Sugamdha Chandra : Menstrual Health and Hygiene Management

Item

Title: Sugamdha Chandra : Menstrual Health and Hygiene Management
extracted text: CHLP Report
- Sugandha Chandra
PART A
Introduction
Hi! I am Sugandha. I was born into an Army family in Meerut where my father was
posted at the time. Soon after he left the army and joined the corporate world. ANd
that meant that we would always be on the move with him. I have lived in many
places and gone to many schools. Towards my senior classes, I was sent to a
boarding school where I could stay stable with my education. Living in an all girls
school was one of the best ties of my life. This is the time that I became independent
and made friends for life.
After school, I did my bachelors in English Literature from Delhi University. To make
the best use of my free time I joined the NCC where I learnt the ways of the military
myself and also became a part of a global youth run organization called AIESEC.
AIESEC is where we would facilitate international student exchanges and have
conferences on matters of the world, most often environmental, but also social,
cultural, political, economic and technological.
Right after my BA was over, I moved to Doha for my first job as a flight stewardess
with Qatar Airways with the agenda to travel the world for free! After 2 great years
there, I came back to India for further studies and decided to engage with the
Masters programme in Sustainable Development Practice at TERI School of
Advanced Studies, Delhi. Here I was involved in many short term field exposure
visits and projects, and research internships which opened my eyes to a very
different perspective. This is also when I got involved in all things related to
menstrual health and hygiene. After spending 5 months in the villages of Raigad
district, collecting and analyzing data on this topic for my major internship, I took up a
job at Eco Femme in Auroville. Two years working on the non-profit program there, I
found a vacancy at SOCHARA and grabbed it with both hands. This gave me an
opportunity to expand my horizon and learn more about the broader space of Water
Sanitation and Hygiene. I have been here for nearly a year now and I have learned
alot and grown as a person through my role here.

Why Fellowship?
I started working at SOCHARA in March 2022 and that's when I learned about CHLP.
I read about it and got interested in understanding, assessing and taking appropriate
action for Community Health in the ever shifting health realities. It helped that it was
part time and online. What also helped was that I could talk to Karthik in person and
learn more about it. It knew that it would give me a deeper understanding of myself

and what I wanted to do, and also guide me on how to do it, all the while having
some structure and endgaol .It has helped me gain theoretical knowledge, work win
the field and connect with many other who work in the space of community health. It
has also helped me see the impact of my work and has motivated me to carry the
same forward. Having a mentor was ideal in my situation, because I could use that
occasional push and guidance that Janelle was patient enough to help me with.

Personal Learning Objectives
My areas of interest are Menstrual Health and Hygiene Management, Waste and
Health, Environmental Health, Tribal Health and Green Spaces
My PLOs at the start of the fellowship were:
1. I would like to better understand the Menstrual Health and Hygiene of
menstruators who are always on the go, such as sanitation workers, police women,
women in the
army, etc
2. To see how does Waste impact the lives of people who deal with it either due to
profession, or by proximity
3. To understand the magnitude of waste generated due to food delivery apps and
the health of people using these apps.
4. To understand the benefits of green spaces beyond mental health
While I was very well aware that all these learning objectives will not be met in such
a short duration of time, I did try my best to integrate most of my areas of interest in
my community based health action project. I focused on my first learning objective
and primary area of interest, i.e., menstrual health and hygiene management.
Working with SOCHARA gave me access to their field areas which include 2 slum
localities of Bangalore and 25 government schools. So, I chose to work with ladies
from one of the slum communities instead to begin with. In this way, my altered
personal learning objective was met.

Module Learnings and Reflections
Axioms of Community Health
From the axioms I realized that there are just so many layers to understanding
context. Autonomy over health is important as one must be able to make informed
choices for themselves. I loved the idea of plural health systems, as that is
something I have seen around me while growing up and I have seen it work well,
many systems together. The ideas of equity, empowerment beyond social conflicts,
integration of health with other developmental activities, promoting the sense of

community (social cohesion), the use of locally relevant resources, confronting
existing super-structures of medical/health care, etc really spoke to me.
It was recognised that HEalth for All is a democratic process and active participation
from the communities is crucial. The context, culture and history of all communities
will be different, so will be their priorities and abilities. There was a recognition to
build capacities, work on political understanding and will, need for power shifting and
breaking hierarchies. The community needs to feel responsible and demand health
as their right.
SEPC Analysis
I was glad to learn about the SEPCE analysis in health as it showed holistic thinking.
I did however reflect on it and was reminded of my short course on Marketing
management which used a similar tool called PESTLE Analysis.
While SEPC here stood for Social, Economic, Political and Cultural, there are more
factors we could use to analyze the status of health in a community or to analyze a
policy by. In my opinion PESTLE is more wholesome as it stands for Political,
Economic, Social, Technological, Legal and Environmental. While we can go on
endlessly adding letters to a mnemonic, I am of the opinion that PESTLE can also be
a great fit as an analyzing tool in the community health/public health space.
Apart from this the module had interesting bits like social justice being about Equity.
The drawing of different boys looking over the fence was very impactful, and how we
realized that the real barrier there was the fence itself.
The Nutcracker approach is probably the most relevant and realistic solution to a lot
of developmental problems. It is a combination of the top down and bottom up
approach.
Health as a Human Right
This module was covered very effectively by Prasanna with very relatable examples.
The concept of a duty bearer being a claim holder who is monitoring and enforcing
mechanisms helps to fix the problem of accountability, unlike the charitable mode
where there is no accountability. Public health action requires three processes- data,
developing policies for priority health needs, and programs to implement strategic
health goals. I liked the idea of Critical consciousness where we try to develop the
agency of the communities. There was aslo a discussion about how the human
rights approach helps us to be more ethical while working towards health and
healthcare.
There part where we spoke about the state’s obligation to make healthcare available
(coverge), accessible (physical, financial, social and information), acceptable
(culturally and feasibility of being appropriate) and of quality (service and
infrastructure wise).
This got me to think about my action project and how we could incorporate these
ideas there. The 4As- Availability, Accessibility, Affordability and Acceptability, like
the four lions in the head of the Ashoka Stambh must stand back to back and

