JMIR Publications

ABSTRACT

Background:

Despite being a natural physiological process, menstruation is often associated with health and safety challenges, stigma, and human rights concerns, especially in low-resource settings. In Nepal, menstrual restrictions are widespread; ninety percent of women and girls follow at least one menstrual restriction. One of these traditions, chhaupadi (severe menstrual seclusion), is a social-religious tradition in which women and girls isolate in menstrual huts or sheds during menstruation. Chhaupadi poses significant health and safety risks for women and families. Physical health risks include snake bites and animal attacks, hypothermia, suffocation from lighting fires in the sheds to keep warm, rape, and sometimes death. Women and girls are also psychologically affected during their stays in sheds. Isolation and limited security can leave women in perpetual states of fear, loneliness, stress, isolation, and low self-esteem. To date, numerous interventions have been implemented with varying degrees of rigorous evaluation and success. However, no known studies have comprehensively assessed which components of chhaupadi interventions hold promise. Further, no known prior interventions have fully engaged communities in the intervention design process to ensure suitability and sustainability that centers community values and voices.

Objective:

This paper describes a protocol for conducting participatory and creative menstrual health intervention research in Nepal that aims to fill gaps in understanding how to sustainably address harms associated with chhaupadi. This study is innovative and timely, as it is the first study to develop a comprehensive assessment of existing chhaupadi interventions and first to use a co-designed intervention approach to address the practice. This integrative three-pillar approach — drawing on Intervention Mapping (IM), Human-Centered Design (HCD), and Arts-based Research (ABR) — seeks to generate not only a co-created, theory- and evidence-based intervention, but also an innovative methodological framework adaptable to addressing multifaceted health issues in other LMIC contexts.

Methods:

In this three-phrase study we will apply a suite of innovative and tested research methods to address our study objectives. We will conduct a Realist Synthesis (Aim 1) to elucidate mechanisms of success or failure of chhaupadi interventions to date, which will inform community-led intervention development using principles of IM, as well as HCD and ABR tools (Aim 2). Next, we will pilot the community-designed chhaupadi intervention in a clinical trial, using a control group (Aim 3). Guided by community-engaged approaches at all stages of the study, we will collect qualitative, quantitative, and visual data (e.g., photographs, community maps, drawings) across multiple districts in Nepal where chhaupadi is practiced.

Results:

This study was funded in September 2023. Data collection began in April 2024 and will continue until August 2028.

Conclusions:

Despite numerous efforts, a comprehensive understanding of the effects of chhaupadi interventions across Nepal remains absent. By embedding diverse community perspectives at every stage of the study, this approach ensures interventions are contextually grounded and culturally relevant. Beyond addressing a culturally situated menstrual health practice – chhaupadi - this community-centered model has the potential to inform strategies for reducing the harms associated with other harmful practices in diverse global settings.