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Baumann SE, Rabin MA, Hawk M, Devkota B, Upadhaya K, Shrestha GR, Joseph B, Burke JG. From stigma to solutions: harnessing local wisdom to tackle harms associated with menstrual seclusion ( chhaupadi) in Nepal. CULTURE, HEALTH & SEXUALITY 2024:1-22. [PMID: 38970806 DOI: 10.1080/13691058.2024.2373793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 06/25/2024] [Indexed: 07/08/2024]
Abstract
In Nepal, menstrual practices, and particularly chhaupadi, impose restrictive norms affecting women's daily lives. Chhaupadi is a tradition that involves isolating women and girls during menstruation and after childbirth, along with following other restrictions, which have physical and mental health implications. To date, interventions have yet to fully and sustainably address harms associated with chhaupadi across the country. This two-phase study conducted in Dailekh, Nepal facilitated the development of community-created solutions to mitigate chhaupadi's adverse impacts on women's health. Using Human Centred Design and a community-engaged approach, the discovery phase identified key stakeholders and contextualised chhaupadi, while the subsequent design phase facilitated the development of five community-created interventions. These included leveraging female community health volunteers (FCHVs) for counselling and awareness, targeting mothers to drive behavioural change, engaging the wider community in behaviour change efforts, empowering fathers to catalyse change at home, and training youth for advocacy. The FCHV intervention concept was selected as the most promising intervention by the women co-design team, warranting broader exploration and testing. Additionally, while it is imperative for interventions to prioritise tackling deleterious aspects of chhaupadi, interventions must also acknowledge its deep-rooted cultural significance and history and recognise the positive aspects that some women may wish to preserve.
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Affiliation(s)
- Sara E Baumann
- Department of Behavioral and Community Health Sciences, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Megan A Rabin
- Department of Behavioral and Community Health Sciences, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Mary Hawk
- Department of Behavioral and Community Health Sciences, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
- Department of Infectious Diseases and Microbiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Bhimsen Devkota
- Faculty of Education, Health Education, Tribhuvan University, Kirtipur, Kathmandu, Nepal
| | | | - Guna Raj Shrestha
- Menstrual Health and Hygiene Partner's Alliance (MHMPA), Kathmandu, Nepal
| | - Brigit Joseph
- Dietrich School of Arts and Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jessica G Burke
- Department of Behavioral and Community Health Sciences, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
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Winkler IT, Lhaki P, Baumann SE. Its manifestations may vary, but menstrual stigma is universal. WOMEN'S HEALTH (LONDON, ENGLAND) 2024; 20:17455057241262007. [PMID: 38881447 PMCID: PMC11185035 DOI: 10.1177/17455057241262007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/21/2024] [Accepted: 05/29/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Inga T Winkler
- Department of Legal Studies, Central European University, Wien, Austria
- Department of Social Sciences, Wageningen University & Research, Wageningen, The Netherlands
| | - Pema Lhaki
- Nepal Fertility Care Center, Lalitpur, Nepal
| | - Sara E Baumann
- Department of Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
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Ndichu EG, Upadhyaya S. Exploring consumer vulnerability in the consumption of menstrual products: Insights from a developing country. Health Mark Q 2023; 40:396-414. [PMID: 37021624 DOI: 10.1080/07359683.2023.2193075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Consumer experiences in the consumption of menstrual products and the factors that underpin consumer vulnerability in the consumption process have largely been overlooked in marketing research. This research addresses this gap by examining consumer experiences of vulnerability in the consumption of menstrual products in a developing country context. Data from in-depth interviews and netnography reveals women's embodied experiences of vulnerability, with structural barriers, such as regulatory gaps and exclusionary marketing practices adversely affecting the women's physical and emotional well-being. Contributions to consumer vulnerability literature and implications for health marketing and policy are discussed.
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Affiliation(s)
- Edna G Ndichu
- School of Business, Whitworth University, Spokane, WA, USA
| | - Shikha Upadhyaya
- College of Business and Economics, California State University, Los Angeles, CA, USA
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Betsu BD, Medhanyie AA, Gebrehiwet TG, Wall LL. "Menstruation is a Fearful Thing": A Qualitative Exploration of Menstrual Experiences and Sources of Information About Menstruation Among Adolescent Schoolgirls. Int J Womens Health 2023; 15:881-892. [PMID: 37283993 PMCID: PMC10239630 DOI: 10.2147/ijwh.s407455] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/05/2023] [Indexed: 06/08/2023] Open
Abstract
Background Although menstruation is a biological phenomenon, it is still subjected to secrecy, shame, and negativity. Schoolgirls lack access to appropriate sources of information about menstruation. Little is known about the content of the information provided to schoolgirls concerning menstruation in northern Ethiopia. This study explored schoolgirls' experiences and the content of information they receive concerning menstrual hygiene management in Tigray. Methods A qualitative design was implemented. Focus group discussions and in-depth interviews were conducted using the local language among 79 schoolgirls who had experienced menarche. Data were audio-recorded, transcribed, translated, and imported into ATLAS.ti-7.5.18 computer software for analysis. Data were coded and analyzed using a thematic analysis. Results Five themes have emerged from the analysis: 1) there is an indistinct and haphazard source of menstrual information; 2) menstruation is perceived as "a natural gift"; 3) menstruation is also considered fearful and embarrassing; 4) negative community perceptions of menstruation lead to menstrual restrictions, and 5) lack of privacy for dealing with menstrual issues as well as the scarcity of menstrual hygiene management materials is an on going problem. Schoolgirls have indistinct and haphazard sources of information concerning menstrual hygiene management, obtaining it from teachers, mothers, sisters, and friends, but the information they receive is shrouded in secrecy and often is factually incorrect. Menstruation is commonly linked to notions of sexuality, shame, and the approach of marriageability. Conclusion The information that schoolgirls in rural Tigray receive about menstrual hygiene management is inaccurate, insufficient, and encumbered with social taboos. Thus, schoolgirls do not have an adequate understanding of the physiology of menstruation and do not receive adequate emotional support at menarche, leaving them with feelings of embarrassment and anxiety. There should be efforts to implement programs that change community perceptions about menstruation.
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Affiliation(s)
- Balem Demtsu Betsu
- Department of Midwifery, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Araya Abrha Medhanyie
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Tesfay Gebregzabher Gebrehiwet
- Department of Anthropology, College of Arts and Sciences, Washington University in St. Louis, Campus, St. Louis, MO, USA
| | - L Lewis Wall
- Department of Anthropology, College of Arts and Sciences, Washington University in St. Louis, Campus, St. Louis, MO, USA
- Department of Obstetrics & Gynecology, Washington University in St. Louis, St. Louis, MO, USA
- Department of Obstetrics & Gynecology, Ayder Comprehensive Specialized Hospital, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
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Kakchapati S, KC SP, Giri S, Bhattarai S, Baral SC. Factors associated with access to sexual and reproductive health services among women with disabilities in Nepal. DIALOGUES IN HEALTH 2022; 1:100068. [PMID: 38515926 PMCID: PMC10954013 DOI: 10.1016/j.dialog.2022.100068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/12/2022] [Accepted: 10/26/2022] [Indexed: 03/23/2024]
Abstract
Aim The aim of the study is to investigate the relationships between social determinants and disability status and access and use of sexual and reproductive health services among women with disabilities in Nepal. Materials ad methods This study used data on women with disability from the Multiple Indicator Cluster Survey (MICS) of 2019, in which 13,320 women and 290 women with disabilities were included for the analysis. We used bivariate analysis to compare the social determinants with disability status and multivariate logistic regression to determine the association between social determinants and access and use of sexual and reproductive health services among women with disabilities. Findings The findings showed, in comparison with non-disabled women, women with disabilities had low education, low economic status, low media exposure and low access to sexual and reproductive health. On provincial level, those from Madesh [AOR = 0.22 (95%CI:0.06, 0.76)] and Lumbini [AOR = 0.24 (95%CI:0.06,0.88)] had lower attitude to violence. The usage of family planning (FP) methods among women with disabilities in Karnali [AOR = 3.57 (95% CI: 1.42-13.22)] and Sudurpashchim [AOR = 1.05 (95% CI: 1.01-1.071)] was higher than those in Province 1. Women with disabilities with secondary education were more than nine times [AOR = 9.28(95%CI:2.67,32,26)] and primary education had more than three times [AOR = 3.59 (95%CI:1.07, 12.02)] of knowledge on HIV/AIDS compared to those of no education. The odds of being tested for HIV/AIDS among women with disabilities with secondary education was more than eight times [AOR = 8.8 (95% CI:2.23-34.6)] than those of no education. Conclusion This study provides noteworthy findings that women with disabilities have poor socioeconomic status, high-risk behavior, and low access to sexual and reproductive health services in Nepal. This study highlights the significance of actions needed to address sexual and reproductive health services in Nepal that unfairly impact women with disabilities.
