Knowledge and Experience of Domestic Violence among Women in Kathmandu Metropolitan City of Nepal

Introduction: Domestic violence has emerged as one of the global social and medical concerns, particularly in developing countries. It has affected women from all spheres of life. The consequences of domestic violence are well documented across the world; however, there is still scanty literature related to the domestic violence exploring its knowledge and experience among Nepalese women. Therefore, this study aimed to find the knowledge and experience of domestic violence among the Nepalese women living in Kathmandu, the capital city of Nepal. Materials and methods: This was a community based crosssectional study conducted in Kathmandu, Nepal. Participants (n = 127 women) were selected from the voters’ list available from the local municipality, using a systematic random sampling strategy. Data were collected using a questionnaire survey in 2012, and the analysis was performed using the Statistical Package for Social Science version 21.00. Findings: Nearly all (92.1%) of the respondents had a high level of knowledge about domestic violence. However, still more than half (60.9%) of the respondents experienced at least one type of domestic violence in the last 12 months of the survey. The unmarried, widowed, divorced or separated women less likely experienced domestic violence than married (OR = 0.08, CI 0.030.22) and upper castes (Brahmin or Chhetri) (OR = 3.39, 95% CI 1.21-9.51) experienced domestic violence more often than their counterparts. Conclusion: This study is an indication that domestic violence is an issue in Nepal’s capital city. It revealed women’s high level of knowledge about domestic violence, which nevertheless, did not protect these women from experiencing the violence. It is imperative to conduct further investigations employing mixed methods approach, covering both urban and rural areas, with a larger sample size to generalize results at national level in Nepal.


Introduction
Domestic violence includes any violent or abusive behavior, whether physical, sexual, psychological, emotional, verbal or financial, in which one person controls and dominates another within intimate relationships [1,2].Domestic violence has not only a devastating societal problem, but also a severe medical and mental health problem worldwide.Nepalese Ministry of Law and Justicedescribes domestic violence as a form of gender based violence that includes physical, mental, sexual, emotional or economic harm perpetrated by one family member on the another [3].Domestic violence is in every community across the world, but is more pervasive in developing countries.It has grown to be a serious and burning issue in Nepal.The recognition of women as the second class citizens in the patriarchal Nepalese society, and the social value that puts husband at higher social status, and allows them to dominate their wives has escalated domestic violence against women in Nepal [3][4][5].Domestic violence has affected women from all ages, background, class, caste, society, religion and nationality.Literature describes this as a result of women's negligence, general ignorance and lack of understanding about domestic violence [6,7].Nepal's cultural, social and religious values that predominantly favor for men have contributed to increased domestic violence against women.Women's illiteracy, lack of education, low mobility and lack of awareness about their rights as a human being have led them to tolerate the day to day violence as their misfortune [8].The low social position of women has been a key barrier in realizing their right, and to raise voices against their right violations such as from the day to day domestic violence.
A range of studies have identified the low education level, unemployment, alcohol abuse, presence of extramarital affairs and mental illness of the partners as key factors associated with increased prevalence of domestic violence [9-13].A Japanese study among university students reported that half of both male and female students had experienced at least one episode of the violence by their intimate partners [14].Yet, these respondents could not recognize the  various forms of the domestic violence and its mitigation measures.Another similar study among married women aged 18 years and above from rural China revealed that nearly two-thirds women had experienced spousal violence during their lives, but three-fourth of them had no knowledge about domestic violence [15].From these evidences, it is shown that domestic violence is higher among women having poor knowledge, those with low education; however, Shaiek (2003) identified that there was no association between the prevalence and/or type of domestic violence and the income or educational levels of the partners [16].Amidst such differential knowledge, our study aimed to find out an association between the level of knowledge and experience and thedomestic violence among the Nepalese women in Kathmandu metropolitan city.

Study setting
This study was conducted in Kathmandu Metropolitan City, the capital city of Nepal in between March and May, 2012.The education level, mobility and exposure of women to media and public life in Kathmandu valley is reported much better compared to the women from rural areas of the country.

Study design and sampling
This was a cross-sectional study.We did a survey of 127 women from a total eligible list of 6361 women in a community of the Kathmandu metropolitan city.The list of eligible respondents (women from study area) was identified from the office of local ward council.The survey participants were selected using systematic random sampling technique.We calculated 127 women using the standard formula n = Z2pq/L 2 , where n is the required sample size, Z = 1.96 at 95% confidence interval, p = 75.2%[15], q = 24.8% and L (desired margin of error) = 10 % of p.

