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Perceptions on violence against women and its impacts on mental health and response mechanisms among community-based stakeholders: a qualitative study from Nepal | BMC Women’s Health

The majority of the health care providers interviewed belonged to the 16–35 age group and have completed a Certificate level in Nursing (Table 2). However, it should be noted that Table 2 does not include the sociodemographic characteristics of the community women and violence surviviors since we did not collect that information. Table 2 presents a concise summary outlining the sociodemographic characteristics of the participants.

Table 2 Sociodemographic characteristics of the participants

Triangulation and field observations of the qualitative data resulted in six themes: “Common Experience in Women’s Lives”, “Social, Cultural, and Traditional Norms Promoting VAW”, “Illiteracy”, “Underlying Reasons for Not Seeking Help”, “Health Center as the Primary Contact for Identifying and Managing VAW” and “Lack of Follow-up or Ongoing Support for the Survivors of Violence within Health Care Settings”. These themes are explained in detail below:

Common experiences in women’s lives

All interview participants reported that women are forced to live with mental and physical injuries, which makes them afraid to break the silence. Some common physical impacts include injuries (ranging from minimal tissue damage to broken bones), pain, and impairment. Mental health impacts include stress, tension, fear, and even suicide. Intimate partner violence not only affects the individual but also the children and family of the violence survivors.

“Physical violence fades away along with healing wounds, but the effects of psychological violence are fatal and long-lasting in people’s minds and hearts, leaving deep scars. I think these mental tortures also create circumstances for a victim to commit suicide.”

KII participant (local NGO representative)

In addition to the effects of intimate partner violence on the individual, participants emphasized that it also has a significant impact on children’s health and well-being.

“If a husband does not care, the children will suffer. We will not be able to educate and feed (our) children properly.”

IDI participant (woman seeking health services)

“Violence is very contagious. It spreads from person to person and home to home. It has negative impact on the children. We further lose our prestige in the society.”

FGD participant (violence survivor women)

Social, cultural, and traditional norms promoting VAW

Some common social, cultural, and traditional norms, such as son preference, dowry, and alcohol abuse, were found to be major contributors to VAW in Madhesh Province.

(a) Son preference

Health care providers have identified “son preference” as a cause of VAW. Sons are considered to have greater economic and social value than daughters for various reasons. Firstly, daughters are seen as a financial burden and liability, mainly due to the expectation of future dowries. Secondly, sons are believed to carry on the family lineage, while daughters typically go to the groom’s house after marriage. Thirdly, since the government’s social security system for retired or elderly people in Nepal is insufficient, it is believed that sons will take care of their parents when they are old. Thus, sons are seen as the only financial security for elderly couples in the absence of a social security system. Lastly, there is a traditional norm that the son should perform the last ritual for a deceased parent, further reinforcing son preference. The longstanding social and traditional norms often lead couples to repeatedly conceive until they have a son, and women are often blamed for not giving birth to a son. Women who fail to give birth to a boy experiences a loss of respect within the family and are frequently subjected to physical and verbal abuse, threats, and sometimes even forced eviction. In some cases, husbands may even marry another woman in the hopes of having a son.

“If there are 4–5 daughters, violence against the women begins. Family members say, “You always give birth to daughters, not sons”. They use derogatory terms such as ‘Hijdi’ (which translates to ‘transgender’). The in-laws scold her, saying, “You do not have a son, so you are a sinner.” Nobody blames the son, but they blame the daughter-in-law. She might even commit suicide, as she feels she has nowhere to go.”

IDI participant (Health care provider)

“There was a case where a woman was in her third pregnancy (Gravida 3). She had two daughters before. Her husband used to beat her for giving birth to daughters due to pressure from his family, especially when he had been drinking alcohol. He threatened to abandon her or throw her out of the house if she did not give birth to a son this time.”

IDI participant (Health care provider)

(b) Alcohol abuse

Most of the participants including all FGD participants, six health care providers, and two women seeking health services, identified alcohol abuse by husbands as one of the reasons for VAW. When husband are drunk, they instigate fights for no reason, verbally abusing women, often resulting in physical injuries. Apart from physical violence, women also experience psychological distress due to fear, stress, and worry about being beaten and the consequences that may unfold when their husbands return home.