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Sharma A, McCall-Hosenfeld JS, Cuffee Y. Systematic review of menstrual health and hygiene in Nepal employing a social ecological model. Reprod Health 2022; 19:154. [PMID: 35773696 PMCID: PMC9245245 DOI: 10.1186/s12978-022-01456-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 06/09/2022] [Indexed: 11/18/2022] Open
Abstract
Menstrual health and hygiene are a major public health and social issues in Nepal. Due to inadequate infrastructure to provide education, healthcare, and communication as well as religious teachings, women and girls are excluded from participation in many activities of daily living and community activities during menstruation. Evidence based research addressing menstrual health and hygiene in Nepal is scares. The objective of this paper is to review the current state of knowledge on menstrual health and hygiene in Nepal through a socio-ecological perspective. This systematic review identifies knowledge gaps and targets for future research and interventions. Studies from Nepal that examined factors contributing to menstrual health and hygiene were identified through searches across six databases (Medline, CINAHL, Web of Science, PsychInfo, Nepal Journals Online and Kathmandu University Medical Journal) in January 2019. The SEM is a public health framework that describes how health is impacted at multiple levels including the individual, interpersonal, community, organizational and policy levels. Key themes were identified, and factors contributing to menstrual health and hygiene were categorized as per the level of socio-ecological model (SEM). After a comprehensive literature review, twenty peer-reviewed publications, published between 2003 and January 2019 were included in this review. Eighteen studies were descriptive and two were interventional. The main outcomes reported were reproductive health concerns and menstrual hygiene practices. Nine studies focused on knowledge, attitude, and practices regarding menstruation, seven studies highlighted reproductive health issues, three studies focused on prevalence of culturally restrictive practices, and one on school absenteeism and intimate partner violence. Lack of awareness regarding menstrual health and hygiene, inadequate WASH facilities, no sex education and culturally restrictive practices makes menstruation a challenge for Nepali women. These challenges have negative implications on women and girls' reproductive as well as mental health and school attendance among adolescent girls. There are gaps in the evidence for high quality interventions to improve menstrual health and hygiene in Nepal. Future research and interventions should address needs identified at all levels of the SEM.
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Affiliation(s)
| | - Jennifer S McCall-Hosenfeld
- Department of Public Health Sciences, Pennsylvania State College of Medicine, Hershey, PA, USA
- Department of Medicine, Pennsylvania State College of Medicine, Hershey, PA, USA
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Maharaj T, Winkler IT. 'You don't just do it because someone else said so': Menstrual practices and women's agency in the Hindu diaspora of Trinidad. CULTURE, HEALTH & SEXUALITY 2022; 24:827-841. [PMID: 33666533 DOI: 10.1080/13691058.2021.1887938] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 02/05/2021] [Indexed: 06/12/2023]
Abstract
Meanings of menstruation are deeply embedded in culture and religion. The current dominant narrative presents menstrual practices as restrictions and often describes Hindu women as 'subjected to' these practices, characterising them as the oppressed victims of their religion. This article seeks to complicate this oversimplified narrative by exploring women's motivations, choices and decisions related to menstrual practices in a small-scale study based on semi-structured interviews and focus groups with women in the Hindu-Trinidadian diaspora. Our findings indicate that the women we interviewed exercise agency in the cognitive, emotional, religious and socio-cultural spheres. Many of them accept the ritual 'impurity' but overwhelmingly restrict this label to the spiritual sphere and separate it from their menstruating bodies. Many reject the idea that the practices are restrictive or stigmatising. They do not understand religion as the source of menstrual stigma but instead value or accept menstrual practices as part of what it means to be a Hindu woman-motivated by religious observance and/or the desire to be part of a community that upholds tradition. These varied manifestations of women's agency challenge the understanding of menstrual practices as necessarily-and-always oppressive and call for acknowledging the nuance and complexity of women's lives.
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Affiliation(s)
- Trisha Maharaj
- Institute for the Study of Human Rights, Columbia University, New York, NY, USA
| | - Inga T Winkler
- Institute for the Study of Human Rights, Columbia University, New York, NY, USA
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Kawata R, Endo M, Ohashi K. Traditional menstruation practices among Nepalese women living in Japan. BMC Womens Health 2022; 22:201. [PMID: 35637480 PMCID: PMC9153173 DOI: 10.1186/s12905-022-01789-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/23/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Traditional menstruation practices in Nepal (Chhaupadi in Nepalese) lack scientific support and undermine women's health. This study aimed to understand the changes in the traditional menstruation practices due to migration from Nepal to Japan. METHODS This study included 104 Nepalese women of reproductive age living in an urban area of western Japan. Participants were recruited using snowball sampling, and the method of data collection was a questionnaire survey. To examine how Nepalese women adapt traditional menstruation practices to their living environment, we compared how women followed frequently 17 traditional practices when they lived in Nepal and later in Japan. We examined the relationships among behavioural changes in traditional practices, education level, and caste. RESULTS The frequency of 14 of the 17 traditional practices decreased after the women moved to Japan. Among women who reduced the frequency of traditional practices after moving from Nepal to Japan, the reduction was not associated with educational level or caste of the participants. CONCLUSIONS This study suggests that the attitudes towards the traditional menstruation practices change in response to living circumstances. Future studies should focus on determining living environment factors related to behavioural changes in traditional practices.
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Affiliation(s)
- Rina Kawata
- Division of Health Science, Graduate School of Medicine, Osaka University, 1-7, Suita, Osaka, 565-0871, Japan
| | - Masayuki Endo
- Division of Health Science, Graduate School of Medicine, Osaka University, 1-7, Suita, Osaka, 565-0871, Japan
| | - Kazutomo Ohashi
- Faculty of Global Nursing, Otemae University, 2-1-88, Cyuoku Otemae, Osaka, 540-0008, Japan.
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Development of a scale to evaluate negative menstrual attitudes among Nepalese women. Reprod Health 2022; 19:120. [PMID: 35578253 PMCID: PMC9112546 DOI: 10.1186/s12978-022-01426-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 04/10/2022] [Indexed: 11/30/2022] Open
Abstract
Background Menstrual attitudes include negative and positive perceptions of menstruation and are associated with reproductive health, underscoring the importance of its evaluation in women. Given that social and cultural factors affect menstrual attitudes, developing evaluation methods specific to distinct societal cultures is necessary. Methods We developed a scale based on the menstrual attitude questionnaire, which is the most widely used measure of menstrual attitudes, to evaluate negative menstrual attitudes among Nepalese women in consideration of Nepalese cultural backgrounds and literacy. In total, 352 Nepalese women aged 20–45 years living in urban or suburban areas in Nepal were enrolled in the study. Participants were randomly divided into two groups using the permuted block method. Using the prototype, Group 1 (n = 176) was evaluated with an exploratory factor analysis to develop a reliable scale, and Group 2 (n = 176) was evaluated with a confirmatory factor analysis to confirm the structure of negative menstrual attitudes. Further, we preliminarily examined the relationship of negative menstrual attitudes with the frequency of traditional menstrual practices and intensity of menstrual pain, which are significant reproductive health issues in Nepal, in Group 2. Results We developed a 15-item, 3-factor scale to evaluate negative menstrual attitudes among Nepalese women using exploratory factor analysis. The first, second, and third factors were “Natural event” (α = 0.82), “Debilitating event” (α = 0.76), and “Bothersome event” (α = 0.69), respectively. Confirmatory factor analysis revealed that negative menstrual attitudes comprised a 3-factor structure. Participants who performed three traditional menstrual practices (“stay in their own house”, “go to public spaces”, and “contact with others generally”) demonstrated significantly higher scores for negative menstrual attitudes than did non-performers. Negative menstrual attitudes were positively correlated with the intensity of menstrual pain (r = 0.558). Conclusions This study is the first to evaluate menstrual attitudes and analyse its factor structure among Nepalese women. In the future, the relationship between accurately evaluated negative menstrual attitudes and reproductive health issues should be examined more comprehensively. For sexually mature women, menstruation may be considered burdensome, but its absence may also be a source of concern. Perceptions regarding menstruation are collectively referred to as menstrual attitudes. Previous studies have reported that negative menstrual attitudes are associated with various reproductive health issues in women and vary according to social and cultural backgrounds. To adequately evaluate negative menstrual attitudes among Nepalese women (20–45 years old), we developed a 15-item scale that considers their cultural background and literacy. We observed that attitudes toward menstruation among Nepalese women consisted of three emotions: one positive emotion, including “menstruation is a natural phenomenon”, and two negative emotions, including “menstruation is debilitating” and “menstruation is bothersome”. In several developing countries, menstruating women are considered unclean, and various restrictions are imposed on women during menstruation (traditional menstrual practices). Nepalese women with strong negative menstrual attitudes, as assessed by our scale, engaged in several traditional menstrual practices with higher frequency. We also observed that women with more negative menstrual attitudes presented with more severe menstrual pain. Our scale was developed to be compatible with the values and literacy of Nepalese women and was easy to answer. We believe that reducing negative emotions toward menstruation will contribute to reducing the frequency of traditional menstrual practices and menstrual pain, thereby facilitating school attendance and entry into the workforce among women in Nepal.
