A Research Report On Menstrual Restriction And Perceived Stress Among Adolescent Girls Among School Going Adolescent Girls, Kailali, Nepal

The practice has negatively influenced health, safety and human rights of women and has augmentedtheprocess of gender-basedviolence in Nepalisociety.(8) Though most study hav[r]

INTRODUCTION

Background

Adolescence, defined by WHO as individuals aged 10-19, marks a crucial transition from childhood to adulthood, during which girls experience their first menstruation, known as "Menarche," signifying sexual maturity The menstrual cycle typically occurs every 28 days, involving bleeding from the uterus that lasts three to seven days if pregnancy does not occur Despite being a natural and essential process, menstruation is often stigmatized in various communities, leading to perceptions of uncleanliness and the perpetuation of myths and taboos, particularly in Nepal, where secrecy and shame surround this vital aspect of female health.

Recent professional journals and popular magazines have highlighted menstrual pathology, often portraying women and girls as angry, depressed, or unreasonable While numerous studies address Mental Health and Sexual and Reproductive Health individually, their interconnectedness remains underexplored Issues in Mental Health can stem from past or present Sexual and Reproductive Health problems and vice versa In recent decades, the impact of stress on health has gained significant attention, with psychological stress recognized as a key factor in the development and worsening of various diseases, including depression, cardiovascular issues, and immune-related disorders This stress is linked to increased mortality rates and decreased life satisfaction, emphasizing the importance of understanding these health relationships.

Many girls lack essential scientific knowledge about menstruation and puberty, often influenced by myths, taboos, and misconceptions This lack of understanding can lead to negative attitudes towards these natural physiological processes In some cultures, menstruating women face restrictions on normal activities such as entering places of worship, cooking, and interacting with others, with extreme cases resulting in isolation Despite progress, myths and taboos surrounding menstruation, such as prohibitions on food preparation and sexual activity, still persist.

Western setting but have become less Regardless, Menstruation is often perceived in negative light, as research on healthy menstruation in “normal: women is very less.(2)

Statement of Problem

Chaupadi, a harmful practice rooted in myths and ignorance, was banned by the Supreme Court of Nepal in 2005 Recognized as a form of violence against women, it was addressed in the National Plan of Action against Gender-Based Violence in 2010 Furthermore, in 2017, the Nepalese parliament passed a bill criminalizing Chaupadi, imposing a penalty of up to three months in jail or a fine for those who continue the practice.

Since August 2018, the Nepalese government has implemented a policy providing 3000 Rupees (approximately 30 USD) to address menstrual restrictions, which affect a significant number of women A 2018 study revealed a troubling prevalence rate of 72.3% regarding menstrual restrictions, with many women facing limitations in daily chores and increased risks of Intimate Partner Violence Furthermore, research conducted in Western Nepal indicated that during their menstrual period, 88% of women refrained from participating in cultural rituals, with only 12% attending urgent ceremonies discreetly This widespread issue highlights the need for increased awareness and support for women's rights during menstruation.

A significant 91% of women practicing Chaupadi reported feelings of diffidence, insecurity, guilt, humiliation, sadness, and depression This tradition is prevalent among Hindus in the hill districts of Far-West and some Mid-West regions, with over 95% of women in Achham District practicing it as of 2010 Recently, Chaupadi has spread to the plains due to migration from hill areas, with 30.1% of women in Tikapur Municipality, Kailali District, adhering to the practice in 2012 Additionally, a 2010 Government of Nepal's Multiple Indicator Cluster Survey revealed that 58% of women in certain Mid and Far Western regions lived in sheds during their menstrual periods, highlighting a severe form of menstrual restriction that adversely affects women's physical and mental health in this century.

Menstruation is often viewed as a taboo subject among Hindus, leading many girls to feel uncomfortable discussing menstrual issues, especially with their fathers This stigma results in a lack of open communication within families, schools, and communities, leaving girls with limited knowledge about their experiences From a young age, girls learn they are considered "untouchable" during menstruation, which restricts their participation in daily activities, such as cooking or visiting temples, even in families that do not strictly enforce these beliefs In many underdeveloped countries, this stigma contributes to a high school dropout rate among girls, with over 23% of girls in India leaving school when they start menstruating The taboos surrounding menstruation significantly affect the emotional well-being, mindset, lifestyle, and health of women and girls in various societies.

As society evolves, the menstrual taboo is expected to fade, yet many women and children in Nepal may continue to face health risks and fatalities due to unsafe menstruation practices Cultural challenges, combined with inadequate sanitation, insufficient protective measures, and limited washing facilities, heighten the risk of stigma, potential infections, and unpleasant odors associated with menstrual blood, ultimately impacting mental health significantly.

Rationale of the study

Despite numerous studies on knowledge and attitudes toward menstrual hygiene management, there is a notable lack of research addressing the mental health impacts of taboos and insufficient knowledge related to menstruation To address this gap, this study was conducted to examine the effects of menstrual practices on young adolescent girls in the remote areas of Kailali District, Nepal The findings aim to provide valuable evidence for designing interventions to eliminate harmful practices like menstrual restrictions and the severe form known as Chaupadi.

4 place in the monthly basis, overall improving the overall physical, mental and social status of adolescent girls in the area.

Objective

To access the prevalence and perceived stress caused due to menstrual restriction among Adolescent girls of Lower Secondary School in Kailali District, Nepal

1 To measure the prevalence of different forms of menstrual restriction

2 To measure the Perceives Stress level of Adolescent girls due to menstrual restriction

3 To measure the association between menstrual restriction and perceived stress.

Research Question

1 What is the prevalence of different forms of menstrual restriction?

2 What is the level of perceived stress among the adolescent girls?

3 Is there any association between perceived stress level and menstrual restriction?

1 Restriction to enter or reside inside houses

3 Restriction to touch male members

4 Restricted to interact with male members

5 Restricted to enter inside temple

7 Restriction to touch plants with holy belief

8 Restricted to touch livestock or animals

9 Restricted to eat together with family

10 Restricted to consume dairy products

11 Restricted to participate in cultural rituals

12 Restricted to go to school

13 Restricted to roam and play with friends

14 Restricted to sleep in any bed

15 Restriction to use heavy blankets and mattresses

16 Restriction to use packed pads

17 Restricted to sundry cloth pad

18 Restriction to use common toilet

19 Restricted to use common Taps

LITERATURE REVIEW

A comprehensive literature review was conducted by examining relevant scientific articles related to Menstrual Restriction and Perceived Stress The primary source for this review was online searches, utilizing platforms such as PubMed and Google Scholar Key search terms included "Menstruation and Taboo," "Perceived Stress," "Menstrual Restriction and Nepal," "Menstruation and South Asia," and "Menstruation and Nepal." Additional phrases like "Menstruation and Perceived Stress" were also employed to enhance the search results.

