"I hope I die. That is what I hope for": Qualitative study of lived experiences of mental health of Indian women living with HIV experiencing intersectional stigma.

Poor mental health due to stigma and discrimination has been well documented among women living with HIV. Although they often have other marginalized and stigmatized identities, little is known about their mental health as a result of experiencing multiple stigmas. Current narratives of mental health as a result of HIV-related stigma center on common mental health disorders such as anxiety and depression. However, biomedical diagnostic categories may not be as well known in all cultural and social contexts, and people may choose to express their distress in their own language. It is therefore important to listen to how women express their mental health concerns in their own language-their lived experiences-in order to best support them. To fill this research gap, semi-structured interviews were conducted in Kolkata, India, with 31 women living with HIV and 16 key informants. Data were coded and analyzed using thematic network analysis. The results showed that women suffered from poor mental health, which in turn affected their physical health. This happened through reduced adherence to medication, lowered CD4 counts, and the physical effects of stress, which could be perceived as prolonged. Participants described women's mental health concerns as worry, sadness, hopelessness, and fear, but biomedical diagnostic labels were rarely used. This allowed women to avoid additional stigmatization due to mental illness, which can attract some risk in this social context. As many women living with HIV experience poor mental health, they should be supported with a combination of psychosocial and psychological interventions. These include screening all women for mental illness and offering them mental health first aid. Those requiring additional support should be offered specialist psychotherapeutic and pharmacological care. This must be accompanied by stigma reduction interventions if they are to be successful in addressing the mental health needs of women living with HIV.

Psychosocial interventions to improve the mental health of survivors of human trafficking: a realist review.

More than 50 million people globally are subjected to modern slavery and human trafficking. Adverse mental health consequences of extreme exploitation are prevalent and often severe. We conducted a systematic and realist review on evaluations of psychosocial interventions for survivors of human trafficking. The review aimed to identify the influence of these interventions on the mental health and wellbeing of trafficked people and examine how they worked for which survivors in which contexts. We searched eight databases (MEDLINE, MEDLINE In-Process, Embase, PsycINFO, Global Health, CINAHL Plus, Web of Science, and Cochrane) for published evaluations of psychosocial interventions for survivors of human-trafficking. We followed a realist approach to analyse the data and report on the limitations of the studies identified. We identified four mechanisms of change as being triggered by the various intervention activities: (1) awareness and understanding; (2) trust, safety, and security; (3) agency, autonomy, empowerment, and social connections; and (4) self-reflection, self-expression, and self-care. Improving mental health after traumatic events is an ongoing, nonlinear process. Intervention effectiveness and transferability would benefit from more transparent programme theories and well articulated assumptions that identify the pathways to change.

'Our courage has grown': a grounded theory study of enablers and barriers to community action to address violence against women in urban India.

Transforming communities into supportive environments for women facing risks of violence requires community members to play an active role in addressing violence against women (VAW). We did a grounded theory study of enablers and barriers to community response to ongoing violence, sampling from programme areas of a non-governmental organisation (NGO)-led community mobilisation intervention in informal settlements in Mumbai, India. We held 27 focus group discussions and 31 semistructured interviews with 113 community members and 9 NGO staff, along with over 170 hours of field observation. We found that residents responded to violence in diverse ways, ranging from suicide prevention to couple mediation to police and NGO referral. Enabling and constraining factors fit into a social ecological model containing intrapersonal, immediate social network, and wider societal levels. We identified four themes interlinking factors: legitimacy of action, collective power, protection against risk and informal leadership. Legitimacy of action was negotiated in the context of individual disputes, making community members question not only whether VAW was 'wrong', but who was 'wrong' in specific disputes. Collective power through neighbourhood solidarity was key to action but could be curtailed by violent gang crime. Interveners in incidents of VAW turned out to need significant physical, social and legal protection against reprisal. However, repeat interveners could become informal leaders wielding influential prosocial reputations that incentivised and facilitated action. Our model integrates multiple perspectives on community action into one analytical framework, which can be used by implementers to ensure that community members receive encouragement, support and protection to act.