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Gyasi-Gyamerah AA, Manukure JM, Andoh LN, Dey NEY, Ansah KO, Agbadi P. Rural-urban variation in exclusion from social activities due to menstruation among adolescent girls and young women in Ghana. Heliyon 2022; 8:e09463. [PMID: 35620617 PMCID: PMC9126932 DOI: 10.1016/j.heliyon.2022.e09463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/14/2021] [Accepted: 05/12/2022] [Indexed: 11/25/2022] Open
Abstract
Menstruation among adolescent girls and young women (AGYW) can be marked by several challenges that often result in exclusion from social activities. Information regarding this subject matter is however sparse in Ghana. This study examined the rural-urban differences in prevalence and correlates of exclusion from social activities due to menstruation among AGYW in Ghana. The study used cross-sectional data drawn from the women dataset of 2017/2018 Ghana Multiple Indicator Cluster Survey Six (GMICS 6). Data of adolescents (n = 2927; age 15–19) and young women (n = 2194; age 20–24) was analyzed in Stata version 14. About 21.65% of the respondents indicated that they excluded themselves from activities during menstruation with slightly higher rates for rural AGYW (22.2%) compared to their urban counterparts (21.11%). Multivariable Poisson regression models showed that compared with nonattainment of formal education, urban AGYW who attained a primary level education were more likely to exclude themselves from social activities due to menstruation [APR = 2.76, 95% CI:1.11, 6.90]. Also, currently married urban AGYW were less likely to exclude themselves from social activities due to menstruation [APR = 0.63, 95% CI:0.44, 0.91]. AGYW residing in the second-lowest wealth household in rural areas had a higher likelihood of exclusion from social activities due to menstruation [APR = 1.34, 95% CI:1.03, 1.75]. Region of residence was a significant correlate in both rural and urban samples but with an observed rural-urban variation. Given the prevalence of AGYW who exclude themselves from social activities, the government and non-governmental organizations that seek to improve menstrual hygiene and empower young women to participate in social activities regardless of their monthly menstrual flow should take into consideration the urban-rural differentials in the associated factors identified in this study.
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Affiliation(s)
- Angela A. Gyasi-Gyamerah
- Department of Psychology, College of Humanities, School of Social Sciences, University of Ghana, Legon, Accra, Ghana
- Corresponding author.
| | - Joseph Mfum Manukure
- Department of Psychology, College of Humanities, School of Social Sciences, University of Ghana, Legon, Accra, Ghana
| | - Lily N.A. Andoh
- Department of Psychology, College of Humanities, School of Social Sciences, University of Ghana, Legon, Accra, Ghana
| | - Nutifafa Eugene Yaw Dey
- Department of Psychology, College of Humanities, School of Social Sciences, University of Ghana, Legon, Accra, Ghana
| | - Kenneth Owusu Ansah
- Department of Psychology, College of Humanities, School of Social Sciences, University of Ghana, Legon, Accra, Ghana
| | - Pascal Agbadi
- Department of Sociology and Social Policy, Lingnan University, Tuen Mun, 8 Castle Peak Road, Hong Kong, SAR
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Wilbur J, Morrison C, Iakavai J, Shem J, Poilapa R, Bambery L, Baker S, Tanguay J, Sheppard P, Banks LM, Mactaggart I. "The weather is not good": exploring the menstrual health experiences of menstruators with and without disabilities in Vanuatu. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 18:100325. [PMID: 35024657 PMCID: PMC8661049 DOI: 10.1016/j.lanwpc.2021.100325] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Menstrual health is essential for gender equality and achieving the sustainable development goals. Though currently lacking, understanding and addressing menstrual health and social related inequalities requires comparison of experiences between menstruators with and without disabilities. METHODS We completed a mixed-methods population-based study of water, sanitation and hygiene, disability and menstrual health in TORBA and SANMA Provinces, Vanuatu. Methods included a census, nested case-control study, in-depth interviews (IDIs), focus group discussions (FGDs), PhotoVoice and structured observations. We undertook a population census of 11,000+ households and recruited 164 menstruators with and 169 without disabilities (aged 10-45) into a nested case-control study. 20 menstruators across both groups were selected for the qualitative component. FINDINGS Menstruators with disabilities were five times (adjusted Odds Ratio [aOR] 5.5, 95% Confidence Interval 1.8 - 16.5) more likely to use different bathing facilities to others in the household, nearly twice as likely (1.8, 1.1 - 3.1) to miss social activities, and three times (3.0, 1.6 - 5.7) more likely to eat alone during menstruation. Menstrual restrictions were widespread for all, but collecting water and managing menstrual materials was harder for menstruators with disabilities, particularly those requiring caregivers' support. These factors negatively impacted menstruators with disabilities' comfort, safety and hygiene, yet they reported less interference of menstruation on participation. INTERPRETATION Negative factors affecting all menstruators disproportionately impact those with disabilities, compounding existing inequalities. Menstruators with disabilities may have reported less interference because they are accustomed to greater participation restrictions than others. FUNDING Australian Government's Water for Women fund and public donations.
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Affiliation(s)
- Jane Wilbur
- International Centre for Evidence in Disability (ICED), London School of Hygiene & Tropical Medicine, Keppel Street, London WCE 7HT, UK
| | - Chloe Morrison
- World Vision Vanuatu, Rue Artoi M/S, P.O Box 247, Port Vila, Vanuatu
| | - Judith Iakavai
- Vanuatu Society for People with Disability, PO Box 373, Port Vila, Vanuatu
| | - Jeanine Shem
- World Vision Vanuatu, Rue Artoi M/S, P.O Box 247, Port Vila, Vanuatu
| | - Relvie Poilapa
- World Vision Vanuatu, Rue Artoi M/S, P.O Box 247, Port Vila, Vanuatu
| | - Luke Bambery
- World Vision Vanuatu, Rue Artoi M/S, P.O Box 247, Port Vila, Vanuatu
| | - Sally Baker
- Melbourne School of Population Health, University of Melbourne, 207 Bouverie St, Carlton, VIC 3053, Australia
| | - Jamie Tanguay
- Vanuatu National Statistics Office, Port Vila, Vanuatu
| | - Philip Sheppard
- International Centre for Evidence in Disability (ICED), London School of Hygiene & Tropical Medicine, Keppel Street, London WCE 7HT, UK
| | - Lena Morgon Banks
- International Centre for Evidence in Disability (ICED), London School of Hygiene & Tropical Medicine, Keppel Street, London WCE 7HT, UK
| | - Islay Mactaggart
- International Centre for Evidence in Disability (ICED), London School of Hygiene & Tropical Medicine, Keppel Street, London WCE 7HT, UK
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The Stressor in Adolescence of Menstruation: Coping Strategies, Emotional Stress & Impacts on School Absences among Young Women in Nepal. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18178894. [PMID: 34501484 PMCID: PMC8431475 DOI: 10.3390/ijerph18178894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/12/2021] [Accepted: 08/13/2021] [Indexed: 11/25/2022]
Abstract
Throughout the developing world, girls face hardships surrounding menstruation, often resulting in poor emotional wellbeing and missing school. Providing ways to keep girls in school will increase their educational and earning potentials, which will ultimately trickle down to improving the economic standing of nations in the next generation. Informed by the Transactional Model of Stress and Coping, this work evaluates the roles that cultural and school environments play in appraisals of menstruation as a major life stressor for adolescent females and the impacts of emotional stress on missing school. Using primary survey data from schools in Nepal, robust results are found to support the theoretical framework based on conditional mixed-process (CMP) estimation with fixed effects, utilizing multiple index building techniques. Strong cultural norms during menstruation appear to increase the probability of girls self-reporting emotional stress, while the presence of hygiene supporting infrastructure at schools reduces this outcome. Furthermore, there is strong support for the finding that the presence of emotional stress during menstruation increases the likelihood of not only missing school but also for an extended period of time. Our findings motivate increasing government policies to provide stronger hygiene infrastructure in schools to improve successful coping skills and attendance rates.
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Wilbur J, Scherer N, Mactaggart I, Shrestha G, Mahon T, Torondel B, Hameed S, Kuper H. Are Nepal's water, sanitation and hygiene and menstrual hygiene policies and supporting documents inclusive of disability? A policy analysis. Int J Equity Health 2021; 20:157. [PMID: 34238285 PMCID: PMC8268379 DOI: 10.1186/s12939-021-01463-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/29/2021] [Indexed: 11/12/2022] Open
Abstract
PURPOSE This study assesses the inclusion of disability in Nepal's policy and guidance relevant to water, sanitation and hygiene (WASH), and menstrual hygiene management (MHM) in comparison to gender. We investigated both policy formulation and implementation, using the Kavrepalanchok district as a case study. MATERIALS AND METHODS We used the EquiFrame framework, adapted for disability and gender, and focusing on WASH and MHM. Ten Nepali policies and guidance documents were reviewed and scored for quality against the framework, which included 21 core concepts of human rights. We also interviewed key informants to consider the inclusion of disability in the implementation of MHM interventions. We applied stratified purpose sampling to 12 government officials and service providers working in Kathmandu and the Kavrepalanchock district; conducted in-depth interviews and analysed data thematically using Nvivo 11. RESULTS Disability was inadequately covered within the policy documents, and MHM policy commitments for disability were almost non-existent. Participation of people with disabilities in policy development was limited; within Kavrepalanchok, policy commitments were not implemented as intended and disability service providers were unable to allocate government resources. Inadequate data on disability and MHM resulted in limited professional understanding of the issues, as service providers had no training. A narrow WASH infrastructure approach to improving MHM for people with disabilities was prioritised. MHM interventions were delivered in schools; these failed to reach children with disabilities who are often out of school. Finally, there were indications that some caregivers seek sterilisation for people with disabilities who are unable to manage menstruation independently. CONCLUSION Though the Constitution of Nepal enshrines gender equality and disability inclusion, there are consistent gaps in attention to disability and MHM in policies and practice. These omit and exclude people with disabilities from MHM interventions. Investment is required to generate evidence on the MHM barriers faced by people with disabilities, which would then be drawn on to develop training on these issues for professionals to improve understanding. Subsequently, policy makers could include more concepts of human rights against disability in relevant policies and service providers could implement policy commitments as intended.
