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Abstract

Background:

Intimate partner violence (IPV) is prevalent worldwide, with high rates in South Asia, increasing the risk of IPV and domestic violence (DV) in Canadian South Asian (SA) women. Currently, there is lack of research that examines IPV/DV-caused brain injury (BI) in this population.

Materials and Methods:

Our exploratory study was conducted via online questionnaires administered through Qualtrics and was available in English, Punjabi, and Hindi. We administered the 14-item South Asian Violence Screen questionnaire to determine, in a culturally appropriate manner, if physical, sexual, emotional, and in-law abuse was present. BI was assessed using a modified version of the Brain Injury Severity Assessment tool to determine self-reported symptoms consistent with BI, and psychosocial health outcomes were assessed using the General Anxiety Disorder-7, Patient Health Questionnaire-9, and International Trauma Questionnaire.

Results:

A total of 54 women were eligible and agreed to participating in the survey. Of these, 15 did not provide any further information; therefore, the total number of participants was 39. We found that 38.46% of participants experienced violence, and 73.33% from an intimate partner. Over 47% reported signs and symptoms of BI. Higher violence scores were correlated with greater anxiety.

Conclusions:

These are the first findings showcasing the occurrence of BI and the correlation between IPV, BI, and mental health in Canadian SA women. Further research is needed to establish prevalence across Canada and support creation of culturally informed interventions for health care providers and community workers.

Keywords

brain injury domestic violence intimate partner violence South Asian women nonfatal strangulation

Background

Intimate partner violence, domestic violence, and brain injury

Intimate partner violence (IPV), affecting about 30% of women globally,¹ is defined as any behavior perpetrated by a current or ex-intimate partner that causes physical, sexual, or emotional abuse.² In Canada, domestic violence (DV)—violence committed by spouses, parents, siblings, or extended family members—is on the rise with a 17% increase from 2018 to 2023.³ IPV is faced by 43% of Canadian women and 29% of visible minority women during their lifetime.² Within Canada, IPV is the leading cause of physical injuries to women ages 15–44 and contributes to physical and mental health challenges.⁴

Many survivors of IPV report injuries to the head, face, and neck region, with brain injury (BI) present in 30%–92% of cases.^5–9 BI is a disruption in brain function due to an external force, and in IPV, includes nonfatal strangulation (NFS).¹⁰ BI is associated with depression, anxiety, post-traumatic stress disorder (PTSD), and cognitive decline.^10,11 BI symptoms can include an alteration or loss of consciousness, neurological deficits, and/or memory loss.^5,6,10 In some cases, when a woman seeks help for IPV or DV, BI is not addressed, as symptoms can be similar to those associated with mental distress post-IPV.^10,11 IPV-BI research has established that survivors show declines in cognitive-motor function, memory, cognitive flexibility, and underlying resting state brain activation.^12–14 Therefore, it is imperative that women are aware of the possibility of IPV-BI and seek specific help for it. With IPV and DV as major health crises and the high prevalence of BI among IPV, IPV-BI is a critical field to explore. To our knowledge, there is currently a lack of research on the occurrence of IPV or DV-caused BI among Canadian South Asian (SA) women. Thus, the current research aims to examine this issue in a cohort of SA women in British Columbia (BC), Canada.

IPV among SA women

IPV prevalence varies globally, with one of the highest rates in SA at 35%.¹⁵ This higher prevalence is thought to be associated with patriarchal beliefs and acceptance of wife-beating in SA cultures. It has been found that husbands use DV as a vehicle to undermine their wives’ autonomy and ensure patriarchal practices are upheld.¹⁶ When assaulted physically, emotionally, or verbally, many SA women do not consider it abuse, as they have been accustomed to believing IPV is normal.^17–19 With SA immigrants being projected to be the largest visible minority in Canada by 2041,²⁰ understanding of IPV among Canadian SA women is critical.

There is currently very little research examining IPV in SA women within Canada.^21–23 Most of the studies that have been done have been qualitative and, therefore, were not designed to gain insight into the prevalence of IPV in SA communities.^17,18,24 SA women in both Southern Ontario and Toronto have been reported to experience more emotional abuse than physical abuse.^25,26 Furthermore, SA women face an intersection of oppressions. Intersectionality recognizes the convergence of multilayers of domination.²⁷ In the lives of immigrant SA women, this includes dominations of gender, socioeconomic status, migration, and ethnicity.

