Perception and practices of menstruation restrictions among urban adolescent girls and women in Nepal: a cross-sectional survey

Forbidden Conversations: A Comprehensive Exploration of Taboos in Sexual and Reproductive Health

This scoping review aims to comprehensively explore the landscape of taboos and their impact on sexual and reproductive health. Titled "Forbidden Conversations," it delves into the intricate web of societal, cultural, and religious norms that have contributed to the elusive and often stigmatized nature of sexual and reproductive health topics. The review navigates through the multifaceted dimensions of these taboos, shedding light on their impact on individuals, communities, and public health while advocating for a paradigm shift toward open, inclusive, and informed dialogue. The analysis within this review spans a decade, capturing the most recent and relevant literature to map the landscape of taboos in sexual and reproductive health. It explores the persistent societal apprehensions and subsequent stigmatization surrounding topics such as menstruation, contraception, fertility, sexual orientation, and gender identity. The review contextualizes the multifaceted challenges presented by these prevailing norms by tracing historically rooted taboos and their evolution across different cultures and contexts. The scoping review identifies the profound implications of these taboos on public health, highlighting how they contribute to disparities in access to healthcare, perpetuate misinformation, and infringe upon the fundamental rights of individuals. It addresses the challenges in sexual education, emphasizing how these taboos impede comprehensive understanding and enforcement of sexual and reproductive health rights among adolescents and young adults. The intersectional approach taken in this review situates these taboos within broader systems of inequality, emphasizing the compounded impact they have on marginalized populations. Through this comprehensive exploration, the review aims to provide actionable insights and identify existing research, policy, and practice gaps. It seeks to lay the foundation for future initiatives that advocate for destigmatization, empowerment, and equity in sexual and reproductive health. Ultimately, "Forbidden Conversations" aims to steer the conversation toward openness and inclusivity while advocating for unbiased, comprehensive sexual and reproductive healthcare with dignity for all individuals.

"You're Not Alone": How Adolescents Share Dysmenorrhea Experiences Through Vlogs

Many adolescents experience severe pain during menstruation, yet their attempts to receive medical attention to alleviate or manage this pain are often met with dismissal or disbelief. In light of these barriers to care, many adolescents turn to social media to share their experiences with menstruation and pain, as well as hear from other members of their community. In this study, we investigated how adolescents present their experiences with menstruation in vlogs (or "video blogs"). Using critical qualitative methods and a four-column analysis structure, we transcribed and thematically analyzed the audio and video content of 17 YouTube vlogs wherein adolescents described their experiences with menstrual pain. We found that stylistically, the vloggers modulated between a polished documentary style and an intimate storytime style of video production. We additionally found that vloggers spoke about their menstrual pain experiences from three perspectives: as a Patient managing and diagnosing physical symptoms, as a Self considering how the pain affects their life and ambitions, and as a Teacher educating their audience. Considering both the visual and audio data, we discuss how healthcare providers can use these findings to inform their approach to discussing menstrual pain with adolescents. We further discuss possible future directions for research into health story sharing on social media.

Factors Associated with Exclusive Use of Hygienic Methods during Menstruation among Adolescent Girls (15-19 Years) in Urban India: Evidence from NFHS-5

Background

Menstrual hygiene is a critical public health concern for adolescent girls in urban India. However, there is a paucity of research on this subject, particularly on a national scale. To the best of our knowledge, this study diverges from previous research, as the majority of prior investigations in India have centered on rural locales, married individuals, and those aged between 15 and 24 years. Thus, this study aims to fill this gap by investigating the factors associated with the exclusive use of hygienic methods during menstruation among urban adolescent girls (15-19 years) in India.

Method

A total of 25136 samples were included in this analysis from the National Family Health Survey 5 (NFHS-5). The Binary logistic regression model has been administered to determine the associated factors of the exclusive use of hygienic methods among adolescent girls.

