Not just a Women’s issue: Menstrual Stigma in Farming Households in Nepal

We evaluate a participatory, community-based intervention designed to reduce menstrual stigma in rural Nepal. The intervention draws on elements developed by an experienced local NGO-the Global South Coalition for Dignified Menstruation (GSCDM)-which has worked in this sector for over two decades. Delivery occurs through half-day workshops facilitated by moderators trained by GSCDM in collaboration with the study team. All workshops are conducted in village community spaces across Chitwan district in November 2025.
Facilitators follow a standardized protocol centered on three components: (i) biological education on menstruation, (ii) critical reflection on lived experiences framed in terms of human and constitutional rights, and (iii) norm-challenging activities grounded in behavioral science, including empathy-building and belief-updating exercises.

We evaluate a participatory, community-based intervention designed to reduce menstrual stigma in rural Nepal. The intervention draws on elements developed by an experienced local NGO-the Global South Coalition for Dignified Menstruation (GSCDM)-which has worked in this sector for over two decades. Delivery occurs through half-day workshops facilitated by moderators trained by GSCDM in collaboration with the study team. All workshops are conducted in village community spaces across Chitwan and East Nawalparasi districts in November 2025.
Facilitators follow a standardized protocol centered on three components: (i) biological education on menstruation, (ii) critical reflection on lived experiences framed in terms of human and constitutional rights, and (iii) norm-challenging activities grounded in behavioral science, including empathy-building and belief-updating exercises.

The study features three mutually exclusive treatment arms:
1. T1 - Women-only workshop: eight married women per village.
2. T2 - Mixed-gender workshop: eight married couples per village.
3. Control - Placebo workshop: eight married women discuss agricultural experiences unrelated to menstruation.
Program participation is defined as attendance at the assigned workshop. All participants are recruited under the condition that they can bring both their spouse and a female friend for survey participation, ensuring a consistent triad structure across arms. In T1 and Control, only women attend the workshop, but both spouses participate in the baseline survey, and all triad members (focal woman, husband, female peer) participate in the endline survey.
Randomization is conducted at the village level to avoid contamination. We first exclude the 20% of villages with the lowest agricultural employment shares (based on Census data) to avoid urban areas, as well as villages with safety or security concerns due to ongoing land disputes or proximity to national parks and wildlife. We then apply covariate-constrained randomization following the multi-arm extension proposed by (Zhou et al., 2022) for three-arm trials. Covariates, drawn from administrative and census sources, include municipality, population size and demographic composition, out-migration rates, ward-level agricultural employment, proximity to infrastructure (schools, health posts, towns), and grid-level relative wealth from the Relative Wealth Index (RWI).
Participants in selected villages are recruited through agricultural cooperatives, with lists and contacts obtained from municipal- and ward-level governments. Cooperative leaders are instructed to recruit at least 25% of participants from Dalits and other historically marginalized castes. Additional eligibility criteria require that participants be married, of reproductive age, not pregnant or breastfeeding, and that both spouses reside in Nepal.
To minimize performance and expectancy bias, participants are told only that the study concerns “health and life experiences in agricultural communities.” They are not informed which intervention is expected to have an effect or which outcomes are of primary interest. Survey and implementation teams are fully separated: enumerators collecting baseline and endline data are blind to treatment assignment, follow identical scripts across arms, and are unaware of the study hypotheses. In addition to self-reported outcomes, we employ partially incentivized measures—including willingness-to-pay tasks and social norm elicitation games—to limit hypothesis guessing and social desirability bias.

2025-11-11

2026-02-28

There are four primary outcomes.
Three partially incentivized indices—(i) menstrual stigma, (ii) normative attitudes about menstruation, (iii) perceived social norms, and (iv) a self-reported index of menstrual practices.

Primary outcome 1: Menstrual stigma.
The Menstrual Stigma index consists of four subindices: survey-based menstrual stigma, observed shame evaluated by enumerators, incentivized willingness to speak about menstruation, and an incentivized measure of the penalty in willingness to pay for ghee (clarified butter) touched by a menstruating woman.

Primary outcome 2: Normative attitudes about menstruation
The Normative attitudes about menstruation index consists of two subindexes: Survey based Personal beliefs and attitudes, and Incentivized Donation to fight menstruation taboos.