“If we do something wrong, they beat us. If we say something, they beat us when they are drunk” (said in a low tone, accompanied by slight laughter).

FGD participant (Violence survivor woman)

“Some instances of violence occur when husbands drink alcohol. When they are drunk, they neglect their wives and children and subject them to abuse.”

IDI participant (Woman seeking health services)

“One of the reasons for wife-beating is alcohol consumption. When husbands come home drunk, they abuse their wives, and if a woman tries to say something, he physically abuses her.”

IDI participant (Health care provider)

(c) Dowry

Most of the participants from all categories (including all FGD participants, two women seeking health services, and eight health care providers) identified dowry as one of the contributing factors to VAW in Madhesh Province. If the bride’s family is unable to meet the dowry demands of the groom’s family before or after marriage, the woman may be subjected to torture, abuse, and taunting to obtain the dowry from her natal parents. Two health care providers mentioned encountering cases of miscarriage and physical injuries resulting from dowry issues. One of the survivors of intimate partner violence recounted being abused and sent back to her maiden home for a year until the dowry demand was fulfilled.

“One of the reasons (for violence) is the dowry system; community people start giving advice such as, ‘If you marry another woman, you will receive certain property, so leave the current one.”

IDI participant (Woman seeking health services)

“I was sent back to my natal house by my in-laws because my parents could not provide the promised dowry within the three months of marriage. They (in-laws) said that they would only take me back only when my parents provided the remaining dowry amount as agreed upon. I later returned to my husband’s home after my father fulfilled the dowry requirement.”

FGD participant (Violence survivor woman)

“Dowry is another reason. Women are subjected to physical assaults and are not allowed to live in the house. Husbands have extramarital affairs and insult their wives when they are unable to provide the demanded dowry.”

IDI participant (Health care provider)

In contrast, one health care provider mentioned that violence due to dowry is less prevalent, as most people nowadays are educated, and violence has decreased over time.

Illiteracy

Participants, excluding women seeking health care services, pointed out that a low level of education contributes to VAW. Different interviewee categories held different views regarding the level of education of perpetrators or women as a contributing factor to VAW. Violence survivors believed that a low level of education among perpetrators contributes to VAW. They believed that educated people are more understanding and would prefer to communicate resolve issues rather than resorting to violence. Additionally, they believed that if men were more educated, they would consume less alcohol. However, health care providers and representatives from local NGOs perceived that the low level of education among women leads to VAW. They believed that if women are more aware of their rights and educated, they would be empowered to report VAW to the authorities, seek legal and social assistance, and prevent further victimization of the survivor.

“In my point of view, the lower caste people (uncomfortable using this term) who have received limited education tend to be more violent, but educated people can understand and know how to mend things.”

IDI participant (Health care provider)

“Uneducated people who have not received formal education may resort to poisoning, murder, hanging, or burning their wives with petrol or kerosene.”

IDI participant (Health care provider)

“Every man abuses his wife. Its just that since we are not educated, violence is even more common. If he (the husband) says something and we interfere in their work, they start abusing us. If the food is not tasty, then they beat us.”

FGD participant (Violence survivor women)

Underlying reasons for not seeking help

A small number of health care providers (4 out of 15) stated that most or all victimized women seek help. Only a few participants (2 out of 15) mentioned concerns about fake allegations and believed that most violence survivors would choose to discuss the violence they are experiencing with someone.

“The real victims who are suffering from this stuff (violence) openly share their experiences they face with a health care provider and their family/friends.”

IDI participant (Health care provider)

In contrast, the majority of the health care providers (9 out of 15), all violence survivors, and representatives from local NGOs expressed concern that survivors do not seek help from formal and informal support systems. Women are forced to live with mental and physical injuries as they are afraid to break the silence, resulting in unreported cases. Some commonly reported reasons for not seeking help are grouped under the following subthemes.