In addition, SA women who are recent immigrants report a lack of appropriate support services within Canada, including formal and informal support, leading to less disclosure of abuse.¹⁸ Literature has established that barriers such as migration stressors, language barriers, cultural norms, limited access to resources, little knowledge of laws/policies, and economic dependency on their abuser stand in the way of SA immigrant women seeking help.^17,28,29 In Toronto, reasons behind delayed help-seeking include gender roles, social stigma, child well-being, knowledge gaps, and loss of social support.¹⁷ Systemic barriers, such as racism, immigration status, and lack of culturally informed responses, further entrap racialized immigrant women in abuse.^30,31 Evidence suggests that abuse often happens in the first 5 years of marriage, emphasizing the need for culturally informed interventions early in relationships.³⁰

IPV, BI, and psychosocial health outcomes

Psychiatric conditions such as depression, PTSD, drug and alcohol use, anxiety, self-harm, suicidality, and suicidal thoughts have been linked to IPV.^1,32,33 Survivors of IPV are six times more likely to report psychosocial distress than other women.³³ SA women who face IPV are three times more likely to report poor mental health,³⁴ with domestic abuse, interpersonal problems, and marital problems as the main reasons behind depression.¹⁷ Furthermore, BI has been shown to affect psychosocial well-being as its pathology can be characterized through changes in brain function, mental health disorders, and cognitive impairment.^5,7,10 Among IPV survivors, BIs likely occur repeatedly and tend to go unreported as most are mild in nature.³⁵ Repeated BIs can lead to long-term damage, negatively affecting health outcomes.¹⁴ Survivors often delay seeking medical help as they may not have the autonomy to go to a physician, or because of the stigma associated with experiencing IPV; therefore, worsening health outcomes.^11,35 As such, survivors of IPV and IPV-BI are at a higher risk of experiencing negative psychosocial health outcomes.

Associations between IPV-BI and future psychosocial health risks have been observed in female veterans; those with persistent symptoms related to IPV-BI were at higher risk for worse health over time.³⁶ While there has been research on PTSD in survivors of IPV-BI, there is no research on complex PTSD (CPTSD).¹¹ Due to being a fairly new diagnosis, there being some discourse on whether CPTSD can be fully differentiated from PTSD, and having some diagnostic overlap with bipolar disorder, CPTSD is currently not included in the DSM-5.³⁷ However, CPTSD may be a better clinical representation of the repeated trauma often experienced by survivors of IPV.^38,39

Study objectives

The current study explored IPV and IPV-BI in a sample of SA women within BC, Canada. This is the first exploratory study examining lifetime IPV-BI in Canadian SA women and the first study in Canada using an IPV screening tool specific to SA women (the South Asian Violence Screen [SAVS]).⁴⁰ We hypothesize a similar occurrence of IPV among SA women compared with women of other ethnicities but a lower rate of IPV-BI, given previous work showing SA women face more emotional than physical abuse.^25,26 We also assessed PTSD, CPTSD, anxiety, and depression among our participants. Given that SA women have been reported to have fewer support systems (a protective factor in mental health outcomes for immigrant women and seeking help for IPV),^17,18,41 we expected greater negative psychosocial outcomes among those experiencing IPV-BI. In addition, a secondary aim of the current study was to gain insight into the help-seeking behaviors of SA women in BC.

Methods

Ethics

This study was reviewed and approved by the Behavioral Research Ethics Board at the University of British Columbia Okanagan (H21-03426).

Sample and recruitment

A total of 39 participants participated. These were SA women, ages ≥ 18 years, who recruited via study posters advertised on social media (n = 27), in women’s shelters (n = 1), and in women’s shelter newsletters (n = 3) over the period of 12 months (February 2023–February 2024). The remaining participants did not indicate where they had heard of the study (n = 8). For the purposes of this study, we defined SA women as those who self-identified as SA. The shelters we advertised our study in are known to have a primarily SA population. In recruiting women, we had a broad set of eligibility criteria, as we wanted to maximize the generalizability of our results. Our inclusion criteria included: fluency in English, Punjabi, or Hindi; no history of moderate to severe BI outside of IPV; residence in BC; and no medical conditions impairing the ability to complete the survey. Women with a history of traumatic BI were excluded to reduce the risk of confounding effects of BI, ensuring observed outcomes were specific to IPV-BI.

Our study was conducted via online questionnaires administered through Qualtrics and available in English, Punjabi, and Hindi. All participants completed the study in English, except for one who completed it in Punjabi. Our study procedure consisted of a screening survey, followed by a consent form, and then questions about demographics and experiences of IPV, BI, and mental well-being. A total of 126 participants accessed the survey, of which 72 were excluded due to one of the following reasons: perpetrator being present or nearby (n = 44); safety concerns (n = 7); serious medical condition such as dementia (n = 5); prior non-IPV BI (n = 8); under the age of 18 (n = 1); not living in BC (n = 5); already participated (n = 1); and disagreeing to participate (n = 1). A total of 54 women were eligible and agreed to participating in the study. Of these, 15 did not provide any further information; therefore, the total number of participants was 39.

