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Baumann SE, Rabin MA, Devkota B, Hawk M, Upadhyaya K, Shrestha GR, Joseph B, Burke JG. Centering Communities in Global Health: Using Human-Centered Design to Facilitate Collaboration and Intervention Development. COMMUNITY HEALTH EQUITY RESEARCH & POLICY 2024:2752535X241264331. [PMID: 39044545 DOI: 10.1177/2752535x241264331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
BACKGROUND Utilizing iterative and collaborative tools, Human-centered Design (HCD) facilitates the creation of tailored solutions for multifaceted issues by fostering empathy and a deep understanding of human behaviors. This paper presents insights gleaned from employing HCD tools to center communities in global health intervention development. PURPOSE The study team collaborated with community members in Dailekh, Nepal to co-design interventions to address harms associated with menstrual seclusion, known as chhaupadi. RESEARCH DESIGN AND STUDY SAMPLE A Community Design Team, comprising 10 women representing various castes and ages convened for a four-day intervention co-design workshop in the community. A Community Validation Team, comprising 12 individuals from diverse occupational and caste backgrounds provided feedback on the interventions. Additionally, six village leaders participated in Key Informant Interviews to garner additional insights. DATA COLLECTION In the study's initial "discovery" phase, the Community Design Team employed HCD tools to generate a nuanced understanding of the context, stakeholders, and community experiences. Subsequently, in the second "design" phase, the Community Design Team crafted interventions to address harms associated with chhaupadi. RESULTS Invaluable lessons gained from this study underscore the necessity of crafting contextually suitable tools, checklists, and prompts for participants, allocating sufficient staff, time, and resources, and adapting to participants' literacy levels and engagement preferences, whether through group or individual activities. CONCLUSIONS Reflecting on these insights, our experience suggests HCD offers promising tools to authentically and equitably involve participants with diverse backgrounds in articulating their own ideas for community-based solutions in Nepal. Health practitioners, researchers, and intervention development experts are encouraged to consider adopting HCD methodologies to prioritize community voices in devising solutions for complex health challenges.
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Affiliation(s)
- Sara E Baumann
- Department of Behavioral and Community Health Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Megan A Rabin
- Department of Behavioral and Community Health Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bhimsen Devkota
- Faculty of Health Education, Tribhuvan University, Kirtipur, Nepal
| | - Mary Hawk
- Department of Behavioral and Community Health Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - 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, Pittsburgh, PA, USA
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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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Marván ML, García-Prieto C, Alcalá-Herrera V, Vacio-Muro MDLÁ. Menarcheal experience, beliefs about and attitudes toward menstruation in Mexico: Changes in the last 20 years. Health Care Women Int 2024:1-14. [PMID: 38635371 DOI: 10.1080/07399332.2024.2342474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 04/09/2024] [Indexed: 04/20/2024]
Abstract
We explored how menarcheal experiences and attitudes toward menstruation of Mexican adolescents have changed in the last 20 years. Two questionnaires were applied to female adolescent students, and the results were compared with those obtained in 2002-3 when adolescents of the same ages were surveyed using the same questionnaires. Although some aspects of menstrual education have not changed, the secrecy surrounding menstruation has diminished. In contrast, the belief that menstruation is disabling and keeps women from their normal activities has increased. It is important that adolescents receive adequate preparation about psychosocial and physical aspects of the menstrual cycle.
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Affiliation(s)
- Ma Luisa Marván
- Instituto de Investigaciones Psicológicas, Universidad Veracruzana, Xalapa, Mexico
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Stoll V, Edwin N, Dahal K, Barnes JA, Pfautsch M, Maharjan L, Blavo C. Health Issues Among Nepalese Youth: A Literature Review. Cureus 2023; 15:e45108. [PMID: 37842493 PMCID: PMC10569343 DOI: 10.7759/cureus.45108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 09/06/2023] [Indexed: 10/17/2023] Open
Abstract
Nepal is one of the world's least-developed countries. Nepalese children are often vulnerable to a lack of resources which leads to suboptimal levels of health in turn. This review article aims to identify health issues and inequities faced by school-aged children greater than five years old in Nepal. A comprehensive search of the literature was conducted in PubMed and Global Health databases to gather relevant studies. Inclusion and exclusion criteria were applied to select appropriate articles, and 35 full-length articles were reviewed in-depth. The literature supports the association between inadequate resource distribution among Nepalese children and poorer health outcomes compared to youth in developed countries. The key health issues of Nepalese youth identified in the literature consist of diarrheal illness, stunted growth, dental caries, visual impairment, poor mental health, and low health literacy. This review article aims to identify key health issues affecting Nepalese youth as well as propose interventions that can lead to an enhanced quality of life in this population.