(i) VAW is regarded as a normal family matter

Acceptance or normalization of violence against women in the community is a major barrier to seeking help or assistance. We found that all FGD participants, one health care provider, and one key informant believed that domestic and/or intimate partner violence is considered a normal family matter and not perceived as a problem that needs to be addressed or managed, nor is it recognized as a violation of human rights. The casual expression of existing VAW in the community by a participant quoted below also indicates the deep-rooted acceptance of VAW in society.

No one fights all the time, but violence must have occurred in 98% of women living in this locality (states very casually).“

FGD participant (Violence survivor woman)

All violence survivors accept violence as the fate of women and something that is inevitable. They believe that husbands have the right to exert control over them, and that slaps and verbal abuse are common in a marital relationship. Women only report intimate partner violence to their natal family when it becomes severe.

“We have to face(violence), all that is written in our fate.“

FGD participant (Violence survivor woman)

“All women whole-heartedly accept their partners and never complain about anything as this is our culture. We often hear women saying, “He is my husband, and he has the right to slap me or beat me. The husband makes every decision in a family; it is no big deal for us.”

KII participant (local NGO representative)

“Many women do not want to disclose that their husband or in-laws are torturing them. They only speak up if it becomes unbearable. They don’t openly talk about it due to fear that their husband and in-laws might kick them out of the house. We are also women and live in the same house with our spouses and in-laws. Our husbands say many things as well, but women have to endure such things.”

IDI participant (Health care provider)

(ii) Silence due to fear of escalating violence

Many women prefer to remain silent out of fear that the violence may escalate once the perpetrator becomes aware of the disclosure of the violence experience to others.

“It is due to fear that her husband and mother-in-law might evict her from the house.”

IDI participant (Woman seeking health services)

“Women here do not go out and seek help for their IPV experience. He (husband) is our own man; he beats and slaps us, but we do not separate. Women here are scared of their husbands”.

FGD participant (Violence survivor women)

“Men warn us not to seek help or go anywhere for support because the violence will increase even more. So, where can we go? We remain silent and stay at home.”

IDI participant (Women seeking health services).

The uncertainty of the consequences faced by the perpetrator if charged by the police or the duration of their incarceration, dependency on the perpetrator due to limited economic empowerment, and the fear of worse consequences upon returning home also deter women from seeking help from formal sectors, such as the police or judicial system. Victimized women become more reluctant to discuss violence in health facilities if other family members are present.

“A victim does not want to conceal it, but their in-laws and sisters-in-law, try to hide it. We do not allow visitors go inside the labor room, so when we ask them at that time, and they open up to us.”

IDI participant (Health care provider)

This fear can also stem from a lack of trust and confidentiality among health care providers. Women fear that sharing their problems with health care providers may result in the dissemination of this information, which would alert the perpetrator and put the woman would be at an increased risk of future victimization.

Women who have experienced intimate partner violence and shared their concerns with health care providers stated, “What if, my husband or family members beat me later after I have shared this? They might even kill me. After all, they have threatened me not to share about these things. It will spread throughout the community.”

IDI participant (Health care provider)

Health care providers should allocate sufficient time and effort to develop trust and rapport, as these are essential in helping survivors disclose IPV.

“They do not spontaneously open up about everything; it takes a lot of time. We dedicate a minimum of 2–3 hours and of 4 hours for one case.”

IDI participant (Health care provider)

Women seeking health services fear that involving the police would tarnish their family’s prestige, as the whole society would become aware of it. They dread the judgements that people might pass. Likewise, involving the police in cases of violence is not seen as a long-term solution. The perpetrator is eventually released, and there is a fear that the violence will escalate even further. Since most women are economically dependent on their husbands for their livelihood, they feel reluctant to take any action against them. Despite the existence of limited safe housing options, victimized women do not seek help or choose not to enter safe housing.

“Even if I try to defend myself or we have them beaten once, they ultimately come back home (uneasy laughing).”

