A qualitative study on gender inequality and gender-based violence in Nepal.

BACKGROUND: Gender inequality and violence are not mutually exclusive phenomena but complex loops affecting each other. Women in Nepal face several inequalities and violence. The causes are diverse, but most of these results are due to socially assigned lower positioning of women. The hierarchies based on power make women face subordination and violence in Nepal. The study aims to explore participants' understanding and experience to identify the status of inequality for women and how violence emerges as one of its consequences. Furthermore, it explores the causes of sex trafficking as an example of an outcome of inequality and violence. METHOD: The study formulated separate male and female groups using a purposive sampling method. The study used a multistage focus group discussion, where the same groups met at different intervals. Six focus group discussions, three times each with male and female groups, were conducted in a year. Thirty-six individuals, including sixteen males and twenty females, were involved in the discussions. The study used constructivist grounded theory for the data analysis. RESULTS: The study participants identify that a power play between men and women reinforce inequality and increases the likelihood of violence for women. The findings suggest that the subjugation of women occurs due to practices based on gender differences, constricted life opportunities, and internalization of constructed differences among women. The study identifies that interpersonal and socio-cultural violence can result due to established differences between men and women. Sex trafficking, as an example of the outcome of inequality and violence, occurs due to the disadvantageous position of women compounded by poverty and illiteracy. The study has developed a concept of power-play which is identified as a cause and consequence of women's subordination and violence. This power play is found operative at various levels with social approval for men to use violence and maintain/produce inequality. CONCLUSION: The theoretical concept of power play shows that there are inequitable power relations between men and women. The male-centric socio-cultural norms and practices have endowed men with privilege, power, and an opportunity to exploit women. This lowers the status of women and the power-play help to produce and sustain inequality. The power-play exposes women to violence and manifests itself as one of the worst expressions used by men.

Does Forum Theater Help Reduce Gender Inequalities and Violence? Findings From Nepal.

Gender inequality and violence against women are present in every society and culture around the world. The intensities vary, however, based on the local guiding norms and established belief systems. The society of Nepal is centered on traditional belief systems of gender roles and responsibilities, providing greater male supremacy and subordination for the females. This has led to the development and extensive practices of social gender hierarchal systems, producing several inequalities and violence toward women. This study has utilized Forum Theater interventions as a method of raising awareness in 10 villages in eastern Nepal. The study aimed to understand the perception and changes in the community and individuals from the interactive Forum Theater performances on pertinent local gender issues. We conducted 6 focus group discussions and 30 individual interviews with male and female participants exposed to the interventions. The data analysis utilized the constructivist grounded theory methodology. The study finds that exposure and interactive participation in the Forum Theater provide the audience with knowledge, develop empathy toward the victim, and motivate them to change the situation of inequality, abuse, and violence using dialogues and negotiations. The study describes how participation in Forum Theater has increased individual's ability for negotiating changes. The engagement by the audience in community discussions and replication of efforts in one of the intervention sites show the level of preparedness and ownership among the targeted communities. The study shows the methodological aspects of the planning and performance of the Forum Theater and recommends further exploration of the use of Forum Theater in raising awareness.

Does childhood experience of family victimization influence adulthood refusal of wife abuse? Evidence from rural Bangladesh.

This study examined how different forms of childhood family victimization are associated with the attitudinal (not actual action) refusal of wife abuse among women and men in rural Bangladesh. It included 1,929 randomly selected married women and men. Of the sample, 31.3% (Men = 49.3%, Women = 13.5%) attitudinally refused overall wife abuse, 38.5% (Men = 53.2%, Women = 23.8%) refused emotional abuse, 67.0% (Men = 82.5%, Women = 51.6%) refused physical abuse, 78.0% (Men = 88.6%, Women = 67.4%) refused abuse on wife's disobeying family obligations, and 32.3% (Men = 50.3%, Women = 14.6%) refused abuse on challenging male authority. Multivariate logistic regression revealed that the odds ratio (ORs) of the attitudinal refusal of overall wife abuse were 1.75 (p = .041) for the childhood non-victims of emotional abuse and 2.31 (p < .001) for the victims of mild emotional abuse, compared to the victims of severe emotional abuse. On the other hand, the ORs of the overall refusal of abuse were 1.84 (p = .031) for the non-victims of physical abuse and 1.29 (p = .465) for the victims of mild physical abuse, compared to the childhood victims of severe physical abuse. Data further revealed that the childhood non-victimization of physical abuse increased all types of attitudinal refusal of wife abuse, e.g., emotional abuse, physical abuse, abuse on disobeying family obligations, and abuse on challenging male authority. Compared to the childhood experiences of severe emotional abuse, data also indicated that childhood exposure to mild emotional abuse might increase the attitudinal refusal of wife abuse on a few issues, e.g., abuse on disobeying family obligations, abuse on challenging male authority, and physical abuse. It appeared that childhood experiences of family victimization greatly influence different types of attitudinal refusal of wife abuse. We argue that the issue of childhood victimization should be brought to the forefront in the discourse. We recommend that state machinery and social welfare agencies should expend significant efforts to stop child abuse within the family and in other areas of society in rural Bangladesh.

