Master of health Science

When submitting your assignment to Turnitin you are implicitly ticking these statements: ? I retain a backup file of this assignment in case the original file is lost or damaged. ? I hereby certify that no part of this assignment or product has been copied from any other student’s work or from any other source except where due acknowledgement is made in the assignment. ? I hereby certify that no part of this assignment or product has been submitted by me in another (previous or current) assessment. ? I hereby certify that no part of the assignment has been written or produced by any person. ?I hereby certify that no part of this assignment has been made available to any other student. ? I am aware that this work will be reproduced and submitted to plagiarism detection software for the purpose of detecting possible plagiarism. This software may retain a copy of this assignment on its database for future plagiarism detection. ? I understand that failure to uphold this declaration may result in academic proceedings in line with the UWS Student Academic Misconduct Policy. Your name: Your student number: 1. Provide your appraisal of the strengths and weaknesses of the presentation of the statistical material in Winkleby et al, 1992 (300-400 words, 18 marks) 2. Provide the description and results of your descriptive analyses (100-150 words, 8 marks) 3. Provide the description and results of relevant regression models and inferential analyses (150-200 words, 10 marks) 4. Provide your answer to the research question (40-80 words, 4 marks)
Instruction:
Please use words as required by task

401077 Introduction to Biostatistics, Spring 2015
Assignment 3
(Due Friday October 23, 2015)
(Due Wednesday October 28, 2015)

When submitting your assignment to Turnitin you are implicitly ticking these statements:
 I retain a backup file of this assignment in case the original file is lost or damaged.
 I hereby certify that no part of this assignment or product has been copied from any other student’s work or from any other source except where due acknowledgement is made in the assignment.
 I hereby certify that no part of this assignment or product has been submitted by me in another (previous or current) assessment.
 I hereby certify that no part of the assignment has been written or produced by any person.
I hereby certify that no part of this assignment has been made available to any other student.
 I am aware that this work will be reproduced and submitted to plagiarism detection software for the purpose of detecting possible plagiarism. This software may retain a copy of this assignment on its database for future plagiarism detection.
 I understand that failure to uphold this declaration may result in academic proceedings in line with the UWS Student Academic Misconduct Policy.

Your name:
Your student number:

1. Provide your appraisal of the strengths and weaknesses of the presentation of the statistical material in Winkleby et al, 1992 (300-400 words, 18 marks)

2. Provide the description and results of your descriptive analyses (100-150 words, 8 marks)

3. Provide the description and results of relevant regression models and inferential analyses (150-200 words, 10 marks)

4. Provide your answer to the research question (40-80 words, 4 marks)

5. References (0 marks)

If you need to give any reference, please use this textbook. Because my teacher follows this one.
LM. (2012). Essentials of Biostatistics in public health (2nd Ed). Jones & Bartlett Learning, Burlington, MA.

My professor has added two clarifications in the question document in response to student questions:
Correcting for age is just including age in the regression model. When age is in the model all other variables are corrected for age (and age is simultaneously corrected for all other variables in the model).
the variable called ‘lgtotchol’ is the logarithm of total cholesterol.

Task

Students will be presented with a research question, a related published journal article and an appropriate data set. Students will be asked to critically appraise selected statistical aspects of the article provided. Then, using the R Commander and the data set provided, students will be asked to conduct and report their own analyses addressing the research question. A Word template will be provided for the answers. Students will need to apply all skills and knowledge they have obtained in this Unit to complete this assessment.

Criteria

You will be assessed on the following:

The accuracy, depth and relevance of your critical appraisal
The appropriateness of your choice of statistical methods in relation to the research question and data set.
The accuracy, clarity and completeness of your description of the statistical methods used.
The accuracy, clarity and completeness of your presentation of the results of the statistical analyses.
The accuracy, depth and relevance of your interpretation of results and your answer to the research question.
Please avoid pasting screenshots of R Commander output into your assignment (graphs are fine). Raw output does not identify the answer to the question. Where ever possible present your answer as a sentence or paragraph.

