Surkhi- managing menstrual health in urban slums of India

SURKHi My red friend

Empowering married women (aged 20-35) in urban slums of India with knowledge and tools to manage their menstrual health by leveraging existing government, non-government and social networks.

RUCHIKA KARNANI Final Major Project MA Service Design 2020 London College of Communication

“

Sister, we do not have the privilege to deal with period pain and mood swings. It’s something that the elite fuss over.

”

- Interviewee, when asked about period pains and mood swings

Image 1: Woman from urban slum

Disclaimer This report and its appendices showcase the original work of the author. Names of interviewees have been anonymised. All sources used have been cited and acknowledged. All in-person interviews and testing sessions were conducted following COVID-19 guidelines.

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus.(WHO, 2019)

Image 2: Picture from book titled India by Taya Zinkin, 1965

Ethical Considerations

Final Major Project 2020 | Ruchika Karnani

Ethical Considerations The research for this project was conducted with people's consent.

However, in cases where the audience is not literate and did not know English, only verbal consent was taken. Permission was taken before recording audio and video of the people involved.

Since menstruation is considered a taboo and talking about it is not easy for many people, cultural sensitivity and privacy was maintained throughout the course of the project.

4 Image 3: Primary Healthcare Centre in NBT Nagar Slum

Acknowledgements

Final Major Project 2020 | Ruchika Karnani

Acknowledgements Even though the project did not go as planned, conducting research and getting in touch with people was extremely challenging due to the COVID-19 pandemic. However, I was pleasantly surprised and truly touched by the number of people who agreed to contribute to my project when I approached them. This project could not have been a reality without their help and support.

My classmates and friends at LCC, for being a part of this journey and for teaching me so much along the way. Angela and Laura for recreating the studio set up virtually and being my constant support system at all hours (across several time zones) , “We’ve got this”. Rhea for hearing me out and helping me make sense of my own ideas and cheering for me from the sidelines.

I reached out to my personal networks and leveraged my contacts to interview and speak to women. A big thank you to all the women who were bold enough to share their period stories openly with me. I am grateful to the doctors who gave their precious time even during a pandemic and to charities for sharing their on field stories. To my maid-Lakshmi Amma for connecting me with her friends so I could speak to women living in the NBT Nagar Slum, Hyderabad, India.

Last but not the least, I would like to thank my family, parents and sister for their unconditional love and support. I wouldn't be here without you all.

A big thank you to all from the bottom of my heart for being a part of this journey. My learning experience would not have been the same without your contribution and support

I’d also like to extend my gratitude to my guide, Dr. Hena Ali, for guiding me to overcome barriers with confidence and for nudging me to do my best.

Shukriya!

Dr. Silvia Grimaldi, Veron Lai, Cordula Friedlander & all the tutors of MA Service Design at London College of Communication, for motivating me and sharing your valuable knowledge.

Special thanks to Dr. Allison Prendiville and Delina Evans for giving their inputs and sharing their experiences.

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Statement of Intent

Final Major Project 2020 | Ruchika Karnani

Statement of Intent Why Menstrual health?

Growing up in India I have always been faced with taboo and stigmas around menstruation. When I first learned about periods from my mother I thought it was a natural bodily function but as I grew up I realized that people around me did not hold the same views. A menstruating woman is considered impure and not worthy of respect. They are isolated from their families and are not given the care that they deserve. This social construct has led to several menstrual reproductive health problems. Patriarchal beliefs, shame and stigma, and lack of proper systems exacerbates this problem leaving hundreds of women to suffer in silence and even if they do seek care, it is too late.

Women deserve to get the right care at the right time.nWithout menstruation, none of us would exist. Menstruation is far from dirty.

Barring caste, gender, socio-economic status, geographical locationMenstruation is a natural bodily function and all those who menstruate deserve to do so with dignity.

I knew period poverty and shame and stigma around menstruation existed in India but I was shocked to find that a developed country like the UK suffered from this too. A 2017 report from Plan International UK states that 1 in 4 girls and young women in the UK said they felt unprepared for the start of their period and 1 in 7 said they didn’t know what was happening. (2017, pp. 11) I began my project with menstrual health in the UK but due to the pandemic, I had to shift my focus to India as I was in India and had better access to stakeholders.