support each other. The comparison can also be stretched to the lengths and
breadths (all 4 directions) something can go to if these 4As are kept in consideration.
SDH and how I came to be interested in Social Cohesion
Having studied a short course on Public Health during my Masters in Sustainable
Development Practice, I was a little familiar with the social determinants of health. It
was interesting to learn that the causes of health were different from the causes of
health inequities, that health inequities are socially produced. This was reinforced by
the Power Walk we did at the CHCC in May 2022.
The CSDH Framework for Action on SDH 2010 is used to guide political action or
any sort of action in this space. Learning about the socio economic and political
context, the structural determinants of health inequities and the intermediary
determinants of health was very detailed,but what came as a surprise was the
recognition of social capital and social cohesion in this framework. Social capital and
Social Cohesion are very important to the framework even though they don't seem to
fit in any particular place, They are at the center of the framework/table. This caught
my attention and I decided to explore it further. Social cohesion refers to the sense of
belonging, trust, and mutual support within a community. It is the glue that holds a
community together and enables individuals to work together to achieve common
goals. It is basically the connectedness in a community, the solidarity and a sense of
belonging. Communities with higher levels of social cohesion may be better able to
mobilize resources and take collective action to address health issues, such as
improving access to healthcare or promoting healthy behaviors. I decided to take this
up in some capacity in my action project.
CHCC
The session on Inner Learning by Ravi was very interesting to me. I heard about the
concept for the first time I think, I mean at least as a formal structured idea. The
emphasis on feeling was refreshing especially in this time where everything has
begun to corporatise. It really made me think- am I thinking or feeling… I also
reminded me that Silence must also be heard, and how we must make space for
those who are silent and those who seem/are voiceless. Empathy over sympathy
and that often comes from deep listening.
It was a great pleasure learning about and interacting with representatives from
ACCORD, Tribal Health Initiative and the Mallur Cooperative. The discussion that
followed was very rich, about not paying the volunteering staff at THI as they should
do it from a sense of belonging and responsibility to the community, but we all still
stand behind the ASHA workers when they rallied for their payments.
The Monsoon Simulation game was probably the most participative, engaging, eye
opening yet fun activity/game I have ever played. It felt like a real life situation where
the rich were trying to get richer without an ounce of though or consideration for the
poor. The poor families were dying and the rich still opposed the building of the bund
just because it did not directly benefit them. We saw how the rich got richer and the
poor nearly perished. All families made decision on the basis of profit they could

squeeze out of the land, without ever thinking about the impact of their decisions on
soil degradation and the environment at large.
Another enriching experience was hearing about the previous year’s fellows talk
about their work. I felt particularly fascinated by Ankit’s story of walking and cycling
across geographies and connecting with people and learning from them and at some
level probably inspiring them; Nivetha’s work through Tend and Mend Foundation on
menstrual health education; Aravindan and Abhirami’s stories and work about
reaching people with healthcare; and Nidhin and Sejal’s work with YuMetta
Foundation.
Another memorable activity was the Power Walk, facilitated by Prasanna. I had seen
something similar on social media, but he changed a few things when we ‘played’ it.
We were not doing it for ourselves, but for personas he had created, each with
different characteristics. He introduced another spin by giving female personas to
men and male personas to women, so one could really experience the advantage or
disadvantage the other might feel at some level.
Finally, the communications workshop on the last day was engaging and I learnt new
things and revised some old ones. The concept of the Common World was
interesting and can be used to understand the community work space better by
working on and expanding commonalities. It was also good to understand and name
different levels of proximity and emotional investment, so one can better
communicate and in turn do more impactful work.
Nutrition
Dr Ravi D’Souza explained in detail about the basic principles and applied aspects of
nutrition. It was interesting to learn about the quantity pyramid model. He said that
undernutrition and obesity can both happen at once and can be caused by junk food.
This module really helped me put myself and my diet in check. Malnutrition in
children was a great topic to learn about and I believe it must be made more easy to
access since a lot is riding on children and their development. There was also a
need to brek the vicious cycle of Malnutrition, Reduced Immunity and Infection which
will solve so many problems in children and adults alike. The ICDS and the Right to
Food campaign made the module whole.
Sanitation and C-WASH
Working in this space for the last 3 years has given me some experience with the
water and sanitation issues. Appropriate technology is something vital to
development and without it, we might not be helping with long term and sustainable
solutions. My project on menstrual health and hygiene is also part of this module.
One new thing that I learnt from this module was Dr. Pruthvish’s part on handling
biomedical waste and how segregation at source can go a long way in managing our
waste properly.

Gender and Women’s Health
Another topic very close to my heart is Gender and women’s health. SubhaSri did a
great job with breaking this module up into very relevant bits, starting with how
gender is a social construct. It helped a lot of fellows to reach common ground on
this topic. She sadi that gender norms become gender roles and this often leads to
sexual division of labor. What really got me thinking in this module was the life cycle
approach. I would like to work on this more deeply at a later stage.

Reflections on the use of LMS
While there is a lot of difference between online and offline learning, LMS gave us
the flexibility and convenience of accessing the content from anywhere and at any
time. A lot of the content that I engaged with was video based. The video lectures,
apart from being appealing to the audio and visual senses, were a great way of
learning for me as you can slow it down or speed it up based on your understanding.
This allowed us to personalize our learning experience which helped me alot. It was
also a fairly easy platform setup to understand and use.
I would however like to add here that having all the content on it from the beginning
would have made things much easier. The uploads for the weekly content used to
happen a little at the last moment which did not help us in using our free time better.

Balance between Work, life and CHLP
I am against the hustle culture that glorifies staying busy. Hustle culture aka burnout
culture, centers around the idea that working long hours and sacrificing self-care are
required in order to succeed. I believe that if you're too busy at work, maybe you are
doing more than one person’s work or you are just inefficient which is why you
always seem busy. I also think that over-professionalism can be toxic in such a way
that it largely reduces empathy in the work environment.
Working at SOCHARA made it easier to balance work and CHLP. I, in general, try to
have a good work life balance, by working in the office hours only. I believe that we
might work to live, but can’t live to work. Sometimes, it got difficult for me to attend
the live online sessions that we had twice a week due to other commitments or not
reaching home on time. While these sessions were recorded for future viewing, I
seldom was able to go back to them because of how I felt I was already lagging
behind. The other content did keep involved and up to speed. An occasional push
from the CHLP team went a long way in getting me back on track.
All in all, it is not difficult to maintain a balance between these three, it is just about
your motivation to do them and ability to manage your time well.