Data collection
Face-to-face interviews were conducted using structured questionnaires.The questionnaire consisted of three parts: i) demographic characteristics of the respondents; ii) knowledge of the domestic violence; and iii) experience of the domestic violence.We employed four medical students as enumerators to conduct the interviews with the selected respondents.The enumerators were given orientation about the questionnaires and the interview technique.

Ethics
The study was approved by the Research Committee of Yeti Health Science Academy, Kathmandu, Nepal.Informed consent was taken from each respondent before interview.The personal identifiers were removed before the data analysis.

Definition of variables
The main outcome variables of this study were the level of knowledge and the experience of domestic violence.Each correct response on domestic violence was given one mark; and the incorrect one was marked zero.The total score obtained by each respondent was summed and the level of knowledge was classified as: high, average, low and very low based on the median value of the scores (Table 1).
by her family members.The independent variables in the study were: education, ethnicity, religion, marital status and occupation.

Statistical analysis
The data were analyzed using Statistical Package for Social Science (version 21:00 for windows).Bivariate analysis was performed to find out the association between knowledge and experience.A p value ≤ 0.05 was considered statistically significant.Binary logistic regression using Backward LR method was performed to see the association between demographic variables and experience of domestic violence at 95% confidence interval (CI) and corresponding odds ratio (OR) was presented.

Results
The study revealed that more than three-forth (76.4%) of the respondents had ahigher secondary or above level education.The majority of the respondents were from Chhetri caste (Chhetri and Brahmin are considered upper caste in Nepalese society) among prevalent castes, accounting for 27.6%, and higher majority (79.5%) were the Hindus among religions.Of the total respondents, 72.4% were married, and 40.2% were the housewives.The mean knowledge score of the respondents was 57.46, and the median knowledge score was 59.The classification of level of knowledge was done based on operational definition and review of literatures.A respondent was reported to have the experience of domestic violence when she reported anyone of the physical, sexual, psychological and economical violence Figure 1 shows that 60.9% of the respondents had suffered at least one type of the domestic violence, which is at least one among the physical, sexual, psychological and economical violence in the last 12 months prior to this study.The exposure to specific type of the violence was asked to the respondents during the survey.For instance, the question asked for the experience of sexual violence included: in the past 12 months, has any male member of your family.Table 3 shows the level of knowledge of domestic violence according to the selected socio-demographic characteristics of the respondents.The most of the respondents (97.3%) with secondary or higher secondary or above education had higher level of knowledge on domestic violence compared to those who were illiterate, or had Table 6 shows the association of theknowledge level of respondents and the experience of the domestic violence.More than the two-third (70%) of the respondents with average or low level of knowledge of the domestic violence experienced at least one form of domestic violence in the last 12 months; however, in the group with high level of knowledge, it is found to be reported among the 60.68% of the respondents.However, there is no statistical significant between knowledge level and experience of domestic violence.
primary level education (53.3%).There was no substantial difference in knowledge among the ethnic categories.Nearly equal proportions of the Brahmin/Chhetri combined (89.1%) and 95% of the other ethnic groups combined (Dalit, Newar, Janajati/Muslim) had higher level of knowledge about domestic violence.A high level of knowledge was found among the higher majority of respondents following Hindu religious belief (91.1%); among the respondents from other religious backgrounds (Buddhist, Muslim, Kirat and Christian) together (96.2%); among the respondents who were unmarried, widowed, divorced or separated together (82.9%); and among those who were married (95.7%), employed (96.3%), and unemployed (89.04%).Table 4 and table 5 show the experiences of domestic violence in past 12 months based on different socio-demographic characteristics of the respondents and their associations.It shows that nearly half (46.7%) of the illiterate respondents or those with primary education had experienced at least one type of domestic violence in the last 12 months compared to 63.4% of the respondents with the secondary or higher secondary and above level of education, however it is not statistically significant (OR = 0.71, 95% CI 0.20-2.60).Brahmin or Chhetri women who are considered as upper caste were 3.39 times more likely experienced of domestic violence than those of other castes (OR = 3.39, 95% CI 1.21-9.51).Similarly, unmarried, widowed, divorced or separated were protective in case of domestic violence which is statistically significant (OR = 0.08, CI 0.03-0.22).The experience of domestic violence varied according to other selected socio-demographic characteristics such as among Hindu (65.3%), other religions (46.2%), un-employed (52.1%), and employed (74.1%).Overall, this shows that any women irrespective of the differences in their socio-demographic characteristics are suffering from domestic violence.