INCLUSION IS A NECESSITY NOT AN ENHANCEMENT. (DOWNE, 2020)

Across the globe, menstrual health is not taken seriously. People are too ashamed to speak about it which leads to lack of awareness about their own bodies. Since they aren't able to communicate effectively with doctors, they don't get help in a timely manner. Several women suffer from conditions like Endometriosis, Polycystic ovarian disorder, Dysmenorrhea and do not get care in a timely manner.

Through my service I would like to empower women with the knowledge of their own bodies.

Why Service Design?

For a taboo topic like menstruation, it is important for all stakeholders to collaborate and make a collective effort and to take responsibility in the society. Through service design I want to create opportunities for all those around women (menstruators) to take charge and help the cause. In the current ecosystem, there is a lack of synergy and most stakeholders are not utilized to their true potential. Concerted efforts from all stakeholders, whilst being culturally grounded, can help to change the narratives around menstruation. Service design methodology and tools are most useful for the same as they aim at involving all stakeholders- human and non-human.

Key Words: Menstrual Health, Menstruation, Women’s health, Slums of India

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Image 4: Screenshot from online event, Driving Transformative Collaboration

Contents 1. Introduction Service Overview Gulabo’s story Field of Study & Opportunities Methodology & Framework

5. Develop 10 11 12 13

2. Scoping Scoping Period Pain points

15 16-18

3. Discover Discover Secondary Research Primary Research Key Insights

20 21-25 26-35 36

4. Define Define Key Themes Problem Space Target User Co-discovery Personas Moving Forward Journey Map Barriers and Opportunities Research Question

38 39 40 41 42-45 46 47 48 49 50

Develop KAP Ideation Prioritization Matrix Inspiration Testing round 1 Feedback Round 1 Reiteration of prototype Testing Round 2 Key Testing Moments Feedback round 2 Learning & Insights

52 53 54-55 56 57 58 59 60 61 62 63 64

6. Deliver Modified research question The Service Systems Map Service Nudges Service Deliverables Business Model Canvas Service Blueprint SWOT Analysis Future Suggestions

66 68 69 70 70-71 72 73 74 75

7. Reflections and Bibliography 8. Appendix

1.

Introduction

Introduction | Service Overview

Final Major Project 2020 | Ruchika Karnani

Service Overview SURKHi My red friend

As the outcome of the research conducted during this project, the author proposed the hypothetical service called Surkhi-My Red Friend.

WHAT

HOW

WHO

WHY

Surkhi is a proposed training

Through the programme ASHA workers will be trained to conduct fortnightly workshops to teach women about menstrual health through experiential tools.

After the education stage, women are encouraged to track their periods on the Period Tracker Calendar designed by Surkhi. These women speak to the ASHA workers during the workshop in case they notice something unusual with their bodies. The ASHA workers further guide them to seek help from the Primary Healthcare Clinics (PHC) that are located in every slum.

For: The training programme offered by Surkhi is currently targeting married women in the age group of 20-35.

Menstrual health can only be promoted if more women start advocating for it.

Since ASHA workers already reach out to expectant mothers and provide care, it’ll be easier for them to include menstrual health in the conversation as menstrual health and reproductive health are interconnected. Moreover, ASHA workers are already in close contact with women in the slums making it easier for them to reach out to women. This service will help women be more aware of their bodies and empower them to communicate about menstruation with those around them.

programme for Accredited Social Healthcare Activists (ASHA) designed to impart knowledge about menstrual health management to women living in slums.

Led by: The service will be led by ASHA workers and the staff at Surkhi Supported by:This programme is a collaboration between Tata Trusts(1919) and NUHM National Urban Health Mission)(2013) Telangana, India.

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Hi! I am Gulabo.

I am a 29 year old domestic worker from Hyderabad, India.

This is an account of one of the most distressing times in my life.

