Global Health Research

Research Article

Mental health and violence against women in Afghanistan, India

and Sri Lanka: a situation analysis

Meaghen Quinlan-Davidson ,1,2,3* Ayesha Ahmad ,4 Laura Asher ,5 Urvita Bhatia ,6,7
Nayreen Daruwalla ,8 Delan Devakumar ,3 Abhijit Nadkarni ,6,9 Alexis Palfreyman ,3
Lamba Saboor,10 TH Rasika Samanmalee 11 and David Osrin 3

1
The Margaret and Wallace McCain Centre for Child, Youth & Family Mental Health, Centre for Addiction and Mental
Health, Toronto, Canada
2
Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
3
Institute for Global Health, University College London, London, UK
4
St George’s University of London, London, UK
5
Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
6
Addictions Research Group, Goa, India
7
Department of Psychology, Health and Professional Development, Oxford Brookes University, Oxford, UK
8
Society for Nutrition, Education and Health Action, Mumbai, India
9
Centre for Global Mental Health, Department of Population Health, London School of Hygiene & Tropical Medicine,
London, UK
10
Independent Consultant, Afghanistan
11
Department of Psychiatry, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka

Corresponding author [email protected]

*

Published April 2025

DOI: 10.3310/GDOM7555

ABSTRACT
Background: Globally, 10–53% of ever-partnered women have experienced physical or sexual intimate partner
violence over their lifetime. Women survivors of violence are at high risk of poor mental health. In this study, we
investigate women’s exposure to violence and mental health conditions in Afghanistan, India and Sri Lanka, while
considering the policy and service contexts.
Methods: A situation analysis tool was developed for the study. We extracted information from grey and peer-
reviewed literature and other publicly available data investigating the prevalence of violence against women and
mental health conditions, policies addressing violence against women and mental health conditions in each country
and the services available to women exposed to violence and women with mental health conditions.
Results: Forty-six per cent of women in Afghanistan, 21% of women in India and 5% of women in Sri Lanka reported
experiencing physical violence within the last 12 months of the most recent survey. Meanwhile, 7% of ever-partnered
women in Afghanistan, 6% of women in India and 7% of women in Sri Lanka reported experiencing sexual violence
during their lifetime. In India, 6.9% of disability-adjusted life-years were attributed to childhood sexual abuse and
4.6% to intimate partner violence. In Sri Lanka, 14.6% of women exposed to physical or sexual violence by a partner
had engaged in self-harm. We found no data on conflict-related sexual violence and trafficking. All three countries
have made commitments to gender equality or preventing violence against women. Implementation of some of these
policies, however, is unclear. The countries also have had mental health policies and services, but there is currently
little intersection between mental health and violence against women.
Limitations: The situation analysis is limited by the data available and the generalisability of findings.
Conclusion: The three countries have limited data, policies and legislation on the intersection between all forms of
violence against women and poor mental health as well as a paucity of mental health service provision.
Future work: Future research should focus on integrating mental health care within social services; translating
trauma-informed approaches into service provision and addressing family violence within violence against women.

This article should be referenced as follows:

Quinlan-Davidson M, Ahmad A, Asher L, Bhatia U, Daruwalla N, Devakumar D, et al. Mental health and violence against women in Afghanistan, India and Sri Lanka: a situation analysis
1
[published online ahead of print April 30 2025]. Global Health Res 2025. https://doi.org/10.3310/GDOM7555
DOI: 10.3310/GDOM7555 Global Health Research 2025

Funding: This article presents independent research funded by the National Institute for Health and Care Research
(NIHR) Global Health Research programme as award number 17/63/47.
A plain language summary of this research article is available on the NIHR Journals Library Website
https://doi.org/10.3310/GDOM7555.

Introduction Meanwhile, demand-side barriers like stigma, sociocultural

norms and lack of financial resources affect uptake. These
Defined as public or private actions or threats made to barriers could be attributed to the social acceptability of
intentionally hurt or harm women physically, sexually or VAW in some settings, overburdened and underfunded
psychologically (such as coercion and loss of freedom),1 mental health systems and the consequent limited
violence against women (VAW) is a human rights violation capacity of staff to respond adequately.29,30 Additionally,
and global public health problem that adversely effects health systems in conflict-affected settings are particularly
women’s health and well-being.2 Global estimates suggest fragile, with most of the population being unable to obtain
that between 10% and 53% of ever-partnered women basic health services.31 In such settings, there is a lack of
have experienced physical or sexual intimate partner understanding of how mental health services respond (if
violence (IPV) in their lifetime.3,4 These estimates are wide- at all) to women survivors of violence.
ranging due to the challenges of collecting accurate data,
given stigma, issues of non-response and safety, cultural In light of these gaps, there is a need to develop effective
and gender norms around violence, non-recognition of mental health and VAW prevention and intervention
VAW and issues of privacy and confidentiality, among strategies. The goal of our wider research programme was
others.5 Recurrent and chronic exposure to violence leads to develop a package of care to support the mental health
to persistent stress and results in poor mental health and of survivors of VAW in Afghanistan, India and Sri Lanka.
well-being.3 This stress commonly manifests as anxiety, Importantly, Afghanistan has been in a state of conflict for
depression, post-traumatic stress disorder (PTSD), self- more than four decades,32 with a recent escalation due
harming thoughts and/or behaviours and/or substance to a change in government in August 2021.33 Sri Lanka
misuse.1–3,6–11 experienced 26 years of civil war (1983–2009)34 and has
recently experienced ethnic and religious tensions and
Violence against women is considered a gendered political conflict.35
issue. The prevalence of domestic and sexual violence
victimisation is higher among women than men. Moreover, Designing intervention strategies that are contextually
VAW exposure places women at higher risk of suffering relevant requires an in-depth understanding of
from depression, anxiety and suicide.12–14 epidemiology as well as existing policies, legislation and
services.36 Experiences of violence and its mental health
Conflict further affects violence prevalence, mental health consequences are shaped by the social, cultural, political
conditions and the ability of services to respond. Conflict and economic contexts. For example, women living
zones have been shown to have some of the highest in countries without domestic violence legislation are
prevalence of VAW globally,15–17 and individuals living estimated to be 7% more likely to experience violence
in them have a greater likelihood of poor mental health than those in countries with legislation. In societies where
than those living in non-conflict settings.18,19 Research violence is not criminalised, a perception that it is broadly
on trafficking has shown similar findings. Trafficked acceptable tends to dominate public discourse. Survivors
individuals report comparable levels of poor mental health of violence may therefore be less likely to seek support
(anxiety, depression and PTSD),20,21 violence and coercion from health services, police or community resources, with
to survivors of domestic violence, prisoners of war and physical and poor mental health repercussions.37 In this
survivors of torture.22–25 Factors contributing to adverse situation analysis, we aimed to quantify the forms of VAW
mental health and violence among trafficked individuals and mental health conditions in Afghanistan, India and Sri
include differential levels of power and control exerted by Lanka to identify policies that integrate these two issues
traffickers.22,26,27 as well as existing services for VAW and mental health and
their integration.
Despite the high prevalence of VAW and coexisting
mental health problems in most parts of the world, access Research group
to care for women survivors of violence experiencing Our group consisted of researchers based in non-
mental health problems is poor. Health systems have been governmental organisations (NGOs) and universities in
slow to respond to VAW and provide targeted services.28 Afghanistan, India, Sri Lanka and the UK. Partners in