Covid-19 Pandemic
Our experience of the COVID-19 pandemic have somehow brought us all closer
together and I’d like to believe that at some level, it has made us more humble and
empathetic. Through my community based health action project, I hoped to increase
social cohesion among the ladies of the Anandapuram slum area so that they may
stand together in times of crisis. The idea was to build a certain resilience in the
community against future pandemics like the one we all suffered from, by getting
them closer to one another, not physically ofcourse, but emotionally. That goes a
long way, I believe.

Mentorship
I was initially apprehensive about the mentorship process as I thought it was
imperative to have a mentor who also had similar areas of interest, and I thought that
there weren’t many people who would match. I also thought being a mentee would
be very time consuming and might affect the work, life and CHLP balance I was
trying so hard to strike.
However, time passed and I was assigned to Ms Janelle Fernandes. Apart from
being the current Associate Director of the CHLP she has also worked as a
Community Health and Public Health Consultant where she created learning content
and facilitated live learning sessions. As we spoke about mentoring, I realized that
she doesn’t need to have interest in my focus area. She was there to guide my
processes and help me think clearer, and that is exactly what happened. Having
discussions with Janelle really helped me clear my head and her suggestions have
always been very helpful. When she asked me to make the Mind Map, I did, and
realized that this can help me beyond the CHLP and my action project.
She always encouraged me to be honest about my progress and ideas, and that
really helped me to share with her more openly and her to push me when needed.
She has been a great mentor and has only wanted me to do what I'm doing to the
best of my ability. My heart is full of respect and gratitude for her.

Take Away from CHLP and what's ahead?
Some key takeaways from the CHLP for me would be the understanding of the
social determinants of health and how they impact the health and well-being of
communities. Also the very interesting discussion we had about the terminologies of
the same on the whatsapp group and how social determinants sounds very final,
while Social Influences on Health is a more hopeful term. I also appreciate my
learnings and awareness on other topics like Nutrition, which inspired me to eat
healthier myself too.

In general, I feel like the CHLP helps us connect to such a large group of not just
fellows but also facilitators, mentors and professionals in this space. This networking
can go along way in future learnings and collaborations too. It also led me to rethink
some of my own ideas and reevaluate some of my perspectives. It made me aware
of my areas of improvement where I thought I knew enough.
Going forward, I will carry these learnings, reflections and connections with me and
try to better my impact on organizations, communities and the environment. More
specifically, from my training of field coordinators as facilitators will ensure that the
work we started keeps moving forward and reaches more people in the community.
Personally, I hope to work with more people in the space of MHHM, learn from them,
grow and take the message to even more people.

PART B
Title: How cohesive is period blood?
Objectives
1. To assess awareness, and fill gaps where needed on the topic of
menstruation in the Anandapuram community.
2. Empower the 3 field coordinators at SOCHARA to become facilitators of
menstrual health and hygiene management sessions.
3. To make alternative flow management products to the ladies of the community
more available, accessible and affordable so they can make informed
decisions about the same.
4. Attempt to increase social cohesion among the ladies of the community by
getting them to talk and share on an intimate topic such as their periods.

Background
Being a staff member of SOCHARA’s C-WASH team, I already had some interaction
with the two slum areas we work with, namely, Maya Bazaar and Anandapuram. We
have been working in Maya Bazaar for a longer time and with more vigor, partly
owing to its proximity from the office. We ventured into Anandapuram only about 2
years ago and focus on WASH related issues, such as waste management, open
defecation, vector borne diseases, handwashing, toilet maintenance, etc.
Anandapuram is an urban poor locality near the K.R. Market of Bangalore. During a
household level survey done here recently, we allotted house numbers and from the
data found that Anandapuram has over 800 households with over 3500 residents.
SOCHARA has 2 field coordinators and 4 local community volunteers working in
Anandapuram.
From the Focus Group Discussion done here, we found that there were gaps in
basic understanding of menstruation, there were many taboos and practices coming
from shame and stigma, and information on the variety of products available was
also low. I thought that working on the 4As here with the context of menstruation will
be helpful to not only help these ladies better manage their periods hygiene wise, but
also to be conscious consumers of products. With the intervention planned, I hoped
to have holistic development in the sphere related to menstrual health and hygiene
management here.

Action Plan

Implementation
1. Discussion with Field Coordinators:
SOCHARA field coordinators have been working in the Anandapuram slum
for over 2 years. They are my link to the community, so I started by asking
them their perspective of the community’s Knowledge, Attitude and Practices
of Menstrual health and hygiene. The ladies were unsure about the level of
knowledge in the community on the topic.
They did know that most women used disposable sanitary pads to manage
their flow, very few used cloth. Some of the community members knew about
a menstrual cup, but none used it. The field coordinators shared that the pads
that the school girls should get for free, are either not given to them, and if
they are, they are of very bad quality. So all girls and women who use
disposable pads were purchasing them. About the disposal of these pads,
there is a provision from BBMP, the local municipality, to dispose of them
separately as domestic hazardous waste in the yellow bins. However, the
coordinators think that very few women were using the yellow bins, most
threw their pads as mixed waste after wrapping the used pads in newspaper
or plastic bags.
When asked if the women of the community have talked about any biological
problems they face during their periods, the coordinators said that they have
heard complaints about irregular periods, too much or too little bleeding, pain
from cramps, fever, vomiting, diarrhea, white discharge, etc.
They also follow different myths and practices like not visiting a place of
worship, which is a very common practice throughout India. They also don’t
sleep with their husbands or visit anyone else’s house while they are
menstruating. The coordinators also said that girls skip school while they are
on their periods only if they have some medical condition. Other perceived
problems according to the coordinators were the lack of safe and clean toilets,
water scarcity, cost of products, indiscreet disposal facility and the attitude
around menstruation. Instead of openly talking about it with family members,
ladies say that they are unwell due to the stigma. Any stained pieces of cloth
are dried in the toilets themselves, to avoid being seen by another person.
L+R: From this discussion I got some insight into the KAP of the
Anandapuram community in regard to menstrual health and hygiene. Despite
having the facility to dispose of pads separately as they should be done,
women aren't really doing it because of various reasons, could be to not make
their menstruating phase public, or for the sake of convenience. Not visiting
other people’s houses while on your period was one new type of cultural
practice for me, one that I hadn’t heard of before.