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Affiliation(s)
- Jane Wilbur
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Nathaniel Scherer
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Islay Mactaggart
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Govind Shrestha
- WaterAid Nepal, JM Road 10, Pabitra Tole Nakkhipot, 44700, Nepal
| | | | - Belen Torondel
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Shaffa Hameed
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Hannah Kuper
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Hennegan J, Kibira SPS, Exum NG, Schwab KJ, Makumbi FE, Bukenya J. 'I do what a woman should do': a grounded theory study of women's menstrual experiences at work in Mukono District, Uganda. BMJ Glob Health 2021; 5:bmjgh-2020-003433. [PMID: 33219001 PMCID: PMC7682193 DOI: 10.1136/bmjgh-2020-003433] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 11/11/2022] Open
Abstract
Menstrual health has received increasing recognition as an essential issue for public health and gender equality. A growing body of research has elucidated adolescent girls’ menstrual needs and informed policy and practice responses. However, the experiences of adult women have received little attention, particularly in the workplace where many spend a significant proportion of their lives. To address this gap, we took a grounded theory approach to generate a nuanced understanding of working women’s menstrual experiences, and the impact of menstruation on their work and health in Mukono District, Uganda. In-depth interviews were undertaken with 35 women aged 18–49. This included 21 women working in markets, 7 teachers and 7 healthcare facility workers. Frequent collaborative analysis sessions throughout data collection, coding of interview transcripts, and generation of participant, workplace, and category memos facilitated analysis. Our core category and underlying theory, ‘being a responsible woman’, underpinned women’s experiences. ‘Being responsible’ meant keeping menstruation secret, and the body clean, at all times. These gendered expectations meant that any difficulty managing menses represented a failure of womanhood, met with disgust and shame. Difficulties with menstrual pain and heavy bleeding were excepted from these expectations and perceived as requiring compassion. Commercial menstrual products were expensive for most women, and many expressed concerns about the quality of cheaper brands. Workplace infrastructure, particularly unreliable water supply and cleanliness, was problematic for many women who resorted to travelling home or to other facilities to meet their needs. Menstruation presented a burden at work, causing some women to miss work and income, and many others to endure pain, discomfort and anxiety throughout their day. Our findings can inform norm and resource-focused responses to improve experiences and should provoke critical reflection on the discourse used in menstrual health advocacy in Uganda.
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Affiliation(s)
- Julie Hennegan
- The Water Institute, Department of Environmental Health and Engineering, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Simon P S Kibira
- Department of Community Health and Behavioural Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Natalie G Exum
- The Water Institute, Department of Environmental Health and Engineering, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kellogg J Schwab
- The Water Institute, Department of Environmental Health and Engineering, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Fredrick E Makumbi
- Department of Epidemiology & Biostatistics, Makerere University College of Health Sciences, Kampala, Uganda
| | - Justine Bukenya
- Department of Community Health and Behavioural Sciences, Makerere University College of Health Sciences, Kampala, Uganda
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Fennie T, Moletsane M, Padmanabhanunni A. Adolescents' experiences of menarche and menstruation in disadvantaged schools in South Africa: a qualitative exploration. HEALTH EDUCATION 2021. [DOI: 10.1108/he-12-2020-0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThis study explores how menstruation is perceived, experienced and navigated by school-going adolescent girls living in low-to-middle income settings in South Africa. Existing research from developing countries suggest that the onset of menstruation has implications for school attendance and academic performance. There is evidence that menstrual cycle–related symptoms (primarily physical) lead to difficulties in, or interference with, and disengagement from school, social relations, and physical activities (van Iersel et al., 2016; Steiner et al., 2011; Kiesner and Pastore, 2010; Taras, 2005). The onset of menstruation can be shame-inducing and has been associated with anxiety and confusion. Few studies have been conducted on menstruation in countries with a history of sectarian violence and characterised by substantial socio-economic disparities and high levels of gender-based violence. Understanding the experiences of girls in these contexts is important in generating contextually-grounded knowledge and appropriate interventions.Design/methodology/approachA qualitative, exploratory, descriptive and contextual research design was used to collect data from 48 adolescent girls aged 13–16 year-old. A total of six focus group discussions (FGDs) were conducted using a semi-structured questionnaire among a purposive sampling method. Data collected were transcribed verbatim and thematically analysed. Written parental consent was obtained for participants under 18 years old.FindingsThe findings illustrated complex psychological experiences in response to menarche and menstruation. Experiences of shame in relation to menstruation were aggravated by unsupportive responses from school teachers. Challenges such as scarcity of sanitary products were experienced as creating a barrier for girls' school attendance.Research limitations/implicationsExisting research from developing countries suggests that the onset of menstruation has implications for school attendance and academic performance. The research data includes the views of adolescent learners and their negative reactions and positive experiences towards menstruation within the school environment.Practical implicationsGiven the comparative paucity of research emerging from developing countries in sub-Saharan Africa, this paper addresses an important gap in the literature by providing contextually-nuanced information about the menstrual experiences of adolescent girls. The study can further provide information for efforts made by the Department of Education and Department of Health regarding the impact of menstruation on adolescent girls' school attendance.Social implicationsThis study provides important insights regarding the experiences of South African school girls in relation to menstruation. Although dominant feelings of shame, confusion and disgust may surround menstruation, the study also highlighted potential positive experiences associated with menstruation. Teachers and school administrators need to be oriented towards the needs of adolescent girls if issues regarding poor school attendance are to be addressed.Originality/valueTo reduce absenteeism in schools and ensure learners are provided with improved allocation of sanitary products in schools, there is a need for the advocacy regarding sexuality education and resources to promote the psychological health of adolescent girls.
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Mohammadinia N, Rezaei MA, Morowatisharifabad MA, Heydarikhayat N. The effect of education based on PEN-3 cultural model on students' menstrual health behaviors: a mixed method study. HEALTH EDUCATION RESEARCH 2021; 36:239-247. [PMID: 33608708 DOI: 10.1093/her/cyab001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Indexed: 05/27/2023]
Abstract
Menstruation is a natural process in girls, but sometimes it is accompanied by beliefs and behaviors with cultural roots that result in poor health consequences; this study aimed to consider perceptions of individual, families and community to current cultural beliefs, and to determine the effect of education based on the PEN-3 cultural model on students' menstrual health behaviors in Iran. Study had a mixed method design. In the qualitative phase, data were collected from students, their mothers and teachers through focused group discussion and in-depth interviews. In the quantitative phase, training was done in four 2-h sessions for intervention group. The data were collected immediately and 2 months after the training by a questionnaire and they were analyzed by Friedman and Wilcoxon non-parametric tests. Training was effective on all of the model structures and significantly increased mean score of the health behavior after training and 2 months later by 8.74 and 13.86, respectively, in intervention group (P<0.05). The perception and behavior of the others and access to sanitary services and products, especially cultural factors affect girls'' menstrual health behaviors, therefore, it is necessary to design the health plans regarding each of these factors, and the cultural context of each community.
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Affiliation(s)
- Neda Mohammadinia
- Department of Community Health Nursing, School of Nursing and Midwifery, Bam University of Medical Sciences, Bam, Iran
| | - Mohammad Ali Rezaei
- Department of Nursing, School of Nursing and Midwifery, Bam University of Medical Sciences, Bam, Iran
| | - Mohammad Ali Morowatisharifabad
- Department of health education and promotion, school of public health, social determinants of health research center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Wilbur J, Kayastha S, Mahon T, Torondel B, Hameed S, Sigdel A, Gyawali A, Kuper H. Qualitative study exploring the barriers to menstrual hygiene management faced by adolescents and young people with a disability, and their carers in the Kavrepalanchok district, Nepal. BMC Public Health 2021; 21:476. [PMID: 33691653 PMCID: PMC7944905 DOI: 10.1186/s12889-021-10439-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 02/15/2021] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Menstrual hygiene management (MHM) is a recognised public health, social and educational issue, which must be achieved to allow the realisation of human rights. People with disabilities are likely to experience layers of discrimination when they are menstruating, but little evidence exists. METHODS The study aims to investigate barriers to MHM that people with disabilities and their carers face in the Kavrepalanchok, Nepal, using qualitative methods. Twenty people with disabilities, aged 15-24, who menstruate and experience 'a lot of difficulty' or more across one or more of the Washington Group functional domains were included, as well as 13 carers who provide menstrual support to these individuals. Purposeful sampling was applied to select participants. Different approaches were used to investigating barriers to MHM and triangulate data: in-depth interviews, observation, PhotoVoice and ranking. We analysed data thematically, using Nvivo 11. RESULTS Barriers to MHM experienced by people with disabilities differ according to the impairment. Inaccessible WASH facilities were a major challenge for people with mobility, self-care and visual impairments. People with intellectual impairments had difficulty accessing MHM information and their carers despaired when they showed their menstrual blood to others, which could result in abuse. No support mechanisms existed for carers for MHM, and they felt overwhelmed and isolated. Menstrual discomfort was a major challenge; these were managed with home remedies, or not at all. Most participants followed menstrual restrictions, which were widespread and expected; many feared they would be cursed if they did not. As disability is often viewed as a curse, this demonstrates the layers of discrimination faced. CONCLUSION Issues related to MHM for people with disabilities is more complex than for others in the population due to the additional disability discrimination and impairment experienced. Research exploring these issues must be conducted in different settings, and MHM interventions, tailored for impairment type and carers requirements,should be developed. Attention to, and resourcing for disability inclusive MHM must be prioritised to ensure 'no one is left behind'.