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Affiliation(s)
- Veenah Stoll
- Department of Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Naomi Edwin
- Department of Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Kripa Dahal
- Department of Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - John A Barnes
- Department of Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Miranda Pfautsch
- Department of Global Health, International Health Initiatives, Inc., Clearwater, USA
| | - Lahana Maharjan
- Department of Public Health, Manmohan Memorial Institute of Health Sciences, Kathmandu, NPL
| | - Cyril Blavo
- Department of Public Health, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
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Rawat M, Shields AN, Venetis MK, Seth J. Women's Agentic Role in Enabling and Dismantling Menstrual Health Taboos in Northern India: A Culture-Centered Approach. HEALTH COMMUNICATION 2023; 38:695-704. [PMID: 34459348 DOI: 10.1080/10410236.2021.1970296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Communication about menstrual health continues to be influenced by institutional and social practices which deem it to be unclean and impure. In a country such as India, several customs and traditions reinforce secrecy and shame about menstruation. As such, scholars advocate the need to generate knowledge that can open opportunities to converse on the topic of menstruation and understand issues related to bodily changes. Using a culture-centered approach, this study examined how college-going adult women from two cities in Northern India made sense of menstrual health. Data collection included 20 focus groups with 180 college-going women and interviews with 16 female family members. Participants discussed communication patterns surrounding menstrual health and how they uphold, challenge, and change social practices. Specifically, participants reflected on how they were communicated to about their menstrual health with underpinnings of secrecy and shame and how the influence of current opportunities for openness encourage them to anticipate positive change. Theoretical and practical implications for studying communication around menstruation in diverse cultural contexts are discussed.
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Affiliation(s)
| | | | | | - Jyoti Seth
- Department of Sociology, Post Graduate Government College for Girls
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Roxanne Rahnejat K, Narice BF. Assessing menstrual equity amongst BAMER women fleeing gender-based abuse in Sheffield (UK): A cross-sectional study. SEXUAL & REPRODUCTIVE HEALTHCARE 2023; 35:100813. [PMID: 36709721 DOI: 10.1016/j.srhc.2023.100813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/04/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Menstruation is not openly discussed in numerous Black, Asian, minority ethnic and refugee (BAMER) communities. Consequently, it is unclear if transitioning between cultures impacts BAMER women's menstrual health. This study aimed to evaluate menstrual equity and sanitary protection preference amongst BAMER abuse survivors displaced to Sheffield (UK). METHODS Fifty participants were recruited from women's support services between December 2018 and May 2019. Selection criteria required participants to menstruate, identify as BAMER, be displaced, and have experienced gender-based abuse. Descriptive and inferential statistical analyses were performed using SPSS (IBM, USA) to assess menstrual equity. RESULTS Many struggled to afford products (86 %), changed them infrequently (68 %) or improvised sanitary wear (40 %). Financially restricted women often changed products irregularly (p = 0.02) or used proxy items (p = 0.02). Participants disliked reusable pads (48 %) and vaginally inserted products (tampons 46 %, cups 78 %) without having tried them. Negativity surrounding reusable pads (p = 0.01) and cups (p = 0.04) was linked to menstrual taboo. Few women knew of menstruation prior to menarche (28 %). These participants were more likely to accept male doctors (p = 0.04), unlike those that regarded menstruation as taboo (p = 0.02), unclean (p = 0.02) or shameful (p = 0.001). CONCLUSION We provide key information regarding the menstrual health status of marginalised women. Our findings suggest limited menstrual-health education at menarche and negative belief-systems may compromise access to products and healthcare in adulthood. This study advises policymakers to unify distribution of hygienic absorbents and menstrual-health education to normalise menstruation, thereby reducing menstrual shame and empowering women to make informed sanitary protective choices.
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Affiliation(s)
| | - Brenda F Narice
- NIHR Academic Clinical Lecturer, University of Sheffield, Obstetrics & Gynaecology, Jessop Wing Maternity Unit, Tree Root Walk, Sheffield S10 2SF, UK.