Resources

There is no requirement to study beyond the text book, tutorial materials and practice exercises. If however, you do not fully understand these materials or find the style difficult, please consider:

concepts and practice questions can be discussed with tutors, fellow students and on the online discussion group.
there are many good youtube videos if you learn better by watching than reading.
any introductory statistics text will cover the same material – see Section 2.5 above for a few examples available online.
Asia-Pacific Journal of Public Health
2015, Vol. 27(7) 785–795
© 2015 APJPH
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DOI: 10.1177/1010539515602743
aph.sagepub.com
Article
Chhaupadi Culture and
Reproductive Health of
Women in Nepal
Chhabi Ranabhat, MPH, PhD1,2,4,
Chun-Bae Kim, MD, PhD1,2, Eun Hee Choi, PhD3,
Anu Aryal, BSc N5, Myung Bae Park, MPH, PhD1,
and Young Ah Doh, PhD, MPA, PHD6
Abstract
Different sociocultural barriers concerning women’s health are still prevalent. Chhaupadi culture
in Nepal is that threat wherein menstruating women have to live outside of the home in a
shed-like dwelling. Our study aims to determine the factors of reproductive health problems
related to Chhaupadi. A cross-sectional study was performed with women of menstrual age
(N = 672) in Kailali and Bardiya districts of Nepal. Data were collected with stratified sampling
and analyzed using SPSS. Reproductive health problems were observed according to the World
Health Organization reproductive health protocol. Regression analysis was performed to show
the association between relevant variables. Results reveal that one fifth (21%) of households used
Chhaupadi. Condition of livelihood, water facility, and access during menstruation and precisely
the Chhaupadi stay was associated (P < .001) with the reproductive health problems of women. The study concludes that Chhaupadi is a major threat for women’s health. Further research on appropriate strategies against Chhaupadi and menstrual hygiene should be undertaken. Keywords Chhaupadi, reproductive health problems, menstrual hygiene, cross-sectional Introduction Menstruation is a normal physiological process in women, but it is perceived differently in diverse societies and cultures.1 There are some beliefs that culture related to menstruation has been linked with religion, which is unfair. Most Christians do not follow any rituals or beliefs related to menstruation,2 except for some eastern orthodox church followers including Russians, 1Department of Preventive Medicine, Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea 2Institute for Poverty Allivation and International Development Yonsei University, Wonju, Republic of Korea 3Institute of Life Style Medcine, Yonsei University, Wonju College of Medicine, Wonju, Republic of Korea 4Health Science Foundation and Study Center, Kathmandu, Nepal 5Good Neighbors International, Jhamsikhel Lalitpur, Nepal 6Korea International Co-operation Agency, Africa and South America Section, Seoul, Republic of Korea Corresponding Authors: Chhabi Ranabhat and Chun-Bae Kim, Department of Preventive Medicine, Yonsei University, Wonju College of Medicine, Wonju, Gangwon 220-701, Republic of Korea. Email: chhabir@gmail.com; kimcb@yonsei.ac.kr 602743 APHXXX10.1177/1010539515602743Asia-Pacific Journal of Public HealthRanabhat et al research-article2015 Downloaded from aph.sagepub.com at University of Western Sydney on October 7, 2015 786 Asia-Pacific Journal of Public Health 27(7) Ukrainians, or Greek, and they advise women not to be in close relationship with others.3 Judaism and traditional Islamic interpretation of the Qur’an prohibits intercourse, but not physical intimacy during a woman’s menstrual period.4 Hinduism has a wide diversity of culture on menstruation and there are mixed interpretations. Buddhist people take menstruation as a natural and normal physiological process, but Japanese Buddhist do not encourage attendance at worship during this period.5 In middle India, including some parts of Nepal, menarche, the first menstruation, is a positive and productive time in a woman’s life. In south India, when girls experience their first menstruation, they are given presents and there are celebrations to mark this special occasion.6 Nevertheless, some cultural practices result in women facing isolation during menstruation, and one of these cultures is the Chhaupadi culture of Nepal. A number of taboos and sociocultural restrictions still exist concerning menstruation, which intimidate women and makes their life difficult.7 The most common social and cultural practices and restrictions during menstruation among young girls and women are the following: prohibition to enter the prayer room and the kitchen,8 looking into a mirror, attending to guests,9 offering prayers, and touching holy books.10 Menstruating Taiwanese women have been found to avoid particular substances and behaviors, such as cold and raw food, exercise, and tub baths, to maintain their menstrual hygiene.11 Perception about menstruation are still clouded by taboos and sociocultural restrictions because they are ignoring scientific facts and the menstrual hygiene aspect that could provide better reproductive