Study design, setting and sampling.

A cross-sectional study was conducted among adolescent girls aged 11 to 19 years. Interviews were conducted between 15 May and 15 Sep 2017. The adolescence period is the critical stage of habit formation, and the majority of adolescents’ girls experience puberty and the first mensuration in their early adolescence. Moreover, adolescent girls usually follow what parents and society instruct them to do on their health and hygiene, which could shape their behaviour; therefore, we decided to recruit adolescent girls in this study.

As available literature suggests, Chhaupadi is widely prevalent in the Karnali and Sudurpaschim provinces of Nepal [1, 5, 26]. Achham is one of the districts in Sudurpaschim province where many incidents, including deaths in Chhau huts, were reported in media over the last decade [1, 10, 27]. We selected Achham as a study district, which had 11 rural local government units. Mangalsen municipality was purposively selected considering feasibility, time factor, accommodation, and available resources for data collection. According to the National Census of 2011, Mangalsen municipality had 6,604 households with about 32,507 population, of which 8,265 were adolescents [28]. Two wards (wards no 6 and 7) of Mangalsen municipality were randomly selected. The sampling frame was the population of adolescent girls aged 11–19 years. The list of households with adolescent girls was accessed from the respective ward office. There were about 650 adolescent girls aged 11–19 years in study wards.

We calculated the sample size based on the prevalence of Chhaupadi practice (15%) reported in MICS 2014 [26]. We assumed an allowable error of 5% and a non-response rate of 10% for calculating the sample size. We used the formula N = Z2pq/d2 [where Z = 1.96, p = 0.15, q = 0.85), d = 0.05] and sample size was estimated to be 221. We selected 221 households of adolescent girls through a simple random sampling technique (every fourth household). An adjoining household was recruited if a girl was absent in a selected household at the survey time. Additionally, in a case where one household had more than one eligible adolescent girl, the eldest adolescent girl was selected for the interview.

Study variables.

The respondents were asked whether they practised Chhaupadi in their most recent menstrual period prior to the survey. This outcome variable had the response of either ’yes’ or ’no’. Explanatory variables were selected based on the review of previous literature [1, 2, 29]; we selected sociodemographic, knowledge and practices related variables. Sociodemographic related characteristics of girls included ethnicity (advantaged: Brahmin and Chhetri, and disadvantaged: Dalits and Janajati) [30], respondent’s age (11–14, 15–17, and 18–19 years), respondent’s education (6–8 grade and 9–12 grade), education of parents (illiterate or no education, basic education (1–8 grade), and secondary (9–10 grade) or above), occupation of mother (unpaid work and paid cash work), occupation of father (job, agriculture, business, and labor work) and the family type (nuclear and joint). At the same time, variables related to knowledge and practice on Chhaupadi included knowing about Chhaupadi (yes, no), factors for Chhaupadi practice (impurity, fear of God, inadequate knowledge, societal fear, and fear of family members falling sick) and the person suggesting staying in Chhaupadi huts (parents, grandparents, and relatives or traditional healers). We further categorised restriction during menstruation: bathing restriction (yes, no), food restriction (yes, no), types of food restriction included (milk and dairy products, vegetable and fruits, and meat and meat products), restriction of activities (yes, no), types of restricted activities (entering the kitchen or cooking, sitting, or touching or seeing male members, wearing new clothes, and buying or touching medicine). Menstrual hygiene was categorised based on place of bathing: home tap, chhau-dhara (designated taps for those practising Chhaupadi), chhau kuwa (designated well for those practising Chhaupadi), and river. Menstrual hygiene management practice included using a sanitary pad (yes, no), reasons for not using a sanitary pad (costly or unavailability, disposal, and other problems). Similarly, sanitary pad related variables included types of absorbents (sanitary pad, new clothes, homemade sanitary pad, and old washed clothes) and places to store sanitary absorbents (own room, cowshed, and wrapped with other clothes).

Data collection and analysis.

