the change objectives.
Thereafter, the intervention materials and delivery strategy were presented to the ICMR-NARI CAB and regional GBV experts and revised based on their feedback. The content of specific exercises for which there remained uncertainty about participant acceptance or comprehension (ie, exercises related to sexual communication and knowledge, career planning, and government schemes) was presented to the community for feedback through 3 focus group discussions with married men (n=7), married women (n=7), and mothers-in-law and fathers-in-law (n=8). Finally, the research team worked intimately with the module publishers and film producers (for the short films used in module 3 to ensure quality and appropriateness of the final product.
We brainstormed potential adopters of the intervention, consulting recommendations from the qualitative data about existing government and nongovernment programs with whom to partner to enhance future scalability and sustainability of the intervention. The brainstorming included free listing of community gatekeepers who could raise awareness about the intervention and recruit participants, individuals and agencies who could deliver the intervention, and potential intervention venues. Subsequently, we met the individuals and agencies to gauge their interest, capacity, and processes they required to formally establish the partnership. Selected interventionists underwent a 1-week interactive training. Necessary paperwork for partnering agencies was completed.
To develop the plan for evaluation of intervention effect, we consulted the matrices of change objectives and the scientific literature to find appropriate, validated tools to measure the desired change. In developing the measures of acceptance, feasibility, and safety, we ensured the evaluation included the perspectives of multilevel stakeholders (ie, participants, interventionists, police stations, CBOs, and community members) as is emphasized by Bartholmew et al [
The resulting
The systematic review [
The
Couple’s interdependence theory is the unifying theory in which the intervention is grounded [
The qualitative data guided the intervention duration, module order, content, and delivery.
Key informant interviews provided guidance on module duration and order of delivery. Participants placed emphasis on the need for intervention timing to be convenient for participants, for interventionists to be respectful of the participant’s time, and for sessions to be limited to 2 hours. An HIV researcher with expertise in working with slum communities guided:
Many will say “our time is up, we are leaving”…You can give training for 1 hour, at the most 2 hours...Whatever time we tell [them], we should do within that.
Although key informants had varying suggestions for ordering of modules, most agreed on beginning with relationship building, as it was the foundation of married life. A founder of a marital counseling CBO expanded on the importance of prioritizing this module:
Because many times they [participants] don’t know...I mean, understanding wife, or understanding husband, usually as marriages are always between the families...they have seen [their respective partner] maybe at the time of marriage or maybe only at the event of meeting the girl, otherwise they don’t know what is [a marital relationship]...And then...first 3-4 months, especially in our communities, there are so many festivals and this and that and go to this temple, that temple, and then there is no time to [spend with each other], you know?
Other common themes about module order included the need for initial intervention sessions to have particularly high appeal (ie, provide information about relevant government services and economic empowerment), delaying the sexual and reproductive health session until group rapport and comfort were established, and ensuring each module built on information provided in the prior sessions. Finally, 1 key informant who works with a CBO that focuses on women’s empowerment and gender equality through male engagement highlighted the importance for the session about domestic violence (DV) to occur at the end to minimize attrition:
And anyways, when we talk of domestic violence to begin with. Then men think, “these people have this only.” [That this is the only agenda this organization is coming to us with]. They get put off by that. We should take that [the issue of violence] up last.
To engage and retain participants, key informants emphasized the need for the intervention to be fun, interactive, and activity-based and to make use of audio-visual tools:
If you just give lectures, nobody will come to you.
The more audio-visual films you will use, the more impact you will have.
You need to make it as engaging and as participatory as possible.
Specific delivery methods (ie, competitions, games, role plays, self-reflection, practice with feedback, songs and dance therapy, and quizzes) and audio-visual tools (ie, flip charts, anatomic models, and films) suggested by the key informants were incorporated throughout all 6 sessions. To foster couple interest and engagement in the sessions, a
Key informant data also led us to repeatedly evaluate the language used in the modules to ensure it was easy to understand, familiar to the participants, and also scientific. For example, a social worker of a CBO that focused on women’s empowerment and gender equality through male engagement advised:
Many times to make it palatable for the slum area people, we use many times the words, which are, they use for their body parts. Now, to begin with this is good, but ultimately we should bring them to the real scientific terms of that body part.