Mixed studies review of domestic violence in the lives of women affected by HIV stigma.

We conducted a mixed studies review to examine domestic violence and stigma against women affected by HIV. We searched Medline, Web of Science, PsycINFO and EMBASE databases with no starting date limit. Studies that reported on experiences of stigma, discrimination, or domestic violence against women affected by HIV in any country were included. Because the review focused on HIV stigma-related violence, we only included studies that reported violence following an HIV diagnosis or at the time of HIV testing. A total 1056 records were screened; 89 articles were assessed for full text eligibility and 49 studies were selected for evidence synthesis. A convergent approach was used and study findings were analysed thematically. Four broad themes emerged: (1) being affected by HIV increases domestic violence, (2) supportive reactions from partners, (3) HIV stigma is associated with domestic violence, and (4) domestic violence associated with HIV-stigma is gendered. Research gaps identified included the burden of intersectional stigma of domestic violence and HIV, and the mediating role of HIV stigma in domestic violence for women with HIV, highlighting the need for further research in this area to reduce violence against women living with HIV.

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

BACKGROUND: Help-seeking for intimate partner violence (IPV) requires women to disclose their experiences. For policymakers, low help-seeking threatens the United Nations Sustainable Development Goals (SDGs) of gender equality, good health, and wellbeing. In India, the Prevention of Domestic Violence Against Women Act (PWDVA 2005) was implemented in 2006. Using two rounds of the India National Family Health Survey (NFHS), one before and one after implementation, we examined the prevalence, pattern, and sociodemographic and socioeconomic factors associated with formal help-seeking for IPV. METHODS: We used univariable and multivariable logistic regression models to assess the prevalence of help-seeking for IPV in the past 12 months and examined associations with different forms of IPV and sociodemographic factors. RESULTS: The proportion of ever-married women aged 15-49 years who reported physical, sexual, or emotional IPV in the last 12 months increased from 23% in NFHS-3 (2005-2006) to 25% in NFHS-4 (2015-2016). In both surveys, few women sought help. Informal sources of help were preferred over formal sources, which declined from NFHS-3 to NFHS-4 (any help: 24.5 to 13.8%; informal help: 24.1 to 13.4%; and formal help: 1.2 to 1.1%). Women from lower castes and women with children were less likely to seek formal help. Over the two surveys, the odds of formal help-seeking for sexual IPV in the past 12 months remained similar (NFHS-3 aOR 1.9, 95% CI 1.4, 2.5. NFHS-4 aOR 1.9, 95% CI 1.4, 2.6). The odds were slightly higher for emotional IPV (NFHS-3 aOR 2.5, 95% CI 1.8, 3.3. NFHS-4 aOR 2.7, 95% CI 2.0, 3.7) and spousal control (NFHS-3 aOR 2.0, 95% CI 1.4, 3.0. NFHS-4 aOR 2.3, 95% CI: 1.4, 3.7). CONCLUSIONS: Low disclosure and help-seeking impact a country's social, cultural, economic, and political progress. The PWDVA did not appear to result in increases in help-seeking among women in India who experienced IPV. Further work is needed to understand barriers to help-seeking in the presence of public policy efforts to support women affected by IPV. These may include poor implementation and enforcement of Policy, as well as normalization and justification of gender-based violence. We recommend a deeper understanding of help-seeking across all systems to establish a barometer of help-seeking. An increase in formal or informal help-seeking is an indicator of reduced tolerance of IPV and the enabling environment of the PWDVA 2005 for tracking progress toward the SDGs of gender equality and the eradication of all forms of gender-based violence and discrimination.

Feeding, caregiving practices, and developmental delay among children under five in lowland Nepal: a community-based cross-sectional survey.