Gender differences in marital violence: A cross-ethnic study among Bengali, Garo, and Santal communities in rural Bangladesh.

Studies on marital violence (MV) in Bangladesh have primarily focused on the women of the mainstream Bengali people, although half of the population is men, and there are also ethnic minority communities with diverse gender constructions. The current study examined the gender differences in MV among the matrilineal ethnic minority Garo, patrilineal ethnic minority Santal, and the patrilineal mainstream Bengali communities in rural Bangladesh. Adopting a cross-sectional design, we randomly included 1,929 currently married men and women from 24 villages. We used cross-tabulations as well as multivariate logistic regressions to estimate the ethnic and gender differences in MV. Data revealed that women were widely exposed to different types of MV, while only a few men experienced such abuses. It showed that 95.6% of the women experienced emotional abuse, 63.5% physical abuse, 71.4% sexual abuse, and 50.6% poly-victimization, whereas these rates were quite low among the men (emotional = 9.7%, physical = 0.7%, sexual = 0.1%). No men reported poly-victimization. The odds ratio (OR) for emotional, physical, and sexual MV were respectively, 184.44 (95% CI = 93.65-363.24, p<0.001), 449.23 (95% CI = 181.59-1111.35, p<0.001), and 2789.71(95% CI = 381.36-20407.08, p<0.001) for women compared to men. Data further revealed that matrilineal Garo women experienced less MV (emotional = 90.7%, physical = 53.4%, sexual = 64.0%, poly = 38.8%) than the patrilineal Santal (emotional = 99.4%, physical = 67.3%, sexual = 71.3%, poly = 53.9%) and Bengali women (emotional = 96.6%, physical = 69.6%, sexual = 78.8%, poly = 58.9%). Multivariate regressions also showed that the Bengali society perpetrated more physical (OR = 1.90, 95% CI = 1.27-2.85, p = 0.002) and sexual (OR = 2.04, 95% CI = 1.34-3.10, p = 0.001) MV than the Garo society. It appears that MV is largely a gendered issue in the country. Though both women and men can be the victims of MV, the nature/extent of victimization noticeably differs according to the social organization. Matrilineal society appears to be less abusive than the patrilineal one. Interventions aimed to prevent domestic violence in rural Bangladesh should take these findings into account.

Does Female Authority Prevent Male Marital Violence? Evidence From Rural Bangladesh.

While relative resource status between husband and wife is widely discussed in the explanation of male marital violence (MMV) behaviors, the influence of relative family authority between husband and wife on the violence has been generally overlooked in previous studies. An examination can provide a better understanding of the issue. This study examined how various levels of female authority within the family are associated with MMV against women in rural Bangladesh. The study adopted a cross-sectional design and included 342 married men randomly selected from five northwest villages. Negative binomial regression was performed to predict the frequency of self-reported MMV behaviors in a 1-year recall period which estimated the ratios comparing absolute male authority to egalitarian authority within the family. Of the sample, 37.4% were the egalitarian/fair female authority, 41.2% were the higher male authority, and 21.4% were absolute male authority families; 71.1% of the men revealed that they had resorted to at least one incident of MMV (psychological or physical or sexual) against their wives in the year preceding the survey. The mean of yearly MMV occurrences was 6.29 (SD = 7.58), ranging from 0 to 42. The study revealed that the frequency of MMV against women was 1.96 times higher among absolute male authority families than in egalitarian families. It further revealed that the frequency of psychological abuse was 1.63 times, physical attack 2.89 times, and sexual coercion 1.88 times higher among absolute male authority families than among egalitarian/fair female authority families. Higher male authority did not appear to be different from egalitarian authority in MMV occurrences. The study suggests that increased female authority within the family unit may prevent women from being exposed to MMV in a patriarchal social order.

Differences in the acceptance of wife abuse among ethnic minority Garo and Santal and mainstream Bengali communities in rural Bangladesh.