health.12 Due to the negative perception about menstruation, women feel some sort of stigmatization and inadequate sanitation that have important consequences for their sexuality, well-being,13 as well as reproductive health problems due to poor hygiene.14 The aforementioned studies indicate that more beliefs related to menstruation are prevalent in South East Asia including in some parts of Nepal; however, these findings are silent in with regard to women’s reproductive health and sufficient hygiene. Chhaupadi culture is a traditional practice wherein menstruating women have some restrictions, such as restrictions to consume of milk products; restricted access to public water sources; not being allowed to touch men, children, cattle, living plants, or fruit bearing trees15; and having to live outside the home such as in an animal shed16 (Figure 1). This practice is widespread in the far west and some parts of the mid-western Nepal.17 It is one kind of violence against women, and there is equal chance for mental health problems because women’s mental health was worsening due to domestic violence in a study in Turkey.18 Anemia and underweight (body mass index <18) of women was 2-fold higher and child health status was poor in Chhaupadi-affected areas in Figure 1. Chhaupadi in Tikapur, Kailali, Nepal. Video available at: https://www.youtube.com/watch?v=UgQ54CZ6uLQ Downloaded from aph.sagepub.com at University of Western Sydney on October 7, 2015 Ranabhat et al 787 comparison with the national average because small children live together with their mothers in Chhaupadi during the menstruation period.19 Reproductive health problems like severe bleeding, backache, and lower abdominal pain are worsening during Chhaupadi stay and some of the women fall prey to negative health behaviors such as smoking and alcohol consumption throughout their Chhaupadi stay.20 Genital infections due to lack of menstrual hygiene, undernutrition due to some food barriers, and uterus and cervical problems due to heavy working, and recurrent infection of human papillomavirus are the major consequences due to Chhaupadi stay.21 Chhaupadi itself does not cause any disease or illness, but it facilitates an unsafe menstruation period. As a result, it increases reproductive tract infection for women due to poor hygiene (limited access to water) and maternal malnutrition (some food restriction), and after continued use it increases behavioral problems (due to isolation, substance abuse, and stigmatization). The baseline health survey on health service improvement in Tikapur (HIT) 2012 states that 30% of households in that community practice Chhaupadi.22 These studies and reports indicate that Chhaupadi might be a major cultural factor that is responsible for poor women’s health status. The research related to menstruation belief and culture are very few, and the issues related to Chhaupadi also have not been widely explored because of the social structure: dominated status of male and offensive situation of female and linking of culture with religion. Likewise, there are few scientific research studies and they explored the Chhaupadi problem as social inequality, which is a very general and ambitious subject. It means there is not only lack of research on Chhaupadi but also specification of study so that it could be point out the direct effect. In other words, women’s reproductive health must be the prime concern and inequality, rights, and so on are secondary concerns. There is multiple impact of Chhaupadi culture but this study is focused on reproductive health problems of women due to unsafe menstruation. The aim of this study is to determine the factors on reproductive tract infection based on the World Health Organization (WHO) protocol in relation to Chhaupadi stay in Kailali and Bardiya districts of Nepal. Our expected outcome is to bring about improvement of Chhaupadi culture for the better reproductive health of women. Methodology Study Design and Sampling This was cross-sectional study conducted from June to August 2014. More explicitly, it is descriptive and some components were framed as analytical. The sampling process was set up in 3 stages. The women of menstruation age based on households were the study unit. Study districts were selected purposively as Bardiya and Kailali districts of Nepal, which are the areas occupied by the migrants who are inhabitants of places where Chhaupadi originated. In the second stage, 6 village development committees (VDCs), which are government geographical units, were selected by simple random sampling in the selected districts. In the last stage, participants were selected from