IDI participant (Woman seeking health services)

(iii) Social stigma surrounding IPV

Biased gender norms lead family members to believe that it is a woman’s responsibility to care for her husband’s family and fulfill the needs of her own family. If she fails to meets the expectations, she is deemed a bad daughter-in-law. This societal notion of an ideal daughter-in-law contributes to women’s reluctance to seek help. Survivors of violence express concerns about how society will perceive them if they disclose their experiences of violence.

“I understand why women hesitate to come forward. They fear acceptance by society. What will people say? Will they love me if I return to my parents’ home, or will they humiliate me?, etc. such things are usually hidden within families in villages due to fear.”

IDI participant (Health care provider)

“We go to our maternal house and stay there in extreme situations so that rumours do not spread.”

FGD participant (Violence survivor woman)

Health care providers and representatives from local NGOs also point out that women face numerous socially imposed restrictions. For instance, they are prohibited from interacting with strangers, are expected to adhere to certain behaviours, and speech patterns, and are restricted in their choice of clothing. These limitations constrain women and confine them within narrow boundaries. Because women are constantly under societal scrutiny, they are afraid to speak up.

“If a female goes from one house to another, then people gossip about her, saying things like ‘so and so’s daughter-in-law went to such a place.’ There is no freedom for women here.”

IDI participant (Health care provider)

Health center as the primary contact for indentifying and managing VAW

Women with evident physical bruises and injuries resulting from different physical violence often seek help at outpatient departments or emergency units to receive treatment. Nurses often identify individuals as survivors of violence during history-taking, but this seldom or rarely leads to a police report or any social interventions. They address apparent physical issues such as bruises, burns, and other injuries, and provide counseling to the women, often offering words of encouragement. However, they rarely advise the woman to leave their perpetrator. Five health care providers were trained in psychosocial counseling or in how to handle violence-related issues.

“First of all, we treat the wounds if they (victimized women) come up with it. After managing the wounds, we asked them about how the incident occurred. We try to counsel them on how to minimize such incidents. We counsel them according to our knowledge.”

IDI participant (Health care provider)

Health care providers also mention cases where a patient expriences extreme fear and tension, indicating that survivors often endure psychological violence alongside physical violence. However, these cases are often not reported unless they manifest as physical or sexual violence. Four health care providers also mentioned that they seldom encounter cases of sexual violence that escalate to rape, as rapes are reported less frequently.

However, three survivors of violence and women seeking health services had a different take-on violence management at health care centers. They raised concerns about the ability of health care centers or other formal institutions to reduce or prevent violence. They prefer to seek help from community leaders or elderly people within families over health care centers to settle disputes, as they are highly regarded and respected in the community.

“People here do not have faith in health centres. Although health centres provide services, they are not sufficient to reduce violence. When it comes to discussing our feelings, we prefer Mukhiya (traditional leaders and decision-makers in villages/communities) and the ward chairman, they are sought to settle down disputes and minor conflicts rising in the village/community.“

FGD participant (Women survivor of IPV)

“If anyone comes to the health center with a complaint of violence, they do not pay any attention to it. They would refer the person to Birgunj (a metropolitan city in the Parsa district of Madhesh province). However, people here are very poor and cannot afford the hotel bills, so where would they stay in Birgunj? There is a problem here.”

IDI participant (Women seeking health services)

Lack of follow-up or ongoing support for the survivors of violence within health care settings

There is no standard procedure or protocol in the health care centers regarding when and how to follow-up with survivors of violence. Health care providers mentioned that due to the lack of follow-up and ongoing support for identified survivors, they remained unaware of the survivor’s situation after the initial counselling.

“We provide our recommendations, but they do not come for follow up. I mean, these types of cases do not show up for follow-up, so we do not have much information about them. However, we offer counselling from our side, based on our knowledge.”

IDI participant (Health care provider)

Service providers were unaware of the effectiveness of their counselling services since they had not undergone formal evaluation.

“They nod and say yes, but we do not know what they would do after going back home. They appear calm and relaxed during counselling. Victimized women show genuine interest in taking action, but we have no idea if they implement those changes in their lives.”