Studies on wife abuse in Bangladesh predominantly include the mainstream Bengali population, although there are at least 27 ethnic minority communities including a few 'female-centered' matrilineal groups living in the country. This study explored ethnic differences in the attitudinal acceptance of wife abuse among matrilineal ethnic minority Garo, patrilineal ethnic minority Santal, and mainstream patriarchal Bengali communities in rural Bangladesh. Adopting a cross-sectional design, the study included 1,929 women and men randomly selected from 24 Garo, Santal, and Bengali villages. Multivariate Poisson regression was performed to predict the number of contextual events, where the respondents attitudinally endorsed wife abuse. Of the sample, 33.2% were from Garo, 33.2% from Santal, and 33.6% from the Bengali communities. The acceptance of wife abuse was high in the sample; specifically, 34.1% of the respondents accepted physical wife abuse, 67.5% accepted emotional abuse, and 71.6% accepted any abuse (either physical or emotional) at least on one contextual reason provided in a 10-item scale. The mean for accepting any abuse was 3.0 (SD = 2.8), emotional abuse 2.3 (SD = 2.2), and physical abuse 0.8 (SD = 1.4). The study showed that the rates of accepting any abuse and physical abuse were respectively 16% and 56% lower among Garo as well as 14% and 33% lower among Santal than that of the Bengali community. Data also revealed that individual level factors like younger age, higher education, prestigious occupation as well as family level factors such as higher income, female mobility, and female family authority were inversely associated with the acceptance of wife abuse in the sample. It appears that the gender regime of a society has a great influence on the attitudes toward wife abuse. We argue that a comprehensive socio-cultural transformation of the patriarchal societies into a gender equal order is imperative for the prevention of widespread wife abuse in the country.

Pregnancy complications, sick leave and service needs of women who experience perinatal distress, weak social support and dissatisfaction in their partner relationships.

INTRODUCTION: Although perinatal distress is acknowledged as a burdening condition for pregnant women, its effects on pregnancy are not well known. This study was conducted to increase knowledge regarding the effects of distress on pregnancy-related problems. The study also assessed women's need for sick leave and increased prenatal care due to distress, and the effects of weak social support and dissatisfaction with their partner relationships. METHODS: In total, 2523 women were screened for perinatal distress three times during pregnancy in this quantitative cohort study. Structured psychiatric interviews were conducted following the screening, with 562 of the participants. Data from participants' pregnancy records were also analysed. The study was conducted in primary healthcare centres in Iceland after receiving approval from the Icelandic National Bioethical Committee. The main outcome measures were pregnancy problems, sick leave issued and prenatal service needs. RESULTS: Data from 503 women were analysed. The perinatal distress group (PDG) was significantly more likely than was the nondistressed group (NDG) to experience fatigue, vomiting and pelvic pain after controlling for background variables. Distressed women who reported weak family support experienced symptoms of nausea and heartburn. The PDG needed more frequent prenatal care than did the NDG and was issued sick leave for up to 42 days longer. Dissatisfaction in the partner relationship and with the division of household tasks and childcare was strongly associated with distress, the development of complications and the need for sick leave. DISCUSSION: Identification of perinatal distress by midwives and other healthcare professionals is important, since distress may be linked to women's complaints of fatigue, vomiting, pelvic pain and need for prolonged sick leave, and additional prenatal care services will be needed. Perceived dissatisfaction in the partner relationship and with the division of household tasks should also form part of clinical practice and assistance provided.

'When helpers hurt': women's and midwives' stories of obstetric violence in state health institutions, Colombo district, Sri Lanka.

BACKGROUND: The paper explores how age, social position or class, and linguistic and cultural background intersect and place women in varying positions of control and vulnerability to obstetric violence in state health institutions in Colombo district, Sri Lanka. Obstetric violence occurs during pregnancy, childbirth and the immediate postpartum period; hence, it is violence that directly affects women. The authors aim to break the traditional culture of silence around obstetric violence and bring attention to the resulting implications for quality of care and patient trust in obstetric care facilities or providers. METHODS: Five focus group discussions were held with 28 public health midwives who had prior experience working in labor rooms. Six focus group discussions were held with 38 pregnant women with previous childbirth experience. Additionally, 10 of the 38 women, whom felt they had experienced excessive pain, fear, humiliation, and/or loss of dignity as patients in labor, participated in individual in-depth interviews. An intersectional framework was used to group the qualitative data into categories and themes for analysis. RESULTS: Obstetric violence appears to intersect with systems of power and oppression linked to structural gender, social, linguistic and cultural inequities in Sri Lanka. In our dataset, younger women, poorer women, and women who did not speak Sinhala seemed to experience more obstetric violence than those with relevant social connections and better economic positions. The women in our study rarely reported obstetric violence to legal or institutional authorities, nor within their informal social support networks. Instead, they sought obstetric care, particularly for childbirth, in other state hospitals in subsequent pregnancies. CONCLUSIONS: The quality of obstetric care in Sri Lanka needs improvement. Amongst other initiatives, policies and practices are required to sensitize health providers about the existence of obstetric violence, and repercussions are required for abusive or discriminatory practices. The ethics of care should be further reinforced in the professional training of obstetric health providers.