The survey tool was developed based on previous literature [1, 2, 14, 29, 31]. For quality assurance, survey tool was pretested among 20 adolescent girls of the adjoining ward (ward no 8) within Mangalsen municipality. Necessary modifications to the survey tool were made mainly in the flow of the pattern of questions and language. The second author (RKT) collected data using the revised questionnaire, and interviews were conducted in the Nepali language. Collected data were entered in Microsoft Excel first, and then necessary data validations and cross-checks were made to avoid possible errors during data entry. Data was exported to Stata (version 14.1) (Stata Crop, Texas, USA). Findings of descriptive analysis were reported with frequency and proportion of Chhaupadi practice. We further estimated the association between outcome and explanatory variables using the Chi-square test.

Identification and selection of policy documents.

The detail of the relevant policy selection process is presented in Fig 2. We identified relevant policies through web search and consultation with experts involved in the Chhaupadi eradication movement in Nepal. We searched different websites to identify the available policies in Chhaupadi eradication in Nepal. Keywords in web search included Karnali and Sudurpaschim province, harmful Chhaupadi practice, religio-cultural practice, practice, Chhau huts, Chhaupadi eradication, Chhaupadi practice, menstrual hygiene policy and Nepal. The documents search was conducted in June 2020. In addition, the authors (RBK, GNK, DST) consulted with experts having relevant experiences in Chhaupadi eradication and requested them to suggest the relevant additional policies. First, we identified policy documents with components of menstrual hygiene management, reproductive health and Chhaupadi practice. Second, we looked at Chhaupadi specific contents in Constitution, Acts, Regulations, policy, directives, and plans of three layers of governments (federal, provincial, and local).

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Fig 2. Flowchart of selection of policy and program documents on Chhaupadi eradication in Nepal.

https://doi.org/10.1371/journal.pone.0256968.g002

Framework for qualitative data analysis.

We used a policy cube framework that comprises three dimensions i) comprehensiveness, ii) political salience with effective means of implementation, and iii) principles of equity and human rights. Comprehensiveness assesses to what extent the existing policies have covered the components to eradicate Chhaupadi practice. First, we reviewed the content of the federal, provincial, and local level policy documents on Chhaupadi eradication. Second, political salience and effectiveness of means of implementation examined policy authority level, budget line item, and accountability system. We mapped the policies by their level of authority and categorised them into highest, middle, and lowest levels. The highest-level policy documents are comprised of the constitution, national laws, and regulations. Policies, strategies, rules, and action plans formulated by federal, provincial, and local levels were categorised as middle-level documents, while directives, guidelines, action plans and implementation plans are considered the documents with the lowest level of authority [33].

Furthermore, we assessed whether budgetary commitments were stated in different levels of policy documents. We also looked at accountability mechanisms by identifying implementing agencies, independent monitoring systems, and remedial actions for policy non-compliance. Third, the principle of equity and human rights dimension assesses the policies to what extent the principle of human rights and social equity and justice were articulated. Finally, we evaluated whether these documents ensure the right to live with self-dignity and self-determination.

Highest level policy documents (e.g., constitutions, acts and regulations).

The highest level policy documents comprise the constitution, laws, and regulations usually endorsed by the parliament [33]. For example, the constitution of Nepal (2015) commits to prohibit any kind of violence or exploitation on the grounds of religion, social, cultural tradition, or practices. Several national laws have been formulated with this mandate. The national law that had the provision of Chhaupadi practice is the Criminal (Code) Act (2017). This Act has the provision of three months’ imprisonment or a financial penalty of NRs 3,000 (~USD 26) for those forcing a recently delivered or menstruating woman to stay in Chhaupadi huts [22].

Some Acts incorporate Chhaupadi eradication related provisions indirectly, such as the Domestic Violence (Offence and Punishment) Act (2009) [39] and Local Government Operation Act (LGOA) (2017) [40]. The former has the legal provision of imprisonment for any acts of domestic violence, like forcing the girls to stay in Chhaupadi huts. At the same time, the latter ensures the local government’s jurisdiction to implement the activities to eliminate Chhaupadi practice and formulate appropriate legislative measures to provide essential healthcare services. Additionally, the Safe Motherhood and Reproductive Health Rights (SMRHR) Act (2018) has a legislative provision to ensure access to fundamental rights (education, information, counselling, and health services, including reproductive healthcare) for every woman [41]. However, policies have not specified any provisions for the management of menstrual hygiene and Chhaupadi practice.

