The Lived Experience of Menarche in Nepalese

Home , Acculturation, Nepalese Americans

THE LIVED EXPERIENCE OF MENARCHE IN NEPALESE

ADOLESCENTS: A PHENOMENOLOGICAL STUDY

______

A Thesis

Presented

To the Faculty of

California State University, Chico

______

In Partial Fulfillment

of the Requirements for the Degree

Master of Science

Nursing

______

Fall 2011

THE LIVED EXPERIENCE OF MENARCHE IN NEPALESE

ADOLESCENTS: A PHENOMENOLOGICAL STUDY

A Thesis

Sita Devkota

Fall 2011

APPROVED BY THE DEAN OF GRADUATE STUDIES AND VICE PROVOST FOR RESEARCH:

Eun K. Park, Ph.D.

APPROVED BY THE GRADUATE ADVISORY COMMITTEE:

Irene S. Morgan, Ph.D. Jennifer Lillibridge, Ph.D., Chair Graduate Coordinator

Janelle Gardner, Ph.D.

PUBLICATION RIGHTS

No portion of this thesis may be reprinted or reproduced in any manner unacceptable to the usual copyright restrictions without the written permission of the author.

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ACKNOWLEDGMENTS

First of all, I would like to thank the girls who were willing to participate in my study and give me the time to interview them.

I want to acknowledge and thank my research chair, Professor Jennifer

Lillibridge, who gave me the time whenever I needed it. She even gave me time on her weekends and vacations. I cannot imagine completing my thesis without her great cooperation and assistance.

I would also like to thank Professor Irene S. Morgan, Professor Dr. Janelle

Gardner, and Kristine D Warner for their cooperation and help. They always encouraged me to complete my study. I also want to thank Susan Larson, who edited my writing from the beginning to the very end of my thesis.

I am very thankful for my three kids and my husband. They have always supported me even when I could not help them with the housework. My husband took me wherever I needed to go during this study. Without their support and cooperation, I do not think I could have completed my study.

TABLE OF CONTENTS

PAGE

Publication Rights ...... iii

Acknowledgments...... iv

Abstract ...... viii

CHAPTER

I. Introduction ...... 1

Background of the Problem ...... 6 Problem Statement ...... 9 Relevance to Nursing ...... 10 Theoretical/Conceptual Framework ...... 13 Purpose of the Research ...... 15 Research Question ...... 16 Operational Definitions of terms ...... 16 Qualification of the Researcher ...... 16 Summary ...... 17 Transitional Statements ...... 17

II. Review of Literature ...... 18

Menarche and Adolescent Transition Globally ...... 19 International Views on Menarche and Menstruation ...... 23 Menarche, Menstruation, and Ritual ...... 29 Nutrition and its Relation to Menstrual Health ...... 32 Leininger’s Sunrise Model ...... 36 Summary ...... 37 Transitional Statement ...... 38

CHAPTER PAGE

III. Methodology ...... 39

Research Methodology ...... 39 Underpinnings Informing the Methodology ...... 41 Sample Characteristics ...... 42 Sampling Process ...... 42 Sample Access ...... 42 Ethical Considerations: Human Subjects Protection ...... 43 Specific Method(s) for Data Collection ...... 44 Process for Data Analysis ...... 45 Process to Establish Rigor ...... 47 Summary ...... 49 Transitional Statement ...... 50

IV. Results ...... 51

Emotional Roller Coaster about First Menstrual Period ...... 52 Dealing with Negativity while Trying to be True to Cultural Values ...... 53 Trying to Balance the Differences Between Traditional and Modern Customs ...... 56 Cultural Confusion: Mixed Messages from Friends/Family/and Elders ...... 57 Rationale Behind Cultural Taboos do not Help Lessen Confusion or Pain ...... 59 Information Mismatch between Nepal and the U.S...... 60 Looking Forward: Challenging the Older Ways ...... 62 Summary ...... 63 Transitional Statement ...... 64

V. Discussion ...... 65

Emotional Effects...... 66 Negativity ...... 67 Modernization vs. Traditional Practices ...... 68 Confusion ...... 70 Rationalization ...... 71 Comparison of source of Sexual Information in Two Countries ...... 71 Cultural Modification...... 72 Limitations of the Study...... 73

CHAPTER PAGE

Implications of the Study ...... 74 Implications for Practice ...... 74 Implications for Research ...... 75 Implications of Education ...... 75 Summary, Conclusions, and Recommendations ...... 76

References ...... 78

Appendices A. Assent Form for the Participant ...... 91 B. Parent Consent Form...... 94 C. Human Subjects ...... 97 D. Significant Statements, Formulated Meanings and Themes ...... 99

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ABSTRACT

THE LIVED EXPERIENCE OF MENARCHE IN NEPALESE

ADOLESCENTS: A PHENOMENOLOGICAL STUDY

Master of Nursing

California State University, Chico

Fall 2011

This phenomenological study explored the lived experience of adolescents residing in Northern California, between the ages of 13 and 16 years, regarding their first cycle and other menstrual cycles. The purpose of this study was to explore the lived experience of cultural practices regarding menstrual cycles and menarche. The study was guided by Leininger’s Transcultural Nursing Model. The interviews took place in each girl’s own house after the researcher received signed consent from parents and assent from the participants.

Research question: What is the lived experience of immigrant Nepalese adolescent females with traditional Nepalese rituals related to menarche and the menstrual cycle?

Findings: The themes from this study are: 1) emotional roller coaster about first menstrual period, 2) dealing with negativity while trying to be true to cultural values,

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3) trying to balance the differences between traditional and modern customs, 4) cultural confusion: mixed messages from friends/family/elders, 5) rationale behind cultural taboos does not help lessen the confusion or pain, 6) information mismatch between Nepal and the U.S., and 7) looking forward: challenging the older way. Three of four girls expressed that they were scared when they had their first menstrual cycle. Two of four girls, upon beginning their menstrual cycle, were kept in a dark room for twelve days; they reported missing their classes for several days, which made it hard for them to catch up in their studies. The other two girls did not have to stay in a dark room for twelve days because they had their first menstrual cycle in the U.S.; their parents had modified their family’s cultural practices related with the first menstrual cycles and other menstrual cycles, in the absence of the older generation. Girls who had their menstrual cycle in Nepal reported that they could not afford pads and had to use pieces of cloth for management of menstrual product.

Conclusion and recommendations: This study recommends adding a sex education curriculum in Nepalese schools to provide detailed information about growth and development of puberty, as well as management of the menstrual cycle and menarche. Education for parents and grandparents is crucial in order to modify strict cultural practices regarding the first menstrual cycle and subsequent menstrual cycles.

CHAPTER I

INTRODUCTION

Nepal’s many distinct cultures share a characteristic that is consistent throughout the country: a set of cultural taboos and practices regarding menarche and menstruation. Although the monthly cycle is a normal occurrence for every female, taboos and traditional superstitions can change this natural process into a situation marked by severe health problems. The taboos surrounding menarche and menstruation lead girls to face difficult conditions, including severe infection and even death. Kandel, Rajbhandar, and

Lamichanne (n.d.) reported that during menarche and the menstrual cycle, females often live in dirty, unheated cattle sheds. Menstruating women are considered impure and unclean. Even though this cultural belief was not based in logic or science, it persists, continuing to be harmful for women and society in general. As menstruation is a normal physical process, from a healthcare perspective, it should be considered normal women experiencing menstruation have the right to be treated as normal. This study explored aspects of Nepalese adolescents’ experiences of menarche and the menstrual cycle from a phenomenological perspective. The target population of the study was Nepalese adolescents between 13 and16 years of age who resided in Northern California and experienced menarche in Nepal or in the U.S.

The problems associated with the onset of menstruation and puberty among

Nepalese girls can be mitigated—and their situation improved—with the intervention of

1 2 nurses. Nurses can play a major role in modifying the health risks associated with menstruation by teaching girls to dry their menstrual cloths in sunlight or use a hot iron to press the cloths, thus killing bacteria in a primitive but effective manner. While they are teaching proper hygiene, nurses can also educate adolescent girls and their families about the changes that puberty will bring. Overall, nurses can help adolescents adjust to puberty, providing proper information regarding puberty and allowing clear approaches to positively experience this developmental stage, along with related cultural practices within their community.

Menarche is defined as a girl’s first menstrual cycle. A girl undergoing menarche in Nepal experiences a traditional practice known as “gupha ,” which literally means “tunnel.” When menarche occurs, a girl will be kept in a dark room for twelve days, with the windows closed to “protect her” from sunlight, as though she were in a tunnel. During this period, the girl will not be allowed to see a man’s face or sunlight, although female relatives and friends can visit her. On the twelfth day, the girl leaves the room and takes part in an adoration of the sun. A United Nations (2006) report supported this occurrence, stating: “Nepali girls at menarche tend to be isolated in a dark room or, as reported, even in cow sheds, and not permitted to be seen by males, including male members of the family, or to be exposed to sunlight even in urban households” (p. 39).

Puberty or adolescence, a period of transition from girlhood to womanhood (Kirk &

Sommer, 2006), can be very challenging, regardless of the imposition of local cultural practices such as gupha . Girls in menarche require support from their families. As menarche is an indication of the development of a girl’s sexual organs, the smooth

3 transition from childhood to womanhood necessitates educating girls about the normal phenomena of puberty and management of menarche. The study by Kirk and Sommer reported that Nepalese girls noted menstruation was a taboo subject, even within their own families, describing a “culture of silence” with regard to their menstruation. The girls felt unable to discuss menstrual issues with their mothers, and certainly not with their fathers. Being unable to talk about their experience and having limited information, the girls treat menstruation as a shameful area of their lives.

Unfortunately, there remains a lack of information about Nepalese girls’ experience of menarche. For this reason, the researcher wanted to obtain crucial information regarding the experience of menarche among Nepalese immigrants residing in the U.S.

While immigrant Nepalese girls may or may not have issues in common with their coun- terparts in their native country, the literature indicates that most Nepalese immigrants practice their own culture, even if they have settled in the U.S. Below are some examples of how Nepalese and Indians maintain their own cultural identity after immigrating to the

U.S. Early marriage, one of these cultural practices, can have a negative influence on girls’ physical and emotional health.

Petkova (2007) observed that the Nepalese preserve the essence of their own culture by retaining their values. Petkova underscored this by providing an example of one Nepalese girl’s experience:

I didn’t know anything about dating, because I grew up in a Nepali culture. Going to school here was very difficult. For me the most shocking was that kids my age had sex. I always knew that sex is done only after marriage. And the Americans talk about everything, even in school there is health education where they teach you about sex. I am Nepali and I won’t do sex before my

4 marriage. But I don’t understand why we don’t talk on this topic. In my family we have never done it and I don’t think it is a good thing. (p. 16)

Petkova depicted another Nepalese girl’s experience as follows:

In her speech the informant from Nepal actually unites two cultural traditions. On the one hand, she follows the Nepalese pre-marriage customs but on the other hand, she is doing it in the “American way”: she talks openly about things that are not allowed to be spoken in her culture. Thus she has obviously preserved the essence of her cultural identity reflected in the native values, beliefs and attitudes upheld but simultaneously she has changed its expression or the modes by which these values, beliefs and attitudes are represented. (p. 16)

Miller (2007, para. 12) explained that “many Nepalese customs and beliefs are heavily influenced by Buddhist or Hindu values.” Oryana (2008) described Sikh immigrants who have left India for the U.S. but retain their cultural identity. A similar finding was presented by Hine-St. Hilaire (2008), who focused on West Indians who have emigrated from India and maintain their cultural practices in the U.S. Neighboring countries

Nepal and India share many important cultural practices. “Many Nepalese-American women continue to wear the Tika, a red sandalwood dot pasted on the forehead, as an indication of marriage” (para 12). As Miller (2007) explained, most Nepalese continue to practice their own culture in the U.S., celebrating religion much as they did in Nepal.

Additionally, their family structures are often the same in both settings; while they can enjoy the benefits of diversity and improved resources in America, they maintain a similar (or identical) lifestyle to the one they led in Nepal.

Oryana (2008) reported that the Sikh community is self-employed and they are autonomous. They keep their religious, cultural, and familial ties. The Sikhs observed in this study were self-employed in order to observe their religious festivals. According to

5 Oryana, the Sikh community keeps its own cultural practices intact, even though they have moved to another part of the world as demonstrated by this quote:

Councillor Keith Rhoades, the mayor of Coffs Harbour City Council, which incorporates Woolgoolga, says the Sikh community has always been a positive influence on the region. . . . Agriculture maintains a key role in the econ- omy of the area and the Sikh community has been instrumental in its growth and development, . . . Keith says. . . . Coffs Harbour is rightly proud of the Sikh culture and the unique influence it has had on Woolgoolga and the wider area . . . (Oryana, para 7)

Hine-St. Hilaire (2008) stated that West Indians wish to “maintain ties with their countries and strengthen their cultural awareness” (p. 55). They live a communal life in which they respect their elders and cooperate with others. West Indian adolescents are proud of their heritage, carrying items that represent their identity and culture. A significant example of their cultural ties occurs during the West Indian Parade Day event in Northern

California. Hind-Hilaire reported that, “as I see in my practice, most West Indian immigrant parents encourage their children to preserve their culture” (p.57). He goes on:

The general belief is that there are more people to care for them, the environment is safer, and the children can learn to live by West Indian values, described as “learning to live a community life,” “to respect elders,” and to “cooperate with others” (cited in Justus, 1976). Attachment to their native country, culture, customs, and norms provides a structure in which adolescents and their families can operate . . . . The second-generation West Indian adolescents that I have seen in my practice show a strong identification with their culture. (Hine-St. Hilaire, p. 57)

Examples such as those above show that other Asian or non-U.S. immigrant populations within the U.S. utilize their cultural associations (often through festivals and religious observance) to maintain strong ties to their native traditions. Although research regarding

Nepalese-Americans’ affiliation to their own culture is currently not available, the observations of the Sikh and East Indian communities in the U.S. indicate the preservation of

6 the immigrant groups’ own culture and traditions. Having contacted several Nepalese

Americans in Northern California, the researcher (herself a Nepalese-American) has personally observed practices that preserve the essence of Nepalese culture, including the population’s national identity, in parallel with the observations of the Sikh and West

Indian communities’ practices. Based on these observations, the researcher believes that the groups of Nepalese-American adolescents show a similarity of practice to those adolescents found in Nepal.

Background of the Problem

Adolescence is one of the most fascinating and complex transitions in the life span. Its breathtaking pace of growth and change is second only to that of infancy. Bio- logical processes drive many aspects of this growth and development, with the onset of puberty marking the passage from childhood to adolescence. Puberty is a transitional period between childhood and adulthood, during which a growth spurt occurs, secondary sexual characteristics appear, fertility is achieved, and profound psychological changes take place. Although the sequence of pubertal changes is relatively predictable, the timing is extremely variable. The normal range of onset is ages 8 to 14 in females (The National

Academies Press, 1999). A British study showed the average age of menarche is 12.83 to

13.47; similarly, other European studies showed onset of menarche to be 12.55 to 13.47 years (Rubin et al., 2009). While adolescence represents a period of increased vulnerabil- ity, it is also a life stage where growth and physical development occur at a faster pace than any other time in an individual’s life. Both humans and primates experience accele- rated physical and mental development during this time, universally exhibiting advanced

7 behavior in recognizable areas and tasks. Adolescence is the period of physical and sexual maturation, acquisition of the skills necessary to carry out adult roles, early individuation from one’s parents, and the development of peer relationships with members of one’s age cohort (National Academies Press).

Early marriage affects girls’ economic health because, in many cases, they must discontinue their education in order to take on family responsibilities. Girls married at a young age often experience life as prisoners:

Rape, beatings and other forms of sexual and domestic violence are common, and early and repeated pregnancies are life-threatening . . . . The damage to a girl’s reproductive organs that results from forced intercourse and early child- bearing makes her far more susceptible to HIV and other diseases. The girls’ economic health suffers as well. (Warner, 2004, p. 240)

There are many reasons attention should be paid to the health of adolescents.

The most important of these is the present challenge of reducing death and disease in young people. The World Health Organization (WHO, 2002a) reported that each year the global mortality rate of young people aged 10 to 19 is 1.7 million; these deaths are mostly the result of accidents, violence, and pregnancy-related problems or illnesses, all of which are either preventable or treatable (WHO).