households. Sampling Strategies The 3R strategy was applied in the sampling process: randomization of participant selection, representativeness by proper estimation of sample size, and reliable information through field researcher selection, training, and data collection with proper supervision. Sampling Frame Individual participants were selected from the list of the local government authority: VDC record list of selected strata. Stratified random sampling was applied to include a subgroup of the population based on population weight. Below the VDC unit, there were also ward-level (Nos. 1-9) Downloaded from aph.sagepub.com at University of Western Sydney on October 7, 2015 788 Asia-Pacific Journal of Public Health 27(7) population subgroups because all subgroups were included by disproportionate stratified random sampling. Sample Size Estimation Previously, baseline health survey for health improvement in Tikapur (HIT) explored that 30% of households had Chhaupadi.22 Based on that study, the sample size was calculated by an online software23 using the following formula: n Z p p d = − 2 2 ( ) 1 , where n is the sample size, the value of Z is 1.96, p is the proportion (30%) of staying at Chhaupadi,22 and d is the standard error (0.01). The sample size was 336 per district, and our study was in 2 districts. Selection of Participants Females who were of mensuration age (usually 12-49 years) and those who had already started the menstruation process were included in the study. One participant was selected from each household. If there were more than one respondent in the household, the latest menstruating woman was selected. Females who having menopause, those staying in the study region for less than 6 months, households that did not have women of menstruation age, and those who did not want to participate in the study were excluded from this study. Recruitment of Field Researchers The field researchers were screened and selected based on previous experience, academic soundness, and experience with field research. More consciously, the researchers were selected from health education backgrounds such as paramedics, nurses, and community health workers because they could screen the reproductive health problems of women. Setting of Research Tool A semistructured questionnaire was developed based on observation of Chhaupadi, focus group discussion with community key informants, field-level health workers, previous reports related to Chhaupadi, and survey findings of the health services in Tikapur (HIT), Nepal. Health problems of women were developed based on comprehensive cervical cancer control manual 2006 (WHO)24 and guidelines for the management of sexually transmitted infections 2003 (WHO),25 particularly reproductive tract infection as shown in the question below. Have you had any of the following problems over the past 1 year? 1. Severe pain and/or foul-smelling discharge during menstruation? 1. Yes 2. No 2. Experience of burning during urination? 1. Yes 2. No 3. Vaginal itchiness? 1. Yes 2. No Any abnormal discharge and/or swelling in your vagina? 1. Yes 2. No Measurement: Any one of those problems or more than one or all of them = present (1); and none of them = absent (0) Downloaded from aph.sagepub.com at University of Western Sydney on October 7, 2015 Ranabhat et al 789 Data Collection Method, Instrument, and Variables Data were collected by field researchers with the help of the complete questionnaire and field guide book. First, the collected data were decoded and entered in Epi Data 3.1 data entry format and exported to SPSS 20. Data were cleaned and verified by a biostatistician and further analyzed by researchers. There were 3 categories of independent variables: demographic (age, ethnicity, education marital status, and district), economics (condition for livelihood, occupation, housing condition, availability of toilet and water), and menstruation-related variables (use of pad, bathing attitude, accessibility of water, and Chhaupadi stay) and presence and absence of reproductive health problems as dependent variables as in the aforementioned table. Statistical Test Categorical variables are presented as frequency and percentage. In order to compare reproductive health problems, we performed the χ2 test (Fisher’s exact test). Logistic regression analysis was used to identify the factors to predict the reproductive health problems. This was quantified by odds ratio using binary logistic regression. P value less than .05 was considered statistically significant, and all statistical analyses were performed using SPSS 20. Validity and Reliability The research tools were verified in a pilot study in a similar area in Baliya VDC Kailali, the sample size was determined by a scientific method, appropriate selection of researchers’ training and field guidebooks were provided for reliable data, the data collection process was supervised to minimize bias, and related variables were adjusted to find the fair result. Ethical Issues The research was approved by the Ethical Review Committee of Nepal Health Research Council, and verbal consent was obtained from the respondents during data collection. For girls under the age of 16, consent was taken from their parents after describing the research objectives in detail. All respondents were requested to provide information voluntarily and were assured that they could withdraw anytime during the study. Results Descriptive Data The respondents were selected from 3 VDCs in each district, that is, Pathariya 21%, Kotatulsipur 13%, and Durgauli 16% from Kailali; and Patabhar 17%, Manau 7.4%, and Sanoshree 26% from Bardiya. Both indigenous people (45.5%) and those who had migrated from other places (54.5%) made up the study population. Of the women, 36% were 20 to 30 years