DHEERA reaching the young, a novel approach addressing gender‐based violence in India

To understand, build capacities, give guidance, and support school‐going adolescent boys and girls on gender stereotypes and violence against women (VAW) and to assess the role of educational training in improving knowledge, attitudes, and practice to stop VAW.

Data published in the National Family Health Survey -4 (2015-2016) and 5 (2019-2021) in India showed that 29.3% of ever-married women have experienced physical, sexual or emotional violence, 3.1% have experienced physical violence during pregnancy, and 82.8% of the time, the current husband is the perpetrator of the violence. 3Since the outbreak of the COVID-19 pandemic, people throughout the world have been affected across a number of dimensions-in terms of access to health, education, financial resources, etc. more so in the case of women.Data from the National Commission of Women show that in India, women filed more domestic violence complaints during the lockdown than were recorded in a similar period in the previous 10 years and intimate partner violence and domestic violence more than doubled during the COVID-19 pandemic; 4 what we identify as VAW is only the tip of the iceberg. 5W is one of the root causes of maternal morbidity, reproductive coercion, and poor physical, emotional, and psychological health of women.It is a cycle of abuse from prebirth in the form of sexselective abortion to childhood to adolescence to reproductive age and beyond. 6imination of VAW has been high on the global agenda for several organizations working in the area of women's health for close to three decades. 2The United Nations' call in 1993 to eliminate VAW, 1 the Beijing Declaration and Platform for Action at the Fourth World Conference on Women in 2015, and the United Nations Agenda for Sustainable Development-2030 all focus on a global target to eliminate "all forms of VAW and girls in the public and private spheres".
Gender-based violence and VAW are two terms often used interchangeably, as most VAW is inflicted for gender-based reasons and such violence affects women disproportionately. 7stetricians and gynecologists are the specialist stakeholders of women's health and occupy a unique position. 8They are the first point of contact for the health and emotional needs of women; by the nature of the patient-physician relationship, they have a good understanding of the issues, so are best suited to be involved in advocating, capacity building, sensitizing, and orienting those affected and educating the young against this scourge of society.DHEERA provided a common platform for all those who were involved in the No to VAW initiative and served as an important milestone to raise awareness on the fact that VAW is a social issue, a human rights violation, and one which is preventable through the collective efforts of policy makers and stakeholders.Across India between 2016 and 2021, several public forums, cycleathons, bikeathons, flash mobs, radio shows, and walkathons were organized to raise awareness of VAW and build consensus on the need to overcome this issue.Work on DHEERA during the earlier years and literature review 9,10 brought home several key findings; namely, VAW is a mindset with roots early in life due to violence witnessed in the family; patriarchal, cultural and religious attitudes; and normalization of VAW in the media and communities alike.The key to bringing about any visible change includes continuing to raise awareness on a larger scale, and educating and involving all stakeholders, especially the healthcare providers and adolescents.

| MATERIAL S AND ME THODS
DHEERA-Say No to VAW was the first large-scale national initiative of its kind to be launched in India.This educational interventional program was conducted among boys and girls (in the 9th to 12th grades) for a period of 18 months (August 2021 to April 2023).DHEERA presented a unique opportunity to bring together students, teachers, principals, school administrations, and parents from public and private schools to sensitize, train, and orient them regarding VAW, a deep-rooted menace, to highlight its impact on women's health, and to raise awareness among various sections of society to begin the end of VAW.The core team drafted and designed a comprehensive plan for the launch and program scale up (Figure 1).Subject matter experts and youth leaders were involved in developing the curriculum so that young minds could relate to it.The program was delivered in a cascade manner by training master trainers (FOGSI members and teachers) who then conducted a 2½-hour-long highly interactive program with case studies and freeflowing question and answer sessions among the students.
Five key pillars were identified for DHEERA and in partnership with the United Nations Children's Fund (UNICEF) India country office, their implementation was initiated in 2021.

