Using an emergency response infrastructure to help women who experience gender-based violence in Gujarat, India

Abstract Problem Many women who experience gender-based violence may never seek any formal help because they do not feel safe or confident that they will receive help if they try. Approach A public–private-academic partnership in Gujarat, India, established a toll-free telephone helpline – called 181 Abhayam – for women experiencing gender-based violence. The partnership used existing emergency response service infrastructure to link women to phone counselling, nongovernmental organizations (NGOs) and government programmes. Local setting In India, the lifetime prevalence of gender-based violence is 37.2%, but less than 1% of women will ever seek help beyond their family or friends. Before implementation of the helpline, there were no toll-free helplines or centralized coordinating systems for government programmes, NGOs and emergency response services. Relevant changes In February 2014, the helpline was launched across Gujarat. In the first 10 months, the helpline assisted 9767 individuals, of which 8654 identified themselves as women. Of all calls, 79% (7694) required an intervention by phone or in person on the day they called and 43% (4190) of calls were by or for women experiencing violence. Lessons learnt Despite previous data that showed women experiencing gender-based violence rarely sought help from formal sources, women in Gujarat did use the helpline for concerns across the spectrum of gender-based violence. However, for evaluating the impact of the helpline, the operational definitions of concern categories need to be further clarified. The initial triage system for incoming calls was advantageous for handling high call volumes, but may have contributed to dropped calls.


Introduction
Globally, over one-third of all women will experience genderbased violence in their lifetime. 1 Such violence includes any act that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, which includes coercion or arbitrary deprivation of liberty. 2 Gender-based violence may be perpetrated by current or former partners, strangers, acquaintances or family members. Women who experience such violence may experience physical and mental health problems across their lifetime, 3,4 including an increased risk of sexually transmitted infections, 5 depression and anxiety, 6 giving birth to low-birthweight infants, 7 and hypertension. 8 While governments and nongovernmental organizations (NGOs) work to build support services and the legal infrastructure to prevent and to confront gender-based violence, women often do not seek out or cannot connect to these resources.
In India, there is a 37.2% lifetime prevalence of gender-based violence among women. 9 Only 31.5% of these women will ever report gender-based violence to anyone, and less than 1% will report it to a formal source, such as the police or a physician. 10 This is below the low global average of 7% of women reporting gender-based violence to any formal source. 10 In January 2013, the Indian Department of Telecommunications released the toll-free phone number 181 across India, and mandated that every state government develop infrastructure for this number that would address the needs of women experiencing gender-based violence. This paper describes a multisectoral collaboration in the state of Gujarat, India, that has met this mandate by creating a toll-free helpline called 181 Abhayam.

Approach
The Indian Administrative Service Secretary for Gujarat, Anju Sharma, who was also the state head of the Women and Child Development Department, brought together key collaborators across sectors to establish the helpline. For ensuring the effectiveness of the interventions and for creating accountability, the secretary enlisted the Government of Gujarat Home Department, which is responsible for the police. The secretary recruited the GVK Emergency Management Research Institute to be responsible for the implementation and operations of the helpline. The institute is the largest provider of free emergency medical services in India, covering 15 states. It operates as a public-private, not-for-profit partnership with each state's government. The secretary also invited the Tata Institute of Social Sciences, which has a history of gender-based violence research, to provide technical expertise for helpline protocols.
The collaborators created a shared vision: any woman, irrespective of caste, religion, class, ability, age, sexual or political orientation, educational or economic status, would be able and empowered to seek and receive emergency services anywhere, at any time. Their mission -paid for by the Government of Gujarat -was to provide a coordinated, effective and timely multi-agency response that offered quality mental health, social, and legal services. They agreed upon a target group that reached beyond the traditional definition of gender-based violence: women in distress, which includes any woman who has or is experiencing psychological, emotional, financial, and/or social crisis or physical harassment. Here, crisis is defined as when a woman's sense of self or safety is likely to be compromised.

Lessons from the field
Helping women who experience gender-based violence in India Jennifer A Newberry et al.
To inform the direction of the helpline, the GVK Emergency Management Research Institute conducted a survey across three cities in which they intended to pilot services. Together, these cities had a total population of 4 661 804 women in 2011. The survey included 8935 participants (93%; 8269 women). Overall, 43% (3821) had experienced at least one type of harassment: 51% (4520) verbal harassment, 27% (2378) physical assault, 17% (1529) sexual assault and 27% (2438) stalking. The majority of respondents did not call the police when experiencing harassment (80%; 7146) and almost all respondents (95%; 8511) wanted an additional agency for gender-based violence-related support. Moreover, participants desired a range of services, such as counselling, policeassisted rescue and legal aid. The helpline's central operations were based in the GVK Emergency Management Research Institute's call centre. The collaborators recruited women with education and experience in social work to become response officers for the helpline. To prepare response officers to answer calls and respond to callers' concerns, the collaborators jointly developed a month long training course. After successful training, a team of 32 female response officers were hired to keep the helpline staffed 24 hours a day, seven days a week.
The collaborators developed specific protocols for the response officer when answering calls. First, response officers triage calls. The protocols outline specific actions based on (i) the caller's concern; (ii) the caller's safety and the urgency of the concern; and (iii) the parameters of established governmental and NGO resources. Second, if the caller's needs cannot be quickly met or if the call is emergent, then the call is transferred to a counsellor. Counsellors are the same aforementioned response officers, but acting in a specific role wherein they have more time to provide in-depth counselling and interventions to the woman calling. Response officers and counsellors, each independently classify every caller's primary concern according to a predefined list of 55 concerns.
Response officers use the infrastructure of the call centre to connect women via phone directly to NGOs and governmental partners. Using the call centre technology, they are able to stay on the line with the caller to ensure that women obtain the help they need. Occasionally, response officers are unable to connect women to appropriate resources. If this occurs when a woman is in an emergent circumstance, then they may use escalation protocols. These protocols involve state level officers, within the home department and the women and child development department, who ensure that women receive the help they need.
In two of the cities and one district the helpline piloted rescue services. The rescue services consisted of a specifically designated van, driver, female police constable from the home department and a field response officer from the helpline. The team provided on-site counselling, mediation and rescue services. Via the helpline, callers could either directly ask for on-scene rescue services or counsellors could recommend the service to the caller.
All services, whether provided on the phone or in the field, are explained by response officers and counsellors and they require a caller's verbal informed consent to proceed. A woman's right to privacy is paramount throughout the process. Data from calls are stored on a central server, only accessible by helpline staff.