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Affiliation(s)
- Jane Wilbur
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | | | | | - Belen Torondel
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Shaffa Hameed
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | | | | - Hannah Kuper
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Amini E, McCormack M. Older Iranian Muslim women's experiences of sex and sexuality: A biographical approach. THE BRITISH JOURNAL OF SOCIOLOGY 2021; 72:300-314. [PMID: 33341961 PMCID: PMC8246973 DOI: 10.1111/1468-4446.12805] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 10/04/2020] [Accepted: 12/07/2020] [Indexed: 06/12/2023]
Abstract
Muslim women in Iran live in a patriarchal society which significantly restricts their freedom and agency. While there is a growing understanding of social change as it relates to younger Muslim women in Iran, the perspectives and experiences of older women are marginalized; mirroring problems with the intersections of age, gender, and sexuality in the West. In order to address this occlusion, this article draws on life history interviews with 30 older Muslim women living in Tehran and Karaj. Adopting a biographical life course approach, and examining pivotal moments related to sexuality in their lives, we discuss how cultural meanings and symbols of sexuality have emerged and been negotiated by these women at the life stages of puberty, first sex at marriage, and menopause. The patriarchal and religious gender order of Iran transgresses these women's human rights so that sexuality is experienced as a source of shame, stigma, and pollution, yet the women also exert forms of agency in their lives as they adopt and challenge these norms.
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Affiliation(s)
- Elham Amini
- Department of SociologyUniversity of DurhamDurhamUK
| | - Mark McCormack
- Department of Social SciencesUniversity of RoehamptonLondonUK
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Thapa S, Aro AR. 'Menstruation means impurity': multilevel interventions are needed to break the menstrual taboo in Nepal. BMC WOMENS HEALTH 2021; 21:84. [PMID: 33639917 PMCID: PMC7971149 DOI: 10.1186/s12905-021-01231-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 02/21/2021] [Indexed: 12/27/2022]
Abstract
Background During their menstrual period, women are generally considered impure in Nepal; in the rural areas of the western part of the country, they are even banished to stay in sheds (called chhaupadi) during this time, which increases their vulnerability to a variety of health consequences. There is lack of clarity regarding the effectiveness of interventions that have been implemented to address menstrual taboo and improve menstrual hygiene and practices in Nepal (e.g., public awareness, community sensitization and legislation). In this paper, we discuss why menstruation management interventions, particularly those implemented to change the menstrual taboo might not work, and the opinions and experiences regarding the implementation of such interventions. Main text Anecdotal reports from the field and empirical studies suggest that interventions to address menstrual taboos have only been effective for short durations of time due to several reasons. First, local community stakeholders have been reluctant to take actions to abandon retrogressive menstrual practices in rural areas. Second, women who have stopped practising chhaupadi have faced stigma (e.g., fear of exclusion) and discrimination (e.g., blaming, physical and verbal abuse). Third, contextual factors, such as poverty and illiteracy, limit the effectiveness of such interventions. Fourth, community sensitization activities against chhaupadi have faced resistance from community leaders and traditional healers. Fifth, the law prohibiting chhaupadi has also faced implementation problems, including poor filing of complaints. Conclusion Multilevel, multisectoral interventions could be more effective than single-component interventions in breaking the prevailing menstrual taboo and in improving menstrual health and hygiene practices among young girls and women in the rural areas of Nepal. Moreover, interventions that have an active community mobilization component could be effective within local contexts and cultural groups.
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Affiliation(s)
- Subash Thapa
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.
| | - Arja R Aro
- Unit for Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark.,EduRes Consulting Ltd, Veikkola, Finland
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Living with Restrictions. The Perspective of Nursing Students with Primary Dysmenorrhea. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228527. [PMID: 33212985 PMCID: PMC7698483 DOI: 10.3390/ijerph17228527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/09/2020] [Accepted: 11/13/2020] [Indexed: 12/30/2022]
Abstract
Primary dysmenorrhea (PD) affects a large number of female university students, diminishing their quality of life and hindering academic performance, representing a significant cause of absenteeism. The purpose of our study was to determine how nursing students experienced restrictions as a result of primary dysmenorrhea. A qualitative exploratory study was conducted among 33 nursing students with primary dysmenorrhea. A purposeful sampling strategy was applied. Data were collected from five focus groups (two sessions each) and the field notes of 10 researchers. A video meeting platform was used to conduct the focus groups. A thematic inductive analysis was performed. Thirty-three female nursing students participated in the study with a mean age of 22.72 (SD 3.46) years. Three broad themes emerged: (a) restrictions on daily activities and sports; (b) academic restrictions, and (c) restrictions on social and sexual relationships. The students described restrictions in performing everyday activities, such as carrying weight, and shopping. Some students even gave up the practice of sports and were absent from classes at the university, and from clinical practices at the hospital. The pain affected their ability to maintain and create new social relationships. Primary dysmenorrhea caused restrictions in the personal, social and academic life of the nursing students.
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Mukherjee A, Lama M, Khakurel U, Jha AN, Ajose F, Acharya S, Tymes-Wilbekin K, Sommer M, Jolly PE, Lhaki P, Shrestha S. Perception and practices of menstruation restrictions among urban adolescent girls and women in Nepal: a cross-sectional survey. Reprod Health 2020; 17:81. [PMID: 32487096 PMCID: PMC7268527 DOI: 10.1186/s12978-020-00935-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 05/24/2020] [Indexed: 12/13/2022] Open
Abstract
Background Menstruation, a natural biologic process is associated with restrictions and superstitious beliefs in Nepal. However, factual data on women’s perspectives on menstrual practices and restrictions are scarce. This study aimed to assess socio-cultural perceptions of menstrual restrictions among urban Nepalese women in the Kathmandu valley. Methods Using a clustered random sampling, 1342 adolescent girls and women of menstruating age (≥15 years) from three urban districts in the Kathmandu valley completed a survey related to menstrual practices and restriction. This was a cross-sectional survey study using a customized program allowing pull-down, multiple choice and open-ended questions in the Nepali language. The self-administered questionnaire consisted of 13 demographic questions and 22 questions related to menstruation, menstrual hygiene, socio-cultural taboos, beliefs and practices. Univariate descriptive statistics were reported. Unadjusted associations of socio-cultural practices with ethnicity, education, four major social classes, three major religions, marital status and family type were assessed using logistic regression models. Results More than half (59%) of the participants were aged between 15- < 25 years. The majority were Hindus (84.5%), reported not praying during menstruation (83.1%) and were encouraged by their mothers (72.1%) to practice a range of menstrual restrictions. Purifying either the kitchen, bed, bedsheets or other household things on the fourth day of menstruation was reported by 66.1% of the participants, and 45.4% saw menstruation as a “bother” or “curse.” There were differences among social classes, where participants of the Janajati caste, an indigenous group, were more likely to enter places of worship [OR (95%CI): 1.74 (1.06–2.86)] and pray [OR (95%CI): 1.79 (1.18–2.71)] while menstruating, compared to the Brahmins. Participants with a master’s degree were more likely to pray while menstruating, compared to participants with less than a high school education [OR (95%CI): 2.83 (1.61–4.96)]. Conclusion This study throws light on existing social discriminations, deep-rooted cultural and religious superstitions among women, and gender inequalities in the urban areas of Kathmandu valley in Nepal. Targeted education and awareness are needed to make changes and balance between cultural and social practices during menstruation.