IDI participant (Health care provider)

Recommendations for reducing/preventing violence

Participants suggested different measures and strategies for reducing or preventing violence. One of the most common suggestions from participants was awareness-raising programs that provide information about the nature and impact of violence. These programs should also include information about the support services offered by the government and NGOs. Awareness can be raised through various communication channels.

“Awareness programs about One-Stop Crisis Management Centers are necessary because most of the people are unaware of their purpose and function? The public lacks knowledge about it. If people know that privacy is maintained here, they will be more willing to seek help.”

IDI participant (Health care provider)

Participants, especially nurses, strongly believed that counselling would benefit survivors. Counselling should not only be limited to survivors but should also be extended to husbands and families, as this can help reduce violence. Participants emphasized the importance of support from male members of society for the success of any intervention.

“First, men should understand the consequences of intimate partner violence and how the patriarchal mindset contributes to gender discrimination in families and communities. Men should know women’s rights. Men should support their wives in engaging in income-generating activities. They should understand the multiple roles women have in household work and respect women’s unpaid work.”

KII participant (local NGO representative)

Apart from this, the study participants also highlighted several measures, such as strict enforcement of laws, informing women about the rules and legal matters, encouraging women to seek help, banning alcohol and stopping the dowry culture. These measures would significantly contribute to preventing violence.

“When a man comes home after drinking alcohol, he scolds; female also yells back at the man. They scold each other and end up fighting. If alcohol is banned, it would lead to improvement among all-men in the village.”

FGD participant (Violence survivor woman)

Survivors of intimate partner violence emphasize the importance of education and employment opportunities for men as preventive measures. Improved education empowers men, reduces alcohol consumption, and contributes to changing socio-cultural practices that promote VAW.

“If there are employment opportunities, men will engage in them, and the violence will not occur. If they have job, they won’t have as much free time. Staying idle causes violence. Men do violence if they have more spare time.”

FGD participant (Violence survivor woman)

Representatives from local NGOs and health care providers recommended improving education and employment opportunities for women to prevent violence. Education empowers women and shifts the help-seeking behaviour from traditional community leaders to formal institutions such as police. Employment opportunities will make women financially independent enabling them to leave their perpetrators.

“There is a saying that if education is given to women then they automatically empower themselves but more than just education, women need empowerment through different means and training.”

KII participant (local NGO representative)

Perception regarding counselling intervention

Health care providers and representatives from local NGOs believe that hospital-based counselling interventions could be effective for women who have experienced violence. Since health facilities are often the first place that severely injured women go to, it can be a good starting point to initiate programs addressing mental health problems related to intimate partner violence or domestic violence. It also provides an opportunity for women to openly share their experiences with health care providers.

“I think hospital-based counseling intervention is effective because women (clients/patients) feel free in the hospital, and can share their experiences with medical person about their intimate partner (and violence).”

KII participant (local NGO representative)

“I believe counseling is highly effective because, when a person cannot open up with their relatives or anyone they know, they are unable to share everything. They are also in fear that the information might spread. However, in this place (hospital), they can share it easily with an unknown person (health care providers). They will get the platform to bring out all the things they have faced and seek help. I think it is effective and reduces mental stress in the long run.”

IDI participant (Health care provider)

Need of training health care providers

In-depth interviews with the health care providers highlighted the importance of training for dealing with women experiencing violence.

“I think it would be easier if we had a counselor who could provide counselling to women experiencing violence here. We can give them to handle these (violence) cases. I am the only person who has been trained in this area. If we could provide training to other staff as well, they could work even in my absence.”

IDI participant (Health care provider)

“At present, we do not offer counseling services to women experiencing violence because we have not received any training so far. But if we receive training for counseling such cases, then we will provide it. We cannot say that we will not help them. It is a necessity for everyone.”

IDI participant (Health care provider)

“If there is any training that is better than the previous one, then it would be better if you could provide it to us. We only know how to handle them until now. If there is better training available, we would be happy to receive it. I believe it will enhance our ability to manage women experiencing violence.”

IDI participant (Health care provider)