NIHR Journals Library www.journalslibrary.nihr.ac.uk

DOI: 10.3310/GDOM7555 Global Health Research 2025

Afghanistan were based at the Humanitarian Assistance part of our research programme, interventions would be
for the Women and Children of Afghanistan, an NGO implemented at more than one site within each country.
that supports women and children across Afghanistan,
including survivors of violence. Partners in India were The situation analysis tool was initially completed by
based in Mumbai [Society for Nutrition, Education & in-country investigators (ND, UB, THRS) in October 2018.
Health Action (SNEHA)] and Goa (Sangath). SNEHA The tool was used to search data between October and
includes a group that works with communities to prevent December 2018. A revision of the data in all countries
and address VAW, while Sangath works to improve mental took place in August and September 2022 (MQ-D).
health by addressing the psychological and social needs Data were primarily drawn from public domain health
of individuals and families. Partners in Sri Lanka were surveillance data, household survey collected through the
based at the Department of Psychiatry in the University Demographic and Health Surveys,40 academic publications,
of Colombo. policy documents, governmental and non-governmental
reports and the World Health Organization (WHO) Mental
Health Atlas (see Appendix 1 for a list of main data sources
Methods by country). Data collected for Afghanistan were under
the previous government. Meaghen Quinlan-Davidson,
As a detailed approach to identifying the barriers, Ayesha Ahmad, Abhijit Nadkarni, Alexis Palfreyman,
facilitators, resources, challenges and opportunities within Laura Asher and Urvita Bhatia reviewed the data for
settings,38 a situation analysis was deemed to be the most completeness and accuracy. Although we did not use a
appropriate method, given the paucity of information systematic approach, we tried to establish the plausibility
available on mental health context in the context of of data by triangulating with grey and unpublished
VAW within these settings. The evidence was collected literature where possible and by checking with members
by mapping grey and peer-reviewed literature and other of our research group with relevant expertise.
publicly available data. It did not include empirical data
collection. Development of the package of care did, The situation analysis is part of a larger programme of work
however, involve qualitative work with providers and that included a transdisciplinary group with team members
survivors. This is detailed in the synopsis article in the from Afghanistan, India and Sri Lanka. These countries
National Institute for Health and Care Research Global were included as team members and aimed to develop a
Health Research journal. To guide data collection, we support package for the mental health of women survivors
developed a situation analysis tool covering three domains of violence and modern slavery. In addition, exploring
and the following inclusion criteria: (1) the prevalence of evidence across select South Asian settings contributes to
violence and mental health conditions among women a much-needed intervention-based work in a high-VAW
(prevalence of different forms of violence, help-seeking burden region. The idea was not to represent South Asia
behaviours, prevalence of mental health conditions, such but to bring together a range of settings and stakeholders
as depression, anxiety, PTSD, substance use, suicide and who work in the prevention of VAW, mental health as well
self-harm, etc.); (2) policy context (policy and legislation as academics conducting research on the topic.
for mental health, VAW and trafficking) and (3) mental
health services (mental health human resources, treatment
coverage, violence and mental health screening). The Results
situation analysis tool was designed by our transdisciplinary
research team. The team also supported the interpretation The prevalence of violence and mental
of the findings. We adapted the Programme for Improving health conditions
Mental Health Care situation analysis tool created to guide
a district-level situation analysis in preparation for the Women’s exposure to violence
implementation of mental health interventions in primary We found that multiple forms of VAW were common
care in five countries.39 Adaptations reflected our focus (Table 1). Prevalence of violence was highest in
on mental health care for women survivors of violence Afghanistan, where 46% of women41 had experienced
and on national or regional indicators. Indicators were physical violence within 12 months preceding the survey
determined by consulting with members of the research (53% in their lifetime)41 and 7% of ever-married women
group who had expertise in VAW, trafficking and mental had experienced sexual violence.42 There were high rates
health conditions. We made a pragmatic decision to focus of marital control; for example, 35% of ever-partnered
on the regional- and country-level indicators due to the women reported psychological abuse (defined as jealousy
lack of locally specific data and the possibility that, as or anger if they talked to other men), and 35% reported

This article should be referenced as follows:

Quinlan-Davidson M, Ahmad A, Asher L, Bhatia U, Daruwalla N, Devakumar D, et al. Mental health and violence against women in Afghanistan, India and Sri Lanka: a situation analysis
3
[published online ahead of print April 30 2025]. Global Health Res 2025. https://doi.org/10.3310/GDOM7555
NIHR Journals Library www.journalslibrary.nihr.ac.uk