Factors shaping political priorities for violence against women-mitigation policies in Sri Lanka.

BACKGROUND: Although violence against women (VAW) is a global public health issue, its importance as a health issue is often unrecognized in legal and health policy documents. This paper uses Sri Lanka as a case study to explore the factors influencing the national policy response to VAW, particularly by the health sector. METHODS: A document based health policy analysis was conducted to examine current policy responses to VAW in Sri Lanka using the Shiffman and Smith (2007) policy analysis framework. RESULTS: The findings suggest that the networks and influences of various actors in Sri Lanka, and their ideas used to frame the issue of VAW, have been particularly important in shaping the nature of the policy response to date. The Ministry of Women and Child Affairs led the national response on VAW, but suffered from limited financial and political support. Results also suggest that there was low engagement by the health sector in the initial policy response to VAW in Sri Lanka, which focused primarily on criminal legislation, following global influences. Furthermore, a lack of empirical data on VAW has impeded its promotion as a health policy issue, despite financial support from international organisations enabling an initial health systems response by the Ministry of Health. Until a legal framework was established (2005), the political context provided limited opportunities for VAW to also be construed as a health issue. It was only then that the Ministry of Health got legitimacy to institutionalise VAW services. CONCLUSION: Nearly a decade later, a change in government has led to a new national plan on VAW, giving a clear role to the health sector in the fight against VAW. High-level political will, criminalisation of violence, coalesced women's groups advocating for legislative change, prevalence data, and financial support from influential institutions are all critical elements helping frame violence as a national public health issue.

The Swedish translation and cross-cultural adaptation of the Functional Assessment of Chronic Illness Therapy - Cervical Dysplasia (FACIT-CD): linguistic validity and reliability of the Swedish version.

BACKGROUND: Cervical dysplasia is a precancerous condition, which has been shown to create anxiety in women. To be able to investigate these women's health-related quality of life, a disease-specific instrument is required. There does not seem to be a Swedish version of an instrument to screen for this specific disease. Therefore, this study aims to translate and cross-culturally adapt the Functional Assessment of Chronic Illness Therapy - Cervical Dysplasia (FACIT-CD) into a Swedish context and evaluate its linguistic validity and reliability. METHODS: The Functional Assessment of Chronic Illness Therapy (FACIT) translation methodology was used, which consists of several steps including pilot testing of the FACIT-CD instrument through cognitive debriefing interviews. Ten women diagnosed with cervical dysplasia participated in the cognitive debriefing interviews. The internal consistency reliability of the Swedish FACIT-CD was estimated by Cronbach's alpha coefficient. Homogeneity of the items was evaluated by corrected item-total correlations. The sample consists of 34 women who were diagnosed with cervical dysplasia. RESULTS: The translation and cross-cultural adaptation went smoothly without any problems for the majority of the items. The cognitive debriefing interviews indicated that the Swedish FACIT-CD consists of relevant items, is easy to understand and complete, and has unambiguous and comprehensive response categories. The translation and cross-cultural adaptation resulted in a Swedish FACIT-CD, which is conceptually and semantically equivalent to the English version and linguistically valid. The total scale of the Swedish FACIT-CD exhibited good internal consistency reliability with a Cronbach's alpha coefficient of 0.84, and all of the subscales exhibited acceptable value between 0.71 and 0.81 except the Relationships subscale, which had a value of 0.67. Finally, all but four items exceeded the acceptable level for the corrected item-total correlations of ≥ 0.20. CONCLUSIONS: The Swedish FACIT-CD is conceptually and semantically equivalent to the English version and linguistically valid; further, it exhibits good internal consistency reliability.

Association between experiencing rape, police reporting, and self-reported health among women visiting three gynecology clinics in Sweden.

