Menstrual hygiene has long been a taboo subject in India, viewed by both men and women as something that should never be discussed. Traditionally, women and girls are seen as impure or untouchable during menstruation, and are forbidden from going to the temple or undertaking certain types of activities, such as taking baths and cooking and serving food. In most rural areas the lack of access to reliable sources of information means that women are not aware that their practices are unsafe. Most will not discuss menstruation among themselves and do not understand the long-term implications of unhygienic habits. Many girls suffer from reproductive tract infections (RTIs), but do not see this as unusual. In some cases it is not until they have to be admitted to hospital that they will admit to having a health problem. Challenging social norms WaterAid India has been working with partners throughout the country on different aspects of menstrual hygiene management (MHM) from biological, sociological, gender-related and rights perspectives. Caramdaksh, a WaterAid partner organisation in north Chhattisgarh state, has been working on the issue for quite a long time. It has provided capacity building and service delivery to different stakeholders, such as schoolgirls, school drop-out girls, women and frontline workers such as Accredited Social Health Activists in a poor rural area where people hold deep-rooted, regressive beliefs and there are cultural myths about menstruation. Caramdaksh noticed that speaking only to women and girls was not enough to bring about significant change. Eventually the team changed their approach and tried to involve the males in the community, so that they too would understand menstruation to be a normal physiological process, provide support to girls and women at home, and start challenging the taboos and social norms that stigmatise menstruation. At first, Caramdaksh held separate meetings with males and with females. To some extent this separation helped awareness-generation and sensitisation around the issue of MHM, but the men did not feel they could openly discuss what they saw as a women's issue. To change this perception, Caramdaksh staff initiated joint meetings with both men and women, but found that still no one would speak about MHM in the presence of their relatives and neighbours, which was not the case for sanitation. The Caramdaksh team felt that it might be better to engage with married couples, because they were more open to discussing intimate issues. They found that young couples, and newlyweds in particular, were more interested. In the new approach, teams with both male and female members met with married couples for about 1.5 hours, which gave them a chance to discuss MHM in depth. To demystify the issue, the team explained the physiology of menstruation and the prevailing practices that females opt for, particularly in rural areas. They made the connection with health and hygiene issues (RTIs and sexually transmitted infections) and explained the impact that not practising and maintaining safe, healthy habits has on the reproductive health of girls and women. Last but not least, in the context of safe sanitation, the team described the challenges girls and women face in relation to open defecation during menstruation. Male and female members met with married couples to discuss menstrual hygienge management in depth. Credit: WaterAid Opening up dialogue Caramdaksh’s ultimate aim was to create an environment conducive to dialogue, enabling people to open up and reveal their true behaviour. They found that men became inquisitive and participated actively in the discussion when approached in this way. If the men understand the turmoil of the women and girls in their community, they are more likely to support the behavioural changes that facilitate the adoption of safe practices and provide a conducive environment for them – for example paying more attention, supplying money for sanitary pads and helping with the household chores, particularly during menstruation. Although this is still a very recent initiative, the initial experience gave everyone cause to feel optimistic. The hope is that the couples engaged with will be agents of change, who, in turn, will help create an open environment in the village by speaking to other couples, enabling Caramdaksh to eventually hold joint meetings with them and work towards breaking the taboos. To monitor behavioural change, WaterAid’s partner will have follow-up sessions with each couple and produce case studies to demonstrate the viability of the method. If it is proven to work, we could advocate engagement with married couples at the village level to government health programmes for an even wider impact.