DOI: 10.3310/GDOM7555
TABLE 1 Types of VAW in Sri Lanka, India and Afghanistan

Exposure to violence Afghanistan India Sri Lanka

Percentage of women who experienced physical violence Last 12 months: 46%35 Last 12 months: 21%37,82 Last 12 months: 4.8%30
from anyone Ever: 53%35 Ever: 30%37 Ever: 18.9%30
Pregnant: unknown35 Pregnant: 4%37 Pregnant: unknown
Postnatal: unknown35 Postnatal: unknown37 Postnatal: unknown

Percentage of ever-married women who experienced 7%35 6%37 7%30

sexual violence from anyone

Percentage of women who experienced conflict-related No data found/identified No data found/identified No data found/identified
sexual violence

Percentage of women who were trafficked No data found/identified No data found/identified No data found/identified

Percentage of ever-partnered women who experienced Type of controlling behaviour :

36
Type of controlling behaviour :
37
Type of controlling behaviour30:
marital control 60% jealousy or anger 27% jealousy or anger 8% jealousy or anger
35% knowing where wife is at all times 20% knowing where wife is at 9% knowing where wife is at all times
25% accusations of infidelity all times 6% accusations of infidelity
9% accusations of infidelity

Percentage of ever-married women who experienced 56%29 33%37 20%30

physical/sexual IPV

Percentage of women who experienced violence by family 94%29 Physical violence since age 15: 7%30
members (other than intimate partner) 42%37

Percentage of women victims who sought help in response Physical and sexual violence: 33%36 14%37 75%73
to violence Physical violence only: 18% Family: 65% Family: 27%
Sexual violence only: 9% Police: 3% Neighbours: 18%
Family: 34% Health service: 1% Police: 7%
Neighbours: 18% Religious leader: 2% Health service: 3%
Police: unknown Husband family: 29% Government institutions: 1.4%

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Health service: unknown Friend: 15% NGOs: 0.4%
Other: 3%
DOI: 10.3310/GDOM7555 Global Health Research 2025

their partner insisted on knowing where they were at all 8% experienced jealousy or anger if they spoke with another
times.42 The highest rates of physical violence perpetrated man and 6% were accused of infidelity.34 Approximately,
by family members were also reported in Afghanistan 7% of ever-married women reported experiencing physical
(40% of ever-married women aged 15–49 years).41,42 violence by a non-partner; of this, 42% was perpetrated
by male family members, while 27% was perpetrated by
In India, 21% of women reported experiencing physical female family members.34 Concurrent to our situation
violence perpetrated by anyone within the last analysis, WHO’s 2018 country profile on VAW reported a
12 months (lifetime estimates of 30%).43 Sexual violence wide range of 18–72% lifetime prevalence among women
was prevalent, with 6% of women reporting it in their of reproductive age, indicating how prevalence data are
lifetime.43 Meanwhile, 33% of ever-married women informed, by what forms and how VAW is researched in a
reported ever experiencing physical, emotional or sexual given context.46
violence by their current partner.43 Marital control among
ever-married women was reported as the following: 27% Mental health problems
experienced jealousy or anger if they talked to other Table 2 illustrates the burden of mental health conditions
men; 20% on knowing where they were at all times and across the three countries. Evidence on mental health
9% were accused of infidelity.43 Nearly one-third of ever- conditions among survivors of violence in Afghanistan was
married women (32%) in India also experienced family scarce. A randomised controlled trial evaluating women’s
physical violence, which includes the husband’s family and empowerment in Afghanistan showed that, compared
step-family members.43 to unexposed women, women exposed to violence in
the last 12 months were six times more likely to have
The COVID-19 pandemic appears to have increased suicidal thoughts.47
VAW in India. In a rapid online survey across India in May
2020, 18% of women reported currently experiencing In India, the Global Burden of Disease Study (2020)50
spousal violence (n = 560). There was a 33% increase in analysed mental health conditions between 1990 and
spousal violence since lockdown. The rates of physical, 2017. The prevalence of depressive, anxiety and eating
sexual, verbal and emotional violence were estimated disorders was higher among females than males. The
at 35%, 11%, 65% and 44%, respectively. Meanwhile, authors attributed these differences in prevalence to
76% of women reported being sad or depressed due to violence, sexual abuse, gender discrimination, negative
violence and 37% reported having thoughts of harming sociocultural norms and pregnancy and post partum
themselves.44 In a qualitative analysis of 586 women stress.51–54 The study also showed evidence for the
during lockdown between April and July 2020, 86% of contribution of risk factors such as childhood sexual
women at initial consultation reported experiencing abuse and IPV to mental health conditions.50 Estimates
emotional abuse, 76% economic violence, 70% IPV, suggested that 7% and 5% of disability-adjusted life-years
64% physical violence, 56% neglect, 56% controlling for depressive disorders were attributed to childhood
behaviours and 35% sexual violence; 86% reported sexual abuse and IPV, respectively, and were significantly
surviving more than one of these forms, while 22% higher among females than males. Women with depressive
had experienced all of these forms of violence; 27% of disorders were also more likely to die by suicide than
women were still surviving violence during lockdown males.50 Indeed, the suicide death rate among women
and 28% were surviving intimate partner or in India was nearly three times that of countries with a
family violence.45 similar Sociodemographic Index,55 with married women
representing the largest proportion of suicide deaths
In 2019, Sri Lanka conducted the first national Woman’s among all women.56,57 Indeed, prior cross-sectional studies
Wellbeing Survey exploring VAW among ever-partnered conducted on suicide attempts in North India have showed
women of reproductive age (15–49 years). The prevalence a higher proportion of suicide attempts and psychiatric
of physical violence among ever-partnered women within comorbidities among women.58–60
12 months of the survey was 5% (lifetime estimate 19%).34
Sexual violence was prevalent, with 7% of ever-partnered Estimates from the 2011 Mental Health Atlas in Sri Lanka
women (15–49 years) having experienced sexual showed that the suicide mortality rate was higher among
violence.34 Approximately, 20% of women had experienced males (44.6) than females (16.8 per 100,000 population).61
physical or sexual violence from a partner during their Evidence from 2009 showed that approximately 2%
lifetime.34 Approximately, 19% of ever-partnered women experienced PTSD (7% of people affected by conflict).62
reported experiencing controlling behaviours by a partner In a cohort analysis of police and hospital data on suicide,
(during their lifetime), of whom 9% reported that their Knipe and colleagues (2014) showed that suicide rates
partner insisted on knowing where they were at all times; were highest among women aged 17–25 years between
This article should be referenced as follows:
Quinlan-Davidson M, Ahmad A, Asher L, Bhatia U, Daruwalla N, Devakumar D, et al. Mental health and violence against women in Afghanistan, India and Sri Lanka: a situation analysis
5
[published online ahead of print April 30 2025]. Global Health Res 2025. https://doi.org/10.3310/GDOM7555
NIHR Journals Library www.journalslibrary.nihr.ac.uk