Results

The results of the multivariate model revealed significant positive associations between higher education levels and usage of menstrual hygiene management products (AOR: 1.860; 95 % CI: 1.418-2.439), (AOR: 2.110; 95 % CI: 1.553-2.867). Additionally, individuals in higher wealth quintiles were more likely to use MHM products, with the richest quintile showing the highest likelihood (AOR: 5.310; 95 % CI: 4.494-6.275). Attendance at cultural events such as cinema or theater was positively associated with MHM product utilization (AOR: 1.338; 95 % CI: 1.181-1.517).Conversely, Lack of access to sanitation facilities was inversely associated with MHM product utilization (AOR: 0.742; 95 % CI: 0.628-0.877). Muslim girls had lower odds than Hindus (AOR: 0.576; 95 % CI: 0.520-0.637). Substantial regional variations were evident, with the Western (AOR: 0.879; 95 % CI: 0.759-1.019), Eastern (AOR: 0.747; 95 % CI: 0.654-0.854), Central (AOR: 0.349; 95 % CI: 0.313-0.388), and North-eastern regions (AOR: 0.597; 95 % CI: 0.490-0.727) displaying diminished odds of MHM product usage relative to the southern region. General caste had higher odds compared to scheduled caste (AOR: 1.255, 95 % CI: 1.103-1.429), while other backward caste had lower odds (AOR: 0.858, 95 % CI: 0.771-0.955).

Conclusion

These findings underscore the importance of addressing inequalities in access to menstrual hygiene products among urban adolescent girls in India. Targeted interventions and educational programs are essential to ensure equitable access and promote overall health and well-being.

Feasibility study of a menstrual health behaviour change intervention for women and girls with intellectual disabilities and their caregivers for Vanuatu's humanitarian responses

The Veivanua campaign is a menstrual health intervention for people with intellectual disabilities and their caregivers in Vanuatu's humanitarian setting. The campaign was adapted from the Bishesta campaign delivered in Nepal's development setting. This feasibility study is designed to assess the feasibility and acceptability of the Veivanua campaign to understand if efficacy testing is warranted. The Veivanua campaign was delivered to a preselected group of 30 young people (individuals with intellectual disabilities) and 35 caregivers (males and females). Data were collected through several qualitative tools to allow for methods triangulation: process monitoring, post-intervention in-depth interviews with caregivers and nine young people, observation of young persons, photovoice and ranking with two young people, campaign resource ranking, and key informant interviews with staff involved in the intervention. Data were analysed thematically using Nvivo 12. Results show that the Veivanua campaign is feasible. Male and female caregivers reported an increased ability to support young people's menstrual health and greater preparedness for the next emergency. Young people understood the training and applied their learning. Key informants want to scale up the intervention in their humanitarian responses. Several changes were made to the adapted campaign, but similar outcomes were recorded in Nepal and Vanuatu. All target behaviours improved, and campaign resources were used, but many caregivers found the menstrual calendar confusing. The intervention was not delivered with fidelity but responded to the context. The campaign cost more than the Bishesta campaign because procurement was more expensive in Vanuatu. In conclusion, this is the first intervention globally, so it begins to fill a substantial gap, but more must be done. As the Veivanua campaign is feasible, it requires efficacy testing in Vanuatu. It should also be adapted to humanitarian crises in other countries to support the menstrual health of this previously excluded population.

Perspectives on prior preparation for menstrual experience from women and female health workers in Malawi

BACKGROUND

While studies have explored various aspects of menstruation, an evident gap remains in the literature concerning the perspectives of young women and female health workers. By shedding light on this unexplored terrain, the study provides novel insights that can inform targeted interventions and foster a more inclusive understanding of menstrual health. As such, this investigation stands at the forefront of academic endeavour in menstrual health research, making an original and valuable impact in the field.

OBJECTIVES

The objective of this study was to explore the experiences of reproductive-aged women during menstruation in Malawi. The specific objectives were to examine the experiences of reproductive-age women related to menstrual preparation, identify factors influencing the choice of menstrual products for women in Malawi, and identify the public health implications of menstrual products.