Adolescent health should also concern the healthcare community because of its impact on the future: the adolescents of today represent future community leaders, parents, teachers, and citizens. As the next generation of children grows into adulthood, their well-being will become the bellwether for civic policy, national and international decision-making, and the general health of global societies and individuals. Seeking ways to improve adolescent health will help reduce the burden of disease in later life and

8 addressing problems (such as nutrition and pregnancy concerns) will mitigate a host of health problems that can affect individuals throughout their lives.

The situation of pre-pubescent and adolescent girls in Nepal reflects a wider, in many cases global, predicament for the young female population. The risk factors involved with growing up in tribal communities (such as those found in rural Nepal)— including early pregnancy, unwanted pregnancy, drug use and smoking—are growing problems among adolescents throughout the world. In Nepal, adolescents aged 10 to 19 years constitute almost one-fourth, 6.3 million (22.9%) of the total population, and those females aged 10 to 19 years constitute 50.0% of the aged 10-19 total population (WHO,

2007). Schroeder (2004) described Nepalese arranged marriages as common, with 16 being the average age of marriage for girls.

Another factor, nutrition, has a significant effect on girls before and during puberty. This situation aggravates other risks to young women, as poor nutrition in girls can delay the onset of puberty and may also lead to physical deformities such as a small pelvis and reduced height. Lack of proper nutrition can also lead to diseases such as ane- mia, malnutrition, and vitamin deficiencies. A global problem, poor nutrition in Nepal among pre-adolescent and adolescent girls is made worse where, in some regions within the country, girls are fed last and least. One documented result of this problem is night blindness in young girls, which is linked to a deficiency of Vitamin A (Christian et al.,

2000).

In general, girls require support from family and friends as they begin puberty.

School nurses, midwifes, pediatric nurses, and public health nurses can support

9 adolescents by recognizing and managing the normal phenomenon of puberty. Addition- ally, adolescents are involved in risk-associated behavior, such as early and unprotected sex, may become infected with which often leads them to dangerous situations that can lead to infection from sexually transmitted diseases, including HIV/AIDS.

Problem Statement

In Nepal, when a girl begins menstruation for the first time, she is separated from her community and is not allowed to see light: Girls are secluded in a darkened section of the house and forbidden to look upon men and allowed to go outdoors only on a dark night. At the end of her bleeding, she reemerges and is taken around and shown the earth, water, flowers, and friends, as if seeing them for the first time. Girls are secluded in a darkened section of the house and forbidden to look upon men and allowed to go outdoors only on a dark night. At the end of the cloistering, the family and villagers celebrate with a feast (Kandel et al., n.d., p. 4.).

Many changes occur during the growth and development of a child and puberty represents one of the most critical changes. In Nepal, sex education is poor or absent in most communities’ school curricula. Cultural factors also create difficulty as the menstrual cycle is seen as a shameful topic of conversation. Adolescents will not discuss problems with their menstrual period, even if they suffer complications. Unable to receive timely help, adolescents descend into physical and mental stress, which this stress may also affect normal development of adolescents. In fact, most of the problems related to puberty are hidden, or at least not easily explicable in neutral terms that young people can understand.

10 The Ministry of Health and Population (2008) reported that women are more susceptible to HIV in rural areas of Nepal because of low education levels, the low social status of females, and the difficulties associated with asking a spouse to use condoms.

Data showed that 21% of low-risk women, both in rural and urban areas of Nepal, are

HIV-positive. This high incidence of HIV infection is due in large part to spouses returning from overseas migrant work where the spouse visited commercial sex workers and thereby became infected. His Majesty’s Government (2005) reported that 28% of adolescent girls never reach school. In Nepal, gender disparity among girls and boys is clearly shown; for example, 32% of males had no education, as compared to 60% of females without education (Demographic Health Survey, 2002). His Majesty’s Govern- ment reported a qualitative study in 11 districts of Nepal. According to the report, parents educated their sons better than daughters, and parents often kept daughters at home to assist in domestic work and to take care of younger siblings.

Timely counseling regarding the normal phenomena of puberty can often prevent negative consequences experienced through neglect or misbehavior of 14- to 16- year-old Nepalese immigrant girls in the Northern California. Due to a lack of research in

Nepal with regard to the experience of menarche in puberty, it remains a challenge to accurately depict the problems associated with puberty among Nepalese girls and women.

Relevance to Nursing

Bharadwaj and Patkar (2004) reported that in countries such as India, Nepal,

Bangladesh, and Pakistan, women have been taught that menstruating is shameful. Even though the menstrual flow is a natural, harmless, and a necessary physical process, girls and women are often made to feel that menstrual blood is dirty, smelly, and unclean, and

11 that they are to be shunned or isolated during their menstrual period. A 2006 Population

Report entitled “What Shape Women’s Attitudes about Bleeding Changes” found that menstrual blood is widely seen as a pollutant, “bad blood” that must be expelled from a women’s body.

Bharadwaj and Patker (2008) described the practice among Bangladeshi women of using a piece of old cloth or a rag at the time of their monthly cycle, even though this often causes infection due to a lack of water and soap for cleaning the cloth.

In addition, the women investigated for this study appeared to feel shame and embarrassment during their monthly cycle, seeking dark, hidden places to dry their cloths.

Bharadwaj and Patker presented anecdotes of tragic consequences when cultural practices interfere with hygiene:

A culture of shame and embarrassment forces women to seek well-hidden places even in their home to dry the rags. These are often damp, dark and un- healthy, leading to serious health risks from moldy cloths. In Bangladesh, Water Aid reports a case where a girl died after a harmful insect entered her body after landing on her rag as she left it to dry. (p. 4)

To prevent such fatal incidents, it is necessary to initiate proper education regarding the menstrual cycle and menstrual hygiene. Bharadwaj and Patker further reported that although a few societies celebrate “menarche,” a woman’s first cycle, menstruation is taboo in most countries. In many cultures menstruation is associated with uncleanness, which restricts the activity of women at these times. For example, in some regions of

Nepal, tradition forces menstruating women to live in separate huts and not participate in community life (Bharadwaj & Patker).

12 In Nepal, menstruation is called para-sarne , which translates in English as

“moving off a distance from [her] usual space.” Women are kept isolated from other people in this time, and when they menstruate they are not allowed to participate in wor- ship, sexual activity, or domestic work, and many other social functions. Belief in female

“ritual impurity” restricts women’s time spent pursuing normal activities within the community, a state of removal from society that can cause stress and alienation.

Nepal is a developing country with many diverse cultures. Different, often conflicting, practices such as restricting girls and women from normal activities make it harder for adolescents to adjust during menarche and menstruation while experiencing the physical and mental changes associated with puberty. As mentioned above, when pubescent Nepalese girls first experience menstruation (menarche, they are kept for twelve days in a dark room, forbidden from seeing the sun or being seen by men. It is a cultural belief that if a girl is seen by males at menarche, her life will be shortened. Girls miss school during this separation, thus hampering their education; they are also expected to stay away from their elders during menstruation. In addition, Nepalese girls are often not given practical information about the proper use of sanitary pads, and only those girls who can afford them can obtain these. Most girls in Nepal use cloth as sanitary pads, which they clean and dry in dark places where no one in the community can see them.

This practice is potentially harmful, since menstrual blood is a medium for bacteria, and darkness promotes bacterial growth. Pre-pubertal girls require knowledge to manage their body changes. Proper counseling is one of the best ways to assist pubertal girls to manage their new body with the changes they experience at the time of puberty. Nurses often

13 provide counseling services to help with problems associated with puberty. Comprehen- sion of specific information related to cultural taboos and practices in different cultures will assist nurses in their work as counselors to pre-pubertal and pubertal girls.

The problems associated with the onset of menstruation and puberty among

Nepalese girls can be mitigated—and their situation improved—with the intervention of nurses. Nurses can play a major role in modifying the health risks associated with menstruation by teaching girls to dry their menstrual cloths in sunlight or use a hot iron to press the cloths, thus sterilizing them in a primitive but effective manner. While nurses are teaching proper hygiene, they can also educate adolescent girls and their families about the changes that puberty will bring. Overall, nurses can help adolescents adjust to puberty, providing proper information regarding puberty and allowing clear approaches to positively experience this stage, along with related cultural practices within their community.

Theoretical/Conceptual Framework

The theoretical framework for this phenomenological study is guided by

Leininger’s Transcultural Nursing Model. According to this model, adolescent girls learn to adapt to their new physiological development. They need to adopt a role that is accept- able to the community, acknowledging that different cultural practices affect adolescents, while at the same time understanding that some simple habits should be taken in order to address basic hygiene and well-being (Leininger, 1991; Morgan, 2002).

According to Leininger’s Sunrise Model, cultural practices that are beneficial to a community should be adopted, while harmful practices should be modified.

14 Leininger (1991) stated that cultural blindness, shock, impositions, and ethnocentrism can create a situation of reduced quality in an individual’s care. To reverse the negative impact such characteristics of an ethnic group or its society can have on individuals’ health, the method of implementing culturally congruent care allows for the satisfaction of clients’ needs and helps them recover from illness, disease, or other health issues.

Cultural care preservation or maintenance takes the form of “assistive, supporting, facilit- ative, or enabling professional acts” (Leininger, p. 38). These actions, ideally, will help affected people to maintain their standing within a particular culture while ensuring their well-being and the recovery from illness. The essence of cultural care accommodations is the attempt to find ways to help individuals “to adapt to, or to negotiate with, a beneficial or satisfying health outcome with the professional care provider” (Leininiger, p. 48).

Indeed, Leininger’s description of “culture care repatterning or restructuring” provides a set of benchmarks for the professional care provider to assist patients adversely affected by their social milieu. Her model seeks to “reorder, change, or greatly modify [patients’] life-ways for new, different, and beneficial health care patterns while respecting [their] cultural values and beliefs and still providing beneficial or healthier life-ways than before the changes were co-established with the [patients]” (Leininger, p. 49).

Nepal presents a milieu where cultural beliefs are often at variance with the standards of modern healthcare; while some cultural practices are beneficial to adolescents, many others tend to harm adolescents’ health. One example of a healthy practice takes the form of traditional bathing practices associated with menstruation: according to custom in some regions of Nepal, girls and women are required to take a full bath and to

15 wash all linen they have used on the fourth day of their menstruation. This practice ensures a certain degree of cleanliness which is good for their health.

Other, harmful practices should be adapted or modified in order to maintain and promote the health of adolescents. For instance, while the “four-day rule” for washing is attended fairly diligently, females often do not change their clothes for the first four days of menstruation, even if their clothing is soiled. This habit, while acknowledged as part of the local custom, is harmful to the individual’s health; the chance of infection increases as a result of using soiled clothing for many days. The bathing custom should be modified in such a way that females are encouraged to change their garments and use clean sanitary pads as needed, a modification that will protect against infection as well as keep their clothes and sanitary pads clean throughout menstruation.

Beneficial practices should be encouraged; at the same time, potentially harmful aspects of traditions should be modified. In this way, existing positive behaviors can be augmented within the traditional framework of Nepalese society, in order to preserve the health and well-being of the female population. Such changes would have the greatest impact if implemented among adolescents in Nepal, so that their healthy practices will be passed on to succeeding generations.

Purpose of the Research

The purpose of this study was to explore the lived experience of cultural practices regarding menarche and the monthly cycle in Nepalese adolescent immigrants in

Northern California. As previous literature described, it can be assumed that most of

16 Nepalese immigrants’ cultural practices are the same in the U.S. as they had been in

Nepal, thereby identifying the need to study the immigrant population in the U.S.

Research Question

“What is the lived experience of immigrant Nepalese adolescent females with traditional Nepalese rituals related to menarche and the menstrual cycle?”

Operational Definitions of Terms

1. Puberty: Period of life a person body changes from child to an adult (American

Academy of Pediatrics, n.d.).

2. Menarche: Medical term for the first time menstruation occurs in girls

(Cornforth, 2008).

Qualification of the Researcher

The researcher is a native of Nepal; a registered nurse, she completed her RN course in her home country in 1978. She worked as a nursing instructor from 1978 to

2003, in the process earning her bachelor’s degree in Community Health nursing in 1981.

She visited Canada for a one-month observation tour at the expense of the Canadian

Government, in order to observe Canadian public health practices. In the course of her observation period, the researcher observed many pregnant teenagers undergoing mul- tiple health problems. All of these factors contributed to her interest in the health concerns of adolescents. The researcher completed the first year of her master’s program

(2002) in Nepal. The researcher is also a master of science, Nursing student of California

State University, Chico and had completed course work in nursing research and theory.

17 Summary

Puberty is a normal developmental stage. Specific cultural practices within a country or region often make the adolescent experience difficult, notwithstanding the fact that puberty is a normal developmental stage. Prepubescent girls in general require counseling regarding the onset of puberty, and it is widely acknowledged that appropriate counseling helps adolescent girls to manage their puberty. Nurses often serve in the role of counselor for problems related to girls’ puberty. The knowledge of cultural taboos within a specific cultural milieu can help guide the work of nurses who counsel adolescents. This research explored the cultural practices of Nepalese girls’ experience of menarche and the monthly cycle. It is hoped that this research will be helpful for nurses in addressing problems associated with puberty among the female population of Nepal and Nepalese immigrant populations or those adhering to traditional cultural practices in general.

Transitional Statements

In Chapter 2, the researcher will present more information about problems related to puberty as identified in the literature, in order to provide clear information salient to the facts of this study.

CHAPTER II

REVIEW OF LITERATURE

Nepal is a developing country with many diverse cultures. Taboos concerning menarche and menstruation affect the normal developmental health of adolescents in

Nepal. The cultural practice of restricting girls and women from daily activity during menstruation makes it harder for adolescents to adjust during a critical stage in their development. While the taboos and restrictions observed in Nepal are characteristic of practices observed in the Subcontinent, the problems these practices create are consistent with issues found throughout the world.

A literature review was conducted using resources available at the California

State University, Chico, library on CINAHL, Pub Med, and Academic Search databases as well as data available from google.com and yahoo.com searches. The main search key words/phrases used included “menarche related ritual in Nepal,” “pubertal health problems in Nepal,” “problems related to menstruation among adolescent girls,” “phenomenological study in adolescents,” and “cultural practice regarding monthly period.” These key phrases provided the basis for this literature review.

The literature review focused on cultural taboos related to menarche and menstruation, and on the health problems of pubertal girls in Nepal, as well as problems related to menarche and menstruation in Nepal among other Asian countries. A survey of the literature revealed that there are several countries practicing cultural taboos, which

18 19 makes it hard for adolescent girls and females to adjust to their daily activities. The literature showed that adolescent girls faced many physical and mental problems originating from taboos concerned with menstruation. The review of literature is organized around the following topics: menarche and adolescent transition; international views on menarche and menstruation; menarche, menstruation, ritual, and nutrition; menstrual health in Nepal; and Leininger’s Sunrise Model.

Menarche and Adolescent Transition Globally

The second decade of life is a period of personal development, almost as rapid as the first. Ten-year-olds are still children, although many are already exposed to challenges from the adult world. By the age of 20, young people are contributing members of society, acquiring rights at a variety of ages: to marry, vote, drive, or fight for their country. Adolescents are no longer children, but not yet adults, and this period of change is full of paradox. Adolescents can seem old beyond their years but still need adult support.

They can put themselves at risk without thinking through the consequences, display optimism and curiosity, quickly followed by dismay and depression. Biologically, they can become mothers and fathers, without being ready for the responsibility. They feel a growing sense of independence but depend on adults for their material needs (WHO,

2002b).

With a population of over 23.2 million (Population Division, 2006), Nepal’s inhabitants are projected to increase by 65% by the year 2020. In Nepal, 24% of the female adolescents aged between 15 and 19 years are already mothers or are pregnant with their first child. The adolescent population—aged 10 to 19 years—constitutes 22%

20 of the total population (Pradhan & Strachan, 2003). Schroeder (2004) related that “nearly

30% of the country’s population is adolescents or teenagers” (p. 714). Adolescent girls are prone to exposure to violence, sexually transmitted diseases (including HIV/AIDS), and sex trafficking (Center for Research on Environment Health and Population Activi- ties [CREHPA], 2005). Key problem areas for adolescent girls in Nepal include early marriage, segregation during menstruation, malnutrition, reduced medical attention

(compared with other members of the household), and poor information (or misinforma- tion) related to the onset of puberty.