“Menstrual Restriction and Perceived Stress” for further reviewing the literature in depth

Id en tific atio n Scr ee n in g E lig ib ilityIn clu d ed

Records identified through database searching Pub Med in END Note (n288)

Additional records identified through other source including GoogleScholar and Google (nw)

Record after duplicate removed (n181) + (nw) 258

Records excluded due to relevance, study type, and inappropriate comparators or outcomes (n60)

Full-text articles assessed for eligibility(nu)

Full-text articles excluded due to relevance, study type and inappropriate comparators or outcomes (nQ) Studies included in data synthesis (n$)

Un-touchability and Social Restriction

A study in India found that only 9.7% of adolescent girls did not impose any restrictions during menstruation, while 90.3% practiced various restrictions, including avoiding religious sites, certain foods, kitchen work, and physical activities In Indonesia, nearly one-third of girls in South Sulawesi (31.1%) and Papua (32.2%) viewed menstruation as a taboo topic, compared to less than one-fifth in East Java (16.3%) and NTT (19.3%) Additionally, perceptions of menstruating girls as unclean varied, with 34.1% in South Sulawesi believing this, while only 10.9% in Papua, 9.5% in East Java, and 2.5% in NTT held the same view Despite these beliefs, only 21.0% of girls correctly identified that menstruating girls are not unclean Misconceptions about menstruation were prevalent, with only 26.0% correctly stating that physical activity is safe during menstruation, 21.2% recognizing menstrual blood as non-harmful, and a mere 5.1% understanding that certain foods do not need to be avoided Celebrations of menarche were rare, with less than 5% of girls in most provinces reporting such practices, except in South Sulawesi, where 37.5% noted community celebrations for reaching menarche.

A cross-sectional study conducted in Doti district revealed that 52.5% of respondents believe that restrictions on household chores during menstruation are significant Conversely, only 47% felt that disregarding cultural traditions and taboos during this time would result in curses from deities Additionally, 54% of participants indicated that men do not fall ill if touched by a menstruating woman Despite increased awareness, deep-rooted cultural taboos continue to hinder changes in attitudes, affecting menstrual hygiene management practices among school students Notably, over half of the female respondents reported isolating themselves in separate rooms during menstruation and being excluded from cultural and religious events.

A study conducted in Western Nepal in 2018 revealed that 88% of women do not participate in cultural ceremonies during menstruation, while 12% only attend in urgent situations and return immediately Additionally, the study highlighted that women practicing Chaupadi are restricted to bathing or washing clothes only at designated Chaupadi Dhara locations, which are separate water sources near the village, limiting their access to regular water taps and wells.

Restricted to enter or reside inside the house/ Abolishment to Chau-Goth

Chaupadi is a Nepalese practice that imposes restrictions on women during menstruation, varying by family, community, and region This tradition forces women to leave their homes and prohibits them from participating in daily activities, often requiring them to stay in cattle sheds Despite these restrictions, women are still expected to perform hard labor, including collecting firewood, farming, and other tasks The duration of these restrictions can last up to 13 days for the first two menstrual cycles, seven days for the third, and four days each month thereafter.

Chaupadi practices expose menstruating women to severe health risks, including extreme cold and infectious diseases, as they are confined to sheds with limited protection A concerning report revealed that 9 out of 32 married women experienced uterine prolapse The absence of registered physicians and medical supplies in local health posts exacerbates these health implications Additionally, menstruating women face a heightened risk of fatality from snake and scorpion bites, as social taboos prevent them from receiving timely medical attention.

Restricted to enter inside Temple andtake part in cultural rituals

A cross-sectional study in the Bangalore area revealed significant cultural practices during menstruation, with 94.2% of participants facing restrictions on attending places of worship and 45.6% observing special functions upon reaching menarche Similarly, a study in rural West Bengal indicated that over 50% of women were prohibited from household chores, participating in religious activities, and attending weddings during their menstrual period.

Food restrictions (different from Usual)

A study conducted in Western Nepal revealed that menstruating women face dietary restrictions, being prohibited from consuming milk and dairy products Instead, they are limited to eating only flatbread with salt, which deprives them of essential nutrients during their menstrual periods Furthermore, these women are not allowed to share meals with their family members.

A study conducted in Doti revealed that 45% of respondents believed menstruating females could consume dairy and sour foods, while 65% considered this abnormal Additionally, 77% of participants acknowledged the need for increased nutrient supplementation during menstruation Similarly, a cross-sectional study near Bangalore found that food taboos during menstruation were prevalent, with 42.6% of respondents avoiding certain items, including sweets (21.6%), spicy foods (3.9%), and dairy products (9.1%) In West Bengal, restrictions during menstruation also included milk, dairy products, and vegetables.

Cows are regarded sacred and venerated in Hindu religion as the mother goddess hence menstruating women are prohibited to touch them.(8)

Restricted to go to school and Play

A cross-sectional study conducted in rural West Bengal revealed that over 50% of participants experienced restrictions on play during menstruation Additionally, thirteen individuals were unable to attend school during their menstrual period, while thirty-eight reported resting more frequently during menstruation compared to other times.