old, almost all (98%) were of the Hindu religion, and 42% were from poor families (unable to maintain a livelihood all year round). In aggregate, 25% reported one or more problems related to their reproductive health. Characteristics of Demographic, Economic, and Menstruation-Related Variables With Reproductive Health Problems The variables were categorized into 3 sections, and all independent variables were dichotomous. Ethnicity (upper caste), respondents of the Kailali district, economic status not sufficient for livelihood, risky house, food restriction during menstruation, no access of water Downloaded from aph.sagepub.com at University of Western Sydney on October 7, 2015 790 Asia-Pacific Journal of Public Health 27(7) during menstruation, bathing habit on more than 2 days, and staying in Chhaupadi had significantly higher reproductive health problems than who had not (Table 1). Likewise, all reported health problems were strongly associated (<.001) with Chhaupadi stay (Table 2). It was further explored that almost all menstruation variables were related to reproductive health problems. Situation of Reproductive Health Problems After Adjustment After the adjustment of predictors using the binary logistic regression, some variables are risk factors to the reproductive health for women. The odds ratio with 95% confidence interval showed that respondents from Kailai 2.38 (1.36-4.18), no utilization of water resource during menstruation 2.78 (1.32-5.88), and who had Chhaupadi 14.6 (6.99-30.5) times risk to have reproductive health problems and were statistically significant (P < .05; Table 3). Among all significant predictors, the Chhaupadi was a high risk factor as reproductive health problem before 30.47 (18.66-49.77) and after final adjustment 14.6 (6.99-30.5), model IV (P < .001). Discussion Currently 20% of the households practice Chhaupadi, a slight decrease from the previous 30%,22 and such culture was deeply rooted in the migrated community from Achham, Dailekh, and Bajhang districts, which are known as a source of Chhaupadi culture. In comparison with Kailali, Bardiya district has low of influence of migration from those districts. As a result, the reproductive health problems were significantly lower in Bardiya district. This study indicates that not only menstruation-related factors but also demographic
and economic factors are responsible for women’s reproductive health problems (Table 1), because they are common factors in most of the studies, but here menstruation-related factors are primary factors. Some food restriction and access to public water sources are menstrual culture without Chhaupadi also. The studies on unsafe menstruation and reproductive health problems are very rare but available comparisons are presented. A study in India indicates that food and some activities are restricted during menstruation, and the average index score was comparatively high for the respondents in the categories of unmarried status, semiurban areas, Hindus, joint family structure, and high school level of education.26 A practice in Judaism, Mikvavh, consisting of ritual bathing that occurs at the end of the menstrual period, has been reported as harmful to women’s health.27 In some Chinese cultures, menstruation is perceived as a weak condition and cold foods and drinks are restricted and herbal teas are recommended for strength (Qi).28 Like the Chhaupadi, there is a similar practice in India for menstruating women to restrict some foods like milk, fruits, and so on, and some important activities. However, another study in India found no significant relationships between attitudes to menstruation and demographic variables.29 These above-mentioned study findings are similar with our result. There are specific beliefs about food that women are restricted on eating during menstruation, pregnancy, and lactation, usually in rural areas of Nepal.30 More than 20% of the women in Kailali and Bardiya districts have low body mass index (<18.5 kg/m2), which should be proxy indicators of food restrictions during their menstruation.31 The reproductive health problems like burning micturition, chronic pelvic pain, painful sexual intercourse and pain occurring during period, abnormal discharge, and so on are the symptoms of fibroid uterus, multiple reproductive tract infection, and cervical and uterus cancers, which are more severe and sometime fatal.32 During the screening for uterine prolapse, the women reported health symptoms as difficult and burning urination, abdominal pain, backache, painful intercourse, white watery discharge, foul-smelling discharge, itching, and difficulty in lifting, sitting, walking, and standing Downloaded from aph.sagepub.com at University of Western Sydney on October 7, 2015 Ranabhat et al 791 Table 1. Characteristics According to Reproductive Health Problems (N = 672)a . Reproductive Health Problems Variables Category Absent (N = 503), n (%) Present (N = 169), n (%) P Value Demographic variables Age <30 years 315 (62.6) 108 (63.9) .7654 ≥30 years 188 (37.4) 61 (36.1) Ethnicity Lower cast 272 (54.0) 34 (20.1) <.0001 Upper caste 231 (46.0) 135 (79.9) Education Higher education 89 (17.7) 27 (15.9) .6092 Lower education 414 (82.3) 142 (84.1%) Material status Married 349 (69.3) 125 (73.9) .2584 Unmarried 154 (30.7) 44 (26.1) District Kailali 195 (38.8) 141 (83.4) <.0001 Bardiya 308 (61.2) 28 (16.6) Economics variables Condition for livelihood Sufficient livelihood 309 (61.4) 78 (46.1) .0005 Insufficient livelihood 194 (38.6) 91 (53.9) Major occupation Paying job 12 (2.3) 3 (1.8) .7718 Not paying job 491 (97.7) 166 (98.2) Type of house Relatively safe 177 (35.2) 44 (26.1) .0284 Weak/dwelling 326 (64.8) 125 (73.9) Toilet Yes 398 (79.1) 111 (65.7) .0004 No 105 (20.9) 58 (34.3) Water facility at home Yes 442 (87.9) 155 (91.7) .1698 No 61 (12.1) 14 (8.3) Menstruation-related variables Food restriction during menstruation Yes 141 (28.0) 116 (68.6) <.0001 No 362 (72.0) 53 (31.4) Application of pad Yes 493 (98.1) 168 (99.4) .3069 No 10 (1.9) 1 (0.6) Utilization of water resource during menstruation Yes 424 (84.2) 49 (28.9) <.0001 No 79 (15.8) 120 (71.1) Bathing attitude during menstruation Daily 420 (83.5) 158 (93.5) .0012 More than 2 days 83 (16.5) 11 (6.5) Chhaupadi Yes 29 (5.8) 110 (65.1) <.0001 No 474 (94.2) 59 (34.9) a Total percentage by column. Table 2. Component of Reproductive Health Problems According to Chhaupadia . Chhaupadi Stay P Value Reproductive Health Problems (Present) N = 139; Yes, n (%) N = 533; No, n (%) Burning micturition 89 (64.0) 15 (2.8) <.0001 Abnormal discharge 67 (48.2) 29 (5.4) <.0001 Itching in genital part 77 (55.4) 26 (4.8) <.0001 Pain and foul smelling menstruation 55 (39.5) 18 (3.3) <.0001 a Reproductive health problems exceed 169 because of the duplication in numbers. Downloaded from aph.sagepub.com at University of Western Sydney on October 7, 2015 792 Table 3. Odds Ratio and 95% Confidence Interval for Reproductive Health Problems. Variables Category Model I; OR (95% CI) Model II; OR (95% CI) Model III; OR (95% CI) Model IV; OR (95% CI) Chhaupadi Yes 30.47 (18.66-49.77)** 18.72 (10.16-34.5)** 19.68 (10.55-36.71)** 14.60 (6.99-30.50)** No 1 1 1 1 Demographic variables Ethnicity Lower cast 0.94 (0.54-1.64) 0.95 (0.54-1.68) 1.18 (0.62-2.25) Upper caste 1 1 1 District Kailali 3.19 (1.91-5.34)* 2.85 (1.65-4.93)* 2.38 (1.36-4.18)* Bardiya 1 1 1 Economics variables Economic status Insufficient livelihood 1.53 (0.95-2.46) 1.61 (1.0-2.62) Sufficient livelihood 1 1 Type of house Weak/dwelling 1.11 (0.65-1.89) 1.2 (0.7-2.05) Relatively safe 1 1 Toilet No 1.22 (0.72-2.06) 1.21 (0.71-2.05) Yes 1 1 Menstruation-related variables Food restriction during menstruation Yes 0.66 (0.31-1.39) No 1 Utilization of water resource during menstruation No 2.78 (1.32-5.88)* Yes 1 Bathing practice More than 2 days 0.77 (0.35-1.7) Daily 1 Abbreviations: OR, odds ratio; CI, confidence interval. *P < .05. **P < .001. Downloaded from aph.sagepub.com at University of Western Sydney on October 7, 2015 Ranabhat et al 793 in Bajhang district of Nepal, which is a Chhaupadi-affected place.33 Reproductive tract infections and uterovaginal prolapse were the leading causes of maternal morbidity34 that were reported in those areas. These results are similar to our study concerning the 4 reproductive tract infections we accessed. Society is complex and it is dynamic because different communities have different myths, values, taboos, and cultures. Previously, there have been general studies on Chhaupadi from the perspective of women’s rights and violence against women. In those areas government agencies and communities have declared Chhaupadi-free societies and some improvement can be observed but these were not to address the reproductive health problems of women. Chhaupadi culture is against the law; however, there is no sufficient law enforcement to change the community.16,35 So only women’s effort is not sufficient for this threat, men’s role is invaluable because the coverage of antenatal care was significantly increased especially for newly married women with the help of their husbands in Bangladesh.36 According to the evolution of society, such menstrual taboo will disappear eventually, but by that time, many women and children will have died or suffered from health problem due to unsafe menstruation in those areas of Nepal. Limitation of the Study No standard instruments were used for this study, but the reproductive health problems were measured to the WHO reproductive health protocol.24,25 The results of this study may not confirm reproductive health diseases of the women clinically or by laboratory and only show the vulnerability to any type of reproductive tract infections due to unsafe menstruation. There might be recall bias regarding the reproductive health problems over the past 1 year, and 4 reproductive health problems may not represent the overall health status of women, but our results strongly support the Chhaupadi as a risk factor of reproductive health of women. Policy and Public Health Implication Basically, this study aims to improve the reproductive health of women and provide more attention to policymakers and health service provider where the Chhaupadi is high and a special program could be set so that the reproductive health problem will be explored in more detail. Menstrual hygiene is the main requirement to control reproductive tract infection and the government