Outcome
The helpline was launched on 4 February 2014. A review of its first 10 months of operation demonstrated that the helpline reached women in distress. During this period, it received 9767 calls. Most callers identified themselves as women (8654). Many were married (5161) and 5479 callers called on their own behalf. The median age was 30 years (interquartile range: 24-38). Although the helpline targeted women, men made 364 calls on behalf of others and 304 calls on their own behalf; 301 did not identify who they were calling for. The caller's primary concern, as classified by the response officer and the counsellor independent of each other, fell into one of six major categories: violence against women; financial vulnerability; mental health; sexual, reproductive and family health; information; and others ( Fig. 1). Overall, 79% (7694) of calls required an intervention beyond information alone (Table 1).
Despite limited poster advertisements, the helpline received calls from all districts in Gujarat. The highest call volume (7245) came from the five most urban districts in Gujarat, while the lowest call volume (194) came from the six most rural districts. There could be several reasons for this, including a lack of marketing and less dense signage in more rural areas. Telephone coverage has not been a major obstacle in rural locations for GVK Emergency Management Research Institute's emergency medical service operations, which uses the same infrastructure.
In March 2015, using the existing emergency response infrastructure, rescue services were expanded across Gujarat with 43 vans. An additional 110 response officers were hired to staff the expansion. In the subsequent nine months, helpline call volume increased, resulting in 73 238 helpline calls. Since the launch, the Note: Calls classified by response officers. For 32 calls, the response officer did not classify the caller's concern. This data is considered missing.

Lessons learnt
Previous data showed women who experienced gender-based violence rarely sought help from formal sources; however, women in Gujarat did use the helpline for concerns across the spectrum of gender-based violence. Multisectoral helplines like 181 Abhayam, which offer both counselling and connection to other partners, may serve as a central source of help and an intermediary for traditional formal sources of help (Box 1).
Response officers and counsellors classified the callers' concerns differently.
For example, we found that if a call was classified by a response officer as violence against women, the counsellor's reclassification predominately fell into information, mental health or other categories. This discrepancy, which repeated across categories, likely reflects the multifaceted nature of gender-based violence. Women call not only to report a particular act, but also to receive mental health counselling and to find legal redress. To better understand the full extent of women's needs, we have changed the data collection process by creating clearer categories and allowing calls to be assigned multiple concern categories. Even though triaging calls was effective, it may have created dropped calls by extending the length of the call and adding a call transfer. An estimated 727 calls were dropped in transfers between response officers and counsellors. Once staffing better matches call volume, the helpline plans to move away from the current triage system to decrease the number of dropped calls.

Next steps
This paper demonstrates the feasibility of a multisectoral collaboration to leverage existing resources to connect women to available gender-based violence services. More work is needed to demonstrate the impact of 181 Abhayam on women's ability to obtain services they are connected with, as well as the longer-term impact on their own health and behaviours. The collaborators are working to strengthen their follow-up process to be able to track outcomes, such as successful linkages to services and women's experience with the helpline. This data will guide efforts to improve and expand services offered across the social service and public health sectors.
The key components of the 181 Abhayam model exist in at least the 15 Indian states where the GVK Emergency Management Research Institute operates, including the same emergency response infrastructure, state-level women and child development departments and home departments. The states also have the same national mandate to staff a 181 helpline. As in Gujarat, states will need a central leader who can bring this infrastructure and key stakeholders together to create a shared vision and to launch a multisectoral model that helps women who experience gender-based violence. ■ Competing interests: None declared. a Linkage refers to calls where the concern is of low urgency and the help required is a linkage to a nongovernmental organization or government resource. b Missing records included 2133 calls of low urgency that may have been closed by the response officer.
The remaining 340 calls were of moderate or high urgency and are considered dropped calls. Note: A person who calls the helpline first talks to a response officer. If the caller's needs cannot be quickly met or if the call is emergent, the response officer transfers the call to a counsellor.

Box 1. Summary of main lessons learnt
• Despite previous data that showed women experiencing gender-based violence rarely sought help from formal sources, women in Gujarat did use the helpline for concerns across the spectrum of gender-based violence. • When women call, their concerns are multifaceted and may require counselling for mental health support, help with legal redress and information about further support. • To handle high call volumes, triaging was used to be able to quickly identify critical calls.
However, the process increases the risk of dropped calls in the transition to the second tier.
Lessons from the field