Songs, Stories, Design, and Dialogue: Intervention Mapping, Human- Centered Design, and Arts-Based Methods for a Chhaupadi (Menstrual Seclusion) Intervention Development in Nepal

In many parts of the world, the monthly cycle of menstruation is treated not as a natural biological event, but as a source of shame or danger. This stigma often leads to strict rules that isolate women and girls, preventing them from cooking, touching food, or even entering their own homes during their periods. In rural Nepal, this practice is known as chhaupadi, or menstrual seclusion. For generations, women have been required to sleep in small, often unsafe huts or animal sheds while menstruating, a custom rooted in deep-seated beliefs about purity. Although the Nepalese government made this practice illegal in 2017, the law alone has not stopped it. In many communities, the fear of social judgment and the weight of tradition keep the practice alive, leaving women vulnerable to cold, animals, and infection. Public health experts have long known that changing such deep cultural habits requires more than just passing a law; it requires understanding the people who hold these beliefs and working with them to find new ways forward.

A team of researchers from the United States and Nepal recently tried a different approach to solve this problem. Instead of arriving with a pre-made plan to tell the community what to do, they invited a group of women to become the architects of the solution themselves. They gathered eleven women from a village in the Dailekh district, an area where chhaupadi is still common, for a ten-day workshop. The goal was not to lecture them on the dangers of seclusion, but to use creative tools like storytelling, drawing, singing, and clay modeling to help the women explore their own experiences and design a new kind of intervention. By combining a structured planning method with local art forms, the researchers hoped to create a program that felt authentic to the community rather than imposed from the outside.

The workshop began by building trust and creating a safe space where the women could speak openly about a topic that is usually whispered about in private. The researchers introduced the women to a visual tool called a "logic model," which simply maps out the causes and effects of a problem, but they did not ask the women to fill it out with words. Instead, they used a method where the women placed colored sticky notes on a large poster to show what they liked, what they disliked, and what was missing. This allowed the women to correct the researchers' understanding of their reality. Over the next few days, the group moved into more creative activities. They took photographs of their community to identify what they loved about their lives, and they worked together to write a fictional story about a girl navigating the rules of chhaupadi. This storytelling exercise allowed them to discuss difficult truths without having to reveal their own personal secrets immediately.

As the days progressed, the activities became more personal and more powerful. The women engaged in a "walk-a-mile" exercise, where the research team visited their homes to see the small sheds where they slept during their periods. This was not just an observation; it was a moment of connection where the women showed the researchers their living conditions and explained the daily struggles they faced. The women then used mirrors to reflect on their own strengths, an activity that many found surprisingly empowering after years of being told they were "impure." They also composed new songs in the local deuda folk style, writing lyrics that expressed their feelings about menstruation and their hopes for change. These songs and the stories they told became the raw material for the intervention they were designing.

One of the most significant moments of the workshop happened when the women were asked to imagine the future. Using a visual ladder, they mapped out the steps needed to end chhaupadi in their village, starting with small changes and moving toward the ultimate goal of ending the practice entirely. They then used a "buy-a-feature" game, where they were given fake money to "purchase" the ideas they thought would work best. This helped them decide which activities to include in their final plan, such as community theater performances and educational songs. The process was not always easy. Some of the planning tools were difficult for the women to grasp because they required thinking about abstract concepts far into the future, a way of thinking that felt unfamiliar to many. There were also logistical hurdles, such as power outages that interrupted video presentations and the lack of childcare, which made it hard for mothers to focus. Tensions also arose when some community members felt left out of the selection process, requiring the team to hold extra meetings to explain the project's goals.

Despite these challenges, the results were profound. The women did not just design a program; they began to change their own behavior while the workshop was still happening. One participant, whose daughter started her period during the ten days, decided to keep her daughter close at home instead of sending her to the shed. Others shared plans to stay inside their own homes during their next cycle, refusing to follow the old rules of isolation. This suggested that the act of coming together, talking openly, and designing a solution was itself a powerful force for change. The researchers found that the most effective tools were the ones that felt familiar and cultural, like singing and acting, rather than the abstract charts and diagrams. The women felt a sense of ownership over the project that they had never felt in previous health programs.

The study concludes that when communities are treated as experts in their own lives, they can generate solutions that are both practical and deeply meaningful. The researchers learned that building relationships and trust is just as important as the data they collect. The process of designing the intervention was not merely a preparation step; it was the intervention itself. By giving the women the space to speak, create, and decide, the workshop sparked a shift in attitude that no law or lecture could have achieved on its own. The findings suggest that future efforts to improve health in similar settings must prioritize these relational and creative methods, recognizing that the journey toward change begins the moment people are invited to shape their own future.