A study in Saudi Arabia revealed a significant link between menstrual problems and stress, with 39% of young female participants experiencing high levels of stress (HPS) and 91.9% reporting some form of menstrual issue Similarly, a 2012 cross-sectional study in Bangalore found that 44.1% of girls expressed fear about menarche, while 26.1% reported feelings of anxiety Additionally, approximately 74.2% of respondents viewed the menstrual cycle as a significant concern.

10 natural phenomenononwhile 17% felt that menstruation occurred due to the curse of God Majority of them (56.8%) feltthat menstruation poses a huge physical and psychological burden on them.(16)

In the study done in Doti among a total of 141 female respondents, 39% responded

Many individuals face significant challenges during menstruation, including feelings of shame when discussing their menstrual status, physical pain, and issues like leaks, stains, and odors, which can lead to teasing from peers Alarmingly, only 29 respondents reported receiving psychological support from their families during this time Furthermore, a staggering 91 percent of respondents practicing Chaupadi expressed feelings of diffidence, insecurity, guilt, humiliation, sadness, and depression.

Despite the legal ban on Chaupadi in Nepal, the practice persists due to ignorance, superstitions, and cultural norms, particularly in remote areas Rooted in Hindu beliefs surrounding pollution and purity, Chaupadi enforces strict adherence to traditional roles for menstruating women, which undermines their health, safety, and human rights, contributing to gender-based violence While studies have highlighted the physical, mental, and emotional impacts of this tradition on women and girls, few have explored the psychological distress experienced by vulnerable populations, such as young adolescent girls A 2018 study noted that women's participation in family and social life during menstruation is often restricted by their husbands and in-laws, yet it failed to address the psychosocial impacts or stress levels associated with menstrual restrictions.

A study conducted in Doti revealed that 91 percent of participants practicing Chaupadi reported feelings of diffidence, insecurity, guilt, humiliation, sadness, and depression These emotional responses suggest a complex interrelation among these negative feelings.

11 of mental, emotional and psychosocial problems yet, none of the studies have accurately found the link between these two as with such believes restrictions do take place

METHODOLOGY

Study Design

A descriptive, cross-sectional study wasconducted.

Study Variables

 Mothers support during menstruation o Menstrual Restriction

 Restricted to enter or reside inside houses

 Restriction to touch male members

 Restricted to interact with male members

 Restricted to enter inside the temple

 Restriction to touch plants with holy belief

 Restricted to touch livestock or animals

 Restricted to eat together with a family

 Restricted to consume dairy products

 Restricted to participate in cultural rituals

 Restricted to go to school

 Restricted to roam and play with friends

 Restricted to sleep in any bed

 Restriction to use heavy blankets and mattresses

 Restriction to use packed pads

 Restricted to sundry cloth pad

 Restriction to use the common toilet

 Restricted to use common Taps

Study Area

This study was conducted in Government Schools of State-7, Godawari Municipality 10,

Study Population

Populations of the study were the adolescent girls of age group 14-17 years from class 8,

Sample Size

Sample size was calculated by using the following formula

307.74~308(18) Considering the non-response rate 20%, (n) = 20% of 308a.6~62 Therefore, the total sample size was 370

Where, z = 1.96, considering 95% confidence interval For this study, p = 72.3 %=estimate at 0.723(7) q = 1-q d = expected error (5%) n = Desired sample size population

Sampling Technique

Proportionate random sampling technique was adopted for this research as shown below

In this study, three schools were randomly chosen, and the total number of students in these schools was determined Samples were then proportionately calculated from each class (8th, 9th, and 10th) in the selected schools, with students being randomly selected from each class.

Total no.of secondary schools in godawari municipality = 6

Shree Janaki Secondary School, Nb=9.7%, n= 37

Tools and Technique of data collection

1.Structured Questionnaire: A structured self-administered questionnaire was developed based on intensiveLiterature Review The whole questionnaire was translated in Nepali and back translation was done into English before pretesting

The Perceived Stress Scale (PSS), adapted for the Nepalese context, consists of 10 items derived from the original scale by Sheldon Cohen, Tom Kamarck, and Robin Mermelstein, which is known for its high reliability (Cronbach's alpha coefficients of 0.84, 0.85, and 0.86) This measure evaluates how individuals appraise various life situations using a five-point Likert scale Respondents reported their experiences related to stress on a scale ranging from 0 (never) to 4 (very often).

Table 1 Perceived Stress Scale (10 items) - Cohen et al, 1994 Technique

S.N Questions (The Perceived Stress Scale (10 items) - Cohen et al, 1994)

1 In the last month, how often have you been upset because of menstrual restriction?

2 In the last month, how often have you felt that you were unable to control important things in your life because of menstrual restriction?

3 In the last month, how often have you felt nervous and “stressed” because of menstrual restriction?

4 In the last month, how often have you felt confident about your ability to handle your personal problems inspite of menstrual restriction?

5 In the last month, how often have you felt that things were going your way inspite of menstrual restriction?

6 In the last month, how often have you found that you could not cope with all the things that you had to do because of menstrual restriction?

7 In the last month, how often have you been able to control irritations in your life inspite of menstrual restriction?

8 In the last month, how often have you felt that you were on top of things?

9 In the last month, how often have you been angered because of menstrual restriction?

10 In the last month, how often have you felt difficulties were piling up so high that you could not overcome them because of menstrual restriction?

Data management, analysis and interpretation procedure

Data Screening, Storage and Transfer

 The received questionnaires were coded and filling was done before transfer of the data

 Immediately following the data collection, prior to data entry, data was checked for completeness

 The researcher managed and transferred the filled questionnaire own self to the destination

 Researcher screened all the data for accuracy, assurance and completeness This promptness helped to address any omissions, errors or inaccuracies also helping to correct the data

 Then finally, the responses were transferred into computer software Epi-Data to create a data set

 Data were stored in specific folder of laptop and backup was stored in external hard disk for prevention from loss

 EpiData v3.1 was used for data entry 10% raw data was entered after developing format for validating the data entry format

 At the end of the data entry 10% of filled questionnaires was selected randomly and crosschecked with the entered data

 The original data set was kept safely in a separate folder to prevent from manipulation and loss

 Recoding and analysis was conducted in a copy of the data set in a separate folder

Data was initially entered into EpiData v3.1 and subsequently exported to SPSS v16.0 for analysis The analyzed data was presented in tables and graphs within the descriptive section, detailing counts, percentages, and cross-tabulations A bivariate analysis was performed to examine the relationships between socio-demographic factors, menstrual restrictions, and perceived stress Finally, data interpretation utilized a 95% confidence interval with the Chi-square test to assess statistical significance.