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Affiliation(s)
- Amrita Mukherjee
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mingma Lama
- Nepal Fertility Care Center (NFCC), Lalitpur, Nepal
| | | | | | - Fatima Ajose
- University of Michigan, School of Public Health, Ann Arbor, MI, USA
| | - Sanjeev Acharya
- Department of Sociology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kristina Tymes-Wilbekin
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marni Sommer
- Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Pauline E Jolly
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Pema Lhaki
- Nepal Fertility Care Center (NFCC), Lalitpur, Nepal.
| | - Sadeep Shrestha
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
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Caruso BA, Portela G, McManus S, Clasen T. Assessing Women's Menstruation Concerns and Experiences in Rural India: Development and Validation of a Menstrual Insecurity Measure. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E3468. [PMID: 32429238 PMCID: PMC7277189 DOI: 10.3390/ijerph17103468] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/07/2020] [Accepted: 05/09/2020] [Indexed: 11/29/2022]
Abstract
Qualitative research has documented menstruator's challenges, particularly in water and sanitation poor environments, but quantitative assessment is limited. We created and validated a culturally-grounded measure of Menstrual Insecurity to assess women's menstruation-related concerns and negative experiences. With cross-sectional data from 878 menstruating women in rural Odisha, India, we carried out Exploratory (EFA) and Confirmatory (CFA) Factor Analyses to reduce a 40-item pool and identify and confirm the scale factor structure. A 19-item, five factor model best fit the data (EFA: root mean square error of approximation (RMSEA) = 0.027; comparative fit index (CFI) = 0.994; Tucker-Lewis index (TLI) = 0.989; CFA: RMSEA = 0.058; CFI = 0.937; TLI = 0.925). Sub-scales included: Management, Menstrual Cycle Concerns, Symptoms, Restrictions, and Menstruation-Related Bodily Concerns. Those without access to a functional latrine, enclosed bathing space, water source within their compound, or who used reusable cloth had significantly higher overall Menstrual Insecurity scores (greater insecurity) than those with these facilities or using disposable pads. Post-hoc exploratory analysis found that women reporting experiencing tension at menstrual onset or difficulty doing work had significantly higher Menstrual Insecurity scores. This validated tool is useful for measuring Menstrual Insecurity, assessing health inequities and correlates of Menstrual Insecurity, and informing program design.
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Affiliation(s)
- Bethany A. Caruso
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - Gerard Portela
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA;
| | - Shauna McManus
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA;
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA;
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Fahs B. There Will Be Blood: Women’s Positive and Negative Experiences with Menstruation. ACTA ACUST UNITED AC 2020. [DOI: 10.1080/23293691.2019.1690309] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Breanne Fahs
- Women and Gender Studies Program, Arizona State University, Glendale, Arizona, USA
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Hennegan J, Sol L. Confidence to manage menstruation at home and at school: findings from a cross-sectional survey of schoolgirls in rural Bangladesh. CULTURE, HEALTH & SEXUALITY 2020; 22:146-165. [PMID: 30931818 DOI: 10.1080/13691058.2019.1580768] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 02/05/2019] [Indexed: 06/09/2023]
Abstract
This study investigated girls' confidence to undertake menstrual management tasks at home and in school environments using cross-sectional data from a survey of 1,359 schoolgirls in Bangladesh. At home, 57% of girls reported they were 'very confident' undertaking tasks to manage their menstrual bleeding, while this figure was only 7% at school. We assessed personal, interpersonal and environmental contributors for each context. The use of sanitary pads was positively associated with confidence to manage menstruation at home, while other menstrual hygiene practices were unrelated. In multivariable models, features of sanitation facilities such as cleanliness and the presence of a bin were associated with increased confidence at home. At school, supportive policies, such providing permission to use the toilet when needed, were associated with greater confidence. Talking to a friend about menstruation was positively associated with confidence at school, while at home having discussed menstruation with parents predicted lower confidence. Findings provide quantitative support for the role of multiple independent predictors in girls' confidence to manage menstruation highlighted by qualitative studies. There is unlikely to be a single 'silver bullet' to improving menstrual experience.
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Affiliation(s)
- Julie Hennegan
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lidwien Sol
- School of Business and Economics, Maastricht University, Maastricht, The Netherlands
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Ong T, Mellor D, Chettri S. Multiplicity of stigma: the experiences, fears and knowledge of young trafficked women in Nepal. Sex Reprod Health Matters 2019; 27:1679968. [PMID: 31722649 PMCID: PMC7888057 DOI: 10.1080/26410397.2019.1679968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We undertook a reproductive health study on young formerly trafficked women in Nepal using a new research method – the Clay Embodiment Research Method – designed with their vulnerability and the cultural context in mind. Following a two-month period of participant observation, six formerly trafficked women participated in a series of seven themed (clay embodiment/three-dimensional body mapping) workshops and, afterward, a group interview using photoethnography. We discovered that these women are subject to cultural stigmas other than those related to sex trafficking, such as menstrual stigma, stigma related to pre-marital sex, stigma related to pregnancy before marriage and stigma for having a female child. These can have a deep impact across the entire reproductive lives of women. As a cultural force, the stigmatisation is generated by both men and women, and has roots that lie in Hinduism and the patriarchal value system in Nepal. Nepal is attempting to address some of these issues and we recommend a public health campaign to eliminate the practice of the menstruation and other stigmatising traditions.
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Affiliation(s)
- Tricia Ong
- Associate Lecturer, Theatre-based Education Programs, Faculty of Health, School of Health and Social Development, Deakin University, Melbourne, Australia
| | - David Mellor
- Emeritus Professor, Faculty of Health, School of Psychology, Deakin University, Burwood, Victoria, Australia
| | - Sabrina Chettri
- Program Officer (Protection and Psychosocial Support), Caritas Nepal, Lalitpur, Nepal
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MacRae ER, Clasen T, Dasmohapatra M, Caruso BA. 'It's like a burden on the head': Redefining adequate menstrual hygiene management throughout women's varied life stages in Odisha, India. PLoS One 2019; 14:e0220114. [PMID: 31369595 PMCID: PMC6675075 DOI: 10.1371/journal.pone.0220114] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 06/21/2019] [Indexed: 11/29/2022] Open
Abstract
There has been growing recognition of menstrual hygiene management (MHM) as a significant public health issue. However, research has predominately focused on the experiences of adolescent girls in school settings. The purpose of this research is to examine detailed accounts of menstruation for women in rural Odisha, India at various life stages with a view toward improving international monitoring of MHM. Focus group discussions and in-depth interviews were conducted to understand women’s experiences of menstruation across four life stages (unmarried women, recently married women, married women, and older women). Thematic analysis was used to identify menstruation-related challenges and needs. We found women voiced needs that aligned with those captured by the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) definition for MHM: access to clean materials, privacy for changing materials, soap and water for bathing, and disposal facilities for materials. However, we also found women require materials that are not only clean but comfortable and reliable; soap and water for more than bathing; privacy for the full spectrum of menstruation-related practices, not just when changing; and disposal facilities that are private and safe, not just accessible. Additionally, we identified needs that extend beyond the existing definition: pain management, social support, and an enabling sociocultural environment. Overall, women representing all life stages discussed menstruation challenges, including bathing, pain, and washing, drying, and storing cloth materials. Cloth management challenges were most acute for unmarried and recently married women, who were concerned that practices could reveal their menstrual status and harm their reputations, thus informing their preference for disposable materials, if attainable. We propose a revised definition of adequate MHM for this population that more comprehensively captures their needs. This definition may also prove useful for other populations, future research, creating measures of assessment, and guiding interventions and program priorities.
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Affiliation(s)
- Elizabeth R. MacRae
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
- * E-mail:
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Bethany A. Caruso
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
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Thapa S, Bhattarai S, Aro AR. 'Menstrual blood is bad and should be cleaned': A qualitative case study on traditional menstrual practices and contextual factors in the rural communities of far-western Nepal. SAGE Open Med 2019; 7:2050312119850400. [PMID: 31205696 PMCID: PMC6537045 DOI: 10.1177/2050312119850400] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 04/23/2019] [Indexed: 12/14/2022] Open
Abstract
Objective: Unhealthy menstrual practices and the contexts surrounding them should be
explored and clearly understood; this information could be useful while
developing and implementing interventions to increase hygienic practices
during menstruation and consequently increase health and well-being of
women. Therefore, this study was conducted to explore traditional menstrual
practices and the contextual factors surrounding the practices in the rural
communities of far-western Nepal. Methods: This was a qualitative case study conducted in the Achham district of Nepal.
Semi-structured interviews were conducted among four women, three men and
two female community health volunteers to collect data and thematic analysis
was performed to analyze the data. Results: We found two commonly reported menstrual practices: seclusion practice
(Chhaupadi) and separation practice. In the Chhaupadi practice, women are
secluded to stay in a small shed away from the house and restricted to wash
or take a bath in public water sources for 5–7 days of the periods, whereas
in the separation practice, women can stay in the house, but they still have
several restrictions. The contextual factors that were reported to influence
the cultural practices are as follows: cultural beliefs that symbolize
menstruation as impure, menstrual stigma, poverty, illiteracy, the influence
of traditional healers and family members, and limited effect of Chhaupadi
elimination interventions. We also found that some development in the
reduction of cultural myths and practices is happening, but the rate of
change is rather slow. Conclusion: Most of the Nepalese women, especially in the rural areas of far-western
Nepal, are forced to follow the harmful menstrual practices because of the
socio-cultural context surrounding their lives. We believe the findings of
this study would be relevant in terms of developing and implementing further
menstrual health-related, community-based interventions that will be
responsive to the local cultural context, beliefs, and practices.
