Factors affecting delayed and non-receipt of healthcare during the COVID-19 pandemic for women in rural Maharashtra, India:Evidence from a cross-sectional study

BACKGROUND: Pathways to low healthcare utilisation under the COVID-19 pandemic are not well understood. This study aims to understand women's concerns about the health system's priorities and their increased burden of domestic responsibilities during COVID-19 as predictors of delayed or non-receipt of needed care for themselves or their children. METHODS: We surveyed married women in rural Maharashtra, India (N = 1021) on their health and economic concerns between Feb 1 and March 26, 2021. This study period was when India emerged from the first wave of the pandemic, which had severely impacted the health systems, and before the second—even more devastating wave had started. We captured if women were concerned about access to non-COVID health services due to healthcare being directed solely to COVID-19) (exposure 1) and whether their domestic responsibilities increased during the pandemic (exposure 2). Our outcomes included women's reports on whether they delayed healthcare seeking (secondary outcome and mediator) and whether they received healthcare for themselves or their children when needed (primary outcome). We conducted adjusted regression models on our predictor variables with each outcome and assessed the mediation effects of delayed healthcare seeking for each of the exposure variables. FINDINGS: We found that women who were concerned that healthcare was directed solely towards COVID-19 were more likely not to receive healthcare when needed (Adjusted Risk Ratio [ARR] = 1.49, 95% CI = 1.14, 1.95). We also found that women whose domestic care burden increased under the pandemic were more likely to delay healthcare seeking (ARR = 1.84, 95% CI = 1.05, 3.21). Delayed healthcare seeking mediated the associations between each of our exposure variables with our outcome variable, non-receipt of needed healthcare. INTERPRETATION: Our findings suggested that women's perceptions of healthcare systems and their domestic labour burdens affected healthcare seeking during the pandemic in India, even before the second wave of COVID-19 incapacitated the health system. Support for women and health systems is needed to ensure healthcare uptake during crises. FUNDING: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, USA (grant numbers: R01HD084453- 01A1 and RO1HD61115); Department of Biotechnology, Government of India (grant #BT/IN/US/01/BD/2010); the EMERGE project (Bill and Melinda Gates Foundation Grants: OPP1163682 and INV018007; PI Anita Raj), and Bill and Melinda Gates Foundation Grant number INV-002967

Violence against women with disability in Mumbai, India: a qualitative study

"We conducted open-ended interviews with 15 women with disability who had reported violence in a preceding survey. Emergent themes included a lack of acceptance by families, the systematic formation of a dependent self-image, and an expectation of limited achievement. Emotional violence was particularly emphasized, as was perceived structural violence stemming from social norms, which led to exclusion and vulnerability. Violence in the natal home was an issue that had been relatively uninvestigated.

The associations of everyday and major discrimination exposure with violence and poor mental health outcomes during the COVID-19 pandemic

Research on discrimination and risks for violence and mental health issues under the pandemic is notably absent. We examined the relative effects of perceived everyday discrimination (e.g., poorer service, disrespectful treatment in a typical week) and major experiences of race-based discrimination (e.g., racial/ethnic discrimination in housing or employment at any point in the lifetime) on experiences of violence and the PHQ-4 assessment of symptoms of depression and anxiety under the pandemic. We analyzed state-representative cross-sectional survey data from California adults (N = 2114) collected in March 2021. We conducted multivariate regression models adjusting for age, race/ethnicity, gender, sexual identity, income, and disability. One in four Californians (26.1%) experienced everyday discrimination in public spaces, due most often to race/ethnicity and gender. We found that everyday discrimination was significantly associated with past year physical violence (single form Adjusted Odds Ratio [AOR] 5.0, 95% CI 2.5–10.3; multiple forms AOR 2.6, 95% CI 1.1–5.8), past year sexual violence (multiple forms AOR 2.5, 95% CI 1.4–4.4), and mental health symptoms (e.g., severe symptoms, multiple forms AOR 3.3, 95% CI 1.6–6.7). Major experiences of race-based discrimination (reported by 10.0% of Californians) were associated with past year sexual violence (AOR 2.0, 95% CI 1.1–3.8) and severe mental health symptoms (AOR 2.7, 95% CI 1.2–6.2). Non-race-based major discrimination (reported by 23.9% of Californians) was also associated with violence and mental health outcomes Everyday discrimination, more than major experiences of discrimination, was associated with higher risk for violence and poor mental health outcomes during the pandemic. Non-race-based forms of major discrimination independently were also associated with these negative outcomes. Findings indicate that efforts to reduce and ultimately eliminate discrimination should be a focus of public health and COVID-19 rebuilding efforts

Assessing the impact of CHARM2, a family planning program on gender attitudes, intimate partner violence, reproductive coercion, and marital quality in India

Using a two-armed cluster randomised controlled trial, CHARM2 (Counselling Husbands to Achieve Reproductive health and Marital equity), a 5-session gender equity and family planning intervention for couples in rural India, showed an impact on family planning outcomes in primary trial analyses. This study examines its effects on gender-equitable attitudes, intimate partner violence, reproductive coercion, and marital quality. We used multilevel mixed-effects models to assess the intervention impact on each outcome. Both male (aIRR at 9 months: 0.64, C.I.: 0.45,0.90; aIRR at 18 months: 0.25, C.I.: 0.18,0.39) and female (aIRR at 9 months: 0.57, C.I.: 0.46,0.71; aIRR at 18 months: 0.38, C.I.: 0.23,0.61) intervention participants were less likely than corresponding control participants to endorse attitudes accepting physical IPV at 9- and 18-month follow-ups. Men in the intervention, compared to those in the control condition, reported more gender-equitable attitudes at 9- and 18 months (ß at 9 months: 0.13, C.I.: 0.06,0.20; ß at 18 months: 0.26, C.I.: 0.19,0.34) and higher marital quality at the 18-month follow-up (ß: 0.03, C.I.: 0.01,0.05). However, we found no effects on women’s experiences of IPV, reproductive coercion, or marital quality. CHARM2 shows promise in improving men’s and women’s attitudes towards gender equality and male perceptions of marital quality. Still, IPV and reproductive coercion reductions may require more intensive programming than that provided within this 5-session model focused on family planning