Discussion
Every year, thousands of Nepalese women experience violence, and 80% of the reported violence are domestic violence.One-third of the women in Nepal experience violence at home, although most violence is still under-reported [17,18].Our study found that more than half of women in illiterate/primary level education group had high knowledge about the domestic violence compared to almost all of the respondents with secondary or higher secondary level education.One of the similar studies conducted by Guo (2006) in rural China revealed three-fourth of women without knowledgeabout domestic violence [15].This study revealed that about sixty one percent of the respondents had suffered at least a type of domestic violence in the past 12 months, which is close to the finding generated by an Indian study by Babu and Kar in 2009.They reported an overall prevalence of 56% of the domestic violence [19].A study conducted by Nepal Health Research Council (NHRC) in 2009 reported 33% prevalence of the domestic violence in the Central Development Region [20].Likewise, the Nepal Demographic and Health Survey, 2011 reported 33% prevalence of spousal violence among married women aged 15-49 [3].One of the limitations of our study is that the knowledge and experience of the domestic violence of the participants is based on their self-reported psychological, sexual and economic violence along with physical violence.
The present study demonstrated that women have been the victims of domestic violence in all segments of socio-demographic characteristics; domestic violence exists among women of all educational level, ethnicity, religion and marital status.Interestingly, this study identified that higher majority of the respondents (63.4%) with secondary or above education level experienced at least one type of domestic violence compared to the only about 47% of the respondents with no education or primary level of education.This is a consistent with the findings from the Nepalese study [21].However, this finding from our study contradicts with a study conducted in South Africa, in which risk factors for domestic physical violence was assessesd and no convincing associations with age, income, education, household size and remunerated occupation was reported [22].Similarly, our study finding on knowledge or education and experience contradicts with the studies performed in Hong Kong, Mangoliya and India, where the studies identified lower level of education as one the risk factor to the exposure of of domestic violence [10,13,23].One reason behind this could be a higher level of education of our respondents who were more aware about domestic violence, and this could have impacted them for frequent reporting.In our study, we found higher percent of women with hindu religious belief, employed and married more commonly experiencing domestic violence.However, similar studies from Hong Kong and Mangolia and Slovania identified unemployment of respodents associated with their experience of the domestic violence [10,12,13].In another study of rural Bangladesh, it was identified that resondents from higher socioeconomic status and those with non-Muslim religious backgrouds had a lower risks of domestic violence [24].As per our study, the experience of domestic violence did not significantly differ due to the overall knowledge level of the respondents.More than two-third of the respondents with an average or low level of knowledge of domestic violence experienced at least one form of domestic violence in the last 12 months.
Despite our efforts to improve the strength of this study, there were some limitations which might have compromised its usefulness.One such limitation was resource constraint due to which the study was located only in a cluster of the Metropolitan city.The authors had to rely on relatively small sample size which might have compromised the findings of this study.

Conclusion
The study revealed that the study population had a high level of knowledge of the domestic violence.However, the higher prevalence of experience of the domestic violence by the participants in this study indicates that Kathmandu, despite an urban and advanced society with a relatively better social position of women in Nepalese context, is not immune from domestic violence.More women with higher education level, from Hindu religious belief, and those who were married and employed reported high level of knowledge about the domestic violence.Although the association between knowledge and experience of domestic violence is not statistically significant, the descriptive analysis suggested that higher knowledge didn't significantly reduced the experience of domestic violence among women.We recommend future large scale studies, employing a mixed method approach to further explore behind, and confirm an association between knowledge and experience of the domestic violence in Nepal.

Figure 1 :
Figure 1: Experienced at least one type of violence n = 127.

Table 2
displays the knowledge level of the respondents about domestic violence.Most of the respondents (92.1%) had a high level of knowledge regarding domestic violence.

Table 1 :
Classification of knowledge level.

Table 2 :
Knowledge level of domestic violence of respondents n = 127.

Table 4 :
Experience of at least one type of domestic violence of the respondents in past 12 months n = 127.

Table 5 :
Variables associated with experience of at least one type of domestic violence, multivariate analysis.

Table 3 :
Demographic characteristics of participants by knowledge level n = 127.

Table 6 :
Association between knowledge level of respondents and experience of domestic violence.