Key informants also provided guidance on which exercises should be performed individually, in couples, and in groups. For example, the input from a counselor of a marital counseling CBO led to the sexual communication and sexual and reproductive health session being delivered in separate gender-concordant groups:
First, sexuality you should conduct in a group and separately too. Because, if the participant has to speak openly, then [conducting men and women group sessions], limitations will come for that. Even if you take a couple...if they are husband and wife, even then, to talk to someone else in front of my partner will be difficult for me.
Individual module content was also informed by key informant data. For example, in response to the advice provided by the director of a CBO that engaged men to promote gender equality below, we designed an activity in module 1 in which couples self-reflected about the time they dedicated to their relationship and strategies to increase that time:
This is a relationship program and you can’t talk about relationships without emotions and without reflections and without communications…You actually need to bring in the self-reflection.
As part of the second and fourth sessions, which respectively aimed to build resilience and empower the couple, interactive informational sessions were held with community resource people (ie, social workers, government scheme enrollment officers, and
The needs of one community may not be the needs of the next [community]. So it will also be important to cater it in that sense. As in, “this is our module, and we now have to use this,”—we can’t do that.
She further expanded that:
...connecting them to government systems becomes important so that it’s longstanding.
The scripts for the module 3 films, used to provoke discussion about effective communication and conflict management strategies, were based on conflict scenarios taken directly from examples provided by our key informants and observations made by our field team. While in the field, our team noted that conflict in the newly married couples often arose from differences in expectations resulting from the newly wed women having moved to the urban slums from surrounding rural areas following marriage, whereas the men had long resided in urban slum environments. This was substantiated by key informant examples. For example, an ICDS project officer, responsible for overseeing
Soon after marriage, one girl came...and she was from a rural area. At that time, when that girl came into the slum, and at that time, the boy was from Pune, so accordingly he had many expectations, that “my wife should wear jeans.”...But she wasn’t used to jeans, because she was from a typical, rural area. “So then how can I do it?” About that they both started arguing.
Module 5 content was derived from the topics identified by key informants as critical to cover (ie, reproductive health systems, conception and pregnancy, communicating sexual expectations, and creating romance). Items for the module 5 misconceptions quiz were pulled directly from misconceptions reported by key informants (ie, penile length being associated with pleasure, pornography guiding performance of sexual intercourse, and erectile drugs being misused). A marital counselor provided the following:
Most of [the men] do sexual abuse in accordance with what they watch in blue films and they perform similar acts on their wives leading to harassment and unnatural sexual acts. This attitude can be changed through proper education.
We added content about sexuality and creating romance based on a suggestion by a key informant who directed a gender-equality CBO that engaged men:
How physical relationships are connected to emotional bonding, we need to focus on this too. Otherwise, if we look at it (marital sexual relationship) only from the perspective of bodily need, then to strengthen the bond in this relationship becomes very difficult.
Finally, module 6 content was developed in response to key informants emphasizing the need to challenge deep-rooted norms of DV acceptance and to enable participants to expand their definitions of behaviors constituting abuse (taking into account the survivor perspective). A feminist sociologist and a DV lawyer informant, respectively, suggested the means for doing so:
What men perceive as violence and what women perceive as violence is very different. I think we need to tease that out.
To be able to say that you know violence is subjective and that we’ll have to understand it from the victim’s perspective.
The finalization of the intervention name,
The decision to engage male and female community educators as the primary interventionists, to bring in community resource people to lead specific intervention exercises, to work with
In selecting interventionists, key informants stressed the need to ensure that the candidate was interested in the intervention, had strong oratory and critical thinking skills and gender-equitable attitudes, capacity to make the participants feel safe and secure, and sensitivity (to note when a participant seemed uncomfortable). Many highlighted the need for the interventionists to be of a similar demographic to the participants to best connect with them. For example, a counselor from the marital counseling CBO described who an ideal interventionist would be:
[People from] the slum community and the ordinary citizens of the society...those who have led successful lives…those who have brought up kids. Those who think that their lives have been spent happily, you should involve such people, because they are a role model in front of them.
The director of a CBO that engaged men to promote gender equality further emphasized this:
...to whom do people connect? To those whose language they are accustomed, to them they connect.
He also elaborated on the need for the interventionists to be emotionally engaged with the participants’ community:
If you are not part of people’s life, people are not part of your project, OK? In that community, in that couple, someone in that couple’s mothers has died during the period [of the intervention], someone’s father has died. It’s someone’s 10th[10thday death memorial ceremony]...If your intervention team isn’t part of their lives, they [the participants] aren’t part of our procedures emotionally.