Informed consent was obtained following the screening survey, and participants were given the option to withdraw from the study at any point by exiting the survey. Participants were provided with resources and information regarding IPV and IPV-BI upon survey completion.

Evaluation of IPV and IPV-BI

We administered the 14-item SAVS questionnaire,⁴⁰ to determine, in a culturally appropriate manner, if physical/sexual, emotional, and in-law abuse are present. The SAVS has good reliability (Cronbach’s α = 0.913) and has been validated using the Index of Spouse Abuse (ISA).⁴⁰ The ISA is a valid and reliable tool in assessing IPV in SA women and is used as a “gold standard” to determine the validity and reliability of other IPV measures.^42–44

Probable BI occurrence was assessed using questions from the Brain Injury Severity Assessment (BISA) tool. The BISA has been used to assess BI specific to IPV and found to be strongly correlated with standardized assessments of BI in other contexts.⁹ We adapted the BISA as it was not originally developed for use as a survey tool. To create the modified version, we utilized questions from the original BISA that asked about signs and symptoms of BI following IPV. The BISA symptoms in our survey served as a screening measure for probable BI resulting from IPV, as defined by self-reported symptoms consistent with BI.

Psychosocial health outcomes were assessed using the General Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), and International Trauma Questionnaire (ITQ).^38,45,46 Both the GAD-7 and PHQ-9 had been previously translated into Punjabi and Hindi. The PHQ-9 Hindi translation has been found to be reliable.⁴⁷ Depression rates have been reported to be higher among SA women who answered the PHQ-9 and GAD-7 in Punjabi compared with English.⁴⁸ Remaining translations were completed by a hired research translator.

Statistical analysis

There was a total of 53 participants who started the study, but 21/53 (39.6%) of respondents did not provide any data beyond age. Therefore, only 39 (N = 39) were included in data analysis. Of these, 18/39 (46%) discontinued the survey prior to answering questions about IPV, therefore making the total sample size for the SAVS, N = 21. Possible reasons for not providing further data may revolve around safety and comfort of the subject matter. Participants were informed that they could exit the survey at any time if they felt unsafe or distressed, including due to the presence of a perpetrator. This was stated at the beginning of the survey and reiterated before violence-related questions.

Among the variables considered for the inferential analysis, 12 out of 378 data points (3.17%) were missing. Because of the relatively small sample size and the normal distribution of the key variables, the missing data points were substituted with values obtained through multiple imputation techniques.

Participants’ personal, family, and socioeconomic demographic characteristics, violence-related experiences, and disclosed signs and symptoms of BI were summarized using descriptive statistics [mean (SD) or number (%)]. SAVS responses were presented as a number (%). Total SAVS scores were calculated by adding the scores on all the items of the SAVS. Mann–Whitney U tests were run to determine differences in SAVS scores across a variety of comparisons (e.g., NFS vs. no NFS, BI signs and symptoms vs. none). Multiple linear regressions were conducted to explore correlations between the mental health measures and SAVS score, controlling for different covariates such as religion, age, country of birth, generation, education, and household annual income. Significance was set at p < 0.05. All statistical analyses were performed using SPSS Statistics version 30.0 (IBM Corp, Armonk, NY).

A Pearson correlation analysis was conducted to examine the association between clinic demographic characteristics (GAD-7, PHQ-9, ITQ, age, and education) and the SAVS score. It did not reveal a significant correlation between any two variables. Because correlation looks only at the pairwise relationship between two variables, while regression models the unique contribution of each predictor in the presence of others as well as their combined effects. Suppression effects occur when adding a predictor and thereby increase the effect of another variable in regression models, even if simple correlations are weak. Therefore, we conducted the multiple linear regression in which the variables may become significant after controlling for other variables.^49–52

Results

Table 1 outlines participant demographics (N = 39). The average age was 29.85 ± 8.42 years, with most residing outside of shelters (89.74%). Nearly half (41.03%) were born in Canada. 53.85% were married, of which 25.81% immigrated due to marriage, and 5.13% had no choice in selecting their partner. Almost half (46.15%) of the participants’ husbands were born in Canada. Hinduism was the most common religion (23.08%), followed by Buddhism, Sikhism, Islam, and Christianity, respectively. English (53.85%) was the most spoken language, 38.46% held a certificate or diploma, and 53.85% were employed outside the home. Household incomes varied, with 35.90% earning $50,000–$74,999, though 25.64% did not disclose income. Other familial and socioeconomic characteristics are outlined in Table 1.