BACKGROUND: Nurturing care, including adequate nutrition, responsive caregiving and early learning, is critical to early childhood development. In Nepal, national surveys highlight inequity in feeding and caregiving practices for young children. Our objective was to describe infant and young child feeding (IYCF) and cognitive and socio-emotional caregiving practices among caregivers of children under five in Dhanusha district, Nepal, and to explore socio-demographic and economic factors associated with these practices. METHODS: We did a cross-sectional analysis of a subset of data from the MIRA Dhanusha cluster randomised controlled trial, including mother-child dyads (N = 1360), sampled when children were median age 46 days and a follow-up survey of the same mother-child dyads (N = 1352) when children were median age 38 months. We used World Health Organization IYCF indicators and questions from the Multiple Indicator Cluster Survey-4 tool to obtain information on IYCF and cognitive and socio-emotional caregiving practices. Using multivariable logistic regression models, potential explanatory household, parental and child-level variables were tested to determine their independent associations with IYCF and caregiving indicators. RESULTS: The prevalence of feeding indicators varied. IYCF indicators, including ever breastfed (99%), exclusive breastfeeding (24-hour recall) (89%), and vegetable/fruit consumption (69%) were common. Problem areas were early initiation of breastfeeding (16%), colostrum feeding (67%), no pre-lacteal feeding (53%), timely introduction of complementary feeding (56%), minimum dietary diversity (49%) and animal-source food consumption (23%). Amongst caregiving indicators, access to 3+ children's books (7%), early stimulation and responsive caregiving (11%), and participation in early childhood education (27%) were of particular concern, while 64% had access to 2+ toys and 71% received adequate care. According to the Early Child Development Index score, only 38% of children were developmentally on track. Younger children from poor households, whose mothers were young, had not received antenatal visits and delivered at home were at higher risk of poor IYCF and caregiving practices. CONCLUSIONS: Suboptimal caregiving practices, inappropriate early breastfeeding practices, delayed introduction of complementary foods, inadequate dietary diversity and low animal-source food consumption are challenges in lowland Nepal. We call for urgent integrated nutrition and caregiving interventions, especially as interventions for child development are lacking in Nepal.

Mechanisms for community prevention of violence against women in low- and middle-income countries: A realist approach to a comparative analysis of qualitative data.

Growing evidence suggests that community-based interventions in low- and middle-income countries (LMICs) can effectively address harmful social norms that promote or sustain gender inequality and drive violence against women (VAW). However, understanding what actions communities are already taking to address harmful social norms and prevent VAW is an essential first step for intervention development. Towards this goal, drawing on collective action theory, we conducted a realist analysis of secondary qualitative data collected with communities in India, Afghanistan, Peru and Rwanda. We coded interview and focus-group data from 232 participants to identify the contexts, mechanisms and outcomes (CMO) relevant for community action. We synthesized CMO configurations from each dataset into a conceptual framework composed of three middle-range theories of mechanisms driving community action to prevent VAW in LMICs. Our results highlight the importance of dedicated spaces for discussing VAW, VAW leaders as positive role models, and community perceptions of VAW as a problem worthy of intervention. In Rwanda and Peru, there was strong evidence to support the operation of these mechanisms. Contextual factors, including national and local policy and programmes targeting VAW, activated mechanisms that led to community action. In India and Afghanistan, evidence for the presence of these mechanisms was weaker, with social norms about women's position and violence being a private family matter preventing communities from addressing violence. Despite contextual differences, our data demonstrated communities in all four settings were somewhere along a pathway of change towards VAW prevention. This supports the need to build future prevention interventions on pre-existing mechanisms that trigger community action, rather than implementing existing interventions without local adaptation. Our conceptual framework serves as a tool for assessing these mechanisms of community action as part of intervention development research, centring community knowledge and fostering local ownership for more relevant and sustainable VAW prevention interventions.

Factors associated with women's healthcare decision-making during and after pregnancy in urban slums in Mumbai, India: a cross-sectional analysis.

