Menstruation & You

Menstruation & You:

Towards Menstrual Health Education & Access to Menstrual Hygiene in India

Overview

Menstruation has remained a conversational taboo in India, restricting the effective delivery of Menstrual Health Education (MHE). Further, the lack of authentic information and the inability to discuss the topic freely gives rise to misconceptions, increases the gap in knowledge, and in a way, reinforces the existing taboo. Our aim with this research is to understand the cultural context and effectively leverage it in designing culturally-responsive Information Communication Technologies for MHE and access to menstrual hygiene in India.

Role

Researcher

Advisor

Pushpendra Singh

Collaborator

Neha Kumar

PhD Mentor

Anupriya Tuli

Number of Studies

Duration

2 years

Problem Statement - Study 1

In the cultural context of India, menstruation is a stigmatized health topic which makes delivery of MHE a challenging task. Using qualitative research methods, we study Menstrupedia - a digital platform for imparting MHE to the Indian audience via its website and comic - to understand the information exchange practices on its website, the education it aims to provide, and the perceptions of its users. We further critically engage with the feminist Human-Computer Interaction (HCI) lens to analyze Menstrupedia’s affordances and shortcomings. Based on our findings, we propose design recommendations for culturally-responsive technologies aimed at dissemination of MHE and education about other stigmatized health topics in India.

Methodology

MENSTRUPEDIA WEBSITE

The website has 4 main segments: a quick guide, a comic section, a Q&A forum, and a blog. For our research, we studied the quick guide (LEARN section) and Q&A forum (ASK section) in detail

ASK section

About the section

Allows registered users to post queries and answers.
Posts are all public.
Users can use pseudonyms as their screen names.
Questions have tags such as "irregular", "prepone periods", "delay periods", "pregnancy", etc.

collected data

Collected the title, content, date of post, number of views, number of responses, author name, and tags for each question asked until January 31, 2018.
Information for 226 questions collected.
3 redundant questions discarded, remaining 223 questions formed the database.
9 more questions discarded due to lack of consensus on topic coding, leaving 214 questions.

codebook

Codebook categories are:
- Menstrual health (165)
  - Irregularity
  - Sex, menses, pregnancy
  - Medical issues
  - Hygiene & management
  - Myths & taboos
  - Controlling menses
  - Pills & menses
  - Education
  - Basic physiology
- Other questions (49)
  - Masturbation
  - Male physiology
  - Pregnancy
  - Contraception
  - Miscellaneous
Only questions pertaining to menstrual health analyzed.

THEMATIC ANALYSIS

Two-level analysis
First-level:
- Informational questions
  - Second-level:
    - Recommendation / opinion (subjective)
    - Fact-based knowledge (objective)
- Conversational questions

LEARN section

This section provides educational information in small paragraphs along with colorful graphics on puberty, menstruation, myths, and hygiene. To check if the content was comprehensive, by examining the facets covered and the extent to which they were discussed, We performed deductive content analysis using a tailored version of the coding scheme used for analyzing the ASK section to examine how comprehensive the content given here was. The deductive analysis categories are:

Education
Hygiene and management
Myths and taboo
Basic physiology
Medical issues
Irregularity
Menses & reproductive health

We also evaluated the content and supporting graphics using the Feminist HCI lens.

MENSTRUPEDIA COMIC

Content Analysis

We analyzed the graphics and text in the Hindi and English versions of the comic using the Feminist HCI lens. We also conducted deductive content analysis using the codebook created for analyzing the LEARN section.

Reading Session

We conducted comic reading sessions with 20 adults (10 male, 10 female) to understand how young adults respond to Menstrupedia’s approach to MHE. These sessions were conducted in public and private settings, to study the impact of the surroundings on the participants’ reading of the comic book.