Table 1.

Participants’ Personal, Family, and Socioeconomical Characteristics

Characteristics	Mean ± SD or # (%)
Characteristics	(Full sample, N = 39)	(Subsample; n = 21)^a
Age, years	29.85 ± 8.42	31.24 ± 6.62
Highest level of education
High school	9 (23.08)	6 (28.57)
Certificate/diploma or Bachelors and above	21 (53.85)	15 (71.43)
No response or do not want to disclose	9 (23.08)	0
What generation Canadian?
First	6 (15.38)	6 (28.57)
Second	9 (23.08)	9 (42.86)
Third or greater	3 (7.69)	3 (14.28)
No response or do not want to disclose	21 (53.85)	3 (14.29)
Where were you born?
Born in Canada	16 (41.03)	10 (47.62)
Born outside Canada	15 (38.46)	11 (52.38)
No response or do not want to disclose	8 (20.51)	0
What is your marital status?
Single	5 (12.82)	3 (14.29)
Married or currently in a relationship	22 (56.41)	18 (85.71)
No response or do not want to disclose	12 (30.77)	0
How long have you been in a relationship?
Less than 5 years	12 (30.77)	8 (38.10)
More than 5 years	11 (28.21)	10 (47.62)
No response or do not want to disclose	16 (41.03)	3 (14.29)
Do you have children?
No	11 (28.21)	8 (38.10)
Yes	15 (38.46)	13 (61.90)
No response or do not want to disclose	13 (33.33)	0
Do you live in a joint family?
No	9 (23.08)	5 (23.81)
Yes	17 (43.60)	16 (76.19)
No response or do not want to disclose	13 (33.33)	0
Annual household income
Under $50,000	9 (23.08)	7 (33.33)
$50,000–$74,999	14 (35.90)	11 (52.38)
$75,000 and above	6 (15.39)	3 (14.29)
No response or do not want to disclose	10 (25.64)	0
Who manages your salary?
Self	22 (56.41)	17 (80.95)
Husband	7 (17.95)	4 (19.05)
Father	1 (2.56)	0
No response or do not want to disclose	9 (23.08)	0
Who keeps your passport?
Self	27 (69.23)	18 (85.71)
Husband	3 (7.69)	3 (14.29)
No response or do not want to disclose	9 (23.08)	0

Subsample (n)—The subsample includes participants who completed the SAVS. N: Full sample.

SAVS, South Asian Violence Screen.

Regarding IPV, 56.41% (n = 22) responded to violence-related items, with 38.46% responding “yes” to having experienced IPV. Most cases involved husbands (60.00%), with 80.00% not specifying when violence began relative to their relationship. Among those who did, 13.33% reported it within the first 5 years and 6.67% between 5 and 10 years of their relationship. Table 2 provides further details on violence-related characteristics in the subsample who self-reported violence occurrence (n = 15).

Table 2.

Violence-Related Characteristics in Subgroups of Participants Who Experienced Violence

Characteristics	No. (%)
What is the relationship with the perpetrator (n = 15)
Boyfriend/Another partner	2 (13.33)
Husband	9 (60.00)
Husband’s family	1 (6.67)
Parents or siblings	1 (6.67)
Multiple (husband, husband’s family and parents)	1 (6.67)
No response or do not want to disclose	1 (6.67)
When did you experience the first incident? (n = 15)
1–5 years ago	11 (73.33)
6–10 years ago	0 (0.00)
11–15 years ago	2 (13.33)
More than 15 years ago	2 (13.33)
No response or do not want to disclose	2 (13.33)
How long after relationship did it occur? (n = 15)
Less than 5 years	2 (13.33)
5–10 years	1 (6.67)
More than 10 years	0 (0.00)
No response or do not want to disclose	12 (80.00)
SAVS score interpretation (n = 21)
Nonphysical	17 (80.95)
Physical	13 (61.90)
Domestic violence	1 (4.76)

SAVS, South Asian Violence Screen questionnaire.

Of the 22 participants who responded to the violence portion of the survey, almost all (n = 21, 95.45%) responded to the SAVS (Table 3). Based on the SAVS, many participants faced emotional violence (n = 17, 80.95%), followed by physical (n = 13, 61.90%), and domestic (n = 1, 4.76%). The most common response for emotional violence was husbands/partners making women occasionally feel they should obey them (n = 12, 57.14%) and husband/partner yelling, occasionally (n = 11, 52.38%) and very frequently (n = 1, 4.76%), when he thinks housework is not done properly.

Table 3.