Key informants emphasized the importance of some sessions to be delivered by content-level experts (ie, legal, health, and social workers and mental health counselors), community resource people (ie,
However much you might think that they [the participants] will not feel shy, it is not at all like that. Hence while conducting the husband’s sex education, you keep a gents community worker [have a male community worker as the facilitator]...and while conducting for ladies, you keep a lady [have a female community worker as the facilitator].
When a woman tells a man, it remains ineffective but when a man tells another man, about what is DV, and how it is contracted and how should one live in day-to-day lives, then the attitude will change. The attitude of looking at domestic violence should change.
Thus, we ultimately decided to have the sessions facilitated by a male and female community educator, who demonstrated strong oratory, group facilitation, critical thinking skills, and community involvement during the behavioral interviewing process. Content-level experts (ie, medical officers) and community resource people (ie, social workers and
A 6-day training for the community educators was held at ICMR-NARI by the research team. It was conducted in Marathi and Hindi and covered basic research ethics and safety, DV, community educator responsibilities (including need to report DV and other safety concerns to the study team), and the content of each of the 6 intervention sessions. First, research team members role-played the delivery of each session. Afterward, community educators mock delivered the session with feedback from the research team and other community educators.
Key informants highlighted the need for the venue to be of choice and convenience to the participants, in a setting where privacy could be maintained, a safe space where participants would feel comfortable sharing, and where discipline could be maintained. A trainer from a CBO, who promoted gender equity and justice, advised that for participants to be engaged, the research team had to dedicate effort to creating a safe space:
People would talk to you, if you actually create that space, very safe for sharing—not just between the trainer and trainees, but also amongst the group of participants, right? How safe they would feel in a physical structure, in a room, in a hall...How safe they feel with the gadgets around, mobile phones, audio-recorders, or video camera...You know, it all depends on the way you create that environment.
Although health care settings were mentioned as optimal spaces for maintaining privacy, they carried associated stigma and fear of infectivity, cost, and challenges of distance and insufficient space.
Factoring in the concerns raised by the key informants, we ultimately decided to hold the intervention in the slum community from which the participants were drawn. Venues were selected in partnership with community educators, weighing likelihood of safety and privacy. In addition, community educators and field team members were provided scripts and protocols for handling specific violations of privacy and safety. Finally, community meetings were held before the intervention delivery to help avert community misconceptions and undue stigma associated with the program.
The detailed evaluation plan, developed using the
Intervention evaluation plan.
Indicator and assessment method | Data source | ||
Time spent in relationship | Ma (Sb) | ||
Satisfaction with time spent in relationship | M (S) | ||
Resilience (CD-RISC-10c) | M (S) | ||
Extent to which feel attained qualities of |
M (S) | ||
Jealousy if spouse talks to other men | M (S) | ||
Self-esteem (RSESd) | M (S) | ||
Conflict negotiation skills (CTS2Ne) | Ff (S) | ||
Confidence in communicating various scenarios with partner | M/F (S) | ||
Extent to which feel attained qualities of |
M (S) | ||
Confidence in setting and achieving goals, and listing resources that support achieving goals | M (S) | ||
Confidence in sexual communication | M/F (S) | ||
Reproductive health beliefs | M/F (S) | ||
Definition of DVh (using items from abridged IFVCSi) | M (S) | ||
Attitudes toward DV acceptance (ATWBSj) | F (S) | ||
Past 1-month DV experience (abridged IFVCS) | F (S) | ||
Extent to which training provided as planned | RTk | ||
Extent to which interventionists delivered each activity as intended | |||
Difficulty interventionists experienced in delivering intervention content | PEl | ||
Number of sessions delivered by PE | RT | ||
Extent to which expected content delivered | RT | ||
Extent to which intended intervention material used | RT | ||
Time required to deliver each activity | RT | ||
Participant engagement in each session activity | RT | ||
Participant completion of home assignments | RT | ||
Participant understanding of content of each activity | M/F | ||
Participant satisfaction with each session, timing, and duration of intervention | M/F | ||