17 based on p-value 0.05 being not significant

Upon completing the study presentation, a dissemination program was held at KCHS, PU Two hard copies and one soft copy of the thesis were submitted to the program coordinator at BPH, Godawari Municipality, PU, along with one hard copy to the NHRC Additionally, a hard copy of the final report was provided to the respective DHO and DPHO Lastly, a manuscript will be prepared for submission to an international journal for publication.

Validity and reliability of study

The validity of the instruments was confirmed using Cronbach's alpha, revealing an internal consistency of 0.82 for the Perceived Stress Scale (PSS-10) and 0.85 for menstrual restriction Additionally, expert consultation, a comprehensive literature review, and pretesting on 10% of the total sample size in Kathmandu were conducted to ensure the reliability of the measurements.

Inclusion and Exclusion criteria

Perceived stress among Adolescent girls as a result of Menstrual Restriction was found

Prior to the study, written consent was secured from the relevant authority, along with ethical clearance and approval from the NHRC Respondents were informed about the study's purpose, ensuring their confidentiality and privacy, and were made aware that their participation was voluntary and could be declined at any time Both verbal and written consent were obtained from the respondents and their guardians.

 Informed Consent and Assent (for below 16 Years)

 Perceived Stress: Refers to the degree to which situations in one‟s life are appraisedas stressful due to menstrual restriction

 Adolescence:Refers to the age group of 14-17 in this study

 Menstruation: Refers to the periodic blood that flows as a discharge usually lasting for 5-7 days

Menstrual restriction refers to the limitations imposed on individuals during menstruation, often resulting in social isolation or exclusion This practice can involve avoiding contact with others, refraining from certain activities like cooking, and using common bathrooms, effectively treating menstruating individuals as untouchable Such restrictions can lead to a near-complete disconnection from society and may even result in punishment through forced separation.

Chaupadi Goth is a centuries-old tradition that forces women to leave their homes during menstruation, relegating them to sleep in sheds, stables, or caves known as "Goths." During this time, they are considered impure and treated as untouchables, eating separately from their families, barred from entering their homes, and often required to wash at designated taps.

 Minority Age Group:Adolescents below 16 years of age

 Age: Age of the respondent in completed years as stated by the respondent, adolescent girl (14-17 years old)

3.15 Time Frame of the study

The period of the study was of 6 months

RESEARCH FINDINGS

A total of 370 adolescent girls, aged 14 to 17 years, voluntarily participated in a study conducted in Godawari Municipality, Kailali District, State 7 of Nepal The findings of the study are organized into three sections, aligning with the research objectives and addressing the specified research questions.

1 Prevalence of different forms of menstrual restriction

2 PSL of Adolescent girls due to menstrual restriction

3 Association between menstrual restriction and perceived stress

The study examines various factors influencing perceptions of menstrual restrictions, including age, grade, ethnicity, and religion It also considers household size and the educational backgrounds of both parents, alongside their occupations Additionally, the research highlights the differing views of fathers and mothers regarding menstrual restrictions, providing a comprehensive understanding of how these elements interact.

Table 2 Distribution according to socio-demographic characteristics

The sample had an average age of 15.26 years (SD = 1.099), with a significant majority of respondents identifying as Hindu (97.84%) Among these, 48.65% belonged to Dalit communities, while 41.62% were from upper caste groups Additionally, the study area exhibited larger household sizes, with 97.84% of participants reporting this characteristic, and an overall high literacy level, particularly at the primary education level, which accounted for 42.16% of respondents.

Fathers View on Menstrual Restriction

Mothers View on Menstrual Restriction

Does Not Wok or Earn Money 11 2.97

Does Not Workor Earn Money 15 4.05

Among the 21 fathers surveyed, there was a nearly equal distribution of literacy levels, with 33.24% being literate and 32.70% having completed primary education In terms of occupation, over half of the fathers (58.11%) were engaged in agriculture, while a significant majority of the mothers (87.03%) also worked in the agricultural sector.

4.2 Level and category of menstrual restriction

This section consists of different categories of restriction with its frequency and percentage as shown in the Table 3

Table 3 Level and Category of Menstrual Restriction

The findings from Table 3 indicate that 51.08% of respondents reported being sent to a Chau-Goth during their menstruation Additionally, a significant majority, 80.27%, faced restrictions on touching male family members, although 82.97% were not prohibited from interacting with them Furthermore, 85.68% of respondents were barred from entering temples, while 82.97% were restricted from cooking food, and 79.19% were not allowed to touch plants due to religious beliefs.

Restriction during the menstrual period Number (%)

Restricted to enter or reside inside the house 214(57.84) 156(42.16)

Restricted to Touch Male members 297(80.27) 73(19.73)

Restricted to interact with male members 63(17.03) 307(82.97)

Restricted to enter inside Temple 317(85.68) 53(14.32)

Restricted to touch plants with holy belief 293(79.19) 77(20.81)

Restricted to touch livestock or animals 186(50.27) 184(49.73)

Restricted to eat together with Family 263(71.08) 107(28.92)

Restricted to consume dairy products 261(70.54) 109(29.46)

Restricted to participate in cultural rituals 120(32.43) 250(67.57)

Restricted to go to School 35(9.46) 335 (90.54)

Restricted to Roam and play around with friends 45(12.16) 325(87.84)

Restricted to sleep in any bed 167(45.14) 203(54.86)

Restricted to use heavy blankets and mattresses 92(24.86) 278(75.14)

Restricted to use packed pads 51(13.78) 319(86.22)

Restricted to sundry Cloth pad 71(19.2) 299(80.8)

Restricted to use the common toilet 141(38.1) 229(61.9)

Restricted to use common taps 276(74.6) 94(25.4)

In a survey of 22 respondents, it was found that 50.27% faced restrictions on touching livestock, while 71.08% were not allowed to eat with their families, and 70.54% were restricted from consuming dairy products Conversely, 67.57% were not restricted from participating in cultural rituals Notably, 90.54% of the respondents could attend school during their menstrual periods, and 87.84% were free to play with friends However, 45.14% of the girls were restricted from sleeping in any bed, and 24.86% could not use heavy blankets or mattresses A significant majority, 86.22%, were not restricted from using packed sanitary pads, while 80.8% were allowed to use cloth pads Additionally, 38.1% faced restrictions on using common toilets, and more than two-thirds, 74.6%, were restricted from using common taps.