Response to South Asian Violence Screen Questionnaire in a Subgroup of Participants Who Experienced Violence (n = 21)

SAVS questions	Response; n (%)
SAVS questions	Never	Rarely	Occasionally	Frequently	Very frequently
My husband/partner makes me feel like I should always obey him.	3 (14.26)	5 (23.81)	12 (57.14)	1 (4.76)	0
My husband/partner has punished me by hitting, slapping, kicking, or otherwise physically hurting me.	6 (28.57)	10 (47.62)	5 (23.81)	0	0
My husband/partner tells me that if I divorce or leave him, it would be a failure on my part	5 (23.81)	9 (42.86)	5 (23.81)	2 (9.52)	0
My husband/partner slaps me around the face and head.	7 (33.33)	11 (52.38)	2 (9.52)	1 (4.76)	0
My husband/partner makes me feel worthless.	5 (23.81)	6 (28.57)	9 (42.86)	1 (4.76)	0
I am the last person to eat during meals.	8 (38.10)	3 (14.26)	9 (42.86)	0	1 (4.76)
My husband/partner forces me to have marital relations when I do not want to.	9 (42.86)	7 (33.33)	2 (9.52)	3 (14.26)	0
My husband/partner has threatened to ruin my reputation or shame my family.	8 (38.10)	3 (14.26)	8 (38.10)	2 (9.52)	0
My husband/partner does not allow me to have control over money.	8 (38.10)	8 (38.10)	5 (23.81)	0	0
My husband/partner’s family keeps my jewelry and valuables with them and does not give me access to them.	8 (38.10)	7 (33.33)	5 (23.81)	1 (4.76)	0
My husband/partner yells at me when he thinks housework is not done properly.	7 (33.33)	2 (9.52)	11 (52.38)	1 (4.76)	0
My husband/partner’s family has made me feel worthless.	5 (23.81)	8 (38.10)	7 (33.33)	1 (4.76)	0
My husband/partner has punished me by threatening to deport me.	6 (28.57)	5 (23.81)	10 (47.62)	0	0
My husband/partner’s family has made me feel worthless.	7 (33.33)	9 (42.86)	5 (23.81)	0	0

SAVS, South Asian Violence Screen

Out of 15 participants who experienced IPV, two-thirds (n = 10, 66.67%) self-reported signs and symptoms that are consistent with the signs and symptoms of BI. The most common being problems remembering things (n = 7, 70.00%), followed by poor concentration, being disoriented, or confused (n = 6, 60.00%) and blurred vision, seeing stars, or abnormal vision (n = 5, 50.00%). Other signs and symptoms are outlined in Table 4 in descending order of presentation.

Table 4.

List of Signs and Symptoms Experienced by the Victims That Are Consistent with the Signs and Symptoms of Brain Injury in a Subsample (n = 10)

Signs and symptoms	No. (%)^a
Problem remembering things	7 (70.00)
Poor concentration, disoriented, or confused	6 (60.00)
Blurred vision, saw stars or spots, abnormal vision	5 (50.00)
Petechiae around head, face, or neck	3 (30.00)
Fatigue, tiredness, or weakness	3 (30.00)
Loss of consciousness or blacked out	2 (20.00)
Dizziness or lightheadedness	2 (20.00)
Headache	2 (20.00)
Tingling sensation around face, neck, or upper extremity	1 (10.00)
Raspy or hoarse voice	1 (10.00)
Sleep difficulties	1 (10.00)
Difficulty breathing or difficulty swallowing	1 (10.00)
Anxiety, depression, or post-traumatic stress disorder	1 (10.00)

Categories are not mutually exclusive.

Mann–Whitney U tests revealed higher SAVS total score (U = 13.50, n = 21, p = 0.03) among those who experienced NFS (n = 5) compared with those who did not (n = 16) (Fig. 1A). Similarly, those who disclosed signs and symptoms of BI (n = 10) demonstrated significantly higher SAVS total score (U = 21.50, n = 21, p = 0.02) compared with those who did not disclose such signs and symptoms (n = 11) (Fig. 1B). Furthermore, those who disclosed signs and symptoms of BI scored significantly higher (p = 0.01) on the SAVS-Physical domain (Fig. 1C), which was not the case for SAVS-Nonphysical domain (p = 0.08) (Fig. 1D). This suggests that those who experienced physical violence were more likely to experience signs and symptoms of BI. Other demographic and familial variables, such as “living in a joint family” (yes vs. no), “having child/children” (yes vs. no), “who keeps salary” (self vs. husband), “age” (<30 years vs. ≥ 30 years), “which generation Canadian” (born in Canada vs. born outside Canada), “duration of marriage” (<5 years vs. ≥5 years), “highest level of education” (high school vs. diploma or university degree), and “marital status” (married vs. not married but in a relationship), did not reveal any significant differences (p > 0.05). This could either be because of a larger number of blank survey responses on different items or due to the small sample size.