2. Focus Group Discussion with Community members:
Around nine local ladies gathered (list in Annex) for a focus group discussion.
There was a good age representation as they varied in age from 16 to 45
years. This was done to gauge the KAP of the community in terms of
Menstrual health and hygiene first hand. When asked about what and when
did they find out about menstruation, they said that girls are told about it when
they start bleeding themselves in their adolescence. Nothing before that. Even
then they are just told what not to do and how to manage the blood flow and
pain. They all believed that period blood is waste blood and it is a good thing
that it is leaving the body and must be treated like any other excretion, like
urine or feces. Most prefer to not go outside during periods.
Product wise, they only knew about disposable sanitary pads and cloth as an
option. While they all used Whisper pads, some said that they use cloth if they
get allergies from pads. However that is temporary, and they only prefer to
use cloth while they are in the comfort of their homes. They said that girls get
pads from government schools, but they are of bad quality and many have got
irritation from it, so they prefer buying branded pads from the market at a
price. About disposal, they all said that they wrap it in newspaper or in a black
cover. After this some flush it down the toilet, some dispose of it separately in
the BBMP waste and some throw it with regular waste. All our respondents
were housewives, so they claimed to sleep separately from their husbands
when on their periods. They also didn’t go out for anything, didn't pray, didnt
water plants, but bathed daily during their periods. The topic of vaginal white
discharge saw some split views; some said it was normal, some said it was
not normal and one needed to see a doctor for it.
L+R: The women were not shy to talk about the topic of menstruation. They
answered and chatted very freely about it. I sensed a sense of pride in telling
me that they all used sanitary pads instead of cloth, as if they expected me to
look down upon cloth users. This however did not affect the answers, they all
genuinely used pads. Besides being super convenient and available, it is also
seen as the more modern option. There certainly are some cultural practices
that they do, which does not shed a very positive light on the topic of
menstruation or their perception of it. It still feels to be a burden to them that
the females have gotten to terms with. Their knowledge about the topic also
comes from very hushed discussions among each other from a younger age.
It seems as though they don’t feel the need to discuss it after menarche
unless someone is facing a problem or a medical condition.

3. Module Creation:
The obvious next step felt like a way to reach the women of this community
with information so that they may be in a position to make informed choices,
in terms of their practices, attitudes, and product usage and disposal.
Since the Field Coordinators have been interacting and conducting sessions
with the community for over a year, I thought it best to consult them on certain
aspects before starting to work on the module. I asked them how do they
mobilize the community for awareness sessions. I was informed that the
community volunteers engaged by SOCHARA are told about the topic and
time of the session, and they go door to door and invite the relevant audience.
They often gather in the streets of the slum area or a room in someone’s
house or most commonly, at the SOCHARA field office. I was told the best
time to call people is 11am to 12 noon or between 2 and 4pm. That is when
people are most available. When asked about how long are the community
people able to spare for our sessions, the coordinators said that usually 30
mins works best. People leave after that. All participants are also given a
snack, usually a packet of biscuits or a milk packet at the end of such
sessions as an incentive to attend. The languages they feel comfortable with
are Tamil and Kannada, but some also understand English and Hindi/Urdu.
When asked what percentage of the community was open to SOCHARA, they
said nearly the whole community is covered by our work.
The module that I was working on was an important one as it delivered
information on an otherwise taboo topic. So it was important that we
approached it sensitively. These sessions would be ideally held in a room
instead of the street, to let women share more freely and comfortably. We
would start by making everyone comfortable, then go to the important
biological information, followed by cycle tracking and the nutritional needs and
hygiene practices, cultural beliefs and myths and finally end with information
on various products. Such a session would not fit in 30mins. So together we
decided to split the module into two parts, of approximately an hour each. We
could modify it based on reception after noticing it in 2-3 sessions.
The first part of the module starts with space for some ice breakers. The idea
was to get women to open up to a small degree right at the beginning, and get
comfortable with each other, all the while it being a light experience. So we
got them to introduce the person next to them, just basics, like their name and
an animal or colour they remind you of. Not to throw the topic at them, since it
is anyway a sensitive one, we would ask them if they feel comfortable talking
about periods. Once there was a majority saying yes, we’d ask if they would
feel comfortable sharing their experiences. The facilitator would start by
sharing their own First Period Story to help others feel more at ease. This
would be followed by 2-3 participants sharing their first period experiences.

This part helps in getting the ball rolling, also helps to further engage the
participants.
Then we go on to ask whether they think that period blood is dirty and impure.
After a short discussion/poll on this and without saying if their belief is right or
wrong, we move on to ask them why and how do we menstruate. After getting
their answers, we move on to say that our bodies are always changing and
show them a visual of the same- male and female bodies across different
ages. Next, we talk about Puberty. First we talk about the changes that boys
go through at this time, so that they are aware of the other side too and don’t
think that only females go through changes. The answers at this point are
expected to come from the participants as they would have noticed this
around them. A facilitator’s role here is only to fill in gaps. Then we do the
same with girls through puberty. After an engaging discussion on this and
saying that periods start around puberty, we move to asking them where the
female reproductive system is. Expecting some shyness around this, and then
showing them a triangular shape with forefingers and thumbs that resemble
the look and size of the uterus. Then get them to make similar triangles with
their fingers and thumbs and place them where their uterus would be. They
might try to put it on their stomach area, but the facilitator must tell them that it
is below the stomach. So far, we have engaged the participants enough and
got them to share too.
We move on to the more physiological and biological side of it. We talk about
what do we see between our legs. More specifically, how many ‘holes’ do
women have down under. We talk about the three ‘holes’ down there and the
role of each briefly. Then we talk about what lies inside, the reproductive
system. It’s important to show visuals as we go along so that all is not left to
their imagination. We get them to say out loud with us the main organs of the
reproductive system in females- the Ovaries, Fallopian tubes, Uterus, Cervix,
and the Vagina. The enunciation of these somewhat tabooed words out loud,
together is empowering. Then we go on to explain in simple terms how the
reproductive system works and how menstruation happens. We also tell
briefly about the phases in a menstrual cycle since Ovulation is an important
process to understand. We mention how cyclical our periods are and compare
it to the moon cycle and the different seasons of the year. This helps them
visualise the entire process that goes on inside of us, instead of just what is
visible on the outside, which is the blood we see during the menstruation
phase. Then we move on to discussing what is and isn’t normal during
periods. While we tell them that every body is different, there are certain
outlines which may be good indicators to know whether there may be a
problem with our reproductive system so we may catch it early and get the
necessary treatment. We direct them to seek advice from a medical
practitioner if and when they feel like something may not be very normal with
their periods.