In some ethnicities within Nepal, girls are traditionally segregated at a non- family member’s home during their first three menstrual cycles; additionally, they are not allowed to see elder males during this period. Some ethnic groups also forbid females from performing their daily household work while they are menstruating (Population

Reports, 2006). Population Reports revealed the necessity of conducting a study to get more information related to menarche and menstrual periods in Nepal.

Although extensive research on young people’s needs and behaviors in Nepal is rare, existing data indicated that young people do not have adequate access to appropriate information and services about sexual and reproductive health issues. For example,

The Centre for Development and Population Activities-Nepal (CEDPA) (2004) study found that girls sampled in Lalitpur and Baglung reported the majority of adolescents in these districts were not receiving accurate information about the normal phenomena related to puberty. The study also indicated that these girls require better sources of information on this topic. Limited sex education is provided in schools. Sexual and

21 reproductive health are not topics openly discussed in families. Girls are in a particularly vulnerable position because they have less access to formal institutional structures (such as schools and healthcare systems) than boys, and are unlikely to be incorporated into or receive accurate information through informal communication networks. Furthermore, the design and delivery of appropriate services for adolescents has been constrained by long-held traditions, beliefs, and ideologies. As a result of inadequate or ineffective services and information, young female populations experience negative reproductive health consequences, including unplanned pregnancies and HIV/AIDS (Mathur, Mehta, &

Malhotra, 2004).

The World Health Organization (WHO) (2008) stated that one-fifth of the world’s population is adolescent. Of this number, 85% live in developing countries.

Further, WHO claimed that one-third of the total disease burden in adults is associated with a condition or behaviors that started at the adolescent stage; HIV infection is also increasing within this age group. WHO estimated that, in 2007, roughly 45% of new HIV infections occurred in those aged 15 to 24 years worldwide. Among those females aged

15 to 19, roughly 16 million give birth every year (WHO). In addition, WHO stated that, among the same age demographic, suicide is the second major cause of death in adolescents. These data indicated that timely promotion of healthy habits during adolescence may protect this age group and prolong a healthy and productive life.

Research in Pakistan showed that, on average, only 37% of girls received information about puberty prior to menarche. Puberty starts for girls at the age of 13.5 years in Pakistan (Marie Stopes International, 2006). One recent study demonstrated that

22 63% of girls in that country did not receive any information about menarche, leading to anxiety and fear at the time of menarche (Marie Stopes International). In a similar study performed by Sultana (2006), only 41% of girls were shown to have prior knowledge of the facts about puberty. In addition, Sultana stated that pubescent girls were unable to receive information about puberty from their parents, largely due to their mother’s illiteracy.

In particular, ethnic and racial differences in the initiation of sexual maturation are quite visible among females in the U.S. The sexual maturation rating (SMR:

Tanner stages of pubertal development [Stang & Story, 2005]), stage 2 (in females, breast buds, small mound, increased diameter of the areola) was found in 48% of African

American girls by the age of eight, as compared to 15% in White American girls. Simi- larly, initial breast development occurred at 8.8 years for African Americans and 9.9 years for Caucasians. Pubic hair development occurred at 8.7 years in African American girls, which is almost two years earlier than in Caucasians (Stang & Story, 2005).

Menarche occurred at approximately the same time in both groups—12.2 years for

African-Americans, 12.8 years for Caucasian girls (Stang & Story). Adolescent girls’ lean body mass increases by 44% and body fat by 120% during puberty.

The University of Maryland (2009) provided information that adolescent girls can develop breasts as early as eight years of age and breast development usually completed between age 12 and 18. Menarche usually starts from age 10 to 15; the average age of menarche in the U.S. is 12.5 years. Girls’ growth in height occurred at age of 9 or 10, and adult height was achieved between 13–14 years of age.

23 Chang and Chen (2008) conducted a study of 240 families consisting of post- adolescent girls, mothers, and grandmothers in Taichung City in central Taiwan. Data were collected from the subjects by questionnaire. The results of this study showed that age of menarche had declined by one year for each generation. The authors reported that this consecutive decreased age of menarche might reflect an increase in nutritional and health status. This descriptive study also indicated that pubertal girls needed to be prepared for menarche earlier than its initial onset.

International Views on Menarche and Menstruation

In addition to determining the age of onset of menarche, Chang and Chen

(2008) also sought information regarding problems of menarche and menstrual period; with the result that the obtained can serve as a factor in educating and improving the health of adolescent girls. This study result showed menstruation is a private matter and most of the girls were surprised with their menarche. They were worried about the lea- kage of menstrual blood through their clothes. This study also found that most of girls had a lack of knowledge regarding the menstrual cycle and menarche.

The CEDPA-Nepal (2004) conducted evaluation research after providing informal education about reproduction to adolescent girls aged 10 to 19 years. The base- line study was conducted in March 2003. This qualitative and quantitative study was conducted from Lalitpur (a southeastern district adjoining the Katmandu district) and

Baglung (in the Hilli region, located in northwestern Nepal). The quantitative approach applied to 352 adolescent girls using a structured interview from both districts. This study also conducted eight focus group discussions with the girls and their parents. It further

24 conducted 32 semi-structured interviews with community-based stakeholders (class management committee and village development committee coordination committee members). The study’s result showed that Lalitpur District girls reached menarche at an earlier age than those in Baglung: 42% of the girls in Lalitpur attained menarche at the age of 10 to 14, while only 18% of Baglung girls within the same age range attained menarche. It is postulated that the early menarche in Lalitpur was due to access to better nutrition

(CEDPA-Nepal).

The CEDPA-Nepal (2004) study found that 72% of the girls sampled in

Lalitpur and Baglung reported having received information about menarche from their mothers, followed by 49% who learned from friends, and 44% from their sisters. It was not explained in the report that adolescents could choose more than one answer, but since some answers received more that 100%, it is clear that some respondents chose more than one answer. Additionally, the study found that 33.5% of the Lalitpur girls and 21% of the girls from Baglung had acquired knowledge regarding menstruation from a project teacher. The majority of adolescents in these districts, therefore, were not receiving accurate information about normal phenomena related to puberty, and the study indicated that these girls require better sources of information on this topic (CEDPA-Nepal). This

CEDPA-Nepal data provided valuable information regarding the source of information given to adolescent girls, but it did not collect information regarding cultural taboos related to menarche and menstruation. This identifies a gap in information that requires further study.

25 According to Schroeder (2004), the ninth- and tenth-grade curriculum in

Nepal offers a course in reproductive health, but teachers were not trained in issues related to sexuality. They were, in effect, incapable of discussing the topic effectively with the young students in their classes. Schroeder further explained that some school teachers were not allowed time for in-class discussion; some teachers only lecture without engaging interactively their students through interaction. Schroeder provided survey reports stating that only one out of ten parents had actually discussed sexual topics with their children. Schroeder provided the following information regarding sexuality and menstruation in Nepal.

Research conducted by Engender Health and the International Center for

Research on Women (as cited in Schroeder, 2004) revealed that young people want to receive information about sexuality and reproductive health, particularly from their mothers, older sisters and brothers, and sisters-in-law. However, they say they do not feel comfortable approaching these individuals with their questions, nor do they feel confident that these identified family members would be comfortable or well equipped to answer.

Young people, in particular, have questions and concerns about the menstrual cycle, nocturnal emissions, and dealing with feelings of sexual arousal that are heightened during puberty. As a result, young people and adults alike are likely to ask questions of the local pharmacist—although concerns about confidentiality remain high. (Schroeder,

2008, p. 718)

Dhingra, Kumar, and Kour (2009) conducted a study with 200 adolescent girls, aged 13 to 15 years, from the Gujjar Tribe in Jammu and Kashmir (India). The

26 researchers collected data by interview. Out of 200 girls, 76 were 13 years old, 70 were

15 years old, and 54 were 14 years old. Age of menarche was reported as 10 to 12 years by 54.2%, while 45.8% reported the onset of menstruation at 13 to 15 years. Management of the menstrual period was described by 96.9% of the subjects as using dirty clothes that were not washed and dried properly. The remaining 3.1% reported using fresh cloths each time they changed. This study showed that none of the 200 girls had received complete information regarding menarche and menstruation. The girls were told by their parents (mostly their mothers) that menstruation is “necessary for every girl, as it was the removal of dirty blood from the body, otherwise a female would develop an infection or disease” (p. 46). Only 64% of the participants were aware of menstruation before menarche. Dhingra et al. provided further data on the source of education about menstruation: 83% of girls reported the source of information as friends, 10% movies, 6.5% relatives, 5% mothers, another 5% magazines, and 3% television (p. 46).

Dhingra et al. (2009) showed that, when the girls experienced menstruation, they were restricted from visiting religious places and from coming near water. All of the girls were told not to look in mirrors and to avoid regular baths. They were also restricted from brushing their teeth, washing, or combing their hair. The girls washed used cloths secretly and dried the cloths in a hidden place where nobody could see them.

Another study of education related to menstruation was conducted in an ultra-

Orthodox community. Zalcberg (2009) performed a phenomenological study of the ultra-

Orthodox Jewish society in Toldot Aharon Hasidim, Israel. The researcher collected data by participatory observation and in-depth interviews between 1997 and 2003. This study

27 involved 25 women aged between 25 to 60 years, using convenience and snowball sampling techniques. The researcher received information from school teachers who described education about menstruation in this way:

This is the mother’s job. She knows what to tell her daughter. I supervise the sixth and seventh grades, and if a girl asks for permission to go home she is given permission. No one asks her any questions. We don’t say anything, and we don’t ask her for a reason. We know she has it. Sometimes we offer her pain medication, but if she wants to go home, then we let her. The girl doesn’t talk about it, and if we find someone who does, then we reprove her and make a big deal out of it. (p. 69)

In Toldot Aharon Hasidim (Zalcberg, 2009), a mother is the main source of communication and education regarding menstruation. One mother explained to the researcher that, when her daughter experienced menarche, she described menstruation in the following way:

This [the first period] is something the mother tells the girls about. She says that there is such a thing and that there is nothing to be afraid of, and that’s all. We don’t talk about it . . . . The girl doesn’t know anything . . . . Until the age of 13 the children here think that an angel brings the babies; yes, yes! [laughs]. Afterwards, a little later, they know a little something, but they don’t ask, and we don’t talk about it. For example, when I came home from hospital a few days ago after visiting someone, my son said to me, “Mommy, you went to the hospital, so I thought you had a baby.” And this is a 15-year-old boy! And I’m not pregnant and I don’t look as though I’m pregnant. They know that when the mother’s feet hurt, then she goes to the hospital and they give her a baby; that’s what they know. We make great efforts for them to know as little as possible. (p. 76)

Zalcberg (2009) showed information regarding the menstrual period within one ultra-Orthodox community in Israel, but the study lacked information about the problems faced by girls during menstruation. In much the same way, this kind of study is lacking for the Nepalese community. The proposed study will fill this gap as it relates to

28 Nepalese (living in the U.S.) adolescents’ experiences of menstruation and any associated problems.

Rembeck, Molier, and Gunnarsson (2006) conducted a quantitative study in southwestern Sweden, involving 12-year-old girls in sixth grade attending six different schools that sought to “elucidate early adolescent girls’ attitude towards menstruation, and their thoughts and feelings towards their bodies” (p. 708). A total of 309 pre- and post-menstrual girl participants were involved in the study. The result showed that post- menarcheal girls expressed less positive feelings toward menstruation than pre- menarcheal girls. This study included girls from urban and rural areas of southwestern

Sweden. The results showed that 38% of girls were called “cunt” and 46% “whore.” The research showed that verbally abused girls talked more about verbal abuse with their friends than their parents. Of those girls verbally abused, 12% reported that they could not discuss the matter with friends, 23% could not talk to their parents, and less than 5% reported they had no one with whom to talk. When they were called “cunt” and “whore,” the girls were made to feel isolated and humiliated. Of the girls interviewed, 76% felt angry and 50% offended (Rembeck et al.).

Yeung, So-Kum, Tang, and Lee (2005) performed a study in Hong Kong by using prepared questionnaires among 476 Chinese pre-menarche teenage girls, aged 11 to

14 years, with a mean age of 12.24 years. This study explored the expectations of menarche and the psychosocial factors influencing the girl’s expectations. This study described the subject’s positive emotional expectations as

grown up (40.4%) and relatively fewer participants thought they would become more feminine (15.2). Only less than 10% of the participants expected

29 to feel happy (7.5%), proud (3.4%), and excited (5.7%) toward their menarche . . . . (p. 125)

The study results showed more negative expectations on menarche than positive. These negative influences were seen to be largely affected by cultural beliefs regarding menstruation. The Chinese teenage girls received information from their mothers and the media; these sources may, in turn, reiterate or underscore cultural myths related to menstruation. Most negative perceptions, according to the study, can be explained as inadequate preparation before menarche.

The study conducted by Yeung et al. (2005) illustrated negative influences related to cultural beliefs, but their work does not explain specifically how these negative beliefs may influence the girls. Further study will be helpful to derive detailed information that could assist adolescent girls.

Menarche, Menstruation, and Ritual

Menarche begins only after breast development. The maximum establishment of ovulation is roughly 19–30 months after menarche (Golub, n.d.). Most menstrual cycles usually last from three to five days. In the U.S., most girls start menstruating at age

12, but girls can start menstruating between the ages of 8 and 16 (Eunice, 2006).

Throughout the world’s cultures, ceremonies are performed when girls reach menarche. Some of these rituals can have a negative effect on adolescents, while others may be experienced positively or with no effect.

When menarche begins in a Navajo girl, a special four-day ceremony takes place; this ceremony is called kinaaldá . During the ceremony, girls are represented as moving toward adulthood where they are sent to run four times in the direction of the

30 rising sun. In the beginning of the kinaaldá, a girl’s hair is washed with suds made from the Yucca plant. After the hair washing, it is tied back and molded several times. The girl’s mother stands the girl upright and passes her hands over the girl in a motion like molding clay, but she does not actually touch the girl’s body. The girl’s hair is taken and pulled straight. Navajos believe that this makes the girl attractive and thin (Smith, 2006).

A very different experience awaits girls in Nepal, where, at the onset of menarche, an adolescent will be sequestered in a dark room for 12 days; this ritual affects the girl’s social life and education, as well as having a direct psychological effect. Kandel et al. (n.d.) provided a case study from a remote region of Nepal, where one woman explained that she must spend every menstrual cycle in the foul-smelling cattle shed. She asked why God had given this condition to torture women. Her meals were eaten in a filthy environment and she was considered impure and unclean—even untouchable—by her family members.

Bharadwai and Pakter (2008) reported that monthly menstrual cycles are normal phenomena for women but that women feel embarrassed to talk about menstruation.

In some Asian cultures, restrictions exist for daily living activities during menstruation.

Those taboos lead women to develop a sense of discomfort and shame around their monthly periods. The writers found that most Bangladeshi women used cloths (usually torn from old saris, pillow covers, or bed sheets) to contain the blood and that these cloths were washed and reused several times. The women dried these cloths in dark and hidden places, to avoid being seen by others in their community. These behaviors often led to serious health problems. The writers provided the case study of one girl from India:

31 I did not have to endure exclusion from religious functions, or seclusion at home and elsewhere and so on, during my periods. But I did face a major problem—attendance at school. It was about 7 km away from my home and commuting was not direct; hence I could not come home easily if I had a problem at school. The school was located in an area with very little ground- water, and municipal water supply was also inadequate. (p. 5)

Bharadwaj and Patkar (2004) showed that females were usually told menstruation was shameful. This kind of cultural misperception is normal in counties like

India, Nepal, Bangladesh, and Pakistan. In the situation depicted above, girls were forced to be absent from school during each monthly period because of the need to change their cloths every four to five hours, with no access to water or privacy.

