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Case study: evolving healthcare needs

Jane Wilbur presents her recent research into the barriers to menstrual hygiene management for adolescents with intellectual impairments in Nepal.
JANE WILBUR: Approximately one quarter of the global population is made up of women and girls of menstruating age. For these people, effective menstrual hygiene management should include a clean menstrual management material, a private and accessible place to change their menstrual product, water and soap to wash their body and materials used, proper disposal of the used material in a safe and dignified way, and accurate information on the menstrual cycle and how to manage it with dignity. However, menstruation is often a taboo. In many countries, menstruating women are seen as impure, contaminating, and dirty. And many menstruating females are restricted from participating in daily life.
Young people with a disability are at greater risk of discrimination and are often omitted from menstrual hygiene management interventions during an important period of development and healthcare transition. In the following example, I will discuss a recent project conducted by WaterAid and the London School of Hygiene & Tropical Medicine, which highlights the importance of suitable menstrual hygiene management interventions for people with disabilities. In this project, we developed an intervention for people with intellectual impairments in Nepal. Through discussions with people with disabilities, carers, and disabled persons organisations, we discovered a number of barriers to good menstrual hygiene management. One of the biggest challenges is inaccessible water, sanitation, and hygiene facilities.
Secondly, premenstrual symptoms experienced by people with an intellectual impairment are not well managed or understood. So for example, during menstruation, people with an intellectual impairment can become withdrawn, hyperactive, and they may self-harm or go out with bloodstained clothes or feel frightened. And if not managed, menstrual cramps can exacerbate these behaviours. We also discovered that if people go out with blood on their clothes, they were abused by family members and community members. Menstrual hygiene management interventions are generally delivered through schools and at the community level. And these interventions don’t reach all people with an intellectual impairment, as they may not be in school or actively included in the community. Some people with intellectual impairments can’t always manage their menstruation independently.
They’re reliant on a carer. And this carer and needs information, support, and guidance about how to manage another person’s menstrual cycle. But they have none, and carers often feel isolated and overwhelmed. To combat these barriers, we developed an intervention called the Bishesta campaign. Bishesta, which means “extraordinary” in Nepali, is a girl with an intellectual impairment with hidden extraordinary talents. Whenever she needs support to understand the changes she’s facing when she’s growing up, Perana, which means “motivation” in Nepali, motivates and helps her. This intervention has a number of components designed to enable people with an intellectual impairment to improve their menstrual hygiene management practices and encourage carers to support them through this process.
We designed period packs for people with intellectual impairments to encourage them to adopt good menstrual hygiene practices. The packs include a menstrual storage bag, which includes reusable menstrual pads, a menstrual shoulder bag for use outside the home. It includes a small waterproof bag to put a soiled menstrual pad in and carry home. That’s in the middle. And a menstrual bin to dispose of the used menstrual products. That’s the photo on the right. In addition, we produced two visual stories, which can be read by the young women and carer to help them learn appropriate practices and discuss their thoughts and feelings about menstruation with one another.
The first story, “I Changed my Pad,” is about Bishesta menstruating for the first time and how Perana supports her to manage as independently as possible. Here are some images from the story. We also developed the Bishesta doll, which has removable clothes, a soiled and clean menstrual pad, and pain symbols. And these can be put on parts of the doll’s body where menstrual discomfort can be felt. The people with intellectual impairments use the doll to communicate about menstrual hygiene management, practice changing a soiled menstrual pad, and putting it in a bin. And the Bishesta campaign was delivered by five facilitators. These facilitators had disability, water, sanitation, and hygiene expertise. And many of them had worked for disabled persons organisations in Nepal.
Our research showed that the Bishesta campaign improved communication and the young women’s ability to manage menstruation more independently. It also enhanced a carers understanding of how to support people with an intellectual impairment during menstruation. For more information on this specific intervention, please take a look at the ‘See Also’ section at the bottom of this page.

In this step, Jane Wilbur (LSHTM) discusses her research, in which she sought to understand and address the barriers to menstrual hygiene management for adolescents and young people with intellectual impairments in Nepal.

In this video, Jane will describe the challenges to effective menstrual hygiene management faced by many young people with developmental disabilities. Jane will then discuss her project, in which she has worked with WaterAid and the London School of Hygiene & Tropical Medicine to develop an innovative menstrual hygiene behaviour change intervention for young people with intellectual impairments and their carers in Nepal.

Jane is a Research Fellow at the International Centre for Evidence in Disability and the London School of Hygiene & Tropical Medicine, focusing on disability and water, sanitation and hygiene (WASH). Prior to this she worked as the Equality, Inclusion and Rights Advisor at WaterAid.

Once you have watched the video, take a look at the resources in the ‘See Also’ section to learn more about the intervention.


  • What are your thoughts on this intervention?
  • Would a similar intervention be appropriate and/or feasible in your setting?
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Integrated Healthcare for Children with Developmental Disabilities

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