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Accerenzi M, Brañas-Garza P, Jorrat D. Parents' knowledge and predictions about the age of menarche: experimental evidence from Honduras. Arch Public Health 2023; 81:20. [PMID: 36765423 PMCID: PMC9912583 DOI: 10.1186/s13690-023-01030-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 01/21/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Access to accurate, timely and age-appropriate information about menarche is an essential part of menstrual health. Reliable evidence shows that girls primarily obtain information from their mothers and/or other female family members, therefore, it is important to determine parents' knowledge and their predictions about other parents' knowledge of the age of menarche. METHODS To this end, we performed a pre-registered study with data collected from 360 households in Santa Rosa de Copán, Honduras. We implemented a novel procedure to avoid social desirability bias whereby participants answered two separated questions: i) their knowledge about the age of menarche (self-report) and ii) to predict or guess the modal response of the other participants regarding the same question (modal guess). Participants were paid according to accuracy. Both questions appeared randomly in the survey. RESULTS Recent studies indicate the age of menarche at 12 years old and 56.11% of the sample gave the same response while 62.78% hit the modal value. We estimated the impact of different sociodemographic variables and found only marginal differences. Interestingly, people with formal education and women tend to respond with lower predictions. CONCLUSION Parents' knowledge about the age of menarche is high in the study area. The study also found that there was no social desirability bias.
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Affiliation(s)
- Michela Accerenzi
- grid.449008.10000 0004 1795 4150Fundación ETEA - Development Institute of Universidad Loyola Andalucía, Córdoba, Spain
| | - Pablo Brañas-Garza
- grid.449008.10000 0004 1795 4150Loyola Behavioral Lab, Universidad Loyola Andalucía, Córdoba, Spain
| | - Diego Jorrat
- Loyola Behavioral Lab, Universidad Loyola Andalucía, Córdoba, Spain.
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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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Thakuri DS, Thapa RK, Singh S, Khanal GN, Khatri RB. A harmful religio-cultural practice (Chhaupadi) during menstruation among adolescent girls in Nepal: Prevalence and policies for eradication. PLoS One 2021; 16:e0256968. [PMID: 34469491 PMCID: PMC8409632 DOI: 10.1371/journal.pone.0256968] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/19/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Chhaupadi is a deeply rooted tradition and a centuries-old harmful religio-cultural practice. Chhaupadi is common in some parts of Karnali and Sudurpaschim Provinces of western Nepal, where women and girls are considered impure, unclean, and untouchable in the menstrual period or immediately following childbirth. In Chhaupadi practice, women and girls are isolated from a range of daily household chores, social events and forbidden from touching other people and objects. Chhaupadi tradition banishes women and girls into menstruation huts', or Chhau huts or livestock sheds to live and sleep. These practices are guided by existing harmful beliefs and practices in western Nepal, resulting in poor menstrual hygiene and poor physical and mental health outcomes. This study examined the magnitude of Chhaupadi practice and reviewed the existing policies for Chhaupadi eradication in Nepal. METHODS We used both quantitative survey and qualitative content analysis of the available policies. First, a quantitative cross-sectional survey assessed the prevalence of Chhaupadi among 221 adolescent girls in Mangalsen Municipality of Achham district. Second, the contents of prevailing policies on Chhaupadi eradication were analysed qualitatively using the policy cube framework. RESULTS The current survey revealed that most adolescent girls (84%) practised Chhaupadi in their most recent menstruation. The Chhaupadi practice was high if the girls were aged 15-17 years, born to an illiterate mother, and belonged to a nuclear family. Out of the girls practising Chhaupadi, most (86%) reported social and household activities restrictions. The policy content analysis of identified higher-level policy documents (constitution, acts, and regulations) have provisioned financial resources, ensured independent monitoring mechanisms, and had judiciary remedial measures. However, middle (policies and plans) and lower-level (directives) documents lacked adequate budgetary commitment and independent monitoring mechanisms. CONCLUSION Chhaupadi remains prevalent in western Nepal and has several impacts to the health of adolescent girls. Existing policy mechanisms lack multilevel (individual, family, community, subnational and national) interventions, including financial and monitoring systems for Chhaupadi eradication. Eradicating Chhaupadi practice requires a robust multilevel implementation mechanism at the national and sub-national levels, including adequate financing and accountable systems up to the community level.