In another study performed by Sharma, Malhotra, Taneja, and Saha (2008) in

New Delhi, India, the researchers reported that 67.2% of their subjects suffered from dysmenorrhea and 63.1% showed problems of premenstrual syndrome. This study also reported that 60% of females reported an adverse effect on their daily activities, 17.24% missed class, and 25% missed work. The results found by Sharma et al. detailed that 60% of females’ daily activities were affected by the experience of menstruation within their cultural milieu. Much the same as Indian females, who experienced the practice of cultural taboos related to menarche and menstruation, Nepalese females also suffered from many difficulties that interfered with their everyday lives. This study by Sharma et al. was performed on 193 adolescents, aged 13 to 19 years. The information was collected via personal interviews with a pretested, semi-structured questionnaire covering menstrual problems and the effects these problems had on their daily life. They suggested holding a screening program to discover problems related to menstruation and providing

32 counseling and treatment services for these problems. The researchers also suggested a program to provide menstrual health services for adolescents.

Nutrition and its Relation to Menstrual Health

“Nutritional well-being is determined by consuming safe food as part of an appropriate and balanced diet that contains adequate amounts of nutrients in relation to bodily requirements” (WHO, 1998, p. 1). In Asian and North African countries, the development of nutritional rickets has been shown to be related to cold climates and sunlight deprivation; the attendant vitamin D deficiency results in reduced calcium absorp- tion. Beyond the health concerns created by such deficiencies in the wider population, daily calcium intake and vitamin D acquisition are two key factors for girls, in order to affect their rapid growth at puberty. It has been suggested that calcium and vitamin D supplements are necessary to prevent rickets in pubertal girls (Dahifar, Faraji, Yassobi, &

Ghorbani, 2007).

The 1998 WHO report of 1998, “Healthy nutrition: An essential element of a health-promotion school,” emphasized that schools are vital settings for the promotion of good nutrition in young people at an age critical for their growth and development. If educated while still in early grade levels, students will have several years in which to form the good eating habits required for their proper growth and development during adolescence. Healthy nutrition is a crucial factor in young children’s health, contributing to the physical, mental, and social development of adolescents, as well as providing a basis for health throughout each individual’s life (WHO).

33 Adolescent girls require proper nutrition—as well as education related to how to properly gain such nutrition through diet—in order to prevent malnutrition. They must have adequate food to fulfill the demands of the body during its development throughout puberty.

Burrows and Johnson (2005) conducted a qualitative study in the Northamp- ton area of the U.S., seeking detailed information on menstruation among their participants. The researchers’ study considered a group of females aged 12 to 15 years. The study’s results showed that participants held a negative view of menstruation, perceiving it as embarrassing, shameful, and a feature that should be hidden. Each group discussion took around 45 minutes. The researchers stated, “The girls that I spoke with expressed largely negative views and in their accounts menstruation was constructed as embarrassing, shameful and something to be hidden” (p. 239). This study suggested that the adolescents were obligated to hide physical signs of menstruation. One girl stated she wore a pad every day, in order to manage the unexpected onset of her period.

Even though the group of participants was small, the qualitative study conducted by Burrows and Johnson (2005) provided important information about how adolescent girls felt when they had their menstrual period. While useful, this study lacks clear examples of problems associated with menarche and menstruation. A similar design would be useful when exploring the experiences of Nepalese adolescent girls’ immigration to Northern California in the U.S.

One qualitative study, seeking information regarding the experience of menarche from different countries, depicted women’s experience as it related to cultural,

34 social, and religious factors (Uskul, 2004). This study comprised 13 focus groups of 53 women from 34 different countries. The participant’s ages were 23 to 52, and most were middle to high income with advanced education, including 18 who were Ph.D. candi- dates, 18 with a master’s degree, and 17 who were undergraduates. All of them were recruited for discussion in summer school in Germany; the discussion took between 45 minutes and 2 hours. The researcher described participants of the sample as subjects who were “highly educated and who could leave their countries for three months to attend a summer school in Germany” (p. 677). The questions included the topics:

(1) how women experienced their menarche, (2) similarities and differences between menarche stories of women who come from different cultural back- grounds, and (3) how women’s menarche experiences related to the general cultural environment in which they experienced their first menstruation. (p. 670)

The women interviewed in this study remembered their menarche well. Some of them had negative experiences, which were described as “embarrassed, ashamed, awfully scared, shocked, confused, terrible, miserable, frightened, depressed, and freaked out,” whereas positive experiences included “happy, proud, cool, relieved, and excited”

(Uskul, 2004, p. 671). Most of the women who described negative experiences were unable to provide any positive reminiscences about menarche. The study provided the following memories of a woman from south-eastern Europe:

Mine was a very miserable experience, because I got my first menstruation in [outside of her original country]. I did not have friends. I had no girl friends to talk with. I vaguely knew that something like that would happen. My mother strangely enough—she is a pharmacist—had never told me about this…. So I was lacking both an adult who was giving me information and peer contact which would have made it easier. So one day I went home and I was so frightened, I just went to my mother and without me saying anything I guess I must have been white like a chalk and she said, “Oh did you have your

35 menstruation? Okay, in the cupboard in the bathroom, there is a pad,” and this was all she did, it was so strange. I went to the cupboard and I had to read the instructions how to put it on and everything. I was so shocked. I think I was also hurt by not getting any attention. (p. 672)

Uskul (2004) concluded from the stories of menarche that this experience involved interactions within the subjects and their cultural, religious, and societal environment. The women’s experiences were bound by their own cultural and religious rules

(or lack thereof). Such factors, therefore, affected how they dealt with menarche. This research provided valuable information on problems related to menarche, but it did not give information about menarche and the monthly period as it related to cultural taboos and problems. In order to fully understand the range of experiences girls and women have at the onset of menarche, it would be beneficial to investigate cultural taboos and problems related to menstruation within the subject’s cultures.

Chang, Chen, Hayter, and Lin (2009) reported their qualitative research on 20 female students aged 10 and 12 years. This study used focus group discussion in a selec- tion of Taiwanese preadolescent girls. Their work suggested that pre-pubertal girls experienced significant physical and emotional problems at the time of their menstruation.

One participant explained menarche and menstruation as it related to social problems in the following way: “When my first period came it scared me because I thought I had excreted feces on my underwear. A few hours later I told my mother and she took me to see the doctor, because she thought it was too early for me” (p. 2044).

Another girl described her menarche:

My first period occurred at home. There was blood in my underwear and when I saw it, I yelled out “Mom, I going to die!” I had a lot of blood in my underwear. My mom said “It’s OK.” But she didn’t tell me what it was and

36 just gave me a pad and taught me how to take care of it. However, I still felt afraid when I went to sleep and I still worried about it thinking, “What was that?” (p. 2044)

The researchers Chang et al. (2009) explained that these problems were mostly seen because of a lack of adequate information. The researchers suggested that nurses should provide education on menstruation to young adolescents, especially addressing menstruation hygiene. The qualitative focus used in this study also explained menarche-related problems, but it did not obtain information on menarche and the monthly period as it was experienced within a ritual context, nor did it encompass any problems associated with these rituals. It would be beneficial to conduct a study in these areas as well.

Leininger’s Sunrise Model

This study used Leininger’s Sunrise Model. In a review of the literature, there is an observable lack of studies using this model for research on adolescents. The study by Rosebaum and Carty (1996) used Leininger’s theory of cultural care diversity and universality in a study of the subculture of adolescence: beliefs about care, health, and individuation within Leininger’s theory. The participants were 27 key informants and 44 general informants. All of them were ninth-grade students, with a mean age of 14 years.

In this study, coping with menarche and menstruation was shown to be heavily influenced by cultural factors.

This study assesses the experience of menarche in a cultural context, with the aim of seeking ways to decrease the problems of menstruation in adolescents by using

Leininger’s Sunrise Model. Specifically, the study observed the lived experience of these problems in female adolescents, aged 13 to 16 years, who emigrated from Nepal to

37 Northern California within the last five years. The purpose of this study was to explore the lived experience of cultural practices regarding menarche and the monthly cycle in

Nepalese adolescent immigrants in Northern California.

This study was aided by using aspects of the Leininger Sunrise Model. It provided context for discussion of findings, which depicts diverse and universal care patterns from a global perspective, offering a way to make decisions and take actions for cultural care preservation/maintenance, cultural care accommodation/negotiation, and cultural care re-patterning/restructuring to provide culturally congruent care to adolescents.

Summary

A review of the literature regarding adolescent girls’ problems during puberty showed a variety of disparate issues. These included cultural restraint during menstruation, hiding menstruation or suppressing related discussion, lack of education on sanitary management of menstrual flow, negligible or non-existent help in the use of sanitary pads or personal cleanliness during menstruation, and so on. The literature also showed problems experienced by adolescents, such as early pregnancy, sexually transmitted diseases, and suicide, among other issues.

There was a notable lack of research related to menarche and menarche- related ritual and problems. Without taking these factors into consideration, a lack of knowledge about menstruation and sexual development in general could lead to severe health problems within the adolescent population. As menarche is a transit period from childhood to adulthood, adolescent girls need to prepare for the changes their bodies will undergo. Research on the problems experienced by 13- to 16-year-old adolescents who

38 have emigrated from Nepal is important for improving adolescent health in Nepal.

Understanding these issues may be helpful to identify the root causes of adolescent health problems related to menarche and menstruation and to provide solutions.

Transitional Statement

Chapter 3 will discuss the methodology used for the study, which includes detail concerning design, population, sample size, method of data collection, and the protection of human subjects.

CHAPTER III

METHODOLOGY

Menarche is a unique experience for every adolescent girl. As menarche is a normal phenomenon for all females, it should be viewed as a normal process. Many countries in the world, including Nepal, engage in some ritual regarding menarche and the monthly menstrual cycle that affects females’ daily activities. This phenomenological study was conducted to obtain data on the lived experience of adolescent Nepalese girls residing in the U.S. regarding menarche and the menstrual cycle.

Research Methodology

This phenomenological study aimed to gather in-depth information about the lived experiences in order to explore, describe, and understand the beliefs and practices associated with the onset of menarche and the monthly cycle as experienced by Nepalese female adolescents aged 13 to 16. A phenomenological study is one kind of qualitative research that facilitates gathering unique lived experiences from participants (Morrissey

& Higgs, 2006).

Following review of phenomenological studies related to adolescents, it was determined that the phenomenological approach would be a suitable method to gather data on the unique experiences of menarche and menarche-related ritual from adolescent girls.

39 40 Phenomenology is the study of phenomena: their nature and meanings. The focus is on the way things appear to us through experience or in our consciousness where the phenomenological researcher aims to provide a rich textured description of lived experience. (Finlay, 2008, p. 1)

As Finlay explained, consciousness is the sense of our awareness related to our environment and what is happening to us. The major focus of the phenomenological concept is intentionality, which is a vital focus for this kind of study. A definition of intentionality is found in Zahavi’s statement (2003): “Intentionality is a relation between two objects in the world” (p. 14). Kockelmans (1994) adds, “intentionality signifies that all consciousness is consciousness of something” (p. 18). Intentionality in this context requires understanding of the original, underlying reality of the observed object, which allows us “to progress in our structural understanding of the idea of logic” (Husserl, 1969, p. 130). The researcher recalled and made comprehensible a judgment of the facts as they applied to the thematic field, which in turn was presented as the recognized truth: the writing was credited as truth (Husserl).

The researcher obtained information about the experiences of the participants by asking questions such as “Can you describe what took place when you had your first menstrual period?” and “How did you feel when you had your first menstrual period?”

Trigger questions included “Can you explained more about what different activities when you had your every menstrual cycle?” “Please explain more about difficulties you felt during your grandparent visited to your family?” “Can you explain more?” “Do you want to explain more about restriction?” “Now, can you describe more how you manage your menstrual product on different days?” “Were there any other problems when your grandparents visited to your house?” and so on. Phenomenological investigation allowed for

41 detailed information about the experiences of menarche by immigrant Nepalese adolescents in Northern California. In order to describe the experiences associated with menarche in female populations such as those found in Nepal, the phenomenological approach aided in the understanding of beliefs and practices connected to menarche within groups of immigrant Nepalese girls.

Underpinnings Informing the Methodology

The researcher utilized Leininger’s Sunrise Model in this phenomenological study, as this model was suitable for determining beneficial or harmful characteristics of cultural practice related to menarche and menstrual period. The model-guided observation of the cultural practices needed “to adapt to, or to negotiate with, a beneficial or satisfying health outcome with the professional care provider” (Leininiger, 1991, p.48).

Thus, this study derived information from the experiences of Nepalese adolescents who provided original information pertaining to their own lived experiences. Husserl (1931) defined phenomenology as a descriptive analysis and pure science, which he called the

“science of essential being.” (para. 1). He also described phenomenology as a “science of essence.” (para. 1). As Husserl explained, “phenomenological reduction is the process of defining the pure essence of a psychological phenomenon” (para. 1). In the context of this study, the phenomenon was the cultural practices related to menarche and the menstrual cycle as experienced by those living within Nepalese society in Northern California.

42 Sample Characteristics

The study was conducted in Northern California. The sample was selected with purposive and snowball sampling. The following inclusion criteria were used to obtain the sample:

1. migrated from Nepal to the U.S. within the previous ten years

2. enrolled in grades seven to nine

3. female adolescents aged between13 and 16

4. menarche took place in Nepal/ U.S.

5. currently living in the U.S. with similar family structures (this was determined through initial telephone of potential participants’ parents) as in Nepal.

Sampling Process

Four to six adolescents were selected using both purposive and snowball sampling. The initial participant was found by the researcher through personal contact with

Nepalese friends. Snowball sampling was used to find other participants who met the inclusion criteria. The researcher asked participants if they knew of other Nepalese girls who could participate in this study; then, having obtained the first participant(s) via

Nepalese friends, snowball sampling was used to find additional participants. Purposive sampling was selected as one method because it is assumed that few Nepalese immigrants were available for this phenomenological study in Northern California.

Sample Access

The initial participants were chosen through personal contact with Nepalese friends. As the researcher is Nepalese, she was expected to have an easy access to the families who have Nepalese adolescents. As the researcher expected, she found families

43 with Nepalese adolescents. Subsequent participants were found through personal contact, as well as phone contact with Nepalese friends. The researcher first contacted one of her

Nepalese friends who provided information and telephone numbers regarding families with adolescent girls. The researcher called the Nepalese families and identified the adolescent age and planned to visit the home where she explained the research objective and received consent from parents (Appendix A) and assent from adolescent (Appendix B).

On the same day, she planned the date and time for the interview. On the planned date of the interview, data were collected by personal face-to-face interview with tape record.

Ethical Considerations: Human Subjects Protection

This study was approved by the Human Subjects Research Committee

(HSRC) of California State University, Chico, to be conducted in Northern California.

This research was conducted on adolescents on topics of a sensitive nature, and therefore required a full review of the HSRC Committee. Informed consent was obtained from the parent(s) (Appendix A), and assent was obtained from participants (Appendix B).

Informed consent for parents was prepared in English only because all parents work as registered nurses and understand English well. The assent form was also presented in English, as the participants are students in public schools in Northern California where English is the primary language.

In order to maintain confidentiality, participants’ original names were not used. The researcher used pseudonyms for each participant. Participation could have been discontinued at any time without prejudice on the part of the researcher if the adolescent wanted to stop the interview, but this was not necessary. To maintain the privacy of each

44 participant, interviews were conducted privately, in their own room. The researcher received permission for tape recording prior to the beginning each interview. Each interview took place in the girl’s own home, so that they were relaxed and comfortable. How- ever, one participant became upset during the interview; the researcher instituted a break for five minutes to give the girl time to relax. The interview began again when the participant was ready to continue. It was not necessary to discontinue interview. The researcher did not need to reschedule the interview for another time or stop altogether.

The researcher stored collected data in a locked file cabinet accessible only to the researcher; this material will be destroyed after five years.

Specific Method(s) for Data Collection

Initially, the researcher looked for Nepalese families in Northern California with 13- to 16-year-old girls by talking with Nepalese friends. From the list of phone numbers and addresses obtained, the researcher called the girl’s parents several times to discuss the research objectives, gain their consent, and set a date and time to meet with the adolescent so that the details of the research could be explained to the adolescent. The researcher also answered any questions that the participants and the parents had; permission was then gained to participate in the study. The researcher also met with the parents and participants at a set time, and received in-person consent from the parents, assent from the participant, and established an appropriate date and time for actual data collection for each interview. Before beginning the interview, the researcher explained the study’s purpose again: to discover the participants’ unique experience of menarche and monthly menstrual period. The interview took place in each girl’s own home, where she felt comfortable and easy. All participants decided to be interviewed alone.