DOI: 10.3310/GDOM7555
TABLE 2 Indicators of poor mental health and treatment in Sri Lanka, India and Afghanistan

Prevalence of mental disorders Afghanistan India Sri Lanka

Suicide rates (per 100,000 population) 5.7 per 100,000118 Overall: 17.9 per 100,000 individuals46 12.9 per 100,000119
Females: 14.7 (13.1–16.2)46 Males49: 44.6
Males: 21.2 (14.6–23.6)46 Females49: 16.8

PTSD (%) No data found/identified General population: 0.2%83 General population: 2%49
Survivors of VAW: 14%120,121 Survivors of conflict: 7%50
Survivors of conflict: 19%121

Common mental disorders (anxiety and No data found/identified General population: 10%82 Survivors of conflict:
depression) (%) 3% (adults) 33%50 (anxiety)
22%50 (depression)

Alcohol abuse/dependence (%) No data found/identified General population: 4.6%82 General population: 5%49

Severe mental disorders (schizophrenia and General population: 47.049 Schizophrenia and other psychotic disorders: 1% (lifetime) No data found/identified
other psychotic disorders, bipolar disorder and and 0.4% (current prevalence)81
moderate-to-severe depression) (per 100,000 Bipolar: 0.5% (lifetime) and 0.3% (current prevalence)81
population)48

Treatment gap (%) (the proportion of people who No data found/identified 70% bipolar affective disorder82 General population:
need but have no access to mental health care and/ 75% psychotic disorders 68% experience treatment gap122
or are not in treatment)49 85% major depressive disorder
83% neurosis
86% alcohol use disorder

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DOI: 10.3310/GDOM7555 Global Health Research 2025

1975 and 2012.63 A more recent analysis indicates that working to prevent VAW and support improved mental
this trend towards younger female suicides has persisted health of women survivors of violence (see Table 3).74
through the latest national data 2022.64 In research on
perinatal women, those with a history of IPV were four Afghanistan made efforts to improve the mental health
times more likely to report suicidal ideation and/or of its population. The National Mental Health Strategy
behaviour during their pregnancies compared to women (2011–5) aimed to promote mental health, tackle
without this violence history.14 The Sri Lanka Women’s stigma and discrimination associated with mental health
Wellbeing Survey (2019) reported that women exposed conditions; reduce the impact of mental health conditions
to violence were more likely to exhibit emotional on individuals, families and the community; prevent the
distress than those who were not exposed to violence.34 development of mental health problems and mental health
Estimates suggest that 15% of women who experienced conditions; and provide quality, integrated, evidence-
physical or sexual violence by a partner engaged in self- and rights-based care for people with mental health
harm when compared with 1% of women who had never conditions. However, implementation of the strategy
experienced violence. At the same time, 36% of women was challenging due to chronic and multiple conflicts and
who experienced physical or sexual violence by a partner an underdeveloped mental health infrastructure in an
had suicidal thoughts when compared with 7% of women existing weak health system.75 The country has recently
who had not.34 introduced the National Mental Health Strategy 2019–23,
which aims to improve access to services, increase mental
Policy context health resources and strengthen the capacity of mental
Where there were policies on VAW and mental health, healthcare providers to respond to the population’s
they focused on prevention (Table 3). The countries varied mental health needs. It also includes developing an
in their policy, programme and strategy responses to VAW integrated programme and package of mental health
and trafficking. In addition, mental healthcare policies for services and support to women survivors of violence.76
women survivors of violence were largely absent from With the recent change in government in Afghanistan, the
the literature. progress in its implementation is unclear.

Afghanistan, India and Sri Lanka have ratified the In India, the government has committed to gender
Convention on the Elimination of All Forms of equality. In its Preamble, Fundamental Rights and Duties,
Discrimination against Women (CEDAW)65 as well as the the Constitution states that women have rights and are
Convention on the Rights of Persons with Disabilities.66 equal under law.77 India passed the Protection of Women
Sri Lanka has ratified the United Nations Declaration on from Domestic Violence Act (PWDVA) in 2005. The Act
the Elimination of Violence Against Women (EVAW),67 articulates the legal rights, financial and other benefits
while India has committed to it.68 All three countries are to survivors of domestic violence. This Act has resulted
signatories to the Sustainable Development Goals (SDGs) in increased advocacy as well as organisations working
(SDG 5 aims to achieve gender equality)69 and the Palermo to ensure its implementation.78 In 2016, the Ministry of
Protocol (see Table 3).70 Women and Child Development developed a National
Policy for Women.79 One of its objectives was to eliminate
Afghanistan has shown some commitment to address all forms of VAW in India. This Policy, however, has not yet
VAW. In 2009, a Presidential Decree was issued on the been launched. India also has the Nirbhaya Fund, which
Law on the EVAW, but it was opposed in Parliament provides financial resources to programmes that support
in 2013 and its current status is unclear.71 In 2017, the safety and dignity of women.80 In 2018, India passed
Afghanistan passed a law prohibiting human trafficking an Anti-Trafficking Bill to protect, rescue and rehabilitate
and migrant smuggling. The law was expected to be victims of trafficking.81 The Bill takes a criminalisation
scaled up across the country, but security, corruption approach to trafficking and sex work. However, due to
and warlord control have hindered its implementation.72 poorly defined crimes and poor enforcement mechanisms,
The Penal Code in Afghanistan recognises VAW, violence there have been low conviction rates (see Table 3).82
against individuals with mental health conditions and
trafficking as crimes.73 The National Action Plan for the The National Mental Health Policy (NMHP) in India was
Women of Afghanistan (NAPWA) (2007–17) aimed to implemented in 2014 and the National Mental Healthcare
pursue gender equality and women’s empowerment Act (NMHA) in 2017.83 The NMHP aims to prevent
through intersectoral strategies to prevent VAW. The mental health conditions and promote mental well-being
country has experienced a shortage of lawyers to and universal access to mental health services.83 The
advocate for women’s rights, but women’s activists are Policy states that women should not be discriminated