At the crack of dawn, I am awakened by the bird songs and other sounds of activity as our little slum comes to life. I switch off my alarm clock, before its shrill sound disturbs my snoring husband and I drag myself up to face another monotonous day.

I was an 18 year old, timid bride when I moved to this city slum, from the village, soon after my wedding. Now, a decade later, my little world consists of my husband, a sweet 10 year old daughter and an over energetic seven year old son.

After the demise of my father-in-law, my mother-in-law too stays with us. We live in a small one bedroom flat with a tiny living room and kitchen. Families living nearby form my small social circle. Occasionally, I visit my parents in the village for short trips.

The day starts with me shuffling between cooking meals for all of us and getting the children up and ready for school. It's a difficult task to make sure they are dressed, fed and reach school on time. However, this is important as they would otherwise play games on my mobile phone and while away their time. I then get on with cleaning and laundry before I get ready to leave for work.

That day, I had just finished cooking when my worried daughter called out to me in tears, she hesitantly showed me her bloodstained undergarment in the bathroom. I was shocked and unprepared, but somehow I explained to her that this was a part of growing up and a monthly cycle. I showed her how to use a menstrual pad, making a mental note to buy more in the coming months. Thus doubling my monthly budget for menstrual products. I didn’t know what else I could do to prepare her for this and I didn’t have any words to explain further.

According to my friend, her 13 year old daughter had been taught about periods at school but my daughter was still young and I was at a loss as to what I could do to help make her comfortable and ease her pain.

After dropping my son to school and picking up some more period supplies from the medical store on my way back I had to inform my mother-in-law, the reason for the little one’s despair. She in turn, became frantic and immediately isolated my daughter from the rest of the family. She was given a list of strict instructions- to stay confined in the room and not to enter the kitchen and place of worship. It is said that we are impure during the first four days of our periods. My mother in law then proceeded to call up all her friends and our relatives. Her granddaughter had come of age and everyone had to be informed.

All women have to go through this, I did too. But seeing my little girl writhing in pain, and treated like an outcast was miserable and heart-wrenching. I usually suffer from painful periods and heavy bleeding myself but somehow I manage every month. I really wish I could handle the situation with confidence, hold her close and assure her that everything will be fine, but I wasn’t even allowed to do that.

Maybe after 4 days when she would be allowed to leave the house, I shall take her to the Primary Healthcare Clinic or ask the ASHA worker (Accredited Social Health Worker) when she visits next to check my pregnant sister-in-law who lives next door.

Taking her to the hospital will be expensive now…. Maybe if we knew about menstrual health related issues, we would have been able to help my sister-in-law who suffered from a severe vaginal infection because she wore her pad for too long.

I sit in my balcony, breathing in the smells of the slum below and wonderingWhat if I was able to help my little girl and others like her to have a better experience?

Why can't we be more vocal and not suffer in silence?

Maybe education and knowledge about my body would have prepared me to face this event in a calm manner.

Thinking about that day always makes me feel so helpless and it breaks my heart to see my daughter go through this. I hope she grows up to change things for her future generations.

Based on stories shared by women through interviews.

Introduction | Field of Study and Overview

Final Major Project 2020 | Ruchika Karnani

Field of Study and Opportunities As the introduction to Dr. Munjaal Kapadia’s podcast, She Says She’s fine, states, “Why is it difficult for women to prioritize their health?

Why is there a vortex of guilt around women’s bodies and their medical care?

How do we alleviate the fears around women’s deepest, most private health concerns?”

This got me thinking, why is it that women, regardless of their race, caste, creed, financial background, literacy level- do not know what is normal with their bodies? Why do they not seek help until things are out of control and a small symptom takes the form of a life-threatening disease.

The Indian healthcare scenario presents a spectrum of contrasting landscapes. At one end of the spectrum are the glitzy steel and glass structures delivering high tech medicare to the well-heeled, mostly urban Indian. At the other end are the ramshackle outposts in the remote reaches of the “other India” trying desperately to live up to their identity as health subcenters, waiting to be transformed to shrines of health and wellness.