should conduct a special campaign about it. Moreover, Nepal’s Ministry of Health and Population could formulate a safety menstruation policy targeting any kind of menstruation malpractice that is responsible for the poor health status of women. It also drives to make more strict laws against Chhaupadi in Nepal and appealing reproductive right act to eliminate all kinds of cultural violence that are threats to women’s health. Conclusion Chhaupadi is responsible for reproductive health problems due to unsafe menstruation. Menstrual hygiene is important to reduce the reproductive health problems because bathing attitude was also significant to reproductive health problems. The Millennium Development Goals are focused on improving the health of women but some inequality and women unfriendly cultures are main threats to improve their health.37 More clinical research, safe menstruation policy, special programs through global effort, collaboration between different organizations, and so on could be a milestone to overcome the problems. Acknowledgment This article was reviewed by Margret Stroey. Downloaded from aph.sagepub.com at University of Western Sydney on October 7, 2015 794 Asia-Pacific Journal of Public Health 27(7) Authors’ Note Chhabi Ranabhat and Chun-Bae Kim contributed equally to this work. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported at the field level with initiation of Good Neighbors International Nepal and the National Research Foundation Grant of Korea, Korean Government for the publication (NRF-2013S1A5B8A01055336). References 1. Adinma ED, Adinma J. Perceptions and practices on menstruation amongst Nigerian secondary school girls. Afr J Reprod Health. 2009;12:74-83. 2. Rani B, Rajeswari R, Prabhakar R. A case of late generalised tuberculosis with normal chest radiograph. Indian J Tuberc. 1986;33:136-137. 3. Spruyt H. The Sovereign State and Its Competitors. Cambridge, England: Cambridge University Press; 1994. 4. Cevirme AS, Cevirme H, Karaoglu L, Ugurlu N, Korkmaz Y. The perception of menarche and menstruation among Turkish married women: attitudes, experiences, and behaviors. Soc Behav Pers. 2010;38:381-393. 5. Jnanavira D. A mirror for women? Reflections of the feminine in Japanese Buddhism. J West Buddhist Rev. 2006;4:1-11. 6. Narayan K, Srinivasa D, Pelto P, Veerammal S. Puberty rituals, reproductive knowledge and health of adolescent schoolgirls in South India. Asia Pac Popul J. 2001;16:225-238. 7. Singh A. Place of menstruation in the reproductive lives of women of rural North India. Indian J Community Med. 2006;31(1):10. 8. Sharma N, Vaid S, Manhas A. Age at menarche in two caste groups (Brahmins and Rajputs) from rural areas of Jammu. Anthropologist. 2006;8(1):7-55. 9. Dasgupta A, Sarkar M. Menstrual hygiene: how hygienic is the adolescent girl? Indian J Community Med. 2008;33(2):77. 10. Ten VTA. Menstrual Hygiene: A Neglected Condition for the Achievement of Several Millennium Development Goals. Brussels, Belgium: European External Policy Advisors; 2007. 11. Furth C, Shu-yueh Ce. Chinese medicine and the anthropology of menstruation in contemporary Taiwan. Med Anthropol Q. 1992;6(1):27-48. 12. Koff E, Rierdan J. 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Cultural variations in attitudes toward menstruation. Can J Psychiatry. 1992;37:196-198. 30. Gittelsohn J, Thapa M, Landman LT. Cultural factors, caloric intake and micronutrient sufficiency in rural Nepali households. Soc Sci Med. 1997;44:1739-1749. 31. Singh A, Singh A, Ram F. Household food insecurity and nutritional status of children and women in Nepal. Food Nutr Bull. 2014;35(1):3-11. 32. Zimmermann A, Bernuit D, Gerlinger C, Schaefers M, Geppert K. Prevalence, symptoms and management of uterine fibroids: an international internet-based survey of 21,746 women. BMC Womens Health. 2012;12:6. 33. Bonetti TR, Erpelding A, Pathak LR. Listening to “felt needs”: investigating genital prolapse in western Nepal. Reprod Health Matters. 2004;12:166-175. 34. Tuladhar H. An overview of reproductive health of women in Bajhang district. Nepal Med Coll J. 2005;7:107-111. 35. Joshi SK, Kharel J, Mentee MV. Violence Against Women in Nepal—An Overview. The Free Library. http://www.researchgate.net/publication/228154733_Violence_Against_Women_in_Nepal. Published 2008. Accessed August 12,2015. 36. Rahman M, Islam MT, Mostofa MG, Reza MS. Men’s role in women’s antenatal health status: evidence from rural Rajshahi, Bangladesh. Asia Pac J Public Health. 2012;27:1182-1192. 37. Say L, Raine R. A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context. Bull World Health Organ. 2007;85:812-819. Downloaded from aph.sagepub.com at University of Western Sydney on October 7, 2015 ** Please note we will only be considering items 10, 12-17 during this Unit. STROBE checklist http://www.who.int/bulletin/volumes/85/11/07-045120.pdf STROBE explanatory document http://annals.org/article.aspx?articleid=737187 or attached Please read these prior to the tutorial.
Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): Explanation and Elaboration Jan P. Vandenbroucke, MD; Erik von Elm, MD; Douglas G. Altman, DSc; Peter C. Gøtzsche, MD; Cynthia D. Mulrow, MD; Stuart J. Pocock, PhD; Charles Poole, ScD; James J. Schlesselman, PhD; and Matthias Egger, MD, for the STROBE initiative Much medical research is observational. The reporting of observational studies is often of insufficient quality. Poor reporting hampers the assessment of the strengths and weaknesses of a study and the generalizability of its results. Taking into account empirical evidence and theoretical considerations, a group of methodologists, researchers, and editors developed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations to improve the quality of reporting of observational studies. The STROBE Statement consists of a checklist of 22 items, which relate to the title, abstract, introduction, methods, results, and discussion sections of articles. Eighteen items are common to cohort studies, case–control studies, and cross-sectional studies, and 4 are specific to each of the 3 study designs. The STROBE Statement provides guidance to authors about how to improve the reporting of observational studies and facilitates critical appraisal and interpretation of studies by reviewers, journal editors, and readers. This explanatory and elaboration document is intended to enhance the use, understanding, and dissemination of the STROBE Statement. The meaning and rationale for each checklist item are presented. For each item, 1 or several published examples and, where possible, references to relevant empirical studies and methodological literature are provided. Examples of useful flow diagrams are also included. The STROBE Statement, this document, and the associated Web site (www.strobe-statement.org) should be helpful resources to improve reporting of observational research. Ann Intern Med. 2007;147:W-163–W-194. www.annals.org For author affiliations, see end of text. Editor’s Note: In order to encourage dissemination of the STROBE Statement, this article is being published simultaneously in Annals of Internal Medicine, Epidemiology, and PLoS Medicine. It is freely accessible on the Annals of Internal Medicine Web site (www.annals.org) and will also be published on the Web sites of Epidemiology and PLoS Medicine. The authors jointly hold the copyright of this article. For details on further use, see the STROBE Web site (www.strobe -statement.org). Rational health care practices require knowledge about the etiology and pathogenesis, diagnosis, prognosis, and treatment of diseases. Randomized trials provide valuable evidence about treatments and other interventions. However, much of clinical or public health knowledge comes from observational research (1). About 9 of 10 research papers published in clinical specialty journals describe observational research (2, 3). THE STROBE STATEMENT Reporting of observational research is often not detailed and clear enough to assess the strengths and weaknesses of the investigation (4, 5). To improve the reporting of observational research, we developed a checklist of items that should be addressed: the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement (Appendix Table). Items relate to the title, abstract, introduction, methods, results, and discussion sections of articles. The STROBE Statement has recently been published in several journals (6). Our aim is to ensure clear presentation of what was planned, done, and found in an observational study. We stress that the recommendations are not prescriptions for setting up or conducting studies, nor do they dictate methodology or mandate a uniform presentation. STROBE provides general reporting recommendations for descriptive observational studies and studies that investigate associations between exposures and health outcomes. STROBE addresses the 3 main types of observational studies: cohort, case–control, and cross-sectional studies. Authors use diverse terminology to describe these study designs. For instance, “follow-up study” and “longitudinal study” are used as synonyms for “cohort study,” and “prevalence study” as a synonym for “cross-sectional study.” We chose the present terminology because it is in common use. Unfortunately, terminology is often used incorrectly (7) or imprecisely (8). In Box 1, we describe the hallmarks of the 3 study designs. THE SCOPE OF OBSERVATIONAL RESEARCH Observational studies serve a wide range of purposes, from reporting a first hint of a potential cause of a disease to verifying the magnitude of previously reported associations. Ideas for studies may arise from clinical observations or from biological insight. Ideas may also arise from informal looks at data that lead to further explorations. Like a clinician who has seen thousands of patients and notes 1 that strikes her attention, the researcher may note something special in the data. Adjusting for multiple looks at See also: Print Related article. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573 Annals of Internal Medicine www.annals.org 16 October 2007 Annals of Internal Medicine Volume 147 • Number 8 W-163 Academia and Clinic Downloaded From: http://annals.org/ on 10/08/2015 Appendix Table. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Checklist of Items That Should Be Addressed in Reports of Observational Studies Item Item Number Recommendation

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