Spatial heterogeneity in intimate partner violence across the 640 districts of India: a secondary analysis of a cross-sectional, population-based survey by use of model-based small-area estimation

BACKGROUND: Although intimate partner violence (IPV) against women is a substantial challenge in India, response is limited by little evidence on substate prevalence. District-level IPV estimates are essential in targeted response and prevention efforts, but cannot be directly calculated from the National Family Health Surveys (NFHS), which is the main source of nationally representative IPV estimates in India. We aimed to use small-area estimation techniques to derive reliable estimates of physical, emotional, and sexual IPV for the 640 districts of India. METHODS: For this secondary analysis of a cross-sectional, population-based survey, we used model-based small-area estimation techniques linking data from the 2015–16 NFHS-4 and the 2011 Indian Population and Housing Census (2011 Indian Census) to derive district-level estimates of physical, emotional, and sexual IPV for the 640 districts of India in the previous 12 months. Only women who had ever been married aged 15–49 years, who were interviewed in NFHS-4, and who were included in the domestic violence module were eligible for inclusion in this analysis. Data collection occurred between Jan 20, 2015, and Dec 4, 2016. The 2011 Indian Census was conducted in all 640 districts from Feb 9 to Feb 28, 2011. It collected information on a range of data including sociodemographic data and housing characteristics. The primary outcomes of this analysis were the district-level mean proportions of women who experienced physical IPV, emotional IPV, and sexual IPV in the previous 12 months. This outcome was estimated for all women aged 15–49 years who had ever been married in the 640 districts of India that were included in the 2011 Indian Census. FINDINGS: 699 686 women aged 15–49 years were interviewed in NFHS-4. One woman per household in a randomly selected 15% of households was chosen for participation in the domestic violence module, resulting in 83 397 (11·9%) of 699 686 women included. Of these 83 397 women, 14 377 (17·2%) were excluded as they had never been married and 3007 (3·6%) were excluded due to privacy limitations. The mean prevalence of physical IPV in the previous 12 months was 22·5% (95% CI 21·9–23·2), of emotional IPV in the previous 12 months was 11·4% (11·0–11·9), and of sexual IPV in the previous 12 months was 5·2% (4·9–5·5). Model-based estimates revealed intrastate and interstate IPV variations. In Bihar, which had the highest state-level physical IPV prevalence (35·1%, 33·3–37·0), district-level estimates varied from 23·5% (23·0–23·9) in Siwan to 42·7% (42·3–43·1) in Purbi Champaran. In Tamil Nadu, which had the highest state-level emotional IPV prevalence (19·0%, 17·4–20·8), district estimates ranged between 13·7% (13·2–14·1) in Kanniyakumari and 30·2% (29·5–30·8) in Sivaganga. Bihar also had the highest state-level sexual IPV prevalence (11·1%, 9·9–12·4), with estimates ranging between 6·3% (6·1–6·6) in Siwan and 18·1% (17·6–18·6) in Saharsa. Across districts, there was substantial spatial clustering of IPV prevalence. INTERPRETATION: This reliable district-level estimation of IPV prevalence in the 640 districts of India has important policy implications. The ability to track substate levels of IPV over time enables the identification of progress in reducing IPV; recognises the heterogeneity of culture and context in India; and informs the targeting of resources, interventions, and prevention programmes to districts with the greatest need. FUNDING: Bill & Melinda Gates Foundation.