Despite the large population, poverty and low rates of literacy, the Indian Government has launched several programmes to uplift communities in both rural and urban parts of the country. One such programme is The National Health Mission (NHM) which encompasses its two Sub-Missions, The National Rural Health Mission (NRHM) and The National Urban Health Mission (NUHM). The main programmatic components include Health System Strengthening, Reproductive-Maternal- Neonatal-Child and Adolescent Health (RMNCH+A), and Communicable and Non-Communicable Diseases. Apart from government initiatives there are also charities and non-government organizations working towards women’s health across the country.

In some cities in the developing world slum residents make up more than half of the population and often do not have adequate shelter, clean water and sanitation, education, or healthcare. India, like most developing and

under-developed nations of the world, has alarming rates of poverty. The contrasts between urban and rural life is remarkable.

However, the slum ecosystem is resilient and robust with advancement in facilities for its residents. There are primary and secondary schools in the slum ensuring that the future generations are educated. For every 10,000 people there is a Primary healthcare Clinic set up by the government. These slums also have several facilities for women and children. For example, each slum has an Anganwadi (child day care) where women can drop off their children and at the same time get care if they are expectant mothers. ASHA or Accredited social health workers are present in every slum to check the elderly and expecting mothers and guide them to the healthcare clinic to get care.

Despite the efforts by the government and private organizations, women’s health is not given its due importance. "The mental conditioning of Indian society has led to women having a very high threshold of patience and silence.” - Ranjana Kumari, women's rights activist and director of the Centre for Social Research in New Delhi. The silence coupled with shame and stigma around menstruation prevents women from getting care in a timely manner.

For women to know about possible menstrual disorders, they must know about their menstrual cycle. To understand if there’s something wrong or unusual, they must be able to communicate about periods effectively. The opportunity lies in empowering women to advocate about their menstrual health and to normalize menstruation.

The project has the potential to make direct and indirect impact on UN Sustainable Development Goals (SDGs). Goal 3- Good Health and Well-being, Goal 4- Quality Education, Goal 5- Gender Equality, Goal 7- Clean Water and Sanitation, Goal 10- Reduced Inequalities and Goal 17- Strengthening Partnerships could be integrated in the solution.

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Introduction | Methodology

Final Major Project 2020 | Ruchika Karnani

Methodology and Framework This project was based on the Double Diamond Framework adapted by the Design Council in 2004 (Design Council). In accordance with the framework, the project was carried out in four phases: Discover, Define, Develop, Deliver. During the course of the project, the researcher used methods and adapted them based on the user feedback. Methods relevant to the project were used for each of the phases.

Scoping

-Scoping -Expert Interviews -Desk Research

Discover

-In-depth interviews -Online ethnography -stakeholder map -desk research

Define

-distilling insights -Personas -Journey Map

Develop

-Knowledge-action Practice framework -Ideation-What ifs -How Might We -Prototype creation -Prototype testing

Deliver

-service overview -systems map -Business Model Canvas -Service Blueprint -SWOT

Reflection on methods: Getting women to talk about their menstrual health cycles proved challenging, which is why I had to modify my interview style to make it more conversational. Sharing part of my own story or expressing sympathy and even comforting the interviewees was essential as it made them feel more relaxed and gave the sense of a safe space.

Access to stakeholders and my target audience was a challenge, as a result of which all research had to be conducted remotely.

Field research and co-design sessions were limited to one or two women at a time. All tools were used with cultural sensitivity and also understanding the barriers of the communities- low literacy rates, little or no access to technology.

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Introduction

Final Major Project 2020 | Ruchika Karnani

2.

Scoping

2

Scoping

Final Major Project 2020 | Ruchika Karnani

Scoping The researcher began the project by exploring women's health, dividing it into phases of women's lives and the problems they face at each stage. With a focus on menstruation the researcher narrowed onto two aspects- one being Endometriosis and the other being period poverty.

Gaining deeper insights by speaking to women and conducting desk research made it evident that the two issues are interconnected. Menstrual health is grossly neglected by women. This problem is further exacerbated in the low income communities where literacy levels are low and shame around menstruation is high. This makes periods even more invisible.