This article should be referenced as follows:

Quinlan-Davidson M, Ahmad A, Asher L, Bhatia U, Daruwalla N, Devakumar D, et al. Mental health and violence against women in Afghanistan, India and Sri Lanka: a situation analysis
7
[published online ahead of print April 30 2025]. Global Health Res 2025. https://doi.org/10.3310/GDOM7555
NIHR Journals Library www.journalslibrary.nihr.ac.uk

DOI: 10.3310/GDOM7555
TABLE 3 Policies, legislation, strategies, plans and programmes on VAW and mental health in Sri Lanka, India and Afghanistan

Policies/
legislation Afghanistan India Sri Lanka

Policies/ CEDAW (ratified)51 CEDAW (ratified)51 CEDAW (ratified)51

legislation Convention on the Rights of Persons Convention on the Rights of Persons with Disabilities Convention on the Rights of Persons with Disabilities (ratified)52
addressing with Disabilities (ratified)52 (ratified)52 United Nations Declaration on the EVAW (ratified)53
VAW Signatory on SDGs55 and Palermo United Nations Declaration on the EVAW (committed)54 Signatory on SDGs55 and Palermo Protocol56
Protocol56 Signatory on SDGs55 and Palermo Protocol56 The Prevention of Domestic Violence Act (2005)76
Law on the EVAW59 PWDVA (2005)66
Afghan Civil Law and the Penal Code61 National Policy for Women 2016 (draft)

Plans/ NAPWA (2007–17)60 No data found/identified National Plan of Action to address Sexual and Gender-based
programmes Violence (2016–20)75
addressing
VAW

Addressing Afghan Civil Law and the Penal Code61 Anti-Trafficking Bill (2018)71 Convention on Preventing and Combatting Trafficking in Women
trafficking Law Prohibiting Human Trafficking and and Children for Prostitution (Act No 30, 2005)75
Migrant Smuggling (2017)60

Mental health National Mental Health Strategy NMHP (2014)68 Mental Health Policy of Sri Lanka (2005–15)96
strategy/policy 2011–578 NMHA (2017)68 Mental Health Policy of Sri Lanka 2020–30
National Mental Health Strategy National Mental Health Programme (1982–Present)81
(2019–23)78

Supporting No data found/identified No data found/identified No data found/identified

survivors of
conflict

Integration National Mental Health Strategy One Stop Centres for women and children exposed to Gender and Women’s Health Unit within the Family Health
of VAW and 2019–23 includes developing an violence to obtain integrated services, including psycho- Bureau to address domestic violence within the health sector76
mental health integrated programme and package of logical, medical and legal services, in one location74 Gender-based violence desks and friendly abode/Mithuru Piyasa/
strategies/ mental health services and support to Natpu Nilayam centres provide safe havens for women exposed

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services women survivors of violence78 to domestic violence and operate in tertiary care hospitals77
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against in the provision of services. It also recognises trafficking; poor co-ordination between government and
the disproportionate burden of mental health conditions NGOs working on VAW and trafficking with mental health
experienced by marginalised populations (e.g. victims of services; a lack of shelters for women survivors of violence
trafficking, those living in conflict, sex workers, children and trafficking; unequal distribution of resources and
and sexual minorities). The government provides shelters services (mainly available in cities); a lack of monitoring
for homeless women under its social welfare scheme,84 and follow-up of existing programmes and minimal funding
along with other third-sector organisations which provide allocated to the prevention of VAW, trafficking and mental
shelter for women exposed to violence. The country has health conditions (see Table 3).89
also implemented One Stop Centres, state-sponsored
service centres for women and children exposed to The Mental Health Policy of Sri Lanka (2005–15) was
violence. These provide an opportunity for survivors passed in 2005 with the aim of establishing community-
to obtain integrated services, including psychological, based, comprehensive mental health services. The policy
medical and legal services, in one location (see Table 3).85 focused on several areas of mental health services,
including service organisation, human resources,
The Sri Lankan government has made several commit­ management at the national and provincial levels,
ments to reduce women’s exposure to violence and research and ethics, stigma and mental well-being and
subsequent harm. These include the National Action Plan the National Institute of Mental Health and mental
to Address Sexual and Gender-Based Violence (2016) health legislation.90 Not all targets were reached under
to eradicate VAW and children using a multisectoral the previous policy, and the recently launched Mental
approach86 and the Prevention of Domestic Violence Health Policy (2020–30) proposes to expand services by
Act (2005).87 The country has also had some service establishing at least one psychiatric centre or community
developments, including a Gender and Women’s Health psychiatric clinic in each Ministry of Health area around
Unit within the Family Health Bureau to address domestic the country (see Table 3).
violence within the health sector87 and the establishment
of Women’s and Children’s Desks at selected police Mental health services
stations, which aim to be the contact point for survivors Mental health infrastructure has evolved across the
and those who wish to report violence, as well as Gender- three countries through activist grassroots organisations
Based Violence desks and Friendly Abode/Mithuru and governmental responses, but mental health
Piyasa/Natpu Nilayam centres (56 centres in 21 districts) services and their accessibility are limited by a range of
that provide support for women exposed to violence individual and systemic barriers. Significant treatment
and operate in certain tertiary care hospitals.46 Sri gaps were identified in Afghanistan, India and Sri Lanka
Lanka has also established the ‘1936’ women’s helpline (see Table 2) with limited mental health human resources
and has been implementing gender mainstreaming (Table 4). There was limited evidence on mental healthcare
programmes. The country also has field officers (Women’s resources for women exposed to violence. It was not
Development Officer, Child Rights Promotion Officer and possible, therefore, to determine if women could safely
Early Childhood Development Officer) working within disclose past or present experiences of violence within
communities to link people with available resources, facilities, gain the care they needed and if there were
and select police stations have Women’s and Children’s adequate diagnostic assessments to understand the
Desks as focal points for violence-reporting and survivor psychological impact of violence.
support, staffed by female officers (see Table 3).46
The government of Afghanistan has made some progress
The government has shown commitment to address with mental health services. Due to the National Mental
trafficking. Actions include the Convention on Preventing Health Strategy (2010–4),91 and its revision in 2015,
and Combatting Trafficking in Women and Children the integration of mental health services within each
for Prostitution (Act No 30, 2005); standard operating level of the healthcare system led to a 75% increase in
procedures to identify and refer potential trafficking the number of provinces with an integrated Essential
victims to protection services88 and training sessions to Package of Hospital Services-based mental health
identify trafficking victims for members of civil society services.92 However, access to mental health care
and local, district and state officials, including health, remains a challenge, especially for women. This challenge
probation, police, immigration, Criminal Investigation is attributed to the sociocultural context and ongoing
Department and National Child Protection Authority conflict on women’s ability to seek and afford health
officials.88 Despite these advances, there is a lack of public care, especially specialist health care. In addition, mental
awareness on the legislation and rights around VAW and health stigma, limited awareness and low perceived