FIG. 1.

Variation of South Asian Violence Screen (SAVS) scores in different groups. (A) SAVS total score in the group who experienced NFS versus who did not; (B) SAVS total score in the group who disclosed signs and symptoms related to BI versus who did not; (C and D) SAVS-Physical score and SAVS-Nonphysical score in the group who disclosed signs and symptoms related to BI versus who did not, respectively. Higher SAVS score indicates higher probability of the occurrence of IPV-BI. BI, brain injury; IPV-BI, intimate partner violence – brain injury; NFS, nonfatal strangulation.

Multiple linear regression analysis (Table 5) showed that GAD-7 was significantly associated with the SAVS. Specifically, higher anxiety symptoms were associated with higher SAVS scores (β = 1.59, p < .05), suggesting that for each one-unit increase in GAD-7, the SAVS score increased by approximately 1.59 units after adjusting for covariates. Similarly, “level of education” was significantly associated with the SAVS in a negative manner (β = −8.40, p < .05). This suggests that individuals with lower education levels scored, on average, 8.4 points higher on the SAVS compared with those with higher education levels, after adjusting for other variables. Other covariates, including PHQ-9, ITQ, age, and religion, did not contribute significantly to the model (p > 0.05).

Table 5.

Multiple Linear Regression Looking at the Relationships Between the Mental Health Measures and SAVS Total Score Controlling for Age, Education, and Religion as Covariates in a Subsample Who Completed SAVS Questionnaire and Mental Health Measures (n = 21)

Exposure variables		SAVS total score (outcome variable)
	Coefficients (B)	Std. error	T	Sig.	95.0% confidence interval
					Lower bound	Upper bound
(Constant)					68.927	17.074	4.037	0.002	30.883	106.971
GAD-7 score	1.588	0.616	2.576	0.028*	0.215	2.961
PHQ-9 score	−0.540	0.485	−1.112	0.292	−1.621	0.542
ITQ score	0.187	0.200	0.936	0.371	−0.259	0.633
Age	−0.890	0.527	−1.689	0.122	−2.064	0.284
Education	−8.439	2.446	−3.450	0.006*	−13.890	−2.989
Religion*	0.066	1.205	0.055	0.958	−2.620	2.751

Bold indicates significance at p < 0.05.

Covariates included in the analysis: age in years, education (High school, Diploma, or Bachelor and above), and religion (Sikhism, Hinduism, Christianity, Islam, or Buddhism).

GAD-7, General Anxiety Disorder-7; ITQ, International Trauma Questionnaire; PHQ-9, Patient Health Questionnaire-9; SAVS, South Asian Violence Screen.

Regarding help-seeking, out of the 39 participants, only a few (n = 5, 12.82%) sought help after experiencing violence. Out of five, three participants sought help 1–3 times, and two participants sought help 4–7 times. Figure 2 describes from whom help was sought.

FIG. 2.

Help was sought from family or friends (n = 3, 7.69%), a community or religious center (n = 2, 5.13%), or a family doctor (n = 1, 2.56%). Many of the participants either did not seek help (n = 15, 38.46%) or did not respond or did not want to disclose their experiences with help-seeking (n = 19, 48.72%).

Discussion

This exploratory study serves as the first step toward filling a gap in the IPV-BI literature regarding IPV in SA women in BC, Canada. Due to the study's exploratory nature and sample size, causal relations cannot be drawn. However, several findings warrant discussion in relation to prior evidence.

Our first hypothesis, informed by prior studies reporting comparable IPV prevalence but greater emotional than physical abuse (35% compared with 24% and 17% compared with 6%)^25,26 among SA women, was that IPV prevalence would be similar in this sample compared with women of other ethnicities, but with a lower prevalence of IPV-BI. This hypothesis was partially supported as the prevalence of IPV observed in our sample of SA women (38%) appeared higher than some published prevalence of global estimates (30%) and estimates from SA (35%), but slightly lower than that of Canadian women on the whole (44%).^1,15,53 These comparisons are intended for contextual comparison and do not imply population-level difference. Furthermore, larger studies are required to determine causal comparisons across populations.