| Forging partnerships: FOGSI, UNICEF India country office
FOGSI forged a partnership with UNICEF and its experts, police, lawyers, and youth leaders to complement the efforts of the DHEERA consultations.
The partnership was forged with the overarching goal to build the curriculum and scale up the training in schools across India using FOGSI's reach of more than 42 000 members throughout the country.A core team was formed, which deliberated and established the way forward on aspects of the program content, curriculum, training scale up, data collection, and program monitoring.

| Training roll-out: 2½-hour training sessions
A phase-wise plan was developed to conduct multiple and in parallel trainings in a cascade manner.Emphasis was given to ensure that trainer fatigue was taken care of and that the language used in the training was appropriate for the students being addressed.Data from pre-test, post-test, and feedback were gathered after obtaining permission from the school authorities.

| Statistical analysis
Data were entered into MS Excel.All categorical variables were expressed as frequency and percentages.A χ 2 test was used to test the difference between qualitative variables and a P value less than 0.05 was considered statistically significant.SPSS version 26.0 (IBM, Armonk, NY, USA) was used for analysis.

| Ethics approval and consent to participate
Ethics approval was not applicable because the DHEERA initiative was led by FOSGI as a training or capacity building activity and was not conducted as a research activity.The information collected during the desk review for curriculum development is publicly available data.Pre-and post-tests were performed among all participants who were informed of the purpose and did so within their official capacity and were selected by FOGSI.Verbal and written informed consent to participate in the training was obtained from all participants.

| RE SULTS
Across India, a total of 3500 DHEERA training sessions were completed, through which we were able to reach 240 000 girls and boys in grades 9 to 12, 7000 teachers, and 1600 master trainers.
A total of 8931 participants (9th to 12th grades) from 26 Indian states submitted their pre-test, post-test, and feedback forms when the program was initiated online during the pandemic.This gave the participants privacy for their responses and they were not influenced by the presence of other students in the same premises.Most were from Andhra Pradesh (19.4%),Maharashtra (13.6%),Tamilnadu (11.9%), and Karnataka (11.4%) (Table 1).
Of these 8931 participants, 5716 (64%) were female and 3215 (36%) were male.The responses of participants to both pre-test and post-test questions were compared.Twelve questions were There was considerable improvement in identifying problematic behavior in the above scenario; participants feeling that Rahul was indulging in both sexism and stereotyping by making joke of a slow driver being a woman changed from 56% (5001) to 59.6% (5324) (pre-test versus post-test) (P < 0.001).The 10th and 11th questions were of utmost importance in assessing the crucial concept of consent in relationships.The appropriate response that Varun must understand her right to not accept his invitation and respect her choice was picked up by 83.4% (7448) of participants in the post-test compared with 3.6% (323) in the pre-test (P < 0.001).The 11th question was about the concept of consent in the coffee invitation scenario of the 10th question, where there was a significant jump in reinforcing the concept of consent from 57.1% (5098) in the pre-test to 64.8% (5788) in the post-test (P < 0.001).The 12th question "Husband under stress for months trying to complete a project just received news over phone that he was fired and would not be compensated for his work, when the wife tries to find out about the conversation, he lashes out at her and hits her.Is it VAW?" was intended to elicit the presence or absence of ambiguity in identifying VAW/Domestic violence by adding an apparently strong reason for violence by the husband.The pre-test response that it was not violence was 18.4% (1641), which fell to 16.4% (1461) in the posttest (P < 0.001).
When stratified for gender, similar improvements were observed for questions 1, 2, 3, 5, 6, 7, 10, and 11 (Table 3).All of these improvements were statistically significant (P < 0.001).For question 4, i.e. if it was appropriate to follow a girl and try to force a conversation as shown in movies, the response that it is not appropriate was not significantly changed in both genders (P > 0.05).For question 8, i.e. women driving a car, the appropriate response that driving is a skill that is not dependent on gender was significantly improved in males but not in females.For question number 12, i.e.
"Husband under stress for months trying to complete a project just received news over phone that he was fired and would not be compensated for his work, when the wife tries to find out about the conversation, he lashes out at her and hits her", the appropriate response would be no.This significantly improved in females but not in males.
Feedback for the entire course was measured again by a set of questionnaires administered after the course along with the posttest.For all the feedback questions, the program received an overwhelming response with very high scores for strongly agree and United Nations declared November 25 as the International Day for Elimination of VAW and every year this day is marked by activities amplifying the voices of survivors, and supporting activists and advocates of women's organizations.In solidarity with the global commitment of the United Nations, WHO, governments, and communities against VAW, in 2016, FOGSI (the Federation of Obstetric & Gynecological Societies of India) and FIGO (the International Federation of Gynecology & Obstetrics) committee on No to VAW initiated DHEERA-a sociomedical campaign.In support of the entire campaign, FIGO released its No to VAW declaration in 2018, which was jointly signed by WHO and all member societies.