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Affiliation(s)
- Subash Thapa
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Shivani Bhattarai
- Department of Public Health, Nobel College, Pokhara University, Kathmandu, Nepal
| | - Arja R Aro
- Unit for Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark
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Hennegan J, Shannon AK, Rubli J, Schwab KJ, Melendez-Torres GJ. Women's and girls' experiences of menstruation in low- and middle-income countries: A systematic review and qualitative metasynthesis. PLoS Med 2019; 16:e1002803. [PMID: 31095568 PMCID: PMC6521998 DOI: 10.1371/journal.pmed.1002803] [Citation(s) in RCA: 163] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 04/12/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Attention to women's and girls' menstrual needs is critical for global health and gender equality. The importance of this neglected experience has been elucidated by a growing body of qualitative research, which we systematically reviewed and synthesised. METHODS AND FINDINGS We undertook systematic searching to identify qualitative studies of women's and girls' experiences of menstruation in low- and middle-income countries (LMICs). Of 6,892 citations screened, 76 studies reported in 87 citations were included. Studies captured the experiences of over 6,000 participants from 35 countries. This included 45 studies from sub-Saharan Africa (with the greatest number of studies from Kenya [n = 7], Uganda [n = 6], and Ethiopia [n = 5]), 21 from South Asia (including India [n = 12] and Nepal [n = 5]), 8 from East Asia and the Pacific, 5 from Latin America and the Caribbean, 5 from the Middle East and North Africa, and 1 study from Europe and Central Asia. Through synthesis, we identified overarching themes and their relationships to develop a directional model of menstrual experience. This model maps distal and proximal antecedents of menstrual experience through to the impacts of this experience on health and well-being. The sociocultural context, including menstrual stigma and gender norms, influenced experiences by limiting knowledge about menstruation, limiting social support, and shaping internalised and externally enforced behavioural expectations. Resource limitations underlay inadequate physical infrastructure to support menstruation, as well as an economic environment restricting access to affordable menstrual materials. Menstrual experience included multiple themes: menstrual practices, perceptions of practices and environments, confidence, shame and distress, and containment of bleeding and odour. These components of experience were interlinked and contributed to negative impacts on women's and girls' lives. Impacts included harms to physical and psychological health as well as education and social engagement. Our review is limited by the available studies. Study quality was varied, with 18 studies rated as high, 35 medium, and 23 low trustworthiness. Sampling and analysis tended to be untrustworthy in lower-quality studies. Studies focused on the experiences of adolescent girls were most strongly represented, and we achieved early saturation for this group. Reflecting the focus of menstrual health research globally, there was an absence of studies focused on adult women and those from certain geographical areas. CONCLUSIONS Through synthesis of extant qualitative studies of menstrual experience, we highlight consistent challenges and developed an integrated model of menstrual experience. This model hypothesises directional pathways that could be tested by future studies and may serve as a framework for program and policy development by highlighting critical antecedents and pathways through which interventions could improve women's and girls' health and well-being. REVIEW PROTOCOL REGISTRATION The review protocol registration is PROSPERO: CRD42018089581.
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Affiliation(s)
- Julie Hennegan
- The Water Institute, Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Alexandra K. Shannon
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Kellogg J. Schwab
- The Water Institute, Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - G. J. Melendez-Torres
- Peninsula Technology Assessment Group, College of Medicine and Health, University of Exeter, Exeter, United Kingdom
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Baumann SE, Lhaki P, Burke JG. Assessing the Role of Caste/Ethnicity in Predicting Menstrual Knowledge, Attitudes, and Practices in Nepal. Glob Public Health 2019; 14:1288-1301. [PMID: 30785854 DOI: 10.1080/17441692.2019.1583267] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Menstruation is a natural, physiological process, but it can be a challenging experience for millions of women around the world. In Nepal, a geographically small yet diverse country of 125 caste/ethnic groups, understanding how caste/ethnicity impacts menstrual health is critical for developing context-specific interventions to improve women's health. A community-based, cross-sectional survey was conducted with 679 women and girls between the ages of 13-51 from the country's most populous castes/ethnic groups. Forty eight percent had high menstrual knowledge, 60% had positive menstrual attitudes, and 59% had positive menstrual practices. Caste/ethnicity was a significant predictor of menstrual knowledge and practices. The caste/ethnic groups Tarai/Madhesi/Other, Newar, Janajati, and Muslim all had statistically significant fewer odds of positive menstrual practices compared to Brahman/Chhetri (high caste groups), with Janajati (indigenous ethnic groups) having the poorest outcomes. Despite Nepal making impressive advances in health, certain caste/ethnic groups have fallen behind in terms of menstrual health outcomes. Consequently, blanket menstrual health programs may not be sufficient for improving menstrual knowledge and practices for all. Future programming should consider the use of local languages and context-specific content that incorporates indigenous beliefs, as well as cultivate partnerships with indigenous health organizations, and develop outcome indicators disaggregated by caste/ethnicity to ensure improved menstrual health for all.
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Affiliation(s)
- Sara E Baumann
- a Department of Behavioral and Community Health Sciences , Graduate School of Public Health, University of Pittsburgh , Pittsburgh , PA, USA
| | - Pema Lhaki
- b Nepal Fertility Care Center , Sanepa , Nepal
| | - Jessica G Burke
- a Department of Behavioral and Community Health Sciences , Graduate School of Public Health, University of Pittsburgh , Pittsburgh , PA, USA
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Chalise B, Aryal KK, Mehta RK, Dhimal M, Sapkota F, Mehata S, Karki KB, Madjdian D, Patton G, Sawyer S. Prevalence and correlates of anemia among adolescents in Nepal: Findings from a nationally representative cross-sectional survey. PLoS One 2018; 13:e0208878. [PMID: 30551124 PMCID: PMC6294609 DOI: 10.1371/journal.pone.0208878] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 11/27/2018] [Indexed: 11/18/2022] Open
Abstract
Anemia is regarded as major public health problem among adolescents in Low and Middle-Income Countries (LMICs) but there is limited primary data in many countries, including Nepal. This study investigated the prevalence and correlates of anemia in a nationally representative sample of adolescents within the 2014 National Adolescent Nutrition Survey in Nepal. A total of 3780 adolescents aged 10 to 19 years were selected from a cross-sectional survey through multi-stage cluster sampling. Structured interviews, anthropometric measurements and hemoglobin assessments of capillary blood were obtained. Bivariate and multivariable analyses were undertaken to compute the Adjusted Odds Ratio (aOR) for socio-demographic, behavioral and cluster characteristics. The overall prevalence of anemia was 31% (95%CI: 28.2, 33.5), 38% (95%CI: 34.0, 41.8) in female and 24% (95%CI: 20.6, 27.1) in male. The likelihood of anemia was significantly higher among older adolescents (aOR 1.75, 95%CI: 1.44, 2.13), females (aOR 2.02; 95%CI: 1.57, 2.60), among those who walk barefoot (aOR 1.78, 95%CI: 1.08, 2.94), and those residing in the Terai (aOR 1.80, 95%CI: 1.18, 2.77). Food consumption from more than four food groups (aOR 0.71, 95%CI: 0.57, 0.88) was protective against anemia. In conclusion, anemia is common in Nepali adolescents. Efforts to improve the nutritional status of this high-risk age group require nutrition that focus on eating habits, sanitation, iron supplementation and the treatment of hookworm infection.
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Affiliation(s)
- Binaya Chalise
- Nepal Health Research Council, Kathmandu, Nepal
- * E-mail:
| | | | | | | | | | | | | | - Donya Madjdian
- Department of Social Sciences, Sociology of Consumption and Households, Wageningen University, Wageningen, the Netherlands
| | - George Patton
- Department of Paediatrics, the University of Melbourne, Melbourne, Australia
- Centre for Adolescent Health, Royal Children’s Hospital and Murdoch Children’s Research Institute, Melbourne, Australia
| | - Susan Sawyer
- Department of Paediatrics, the University of Melbourne, Melbourne, Australia
- Centre for Adolescent Health, Royal Children’s Hospital and Murdoch Children’s Research Institute, Melbourne, Australia
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Amatya P, Ghimire S, Callahan KE, Baral BK, Poudel KC. Practice and lived experience of menstrual exiles (Chhaupadi) among adolescent girls in far-western Nepal. PLoS One 2018; 13:e0208260. [PMID: 30532183 PMCID: PMC6287853 DOI: 10.1371/journal.pone.0208260] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 11/14/2018] [Indexed: 11/21/2022] Open
Abstract
Background Menstrual exile, also known as Chhaupadi, is a tradition of “untouchability” in far-western Nepal. Forbidden from touching other people and objects, women and girls are required to live away from the community, typically in a livestock shed, during menstruation. We assessed the lived experiences of Chhaupadi among Nepalese adolescent girls in the far-western Achham district of Nepal, observed the safety and sanitation of their living spaces during Chhaupadi, and assessed the perceptions of local adult stakeholders towards the practice of Chhaupadi. Methods We collected data from 107 adolescent girls using a self-administered survey in two local schools in Achham. We also conducted a focus group discussion with seven girls, held key informant interviews, and observed the girls’ living spaces during Chhaupadi, using a checklist. Descriptive statistics of the quantitative survey and thematic analyses of qualitative interviews are presented. Results The majority of the girls (n = 77, 72%) practiced exile, or Chhaupadi, during their menstruation, including 3 (4%) exiled to traditional Chhau sheds, 63 (82%) to livestock sheds, and 11 (14%) to courtyards outside their home. The remaining girls (n = 30, 28%) stayed inside the house, yet practiced some form of menstrual taboos. Of the 77 observed living spaces where the girls stayed during exile, only 30% (n = 23) had a toilet facility. Most exiled girls (97.4%) were restricted from eating dairy products. Participants reported having various psychological problems, including lonliness and difficulty sleeping while practicing Chhaupadi. Three of the girls were physically abused; nine were bitten by a snake. Notably high proportions of the living spaces lacked ventilation/windows (n = 20, 26%), electricity (n = 29, 38%), toilets (n = 54, 70%) and a warm blanket and mattress for sleeping (n = 29, 38%). Our qualitative findings supported our quantitative results. Conclusions Chhaupadi has been condemned by human rights organizations. While the government has banned the practice, implementation on the ban is proceeding slowly, especially in far-western Nepal. Thus, as a temporary measure, public health professionals must work towards promoting the health and safety of Nepalese women and girls still practicing Chhaupadi.