Contrary to our hypothesis, self-reported symptoms of probable BI were high among our sample. A total of 67% of survivors of IPV reported signs and symptoms of BI, which may be due to physical IPV (as the SAVS scores indicate a higher probability of occurrence of IPV-BI), consistent with previous IPV-BI estimates of between 30% and 92% in survivors.^5–9 This high rate of probable IPV-BI suggests that IPV-BI needs to be further investigated in this population. More recent work in the United States also supports that the most prevalent type of DV in SA women is found to be physical violence (48%).⁵⁴ These findings highlight the need to screen for BI in SA women experiencing IPV/DV, as BI may be an underrecognized but prevalent outcome. Incorporating culturally responsive approaches into IPV services can help identify survivors at higher risk and support timely intervention.

On the contrary, the SAVS, a culturally specific IPV screening tool, indicated that emotional violence (81%) was more prevalent than physical violence (62%), supporting prior research.^25,26 We also assessed NFS as a distinct indicator of severe physical violence and found that although emotional violence was endorsed more frequently on the SAVS than physical violence, higher SAVS scores were associated with increased reports of NFS. This discrepancy suggests that the SAVS may be underestimating physical violence in SA women, and the inclusion of NFS would help to gain a better understanding of physical violence occurrence. Given that NFS is a major risk factor for homicide,⁵⁵ inclusion of it in screening tools is critical.

Our hypothesis that SA survivors of both BI and IPV would have greater rates of PTSD, CPTSD, anxiety, and/or depression was also partially supported. This hypothesis was made based on prior research recognizing that SA women who face IPV are three times more likely to report poor mental health and domestic abuse, interpersonal problems, and marital problems, being the main reasons behind depression in SA women in Toronto.^17,56 While no significant associations were made for depression, PTSD, and CPTSD, results of this study suggest GAD-7 (anxiety) scores to be 1.59 higher in those who scored higher on the SAVS. This exploratory association suggests psychological distress may both result from and exacerbate vulnerability to abuse. Past work shows that abused SA women have reported compromised physical and mental health in the United States,⁵⁶ and our findings suggest similar findings for Canada. However, due to the small sample size for the regression model used in Table 5—which looked at the association between GAD-7 and SAVS—the results were probably underpowered and overly fitted. Hence, the results of the regression analysis should be interpreted with caution.

Consistent with previous work,¹⁷ our results also suggest delayed or no help-seeking. Most survivors in our study did not seek help or did not want to disclose whether they had sought help. This may be due to stigma, societal expectations, not being aware of available supports, or a lack of autonomy. These findings reinforce the need for culturally sensitive interventions and integrated care models that address IPV and mental health in an SA context, rather than individual services.

Beyond measured constructs, potential contextual interpretations can be cautiously considered from our study results. Of the subsample in our study who experienced IPV/DV, 71% were either 1^st or 2^nd generation Canadian, which may reflect that ideologies and practices from SA may be prevalent among SAs in Canada and possibly influence familial practices. Notably, 47% of participants reported being threatened with deportation by their husband or partner, a form of coercive emotional control assessed in the SAVS. For SA women, stigma and immigration-related vulnerabilities may prevent disclosure of IPV, suggesting underreporting. However, interpretation of the higher rate of IPV relative to global rates must be done in the context of racialization, isolation, and systemic barriers in Canada for SA women who are a minority. That said, our findings also suggest higher rates of IPV compared with the 29% rate previously reported among visible minorities in Canada.⁵³ While previous work found no significant difference in IPV prevalence among SA women, compared with a sample of women of other ethnicities,²⁵ this study did not administer its questionnaires within completely private locations, and this may have led to underreporting of IPV due to fear or shame of disclosing.

Finally, this study suggests a potential intersection between educational attainment and IPV risk. The probability of IPV occurrence based on the SAVS score was 8.44 times higher in women who had a lower level of education (high school) compared with those who had a higher level of education (Diploma or Bachelor and above). Previous work has found that education significantly decreases the incidence of DV among an Indian population.¹⁶ This finding warrants further research investigating education, violence, and BI among Canadian SA women. As Tuck argues, researchers must avoid reinforcing stereotypes of cultural pathology.⁵⁷ In the context of this work, it is important to note that this research does not suggest that SA communities are inherently oppressive or violent. For SA immigrants in Canada, systemic barriers to seeking support must be considered. Therefore, these data suggest a compounded risk of IPV due to the intersection of lower education, gender, and migration status.

Overall, these exploratory findings suggest that IPV-BI and physical violence may be underrecognized in this population. Future, large-scale studies are needed to fully understand the relationship between IPV, BI, mental health, and help-seeking in SA women.