This article should be referenced as follows:

Quinlan-Davidson M, Ahmad A, Asher L, Bhatia U, Daruwalla N, Devakumar D, et al. Mental health and violence against women in Afghanistan, India and Sri Lanka: a situation analysis
9
[published online ahead of print April 30 2025]. Global Health Res 2025. https://doi.org/10.3310/GDOM7555
DOI: 10.3310/GDOM7555 Global Health Research 2025

TABLE 4 Mental health resources in Sri Lanka, India and Afghanistan

Afghanistan India Sri Lanka

Human resources (per 100,000)

Psychiatrists 0.34118 0.3080 0.58119

Mental health workers 1.6680 1.9380 7.1480

Nursing officers 0.07118 0.8080 2.93119

Psychologists 0.35118 0.0780 0.29119

Facilities (N)

Community-based mental health outpatient facilities 2622118 121780 2080

Psychiatric hospitals 180 13680 180

Psychiatric units in general hospitals 480 38980 36119

Mental hospital beds (per 100,000) 0.26118 1.4380 6.61119

needs and reliance on traditional healers remain barriers services at the community level. By 2014, approximately
to seeking mental health care.76 20% of districts had implemented a DMHP.94

Contributing to these challenges is the paucity of mental Despite political and legal commitments, the
health human resources and facilities in Afghanistan. implementation of mental health services has been
There were an estimated 0.34 psychiatrists, 0.07 nursing challenging for India. The country faces a large treatment
officers and 0.35 psychologists per 100,000 population. gap and a lack of accessibility. The most recent National
In addition to mental health outpatient facilities, there Mental Health Survey of India95 estimates that there
was one mental health hospital and four psychiatry units is a large treatment gap for all mental disorders. For
in general hospitals in the country. Afghanistan, therefore, example, it is estimated that 85% of people with major
relies on NGOs to provide mental health care under the depressive disorder do not access evidence-based care.96
remit of the Ministry of Health. Most of the NGOs and There is also a lack of evidence-based care, while women
large public mental health services with trained service experience poorer mental health treatment compared to
providers are located in the major cities (Kabul, Herat and men.50,97–102 Indeed, women with mental health conditions
Balkh), with other regions experiencing limited access to may be institutionalised without consent.96 Adding to the
services.93 According to a trans-sectional probability survey treatment gap is the shortage of mental health service
of the general population,92 results showed that 19% of providers. The most recent estimates suggest that there
participants who reported any mental health problem are less than one psychiatrist (0.3) and two mental
received help at some point, with 12% receiving help health workers, 0.12 nurses and 0.07 psychologists per
within the last 12 months. There was regional variation 100,000 population.93 According to the literature, this
in mental health help-seeking, from 4% in the Central gap is attributed to seeking mental health care from
highland region to 22% in the South. Results indicated that faith healers96 as well as a low perceived need for care,
mental health help providers included the health sector stigma103–106 and discriminatory attitudes of healthcare
and non-health sector (e.g. healer or religious leader). providers.103,107
Access to mental health care was adversely influenced by
the regional exposure to danger (i.e. number of attacks), With the Mental Health Policy of Sri Lanka in 2005,
traumatic events and clinical needs.92 community-based mental health care was prioritised.
As a result, there was an increase in district hospital-
India has demonstrated strong political and legal based clinics, outreach clinics, home-based care,
commitments to enhancing mental health services. Since community support centres, domiciliary care, helplines
1982, the country has implemented the National Mental and intermediate rehabilitation centres.108 Although
Health Programme,94 which focuses on expanding access community services are available to all age groups,
to care through capacity-building and incorporating treatment services prioritise adults with severe mental
mental health into primary care. The District Mental Health disorders, including schizophrenia and substance use
Programme (DMHP) was created to focus on scaling up disorders.109 In 2012, Sri Lanka initiated a screening