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Affiliation(s)
| | | | | | | | - Resham B. Khatri
- School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Health Social Science and Development Research Institute, Kathmandu, Nepal
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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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Baumann SE, Merante MM, Wiltrout CT, Cutlip T, Finkel M, Maharjan B, Lhaki P, Burke JG. Is criminalization the answer? Perspectives of community members and police on menstrual seclusion policy in Far-West Nepal. Health Policy Plan 2021; 36:1003-1012. [PMID: 34051090 DOI: 10.1093/heapol/czab032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/11/2021] [Accepted: 02/22/2021] [Indexed: 11/14/2022] Open
Abstract
Chhaupadi is a form of menstrual seclusion practiced in Nepal in which women and girls are isolated during their menstrual cycles and follow numerous restrictions. The tradition dates back centuries and can have serious physical and mental health consequences. While the practice was criminalized in 2017 with fines and jail time, this legislative action comes after more than a decade of legal history, from an initial ban in 2006, to declaring it a form of violence against women in 2009, and finally, its criminalization in 2017. Exploring levels of awareness regarding the 2017 chhaupadi criminalization, perceptions of the legal penalties, and whether or not criminalization will lead to behaviour change are imperative next steps for informing the development of evidence-based interventions targeting chhaupadi. In this qualitative investigation conducted in Kalikot district, six focus group discussions and 33 in-depth interviews were conducted with a total of 81 participants. School-going girls, girls who have dropped out of school before completing twelfth grade, mothers, fathers, teachers, health care providers, religious leaders, traditional healers, grandmothers and police participated in the study. The results indicate that criminalization is generally perceived as a positive step for initiating chhaupadi behaviour change, and one-third of participants expressed that they plan to change their behaviours after learning that chhaupadi is publishable with fines and/or jail time. However, accurate information about the criminal code is extremely low and therefore interventions ensuring communities and law enforcement are informed of the criminalization and associated penalties are urgently needed. In addition, even after its criminalization, chhaupadi behaviour change is anticipated to be gradual and is expected to require long-term interventions targeting social pressure associated with upholding the tradition and raising awareness via appropriate trainings, engaging the media, and beyond.
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Affiliation(s)
- Sara E Baumann
- Department of Behavioural and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Monica M Merante
- Department of Behavioural and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Christopher T Wiltrout
- Department of Behavioural and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Trevor Cutlip
- Department of Behavioural and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Müge Finkel
- Graduate School of Public and International Affairs, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Jessica G Burke
- Department of Behavioural and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
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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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14
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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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15
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Cunningham K, Pries A, Erichsen D, Manohar S, Nielsen J. Adolescent Girls' Nutritional Status and Knowledge, Beliefs, Practices, and Access to Services: An Assessment to Guide Intervention Design in Nepal. Curr Dev Nutr 2020; 4:nzaa094. [PMID: 32617452 PMCID: PMC7319728 DOI: 10.1093/cdn/nzaa094] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Despite growing recognition of the importance of the adolescent period for health and nutritional well-being, scant evidence exists to inform interventions. Beyond limited understanding of adolescents' knowledge and practices, gaps in adolescent research also include limited understanding of how best to reach them with programs and policies and how the contexts in which they live present barriers and opportunities. Given that most studies on adolescent health and nutrition have used data from surveys of women of reproductive age, this study also sought to understand variation among younger and older adolescents and those who were already mothers. OBJECTIVES The primary aim was to support the design of an evidence-based adolescent program (Suaahara) in Nepal by describing adolescent girls' nutritional status; their exposure to information and services, knowledge, and practices in nutrition, health, family planning, and water, sanitation, and hygiene (WASH); and contextual factors; and to quantify variation by stage of adolescence. METHODS Using the first round (2017) from a panel of Nepalese adolescent girls, we categorized adolescent girls as: younger (10-14.9 y; n = 512), older (15-19.9 y; n = 325), and mothers (15-19.9 y; n = 256). Descriptive analyses generated proportions and means ± SDs, with statistical significance testing of differences. RESULTS The prevalence of underweight was highest in younger adolescents, whereas the prevalence of overweight/obesity in mothers was double that of the other 2 groups. More younger adolescents were in school, but fewer owned a mobile phone or had radio access. Exposure, knowledge, and behaviors across thematic areas also differed by stage of adolescence. CONCLUSIONS These findings have implications for Suaahara and other programs and policies aiming to support the health and nutritional well-being of adolescent girls. Heterogeneity among adolescent girls should be considered when identifying which interventions are needed and have the most potential for each subpopulation.
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Affiliation(s)
- Kenda Cunningham
- Suaahara II, Helen Keller International, Patan, Nepal
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Dorit Erichsen
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Swetha Manohar
- Nitze School of Advanced International Studies and Bloomberg School of Public Health, Johns Hopkins University, Washington, DC, USA
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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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17
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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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