Limitations

This study has several limitations. The small sample size limits the ability to conduct statistical analyses and extrapolate findings to the broader population of SA women in BC. Because the sample size in this study was small, the results were probably underpowered and overly fitted. Hence, the results of the regression analysis and the findings of the study should be interpreted with caution. Despite efforts to improve accessibility, including consultation of a primarily SA women’s shelter director to ensure comprehensiveness and ease to complete, and survey availability in three languages, participation remained low. As aforementioned, possible reasons for low participation may include stigma surrounding IPV-BI, lack of awareness, living with perpetrator, and concerns about confidentiality. Future studies may benefit from recruitment through word of mouth or at community centers, rather than newsletters, social media, and posters in women’s shelters.

Another limitation of our study is that we did not determine the reliability and validity of the BISA tool in our survey context. Therefore, the BISA served as a basis for self-reporting of BI in our study, but causal inferences of BI prevalence cannot be made.

Recruitment through social media and community shelters may have introduced selection bias, as participants may have been more likely to have existing connections to support services or access to technology. As a result, SA women with limited internet access and not engaged with support systems may be underrepresented. This may have led to an overestimation of IPV prevalence if women with lived experiences and existing supports were more able to participate. However, underestimation is also possible if highly marginalized women without access to the internet and supports were unable to access the study. As such, the findings of the study should be interpreted as exploratory and may not be generalizable to the broader population of SA women in BC.

Another limitation included a high rate of incomplete surveys. While many started the survey, many participants did not finish, reducing data availability. Possible explanations may include emotional distress, discomfort answering IPV questions at home, or safety concerns if a perpetrator was present. A high proportion of participants also chose “do not wish to respond,” limiting the ability to gain a comprehensive understanding of IPV and DV in this population. Reluctance to respond may be due to stigma associated with speaking out about DV.

While computerized, rather than verbal, surveys have been shown to be preferred for IPV screening,⁵⁸ our findings suggest that in SA populations, computerized methods may still limit disclosure. Written self-completed surveys have also shown lower disclosure of IPV.⁵⁸ Therefore, we recommend future projects to consider one-on-one interviews to better understand IPV-BI in the SA population.

Overall, given the small sample size and incomplete surveys, our findings should be interpreted as exploratory, serving as a foundation for larger studies.

Recommendations

We recommend updating the SAVS to include an NFS-related question, as NFS was associated with higher total SAVS, suggesting the SAVS may be missing a critical question to understand physical violence. We also recommend that future studies consider administering in-person surveys, given high noncomplete rates with online administration. A larger, potentially nation-wide, study with a larger sample size is also needed to gain a better understanding of IPV and DV in SA women in Canada. Finally, many service providers address IPV from a Western feminist discourse that does not consider the way ethnic women may be experiencing IPV.^34,59 Therefore, it is vital to understand and consider cultural impacts, resilience, and minority women’s perceptions in both research and health care to better aid them.^34,59

Conclusions

Our results provide valuable insight into IPV among SA women in BC and its relation to BI and psychosocial wellbeing. Further research is needed to establish prevalence across Canada and support the creation of culturally informed health care and community interventions. Overall, our study provides insight into an area not previously studied and points to the need for more research investigating BI in SA women experiencing IPV and DV.

Authors’ Contributions

J.K.D.: Conceptualization, questionnaire development, conducting a survey, data cleaning and data analysis, and article writing (original drafting, reviewing, and editing). S.P.A.: Conceptualization, questionnaire development, conducting a survey, data cleaning and data analysis, and article writing (original drafting, reviewing, and editing). N.M.: Conceptualization, questionnaire development, and article writing (reviewing and editing). P.v.D.: Conceptualization, questionnaire development, and article writing (reviewing and editing).

Footnotes

Acknowledgments

The authors wish to acknowledge all the community organizations that directly or indirectly supported this project through promotion, recruitment, and execution. The authors would like to thank Kusum Soni for her support in providing translations for the study. The authors extend special gratitude to the valued, lived experience of survivors of IPV who supported this project with their time, energy, and attention as research participants.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This research was supported by a grant from the Department of Women and Gender Equality Gender-Based Violence Program (grant number 62R01998).

Abbreviations

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Characterizing Domestic Violence and Probable Brain Injury in Canadian South Asian Women: An Exploratory Survey

Abstract

Background:

Materials and Methods:

Results:

Conclusions:

Keywords

Background

Intimate partner violence, domestic violence, and brain injury

IPV among SA women

IPV, BI, and psychosocial health outcomes

Study objectives

Methods

Ethics

Sample and recruitment

Evaluation of IPV and IPV-BI

Statistical analysis

Results

Discussion

Limitations

Recommendations

Conclusions

Authors’ Contributions

Footnotes

Acknowledgments

Author Disclosure Statement

Funding Information

Abbreviations

References