BACKGROUND: Understanding factors associated with women's healthcare decision-making during and after pregnancy is important. While there is considerable evidence related to general determinants of women's decision-making abilities or agency, there is little evidence on factors associated with women's decision-making abilities or agency with regards to health care (henceforth, health agency), especially for antenatal and postnatal care. We assessed women's health agency during and after pregnancy in slums in Mumbai, India, and examined factors associated with increased participation in healthcare decisions. METHODS: Cross-sectional data were collected from 2,630 women who gave birth and lived in 48 slums in Mumbai. A health agency module was developed to assess participation in healthcare decision-making during and after pregnancy. Linear regression analysis was used to examine factors associated with increased health agency. RESULTS: Around two-thirds of women made decisions about perinatal care by themselves or jointly with their husband, leaving about one-third outside the decision-making process. Participation increased with age, secondary and higher education, and paid employment, but decreased with age at marriage and household size. The strongest associations were with age and household size, each accounting for about a 0.2 standard deviation difference in health agency score for each one standard deviation change (although in different directions). Similar differences were observed for those in paid employment compared to those who were not, and for those with higher education compared to those with no schooling. CONCLUSION: Exclusion of women from maternal healthcare decision-making threatens the effectiveness of health interventions. Factors such as age, employment, education, and household size need to be considered when designing health interventions targeting new mothers living in challenging conditions, such as urban slums in low- and middle-income countries.

Intimate partner violence against women with disability and associated mental health concerns: a cross-sectional survey in Mumbai, India.

OBJECTIVES: The risk of intimate partner violence (IPV) against women with disability is believed to be high. We aimed to compare the prevalence of past-year IPV against women with and without functional difficulties in urban informal settlements, to review its social determinants and to explore its association with mental health. DESIGN: Cross-sectional survey. SETTING: Fifty clusters within four informal settlements. PARTICIPANTS: 5122 women aged 18-49 years. PRIMARY AND SECONDARY OUTCOME MEASURES: We used the Washington Group Short Set of Questions to assess functional difficulties. IPV in the past year was described by binary composites of questions about physical, sexual and emotional violence. We screened for symptoms of depression using the Patient Health Questionnaire-9 and of anxiety using the Generalised Anxiety Disorder-7. Multivariable logistic regression models examined associations between functional difficulties, IPV and mental health. RESULTS: 10% of participants who screened positive for functional disability had greater odds of experiencing physical or sexual IPV (adjusted OR (AOR) 1.68, 95% CI 1.23 to 2.29) and emotional IPV (1.52, 95% CI 1.16 to 2.00) than women who screened negative. Women who screened positive for functional disability had greater odds than women who screened negative of symptoms suggesting moderate or severe anxiety (AOR 2.50, 95% CI 1.78 to 3.49), depression (2.91, 95% CI 2.13 to 3.99) and suicidal thinking (AOR 1.94, 95% CI 1.50 to 2.50). CONCLUSIONS: The burden of IPV fell disproportionately on women with functional difficulties, who were also more likely to screen positive for common mental disorder. Public health initiatives need to respond at local and national levels to address the overlapping and mutually reinforcing determinants of violence, while existing policy needs to be better utilised to ensure protection for the most vulnerable.

Improving the mental health of women intimate partner violence survivors: Findings from a realist review of psychosocial interventions.

BACKGROUND: Intimate partner violence (IPV) is highly prevalent and is associated with a range of mental health problems. A broad range of psychosocial interventions have been developed to support the recovery of women survivors of IPV, but their mechanisms of action remain unclear. METHODS: Realist review following a prospectively published protocol in PROSPERO (CRD42018114207) and reported using the Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMSES) guidelines. RESULTS: Evidence was extracted from 60 reviews and triangulated in expert consultations. Mechanisms of action were categorised as either associated with intervention design and delivery or with specific intervention components (access to resources and services; safety, control and support; increased knowledge; alterations to affective states and cognitions; improved self-management; improved family and social relations). CONCLUSIONS: Findings suggest that psychosocial interventions to improve the mental health of women survivors of IPV have the greatest impact when they take a holistic view of the problem and provide individualised and trauma-informed support.

Characteristics and birth outcomes of pregnant adolescents compared to older women: An analysis of individual level data from 140,000 mothers from 20 RCTs.