4.3 Mean score of individual items of Perceived Stress

This section consists of table presenting the mean and standard deviation for each item of the perceived stress scale

Table 4 Mean score of an individual item of Perceived Stress

Perceives Stress Questionnaire (10 Scale) Mean Std Deviation

8 In the last month, how often have you felt that you were on top of things? 2.17 1.30

10 In the last month, how often have you felt difficulties were piling up so high that you could not overcome them because of menstrual restriction?

Total Perceived Stress Scale Score 19.59 5.51

Table 4 presents the mean scores for various items related to menstrual restrictions, revealing significant emotional impacts Item 1 recorded a mean score of 1.85±1.22, indicating frequent feelings of upset due to menstrual restrictions Item 2 showed a mean of 1.64±1.24, reflecting a sense of lost control over important life aspects Similarly, item 3 had a mean score of 1.83±1.24, highlighting feelings of nervousness and stress In contrast, item 4 indicated a slightly higher mean of 1.88±1.31, suggesting some confidence in managing personal problems despite these restrictions Lastly, item 5, which assessed the perception of things going well despite menstrual challenges, did not provide a complete mean score but contributes to understanding the overall emotional landscape.

The study revealed a standard deviation of 2.34±1.25 for the overall impact of menstrual restrictions Specifically, respondents indicated a mean score of 1.92±1.30 for item no 6, which assessed their ability to cope with daily tasks in the past month due to menstrual limitations Additionally, for item no 7, the findings highlighted the frequency with which individuals managed to control irritations despite these restrictions.

The study revealed that the perceived stress levels among participants were significant, with a total Perceived Stress Scale score of 19.59±5.51 Specifically, for item no 8, which assessed how often individuals felt on top of things in the last month, the mean score was 2.17±1.30 Item no 9, focused on feelings of anger due to menstrual restrictions, yielded a mean score of 2.02±1.36 Lastly, item no 10, which addressed the perception of overwhelming difficulties stemming from menstrual restrictions, had a mean score of 2.11±1.57.

The table 5 shows that there was a high prevalence of perceived moderate stress, 79.2% among young adolescent's girls followed with 9.7% suffering from high perceives stress and 11.1% suffering from low perceived stress

4.4 Association between Socio-demographic and PS

This section presents a table that illustrates the relationship between various demographic variables, including age, ethnicity, household size, and the education levels of both parents, in relation to their views on restrictions The analysis was conducted using a chi-square test, with the results detailed in the tables below.

Table 6 Association between Socio-demographic and PSS

High PS Moderate PS Low PS Value P-Value

Table 6 indicates that there is no significant association between perceived stress (PS) and age, with a p-value of 0.240 Additionally, the relationship between students' grade levels and PS also showed no significance, as evidenced by a p-value of 0.170 Furthermore, the perceived stress levels were not significantly associated with fathers' education (p-value = 0.764) or mothers' education (p-value = 0.108) Lastly, fathers' views on menstrual restrictions did not demonstrate a significant association with PS, reflected by a p-value of 0.732.

Mothers view on restriction p-value (0.49) was not found to be associated with PS as well

4.5 Association between Menstrual Restriction and PS

This section consists of results showing association between different forms of restrictions and level of the perceived stress level in the represented table below

Table 7 Association between Menstrual Restriction and PS

Types of Restrictions Total n (%) High PS Mild PS Low PS

Restricted to enter the inside house

Restricted to touch male members

Restricted to touch livestock or animals

Restricted to eat together with a family

Restricted to Consume dairy Products

Restricted to participate in cultural rituals

Restricted to go to school

Restricted to roam around and play with friends

Table 7 reveals significant associations with various restrictions faced by individuals, including limited access to their homes (p < 0.001), being sent to Chau-goth (p < 0.001), and prohibitions on physical contact with male family members (p < 0.033) Additional restrictions include limitations on touching livestock (p < 0.001), sharing meals with family (p < 0.003), consuming dairy products (p < 0.001), participating in cultural rituals (p < 0.001), attending school (p < 0.284), playing with friends (p < 0.146), sleeping in any bed (p < 0.003), using heavy blankets and mattresses (p < 0.001), utilizing packed pads (p < 0.005), opting for sundry cloth pads (p < 0.002), and accessing common toilets (p < 0.001) and taps (p < 0.001).

Restricted to sleep in any bed

Restricted to use heavy blankets and mattresses

Restricted to use packed pads

Restricted to sundry cloth pad

Restricted to use the common toilet

Restricted to use common taps

DISCUSSION

A community-based mixed-method study in Pyuthan district, mid-western Nepal, revealed that a significant majority (94.5%) of participants experienced Chaupadi (Menstrual Shed) during menarche, highlighting its commonality and associated health issues The study indicated a high prevalence of restrictive practices, with 71.6% unable to go outside and 85.68% barred from entering temples during menstruation Additionally, 40.4% of participants used sanitary pads, with 82.7% reporting no restrictions on their use Comparatively, a study in Rural West Bengal noted only 11.25% of girls used sanitary pads, indicating similar low acceptance rates The qualitative study in Far-west Nepal emphasized that all participants adhered to menstrual taboos, facing various physical and psychological challenges, with 9.7% suffering from high perceived stress Our findings align with these studies, showcasing the pervasive impact of Chaupadi on adolescent girls' health and well-being.