45 With permission, the interview began, at which time the audiotape was turned on to begin recording. The researcher briefly noted the participant’s permission, as well as repeating this point at the end of each interview. One participant became distressed during the interview; the researcher paused the tape and stopped the interview for a brief period of time, in order to give the participant time to relax. The interview began again only after the participant was ready to return to the interview.

Process for Data Analysis

Analysis of the data started from data collection through the completion of the study (Bradley, Curry, & Devers, 2007). Data analysis was based on a review of the tapes and transcription of data (Peteva, 2007). As data analysis began, following data collection, the researcher listened to the audiotape several times, in order to gather pertinent information, and then associate related topics from the data. A professional transcrip- tionist was not hired to make a transcript of interview. The researcher analyzed the first interview after listening to the interview several times, before moving on the next interview. Data analysis followed the process provided by Colaizzi (1978), which includes seven steps (only four was used for this study).

1. Understand each participant’s comments by remembering comments that impressed the researcher. Such impressions are based on the vividness of subjects’ comments (Colaizzi, 1978). To get a real sense for the information, the researcher read a transcript of the interview or listened to the audiotape several times (Saunders, 2003). The researcher listened to the audiotape several times and made list of significant statements.

46 2. Extract significant statements. The second step involves highlighting relevant comments from each interview. During this process 102 significant statements were extracted, then read and reread against and again the transcription in order to get each participant’s lived experiences (Saunders, 2003). The process was to “cut from the appropriate transcript and paste on to a separate sheet retaining the transcript, page and line number” as one method of sorting through the data (Saunders, p. 295).

3. Formulated meaning. By formulating meanings from the data, the researcher can accurately describe participants’ lived experiences (Colaizzi). The researcher determined formulated meanings from each significant statement. The researcher highlighted important information gained from the significant statements identified in step 2. The researcher made a comprehensive list of formulated meanings from all significant statements (Saunders).

4. Formulate clusters of themes. Colaizzi described the fourth step as formulation of clusters of themes from formulated meanings. Themes emerge after reading and reread- ing the transcripts and the formulated meanings, and from listening to the interviews on the audiotape again and again. Themes developed through groupings of similar formulated meanings. The researcher searched for discrepancies in the clusters of themes.

Those formulated meanings that did not fit were ignored (Colaizzi). In this way, the researcher formulated 73 clusters of themes. Finally, seven themes merged out of 73 clusters of themes.

As this is research for a master’s thesis, the data analysis process was focused only on formulating emergent themes, thereby stopping at step 4 in the data analysis

47 process and not proceeding through to development of an exhaustive description. The researcher got feedback from the academic thesis chair at every step several times.

According to the feedback received, the written narrative was modified and resent to the academic thesis chair, in order to ultimately establish accurate and appropriate clusters of themes and contribute to rigor.

Process to Establish Rigor

Crawford, Leybourne, and Arnott (2000) explained that qualitative research is constructive inquiry, so it is necessary to be sympathetic in order to understand the situation of participants’ behavior. Saunders (2003) stated that “in qualitative research, there is a need to determine whether the study is believable, accurate, and right, and whether it is useful to people beyond those who have participated in the study” (p. 293). Trustworthi- ness will be maintained by attaining credibility, transferability, dependability, and confirmability (Siegle, n.d).

Lincoln and Guba (1985) explained that credibility is maintained by prolonged engagement, persistent observation, and triangulation (p. 301). Peer debriefing and member checking are two ways to establish strong credibility for a study. However, member checking with participants was not carried out in this study, because the study was conducted with adolescent girls who may not wish to participate in this process and revisit a sensitive topic. Peer debriefing with the thesis chair was carried out in this study to maintain credibility. Prolonged engagement was maintained by spending more time with the participant. Interviews only proceeded after developing a trusting relationship with the participant and making sure they are comfortable (Lincoln, & Guba, 1985). A

48 trusting relationship was established by talking about different topics besides the study per participant wish at the beginning of the interview.

Prolonged engagement allows the researcher to obtain answers free of falsification, bias, and other extraneous environmental effects (Siegle, n.d.). In this study, the researcher maintained credibility by closely observing a given participant’s expres- sions, keeping a notebook after each interview to document a participant’s expression, and asking open questions, with the goal of evincing more information. The researcher wrote field notes about, for example, the environment and body language, etc. for each interview following completion of the interview. The information was collected from original sources, in order to avoid environmental effects, falsification, and bias. Siegle described triangulation as obtaining information from different points of view. This was realized through asking different questions, getting information from different sources

(such as the interview), observation of environment, facial expression gestures, and so on.

This was performed by collecting data via face-to-face interviews and using open-ended questions, which provided data that represented participants’ rich lived experiences

(Lincoln & Guba, 1985)

Transferability refers to what can be applicable or generalizable with another community; this is also known as applicability. While it was not possible to get true gene- ralizability in this study (due to the specific nature of the topic and the participants’ background), the researcher tried to establish some level of transferability by obtaining suffi- cient information from the participants to allow for general points to made (Siegle, n.d.).

49 The complete research report will be made available to other researchers, which will allow the repetition or application of this study’s findings in other cultural contexts.

Dependability is described as the replication of data by the same kind of respondents in similar context (Siegle, n.d.). As Siegle stated, there is “no credibility without dependability” (para. 19). This study provided credibility, so dependability was also established. The researcher maintained dependability by documenting critical incidents in analysis decisions in the interview field notes.

Siegle (n.d.) described confirmability as the audit of raw data, which included audiotape and taking notes on the interview. Davis (1997) provided a definition of audi- tability as the state observed

in qualitative research, when another researcher can clearly follow the “decision trail” used by the investigator. In addition, another researcher could ar- rive at the same or comparable but not contradictory conclusions given the researcher’s data, perspective, and situation. (para. 11)

Davis described confirmability as equivalent to objectivity. In this study, confirmability was obtained by means of qualified debriefing and feedback from the academic thesis chair. After this, the process continued with a revision of the analysis per the suggestions obtained in debriefing and feedback from academic thesis chair, who is an expert in qualitative research and another committee member who is also expert in qualitative research.

Summary

The goal of this study was to explore, describe, and understand menarche- and menarche-related rituals experienced by female Nepalese adolescents. This research was performed in Northern California. This study was conducted in participants’ homes, and

50 data were collected by means of an interview recorded on audiotape. The target population was four to six female adolescents, aged 13 to 16 years, who attend grades 7 to 9; four participants were obtained and interviewed.

Transitional Statement

In Chapter 4, the findings of the study are presented. As this research was a phenomenological study, the researcher presented the adolescents’ in-depth feelings related to their experience of menarche and menstruation in Nepal and in the U.S. by way of direct quotes.

CHAPTER IV

RESULTS

Every girl goes through different experiences when she has her first menstrual cycle. The unique experiences of four Nepalese girls who currently reside in Northern

California during their first menstrual cycle were explored in this phenomenological study. Even though menarche is a normal process of life that all girls go through, the four girls in this study faced different problems during their first menstrual cycle and other menstrual cycles due to their culture.

The purpose of this study was to explore the lived experiences of cultural practices regarding the menstrual cycle and menarche of Nepalese adolescent girls. The lived experiences demonstrated in the significant statements were affected by where menarche took place and the presence of members of the older generation. Seven themes were identified through the data analysis process, they are: 1) emotional roller coaster about first menstrual period, 2) dealing with negativity while trying to be true to cultural values, 3) trying to balance the differences between traditional and modern customs,

4) cultural confusion: mixed messages from friends/family/elders, 5) rationale behind cultural taboos does not help lessen the confusion or pain, 6) information mismatch between Nepal and the U.S., and 7) looking forward: challenging the older way. The pseudonyms given for each girl are Anita, Babita, Kabita, and Ramita. These themes are presented below.

51 52 Emotional Roller Coaster about First Menstrual Period

The experience of emotional “ups and downs” occurred at the onset of the girl’s first menstrual cycle. The girls felt scared and uncomfortable, feeling bad and left behind. Anita and Babita (who had menarche in Nepal) were made to spend 12 days in a dark, separate room, and they reported feeling panicked and bad during their first menstrual cycle. Out of the four, three participants expressed that they were scared when they first had their menstrual cycle, even though they had information regarding normal menstrual cycles.

Anita, who had her first menstrual cycle in Nepal and had started her menstrual cycle at age 12, comments on her first menstrual cycle:

After the non-stop pain, I went to the bathroom and noticed that I was bleeding. I was panicked a little then ran into my room and told my older sister what happened. She called my mother into our room and told her about it.

She further stated: “It was my first time. I was really uncomfortable because it was the first time and I know that it was change and sometimes changes are really hard and uneasy to get used to.”

Babita who also had her menstrual cycle in Nepal, expressed her emotions during her first menstrual cycle in this way:

I did not know that I had my first period, so I panicked, but decided not to tell anyone what happened. But, I kept having stomach aches and cramps. So, every time I went to the bathroom, I would bleed. So, I told my sister what happened and she told me that I might have my period. But, I did not believe it.

53 Kabita had her first menstrual cycle in the U.S., a month before she turned twelve. She was also scared about her first menstrual cycle. She had received education in school regarding menstruation. She describes her first menstrual cycle:

At first, I thought I peed on myself, but when I went to the bathroom, I could see a lot of blood in the toilet bowl. I got scared and came back to my room. I called my twin sister and told her what had happened. She told my mom. My mom gave me sanitary pads and explained how to use the pad safely. She also told me, when I had menstrual period don’t go to praying room.

The roller coaster of emotions related to menarche was affected by whether the participants were prepared for their first menstrual cycles or not. One girl, Ramita, was prepared for menarche because her twin sister had had menarche before her, did not experience the emotional roller coaster that the other girls did.

Dealing with Negativity while Trying to be True to Cultural Values

Even though the girls liked their own culture, all of them felt that the strong restrictions caused negative feelings for the cultural practices. Cultural practices are unique to every society, but in some societies these create hurdles for young people seeking to adjust to their new social roles. One example from this study is the Nepalese practice of staying inside a dark room for 12 days during the first menstrual cycle. Anita reports:

Bad point of having these cultural taboos well! When I had my first menstrual cycle, I had to stay in a room for 12 days! I was not allowed to meet my family members or talk to them so I really missed them. The room I stayed in was very dark without sunlight since I could not see sunlight for 12 days it was a little depressing.

During those twelve days, Anita missed school for ten days and she had a very hard time to catch up with her studies. She further comments:

54 On top of that I also missed school days. In Nepal, I had eight classes every day and they were different classes; for example if I had health Monday then same time Tuesday I would have physics. So missing school days meant more work for eight classes, which were different every day. Since I had to stay in dark room there wasn’t much I could do. On normal menstruation cycle, I was not allow to go to kitchen, dining area, and praying area so I had to stay in my room and also not touch anything so that kind of messes my daily activity.

Babita is her parent’s first child. She did not get a chance to observe and get information from an older sibling. Her paternal grandmother was very strict. She describes how she felt during her first menstrual cycle with the cultural restrictions:

I have experience this situation several times. I used to see my family enjoying with each other and participating in the festival. But since I could not participate in the festival, I used to be in my room by myself not being able to be a part of the family during the festival. My parents, my sister, and my brother used to come to my room and tell me not to feel bad but I could not help feeling bad. Also my grandmother is really strict about me following the traditions related with menstrual cycle, so when I sat next to her accidentally, she used to say that she got sick because of me. Therefore, I do not think those cultural practices should be practiced even though it is good in some ways, but it also hurts the women emotionally.

Kabita had her first menstrual cycle before her twin sister. Kabita’s mother is a nurse and she knows that the menstrual cycle is a normal developmental process of life.

Since they had moved to the U.S. before she began menstruating, she did not have to stay in one room for 12 days and she did not have any cultural restrictions, other than that she was not allowed to touch elder males or go to the prayer room when her grandparents were with them. She also had a hard time when her grandparents were with her. Kabita expressed her emotions:

I wanted to cry because of the restrictions, I did not have any restriction when my grandparents were not with us, but when they were with me I had hard time when I had my menstrual cycle. I love my grandparents very much, but restriction at time of monthly cycle, I did not like it. I also did not like my grandparent’s behavior towards me when I had menstrual period. . . . After

55 they went back to Nepal, I was allowed to enter the kitchen again even during my menstrual cycle, so I felt better even though I missed my grandparents very much.

Kabita further explained the difficulties she had to overcome while her grandparents were with her. As they were her grandparents, she loved them but she did not like having restrictions placed on her during her menstrual cycle. So She described the situation like so:

Yes, I feel uncomfortable with restrictions. I did not like behave differently when I had my menstrual cycle. I know, it is normal phenomena for female and I am keeping myself clean. I don’t think females need to behave differently at time of menstrual cycle if they keep them clean.

Ramita had her first menstrual cycle after her sister had hers. She got a chance to learn about her first menstrual cycle before she had it. She knew what was going to happen to her. She was ready for her first menstrual cycle. When her grandparents were with her family, she actually had fun with the restrictions. She also delineates her experience when her grandparents were with her as:

It was actually fun because I got to order my sister around. I would tell my sister to get me a glass of water or some food for me and she would say “No.” So, I would tell her that I cannot go to the kitchen remember. So it was really fun. It was a hassle sometimes because I could not go to the kitchen when I wanted something. So, if my sister was not home or she was busy, I would have to wait for someone to get the thing I wanted from the kitchen so it was a little inconvenient at sometimes.

She again depicts the situation when her grandparents were with them. She explains that she did not have to work in the house, which she liked:

Since, I had my period; I did not have to do any house hold chores, so that was convenient for me. . . . When my grandparents visited us, it was little inconvenient sometimes. As I told you, most of time I enjoyed it because I could order my sister and tease her time to time when I needed something and she

56 had to bring it for me. When she had her menstrual period, I had to help her too but she usually did not tease me.

When the girls had their menstrual cycle, they had to deal with many restrictions due to cultural taboos. Although many of the girls respect and like their culture, the taboos and restrictions make many girls feel bad about themselves. The girls especially had to follow these restrictions in the presence of elders. Only one, Ramita, found a way to have “fun” due to their restrictions. In the end, while trying to follow their culture, the girls felt negative and depressed.

Trying to Balance the Differences Between Traditional and Modern Customs

Girls who had started their menstrual cycle in Nepal could not afford sanitary pads or tampons to manage their menstrual product. Most of the girls and women used pieces of cotton for protection and they would have to re-use those cloths several times.

In the remote villages, women and girls did not use anything to manage their menstrual product. They would stay in one place for four days and after that time, they would take a bath and wash all of their linens.

Anita used a piece of cloth for protection when she was in Nepal. She expressed her problems in this way:

But in Nepal, sanitary pads are not used often, instead we used piece of cloth for protection. I also have to use the piece of cloth. . . . Those pieces of cloths I had to use over and over again so what I would do. I used to clean them in the bathroom and air dries them in the room. It would be embarrassing if someone saw them so I keep them in my room.

Babita also had to use a cloth to manage her menstrual product. She stated her experience:

57 When I was in Nepal, it was not common for women to wear sanitary pads. I used to wear a piece of cotton cloth as the pad in Nepal. When the cloth was used I would change it. I used to stock cotton cloths and wear them, so I would not leak. Because, unlike the sanitary pads, cotton cloths definitely leak. After I changed a cloth, I used to wash it in warm water, and I used to sun-dry those cloths I had used. It is uncommon for people to own washing machines in Nepal, so I used to hand-wash my cloths and dry them.

Babita expressed her problems during the day:

In Nepal when I was in school, I used to change and put the cotton cloth in a plastic and keep it in my bag, and take it home and wash it. In here, after I change my pad, I wrap it up with a toilet paper and dispose it in the trash.