BACKGROUND: Adolescence is a critical period of maturation when nutrient needs are high, especially among adolescents entering pregnancy. Using individual-level data from 140,000 participants, we examined socioeconomic, nutrition, and pregnancy and birth outcomes for adolescent mothers (10-19 years) compared to older mothers in low and middle-income countries. METHODS: This study was conducted between March 16, 2018 and May 25, 2021. Data were obtained from 20 randomised controlled trials of micronutrient supplementation in pregnancy. Stratified analyses were conducted by age (10-14 years, 15-17 years, 18-19 years, 20-29 years, 30-39 years, 40+ years) and geographical region (Africa, Asia). Crude and confounder-adjusted means, prevalence and relative risks of pregnancy, nutrition and birth outcomes were estimated using multivariable linear and log-binomial regression models with 95% confidence intervals. FINDINGS: Adolescent mothers comprised 31.6% of our data. Preterm birth, small-for-gestational age (SGA), low birthweight (LBW) and newborn mortality followed a U-shaped trend in which prevalence was highest among the youngest mothers (10-14 years) and then reduced gradually, but increased again for older mothers (40+ years). When compared to mothers aged 20-29 years, there was a 23% increased risk of preterm birth, a 60% increased risk of perinatal mortality, a 63% increased risk of neonatal mortality, a 28% increased risk of LBW, and a 22% increased risk of SGA among mothers 10-14 years. Mothers 40+ years experienced a 22% increased risk of preterm birth and a 103% increased risk of stillbirth when compared to the 20-29 year group. INTERPRETATION: The youngest and oldest mothers suffer most from adverse pregnancy and birth outcomes. Policy and programming agendas should consider both biological and socioeconomic/environmental factors when targeting these populations. FUNDING: Bill and Melinda Gates Foundation (Grant No: OP1137750).

Risk factors for violence against women in high-prevalence settings: a mixed-methods systematic review and meta-synthesis.

INTRODUCTION: Violence against women (VAW) affects one in three women globally. In some countries, women are at much higher risk. We examined risk factors for VAW in countries with the highest 12-month prevalence estimates of intimate partner violence (IPV) to develop understanding of this increased risk. METHODS: For this systematic review, we searched PUBMED, CINAHL, PROQUEST (Middle East and North Africa; Latin America and Iberia; East and South Asia), Web of Science, EMBASE and PsycINFO (Ovid) for records published between 1 January 2000 and 1 January 2021 in English, French and Spanish. Included records used quantitative, qualitative, or mixed-methods, reported original data, had VAW as the main outcome, and focused on at least one of 23 countries in the highest quintile of prevalence figures for women's self-reported experiences of physical and/or sexual violence in the past 12 months. We used critical interpretive synthesis to develop a conceptual model for associations between identified risk factors and VAW. RESULTS: Our search identified 12 044 records, of which 241 were included for analysis (2 80 360 women, 40 276 men, 274 key informants). Most studies were from Bangladesh (74), Uganda (72) and Tanzania (43). Several quantitative studies explored community-level/region-level socioeconomic status and education as risk factors, but associations with VAW were mixed. Although fewer in number and representing just one country, studies reported more consistent effects for community-level childhood exposure to violence and urban residence. Theoretical explanations for a country's high prevalence point to the importance of exposure to other forms of violence (armed conflict, witnessing parental violence, child abuse) and patriarchal social norms. CONCLUSION: Available evidence suggests that heightened prevalence of VAW is not attributable to a single risk factor. Multilayered and area-level risk analyses are needed to ensure funding is appropriately targeted for countries where VAW is most pervasive. PROSPERO REGISTRATION NUMBER: The review is registered with PROSPERO (CRD42020190147).

Domestic Coercive Control and Common Mental Disorders Among Women in Informal Settlements in Mumbai, India: A Cross-Sectional Survey.