We also address the issue of vaginal discharge. This is a vital topic to cover
as there are many misconceptions about this, and while people might be
talking about period blood now, there are very few who talk about vaginal
discharge. The module talks about how discharge is normal, and the vagina’s
way of cleaning itself. It also states that vaginal discharge or mucus changes
throughout the cycle too, in consistency and in colour. It also talks about it not
being normal if the discharge is yellow, grey, brown or greenish and if it
smells very foul. These could be early signs of infections.
Next we talk about one menstrual cycle, we discuss times of high and low
fertility. We learn to track periods on a yearly calendar so that girls and women
can be better prepared for their next period. This will also help them give more
clarity to doctors if they happen to visit one. Other benefits are that they can
track irregularities and be more connected to their cycles, ensuring higher
body literacy. For this we distribute one modified calendar per participant, for
them to take with them.
This is followed by talking about some common menstruation related
problems like PMS, PCOS/PCOD, Endometriosis, RTIs and Anaemia. This is
just to inform them about some symptoms of these issues so they can
recognise them in themselves of their loved ones and seek a consultation with
a doctor at their convenience.
The first part of the module is concluded with an activity that demonstrates
that all bodies are different and all periods are different in their biology and
experience. We drop inkblots on one sheet for each participant and the
designs it makes will be different for each of them.
The second part of the module can be conducted the same day if time and
patience permit, else it would be ideal to do it another day, not much later than
the first session though, within a week would work best.
It shall begin with welcoming the group again and settling back into the space
that we had left last time. Give space for comments or questions that came up
upon reflection in the time between these sessions.
Then we move on to how to care for ourselves during our periods. It is
important to talk about nutrition at this point, laying emphasis on the need to
top up our Iron and Vitamin C needs. Asking the participants what contains
iron and Vit C helps since they usually have a good idea of this, and it is a
great way to keep them engaged. Talk about local low cost food that are
available to them, which they can easily incorporate into their diets. Drinking
water is also emphasized. Taking enough rest, more than usual, during
periods is discussed along with natural and easy ways to deal with period
cramps. Using a hot water bottle or variations of heat therapy are encouraged
before resorting to taking medicines for mild pain. Light exercise, yoga poses
and taking a walk are other things that help to regulate blood and oxygen flow
in the body. Another way that we must care for ourselves at this time is by
maintaining hygiene. Washing hands and changing our menstrual absorbent

frequently is discussed. The duration for which an absorbent must be used is
between 6 to 8 hours and the scientific reason for this is shared with the group
so that they don’t think it is coming from a commercial point of view where we
want them to change pads more frequently because we want them to use
more and buy more. We also discuss the correct way to wash and dry oneself
down there, from front to back to avoid infections.
Next we address common myths and beliefs about menstruation that we
heard from them in the focus group discussion. It is important to convey that
we are not here to ‘break’ any taboos, but to help them to understand, analyze
and perhaps question these taboos. Well entrenched cultural practices can be
difficult to take out of our lives, but a facilitator can always start reflective
conversations. While discussing taboos, it is better to use the terms safe and
unsafe practices rather than right and wrong practices. Convey how menstrual
blood is not impure, and that it is similar to other non-tabooed excrements,
such as the mucous from our nose, spit from mouth, or urine from urethra. It is
in fact the basis of all our life as it is the nutrients in the menstrual blood that
nourishes a baby in the womb and protects it from infections. A game is also
planned around this to lighten the mood and get the audience engaged once
more. It is called the Chinese Whisper. Some or all participants can play this.
The facilitator starts by whispering a confusing 5-6 word phrase into the first
player’s ear. The players have to whisper what they heard to the next person.
This generally creates confusion and chaos, and very often what the last
person hears is not what the facilitator had originally said. It helps to lighten
the mood from an otherwise heavy topic and gets our point across that these
traditions and practices that we may have been mindlessly practicing, might
not be relevant in the present time and might not even have any proof of their
concept.
We move on to the final part of the module, which is to discuss various period
products available in the market. We show them pictures of different products
and ask them if they are familiar with them. Next we move on to Product
Analysis. Product analysis is a participatory process whose objective is to
empower women to make an informed choice after critically analyzing
different menstrual products on various parameters, specifically pros and cons
of different available products. Women have the purchasing power to make
informed choices. Mothers have the purchasing power of what they or their
daughters use. Therefore educating a mother will also ensure their daughters
make better flow management choices too. It is vital to emphasize that there
are no right or wrong answers or choices. We draw a table where the columns
display various parameters on which the products will be analyzed and the
rows are the different products being discussed. We keep a sample of each
product which we show and pass around while discussing so that each
participant has time to look at, feel and ask questions about each product.
Each product is analyzed fully before starting on the next. We try to get
maximum answers from the ladies, specially about familiar products such as

cloth pieces and sanitary pads. Then we note the main points in 1 or 2 key
words on the table for reference later. The products that we discuss are
disposable sanitary pads, cloth pieces, reusable cloth pads with leak proof
lining, tampons and menstrual cups. While there are many more products that
have surfaced in the market now such as period panties, sponges and
menstrual discs, the ones we have chosen are the most researched and
easily available. The parameters that we discuss these products on, are How
to Use them, the Materials that go into making them, the Lifespan of each
product and the method of its disposal, and the Cost of the product per month.
We try to see the cost per month because some of the products that we
discuss are reusable and it would be unfair to judge them by their upfront
costs only. At the end of this, we rank products based on how the women feel
about them after learning about them in detail and see which they prefer,
keeping in mind their circumstances.
The session ends by opening the floor for questions, comments and
feedback.
L+R: I have been working in the space of menstrual health and hygiene for
about 4 years now. My major internship with Swades Foundation in the
Raigad district of Maharashtra was to do research with 300 girls and women
from the rural and tribal areas of two main blocks. Then I had to come up with
a relevant intervention, if one was needed, for the target group. After this I
took care of the non profit program for Eco Femme where I had to redevelop
a module for women on Menstrual health and hygiene, and then train trainers
of different grassroot level organizations to take these trainings forward. So,
with my past experience, I realized that the content pretty much remains the
same across areas, because knowledge gaps are similar. The way to deliver
the content varies on the skills and resources available everywhere. It also
depends on the background of the target group, i.e., it will be different
between young girls and women, and will also vary depending on their
educational background. The things to keep in mind for this group was where
the people lived, how much time they could spare for our sessions, what
would keep them engaged, what information would interest and help them
and when would we be able to reach them.
Apart from this, a little basic knowledge about what is going on inside our
bodies is always useful. Many women even after childbirth don’t know that the
place from where we bleed during periods is different from the place we
excrete urine. The connection between bearing children and menstruation is
unknown to many girls and young women. A lot of women do not believe
vaginal discharge to be normal and seek a doctor’s opinion for regular white
discharge too. No extra care is taken of the self during periods. There is no
felt connection to the body, among many girls and women and they view
periods as just something they have to get by. Numerous traditional practices
are being followed without a thought or question in mind. The product that