Pillar 1 :Pillar 2 :Pillar 3 :Pillar 4 :Pillar 5 :
Launch of DHEERA school certification program.This generated a lot of interest and ensured participation of the schools, teachers, and students.Boys and girls were sensitized and educated together.On successfully completing the program, all participants were awarded a DHEERA Champion certificate.Involve obstetricians and gynecologists.FOGSI has more than 42 000 obstetricians and gynecologists as members and tapping into the large numbers gave us the advantage of reaching large geographical regions across the country.As obstetricians and gynecologists are often the first point of contact in cases of injuries related to VAW, building capacities and sensitizing healthcare professionals to the dynamics of VAW helped, as they could now contribute towards its reduction.Group level interventions working with parents of the students.Intensive community-level work and awareness raising campaigns.Engage government (Ministry of Health and Family Welfare/Ministry of Women and Child Development and Ministry of Education) key stake holders to ensure that DHEERA becomes part of the school curriculum.
The 2½-hour curriculum included case studies, videos, and a dedicated time for questions and answers.A special video, which gave a demonstration on the universal sign of distress, which can be used without attracting the perpetrator's attention or anger, was created and played during the training programs.Chat box of the online delivery platform was used extensively to elicit participant responses and keep them engaged.Pre-test, posttest, and feedback surveys were developed and used to gather information on baseline knowledge and gains after training.Pre-test and post-test surveys were developed keeping in mind the curriculum content being delivered during the training and the expert group, which included adolescent leaders' inputs on what they collectively felt were critical net take home messages from each training module that should remain etched in the minds of the participants long after the trainings have long been completed.
over a period of 18 months from August 2021 to April 2023.The initial months were spent on preparation of the curriculum, pilot testing it, updating the curriculum, and working out the strategic plan for program launch and scale up.Once the content was tested and finalized, master trainers were trained and a platform for roll-out of F I G U R E 1 Summary of DHEERA initiative preparation and roll-out in India-August 2021 to April 2023.