Middle-level policy documents (e.g., policies, plans and strategies).

The middle-level policy documents consist of policies, plans and strategies formulated by federal, provincial, and local governments. National Dignified Menstruation Policy (2020) is one of them, which has been drafted and yet to be endorsed [42]. On the other hand, there are some policy efforts from provincial and local governments. For instance, the Chhaupadi Malpractice Elimination Policy (2019) was endorsed by Sudurpaschim Province [43]. Likewise, Mangalsen Municipality endorses an annual work plan and budget (2019) incorporating the provisions to eradicate Chhaupadi practice [44–46].

All these documents have considered Chhaupadi practice as superstition and malpractice and have focused on community awareness through education, community mobilisation and mass campaigns for its elimination. However, these documents neither have the commitment of adequate financial resources nor an efficient accountability system of implementation. For instance, there are no financial resources for implementing community awareness activities as suggested by the policies formulated by provinces and local governments. Additionally, such policies lack the provision of a public reporting system, independent monitoring mechanism and remedial actions for any non-compliances.

Lowest policy documents (e.g., directives, strategies, and action plans).

A directive was endorsed to eradicate the Chhaupadi custom in 2008 [47]. This directive had immediate and long-term interventions for preventing Chhaupadi practice. The immediate interventions included public awareness and health education, whereas the long-term interventions consisted of women empowerment through women’s participation and legal reforms that ensured women’s rights. Although this directive urges the district and local level agencies to implement listed interventions, however, is silent about the financial resources required for implementing those activities [47].

Comprehensiveness.

Discussing the comprehensiveness of policy documents, we did not find any Chhaupadi-specific policy formulated in a holistic approach. Furthermore, we did not find any gold standard literature that explains a comprehensive strategy to eradicate the social custom-like Chhaupadi. However, evidence shows that eradicating other harmful practices like child marriage requires interventions that integrate legal efforts and other supportive interventions. Such comprehensive interventions include empowering girls, educating and mobilising parents and community members, supporting girls for enrollment and continuation in schools and offering economic supports and incentives [61, 62].

In Nepal, Chhaupadi eradication policies are implemented on an ad hoc basis. Most of them are coercive and aim to demolish the menstrual huts or criminalise the accused person without adequate supportive enforcement strategies [6]. For instance, more than 9,210 menstrual huts in 19 districts of Karnali and Sudurpaschim provinces were demolished through a campaign in 2020. More than 6,146 menstrual huts were demolished in the Achham district alone [63]. The Chhaupadi huts were demolished without providing alternative solutions resulting in women being forced to stay in the cowshed during the menstrual period [63]. Although new menstrual huts have been stopped, women are forced to remain in more vulnerable places like cowsheds after demolition.

Non-acceptance by parents-in-law and the psychological fear of getting ill are the reasons behind the prevailing Chhaupadi practice [63]. The existing eradicating approaches, like the demolition of menstrual huts, are not effective. The evidence from the Achham district suggests that more than one-fifth of menstrual huts have been reconstructed again after the demolition campaign [63]. Thus, a multilevel/ multidisciplinary and comprehensive policy framework only could address individual, family, community, and societal barriers for Chhaupadi eradication. Such a comprehensive framework can be designed to adopt a socio-ecological model [62]. It must be embedded in policies of all levels to ensure the right of protection, health, and survival of every woman and girl. Policy interventions need to be targeted and focused on affected communities and individuals through formal/informal systems that may influence to eradicate this centuries-long harmful cultural practice.

Effective means of implementation.

Our analysis showed that the Criminal Code Act (2017) [23] is only the policy with the highest level of authority to eradicate Chhaupadi practice. Yet, there are several challenges in its effective implementation. Firstly, it criminalises the one who forces the women to stay in Chhaupadi huts. This person will be no other than a close family member. Filing a criminal charge against own family member could break the social fabric and family relationship.