On average, girls miss six days of class each month due to shame surrounding their periods or a lack of sanitary products in India.

(The Borgen Project, 2019)

176 million women today suffer from endometriosis”

(Indian Center for Endometriosis 2018)

40% of girls in the UK have used toilet roll because they've struggled to afford sanitary wear.

(Plan International UK, 2017)

Endometriosis costs the UK economy £8.2bn a year in treatment, loss of work and healthcare costs.

(Simoens, Dunselman, Dirksen, et al. 2014)

Scope for bringing about change even at a policy level

Scope for bringing about change even at a policy level

Image 5: Screenshot of Miro board a

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Scoping

Final Major Project 2020 | Ruchika Karnani

COVID-19 Menstrual Health On average it takes 7.5 years from onset of symptoms to get a diagnosis. (Endometriosis UK, 2011)

“Women were so scared that they would run out of sanitary napkins that they began to wash disposable sanitary pads and dry them under the sun in case they would have to reuse them next month.” - Ananya Chachhoria (Paint it red)

Stigma and Shame

Sustainable periods Menstrual Health Alliance India, one sanitary pad could take 500 to 800 years, (n.d.)

Period Pain Points

Unwanted periods “Most people deal with blood and tissue, And yet my body forces me to surrender, Cause every time I get my cycle, Is another day I shed my gender”(The Period Prince, 2017)

48% of girls in Iran, 10% in India and 7% in Afghanistan believe menstruation is a disease (Plan International UK, 2018)

Accessibility to menstrual products

Menstrual Hygiene The prevalence of Reproductive Tract Infections (RTIs) and sexually transmitted infection (STIs) in women aged 15–44 years in Odisha, India was 35.2% in 2002–2004.

(Desai and Patel, 2011)

Among 78 women Women for refugee women (WRW) interviewed, 75% struggled to obtain period pads or tampons while destitute, forcing them to overuse a period product, improvise period wear or beg for money to buy a pad. (Bloody Good Period, 2019)

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Scoping

Final Major Project 2020 | Ruchika Karnani

Period Pain Points Menstrual Hygiene Rough sleepers and homeless people do not have access to clean bathrooms to wash themselves up when on their periods.

They use public toilets which are a hotbed of infections. This puts them at a high risk of contracting urogenital infections.

Sustainable periods Used sanitary napkins add on to the plastic waste and are also a biohazard. More and more women are shifting to reusable menstrual products but there still is a lot of aversion from several communities. Even though sustainable menstrual products like menstrual cups, period panties and tampons are easily available, they are not accessible to everyone.

Accessibility to menstrual products Period poverty is the lack of access to menstrual products to manage monthly periods. Women across the globe are affected by period poverty- in developed and developing countries alike. It is common practice to use toilet paper, cardboard, old rags and some women are even forced to free-bleed. Not only is this unhygienic but it also makes menstruators feel undignified.

Unwanted periods Periods can be especially traumatic for transgenders and non-binary. “Not all women menstruate and not all menstruators are women”. Non-binary people are left out from the menstruation conversation and this is proves as a large barrier. Non-binary or trans menstruators do not get the care for their periods and often do not have the liberty to go through hormonal treatments.

Menstrual Health Menstrual disorders like Endometriosis, PCOS, Dysmenorrhea etc affect women all over the world. Most often women are not aware about these disorders. Some common symptoms like severe period pain are normalized by women and sometimes even by medical professionals. Menstrual disorders and poor menstrual health can disrupt women's lives, often preventing them from performing simple tasks like showering, cleaning and even working.

COVID-19 “Periods don’t stop in a pandemic” The impact of the COVID-19 pandemic has been grave on all communities across the world.

During the pandemic, the government, charities and individuals set up mutual aid groups to help women across the country.

Period products were not categorized as essential goods in the beginning of the lockdown in India and this led to further despair.

Stigma and Shame The shame and stigma around menstruation makes it extremely difficult for women and girls to communicate and clearly express their problems. Some women find it difficult to discuss their periods even with female member of the house.