think-aloud session

Lasted for 30 min on an average
Participants are given the choice of reading the Hindi or English version of the comic
Participants verbalize what they are doing and thinking as they read the comic

cHAPTER-wise questions

4 chapters in the comic
Asked participants the following questions after each chapter:
- What they liked,
- What they disliked
- If they learned something new
- Comfort with overall chapter

post-session

interview

Lasted for 10 min on an average
Semi-structured
Questions:
- 3 things they liked
- 3 things they disliked
- If they learned something new
- Would they feel comfortable reading the comic in a public space
- Would they like to include a male character
- Would they recommend the comic to:
  - a young girl (9-14 years old)
  - an "adult" girl
  - an "adult" boy
- After reading the comic, are they less afraid of talking about MHE with others

follow-up survey

Asked participants to fill out a survey of 9 questions:
- 7 demographic questions
- 1 rating question regarding their preference of media for receiving MHE. Media options:
  - Comic book
  - E-book
  - Mobile app
  - Video
  - Game
  - Website
  - Internet forum
  - Science textbook
  - Other (eg. newspaper, talk to parents, teacher, friends)
- 1 checklist of emotions about their experience of with the comic

Key Findings

Online Participation: Information Solicited and Revealed

Who are the users?

Menstrupedia allows only registered members to post questions, revealing their screen-names, profile pictures, and timestamps for posts.
96% of users did not use a profile picture
Almost 5% of users had “anonymous” as their screen-name
61% of users used a pseudonym (as far as we could tell)
From self-reported data of users in the text:
- 69% of the questions were posted by female participants &15% by male participants
- 26% of users explicitly mentioned their ages (minimum 14, maximum 52, median 22)
- Approximately 5% of the questions were about the well-being of the user’s daughter, mother, sister, friend, wife, or sexual partner
Thus, the Menstrupedia platform is not used by women alone; an ecology of actors participate.

What did they ask?

MENSTRUAL-HEALTH RELATED

165

IRREGULARITY

17.29 %

“I am a girl of 16 Its been 40 days since my last periods. What’s the reason for it?” (Q75)

SEX, MENSES, PREGNANCY

16.82 %

“We had sex 4 days before her periods date and aftet ipill consumtion she did not have period for december. do you think we should worry about pregnancy.” (Q91)

MEDICAL ISSUES

12.62 %

“Continual white discharge through out the month before and after the periods, feeling so discomfort.” (Q8)

HYGIENE & MANAGEMENT

11.21 %

MYTHS & TABOOS

4.67 %

CONTROLLING MENSES

4.67 %

“Is there protection that works best for extreme sports?” (Q118)

“Why is it not allowed to have head bath during 1st 2 days of menstruation?” (Q37)

“What is the process to get periods before my periods time? ” (Q21)

PILLS & MENSES

3.74 %

“Does intake of Heavy Antibiotics affects Menstrual Cycle?” (Q11)

EDUCATION

3.27 %

BASIC PHYSIOLOGY

2.80 %

“What is the appropriate age to educate young girls about periods?” (Q158)

What are the causes of delayed onset of menses in a 16 yr old girl?” (Q156)

INFORMATIONAL

82.42 %

“During periods, my stomach and hip pains a lot. I feel very tired. I feel like my head is rounding. Because of this i miss my school. What to do?” (Q14)

RECOMMENDATION / OPINION

52.94 %

FACT-BASED

46.32 %

“I usually get abdominal cramps during the first two days of my periods! is it normal? why do we get it anyways?” (Q110)

CONVERSATIONAL

17.58 %

“Why shouldn’t a girl go to the temple during her periods?” (Q164)

Menstrupedia Comic: Information Provided and Participant's Response

Friendly Format

The characters in the comic were widely appreciated
Participants were comfortable engaging with instructional content delivered by a doctor figure (the older sister) in the comic
The chosen characters enhance the perception of the comic as a legitimate source of information
Specific aspects of the comic such as the warnings regarding when to consult a doctor were appreciated

Boundaries of Comfort

Participants found most visual representations and diagrams in the comic appropriate except the visuals below, affirming the lack of comfort around taboo topics
Approximately 70% of male participants and 40% of female participants indicated their discomfort in reading the comic in crowded public spaces because they felt they would be judged
Participants indicated that covering the comic would not solve the problem, it is the content and illustrations inside that would make them uncomfortable

Instructional

Reviews of the comic also indicated that it was a good and much-needed initiative, affirming its instructional value
Around 80% (62/77) of user reviews praised Menstrupedia’s efforts using expressions
Some raised concerns around the length of the comic, saying that 88 pages were too “stretched” and “dragged” and impacted their engagement
All the female participants found the last chapter to be the most informative and the 3rd chapter to be redundant
Most female participants felt curious while reading the comic while fewer boys reported having felt curious

Engaging the Non-Menstruating Sex

All the lead characters and most supporting characters (including the pet dog) were female, supporting the stereotype that menstruation is a “girl's thing”
The only male characters in the comic have a visual presence but do not speak even during critical points in the narrative
17 out of 20 participants believed that including a male lead character would be a compelling way to have a male perspective on menstruation and help male readers relate better to the content. This could sensitize male readers, informing them of ways in which they can provide support to the menstruating sex.