Coercive control behaviors central to the abuse of power appear more frequent than other types of domestic violence, but little is known about its frequency, features, and consequences for women in India. We aimed to examine the prevalence of domestic coercive control and its association with physical, sexual, and emotional domestic violence in the preceding year and symptoms of depression, anxiety, and suicidal thinking. In a cross-sectional survey, we interviewed 4,906 ever-married women aged 18-49 years living in urban informal settlements in Mumbai, India. We developed a 24-item scale of coercive control, assessed physical, sexual, and emotional violence using existing questions, and screened for symptoms of depression with the Patient Health Questionnaire (PHQ9), anxiety with the Generalized Anxiety Disorder (GAD7) questionnaire, and suicidal thinking with questions developed by the World Health Organization. Estimates involved univariable and multivariable logistic regression models and the prediction of marginal effects. The prevalence of domestic coercive control was 71%. In total, 23% of women reported domestic violence in the past 12 months (emotional 19%, physical 13%, sexual 4%). Adjusted models suggested that women exposed to controlling behavior had greater odds of surviving emotional (aOR 2.1; 95% CI 1.7, 2.7), physical (1.4; 1.0, 1.9), and sexual (1.8; 1.1, 3.0) domestic violence in the past 12 months; and higher odds of a positive screen for moderate or severe depression (1.7; 1.3, 2.2), anxiety (2.1; 1.3, 3.1), and suicidal thinking (1.7; 1.2, 2.3), and increased with each additional indicator of coercive control behavior. When women reported 24 indicators of coercive control, the adjusted predicted proportion with moderate or severe depressive symptoms was 60%, anxiety 42%, and suicidal thinking 17%. Inclusion of coercive control in programs to support domestic violence, would broaden our understanding of domestic abuse to resemble most victims experience and improve interventions.

Mental health of women and children experiencing family violence in conflict settings: a mixed methods systematic review.

BACKGROUND: Armed conflict has significant impacts on individuals and families living in conflict-affected settings globally. Scholars working to prevent violence within families have hypothesised that experiencing armed conflict leads to an increase in family violence and mental health problems. In this review, we assessed the prevalence of family violence in conflict settings, its association with the mental health of survivors, moderating factors, and the importance of gender relations. METHODS: Following PRISMA guidelines, we systematically reviewed quantitative and qualitative studies that assessed the prevalence of family violence and the association between family violence and mental health problems, within conflict settings (PROSPERO reference CRD42018114443). RESULTS: We identified 2605 records, from which 174 full text articles were screened. Twenty-nine studies that reported family violence during or up to 10 years after conflict were eligible for inclusion. Twenty one studies were quantitative, measuring prevalence and association between family violence and mental health problems. The studies were generally of high quality and all reported high prevalence of violence. The prevalence of violence against women was mostly in the range of 30-40%, the highest reported prevalence of physical abuse being 78.9% in Bosnia and Herzegovina. For violence against children, over three-quarters had ever experienced violence, the highest prevalence being 95.6% in Sri Lanka. Associations were found with a number of mental health problems, particularly post-traumatic stress disorder. The risk varied in different locations. Eight qualitative studies showed how men's experience of conflict, including financial stresses, contributes to their perpetration of family violence. CONCLUSIONS: Family violence was common in conflict settings and was associated with mental health outcomes, but the studies were too heterogenous to determine whether prevalence or risk was greater than in non-conflict settings. The review highlights an urgent need for more robust data on perpetrators, forms of family violence, and mental health outcomes in conflict-affected settings in order to help understand the magnitude of the problem and identify potential solutions to address it.

Relationship-building around a policy decision-support tool for urban health.

Contemporary challenges linked to public health and climate change demand more effective decision-making and urban planning practices, in particular by taking greater account of evidence. In order to do this, trust-building relationships between scientists and urban practitioners through collaborative research programmes is required. Based on a policy-relevant research project, Complex Urban Systems for Sustainability and Health (CUSSH), this project aims to support the transformation of cities to meet environmental imperatives and to improve health with a quantitative health impact assessment. A case study in Rennes, France, focuses on the role of a policy decision-support tool in the production and use of knowledge to support evidence-informed decision-making. Although the primary objective of informing decision-making through evidence-based science is not fulfilled, the use of a decision-making support tool can lay the foundations for relationship-building. It can serve as a support for boundary-spanning activities, which are recognised for their effectiveness in linking science to action. This case study illustrates that the path of knowledge transfer from science to policy can be challenging, and the usefulness of using models may not be where it was thought to have been.

Intersectional tension: a qualitative study of the effects of the COVID-19 response on survivors of violence against women in urban India.