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DOI: 10.3310/GDOM7555 Global Health Research 2025

programme for postnatal depression, embedded in the Sri Lanka could be attributed to fear of not being believed,
national pregnancy care programme, but implementation embarrassment, the normalisation of violence, protecting
has been uneven and limited.14 family reputation and lack of knowledge of options and
support services.34,112 Meanwhile, limited evidence from
Sri Lanka faces a shortage of mental health resources. India suggests that domestic violence increased threefold
In 2017, Sri Lanka had 0.52 psychiatrists, 1.47 Medical during the COVID-19 pandemic.113–115 There was a lack
Officers of Mental Health, 3.28 nursing officers and 0.25 of data on the impact that COVID-19 has had on VAW
psychologists per 100,000 population.109 The specific in Afghanistan and Sri Lanka. Although we did not have
needs of women survivors of violence are overlooked, specific age criteria, the data reported were based on
reducing accessibility to available mental health services.109 estimates for women 15–49 years of age.
Estimates suggest that the treatment gap for common and
severe mental health disorders, as well as substance use There was some evidence on mental health conditions,
disorders, is high, at 68%. This treatment gap is attributed with limited data on the associations between women’s
to stigma and limitations in cognitive and other forms of exposure to different forms of VAW and symptoms of
access to mental health services.93 depression, suicidality and self-harm in India and Sri
Lanka.34 Scarce evidence was shown in Afghanistan among
women exposed to violence and suicidal thoughts.47 This
Discussion lack of evidence could be attributed to the paucity of
mental health resources and cultural conceptualisations
This study is the first, to our knowledge, to investigate of mental health.116 Future research could investigate
data from Afghanistan, India and Sri Lanka on the mental the bidirectional relationship between VAW and mental
health needs and context of women survivors of violence health conditions, with violence as a risk factor for, and
using a situation analysis tool. The evidence suggests that consequence of, poor mental health. Prior evidence has
Afghanistan, India and Sri Lanka share similarities in terms shown a bidirectional, cumulative and dynamic interaction
of a lack of data, implementation of policies and legislation between mental health conditions and violence.117 Indeed,
on all forms of VAW and limited recognition of women’s mental health conditions may influence a woman’s
mental health needs among survivors of violence. Further, decision to stay in a violent relationship in choosing their
there is a paucity of mental health service provision in partner and assessing their risk.118 At the same time,
these countries. These points should be considered in light poor mental health status among women experiencing
of the scarcity of data on the topic. violence may adversely influence their ability to safely
leave.119 These challenges are compounded by controlling
The study showed that women in Afghanistan, India and behaviour, wherein women with poor mental health may
Sri Lanka experienced multiple forms of violence, with be less able to protect themselves against violence.119
most of the data on violence focused on that which is The countries need to develop prevention policies and
committed by a partner or family member.12,15 We were programmes to support women exposed to violence with
unable to identify data on the percentage of women mental health problems.
who had experienced conflict-related sexual violence, or
on women who had been trafficked, illustrating gaps in Although mental health policies were present in
the literature. The lack of data on conflict-related sexual Afghanistan, India and Sri Lanka, a lack of resources
violence and trafficking could be attributed to a fear of and individual barriers contributed to poor policy
intimidation and retaliation against women survivors implementation. For example, there are challenges to
of conflict-related sexual violence as well as a lack of developing a standardised mental health infrastructure
collection.110 Similarly, the lack of data on trafficking that addresses the needs of women survivors of violence.
could be attributed to the difficulty faced by community Evidence has shown that mental health providers may not
members, service providers and law enforcement officers be trained on how to identify or screen for VAW.120 There
in identifying survivors, incomplete reporting and a lack is also a lack of clinical reporting of women exposed to
of services targeting trafficking survivors.111 Without VAW.121 Due to limited health resources, the workload that
this information, it is difficult to develop prevention and mental healthcare providers have within these settings may
intervention programmes for women survivors of conflict- prevent them from adequately and appropriately attending
related violence and trafficking with mental health women exposed to violence.122 Further, women survivors
conditions in these settings. Beyond being influenced by of violence have reported discrimination by clinicians.123
how violence research is designed and conducted (e.g. To address these challenges, mental healthcare services
definitions and tools), the lower rates of VAW reported in could screen for VAW, with referral mechanisms to

This article should be referenced as follows:

Quinlan-Davidson M, Ahmad A, Asher L, Bhatia U, Daruwalla N, Devakumar D, et al. Mental health and violence against women in Afghanistan, India and Sri Lanka: a situation analysis
11
[published online ahead of print April 30 2025]. Global Health Res 2025. https://doi.org/10.3310/GDOM7555
DOI: 10.3310/GDOM7555 Global Health Research 2025