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Affiliation(s)
- Prabisha Amatya
- Department of Public Health, Central Institute of Science and Technology (CIST) College, Pokhara University, Kathmandu, Nepal
| | - Saruna Ghimire
- Agrata Health and Education (AHEAD)-Nepal, Kathmandu, Nepal
- School of Community Health Sciences, University of Nevada Las Vegas, Las Vegas, NV, United States of America
- * E-mail:
| | - Karen E. Callahan
- School of Community Health Sciences, University of Nevada Las Vegas, Las Vegas, NV, United States of America
| | - Binaya Kumar Baral
- Department of Biochemistry, Nepal Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Krishna C. Poudel
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, United States of America
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Cardoso LF, Clark CJ, Rivers K, Ferguson G, Shrestha B, Gupta J. Menstrual restriction prevalence and association with intimate partner violence among Nepali women. BMJ SEXUAL & REPRODUCTIVE HEALTH 2018; 45:bmjsrh-2017-101908. [PMID: 30266716 PMCID: PMC6352404 DOI: 10.1136/bmjsrh-2017-101908] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 06/27/2018] [Accepted: 08/24/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Emerging research has linked women's sanitation and menstrual hygiene experiences with increased vulnerability to violence outside the home. Few studies, however, have investigated the relationship between menstruation and violence perpetrated by family members. This type of violence may be linked specifically to restrictions placed on women during menstruation, which are common in some regions of Nepal owing to shared power differentials that disfavour women, and societal norms that stigmatise menstruation. OBJECTIVE To record the prevalence of menstrual restrictions experienced by married women and examine potential associations between intimate partner violence (IPV) in the past year and menstrual restrictions imposed by husbands and/or in-laws among women in three districts of Nepal: Nawalparasi, Kapilvastu and Chitwan. METHODS Baseline data from a larger randomised control trial aiming to reduce IPV in three districts of the Terai region of Nepal (n=1800) were used to assess the prevalence of menstrual restrictions and the association with IPV. RESULTS Nearlythree out of four women (72.3%) reported experiencing high menstrual restriction, or two or more types of menstrual restriction. When controlling for demographic variables and IPV, no type of IPV was associated with high menstrual restrictions. CONCLUSION The experience of menstrual restriction was widespread in this sample of women in Nepal. Future research should seek to identify how best to capture menstrual stigma and deviations around such norms. The global health and development community should prioritise integration with existing water and sanitation programmes to reduce stigma and ensure the well-being of menstruating women and girls. TRIAL REGISTRATION NUMBER NCT02942433.
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Affiliation(s)
- Lauren F Cardoso
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, USA
| | - Cari Jo Clark
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Kelsey Rivers
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, Virginia, USA
| | - Gemma Ferguson
- Equal Access International, San Francisco, California, USA
| | | | - Jhumka Gupta
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, Virginia, USA
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Hawkey AJ, Ussher JM, Perz J, Metusela C. Experiences and Constructions of Menarche and Menstruation Among Migrant and Refugee Women. QUALITATIVE HEALTH RESEARCH 2017; 27:1473-1490. [PMID: 27742765 DOI: 10.1177/1049732316672639] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Experiences and constructions of menarche and menstruation are shaped by the sociocultural environment in which women are embedded. We explored experiences and constructions of menarche and menstruation among migrant and refugee women resettled in Sydney, Australia, and Vancouver, Canada. Seventy-eight semistructured individual interviews and 15 focus groups comprised of 82 participants were undertaken with women from Afghanistan, Iraq, Somalia, South Sudan, Sudan, Sri Lanka, and varying South American countries. We analyzed the data using thematic decomposition, identifying the overall theme "cycles of shame" and two core themes. In "becoming a woman," participants constructed menarche as a marker of womanhood, closely linked to marriage and childbearing. In "the unspeakable," women conveyed negative constructions of menstruation, positioning it as shameful, something to be concealed, and polluting. Identifying migrant and refugee women's experiences and constructions of menarche and menstruation is essential for culturally safe medical practice, health promotion, and health education.
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Affiliation(s)
- Alexandra J Hawkey
- 1 Centre for Health Research,Western Sydney University, Penrith, New South Wales, Australia
| | - Jane M Ussher
- 1 Centre for Health Research,Western Sydney University, Penrith, New South Wales, Australia
| | - Janette Perz
- 1 Centre for Health Research,Western Sydney University, Penrith, New South Wales, Australia
| | - Christine Metusela
- 1 Centre for Health Research,Western Sydney University, Penrith, New South Wales, Australia
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Alam MU, Luby SP, Halder AK, Islam K, Opel A, Shoab AK, Ghosh PK, Rahman M, Mahon T, Unicomb L. Menstrual hygiene management among Bangladeshi adolescent schoolgirls and risk factors affecting school absence: results from a cross-sectional survey. BMJ Open 2017; 7:e015508. [PMID: 28694347 PMCID: PMC5541609 DOI: 10.1136/bmjopen-2016-015508] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 05/08/2017] [Accepted: 05/10/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Many adolescent girls in low-income and middle-income countries lack appropriate facilities and support in school to manage menstruation. Little research has been conducted on how menstruation affects school absence. This study examines the association of menstrual hygiene management knowledge, facilities and practice with absence from school during menstruation among Bangladeshi schoolgirls. METHODS We conducted a nationally representative, cross-sectional study in Bangladeshi schools from March to June 2013 among girls 11 to 17 years old who reached menarche. We sampled 700 schools from 50 urban and 50 rural clusters using a probability proportional to size technique. We interviewed 2332 schoolgirls and conducted spot checks in each school for menstrual hygiene facilities. To assess factors associated with reported school absence, we estimated adjusted prevalence difference (APD) for controlling confounders' effect using generalised estimating equations to account for school-level clustering. RESULTS Among schoolgirls who reached menarche, 41% (931) reported missing school, an average of 2.8 missed days per menstrual cycle. Students who felt uncomfortable at school during menstruation (99% vs 32%; APD=58%; CI 54 to 63) and who believed menstrual problems interfere with school performance (64% vs 30%; APD=27; CI 20 to 33) were more likely to miss school during menstruation than those who did not. School absence during menstruation was less common among girls attending schools with unlocked toilet for girls (35% vs 43%; APD=-5.4; CI -10 to -1.6). School absence was more common among girls who were forbidden from any activities during menstruation (41% vs 33%; APD=9.1; CI 3.3 to 14). CONCLUSION Risk factors for school absence included girl's attitude, misconceptions about menstruation, insufficient and inadequate facilities at school, and family restriction. Enabling girls to manage menstruation at school by providing knowledge and management methods prior to menarche, privacy and a positive social environment around menstrual issues has the potential to benefit students by reducing school absence.
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Affiliation(s)
- Mahbub-Ul Alam
- Environmental Interventions Unit, Infectious Disease Division, International Center for Diarrheal Disease Research, Dhaka, Bangladesh
| | - Stephen P Luby
- Environmental Interventions Unit, Infectious Disease Division, International Center for Diarrheal Disease Research, Dhaka, Bangladesh
- Stanford Woods Institute for the Environment, Stanford University, Stanford, California, USA
| | - Amal K Halder
- Environmental Interventions Unit, Infectious Disease Division, International Center for Diarrheal Disease Research, Dhaka, Bangladesh
| | | | | | - Abul K Shoab
- Environmental Interventions Unit, Infectious Disease Division, International Center for Diarrheal Disease Research, Dhaka, Bangladesh
| | - Probir K Ghosh
- Environmental Interventions Unit, Infectious Disease Division, International Center for Diarrheal Disease Research, Dhaka, Bangladesh
| | - Mahbubur Rahman
- Environmental Interventions Unit, Infectious Disease Division, International Center for Diarrheal Disease Research, Dhaka, Bangladesh
| | | | - Leanne Unicomb
- Environmental Interventions Unit, Infectious Disease Division, International Center for Diarrheal Disease Research, Dhaka, Bangladesh
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