Girls who had their menstrual cycle in Nepal had more problems in comparison with girls who had started their menstrual cycle in the US. Kabita had her menarche in the U.S., so she did not have any problems managing her menstrual product. She stated that “After my mom provided me with a sanitary pad, I used pads. I did not get any problem to manage with my menstrual product.” Like Kabita, Ramita also had her first menstrual cycle in the U.S. She also did not have any problems managing her menstrual product:

Treatment of the menstrual cycle for girls is very different in Nepal. There, primitive techniques are used to take care of menstrual product, such as cotton cloths, which have the potential for leaking and causing infection. Taking care of the menstrual cycle is much easier, cleaner, and safer in the modern setting of the U.S.

Cultural Confusion: Mixed Messages from Friends/Family/Elders

Anita and Babita, who had their first menstrual cycle in Nepal, had the cultural ceremony for their first menstrual cycle, but Kabita and Ramita, whose menarche occurred in the U.S., did not have any kind of cultural ceremony. Anita had this to say:

There are culture events that take place when a girl has her first menstrual cycle and those also applied to me. Immediately after, she [mother] told me all

58 the culture rules and regulations. She [mother] took me to upstairs since our house was a three-story house. The middle floor was unoccupied. She [mother] took me to a room there and told me to stay only in the room. The room I stayed in was very dark and not a glimpse of sunlight was allowed to come in the room, and I would have to stay like this for 12 days.

Anita also had another cultural ceremony related to her first menstrual cycle.

She described her experience in this way:

After the 12 days ended, on the morning of the 13 th day, I had to take bath before sunrise, and then I dressed in a traditional dress. After that I was allowed to come out and the first thing I had to do was pray to the sun at sunrise. After praying, I was allowed to meet my other family members and receive a blessing from all the elders from my household.

Babita had a similar experience during her first menstrual cycle:

My grandmother came to my room and put curtains all around my room. It was really dark inside the room even though there was sun outside. She told me that I had to stay in the room for 12 days because it is our traditions we follow after we become a woman.

On the twelfth day of her first menstrual cycle, Babita had a special ceremony to celebrate her maturity:

After 12 days, my grandmother told me to take a shower. I remember that it was really cold in the morning so she warmed water for me so I could take a shower. After I was done taking a shower, my grandmother handed me Nepa- lese traditional dress to wear. I wore the traditional dress and came outside. After that I was allowed to see my family members, so I went to my family and got a blessing from them. Even though it was after the 12 days and I was allowed to meet my family, I was still not allowed to enter the kitchen or the temple. Although I was allowed to see my family, I was still not allowed to go to certain rooms, so I felt like a visitor in my own house.

Because they had their first menstrual cycle in Nepal, Anita and Babita needed to spend 12 days in a dark room separated from the rest of their family. Kabita and Ramita did not have any cultural ceremonies because they moved to the U.S. Kabita describes it:

59 My mother told me that it is our culture and when the women have menstrual period, the female cannot touch God. The female needs to take bath on day 4 and 7; then the female can pray and go to praying room. My mother also told me when our grandparent visit; I could not go to kitchen and touch food, water and senior male members of family. My mother told me that as she is a nurse my mother did not care about it but we have to follow rule when our grandparent visits. My mother also told me that when a girl has her first monthly period, girl would be kept in separate house for 12 days, but my mother was not going to do that for us as my mother thinks it was normal phenomena.

Ramita describes her mother explaining to her regarding culture ceremony as follow:

My mother explained to me that in Nepal people are used to keep 12 days in separate house for girl when girl has first menstrual cycle. Female could not touch water, food, anything which use for praying god. Menstrual girl could not touch senior male member of family too. I just wonder about it.

The younger generations are modifying the cultural practices that are unheal- thy, which interfere with the daily activities of life. Babita stated her experience,

“Although I was allowed to see my family, I was still not allowed to go into certain rooms, so I felt like a visitor in my own house.” This statement showed girls had stress during these restrictions that was not beneficial for the young girls. Kabita’s and Ramita’s mother is a nurse and their family moved to the U.S., so she did not restrict her daughters during the menstrual cycle. The only restriction she kept for them was that they were not allowed to go to the praying room and touch God when menstruating.

Rationale Behind Cultural Taboos do not Help Lessen Confusion or Pain

The girls were told why people treated women and girls differently during their menstrual cycle, but the historical rationale still did not help the girls to relieve their pain and confusion.

60 She told me that in Nepal female unable to keep them clean when they had menstrual cycle. They did not use pad and their menstrual product all over on their linens. They would only take bath on day four and seven only. It was actually very unhygienic condition for them. It might be reason people treat them like un-pure when they had menstrual cycle. (Kabita)

She explained to me, she did not know exact reason behind it. But she told me that it might be because of unhygienic condition of female during menstrual period in Nepal. She told me in Nepal there was not enough water available for bath and wash. It was hard to supply even soap for bath and wash. Female only allowed taking bath on day four and day seven. Day four, they had to take bath and wash all their linens. On day seven, they had to take bath again before regular pray. In village of Nepal, some females did not use any protection during menstrual cycle. (Ramita)

Many of the girls wondered why women were treated as lesser people when they go through their menstrual cycle.

Information Mismatch between Nepal and the U.S.

Nepalese schools have no curriculum requirements to teach young girls about normal growth and development, nor do they educate about the management of puberty.

Girls in Nepal, therefore, receive little or no information regarding menarche and the management of menarche from school; if they do not get the information from family members, they may have problem to manage during menstrual cycle. In the U.S., schools typically feature health classes, where girls receive information related to puberty and how to handle their body’s changes.

My health class did not go over any of these process however luckily for me my mother was a nurse so she called me and explained to me about all bodily processes and how our body changes as we grow up. (Anita)

I did not really get any information about menstrual cycle from my school. . . . The school in Nepal does not really teach about sex education, so they did not really give me any information about menstruation. We did have a health class in Nepal but they did not teach about menstruation, they taught us about sanitary process and drugs. But we did not really learn about human body and sex

61 education. So I did not get any information from my school about menstruation. (Babita)

I got most of my information from my school. I think from 5th and 7th grade. (Kabita)

Kabita further explains her experience as:

I think, information was good, but I think needs more information. They need to explain it more so that the girls will not scared or panic when they get their first period. They might also perceive their first period wrong because of the lack of information provided by the educator.

Preparedness before the first menstrual cycle makes girls ready to handle the situation. Even with this information, the girls felt scared about their first menstrual cycle.

They expressed their feeling like so:

My mother had talked to me about the menstrual cycle before I had my first menstrual cycle. I knew it was a normal process. However I still felt uneasy and uncomfortable about it. She took her book and showed me the illustration and explained to me the process. She told me that as we grow up our body starts changing and this was one of the normal processes for our bodies. I also had my older sister who already had her first menstrual cycle. She helped me and explained to me many things that were related to the menstrual cycle therefore I knew it was a normal process. However I still felt uneasy and uncomfortable about it although I was glad that I had proper knowledge about what it was. (Anita)

Yes, I got the information from my mother, since she is a healthcare professional. I was really young, so I did not really pay attention to what she was telling me. She explained to me what the menstrual cycle is, because I was always curious about why my mother was not allowed to go to the kitchen every month. So, I always used to ask her why she was not allowed to go to the kitchen. So, she explained the reasons to me. (Babita)

My mom gave me sanitary pads and explained how to use the pad safely. My mother also told me, when I had menstrual period don’t go to praying room. … After my mom provided me sanitary pad, I used pads. I did not get any problem to manage with my menstrual product. (Kabita)

My mother took me to my room and gave me a sanitary pad and explained how to use it safely. So, I used it well, I did not get any problem to use pad

62 because my twin sister had her first menstrual cycle before me and I knew about it. (Ramita)

In the U.S., girls usually learn about the menstrual cycle in the fifth grade.

Then, when the girls have their menstrual cycle, they are more prepared. In Nepal, girls are not given equivalent information. Girls in Nepal are, therefore, not ready to take care of their menstrual cycle and it is extremely difficult and confusing for them. Luckily, the four girls interviewed have mothers who are nurses, and so the girls received some information about the first menstrual cycle.

Looking Forward: Challenging the Older Ways

The girls felt that the rules were very strict and needed to change. They wanted to challenge the older rules and demanded modifications to the traditional stance.

Parents are also modifying their own rules, but they seemed unable to change when members of the older generation were present. Two girls delineate their situation:

The rules are really strict. I do not think during my menstruation cycle that when I touch water it was going to be unsanitary. I think these practices should not be practiced. I wanted to go to the kitchen and get the food, because I am really a neat person and I take really good care of myself. I do not want someone to tell me I am unsanitary. It does not make me feel good; therefore they need to stop the practices. (Anita)

Although the traditions are important because they maintain your culture, the practice of keeping women away from their family and not letting them get involved with the family is not good, since it makes the woman feel bad and hurts them emotionally. When I had my period, even though I was not allowed to get involved with my family and take part in festivals, I think it is good in a sense that, I did not have to help out in the housework, so I had time to rest, which was convenient. Also, they require women to clean themselves, which is a good aspect of the cultural practice. (Babita)

Kabita explained what her mother told her:

63 My mother told me that as she is a nurse she did not restriction during menstrual cycle but we have to follow rule when our grandparent visits. My mother also told me that when a girl has her first monthly period, girl would be kept in separate house for 12 days, but she was not going to do that for us as she thinks it was normal phenomena.

Ramita also described statement her mother explained to her:

My mother told me “I am not going to put any restrictions on you about en- tering the kitchen because it is a normal process, but when your grandparents come to our house, you cannot enter the kitchen when you have your period.”

Kabita and Ramita’s mothers did not restrict their normal activity, with the exception of not allowing them to touch god and go to the praying room. When they had their first menstrual period, their mother did not keep them 12 days separate in one room.

In this way, new generations are willing to challenge older ways. The cultural taboo that the girls have to deal with during their menstrual cycle makes many of the girls feel very depressed and bad about themselves. Many of the girls think these cultural traditions are unnecessary now that they know how to take care of themselves during the menstrual cycle in cleaner and safer ways. Without these cultural taboos, girls will feel less pain and negativity about themselves while on their menstrual cycle.

Summary

This study collected detailed information regarding the lived experiences of girls residing in Northern California about their menstrual cycle. Lived experiences provided information on the following themes: emotional roller coaster about first menstrual period, dealing with negativity while trying to be true to cultural values, trying to balance the differences between traditional and modern customs, cultural confusion: mixed messages from friends/family/elders, rationale behind cultural taboos does not help lessen the

64 confusion or pain, information mismatch between Nepal and the U.S., and looking forward: challenging the older way.

Transitional Statement

Chapter 5 will present the discussion regarding findings, limitations of the study, implications, and recommendations.

CHAPTER V

DISCUSSION

This phenomenological study was conducted in Northern California. In this study, the researcher interviewed four Nepalese girls who emigrated from Nepal to

Northern California. After listening to the lived experiences of the four girls, it was clear that the cultural practices of Nepal need evaluation and modifications so that young girls can handle the new changes occurring in their bodies. The main goal of this phenomenological study was to find out about the lived experiences from young Nepalese girls regarding menarche and their menstrual cycle related to cultural practices. Findings from this study may assist young females who experience hardships adjusting to bodily changes while maintaining respect for their culture.

This chapter will discusses the findings of the study in the context of the literature. The discussion topics that became apparent were emotional effects, negativity, modernization vs. traditional practices, confusion, rationalization, comparison of the source of sexual information between two countries, and cultural modifications. The implications and limitations of the study will also be discussed.

Based on the findings from this study, immigrant Nepalese families that move to the U.S. are not as stringent in following cultural practices related to menarche as the families that remain in Nepal. Leininger’s (1991) Transcultural Nursing Model states that cultural practices that are beneficial to a community should be adopted, while harmful

65 66 practices should be modified. The immigrant Nepalese families in this study follow this model; for example, at the onset of menarche, the girls are not forced to stay in a dark, isolated, and enclosed space without sunlight for twelve days, unlike the Nepalese girls in

Nepal who are still obligated to take part in these practices. Leininger describes a “cultural blindness” that may affect quality of life. Lenininger’s principles clearly support modification by the culture so practices that negatively affect the quality of life can be removed or mitigated, and the ones that facilitate normal life can be adopted. In fact, the mothers of two of the girls from this study incorporated helpful cultural practices and altered practices that hampered the girl’s daily activities.

Emotional Effects

Females go through emotional effects during their first menstrual cycle that affect their normal physiological and emotional health. During puberty, all females experience menarche. Girls are usually scared; they feel uncomfortable and nervous during their first menstrual cycle. Even girls in this study who were prepared for menarche indicated that they were scared. Several cultural restrictions make it harder for the girls to adjust to a normal phenomenon of life. Two of the girls from this study experienced their menarche in Nepal. They had to spend 12 days in a dark room when they had menarche as well as following several cultural restrictions during four days of their normal menstrual cycles. Those cultural restrictions and practices caused the girls to face cultural, physiological, and family conflicts. The combination of cultural expectations and treatment by adults hurt the young girls emotionally. They experienced sadness as a normal process of life caused them to feel isolated. The findings from this study support the

67 claim that girls go through many emotions during their first menstrual cycle, such as those described by Kandel et al. (n.d.). Kandel et al. describe the negative emotional effects of one girl who described a feeling of “torture” she got during menstrual cycle because she had to spend four days in foul-smelling cattle shed during her menstrual cycle.

Girls from this study spoke of being sad because a normal process of life caused them to be isolated and that they were put into a difficult position. The two girls who had their menarche in Nepal also expressed social stress, which came from isolation, and emotional stress, which came from missed classes and other school activities that required catching up. Butler (2011) supports this finding in discussing the experience of one girl who had emotional stress and used to cry during her menstrual cycle. Butler further delineated that this girl had to miss school during menstruation, which lead to low school performance. This type of restriction can lead girls generally to feel depressed.

Negativity

The theme “Dealing with negativity while trying to be true to cultural values” reflects unanimous negativity expressed by the girls regarding cultural restrictions around the menstrual cycle. When the girls had menarche and their menstrual cycle, they had to take care of themselves more than other times in their lives. They sometimes suffered from several problems related to menstruation. Girls usually need assistance to deal with those problems. Instead of getting help, the girls in Nepal had many restrictions during this difficult time, so they developed negative feelings regarding their cultural practices during menarche and the menstrual cycle. Since moving to the U.S., their families have

68 moved away from the restrictions concerning the girl’s menstrual cycle. However, this changed when the girl’s ‘grandparents visited. The older generation continues to be very strict about following cultural practices, so when their grandparents visited from Nepal, the girls must again follow traditions as they ware practiced in Nepal. This practice supports the report of Wafiroh (2008), who described a girl from Nepal who had to live with her grandmother during her menarche. Her grandmother restricted her to not touch her male relatives for 13 days and also restricted her not to go outside in the daylight. Even though the girl did not understand any scientific reasons, she could not go outside during the day and she had to follow the rule (Wafiroh).

As the girls in this study had to follow restrictions, it presented difficulty for them and often made them feel sad or depressed with restrictions applied to them.

Burrows and Johnson (2005) also reinforced that most females in their study had negative perceptions regarding menarche and menstruation. Their study showed that females thought menstruation was an embarrassing and shameful subject for discussion, which led them to have negative feelings regarding the cultural practices they experienced.

Modernization vs. Traditional Practices

Nepalese girls who experienced menarche in Nepal (when they were in Nepal) had to use and reuse pieces of cloth for menstrual protection. They had to use them several times, but were expected to wash and dry these cloths privately. Bharadwai and

Pakter (2008) supported the experience of girls who had their menarche in Nepal. Their study reported that most Bangladeshi women use a piece of cloth to manage their menstrual product, drying these pieces in dark, unsanitary places. However, the girls in this

69 study, after moving to the U.S., were able to use sanitary pads. Families of the girls who began menstruation in the U.S. follow modern cultural practices for some aspects of the menstrual cycle, whereas in Nepal, girls still practice traditional and primitive ways to deal with menstruation. Two girls who had menarche in Nepal in this study expressed how their lack of resources made it hard for them to adjust to daily activities of life and might lead to several health problems. So, they disliked the traditional ways and were happy to practice modern ways when dealing with the menstrual cycle. After moving to the U.S., all of the girls were spared the harsh cultural practices observed in Nepal, because their parents had allowed for cultural modifications following immigration.