was given to a girl at menarche is very often the product she continues to use
month after month without thinking if that's the best suited for her.
The idea behind the module is not to birth rebels or radicals, but to get women
to think, think about their past, their practices, their products, and make
informed choices overall. The module should empower women to think, talk,
share and have more agency in their lives, especially in terms of their
menstruation. It should not just be another awareness session with Dos and
Don’ts that women sit through. It should engage them physically, mentally and
emotionally.
P.S.: I have taken the product analysis activity from the guide we used at Eco
Femme.

4. Training of Trainers:
Seeing how well the field coordinators knew of the community’s issues, it was
hint enough that the people trusted them and talked to them freely about an
otherwise taboo topic such as this. So it made most sense to get them to
conduct the sessions for the menstruators of the community.
When I asked the field coordinators about the sessions that they had done in
the past, I was informed that they had conducted several sessions with the
community on topics like Waste Segregation, Vector-borne disease, Hand
washing, Covid-19, etc. It was reassuring that the field coordinators had
delivered sessions before confidently and with clarity. The task that lay in front
of us was to train these facilitators such that they can create a safe space for
girls and women to share, without shame or judgement. So, I shared some
tips with the field coordinators that would come in handy when dealing with
sensitive topics in their sessions. These included, making eye contact with the
participants, regulating energy of the group while holding space, ensuring that
the participants feel engaged at all times but trying not to turn the session into
a one way lecture, avoiding words like Should and replacing them with Could
or can (so as to be suggestive), using simple words that the community is
familiar with, speaking with ease and having an open/positive body language,
being respectful of the ladies’ thoughts and beliefs, and be authentic to build
trust. If there is a question of which they are unsure what the answer is, don’t
pretend to know it. Try to get back to them with the correct answer later.
Information, Education and Communication material was provided to the
facilitators so they don’t have to depend on projectors etc, since they anyway
aren’t very tech-savvy and carrying projectors around isn't easy in itself. Then
again, one can not depend on the electricity in the slums of Bangalore. The
module was given to them in the form of flipcharts that were very visual and
content training was given to them at the office. I saw that the facilitators were
also shy of saying some of the content out loud, especially about fertility,
genetilia and vaginal discharge. This was worked upon and lots of back and
forth happened. Some of the points were new to them too, so it became a fun
learning space. We also had some gaps in understanding each other since I
only speak English and Hindi and none of these are their first or even second
language. Their drive to learn and my experience with such trainings in the
past really came in handy here, and we reached common ground after a 3
hour training session. Demo kits were also ordered for the facilitators and it
was made sure that they were familiarised with it.
The field coordinators seemed to struggle with the amount of information at
first, but seeing the flow and the need for such a session, they put in a lot of
hard work to learn the key points and deliver good sessions. I promised to
attend their sessions initially so that I can help in filling any gaps for them and
to give constructive feedback.

L+R: It is very important that the facilitators are free of shame themselves.
They must be convinced of the content we are delivering. It is not enough to
train them on the content, but also to orient them on the need for such a
module and their role as facilitators. They are the ones who will empower girls
and women with information about menstruation. Getting them onboard of this
agenda required that they be comfortable talking about such a topic
themselves, for them to be freely sharing their experiences in the safe spaces
they create. I learnt that the facilitators will carry their own biases to the
community they interact with. The next step was to gauge their strengths and
shortcomings. Seeing that they are not great with technology, I had to bring in
IEC materials that did not depend on digital technology, so we made flipcharts
out of the module, so that the content could reach the target group in the most
accurate way. Another IEC material that we got was the demo kit from Eco
Femme that has a prototype of each product we do the product analysis.
Language was a barrier for me with the community, and language was a
strength for the field coordinators. They would be able to reach the people in
their local language.
This training was an important step as this was empowering three ladies to
take this message to more women and girls. They can use this information in
their own lives and that of their loved ones apart from helping so many others
get access to this knowledge. Even if I exit the project, they can continue
spreading the good word.

5. MHHM Session in the Community:
I conducted a session on Menstrual Health and Hygiene Management in
Anandapuram using the module I had created. Over 25 girls and women
attended the session which was held at the anganwadi kiosk. Prema, one of
the field coordinators, who had also received the training on the module
already, supported me with translations.
The sessions started as planned in the module with ice breakers which the
women really seemed to enjoy. Some of them did not know each other, but
got familiar with this activity and they all said colours that reminded them of
the other. They hadn't done such an activity before. Then we started with the
first period stories. They were all amused to hear mine because of how
different it was and then some of them went on to share their own. One
common thing among their stories was the small celebration and the gifting of
new clothes and gold to the recently menarche-d girl. While discussing if they
thought period blood was dirty and impure, we got mixed answers, but the
majority was a Yes. When asked if they knew how and why we menstruate,
the majority answered with a No. The discussion on Puberty went very well as
they had all gone through it and they see others going through it all around, it
is common knowledge. Everyone really enjoyed the little activity with their
thumbs and fingers to see the size and placement of their uterus. There was
some expected shyness around the physicality of the vagina, urethral opening
and the anus. Some were surprised to know that we do not pee and bleed
from the same place. Moving on to the reproductive system and its organs
and functions. This part went well, with the audience applauding my efforts to
say the organ names in their local language. The different phases were briefly
mentioned and the role of the endometrium was discussed through a story.
The group was receptive to the cyclical nature of menstruation and added with
different comparisons.
When talking about what is and isn’t normal during periods, many spoke up
about issues they are facing or someone they know is facing, like very heavy
flow or severe pain, or long gaps between two periods, etc. We replied to
them with the best of our knowledge and then redirected them to a medical
practitioner for diagnosis and treatment.
The topic of vaginal discharge came as a surprise to them, and to learn how it
changes through the cycle and when it is not normal. After hearing some
sharing from the ladies, we moved to cycle tracking. Each got a yearly
calendar sheet on which they could track their periods. We spoke about the
need and importance of tracking and the audience seemed partially
convinced. Running short on time, we moved to the common menstruation
related problems women face these days. Talking about symptoms and
effects of some of the problems seemed to resonate with the ladies and they
had questions which we asked them to redirect to a doctor. Doubting that

