Last week, my team and I learned a valuable lesson in cultural sensitivity. Having traveled as much as I have and having been in many situations where I have been privy to privileged information, I considered myself to be well versed in culturally sensitivity. However, as I have learned countless times in essentially every aspect of life, there is always space for improvement and a seemingly endless stream of lessons to be learned.As I am currently in India studying a highly sensitive topic, in planning my research, I attempted to make every effort to ensure that my data collection was appropriate and inoffensive. I have spent years rearching this facinating culture but despite my research on these topics, I still had a lot to learn being on the ground interacting with women. Before leaving, I felt like I was constantly debriefing my team members on what to expect with Indian culture. We set up focus groups with Community Health Workers (CHWs) to refine our questions, piloted the final result, and asked our questions with well-educated Telugu translators. I knew that the women in villages would be too embarrassed to discuss their menstruation habits with men, so I arranged to conduct interviews with the only female translator that was available. The other members of my team, both male, interviewed CHWs and, unfortunately, had to take a male translator.
This is where we made our first mistake–the assumption that because the CHWs interact with both male doctors and men about sensitive health information, that they would feel comfortable talking about the menstrual health habits of women in their villages with a male American medical student. However, the questions asked were still too sensitive and the situations in which they were asked brought embarrassment to the CHWs. On our first day, at the suggestion of our male translator, the male portion of our team interviewed the CHWs outside their home. The translator had a very loud and projecting voice and he spoke so loudly that I had to send my translator out from where I was interviewing to ask him to speak quietly. The next day, we realized that these questions needed to be asked in a private environment and, with the intense heat (110 F +), again at the suggestion of the male translator, this team decided to interview the CHWs in a private, air conditioned car. In making this decision, no one considered how this would appear to the villagers, and we neglected to think of having a female chaperone.
In both of these situations, our team attracted attention to our project. As we are discussing such a sensitive and taboo topic, much of the attention that we drew was negative. In a society that is unfortunately dominated by males, the husbands of our interviewees interrogated their wives and became angry at us for asking their wives such sensitive questions. In retrospect, I see how someone might be offended if a group of men took another man’s wife into a private vehicle and asked whether she or the women in her village wore underwear… Sometimes it takes this sort incident to shift the lens and change perspective.
Some of the questions themselves that we asked were offensive. For example, we were interested in finding out about the villager’s and CHW’s general knowledge of menstruation. We quickly found that no one knew anything about the physiological process of menstruation and that this lack of knowledge made them feel uncomfortable. One question in particular, asking about the origin of menstrual blood, was extremely offensive. Even a seemly innocuous question—a question about which religion our interviewee followed–was met with extreme discomfort. Unfortunately, this question was misunderstood by the villagers, who thought that we were asking about their caste.
Unfortunately, we did not know that any of this was going on for our first two days of interviewing–we were at the mercy of our translators. We had made yet another assumption that our translators would translate the full responses, including the discomfort and the scolding that apparently went on in some of the interviews. We only learned of the trouble we caused when it was large enough to inhibit the study’s progress. One evening at dinner, we were told that the CHWs were calling each other and saying that we should not be allowed into their villages, as we were asking “bad questions”. We also were told that the husbands were particularly angry that we were asking their wives such sensitive information, and that if we proceeded with the study as is, we could be met with violence in some villages. I think that this lack of communication was due to the fact that our translators, who were also our hosts, felt obligated to proceed with our faulty and insensitive study, as they did not want to offend us. Having worked closely with people in this part of India for the last two and a half years, including one of our translators, I regretfully should have anticipated this issue and should have spoke with our translators more about giving us “bad news”.
The trouble that we faced happened because we made assumptions. We made the assumption that menstruation was less taboo of a subject, the assumption that the CHWs would be comfortable talking with men about menstruation, and the assumption that our translators would translate our interviewees discomfort and inform us if our study was not well received. As painful and frustrating as this experience was, myself and my team learned important lessons in global health and cultural sensitivity that we will take with us on future endeavors.
Currently, the newly designed study is going smoothly. The women leave the interviews smiling and many wait for all the interviews to complete to take pictures with me or walk me to my vehicle with their children. The CHWs are happy and comfortable, generously offering their home and electricity so that I can have both comfortable and private interviews. So far, my findings are interesting and my mind keeps rolling with new study ideas and possible interventions. In fact, one important finding is that many of the women in the villages suffer from painful menses and cite this as a primary reason for missing work or school. Today, I was able to present information on normal menstruation as well as an intervention for painful menstruation to 22 CHWs at the quarterly CHW training.
In closing, I learned a valuable lesson in cultural sensitivity and in making assumptions. However difficult, this experience will undoubtedly shape my approach to future work abroad. Luckily, I was able to salvage and reshape the study and look forward to sharing the results in the coming months.