Furthermore, administrative measures such as arresting the accused person by police and filing a case in district court are even challenging due to over-complicated bureaucratic processes. Likewise, Chhaupadi is a complex and multifaceted problem that requires coordinated efforts from the administration, police, court, schools, health facilities, family, community, and civil society. Thus, implementing coercive measures like the demolition of Chhaupadi huts is ineffective unless obtaining commitments from relevant stakeholders. The governments have enforced several interventions to eradicate Chhaupadi at their local level; however, such efforts often lack concrete action plans, strategies, and adequate financial resources.

Although provincial and local governments have initiated to endorse the policies to eradicate Chhaupadi, there are no specific policies at the federal level to ensure menstrual hygiene or eradicate Chhaupadi practice. The Dignified Menstruation Policy (2019) is the only policy specific to Menstrual Hygiene Management (MHM); however, it has not been endorsed yet. The drafted policy has encouraged mobilising religious and social leaders and change agents (individual, group, or community) to eradicate menstruation superstition, accustom, and beliefs. The aforementioned drafted policy also encourages legal actions and reforms, multisectoral and multi-layer coordination to eradicate Chhaupadi practice [42]. Although the document emphasises strong inter-ministerial coordination, the delay in endorsement of this policy was due to a lack of clarity among the sectoral ministries (Health, Education, and the Water Supply) in leadership and taking overall implementation responsibilities [48].

Many policy documents lack a public reporting mechanism, independent monitoring system, and provision of remedial actions for any non-compliance, resulting in weak policy implementation. For example, a multi-country study conducted in Africa (Mozambique, Senegal, and Tanzania) showed the lack of policy coherence, enforcement, accountability mechanisms, and adequate financing resulted in poor policy implementation [64]. Although integrated actions with clarity in roles and responsibilities, robust reporting mechanism, guaranteeing of confidentiality, and independent investigations mechanism have proven to be effective in policy implementation [64], adequate policy harmonisation is lacking at the implementation level. Moreover, the overlapping roles and responsibilities have created ambiguity in implementation.

Furthermore, our quantitative study suggests a high prevalence of social and cultural aspects of Chhaupadi practice. In contrast, qualitative findings suggest inadequate policy provisions to address those issues at the implementation level. In addition, these policies lack adolescent responsive approaches and hence have not identified evidence-based interventions that can address socially deep-rooted customs on Chhaupadi practice. The Sudurpaschim Province endorsed the Chhaupadi Malpractice Elimination Policy (2018) [43]; but, this policy lacks secured financial resources, a structured policy progress reporting system, an independent monitoring mechanism, and appropriate means for remedial actions.

A policy directive on eliminating the Chhaupadi practice (2008) also had ambiguity in different stakeholders’ roles and responsibilities. Surprisingly, the directive was silent regarding the assurance of financial resources to implement those activities, indicating the directive was endorsed to fulfil the judicial obligation. Earlier, after hearing the case of Dil Bahadur Bishwakarma and others versus Cabinet Secretariat (Writ No. 7531 of the year 2005), the supreme court ordered the government to eliminate Chhaupadi practice with appropriate legal reforms and community mobilisation [47]. This argument can be substantiated because the national laws to eliminate Chhaupadi practice with appropriate legal reforms and community mobilisation were endorsed 12 years after the judicial order [65]. Importantly, quantitative findings revealed many social and cultural practices and restrictions at the ground level; these issues should be addressed by municipal level/context-specific plans and strategies that are yet to be formulated and implemented in coordination with local-level stakeholders.

Principles of equity and rights.

The human rights approach in eliminating Chhaupadi practice aims to provide enabling environment to live with dignity, maintain privacy, ensure access to quality healthcare, quality education and the working environment in a gender transformative approach during menstrual periods [66, 67]. There is a paucity of the highest level of policy documents to protect women’s dignity, self-respect, and reproductive health rights associated with Chhaupadi practice.

Forcing girls to live in Chhaupadi huts during the menstrual period violates human rights and survival rights. Further, women/girls are exposed to the risk of malnourishment, infectious diseases, gynaecological complications, psychological impacts, and snakebite [68]. Policies on eradicating Chhaupadi practice are not designed from the human rights perspective, despite Nepal being a signatory of several international conventions and treaties like the Convention on the Elimination of All Forms of Discrimination against Women [69] and the Convention of Rights of the Child [70].