OBJECTIVES: There is a concern worldwide that efforts to address the SARS-CoV-2 pandemic have affected the frequency and intensity of domestic violence against women. Residents of urban informal settlements faced particularly stringent conditions during the response in India. Counsellors spoke with registered survivors of domestic violence in Mumbai, with two objectives: to understand how the pandemic and subsequent lockdown had changed their needs and experiences, and to recommend programmatic responses. DESIGN: Qualitative interviews and framework analysis. SETTING: A non-government support programme for survivors of violence against women, providing services mainly for residents of informal settlements. PARTICIPANTS: During follow-up telephone counselling with survivors of violence against women who had previously registered for support and consented to the use of information in research, counsellors took verbal consent for additional questions about the effects of COVID-19 on their daily life, their ability to speak with someone, and their counselling preferences. Responses were recorded as written notes. RESULTS: The major concerns of 586 clients interviewed between April and July 2020 were meeting basic needs (financial stress, interrupted livelihoods and food insecurity), confinement in small homes (family tensions and isolation with abusers) and limited mobility (power imbalances in the home and lack of opportunity for disclosure and stress relief). A major source of stress was the increased burden of unpaid domestic care, which fell largely on women. CONCLUSION: The COVID-19 pandemic has increased the burden of poverty and gendered unpaid care. Finance and food security are critical considerations for future response, which should consider inequality, financial support, prioritising continued availability of services for survivors of violence and expanding access to social networks. Decision-makers must be aware of the gendered, intersectional effects of interventions and must include residents of informal settlements who are survivors of domestic violence in the planning and implementation of public health strategies.

Evaluation of the Hindi version of the London Measure of Unplanned Pregnancy among pregnant and postnatal women in urban India.

BACKGROUND: Valid and reliable measures such as London Measure of Unplanned Pregnancy (LMUP) are imperative for understanding fertility-related behaviors and estimating unintended pregnancy. The aim of this study was to validate the LMUP in the Hindi language for a wider reach in India. METHODS: An interviewer administered version of the LMUP was translated and pretested in Hindi. The LMUP was field tested with married women in the reproductive age group across forty informal settlements in Mumbai in the post intervention census of a cluster randomized control trial to improve the health of women and children. Analyses involved the full sample and sub-groups according to time-from-conception. Reliability (internal consistency) was assessed using Cronbach's alpha, inter-item correlations, and item-rest correlations. Construct validity was assessed by hypothesis testing and confirmatory factor analysis. RESULTS: 4991 women were included in the study (1180 were pregnant, 2126 in their first- and 1685 in their second postnatal year). LMUP item completion rates were 100 % and the full range of LMUP scores was captured. Reliability: the scale was internally consistent (Cronbach's α = 0.84), inter-item correlations were positive, and item-rest correlations were above 0.2 for all items except item six (0.07). Construct validity: hypotheses were met, and confirmatory factor analysis showed that a one-factor model was a good fit for the data, confirming unidimensional measurement. The sub-group analysis (by pregnant, first-, and second postnatal year) showed that the psychometric properties of the LMUP were similar across the groups. In terms of LMUP scores, the women in the postnatal groups were very slightly, but significantly, more likely to have an LMUP score of 10 + compared to pregnant women; the difference between the first and second postnatal year was not significant. CONCLUSIONS: The Hindi LMUP is valid and reliable measure of pregnancy intention that may be used in India. TRIAL REGISTRATION: This study is registered with ISRCTN, number ISRCTN56183183, and Clinical Trials Registry of India, number CTRI/2012/09/003004.

Modelling collective action to change social norms around domestic violence: social dilemmas and the role of altruism.

Interventions promoting collective action have been used to prevent domestic violence in a range of settings, but their mechanisms of operation remain unclear. We formalise and combine feminist theoretical approaches to domestic violence into a game-theoretic model of women's collective action to change gendered social norms and outcomes. We show that social norms create a social dilemma in which it is individually rational for women to abstain from action to prevent domestic violence among neighbours, but all women suffer negative consequences if none take action. Promoting altruism among women can overcome the social dilemma. Discouraging women from tolerating domestic violence, imposing additional external punishment on men for perpetrating violence, or lowering costs to women of taking action against violence may not work or even backfire. We invite researchers on community mobilisation to use our framework to frame their understandings of collective action to prevent domestic violence.

