Measuring the Effectiveness of Communication Programming on Menstrual Health and Hygiene Management (MHM) Social Norms among Adolescent Girls in India

"...SBCC interventions focused on addressing norms around taboo topics have the potential to increase the uptake of positive, progressive social norms."

In rural India, menstruating women are considered unclean and thus may be excluded from participating in certain daily activities and cultural and religious practices. Such stigma creates negative attitudes and social norms. Implemented by the United Nations Children's Fund (UNICEF) and local non-governmental organisations (NGOs) in Uttar Pradesh, India, the GARIMA initiative aimed at breaking the culture of silence around menstruation at the individual and community levels by addressing underlying social norms framing menstruation as taboo. This paper examines whether GARIMA's social and behaviour change communication (SBCC) approach creates more positive social norms that will improve desired menstrual health and hygiene management (MHM) behaviours. It also compares two different ways of measuring social norms.

In brief, GARIMA (described elsewhere - see Source section below) focused on: (i) behaviour change - by addressing knowledge, attitudes, and practices through multi-media channels, with the individual as the primary audience, and (ii) social change - by transforming power within social and political institutions, with the community as the unit of change. It centred around audio-visual, print media, and life-skills-based activities in groups and one on one. GARIMA was ground-up, in that adolescent girls could choose which topics they wanted to discuss based on local customs and contexts. The initiative utilised ideation as its conceptual basis, whereby interventions are thought to address social and behaviour change directly and also have an indirect impact by improving intermediate variables, including social norms.

This study used a cross-sectional, case-comparison design. Data were collected in 2018 from three districts where the GARIMA initiative had been implemented: Mirzapur, Jaunpur, and Sonebhadra. For the study, interviews were conducted (n = 2,212) among post-menarche adolescent girls (1,132 in intervention villages and 1,080 in comparison villages) between the ages of 12-19 years. Social norms were operationalised in two ways:

1. A composite measure that focuses on personal beliefs and perceptions of practice of desired MHM behaviours - Questions pertaining to injunctive and descriptive norms revolved around eight MHM behaviours: using sanitary pads, using cloth, using dry cloth in the sun after washing with soap, disposing of absorbents by burning or burying, attending school, demanding iron-rich foods, demanding a private place to bathe, and interacting with boys. Respondents were asked to specify if they themselves approved of the desired behaviours and about their perceptions of approval and practice among other adolescent girls in their community. Injunctive norms around each behaviour were operationalised as 0 (disapprove) or 1 (approve); descriptive norms were operationalised as 0 (not practicing) or 1 (practicing).
2. A measure based on social restrictions - Respondents were asked to self-identify restrictions on their daily lives during menstruation and then classify them as either personal, structural, or social restrictions. This operationalisation is based on the justification that restrictions are dependent on prevailing negative taboos and social norms around menstruation. Respondents identified restrictions around four areas: clothing, food, mobility, and social/religious activities. The responses were then categorised as things they "cannot do", "will not do", or "should not do"; this manuscript focuses on the restrictions that respondents identified as the latter.

Selected findings:

• Significantly more respondents in intervention villages reported positive perceptions that other adolescent girls like themselves in their community approved of (45.05% vs 22.69%) and practiced (31.54% vs 16.39%) all eight desired behaviours surrounding MHM - indicating higher levels of positive injunctive and descriptive norms among intervention girls.
• Adolescent girls in the intervention group had more positive social norms (43.99% versus 21.11%), and those reporting positive social norms had 1.66 (95% confidence interval (CI): 1.33-2.09) times greater odds of being in the "high" MHM practice group.
• Overall, intervention girls reported significantly more social restrictions (54.68%) versus comparison girls (40.83%). However, in intervention villages, a significantly higher proportion of respondents reported they challenge these restrictions (e.g., participating in forbidden social/religious activities - 5.87% vs 2.56%). Furthermore, intervention respondents characterised these restrictions as being socially imposed in significantly higher numbers than comparison respondents. One possible explanation is that participation in GARIMA allowed adolescent girls to question their reasons for not doing certain activities during menstruation, whereas girls in comparison villages were more likely report following the restrictions because of tradition ("that is how it has always been done" and "that is just how things are"), suggesting they had internalised the restrictions.
• The composite measure (#1, above) had a better model fit with MHM practice in comparison to the socially imposed restriction model, suggesting that social norms should be examined as a multidimensional construct with a two-way relationship between personal beliefs and injunctive and descriptive norms.

Thus, this study finds evidence that interventions that address harmful traditional practices, such as MHM, can have an impact if they highlight the normative dimensions of these practices (i.e., foster the realisation that MHM restrictions are a function of social norms) and address misconceptions about prevalence (descriptive norms), while also aligning personal beliefs and social expectations (injunctive norms) around adequate MHM.

In conclusion: "The results provide preliminary evidence that SBCC interventions like GARIMA can encourage marginalised adolescent girls to adopt positive social norms around MHM, hence paving the way for social change. The fact that adoption of positive social norms was significantly associated with high MHM practice suggests that SBCC interventions can promote positive social norms as a mechanism to increase adequate MHM behaviour."