The way individuals react to stress is influenced by various factors, including personal traits, lifestyle choices, social support, and their perception of stressors A study revealed that perceived stress levels decrease with age, peaking in individuals aged 14 and declining in those aged 17 Additionally, adolescent girls in grade 8 reported the highest stress levels, while those in grade 10 reported the lowest Furthermore, perceived stress was notably higher among upper caste groups and Dalits, who adhere to strict menstrual restrictions, compared to the disadvantaged Janajati communities in the hills.

Larger household sizes were associated with moderately high levels of perceived stress A significant correlation was found between menstrual restrictions and perceived stress, with over 80% of the measured menstrual restrictions demonstrating this association.

International studies indicate that adolescent girls consistently report higher levels of psychological stress compared to boys However, recent findings suggest a lower overall stress level among adolescents, potentially linked to increased maturity with age In Korea, 30.5% of female adolescents reported perceived stress, while in England, 54.5% of stressed adolescents were girls Similarly, Brazilian studies reveal a prevalence of 30.1% among girls, with Rio Grande do Sul showing that 61.5% of stressed adolescents are female These results highlight the need for targeted interventions in developing societies, focusing on promoting financial and social equality, social skills training, and healthy lifestyles, particularly benefiting females and those with lower education levels.

In the hilly regions of Nepal, such as Achham, winter conditions are severe, and our observations during Chaupadi revealed that many girls lack proper bedding, often sleeping on rugs or bare floors with only sacks for warmth This inadequate sleeping situation contributes to a significant risk of hypothermia among those adhering to Chaupadi practices Our study found that only 24.86% of participants had access to heavy blankets and mattresses during their menstrual periods, highlighting the social restrictions related to food and daily activities that accompany Chaupadi.

In a surprising finding, most participants in the study were allowed to attend school and read books during their menstrual cycle, despite a traditional Hindu belief that the goddess of education, Sarashwoti, disapproves of menstruating girls engaging in such activities Specifically, 90.54% of the participants reported no restrictions on their school attendance, while only 9.46% faced limitations This shift in cultural practices highlights a significant change in attitudes toward menstruation and education.

This study reveals a significant correlation between menstrual restriction and perceived stress among adolescent girls in Godawari Municipality, Kailali District The adolescent phase is particularly challenging in underdeveloped countries where discussions on sexual and reproductive health remain taboo Such restrictions can lead to mental trauma and heightened stress levels, which are linked to various mental health issues It is crucial for educational policies to incorporate psychologists and nutritionists in schools to address stress related to menstrual restrictions If this is not feasible, Physical Education, Mental Health, and Nutrition teachers should focus on health education through videos, seminars, and lectures to combat harmful practices and reduce stress Advocacy for normalizing menstruation and sexual health at the community level is essential, alongside sharing experiences and providing mental health counseling tailored to adolescents Discriminatory practices like Chaupadi must be strictly punished to safeguard young girls' psychosocial well-being Future research should involve larger community populations and explore men's perspectives and factors related to Chaupadi and other menstrual restrictions.

The study's strength lies in its use of a random sample that accurately represents adolescents, making it one of the first comprehensive studies conducted in the Kailali District.

Finally, the results found can be a base for comparison with other studies, besides drawing the attention of the stress issue among adolescents, which should be observed by other professionals

CONCLUSION AND RECOMMENDATION

Tools of Data Collection (English and Nepali Version) xiv Annex 2 Mapping of study area Error! Bookmark not defined

Purbanchal University Faculty of Medical and Allied Science Karnali college of Health Science Department of Public Health Battisputali, Kathmandu, Nepal

For the researchers purpose only

Please circle the appropriate single option as response and fill the appropriate information‟s in the blank dotted areas as applicable

3 Which grade do you study in? 1

3 Disadvantaged non Dalit Terai caste groups

Hindu Buddhist Muslim Kirat Christians Others (specify)

7 How many members are there in your family?

Married Unmarried Others (Divorced, widower)

Illiterate Literate Basic Level (1-8) Secondary Level (9-12) Bachelors Level Masters Level

Section: A Socio-demographic information xv

(If not married skip this question)

12 Is your Father against Menstrual Restriction or supports it?

Against menstrual restriction Supports menstrual restriction

13 If your father is against restriction what kind of support do you receive from his side?

Support to break all taboos and restrictions

Do not restrict you during menstruation Emotional support

14 Is your Mother against Menstrual Restriction or supports it?

15 If your mother is against restriction what kind of support do you receive from his side?

16 Is your Husband against Menstrual Restriction or supports it? (If not married skip this question

17 If your husband is against restriction what kind of support do you receive from his side?

(If not married skip this question

18 What is your fathers occupation? 1

Does not work (Does not earn money) Governmental

Non- governmental Agriculture Small scale transaction Labor

19 What is your mothers occupation? 1

Student House wife Business Other (Specify)………

20 What is your husband‟s occupation? 1

Student Business Other (Specify)……… xvi

How often do you face the following circumstances during menstruation please mention your response with a tick in the appropriate box