Primary outcome 3. Perceived social norm about menstruation
The Perceived Social Norms About Menstruation index consists of two subindices: an incentivized measure of perceived social norms regarding behavior during menstruation, and a survey-based measure of second-order beliefs.

Primary outcome 4: Menstrual practices is constructed based based on the following questions (differently for men and women)
1. During your last menstrual period, how much effort did you put into not to being seen during washing, drying and disposal of your menstrual product
Follow-up question:
What did you do to avoid being seen?

2. Now think about the past two months and the times you menstruated. How was your workload in terms of work you do outside of the household for tasks such as working in the field, getting firewood, cutting grass or other tasks that do not take place at home when you were menstruating compared to when you were not menstruating?

3.Explicit following of practices: For each of the following, state whether you (for women)/your wife (for men) did it during your/her last menstruation or not?
- Going to the market and buying groceries such as oil, ghee, sugar, milk, honey or fruit
- touching plants, fruit or vegetables in growing or ripe state or seedsEating together with family members
- Touching or cooking food for others or touching cooking utensils
- Touching men or older women
sleeping in same bed as always
- carry out everyday puja or attending a religious festival such as Teej or Dassain

4. Imagine you/your wife accidentally do/does something that you/she try/tries to avoid during menstruation. Which of the following steps would you take?

5. Is there any ritual you do on the 3rd or 4th day of menstruation to purify your room/home?

6. Think about the last two months. I will now read a list of things to you. For each of them, please tell me if you/yourwife use/s the same item on the days you/she menstruates as on the days when you/she do/es not menstruate.

7. In the past two months, has it happened that you could not access food and drink when you wanted to during your menstruation? (only for women)

Downstream outcomes are not targeted directly but may plausibly respond over time to reductions in menstrual stigma. These include: (i) gender attitudes; (ii) a composite “positive outlook” index (aspirations, life satisfaction, and perceived social status); and (iii) menstrual well-being.

Mechanisms capture the channels through which the intervention may affect primary outcomes. Each corresponds to a core component of the workshop:
1. An index of factual beliefs and biological knowledge, reflecting the educational module.
2. An empathy and perspective-taking index, linked to the participatory experience-sharing component.
3. A self-esteem index, potentially influenced by the human-rights framing and opportunities for personal reflection.

We implement a cluster-randomized controlled trial in 90 rural villages in Chitwan, Nepal, to evaluate whether a participatory intervention can reduce menstrual stigma, alter menstrual practices, and shift related social norms. Villages are randomly assigned in equal proportions to one of three arms using covariate-constrained randomization to balance demographic and geographic characteristics: (i) women-only workshops (T1), (ii) couples’ workshops including both wives and husbands (T2), and (iii) a placebo control discussing farming experiences.
Workshops in the treatment arms follow a standardized protocol combining biological education, human-rights framing of menstrual taboos, guided reflection, and norm-based facilitation. Content is identical across T1 and T2, varying only in the inclusion of male participants. Placebo workshops center on agricultural experiences unrelated to gender or health.
The unit of analysis is a triad consisting of the focal woman participant, her spouse, and her named female friend. Primary and secondary outcomes are measured for all three individuals. To ensure consistent selection across arms, enrolled women agree ex ante to bring both their spouse and a female friend. Depending on treatment assignment, the husband either participates in the workshop (T2) or is released from participation (T1 and Control), but all triad members complete endline surveys. Baseline data are collected from all focal women and their spouses.
Randomization is conducted at the village level to prevent contamination. Surveys are administered via CAPI by enumerators trained in sensitive interviewing techniques. The study follows WHO ethical guidelines for research on gender-based norms, with protocols in place for ensuring privacy, providing referrals, and monitoring potential backlash.

Randomization is conducted at the village level to avoid contamination. We first exclude the 20% of villages with the lowest agricultural employment shares (based on Census data) to avoid urban areas, as well as villages with safety or security concerns due to ongoing land disputes or proximity to national parks and wildlife. We then apply covariate-constrained randomization following the multi-arm extension proposed by (Zhou et al., 2022) for three-arm trials. Covariates, drawn from administrative and census sources, include municipality, population size and demographic composition, out-migration rates, ward-level agricultural employment, proximity to infrastructure (schools, health posts, towns), and grid-level relative wealth from the Relative Wealth Index (RWI).

village

Yes

30 per treatment arm, 90 in total

2,160 participants

240 triads per treatment