Family satisfaction with subject’s participation in intervention | M/F | ||
Participant satisfaction with interventionists | M/F | ||
Participant acceptance of safety measures | F (S) | ||
PE satisfaction with each session | PE | ||
Number approached and number of attempts to reach potential participant pre-enrollment | RT, M/F | ||
Time between initial contact with community gatekeeper and completion of recruitment | RT, M/F | ||
Family presence during permission process | RT, M/F | ||
Number consented and barriers to consenting | RT, M/F | ||
Number assessed for eligibility, and ineligibility reasons | RT, M/F | ||
Number randomized | RT, M/F | ||
Number of barriers to baseline and 3-month survey completion; staff attempts and reminders | RT, M/F | ||
Number or duration of sessions participant attended and barriers to attendance | RT, M/F | ||
Number terminated, exited from the study and reason | RT, M/F | ||
Number of staff reminders and home visit reminders | RT, M/F | ||
Number of staff calls or home visits for missed sessions | RT, M/F | ||
Response from police, community leaders, and family members when household approached | RT | ||
Number of community sensitization meetings held, number in attendance, and response to or acceptance of intervention | RT | ||
Barriers or facilitators encountered by the study team in implementing the program | RT | ||
How research is being discussed in the community | PE | ||
1-month DV experience | PE; RT; F (S) | ||
Family conflict attributed to intervention | PE; RT; F (S) | ||
DV reported by participants (or noted by staff) at Women’s day or during intervention | PE; RT; F (S) | ||
Adverse events | PE; RT; F (S) | ||
Number of potential PE approached and eligible to serve as interventionists and associated barriers | RT | ||
Number of PE completion of training | RT | ||
Number of community key persons, E-seva Kendra officials, and medical officers attending sessions 2, 4, and 5, respectively (and associated barriers) | RT | ||
Venue identification, privacy, and retention | RT | ||
Cost of intervention delivery | RT |
aM: male participant.
bS: pre- and postintervention survey item.
cCD-RISC-10: Connor-Davidson Resilience Scale-10 item.
dRSES: Rosenberg Self-Esteem Scale.
eCTS2N: Conflict Tactics Scale-2 Negotiation Subscale.
fF: female participant.
gIPV: intimate partner violence.
hDV: domestic violence.
iIFVCS: Indian Family Violence and Control Scale
jATWBS: Attitudes Toward Wife Beating Scale.
kRT: research team.
lPE: peer educator.
Primary prevention of IPV in low-SES communities in India is critical, as IPV is not only a human rights violation but also a critical public health problem, with high frequency and significant associated psychosocial and physical morbidity.
Enrollment into the pilot study to assess the safety, acceptance, feasibility, and preliminary efficacy in 40 couples (20 intervention and 20 control) commenced in January 2018 and was completed in May 2018. Preliminary feedback from participants, community educators, and the research field team suggests the intervention was highly accepted and safe. Three-month follow-up visits have been completed, and pilot results will be available in the spring of 2019. If pilot results are promising, the efficacy of
Matrix of change objectives.
Theory-informed methods and practical applications.
Attitudes Toward Wife Beating Scale
community advisory board
community-based organization
Connor-Davidson Resilience Scale-10 item
Conflict Tactics Scale-2 Negotiation Subscale
domestic violence
female participant
gender-based violence
Integrated Child Development Scheme
Indian Council of Medical Research-National AIDS Research Institute
Indian Family Violence and Control Scale
male participant
peer educator
intervention mapping
intimate partner violence
Rosenberg Self-Esteem Scale
research team
pre- and postintervention survey item
socioeconomic status
The authors would like to thank the community educators (Bharat Bhadve, Pooja Bhadve, NityanandDiggikar, Vimal Bhosale, Arjun Bhadve, Lata Mahankale, MufidBaig, Bharati Kalal, Anuradha Patil, Surya Prakash Lahade, and Anita Pawar) for wholeheartedly delivering the intervention, Mangala Patil for her support with implementation, the ICMR-NARI CAB and GBV experts for the insightful feedback, and the many study participants for their invaluable contributions in developing the intervention. Furthermore, we express sincere gratitude to Nayana Yenbhar for her meticulous entry and management of the data. Finally, the authors acknowledge the continued support of this study by the ICMR-NARI director in-charge, Dr Raman Gangakhedkar as well as the ICMR.
The study was funded by the Fogarty International Center of the National Institutes of Health (Award K01TW009664). The content does not necessarily represent the views of the National Institutes of Health.
None declared.