1 Are you restricted to enter inside the house while menstruating

2 Are you restricted to reside inside house

(not sent to chau goth) while menstruating

3 Are you restricted to reside inside house?(Sent to a chau- goth) while menstruating

4 Are you restricted to see male members while menstruating

5 Are you restricted to touch male members while menstruating

6 Are you restricted to interact with male members while menstruating

7 Are you restricted to enter inside temple while menstruating

8 Are you restricted to touch food to be eaten by others while menstruating

9 Are you restricted to cook food while menstruating

10 Are you restricted to touch plants with holy beliefs like Tulsi, Pipal, Bel etc while menstruating

11 Are you restricted to consume Vegetables while menstruating

12 Are you restricted to consume Fruits while menstruating

13 Are you restricted to eat together with family while menstruating

14 Are you restricted to touch livestock while menstruating

15 Are you restricted to eat together with family while menstruating

16 Are you restricted to consume Dairy

Products like milk, curd, ghee while menstruating

17 Are you restricted to consume Animal

Products like meat, fish, eggs

18 Are you restricted to get involved in cultural rituals or family functions during menstruation

19 Are you restricted to go to school during menstruation

20 Are you restricted from playing or roam with your friends during menstruation

21 Are you restricted to sleep in your usual bed while menstruating

22 Are you restricted to sleep in any bed while menstruating

23 Are you restricted to use heavy blankets and mattresses during menstruation xvii

24 Are you restricted to use packed pads and forced to wear strained unwashed cloths during menstruation

25 Are you restricted to sundry the clot pad you used while menstruating?

26 Are you restricted to use the common toilet during menstruation

27 Are you restricted to touch or use water taps and wells during menstruation

Thank You for your Support

Please tick your response in the appropriate box

35 In the last month, how often have you felt that you were on top of things?

37 In the last month, how often have you felt difficulties were piling up so high that you could not overcome them because of menstrual restriction? xviii k'af{~rn ljZjljBfno ˆofsN6L ckm d]l8sn PG8 PnfO8 ;fOG;]; s0ff{nL sn]h ckm x]Ny ;fOG;]; hg:jf:Yo ljefu, sf7df08f}, g]kfn ổs}nfnL g]kfnsf] ljBfno hfg] lszf]/Lx? dlxgfjf/L x'Fbf x'g] k|ltaGw / slyt tgfjặ “Menstrual Restriction and Perceived Stress among School going Adolescent Girls in Kailali, Nepal” cg';Gwfgsf] nfuL k|ZgfjnL cg';Gwfgstf{sf] p2]Zosf nflu dfq

;fdflhs tyf hg;f+lVos hfgsf/L s[kof tkfO{nfO{ pko'Qm nfUg] ljsNkdf uf]nf] nufpg' xf]; / vfnL 7fpFdf cfkm'nfO{ nfu]sf] pQ/ n]Vg'xf];

= tkfO{sf] pd]/ -slt jif{ k'/f x'g'eof]

:yfO{ a;f]af; - jf8{ g+ dfq}_ pNn]v ug'{xf];

= tkfO{sf] hft pNn]v ug'{xf];

= sfdL, bdfO{, ;fsL{, ufOg], aflb

= du/, tfdfê\, /fO{, lnDa', z]kf{, ef]6], jfn'ê\, ;'g'jf/, s'dfn, lh/]n, bg'jf/, yfdL, /fhL

= a|fx|d0f, If]qL, 7s'/L, ;Gof;L, /fhk't, sfo:y, aflgof, df/jf8L, h}/], g'/fË, aËfnL

== tkfO{sf] wd{ pNn]v ug'{xf];

] kl/jf/df slt hgf

= tkfO{sf] a}jflxs l:ytL pNn]v ug'{xf];

= cGo -kf/kfr's], Psn dlxnf_

] a'afsf] z}lIfs of]Uotf pNn]v ug'{xf];

] cfdfsf] z}lIfs of]Uotf pNn]v ug'{xf];

& cGo -pNn]v ug'{xf;\_============================ xx

>Ldfgs f] z}lIfs of]Uotf pNn]v ug'{xf];

] j]nf x'g] k|ltaG wsf] lj/f]w ug'{ x'G5 jf

] a]nf x'g] k|ltaG wsf] lj/f]wL xf] eg] jxfF af6 tkfO{n

= ;a} cGwljZjf; tf]8\g ;d{yg / xf};nf lbg'x'G5

= ;a} aGb]hx? Tf]8\g ;d{yg / xf};nf lbg'x'G5

] j]nf x'g] k|ltaG wsf] lj/f]w ug'{ x'G5 jf

/h:jnfsf] a]nfx'g] k|ltaGw sf] lj/f]wL xf] eg] jxfF af6 tkfO{n] s:tf]

] j]nfx'g] k|ltaG wsf] lj/f]w ug'{ x'G5 jf

- olbcljjfl xt x'g'x'G5 eg] k|Zg g+ !* df hfg'xf];\ _

] a]nf x'g] k|ltaG wsf] lj/f]wL xf] eg] jxfF af6 tkfO{n

= tkfO{sf] a'afsf] k]zf s] xf] <

Hofnfbf/L >lds ljBfyL{ u[lx0fL Jofkf/ cGo - v'nfpg'xf];\_======================================= xxii

Hofnfbf/L >lds ljBfyL{ u[lx0fL Jofkf/ cGo - v'nfpg'xf];\_=======================================

;d'x M v Dlxgfjf/Lsfa]nfx'g] k|ltaGw xxiii

Dlxgfjf/Lsf] ;dodf tkfO{n] lgDg kl/l:yltx? ;fdgf ug'{ePsf] 5 eg] pko'QmaS;df - √ _ lrGxnufO{ tkfO{sf] k|ltls|of lbg'xf];\ qm=

/h:jnf ePsf] a]nf tkfO{nfO{ 3/ leq k|a];

@#= /h:jnf ePsf] a]nf tkfO{nfO{ 3/ leq jf; j:g /f]s jf aGb]h 5 < - t/ 5fpuf]7df k7fpg'x'Gg _

@$= /h:jnf ePsf] a]nf tkfO{nfO{ 3/ leq jf; j:g /f]s jf aGb]h 5 < - 5fpuf]7df k7fpg'x'G5

/h:jnf ePsf] a]nf tkfO{nfO{ k'?ifx?nfO{ x]g{ /f]s jf aGb]h 5 <

@^= /h:jnf ePsf] a]nf tkfO{nfO{ k'?ifx?nfO{ 5'g /f]s jf aGb]h 5 <

/h:jnf ePsf] a]nf tkfO{nfO{ k'?ifx? ;Fu s'/fsfgLug{ /f]s jf aGb]h 5 <

@*= /h:jnf ePsf] a]nf tkfO{nfO{ dlGb/ hfg

@(= /h:jnf ePsf] a]nf tkfO{nfO{ c?n] vfg] vfgf 5'gdf /f]s jf aGb]h 5 <

#)= /h:jnf ePsf] a]nf tkfO{nfO{ vfgf ksfpg

#!= /h:jnf ePsf] a]nf tkfO{nfO{ wfdL{s cf:yf af]s]sf af]6 lj?jf jf ?v h:t} t'n;L, lkknjf j]n cflb 5'g /f]s jf aGb]h 5 <