OBJECTIVE: To describe the frequency of police reporting among rape victims based on two hypotheses: (1) victims of rape more often report poor health than those who have not been victims of any abuse, and (2) victims who report abuse to the police are more likely to state poor self-reported health than those who do not report any abuse. DESIGN: Cross-sectional questionnaire study. SETTING: Three Swedish departments of obstetrics and gynecology. SAMPLE: From an original sample of 2,439 women, those who had experienced rape and those who had no history of abuse were included (n=1,319). METHOD: Analysis of associations between self-reported poor health, rape, and police reporting among rape victims were assessed by multivariate models adjusted for type of abuse, perpetrator, and sociodemographic factors. MAIN OUTCOME MEASURES: Odds ratios (ORs) for poor health among rape victims. RESULTS: Rape was seldom reported to the police (23.5%, 44/187). Both hypotheses were confirmed; rape victims more often state poor health than non-abused women (adjusted OR 3.9; 95% confidence interval (CI) 2.4-6.3), and women who had reported abuse to the police stated poor health more often than those who had not reported abuse to the police (adjusted OR 3.0; 95% CI 1.1-8.1). CONCLUSIONS: Three of four rape victims had not reported any abuse to the police, and those who had were more likely to report poor health. Rape myths are prevalent in society and affect how victims of sexual abuse are treated both by formal and informal support providers, which in turn may affect the recovery and health of victims. Our results send an urgent message to the current debate on sexual abuse against women: Why do women not report rape to the police?

Nullified: women's perceptions of being abused in health care.

OBJECTIVE: In a study performed with The NorVold Abuse Questionnaire (NorAQ) among Nordic gynecological patients, the prevalence of lifetime abuse in health care (AHC) was 13 - 28%. In the present study we chose a qualitative approach. Our aim was to develop a more in-depth understanding of AHC; as experienced by female Swedish patients. STUDY DESIGN: Qualitative interviews with 10 Swedish gynecological patients who had experienced AHC. The interviews were analyzed through Grounded Theory. RESULTS: Saturation was reached after six interviews. In the analyses four categories emerged which explain what AHC meant to the participating women: felt powerless, felt ignored, experienced carelessness, and experienced non-empathy. To be nullified is the core category that theoretically binds the four categories together. The women's narratives described intensive current suffering even though the abusive event had taken place several years ago. CONCLUSIONS: The fact that AHC exists is a critical dilemma for an institution that has the society's commission to cure and/or to alleviate pain and suffering. In their narratives, women described the experience of 'being nullified', a core category that embodies AHC.

Validation of the Abuse Screening Inventory (ASI).

AIMS: To assess the test-retest reliability and concurrent validity of the Abuse Screening Inventory (ASI) in a female sample. METHOD: The ASI comprises 16 items concerning four kinds of abuse: psychological, physical, and sexual abuse, and abuse in healthcare. A randomized sample of 699 women answered the ASI once. Six months later 53 of them answered the ASI again and were interviewed. To assess concurrent validity, answers in the interviews were considered as the gold standard and the ASI as the diagnostic test. RESULTS: The ASI presented good overall test-retest reliability ranging from 81% to 96% for separate items. The ASI separated very well abused from non-abused women. No false positive answers were found. Sensitivity ranged from 72% to 82% for items concerning abuse. CONCLUSION: The ASI is a short abuse screening questionnaire that had acceptable validity and test-retest reliability in a random female Swedish sample.

Are sociodemographic and regional and sample factors associated with prevalence of abuse?

BACKGROUND: The aims of the present study were: 1) to estimate the prevalence of emotional, physical and sexual abuse and abuse in the health care system, and 2) to study the associations between prevalence of abuse and sociodemographic and sample variables. METHODS: This cross-sectional study used a validated postal questionnaire in four Swedish samples; patients at three gynecologic clinics with different character and in different regions (n = 2439) and women in one randomized population sample (n = 1168). RESULTS: Any lifetime emotional abuse was reported by 16.8-21.4% of the women; physical abuse by 32.1-37.5%; sexual abuse by 15.9-17.0%; and abuse in the health care system by 14.0-19.7%. For 7-8% abuse had included life threats and 9-20% of all women in the study currently suffered from their experiences of abuse. Most women had not disclosed their background of abuse to the gynecologist. There were differences in sociodemographic variables between the four samples. Generally, in the multivariate analyses we found associations between prevalence of abuse and age, educational level, civil status and occupation, but no consistent association between prevalence of abuse and sample variables. CONCLUSION: Lifetime prevalence rates of the four kinds of abuse were high in all samples as measured by the NorVold Abuse Questionnaire (NorAQ), and 1/10-1/5 women in the study suffered currently from abusive experiences. In multivariate analyses prevalence of abuse was consistently associated with sociodemographic but not to sample variables.