there might be a problem and going to a doctor is a great step in caring for
oneself. We ended the first part with the inkblot activity which everyone
thoroughly enjoyed.
We took a break for lunch, which we provided there, so that nobody feels the
need to leave. We had to do both sessions on one day due to availability
concerns among ourselves.
The second half was shorter, with us discussing ways of taking care of
ourselves. Many of these were common sensical and the ladies caught on
quickly. They all actively participated and answered the nutritional
requirements, but then said they know it but don’t usually follow it because
they don’t think so much about it. We told them the benefits of eating
nutritional diets. On the topic of exercise and rest during periods, they shared
that they just want to rest after their daily chores are done with, but agreed to
try some yoga poses to help relieve cramps. Hygiene part of it went smoothly.
Coming to the menstruation related myths they believe in and various cultural
practices they practised, we discussed them again and without saying if they
were right or wrong, we got them to think if they were still relevant and
necessary. I told them about my friend who collected her menstrual blood and
poured it into her tulsi plant (supposed to be a sacred plant). Her tulsi not only
survived, but thrived as opposed to common belief that says one mustn't
water the tulsi plant when on their periods. This shocked a few, but it also got
them to think, and that was our agenda. To make our point clearer, we played
the Chinese Whisper game which all participants thoroughly enjoyed. At the
end I said that if the message did not pass on clearly while we were all
together in one room, who is to say we haven't been receiving the right
message over the years in muffled sounds and shrouded practices.
The session’s last activity was the participatory Product Analysis where we
discussed the different products available in the market for flow management,
their pros and cons, their costs and suitability for the community. They were
all new to reusable cloth pads, tampons and menstrual cups and were very
attentive till the end. Reusable cloth pads stood as a possible winner despite
nobody having used them before. Finally we opened the space for comments
and feedback. Everyone had positive things to say and commented that they
did not realise how 3 and a half hours flew by. This was very encouraging,
even for the field coordinators who would conduct similar sessions with others
from the community to maximise coverage.
As is done in all sessions, we distributed snacks at the end, before everyone
left. Due to budget constraints, we were unable to give much, but it was
appreciated that we got them peanut chikki which are slim slabs of peanuts in
jaggery. We announced why this snack was different from their usual one of
mil or biscuits. It was because both jaggery and peanuts are a good source of
Iron, which is one of the main nutrient Indian ladies lack and is important for

blood circulation and hence helps during menstruation too. This switch will
also help in content recall.
L+R:
The session wouldn’t have been possible or would be a major flop show
without the invaluable support from Prema with translations. Language is the
basis of communication, and if I wasn’t reaching them in the language that
they were familiar with, the session would not have been a fruitful one. Apart
from just translating what I was saying, Prema also added some context to the
content to make it more relatable to the group, which was another great help. I
must admit that all points weren’t conveyed 100%, but there was at least 90%
clarity. The participants also showed great interest as they saw me go the
extra mile by learning some organ names in Tamil to better conduct the
session. Being animated with my expressions and hand gestures also
amused them and kept the session light and engaging. Listening to first period
stories of different women from different areas and backgrounds is always an
eye opener for me, always something new to learn from.
This session unintentionally acted as a great demo for the field coordinators
whom we had trained to conduct these sessions to see how they go, how
much time each section roughly takes and what are the kind of questions that
come up.

6. Feedback from Community and gauge Behavior Change:
Out of the 26 ladies from the main MHHM session, 19 came for the followup
and feedback session. They all said that they had liked the session that we
had conducted on Menstrual health and hygiene management. When asked
which part they liked best, they claimed to have enjoyed the part about
squashing belief systems and myths, and the product analysis. About the part
that they learned most from were the bits on nutrition, cycle tracking, female
anatomy and the different flow management products. The part they found
most helpful was the discussion that vaginal discharge is normal, unless it
looks or smells different than it should. When asked if they have done
anything differently since the session, they said that they all dispose of their
disposable pads properly now and try to be more conscious of what they eat
during their periods.
It was interesting to know what they shared their learnings or reflections from
the session with people outside too, such as their sons, friends, sisters and
neighbours. They all said that they feel more comfortable talking about
periods now than they did before attending the session. When asked if they
think more people will benefit from and be interested in more such sessions,
there was a resounding Yes. When asked if they think we missed anything
and should have been included in the module, they couldn’t think of anything
else. None of them had consulted a doctor after the session, but there was a
need, they said, and when asked if they would like us to bring a doctor into
the community for an hour or so, so they may clear their doubts and ask
questions, most thought it would be helpful, specially if we got a female doctor
in on a weekend, when more people are available. One problem that they
expressed was loss of faith in doctors to some degree, as they did not follow
up with the patients very well.
Finally, when asked about interest in product switch, 8 of them enquired about
the reusable cloth pads. None of the ladies wanted to try the menstrual cup or
the tampon since it required insertion into the vagina. They did not feel
comfortable with the idea and wanted to give clothpads a chance. We took
down orders. 11 women out of the 19 that were present, placed orders for
reusable cloth pads. They all got only 2 each. Though 2 are not enough to
rotate in a cycle since they need to be washed and dried before reuse, they all
wanted to only risk a small amount as this was for trial, understandably so.
This was a big win anyway, as we were able to get through to these ladies at
so many levels.
L+R: I was glad to see a good turnout in the feedback session. It was
something I truly wasn't expecting, but the ladies came back with smiles that
warmed my heart and greeted me with a lot of love. I believe feedback is very
important after any session or intervention, to understand the felt impact of
one’s work.