The families that moved to the U.S. are still practicing their Nepalese culture, but they have modified some of the cultural practices that hinder daily activities during the menstrual cycle. As described by Leininger’s (1991)Sunrise Model, cultural practices that are beneficial to a community should be adopted, while harmful practices should be modified. Indeed, Leininger’s description of cultural care re-patterning provides a new, different, and beneficial health care pattern by respecting one’s own cultural values

(Leininger). This theory, in practice, was adopted by the Nepalese immigrant families in this study once they migrated to the U.S. The girls in this study stated that they were happier in the U.S. because they did not have to follow strict rules and were able to afford and use sanitary pads for protection. This practice supports the work of Patel and Power

(1996), who report that Indian immigrants to the U.S. tried to maintain their cultural values with an emphasis on manners, politeness, and respect for seniors, while at the same time becoming highly acculturated and Americanized in other ways.

70 Confusion

The girls in this study experienced cultural confusion by getting mixed messages from their elders. The girl’s mothers told them that the menstrual cycle is a normal process of life. This caused confusion in the girls, because they wondered why restrictions should be put on a normal phenomenon of life. They were surprised that they could not talk about menstrual problems openly. These experiences made the girls confused as to why they had to obey such restrictions. As girls need to keep their menstrual cycle a secret (according to tradition), if a girl faces any problems with her menarche and menstrual cycle, she cannot ask anyone for help. The limited education this situation engenders creates more problems and confusion than girls would normally face during menarche. As Kirk and Sommer (2006) describe, Nepalese girls are not able to talk openly about menstruation because it is seen as a taboo due to cultural restrictions. This practice is also supported by the work of Dhingra et al. (2009), who found that every girl was told by their mother that the menstrual cycle is a process of removal of dirty blood from the body, which is necessary for every girl to keep them healthy. They were restricted from visiting religious places and touching water; they were told not to look in a mirror, to avoid regular bathing, brushing their teeth, and combing their hair. They had to wash and dry used cloths in secret. Those studies and the current study results support the notion that girls were confused regarding the reason of restrictions during menstrual cycle.

71 Rationalization

The girls expressed wonder that Nepalese girls had so many cultural restrictions during their menstrual cycle. Only the girls who had their first menstrual cycle in the U.S. were told by their mothers the reason for these cultural practices. They might have been treated differently, they were told, had they begun menstruation in Nepal, because of that developing country’s unhygienic conditions. In turn, during the menstrual cycle, girls and women in Nepal are not able to clean themselves and manage their menstrual product well due to a lack of resources. This rationale is supported by Oster and

Thornton (2010), who state that 98% of the girls in Nepal use and re-use cloths for protection during their menstrual cycle. Despite being given explanations by their mothers, the girls were still left confused as to why a normal life process was looked upon with disgust and negativity.

Comparison of Source of Sexual Information in Two Countries

The theme “Information mismatch between Nepal and the U.S.” describes how, in developed countries, schools offer curricula to educate girls about menstruation before menarche, whereas Nepalese schools do not have such a curriculum. The girls in the U.S. were given information about growth and development from their health classes in fifth grade, in addition to the information their mothers gave them. Unfortunately, the two girls who had menarche in Nepal got information regarding menarche from their mothers only. Francoeur (n.d. ) reports that, in Nepali schools’ curricula, reproductive health is covered only in the ninth and tenth grades. Teachers providing education are not trained in sexuality issues, so they could not discuss the topics well, and some teachers

72 did not even address the topic, while others provided lectures without discussion. Parents were not given resources for sexual information either. The results of the Francoeur study show that government hospitals are the main source for sexual information in Nepal.

Another study, by Tiwari, Oza and Tiwari (2006), shows that in India, the main source of information regarding menarche is the mother. According to this study, 60.7% of girls got their information from their mother, 15.8% from a sibling, and teachers and others play a smaller role. Dasgupta and Sankar (2007) also report that in India the mother is the source of information related to menarche and menstrual cycle 37.5% of the time. This study also shows that 32.5% of girls did not receive any information before menarche, and the rest got information from friends and relatives. These findings demonstrate that teachers play a limited role in providing information to adolescents in developing countries, whereas this is not the case in the U.S., as evidenced by stories from the girls in this study.

Cultural Modification

The situations of girls who had their menarche in the U.S. and Nepal were observed to be incredibly different. In the U.S., cultural modification is beneficial, as suggested by Leininger’s (1991) Sunrise Model. Restrictions and ceremonies that inter- rupt daily activities—which could also be harmful to the body—have been removed or modified, and those that are beneficial have been adopted. For example, the 12-day ceremony for first menstruation has been abandoned in the U.S., but this still takes place in

Nepal.

73 The girls interviewed in this study were able to provide detailed, lived experiences of menarche and other menstrual cycles. They were very interested in discussing their problems and ideas. The girls who experienced menarche in Nepal stated that they were happier in the U.S. because most of the cultural restrictions related to menstruation had been removed. They were glad that they at least had received preinformation about menarche from their mothers, even though they did not receive a rationale as to why such cultural restrictions were applied to them during menarche and menstrual cycles. Even though all of the girls’ mothers are nurses, and they provided preinformation regarding menarche and menstrual cycle to them, the two girls who experienced menarche in the U.S. did not need to follow restrictions, as did the other two girls who had their menstrual cycle in Nepal. This information demonstrates that families in this study who moved to the U.S. modified some of the cultural restrictions related to menarche and menstrual cycle. This is supported by Petkova (2007), who describes a

Nepalese girl who combined two cultures: one, her traditional culture, the other, that of her adopted home in the U.S. Petkova states that the girl kept her cultural ways to maintain abstinence before marriage, but she talked openly—in an “American way”— regarding sexual matters, which are not usually discussed in Nepal. This definitely shows that immigrant Nepalese-Americans modify their culture to make it better or easier for life.

Limitations of the Study

This study is limited to only four participants who migrated from Nepal to

Northern California. Two of them had their first menstrual cycle in Nepal before arriving

74 in the U.S., while the other two had their first menstrual cycle in the U.S. Even though this study focuses on a small group, this work provides in-depth and lived experiences of the four girls. Although the findings cannot be generalized to other populations, it is beneficial to get an in-depth look at this phenomenon so that others can determine if the same findings apply to girls in similar situations elsewhere and in other cultures.

Implications of the Study

The research highlights that there are many cultural problems for Nepalese girls regarding menarche. This phenomenological study represents the main problems that are related to the first menstrual cycle and other menstrual cycles. The study supports the idea that many girls in other countries continue to have problems with the cultural practices that take place during menarche and other menstrual cycles, a situation that needs to be addressed and modified.

Implications for Practice

This study reports that the participating girls want to adapt rules that help them keep clean, and they do not want the world to view menstruating girls as impure, because they agreed with the medical understanding that the menstrual cycle is a normal process of life that all females experience. The girls feel that they can take care of themselves and keep clean, making it unnecessary to be perceived as dirty. The cultural practices in Nepal could be improved through encouraging females to keep clean, to take daily baths, and change their underclothes frequently when soiled. While it is ideal to use sanitary pads or tampons for protection, if these items are unavailable or not affordable

75 and the girl needs to use a piece of cloth for protection, then the cloth should be cleaned regularly and dried, either in sunlight or by using an iron to thoroughly kill bacteria.

In order to clarify any confusion or problems that may arise concerning menstruation, nurses working in health posts, health centers, hospitals, and other health organizations in Nepal must find opportunities to teach adolescents, parents, and grandparents about all aspects of the menstrual cycle and management of the menstrual product. The reports from Nemade, Anjenaya, and Gujar (2009) provide examples of success- ful educational interventions about menstrual teaching. Their pretest report shows that only 51.28% of girls used to wash menstrual cloths with soap and water, but at the post- test this number increased to 87%. This report claimed that improved menstrual hygiene occurred after girls received health education.

Implications for Research

This study is limited to only four adolescents residing in Northern California.

Further research on a large population group and different geographical regions of Nepal will help to compare the results and make further recommendations. It might be of use to study the school curriculum, the rituals of menarche, menstrual taboos, and the management of menstrual product in the many different regions of Nepal. This study also sug- gests the benefits of studying adolescents’ problems with managing the menstrual product in different schools in Nepal, in order to learn how best to educate girls and address their problems.

Implications of Education

In Nepal, teachers or school nurses need to work in small groups to minimize embarrassment and to discuss problems related to menstruation, while teachers need to

76 create an environment where discussing subjects like sexuality is as comfortable as possible. The curriculum in Nepal needs to be reviewed, with a requirement for classes on puberty and sex education. Current or incoming teachers should also be given training so that they are able to teach classes on growth and development of the human body. The

UNICEF regional Office for South Asia in Nepal has a program for developing rights- based education Sector Wide Approaches (SWAps) in South Asia. The program description states that “children, parents and communities have a right to participate in decisions about education” (Durston, Seel, Evans, & Huebler, 2008, p. 39). This description makes it clear that it is beneficial to add programs to educate the parents and the community regarding the normal menstrual cycle and proper care during menstrual cycle.

Summary, Conclusions, and Recommendation

This study collected in-depth data from four adolescent girls residing in

Northern California. The results of this study supported the literature review. For example, all the girls were scared during their first menstrual cycle. Chang et al. (2009) tell stories of girls’ fears regarding menstruation. To prevent such apprehension, it is recom- mended that an education program for premenstrual girls be initiated. Pediatric nurses and school nurses are appropriate health care professionals for educating young girls.

To avoid an extreme or traumatic response to menarche, girls should be well supported, and they should also receive detailed information regarding the management of menstruation and menarche. In this way, girls may welcome their first menstrual cycle as a normal phenomenon of growth and development, instead of becoming unduly scared or feeling bad about their bodily changes. This study recommends research on a large

77 population in different regions and different ethnic groups of Nepal, which will provide more examples of lived experiences from different regions of Nepal; this will be useful and instructive, because different regions and different ethnic groups have different cultural practices regarding the menstrual cycle.

As shown from the lived experiences of the immigrant girls from Nepal, there are no health classes in that country providing information regarding the menstrual cycle and management of the menstrual product. This study recommends the addition of health classes between grades five to seven, providing education on menstruation and care of menstrual product for girls before they have their menarche. This will help girls manage their first menstrual cycle without becoming frightened or experiencing traumatic problems. Educating parents and grandparents is crucial as well, in order to modify strict cultural practices regarding the first and subsequent menstrual cycles.

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APPENDIX A

ASSENT FORM FOR THE PARTICIPANT

Study Title: The lived experience of menarche in Nepalese Adolescents: A phenomenological study Investigator: Ms. Sita Devkota (Registered Nurse) is a student of the Masters of Science in Nursing program (MSN) at California State University, Chico. Purpose of the study: I would like to invite you to participate in this study about the cultural practices regarding the beginning of your menstrual cycle and your monthly period in Nepalese adolescent immigrants in Northern California. The reason I am asking you to participate in this study is because you are an adolescent who began your menstrual period in Nepal and immigrated to the USA within the last five years. Ethical Considerations: This study has been approved by the Human Subjects Research Committee (HSRC) of California State University, Chico. This study will not harm you, but it may take time to think about your responses. There is a potential benefit of improving health of other adolescent girls of Nepalese descent. All information that you provide will be kept confidential. You will not need to give your name, as a pseudonym or different name will be used for you. I will use this pseudonym when reporting what I find during the interview. There will be no information in the report that will connect you with what you specifically said in the interview. The form you sign will not be linked with anything that you say during the interview, it is only to give to give permission for me to talk to you. Sometimes when we talk about sensitive topics it doesn’t bother us at the time but we can feel upset later. If this happens to you and you want to talk to someone about your feelings you can call Kami B. Bath, MSN (Family Nurse Practitioner), Olivehurst, CA, office phone: +1-530-673-9420 and home phone: +1-530-751-1174. Data Collection: I would like to talk to you about when you began having your period and your current monthly periods. This will take about 45 and 90 minutes. We will talk in a private room in your home. You can decide whether you will want one or both 92 93 of your parents to be with you, or if you want to be by yourself. Talking to me about your experiences is up to you. If you feel uncomfortable before or during the time we are talking, you can stop at any time, with no consequences. What you say about your experiences is greatly valued. A scientific calculator and a thank-you note will be given to you for your participation. If you have any questions regarding this study, you can call me at +1-530-751-3831, or email me at the [email protected]. I have read this assent form and I voluntarily agree to participate in this study.

Student’s signature:

______Date:______

APPENDIX B

PARENT CONSENT FORM

Study Title: The lived experience of menarche in Nepalese Adolescents: A phenomenological study Investigator: Ms. Sita Devkota (Registered Nurse) is a student of the Masters of Science in Nursing program (MSN) at California State University, Chico. Purpose of the study: The purpose of this study is to explore the experiences of cultural practices regarding menarche and the monthly cycle in Nepalese adolescent immigrants in Northern California. This study is expected to provide benefits in improving health care for adolescent girls. Ethical Considerations: This study has been approved by the Human Subjects Research Committee (HSRC) of California State University, Chico. This study will not harm your daughter, but it may take time for your daughter to think about her responses. All information provided will be kept confidential, and will be used only for the purpose of this study. Your daughter will not need to give her name on the tape recording, as pseudonym will be used for your daughter. I will use this pseudonym when reporting what I find during the interview. I will use direct quotes in reporting the findings, but pseudonyms will be used so there will be no way to connect anything your adolescent says with the report. Data Collection: I would like to invite your daughter’s participation in this study about the cultural practices regarding menarche and the monthly period in Nepalese adolescent immigrants in Northern California. The reason, I am asking your daughter to participate in this study is because your daughter is an adolescent who began her menstrual period in Nepal and immigrated to the USA within the last five years. I would like to talk to your daughter about her onset of menarche and her monthly periods. This will take about 45 to 90 minutes to complete. The interview will be conducted in a separate room of your home. Participation in this study is voluntary. If your daughter feels uncomfortable before or during the interview, she can stop the

95 96 interview at any time, with no consequences. Your daughter’s participation will be greatly valued. A scientific calculator and a thank-you note will be given to your daughter for her participation. The form you sign will not be linked with anything that your daughter says during the interview, it is only to give to give permission for me to talk to your daughter. Sometimes when we talk about sensitive topics it doesn’t bother us at the time but we can feel upset later. If this happens to you daughter and your daughter wants to talk to someone about her feelings she can call Kami B. Bath MSN (Family Nurse Practitioner), Olivehurst, CA, office phone: 530-673-9420 and home phone: +1- 530-751-1174. Researcher contact: If you have any questions regarding this study, you can call me at +1-530-751-3831, or email me at the [email protected]. I have read this consent form and I voluntarily agree to allow my child to participate in this study.

Parent’s signature: ______Date: ______

Printed name and address: ______

APPENDIX C

HUMAN SUBJECTS

APPENDIX D

SIGNIFICANT STATEMENTS, FORMULATED

MEANINGS AND THEMES

Significant statement Formulated meanings Clusters of themes 1: I was panicked a little then I ran into my Inner feelings regarding Emotional roller coaster room and told my older sister what had hap- menarche about first menstrual pened. cycle 1: I knew that our body changes and having my Scared and mad about first menstruation meant that my body is menstrual cycle changing and growing with me. I knew these were all normal process however I was still uncomfortable and uneasy since it was my first menstruation and it happened suddenly. Al- though I knew it was normal, I was scared of these changes. 1: It was my first time. I was really uncomforta- Uncomfortable feelings ble because it was the first time and I knew that during first menstrual cycle it was change and sometimes changes are really hard and uneasy to get used to. 2: My mother was in America, so I did not re- Scared at first menstrual ally know what it was until it happened. I was period because mother really scared and did not understand what it was. absent during her first I was confused because I did not know what was menstrual cycle going on. 2: I went through a lot of emotions when I had Emotional effects from first my first period. I was scared because I did not menstrual period know what was happening even though my mother explained to me what the period was. 2: My parents, my sister, and my brother used to Feeling bad even though come to my room and tell me not to feel bad, menstrual cycle is normal but I could not help feeling bad. Also my process grandmother is really strict about me following the traditions related to the menstrual cycle, so when I sat next to her accidentally, she used to say that she got sick because of me. 2: Therefore, I do not think those cultural prac- Feeling left behind tices should be practiced, even though it is good in some ways, but it also hurts women emotionally.