#@= /h:jnf ePsf] a]nf tkfO{nfO{ xl/of] t/sfl/†;AhL vfg /f]s jf aGb]h 5 <

##= /h:jnf ePsf] a]nf tkfO{nfO{ kmnkm'n vfg /f]s jf aGb]h 5 <

#$= /h:jnf ePsf] a]nf tkfO{nfO{ 3/kfn'jf kz'klG5 jf hgfj/ 5'g /f]s jf aGb]h 5 <

#%= /h:jnf ePsf] a]nf tkfO{nfO{ kl/jf/ ;Fu a;]/ vfgf vfg /f]s jf aGb]h 5 <

#^= /h:jnf ePsf] a]nf tkfO{nfO{ b'w, blx, £o" nufot cGo b'Uw ;fdfu|L vfg /f]s jf aGb]h 5 <

#&= /h:jnf ePsf] a]nf tkfO{nfO{ df5f, df;', c08f cflb vfg /f]s jf jGb]h 5 <

#(= /h:jnf ePsf] a]nf tkfO{nfO{ ;+f:s[tLs sfo{s|d jf kfl/jfl/s e]63f6df ;+DnUg x'g /f]s jf jGb]h 5 <

$)= /h:jnf ePsf] a]nf tkfO{nfO{ ljBfno hfg

$@= /h:jnf ePsf] a]nf tkfO{nfO{ ;fyLx? ;Fu v]Ng†w'Dg /f]s jf aGb]h 5 <

$#= /h:jnf ePsf] a]nf tkfO{nfO{ cfˆgf] vf6df ;'Tg /f]s jf aGb]h 5 <

$$= /h:jnf ePsf] a]nf tkfO{nfO{ s'g} klg vf6df ;'Tg /f]s jf aGb]h 5 <

$%= /h:jnf ePsf] a]nf tkfO{nfO{ ef/L l;/s,

8Zgf cf]9\g cf]5\ofpg /f]s jf aGb]h 5 <

$&= /h:jnf ePsf] a]nf tkfO{nfO{ ahf/df lsGg kfOg] l8ikf]h]jn Kof8sf] k|of]u ug{ /f]s jf aGb]h 5 <

$*= /h:jnf ePsf] a]nf tkfO{nfO{ cfkm'n] xxiv k|of]u u/]sf] sk8f wf]P/ 3fddf ;'sfpg /f]s jf aGb]h 5 <

$(= /h:jnf ePsf] a]nf tkfO{nfO{ cfˆgf] 3/sf]

;a}n] k|of]u ug]{ rkL{ k|of]u ug{ /f]s jf aGb]h 5 <

%)= /h:jnf ePsf] a]nf tkfO{nfO{ s'g} klg wf/f jf kfgLsf] d'xfg 5'g / k|of]u ug{ /f]s jf aGb]h 5 <

;d'x M u cg'e't tgfj s[kof x/]s k|:gsf] nflu pko'Qm ljsNkdf uf]nf] nufpg' xf]; olb tkfO{nfO{ /h:jnf ePsf] a]nf s'g}kgL s'/fdf k|ltaGw 5}g eg] s'g}kgL ljsNkdf uf]nf] gnufpg'xf];

@= utdlxgfdf, /h:jnfsf] ;dodf ePsf] k|ltaGwsf] sf/0fn] tkfOF k|fo slt lg/f; x'g' eof] < slxN o} eO{g ) nueu slxNo} eO{g

/h:jnfsf] ;dodf ePsf] k|ltaGwsf sf/0f s]xL dxTjk'0f{ s'/fx? lgoGq0f ug{ c;dy{ lyP eGg] k|fo sltsf] dx;'; ug{'eof]< slxN o} ul/g ) nueu slxNo} ul/g

@ k|fo ul//fv]sf] x'Gy]F

/h:jnfsf] ;dodf ePsf] k|ltaGwsf sf/0f eoft'/(nervous) / tgfj k|fo sltsf] dx;'; ug{'eof]< slxN o} ul/g ) nueu slxNo} ul/g

/h:jnfsf] ;dodf ePsf] k|ltaGwsf sf/0f ef]u]sf] k/]zfgL;Fu k|fo sltsf]

< slxN o} ul/g ) nueu slxNo} ul/g

= utdlxgfdf /h:jnfsf] a]nfdf ePsf] k|ltaGwsf afah'b cfˆgf] hLjgsf dxQjk'0f{ kl/jt{gx?nfO{ k|efjsf/L

9+un] ;fdgf ul//x]sL5' eg]/ stLsf] dx;'; ug'{ePsf]

< slxN o} ul/g ) nueu slxNo} ul/g

&= utdlxgfdf /h:jnfsf] a]nfdf ePsf] k|ltaGwsf afah'b tkfO{n] cfˆgf JolQmut

5' eGg] stLsf] dx;'; ug'{eof] < slxN o} ul/g ) nueu slxNo} ul/g

= utdlxgfdf tkfO{n] sltsf] dx;'; ug'{eof] sL /h:jnfsf] j]nf ePsf] k|ltaGwsf afah'b d]/f sfdx? d}n]

;f]r]sf] h:t} e}/fv]sf 5g\ < slxN o} ul/g ) nueu slxNo} ul/g

= utdlxgfdf tkfO{n] sltsf] dx;'; ug'{eof] sL tkfOFn]

/h:jnfsf] a]nf ePsf] k|tLaGwsf sf/0fn] ubf{ tkfO{n] ug'{kg]{ ;a} slxN o} ul/g ) nueu slxNo} ul/g

Tiêu đề	Menstrual restriction and perceived stress among school going adolescent girls, Kailali, Nepal
Tác giả	Alisha Dahal
Người hướng dẫn	Mr. Krishna Prasad Sapkota, Guide
Trường học	Purbanchal University
Chuyên ngành	Public Health
Thể loại	Research report
Năm xuất bản	2019
Thành phố	Kathmandu

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