DESIGN

This cross-sectional study employed qualitative research methods to explore the acceptance and implementation of menstrual cups as a feminine hygienic product for women in Malawi.

METHODS

The study involved focus group discussions and interviews with reproductive-age women aged 18-54 years and health providers at Bwaila and Mitundu family clinics and Lighthouse HIV management centres. Thematic content analysis was performed using NVivo 12. Ethical approval was obtained from the College of Medicine Research and Ethics Committee (P.08/21/3379).

RESULTS

Education on menstruation is provided as early as 10 years before menarche by sisters, friends, mothers, aunties and grandmothers. Parents remain silent on menstrual issues. Commonly used menstrual products include disposable pads, cloths, reusable pads and cotton wool. While a few mentioned using tampons, pieces of blankets and flex foam, the majority demonstrated widespread ignorance about menstrual cups. Mentors or counsellors, affordability, accessibility, comfort and disposal issues influence women's choice of products being used.

CONCLUSION

Parents need to break the silence on menstrual issues. Messages on menstruation and menstrual products are explicit in forming female adolescents what to expect with menarche, how to manage menses including health-related impacts, and ways of mitigating menses-related misconceptions, discrimination and stigma, and could be incorporated into the primary school curriculum. Safe menstrual products are accessible free of charge or at a subsidised cost.

Prevalence of heavy menstrual bleeding and associations with physical health and wellbeing in low-income and middle-income countries: a multinational cross-sectional study

BACKGROUND

Data on the prevalence of heavy menstrual bleeding in low-income and middle-income countries (LMICs) are scarce. We aimed to assess the validity of a scale to measure heavy menstrual bleeding and calculate its prevalence in southern Asia and sub-Saharan Africa, and to examine associations between heavy menstrual bleeding and health outcomes.

METHODS

Between Aug 2, 2021 and June 14, 2022, we surveyed 6626 women across ten cities (Meherpur and Saidpur, Bangladesh; Warangal, Narsapur, and Tiruchirappalli, India; Kathmandu, Nepal; Dakar, Senegal; Nairobi, Kenya; Kampala, Uganda; and Lusaka, Zambia), including questions on demographics, health, and the SAMANTA scale, a six-item measure of heavy menstrual bleeding. We conducted confirmatory factor analysis to assess construct validity of the SAMANTA scale, calculated the prevalence of heavy menstrual bleeding, and used regression analyses to examine associations of heavy menstrual bleeding with health outcomes.

FINDINGS

4828 women were included in the final analytic sample. Factor analysis indicated a one-factor model representing heavy menstrual bleeding. In the pooled analytic sample, 2344 (48·6%) of 4828 women were classified as experiencing heavy menstrual bleeding, and the prevalence was lowest in Dakar (126 [38·3%] of 329 women) and Kampala (158 [38·4%] of 411 women) and highest in Kathmandu (326 [77·6%] of 420 women). Experiencing heavy menstrual bleeding was significantly associated with feeling tired or short of breath during the menstrual period (risk ratio 4·12 (95% CI 3·45 to 4·94) and reporting worse self-rated physical health (adjusted odds ratio 1·27, 95% CI 1·08 to 1·51), but was not associated with subjective wellbeing (β -3·34, 95% CI -7·04 to 0·37).

INTERPRETATION

Heavy menstrual bleeding is highly prevalent and adversely impacts quality of life in women across LMIC settings. Further attention is urgently needed to understand determinants and identify and implement solutions to this problem.

FUNDING

Bill & Melinda Gates Foundation, United States Agency for International Development, National Institutes of Health.

Health Issues Among Nepalese Youth: A Literature Review

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.