STEP 1 :
FOGSI, UNICEF Partnership Established Core team established STEP 2: Content Creation Completed STEP 3: Training Rolled out and taken to Scale Phase I (Aug 21) Contents as per strategic approach and implementation plan created Phase II (Sept -Nov 21) Mock training sessions conducted with core team and MTs identified Phase III (Dec 21) MTs trained and training timeline created, and logistics done Phase IV (Jan 22 -Apr 23) Program scaled up across India using online, hybrid and physical modes of training STEP 4: Results and Documentation 3500+ Training sessions completed.240,000+ Students trained.7000+ Teachers trained.1600+ Master Trainers trained.BOX 1 Curriculum modules a.What is violence against women (VAW)?b.Types of VAW? c. Management of VAW-whom to contact, when to contact, confidentiality, consent, helpline numbers, etc. d.Role of bystanders.How can they help?e. Bridging the gender divide-stereotypes, roles, societal issues, etc. f.Peer Pressure and how to handle the same?virtual training was created by the FOGSI program secretariat; trainings were conducted in a phase-wise manner.Phase I (August 2021) Development of master trainers and participants registration forms, pre-test and post-test questionnaires, program feedback forms, certificates for students, teachers, master trainers, and schools, standard online platform templates for online/hybrid training, school participation invitation letters, anticipated or expected questions and standard responses, database collection templates, programmonitoring specific software, program training plan and implementation guide, and preparation of master schedule to conduct multiple and in parallel trainings for all.Phase II (September to November 2021) Mock sessions by core team to ensure that national trainers were on the same page with the program strategic needs, training flow, language requirements as per the State in which the program was being conducted, and anticipated or expected questions and standard responses.Phase III (December 2021) All master trainers who volunteered to participate in this massive initiative were trained as master trainers by the national core team.Phase IV (January 2022 to April 2023) National scale up commenced.Schools and State Government Department of Education were approached by FOGSI members.The response to the program was overwhelming and on some days we were conducting four to six parallel programs.Once the pandemic situation improved and restrictions were withdrawn, the program implementation was modified to (1) accommodate hybrid and physical modes of training delivery and (2) conduct additional master training programs to create trainers from geographical regions where we had no trainers and training was being conducted in physical mode.
VAW because healthcare professionals are often "the first-line response" for many people who experience domestic violence.Unfortunately, healthcare professionals face personal barriers, including attitudes and perceptions that violence is a private issue, fear of offending their patient, fear of the patients' abuser, a lack of understanding of abuse, lack of confidence, or lack of training on screening techniques.Studies have shown that time constraints, inadequate resources and support, lack of referral sources, and lack of adequate procedures for screening are all additional barriers that healthcare professionals may face.23No change is possible until young people embrace it and make it part of their lives.Young minds are creative, open, accepting, and fair, and the young can be harbingers of real change.Young people, who are the future generations of any society, are the key to any initiative on stopping VAW.Changing mindsets is difficult and perhaps may take generations, so it is critical that any program addressing VAW needs to be initiated now and among these young impressionable minds.Program planning, its strategic approaches, and its tight implementation using modern technologies to reach the unreached add to the overall success of program implementation with major improvements in knowledge and attitudes of those receiving such exposure.A program implemented on a large scale should be self-sustaining, so embedding such programs within the institutions responsible for shaping young minds is important.We need to look at all opportunities to institutionalize all such programs.DHEERA implementation strongly demonstrated that (1) it is possible to launch and scale up a very large nationwide program and deliver a program online and in hybrid/in-person modes through systematic planning;(2) it is important to involve healthcare professionals in program training delivery because they add to its credibility; and (3) involvement of an association/body representing a large group of healthcare professionals adds organizational weight and collective commitment.One of the key limitations we observed was in the selection of schools, whether they were all girls, all boys, or co-ed could lead to a bias in the results.Implementors of similar programs in the future may like to consider exploring and adding to our findings; comparison between the results of an online versus hybrid/in-person program, and differences in responses of (1) a 9th versus a 12th grader (did age make a difference?);(2) English medium schools versus other language medium schools; and (3) what are the differences in responses by students from different States/geographic regions.In conclusion, this was a novel nationwide educational interventional program to assess the effectiveness of an educational intervention to stop VAW.The program had a high impact, as seen from P values, and there was significant improvement in the knowledge base and attitude after the 2½-hour modular training to students towards stopping and preventing VAW.

TA B L E 1
State-wise distribution of study participants.a a Data are presented as number and percentage.TA B L E 2Comparison of responses of study participants towards violence against women between pre and post-intervention.a There was a significant change in the perception and responses after the 2½-hour course module in the post-test.The percentage of responses that they would seek out friends and family if subjected to violence improved from 76% (6789) to 83.8% (7483) in the post-test and the response that they would be silent reduced from 24% (2142) to 16.2% (1448) (P < 0.001).To the question of whether it was appropriate to follow a girl and try to force a conversation as shown in movies, the response that it is not appropriate

Question Response Females (n = 5716) Males (n = 3215) Pre-test, % Post-test, % Pre-test, % Post-test, %
A husband spends months completing a project, is stressed as he is fired over a phone call.Not compensated.His wife tries to find out who he is talking to and he lashes out tossing the phone and hits his wife.Is the action justified?Gender-wise comparison of responses of study participants towards violence against women between pre-and post-intervention.a (97.07%; 8670).The responses are listed in Figure2.TA B L E 2 (Continued)TA B L E 3d.He should follow her every day, so that she is impressed and agrees.