The Menstrupedia Platform: A Multi-Faceted Approach for Delivering MHE

Access to Menstrupedia

The Menstrupedia platform provides support for both online (website) and offline (comic) information delivery
The comic is available in English, Hindi, and nine regional Indian languages
However, there are some issues:
- Cost of the comic ($4.5 to $6) is unaffordable for many across rural India having low monthly per capita consumer expenditure
- The books can only be ordered online, also limiting access
- The content has merely been translated across languages without an accompanying change in cultural expression

Disparities and Inadequacies of Content

The comic does not mention any digital means (e.g., mobile tracking applications) that are now available for tracking
The comic only covers sanitary napkins and cloth pads, leaving out other products, such as tampons and menstrual cups
Information about infections or diseases related to menstrual health is missing on both the website and in the comic.
- Pre-menstrual syndrome (PMS) is discussed in the comic but is missing from the website
- Information about Polycystic Ovarian Syndrome/Disease (PCOS/PCOD), urinary tract infection, cervical cancer, and toxic shock syndrome is absent

Digital vs Material

Majority of the participants preferred comics because:
- The tangibility of a comic would bring them to reflect more on the topic and stay committed
- The comic eliminated the possibility of getting distracted easily, which is what could happen on digital platforms

Participants saw value in seeking answers to specific personalized queries on internet fora
Different modes of engaging with MHE offer insights for designing different kinds of interactions
- Comics offered the opportunity to learn in an engaging manner, without distractions
- Websites offered quick look-ups when in an information-seeking mode

Engaging Feminist HCI

Encouraging Active Participation

A one-size-fits-all use of the platform, which offers the same information to all its users, may hurt some of the sensibilities on account of explicit questions
Users could highlight lines of text or clap several times or could add question marks if they wished for greater detail

Taking a Holistic Approach

Ecological approach - to foster open and respectful information exchange across peers, medical experts, family members, teachers, and society as a whole
Technology design should focus on supporting, leveraging, and extending human communication; a human must be in control of the information being accessed and consumed

Embracing Different Backgrounds

Pluralism - address many more types of differences, beyond age and gender, present among the target audience such as literacy and cultural background
Self Disclosure - recognize deeply divergent backgrounds of users and allow every user to achieve a personalized and effective interaction
Granting users the opportunity to clearly convey what information they are ready for and no more.

Embodiment - begin with visuals that are less explicit, with the goal of having adolescents physically engage with their bodies to better understand how these are impacted by menstruation
Make the design more pluralistic by showing respect towards the sensibilities and constraints of the user, even if these are projected onto him/her by the environment

Engaging with the Body

Fostering Advocacy

How much must design abide by societal norms to gain adoption and approval, and how far might it push these boundaries?
Generating both short- and long-term goals for designers, and ensure that users are in the right place at the right time to engage with the right design for them

Participation

Pluralism

Self Disclosure

Advocacy

Ecology

Embodiment

Publications

Screen Shot 2019-11-22 at 21.24_edited.j

Learning from and with Menstrupedia: Towards Menstrual Health Education in India

Author: Anupriya Tuli, Shaan Chopra, Neha Kumar, Pushpendra Singh

Venue: Conference on Computer-Supported Cooperative Work & Social Computing (CSCW) 2018.

Study 2 - Safe Spaces for Menstruation

COMING SOON!

Menstrual (Im)Mobilities and Safe Spaces

Author: Anupriya Tuli, Shaan Chopra, Pushpendra Singh, Neha Kumar

Venue: Conference on Human Factors in Computing Systems (CHI) 2020.

More Information Coming Soon!

SHAAN | Research & Design