Optimizing the construction of outcome measures for impact evaluations of intimate partner violence prevention interventions

Most impact evaluations of intimate partner violence (IPV) prevention interventions use binary measures of "any" versus "no" physical and/or sexual IPV as their primary outcome measure, missing opportunities to capture nuance. In this study, we reanalyzed secondary data from six randomized controlled trials conducted in low- and middle-income countries-Bandebereho (Rwanda), Becoming One (Uganda), Indashyikirwa (Rwanda), MAISHA CRT01, MAISHA CRT02 (Tanzania), Stepping Stones Creating Futures (South Africa), and Unite for a Better Life (Ethiopia), to assess how different conceptualizations and coding of IPV variables can influence interpretations of the impact of an intervention. We compared the standard outcome measures to new measures that reflect the severity and intensity of violence and whether interventions prevent new cases of IPV or reduce or stop ongoing violence. Results indicate that traditional binary indicators masked some of the more subtle intervention effects, and the use of the new indicators allowed for a better understanding of the impacts of the interventions. Conclusions on whether a program is perceived "to work" are highly influenced by the IPV outcomes that the investigators choose to report, and how they are measured and coded. Lack of attention to outcome choice and measurement could lead to prematurely abandoning strategies useful for violence reduction or missing essential insights into how programs may or may not affect IPV. While these results must be interpreted cautiously, given differences in intervention types, the underlying prevalence of violence, sociodemographic factors, sample sizes, and other contextual differences across the trial sites, they can help us move toward a new approach to reporting multiple outcomes that allow us to unpack the "impact" of an intervention by assessing intervention effect by the severity of violence and type of prevention, whether primary and secondary

Violence against women with disability in Mumbai, India: a qualitative study

"We conducted open-ended interviews with 15 women with disability who had reported violence in a preceding survey. Emergent themes included a lack of acceptance by families, the systematic formation of a dependent self-image, and an expectation of limited achievement. Emotional violence was particularly emphasized, as was perceived structural violence stemming from social norms, which led to exclusion and vulnerability. Violence in the natal home was an issue that had been relatively uninvestigated.

Prevention of violence against women and girls: a cost-effectiveness study across 6 low- and middle-income countries

Background Violence against women and girls (VAWG) is a human rights violation with social, economic, and health consequences for survivors, perpetrators, and society. Robust evidence on economic, social, and health impact, plus the cost of delivery of VAWG prevention, is critical to making the case for investment, particularly in low- and middle-income countries (LMICs) where health sector resources are highly constrained. We report on the costs and health impact of VAWG prevention in 6 countries. Methods and findings We conducted a trial-based cost-effectiveness analysis of VAWG prevention interventions using primary data from 5 randomised controlled trials (RCTs) in sub-Saharan Africa and 1 in South Asia. We evaluated 2 school-based interventions aimed at adolescents (11 to 14 years old) and 2 workshop-based (small group or one to one) interventions, 1 community-based intervention, and 1 combined small group and community-based programme all aimed at adult men and women (18+ years old). All interventions were delivered between 2015 and 2018 and were compared to a do-nothing scenario, except for one of the school-based interventions (government-mandated programme) and for the combined intervention (access to financial services in small groups). We computed the health burden from VAWG with disability-adjusted life year (DALY). We estimated per capita DALYs averted using statistical models that reflect each trial’s design and any baseline imbalances. We report cost-effectiveness as cost per DALY averted and characterise uncertainty in the estimates with probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEACs), which show the probability of cost-effectiveness at different thresholds. We report a subgroup analysis of the small group component of the combined intervention and no other subgroup analysis. We also report an impact inventory to illustrate interventions’ socioeconomic impact beyond health. We use a 3% discount rate for investment costs and a 1-year time horizon, assuming no effects post the intervention period. From a health sector perspective, the cost per DALY averted varies between US$222 (2018), for an established gender attitudes and harmful social norms change community-based intervention in Ghana, to US$17,548 (2018) for a livelihoods intervention in South Africa. Taking a societal perspective and including wider economic impact improves the cost-effectiveness of some interventions but reduces others. For example, interventions with positive economic impacts, often those with explicit economic goals, offset implementation costs and achieve more favourable cost-effectiveness ratios. Results are robust to sensitivity analyses. Our DALYs include a subset of the health consequences of VAWG exposure; we assume no mortality impact from any of the health consequences included in the DALYs calculations. In both cases, we may be underestimating overall health impact. We also do not report on participants’ health costs. Conclusions We demonstrate that investment in established community-based VAWG prevention interventions can improve population health in LMICs, even within highly constrained health budgets. However, several VAWG prevention interventions require further modification to achieve affordability and cost-effectiveness at scale. Broadening the range of social, health, and economic outcomes captured in future cost-effectiveness assessments remains critical to justifying the investment urgently required to prevent VAWG globally

Economic violence against women in India: Qualitative focus group discussions

Data for Paper: “We don’t get money in our own hands”: Evidence from focus group discussions on economic abuse against women in two states of Indi