Developing a programme theory for a transdisciplinary research collaboration: Complex Urban Systems for Sustainability and Health.

Background: Environmental improvement is a priority for urban sustainability and health and achieving it requires transformative change in cities. An approach to achieving such change is to bring together researchers, decision-makers, and public groups in the creation of research and use of scientific evidence. Methods: This article describes the development of a programme theory for Complex Urban Systems for Sustainability and Health (CUSSH), a four-year Wellcome-funded research collaboration which aims to improve capacity to guide transformational health and environmental changes in cities. Results: Drawing on ideas about complex systems, programme evaluation, and transdisciplinary learning, we describe how the programme is understood to "work" in terms of its anticipated processes and resulting changes. The programme theory describes a chain of outputs that ultimately leads to improvement in city sustainability and health (described in an 'action model'), and the kinds of changes that we expect CUSSH should lead to in people, processes, policies, practices, and research (described in a 'change model'). Conclusions: Our paper adds to a growing body of research on the process of developing a comprehensive understanding of a transdisciplinary, multiagency, multi-context programme. The programme theory was developed collaboratively over two years. It involved a participatory process to ensure that a broad range of perspectives were included, to contribute to shared understanding across a multidisciplinary team. Examining our approach allowed an appreciation of the benefits and challenges of developing a programme theory for a complex, transdisciplinary research collaboration. Benefits included the development of teamworking and shared understanding and the use of programme theory in guiding evaluation. Challenges included changing membership within a large group, reaching agreement on what the theory would be 'about', and the inherent unpredictability of complex initiatives.

Economic abuse and its associations with symptoms of common mental disorders among women in a cross-sectional survey in informal settlements in Mumbai, India.

BACKGROUND: Domestic violence takes a range of interconnected forms, of which economic abuse is common, but less studied than others. We examine the prevalence of economic abuse, its determinants, and its association with symptoms of depression, anxiety, and suicidal ideation. METHODS: Our cross-sectional survey in informal settlement areas in Mumbai, India, asked women aged 18-49 years 15 questions about acquisition, use, and maintenance of economic resources, demographic and socioeconomic factors, and physical, sexual, and emotional violence. We administered the Patient Health Questionnaire 9 (PHQ-9) and Generalised Anxiety Disorder 7 (GAD-7) scales and asked about suicidal thinking. Determinants of economic abuse and its associations with positive screens for depression and anxiety were explored in univariable and multivariable logistic regression models. RESULTS: Of 4906 ever-married women respondents, 23% reported at least one form of economic abuse by either an intimate partner or another family member. The commonest were denial of property rights (10%), not being trusted with money (8%), and coercive appropriation of belongings (7%). Economic abuse was more commonly reported by widowed, separated, or divorced women than by married women (aOR 12.4; 95% CI 6.4, 24.1), and when their partners used alcohol or drugs (aOR 1.4; 95% CI 1.2-1.7). Women had greater odds of reporting economic abuse if they had suffered emotional (aOR 6.3; 95% CI 5.0-7.9), physical (aOR 1.9; 95% CI 1.4-2.6), or sexual violence (aOR 5.4; 95% CI 3.6-8.1) in the preceding 12 months. Economic abuse was independently associated with positive screens for moderate-severe depression (aOR 2.6; 95% CI 2.0-3.4), anxiety (aOR 2.7; 95% CI 1.9-3.8), and suicidal ideation (aOR 2.2; 95% CI 1.5-3.1). The odds of anxiety and depression increased with each additional form of economic abuse. DISCUSSION: To our knowledge, this is the first community-based study in India of the prevalence of economic abuse and its associations with symptoms of common mental disorders. It provides empirical support for the idea that economic abuse is at least as harmful to women's mental health as physical violence. Surveys should include questions on economic abuse and prevention and intervention strategies need to help survivors to understand its forms.