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Significant statement Formulated meanings Clusters of themes 3: At first, I thought I peed on myself, but when Scared about first menstrual I went to the bathroom, I could see a lot of cycle blood in the toilet bowl. I got scared and came back to my room. 1: Bad point of having these cultural taboos Feelings of depression due Dealing with negativity well! When I had my first menstrual cycle, I had to cultural practice during while trying to be true to to stay in a room for 12 days! I was not allowed first menstrual cycle cultural values. to meet my family members or talk to them so I really missed them. The room I stayed in was very dark without sunlight since I could not see sunlight for 12 days it was a little depressing. 2: I have experienced this situation several Emotional effects related to times. I used to see my family enjoying each restriction on menstrual other and participating in festivals. But since I cycle because of isolation could not participate in the festivals, I used to be from family members in my room by myself, not being able to take part in the family’s observances of festivals. 3: I wanted to cry because of the restrictions, I Emotional effect on female did not have any restriction when my grand- related with restriction on parents were not with us, but when they were menstrual cycle with me I had hard time when I had my menstrual cycle. I love my grandparents very much, but restriction at time of monthly cycle, I did not like it. I also did not like my grandparents’ behavior towards me when I had menstrual period. After they went back to Nepal, I was allowed to enter the kitchen again even during my menstrual cycle, so I felt better even though I missed my grandparents very much. 3: Yes, I feel uncomfortable with restrictions. I Bad feelings due to did not like behave differently when I had my religious restrictions during menstrual cycle. I know, it is normal phenomena menstrual cycle for female and I am keeping myself clean. I don’t think females need to behave differently at time of menstrual cycle if they keep them clean. 4: Sadly, my grandpa passed away after he went Emotional effects on the back to Nepal after one year, I was very upset girl due to cultural beliefs; about it. Sometimes, I thought, was it happen at some level she believes in because of me(?), then I explained myself, no, the cultural traditions, thus menstruation is normal process. It must be be- was upset that she might cause of his health condition. I love my grand- have contributed to her parents very much. I missed them. grandfather’s death 1: Although I have to stay away from family Girl’s feelings about cul- members and friends I am absolutely fine with tural practices regarding these traditions because these are our cultures menstrual cycle and traditions that had been practiced from generations before me and will be practiced genera-

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Significant statement Formulated meanings Clusters of themes tions after me so I am just glad to be continuing the cycle. I think these traditions make our culture unique. Personally, I really enjoyed being a part of it even though sometimes the rules and regulations were kind of strict. 2: I like my cultural practices, but I do not agree Girl’s feelings about cul- with the traditions associated with the menstrual tural practices regarding cycle. When I had to follow the traditions asso- menstrual cycle ciated with menstrual cycle in Nepal, I felt really bad about myself. Therefore I think these traditions are there to make women feel bad about them. 2: It is good in the sense that they let you rest Girl’s feelings about cul- because you are not allowed to go outside or get tural practices regarding involved in the family work. But, it is bad be- menstrual cycle cause you are by yourself so you are isolated from the family.

4: It was actually fun because I got to order my Feelings toward religious sister around. I would tell my sister to get me a restrictions during men- glass of water or some food for me and she strual cycle; the younger would say “No”. So, I would tell her that I can- generation has very differ- not go to the kitchen remember. So it was really ent values from the older fun. It was a hassle sometimes because I could generation not go to the kitchen when I wanted something. So, if my sister was not home or she was busy, I would have to wait for someone to get the thing I wanted from the kitchen so it was a little inconvenient at sometimes. 4: Since, I had my period; I did not have to do Enjoys having fewer house- any house hold chores, so that was convenient hold chores for me. 4: When my grandparents visited us, it was little Feelings about restrictions inconvenient sometimes. As I told you, most of when grandparents visited time I enjoyed it because I could order my sister and tease her time to time when I needed something and she had to bring it for me. When she had her menstrual period, I had to help her too but she usually did not tease me. 1: But in Nepal, sanitary pads are not used often, Piece of cloth used for Trying to balance the instead we used piece of cloth for protection. I protection during menstrual differences between also have to use the piece of cloth. She also told cycle traditional and modern me that I have to clean them for daily use. customs 1: Those pieces of clothes I had to use over and Repeated use of piece of over again so what I would do. I used to clean cloth for menstrual protec- them in the bathroom and air dry them in the tion

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Significant statement Formulated meanings Clusters of themes room. It would be embarrassing if someone saw them so I keep them in my room. 2: When I was in Nepal, it was not common for Management of menstrual women to wear sanitary pads. I used to wear a product with a piece of piece of cotton cloth as the pad in Nepal. When cotton cloth in Nepal, pri- the cloth was used I would change it. I used to mitive practices in Nepal stock cotton cloths and wear them, so I would not leak. Because, unlike the sanitary pads, cotton cloths definitely leak. After I changed a cloth, I used to wash it in warm water, and I used to sun-dry those cloths I had used. It is uncommon for people to own washing machines in Nepal, so I used to hand-wash my cloths and dry them. 2: In Nepal when I was in school, I used to Management of menstrual change and put the cotton cloth in a plastic and product in school in Nepal keep it in my bag, and take it home and wash it. In here, after I change my pad, I wrap it up with a toilet paper and dispose it in the trash. 3: After my mom provided me sanitary pad, I Management of menstrua- used pads. I did not get any problem to manage tion cycle product by using with my menstrual product. I do not really get sanitary pads bad cramps. But, sometimes I do get bad cramps, so I used to sleep a lot. 3 Well, in the first day, it is not really bad; I do Management of menstrual not bleed a lot. I bleed really little so I change product my sanitary pad once a day.

In the second day, I get little more bleeding compared to the first day, but it is manage able. So, I change the sanitary pad may be two or three times a day.

In the third day, I usually bleed a lot, so I have to change my pad a lot more. I usually change it for like three to four times a day. 4: Sometimes it is a little awkward, you know. If Problem of menstruation in someone asks if they can see my backpack, I school would be like no you can’t. So, it is a little awkward in that and I had to go to the bathroom after or during every class period ended. So, it was kind of a hassle. When I told the teacher that I just have to go to the bathroom, it was kind of awkward. But, the teachers understand that I am a girl so they are totally about it. It is awkward because the students are just looking at you and it was embarrassing because of that. But, everybody does understand because they

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Significant statement Formulated meanings Clusters of themes have all been to the health class because in sixth and seventh grade, the girls and boys had to take the health class together. So, everybody knows; it is not like a big deal. 1: There are culture events that take place when Cultural ways to deal with Cultural confusion: a girl has her first menstrual cycle and those also menarche mixed messages from applied to me. Immediately after, she told me all friends/family/elders the culture rules and regulations. She took me to elders upstairs since our house was a three-storey house. The middle floor was unoccupied. She took me to a room there and told me to stay only in the room. The room I stayed in was very dark and not a glimpse of sunlight was allowed to come in the room, and I would have to stay like this for 12 days. 1: For the first menstruation cycle I had to stay Cultural practice requires in a dark room for 12 days. The room, I stayed that girls stay in dark room was very dark and not a glimpse of sunlight that for 12 days was allowed to come in the room and I would have to stay like this for 12 days. 1: After the 12 days ended, on the morning of Cultural celebration on first the 13th day, I had to take bath before sunrise, menstrual cycle and then I dressed in a traditional dress. After that I was allowed to come out and the first thing 1: I had to do was pray to the sun at sunrise. After praying, I was allowed to meet my other family members and receive a blessing from all the elders from my household. 2: After a while she came to my room and told Cultural practice is to keep me to take a shower and clean myself, and go adolescent in dark room for back to my room. So, I took a shower and went 12 days because of first to my room. My grandmother came to my room period and put curtains all around my room. It was really dark inside the room even though there was sun outside. She told me that I had to stay in the room for twelve days because it is our traditions we follow after we become a woman. 2: Usually when I had to go to the bathroom, my Cultural restriction to stay sister would go and tell my family member that away from male members I was going to the bathroom, so my family of house for 12 days members would go into a separate room. My clothes and the things I used were kept separated from other family members. My grandmother or my sister used to serve me food every day. So, that is how I stayed for twelve days. 2: After twelve days, my grandmother told me Religious celebration after to take a shower. I remember that it was really 12 days of first menstrual

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Significant statement Formulated meanings Clusters of themes cold in the morning so she warmed water for me cycle so I could take a shower. After I was done taking a shower, my grandmother handed me Nepalese traditional dress to wear. I wore the traditional dress and came outside. After that I was allowed to see my family members, so I went to my family and got a blessing from them. Even though it was after the twelve days and I was allowed to meet my family, I was still not allowed to enter the kitchen or the temple. Al- though I was allowed to see my family, I was still not allowed to go to certain rooms, so I felt like a visitor in my own house. 4: She explained to me that in Nepal even Religious celebration after people keep 12 days in separate house for girl 12 days of first menstrual when girl has first menstrual cycle. Female cycle could not touch water, food, anything which use for praying god. Menstrual girl could not touch senior male member of family too. I just wonder about it. 4: She told me it is our cultural restriction to Religious restriction during female. She explained to me that in Nepal even menstrual cycle in Nepal people keep 12 days in separate house for girl when girl has first menstrual cycle. Female could not touch water, food, anything which use for praying god. Menstrual girl could not touch senior male member of family too. I just wonder about it. 2: Usually, my mother or sister used to get a Primitive behavior of older bucket of water and separated it for me and that generation during menstrual is what I used to clean my dishes, myself, and cycle in Nepal my clothes. After the fourth day, on the fifth day, I had to take a shower in the morning and after I clean myself and wear clean clothes, I was allowed to go to the kitchen. The bedding supplies and clothes I used were sprayed in gold water by my grandmother. My grandmother used to dip gold into a bucket of water and spray it on my clothes so it is pure. Even though, I was allowed to go to the kitchen after the fourth day, I was not allowed to go to the temple. So, on the seventh day I was allowed to go to the temple after I took a shower, cleaned myself and wore new clothes. 2: When I had my period in Nepal, my parents Primitive behavior of older and my siblings did not really treat me diffe- generation during menstrual rently, but my grandmother, since she is very cycle in Nepal traditional, she used to treat me differently so I

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Significant statement Formulated meanings Clusters of themes felt bad about myself. Therefore, being excluded from the family during the period is a problem. 2: Also my grandmother is really strict about me Primitive behavior of older following the traditions related with menstrual generation during menstrual cycle, so when I sat next to her accidentally, she cycle in Nepal used to say that she got sick because of me. Therefore, I do not think those cultural practices should be practiced even though it is good in some ways, but it also hurts the women emotionally. 4: In normal menstrual cycle, I did not feel ab- Primitive behavior of older normal because I was not praying every day and generation during menstrual there was no other restriction. So later on, when cycle my grandparents came to visit, I was not allowed to enter the kitchen and touch the praying room. It was nothing that drastic because I was still allowed to look at the male member of my family. I couldn’t touch the elder male of the family though. I needed to ask my sister and mom for my food. I needed to eat in separate room. 4: Oh… yes! One day, I touch my grandpa acci- Primitive behavior of older dentally when I had my menstrual cycle then my generation during menstrual grandma, got angry with me. She told me, it cycle affects health of my grandpa, he might get sick. I got wondered about that. I talked with my mom, she told me to not argue with your grandparents; just follow what they wanted from you. They would stay with us for five to six months only and she did not want to make them angry. Then, when my grandparents with us, I was more conscious not to touch them and followed restriction when I had my menstrual period. 3: She told me that in Nepal female unable to Unhygienic conditions Rationale behind cul- keep them clean when they had menstrual cycle. during menstrual cycle in tural taboos are ex- They did not use pad and their menstrual prod- Nepal plained by history but uct all over on their linens. They would only explanation of history take bath on day 4 and 7 only. It was actually does not help; lessen the very unhygienic condition for them. It might be confusion or pain reason, people treat them like un-pure when they had menstrual cycle. 4: She explained to me, she did not know exact Unhygienic conditions reason behind it. But she told me that it might be during menstrual cycle in because of unhygienic condition of female dur- Nepal ing menstrual period in Nepal. She told me in Nepal there was not enough water available for bath and wash. It was hard to supply even soap for bath and wash. Female only allowed taking

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Significant statement Formulated meanings Clusters of themes bath on day four and day seven. Day four, they had to take bath and wash all their linens. On day seven, they had to take bath again before regular pray. In village of Nepal, even female did not use any protection during menstrual cycle. 4: They had to wear same dress for four days Possible reason for because they did not use any protection, blood restrictions all over their linens. Because of those unhygienic conditions of female during menstrual cycle, people restricted female so they did not conta- minated menstrual blood to food, water... No sex education for Information mismatch 2: I did not really get any information about adolescents in Nepalese between Nepal and the menstrual cycle from my school. schools U. S. 4: Yes, at school, in fifth grade they taught us Source of pre-information about menstruation cycle in my health class. regarding menstrual cycle They put girls and boys in a separate room and they talked about the menstrual cycle to us girls.

4: Yeah, and because my sister had her period Information from mother before I did so my mom talked to us about it. and sister to prepare her for So, I also got my information from my mom and first menstrual cycle my sister too. I guess I was lucky because I had my first menstrual cycle after my twin sister had hers. I got a chance to learn about it from her. I knew about menstruation and I knew it would happen to me soon. I mean, I was ready for my first menstrual cycle and I did not get scared when I had my first menstrual cycle. 2: The school in Nepal does not really teach No sex education from about sex education, so they did not really give schools in Nepal, which me any information about menstruation. We did contributed to lack of have a health class in Nepal but they did not preparedness of adolescent teach about menstruation, they taught us about for first menstrual cycle sanitary process and drugs. But we did not really learn about human body and sex education. So I did not get any information from my school about menstruation. 3: I think, information was good, but I think Suggestion for needs more information. They need to explain it preinformation more so that the girls will not scared or panic when they get their first period 3: They might also perceive their first period May have misperceptions if wrong because of the lack of information pro- detailed information is not vided by the educator. Ah…., I think, it is better received before first men-

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Significant statement Formulated meanings Clusters of themes to add, usually age of menarche, and different strual cycle factor affect menarche, how can manage menstrual product … 4: I think, it was somewhat enough but if it give Suggestion from girl for more information about how to manage men- content of information at strual product it may be more useful for young school education girl. I got information from my mom and sister so I did not have any problem. I may be problem for young girl if they do not know how to use sanitary pad. One of my Nepalese friends did not know how to use sanitary pad and she was asking with me when she had her monthly period. I showed her how to use sanitary pad safely. We did not use tampon even it is good to know how to use tampon safely too. 1: The rules are really strict. I do not think dur- Cultural practices that Looking forward: chal- ing my menstruation cycle that when I touch should be modified lenging the older ways water it was going to be unsanitary. I think these practices should not be practiced. I wanted to go to the kitchen and get the food, because I am really a neat person and I take really good care of myself. I do not want someone to tell me I am unsanitary. It does not make me feel good; therefore they need to stop the practices. 1: The rules are really strict. I do not think dur- Cultural practices that ing my menstruation cycle that when I touch should be modified water it was going to be unsanitary. I think these practices should not be practiced. I wanted to go to the kitchen and get the food, because I am really a neat person and I take really good care of myself. I do not want someone to tell me I am unsanitary. It does not make me feel good; therefore they need to stop the practices. 3: I think, information was good, but I think Suggestion for needs more information. They need to explain it preinformation more so that the girls will not scared or panic when they get their first period 3: They might also perceive their first period May have misperceptions if wrong because of the lack of information pro- detailed information is not vided by the educator. Ah…., I think, it is better received before first men- to add, usually age of menarche, and different strual cycle factor affect menarche, how can manage menstrual product … 4: I think, it was somewhat enough but if it give Suggestion from girl for more information about how to manage men- content of information at strual product it may be more useful for young school education girl. I got information from my mom and sister

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Significant statement Formulated meanings Clusters of themes so I did not have any problem. I may be problem for young girl if they do not know how to use sanitary pad. One of my Nepalese friends did not know how to use sanitary pad and she was asking with me when she had her monthly period. I showed her how to use sanitary pad safely. We did not use tampon even it is good to know how to use tampon safely too.