Prosopagnosia (face blindness) and child health during the COVID-19 pandemic

Prosopagnosia or 'face blindness' is the inability to recognise people's faces. There are two types: congenital or developmental prosopagnosia, which is the most common, and acquired prosopagnosia, which may occur secondary to brain tumours, stroke or other brain disorders. The authors of this article explored if mask wearing as a result of the restrictions imposed by the coronavirus disease 2019 (COVID-19) pandemic may affect social and developmental outcomes in children, including the development of prosopagnosia. Limited research on this topic is available and, although some relevant publications were found, no definitive evidence of mask-induced prosopagnosia in children was identified. However, nurses should be aware of this issue and discuss coping strategies to support children with the condition. Longitudinal studies on outcomes in children from different age groups who grew up during the COVID-19 pandemic will provide further insight.

Exploratory systematic review and meta-analysis on period poverty

BACKGROUND

Period poverty is a global health and social issue that needs to be addressed. It has been reported that many females compromise their education, employment, and social commitments during their menstruation days due to a number of reasons, including lack of access to toilets or menstrual products.

AIM

To provide a comprehensive understanding on period poverty, including outcomes associated with menstruation.

METHODS

All observational and randomised clinical trials reporting menstruation challenges, menstrual poverty and menstrual products were included. Our search strategy included multiple electronic databases of PubMed, Web of Science, ScienceDirect, ProQuest and EMBASE. Studies published in a peer review journal in English between the 30^th of April 1980 and the 30^th of April 2022 were included. The Newcastle-Ottawa Scale was used to assess the risk of bias of the systematic included studies. Pooled odds ratios (ORs) together with 95% confidence intervals (CIs) are reported overall and for sub-groups.

RESULTS

A total of 80 studies were systematically selected, where 38 were included in the meta-analysis. Of the 38 studies, 28 focused on children and young girls (i.e., 10-24 years old) and 10 included participants with a wider age range of 15-49 years. The prevalence of using disposable sanitary pads was 45% (95%CI: 0.35-0.58). The prevalence of menstrual education pre-menarche was 68% (95%CI: 0.56-0.82). The prevalence of good menstrual hygiene management (MHM) was 39% (95%CI: 0.25-0.61). Women in rural areas (OR = 0.30, 95%CI: 0.13-0.69) were 0.70 times less likely to have good MHM practices than those living in urban areas.

CONCLUSION

There was a lack of evidence, especially from low- and middle- income countries. Further research to better understand the scope and prevalence of period poverty should be considered. This will enable the development of improved policies to increase access to menstrual products and medical support where necessary.

Unlocking the potential for engaging men to improve reproductive, maternal, and neonatal health in Karnali Province, Nepal

Background

Adolescent girls and young women (AGYW) often experience early childbearing and have poor utilization of reproductive, maternal, and neonatal health (RMNH) services in Nepal. Involving men in such services has been increasingly recognized globally to improve gender-equitable reproductive health behaviour in husbands. This qualitative study assessed the implementation of Healthy Transitions’ male engagement interventions in Karnali Province, Nepal which were implemented to improve gender-equitable attitudes, and supportive RMNH care-seeking behaviors among the husbands of young women.

Methods

We conducted a summative qualitative study that included in-depth interviews with 12 AGYW as primary beneficiaries and their husbands (N = 12) and in-laws (N = 8). In addition, key informant interviews were conducted with health workers (N = 8), local government representatives (N = 4), members of Health Facility Operation and Management Committee (N = 8) and project implementers (N = 12). Due to COVID-19-related travel restrictions and lockdowns, all interviews were conducted via phone calls and online consultation. Data were analyzed using multistage coding and thematic content analysis.

Results

AGYW, their husbands, in-laws and health workers were receptive to the Healthy transitions’ male engagement initiatives. They perceived that the project contributed a momentum to facilitate men’s gender-responsive behaviour. Many participants reported that male engagement interventions, including home visits, community dialogues, and social events improved husbands’ support for their wives during menstruation, pregnancy, and childbirth. The activities also facilitated spousal communication and improved the couple’s decision-making for family planning use. Women reported that improved support from their husbands increased their self-confidence.

Conclusions

This study sheds light on the role of male engagement strategies to improve RMNH in a context where inequitable gender norms and roles are highly prevalent. Our findings highlight the potential to improve RMNH by addressing barriers to male engagement.

