Tag Archives: Research

A Lesson in Cultural Sensitivity: Assumptions

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.

Focus Group

 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.

 

Hut in a Village

 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”.
 

Esther and BeBe (CHW)

 After learning this unfortunate and surprising news, we were all understandably upset. After all, we came to India in attempts to help alleviate some suffering, not to cause further discomfort and suffering. I felt (and am) responsible for the discomfort caused and couldn’t help but think that I could be responsible for episodes of domestic abuse, which is horrifyingly all too common in the villages. I retreated to my room, where, between several episodes of crying out of frustration and guilt, I began to brainstorm ways to salvage the study. After several Skype calls with friends and mentors, I was able to organize my thoughts and come up with a plan. In the period of about 16 hours (including about four and a half hours of sleep), I shifted the focus of the study, pulled the males (and with them, an important aspect of the study, as I do not have time to do in-depth interviews with all 25 CHWs on my own), and built in the mentorship and knowledge of key persons into the study, getting every question approved by multiple wise and influential women. 

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. 

  

Post Interview

  

 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.

Chalagamari VIllage

India, India! (I return)

After over two years, I’m back in India. For whatever reason, this country has grabbed me more than most, and I have returned to the same place again in my travels, with plans to return for many many more visits… 

  

SNP Widows

 In the middle of an unrelenting heat-wave, I am back at the BIRDS campus in the village of Muthylapadu, in the Kurnool District of Andhra (no longer Andhra-Pradesh), India. The school children are on summer break and without them, the campus feels empty but at peace. Taking their place, are the widowed employees of Shelter International’s Sanitary Napkin Project. Visiting them in their workshop and my interactions with them have been a highlight of the last few years. Words do not begin to express my sentiments and I hope that I am able to process and share these feelings in the future.

While I am here for the widows, I am also here to research the beliefs and practices of feminine hygiene in this portion of village India. Two friends have joined me and together we are trying to create a concrete and evidence-based picture of the area’s current feminine hygiene practices. As tools, we are using focus groups and individual interviews with women and Community Health Workers (CHWs).

 

Transportation

 So far, only two days into the individual interviews, our results are quite interesting. It seems that the majority of women here already use sanitary napkins, most having adopted them recently because they wanted the “freedom” and “comfort” to move about. Previously, they used bits of cloths that restricted their movements, caused mortifying menstrual mishaps, unpleasant smells, rashes, and were embarrassing to wash, dry, and reuse. When I ask these impoverished women the maximum price that they would pay for napkins, they almost unanimously reply, “Napkins are now a necessity. Even if the cost was 100 rupees (current prices in the villages range from 26-45 rupees), we will pay it, because we will never go back to the old ways.” 

Despite this unexpected progress, many of the women still face restrictions on their behaviors and movements during menstruation. So far, none of them worship during their menses, as they feel “impure.” Several do not travel or leave the house, many restrict the foods that they eat, and some are forced to stay outside or in a corner for the duration of their period. Thus, while some women do have the freedom and comfort to go about their days normally, because of custom, many women are still restricted and stay home from work or school during menstruation.

Education is also lacking and, perhaps surprisingly, mothers do not tell their daughters about menstruation until after menarche (their first period). And, as one might expect, sex education is lacking in the Indian school system. Thus, when girls see their first drops of blood, they fear disease or death and run crying to their mothers, who then tell them that this is a normal process for girls– their entrance into womanhood. Several of the women revealed that they never had the opportunity to learn from their mothers, because they were married within a month of menarche and their mothers did not have time to explain how to manage menses. Furthermore, women have no knowledge of the physiological process of menstruation and very few women are able to identify the origin of menstrual blood.

Still early in this process, my mind rolls over future projects and mostly educational interventions. I am also dreaming up ways to expand Shelter to employ more widows, as widows frequently travel great distances hearing that we employ widows and treat them well (unfortunately, the stigma of widows is still strong). While I do have a slight bias, I have already seen the impact that Shelter has had on the lives of our employees and even on women in the villages. I feel so lucky and thankful to be able to do this work. It is what drives me and gives me the energy to succeed in my studies.

More to come as time, internet, and power allow…

 

I interviewed this widow over 2.5 years ago. She is still alive, wearing the same blouse, and is now in her 90s.

  

Raw Material and almost finsihed product

    

The BIRDS farm