Through this session I also attempted to make products more available and
accessible to the ladies who would like to try something else, and might make
a permanent switch. It is a part of the 4 As approach- Availability,
Accessibility, Affordability and Acceptability. First we generate Awareness
about the availability of different kinds of products, then we make them
accessible through my network and make it affordable to the ladies. Once
they buy some to try and see how suitable they are (checking acceptability),
we upscale our work and spread the word. It is not just the products we are
making available, but also information on ways to better care for oneself
during periods so that they may make more informed and conscious choices.
Since we could not answer all questions, it is better if we can connect them to
the local PHC doctor for special needs, which they don’t feel comfortable
bringing up to their notice otherwise.

7. Follow Up session to understand social cohesion:
This follow up session was done months after the original session in the
community, yet there were 16 ladies who came back, again a great turn out.
This session was less content oriented, but more generic, like a catch up
among friends, the vibe was also such. I started by asking how they were and
how everything had been with them. Most were shy to reply to such
questions, they prefer if I ask them ‘study’ related questions. So, we got to it.
They did not really have any problem with their periods since they made small
changes suggested by us, but said that it would still be helpful to bring a
doctor into the community for a basic consultation. The products that they
were using were okay. One lady who bought the Eco Femme reusable cloth
pads said that the size of the pads was a little small for her, so she used one
and gave the other to her daughter to use.
Moving to questions more related to understanding the effects of our sessions
and meetings on social cohesion. While most women knew each other even
before our session, others got familiar with them too after having spent those
3 hours together and meeting again in the follow up feedback session. Then I
asked if, after having discussed intimate topic such as Menstruation in the
presence of each other, do they feel more free with each other, as if they
could share more freely with each other now. This got a positive response.
However, they said that they more comfortable sharing with people closer to
their own age. They were still not ready to talk across generations, still this
was a step in the right direction.
Lastly, I said that we should all give each other a hug as a way to hold each
other and let emotions flow freely. This idea got some giggles and pushback
until I hugged the girl next to me. This was followed by a wave of hugs around
the room, smiles on every face. They had never done this before, but did not
hate trying it out.
L+R: Seeing the great turnout, is very reassuring of the love of the community
and the work we have done there. Their willingness to spare time for my
follow up sessions inspires gratitude in me. I realised that each meeting
requires a little ice breaking time at the beginning to get the ladies comfortable
with the space, with the facilitator and with each other. It need not be with
activities or games only, could even be with informal chitter chatter.
The idea to hug each other was in hopes to accelerate any deepening of
social cohesion if at all. To my surprise, these people who live in such close
proximity, in such a densely populated space, were apprehensive of physical
touch and of expressing love through hugs. This was not particular to any age
group, all ladies present, felt alike about this. Once I hugged the girl next to
me, I realised it was something they weren't expecting me to do, but they
were so happy when I did it. They all embraced each other after that.

8. Connecting the community with the PHC:
The idea behind doing this was to link the community with the local institution
for a long term impact. Instead of getting a gynecologist or any other female
doctor to address the community's needs, why not invite the local Primary
Health Centre’s doctor. With this agenda in mind, I set out to meet the local
PHC’s doctor. At the PHC, I saw a list of services available there and it
included “Counselling for Adolescent Health, Menstrual Hygiene, RTI, STI &
Iron Supplementation”.
Dr. Tejaswi was the doctor at the PHC there. She was very kind and
courteous and gave us ample time to ask our questions. She informed us that
the PHC doesn’t provide free sanitary pads to those in need. She told us that
women come to her for menstruation related problems too, such as irregular
periods, weight gain, acne, heavy bleeding and PCOS related issues. She is
the one who addresses all their concerns. There is no separate specialist at
the PHC. When asked, to what extent can the PHC help the ladies who come
in with issues related to menstruation, we were told that she can give a clinical
diagnosis. For anything more, patients are referred to bigger hospitals. She
also spoke of limited supply of medicines and that tests can not be done at
the PHC, including the Pap Smear. Unlike some doctors, she was of the
opinion that regular vaginal discharge is normal, which was a relief.
Doctor also told us that she is aware about recent studies linking sanitary pad
usage to cancer, etc. yet she would support the use of pads over cloth. She
recommends that pads be changed regularly to avoid problems with the
product. She also said that India is not ready for products like tampons and
menstrual cups and even she recommends that only married women use
such products that need to be inserted inside the vagina.
Lastly, when we told her about our sessions in the community, she seemed
more than happy to help out and do an in-community meet with the ladies.
She gave us a date in March 2023 and said that she could come for an hour
after 3pm. Our field coordinators were still doubtful of her availability and
willingness and said that they don’t think she will follow through.
L+R: Connecting the community’s needs with the local institution that should
be providing support on such matters would ensure sustainability of the
intervention. It would also help to hold government institutions responsible for
the role they are entrusted with.
I thought it was a good idea to meet the PHC doctor before we extend the
invitation for the in-community consultation. I also wanted to know if we stood
on the same ground about the information we gave in our sessions so as not
to confuse the community later.
There are varying opinions on many products these days, hence the idea to
cross check. I found that the doctor and our opinions clashed on the use of

menstrual cups and reusable cloth pads. The doctor, like many others, was of
the opinion that menstrual cups should only be used by married women. This
ideology often stems from the need to preserve honour of women through the
social construct that is virginity and the breaking/tearing/stretching of the
hymen. Another opinion that I found problematic was the complete rejection of
cloth as a menstrual absorbent. The emphasis was on ‘moving forward’ and
leaving ‘old practices’ behind, even at the cost of irrationality. When I asked if
clean and dry cotton cloth can be used to manage period flow, she said that
cloth pieces are not autoclaved and are hence not appropriate. This jargon
has been popularized by sanitary pad manufacturers who want to push their
products. There is no need for autoclaving clean and dry cloth pieces just like
we don't autoclave our panties everyday. Instead of helping people use the
most available, accessible and affordable flow management product by
providing the much needed maintenance methods, some doctors these days
would rather vouch for products that are pushed to the point of mainstreaming
by big corporations. All this amid research study publications proving that link
chemicals in pads to diseases like cancer and other reproductive issues.

:Annexure:

Media: Sugandha.pdf

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