Traditional menstruation practices among Nepalese women living in Japan

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.

Development of a scale to evaluate negative menstrual attitudes among Nepalese women

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.

Rural-urban variation in exclusion from social activities due to menstruation among adolescent girls and young women in Ghana

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.

A harmful religio-cultural practice (Chhaupadi) during menstruation among adolescent girls in Nepal: Prevalence and policies for eradication

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.

The Stressor in Adolescence of Menstruation: Coping Strategies, Emotional Stress & Impacts on School Absences among Young Women in Nepal

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.

Is criminalization the answer? Perspectives of community members and police on menstrual seclusion policy in Far-West Nepal

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.

Acceptability and feasibility of using vaginal menstrual cups among schoolgirls in rural Nepal: a qualitative pilot study

INTRODUCTION

Menstrual hygiene management can be challenging in low-income settings and among school-aged girls due to traditional beliefs, lack of knowledge and information on best hygienic practices, and limited access to appropriate and affordable menstrual hygiene products. An alternative method for menstrual hygiene management, instead of sanitary pads or tampons, is the vaginal menstrual cup. As evidence on the use of menstrual cups is relatively limited, this study aimed to explore the acceptability and feasibility of using vaginal menstrual cups among school-aged girls in Thokarpa, Sindupalchowk, Nepal.

METHODS

This is an exploratory study based on four focus group discussions with a purposive sample of 28 schoolgirls between 13 and 19 years of age who were provided with vaginal menstrual cups in Thokarpa, Sindupalchowk, Nepal. The data were collected between February and March 2019, i.e. approximately three months after the distribution of the menstrual cup. Participants were included in the study if they had started their menstruation and never given birth. Conventional content analysis was applied.

RESULTS

Most participants perceived the menstrual cup positively. Not missing a single class in school due to problems related to menstrual hygiene management was described as a major benefit. The participants found using the menstrual cup easy and convenient, and described economic and environmental advantages of using it. Cleaning the menstrual cup did not cause any problems, according to the participants. Discomforts mentioned by the participants were: pain when inserting the menstrual cup, feeling the menstrual cup sticking out of the vagina, feeling a constant urge to urinate and leakage. Concerns were related to the size, shape and texture of the menstrual cup, and that it may "get stuck" in the vagina, while relatives were said to be concerned about the use of the menstrual cup leading to reduced fertility or losing virginity.

CONCLUSION

The use of vaginal menstrual cups for menstrual hygiene management among schoolgirls in Thokarpa, Sindupalchowk, Nepal, appears feasible and acceptable, as it involves practical, economic and environmental advantages. However, the scale-up of menstrual cups will require resolving described concerns and discomforts and fostering peer and family support.

The influence of culture on open defaecation in some basic schools in selected districts in Ghana: A preliminary study

Open defaecation has remained a major public and environmental health concern which has gained global attention. This study explored cultural factors including superstition, taboo, norms and values influencing open defaecation behaviour among basic school pupils in the Eastern and Volta Regions all within Southern Ghana. Self-reported data were collected from 400 pupils using structured questionnaire and focus group discussions. Descriptive, bivariate and multivariate statistics were used to analyze the quantitative data. The qualitative data was analyzed using thematic content analytical procedure. The results of the study showed, superstitions, traditional norms and taboo yielded statistically significant effect sizes with pupils’ open defaecation behaviour: and superstition: r = 0.728, p< 0.05; traditional norms: r = 0.425, p <0.05; taboos: r = 0.462, p<0.05. The study concluded that superstitions and traditional norm and taboo constituted the key cultural drivers influencing pupils’ open defaecation behaviour in the Eastern and Volta Regions. It is recommended that the Ministry of Education should incorporate open defaecation issues into the educational curriculum and develop culturally sensitive educational programs for a massive educational campaign to stop open defaecation in the schools. To ensure that the messaging for these campaigns resonate with target audience, communication campaigns should promote a number of positive emotional and social issues related to improved social status and positive self-esteem, better growth and economic opportunities with toilet use.