specialised services and programmes. The services could political and professional stakeholders, service users and
ensure that mental health providers are appropriately communities in the co-design of the situation analysis and
trained to effectively treat women survivors of violence. interpretation of findings, but the wider work did involve
In addition, there needs to be greater collaboration qualitative data collection and engagement with survivors
between community-based organisations and the mental and service providers.129–131
health system to provide support networks for women
survivors of violence.123 Task-sharing, including the use of The utility of this knowledge is to provide a roadmap for
alternative technologies, is another strategy whereby non- how services could be updated in future work centred
specialists and community health workers can be trained within these settings. In addition, and as part of the larger
to deliver mental health services for women survivors programme of work, additional research is required on
of violence.124,125 Safety and confidentiality would be integrating mental health care within social care, identifying
important considerations. ways to incorporate trauma-informed approaches into
service provision and addressing family violence.
Evidence from the situation analysis illustrates an
opportunity to develop mental health interventions,
policies and programmes for women survivors of violence Conclusion
in the three countries. A targeted, intersectoral approach to
identify and treat mental health conditions among women This is the first study to investigate data from Afghanistan,
survivors of violence is needed, with a particular focus on India and Sri Lanka on women’s exposure to violence and
designing, testing and refining interventions.57,103,126,127 For mental health conditions. Based on the findings, the three
example, there is a possibility of integrating mental and countries experience a lack of data, prevention policies
physical/sexual health and protection services with access and legislation on different forms of VAW and limited
to housing, legal and financial services as well clear referral recognition of women survivors’ mental health needs.
pathways.30,121 Integration implies ensuring the availability There is also a paucity of mental health service provision
of adequate mental health services and appropriately in these countries. These findings have implications for
trained service providers, flexible service hours, seamless the development of effective VAW prevention and mental
referral to other services, greater community awareness health promotion strategies.
of these services and the institutionalisation of a
trauma-informed approach.128
Community engagement and involvement
We have identified some limitations to the study. Given
that the analysis included sources in the public domain, it Community engagement and involvement was not
is important to consider the rigor with which the data were included in the situation analysis. It was, however, part of
collected. Our analysis was limited by the data available, the larger project, in which three different communities
and their limited availability also precluded the direct were involved, including survivors of domestic violence
comparison of findings across countries. For example, and human trafficking, counsellors, caseworkers,
further research needs to be conducted on mental health psychologists, psychiatrists and lawyers.
resources in each country. In addition, some of the data
collected and presented in this analysis are limited due to
data collection and recruitment strategies, affecting the Equality, diversity and inclusion
generalisability of findings. For example, approximately
69% of women respondents from the rapid online survey Power differentials were considered across the entire,
on spousal violence in India identified as being from upper larger project in terms of knowledge and participant status.
and upper-middle income. Variability between regions, To address these power dynamics, one-to-one interviews
especially in a large country such as India, restricted were held with survivors of violence; we also engaged
our ability to assess the implementation of VAW and people with lived/living experience in workshops.
mental health programmes. Future research needs to
be conducted on women’s economic and employment
opportunities in relation to violence exposure and poor Additional information
mental health. It should be noted that the analysis for
Afghanistan covers up until the country came under CRediT contribution statement
Taliban control again in 2021. Where feasible and safe, new Meaghen Quinlan-Davidson (https://orcid.org/0000-0002-
research should be conducted on VAW since the Taliban 7875-3753): Formal analysis (lead), Investigation (lead), Writing
took over. This analysis did not include engagement with – original draft, Writing – review and editing (lead).

12

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DOI: 10.3310/GDOM7555 Global Health Research 2025

Ayesha Ahmed (https://orcid.org/0009-0005-8846-0603): Data Protection Officer here www.ucl.ac.uk/data-protection/

Writing – review and editing (equal). data-protection-0.

Laura Asher (https://orcid.org/0000-0002-9857-6766): Writing Disclosure of interests

– review and editing (equal). Full disclosure of interests: Completed ICMJE forms for all
authors, including all related interests, are available in the
Urvita Bhatia (https://orcid.org/0000-0002-3156-5317): toolkit on the NIHR Journals Library report publication page at
Writing – reviewing and editing (equal). https://doi.org/10.3310/GDOM7555.

Nayreen Daruwalla (https://orcid.org/0000-0002-5716-1281): Primary conflicts of interest: None of the authors declares a
Conceptualisation (equal). conflict of interest.

Delan Devakumar (https://orcid.org/0000-0002-8695-6817): Department of Health and Social Care

Conceptualisation (equal), Project administration (lead), disclaimer
Supervision (equal). This publication presents independent research commissioned
by the National Institute for Health and Care Research (NIHR).
Abhijit Nadkarni (https://orcid.org/0000-0001-5832-5236): The views and opinions expressed by authors in this publication
Writing – review and editing (equal). are those of the authors and do not necessarily reflect those of
the NHS, the NIHR, MRC, NIHR Coordinating Centre, the Global
Alexis Palfreyman (https://orcid.org/0000-0001-9248-4142): Health Research programme or the Department of Health and
Resources (equal), Writing – review and editing (equal). Social Care.

Lamba Saboor: Resources (equal); Writing – review and editing This article was published based on current knowledge at
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inclusive and will continually monitor best practice and guidance
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9588): Writing – review and editing (equal). relevant to our stakeholders.

David Osrin (https://orcid.org/0000-0001-9691-9684): Funding

Conceptualisation (equal), Funding acquisition (lead), Supervision This research was funded by the National Institute for Health and
(equal). Care Research (NIHR) Global Health Research programme (NIHR
award ref: 17/63/47) using UK aid from the UK Government
Acknowledgments to support global health research. The views expressed in this
We thank Alexander Catalano and Khawla Zainab for helping publication are those of the author(s) and not necessarily those
extract relevant data for India and Lida Ahmad from Afghanistan. of the NIHR or the UK government.

Data-sharing statement This article reports on one component of the research award NIHR
Global Health Research Group on a package of care for the mental
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This article should be referenced as follows:

Quinlan-Davidson M, Ahmad A, Asher L, Bhatia U, Daruwalla N, Devakumar D, et al. Mental health and violence against women in Afghanistan, India and Sri Lanka: a situation analysis
13
[published online ahead of print April 30 2025]. Global Health Res 2025. https://doi.org/10.3310/GDOM7555
DOI: 10.3310/GDOM7555 Global Health Research 2025

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This article should be referenced as follows:
Quinlan-Davidson M, Ahmad A, Asher L, Bhatia U, Daruwalla N, Devakumar D, et al. Mental health and violence against women in Afghanistan, India and Sri Lanka: a situation analysis
19
[published online ahead of print April 30 2025]. Global Health Res 2025. https://doi.org/10.3310/GDOM7555
DOI: 10.3310/GDOM7555 Global Health Research 2025

Appendix 1 Main sources of data by country Home Affairs, US State Department, Global Status Report
on Alcohol, National Health Portal.

Afghanistan
Sri Lanka
Websites from Ministry of Women’s Affairs; Afghanistan
Independent Human Rights Commission; WHO Mental Websites from the Ministry of Women and Child affairs;
Health Atlas (data is routinely collected every 3 years); Ministry of Health and Indigenous Medicine; Director
US Department of State; Demographic and Health Survey of Mental Health; Family Health Bureau; National Child
(routinely collected household survey, every 5 years); and protection Authority Sri Lanka; Sri Lanka Police Children
National Mental Health Strategy. and Women Bureau; Department of Social Services; WHO
Mental Health Atlas (data are routinely collected every
3 years).
India

Websites from Demographic and Health Survey (routinely

collected household survey, every 5 years); Ministry of

20

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