Myths and taboos are the primary reason for women to not receive the care that the deserve.

Some common myths and taboos are mentioned on the following page.

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Scoping

Final Major Project 2020 | Ruchika Karnani

“Once I was on my period and could not attend a prayer meeting in my own house. It enraged me so much, I stuck posters all over the house saying things like “I’m not impure”, “Periods don’t make you bad.”. Even though it was very dramatic, I’m glad I spoke up for myself. My parents were so ashamed and perplexed. But it was worth it because later my grandmother told me she’s glad I’m standing up for myself because she couldn’t!”

- Interviewee, 25

Image 8: Common Myths in India(Myna Mahila Foundation 2015)

Shame and stigma is the primary reason for most problems around mesntruation that exist today. Since menstruation is not visible to everyone, shame makes it difficult even more difficult for people to accept periods are a natural bodily function.

Image 7

Image 6

Images 6 and 7 are screenshots from the authors personal Instagram account. The images are a result of a social media survey conducted by the author wherein women are mentioning some period taboos they have heard/been subjected to. Names have been anonymized for privacy reasons.

Representation is the key to everything. It shapes what we think is normal and acceptable and what we find taboo. In culture, we find blood acceptable. It’s not shocking to see blood in coverage of live sport. Or in crime series. Or horror films. You see it all the time in video games and graphic novels. However, period blood is something completely different. It’s absent. It is euphemised. Or used to shame and humiliate women. This underrepresentation and misrepresentation has contributed to a world in which women feel disgusting and men feel disgusted. (Revol, Hulley and Lossgott, 2018) 18

Introduction

Final Major Project 2020 | Ruchika Karnani

3.

Discover

2

Discover

Final Major Project 2020 | Ruchika Karnani

Discover Narrowing down from the larger themes around menstruation, the researcher proceeded to focus on menstrual health management in India as 75% of girls experience some problems associated with menstruation including delayed, irregular, painful, and heavy menstrual bleeding. Through the desk research and expert interviews, it was evident that there is a lack of information about menstrual health.

During the discovery phase of the project, the researcher began by identifying and interviewing the key stakeholders around women. The researcher then gathered contextual information from desk research and also conducted semi-structured interviews with women from all socio-economic backgrounds in urban India, doctors and charities. To gain a better understanding, the researcher conducted non-participant online ethnography and attended events on menstrual health and hygiene.

Doctors

Forums

Charitable organizations

Menstruating women and young girls in urban India

Health+Tech

Friends and Family

Government services and initiatives

Initial Stakeholder Map

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Discover | Secondary Research

Final Major Project 2020 | Ruchika Karnani

Secondary Research “A 2014 report by the NGO Dasra titled ‘Spot On!’ informed that almost 23 million girls in India drop out of school annually, because of lack of menstrual hygiene management facilities, including availability of sanitary napkins and awareness about menstruation.”

“In India, 71% of girls report having no knowledge of menstruation before their first period. Girls often turn to their mothers for information and support, but 70% of mothers consider menstruation “dirty,” further perpetuating taboos.” (Menstrual Health in India 2016) “All women (including transgender people) at Zomato can avail up to 10 days of period leaves in a year.” (Zomato, 2020) “Despite national-level efforts, ~53% of all households in India lack a toilet, requiring women and girls to use communal or public toilets, which may be far away, or defecate in the open, increasing women’s vulnerability to violence.”(Menstrual Health in India 2016)

“A study done on 119 women in Puducherry, India showed that only a third of those with a menstrual complaint (36%) seek treatment from a health facility. The rest of them resorted to home remedy (10%), self-medication (6%), or did not take any measure (43%).” (Laksham, Selvaraj,et al. 2019)

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Discover | Secondary Research

Final Major Project 2020 | Ruchika Karnani

Common Menstrual Disorders Premenstrual Syndrome (PMS) PMS is any unpleasant or uncomfortable symptom during your cycle that may temporarily disturb normal functioning.

These symptoms may last from a few hours to many days, and the types and intensity of symptoms can vary in individuals.

Common symptoms of PMS include bloating, anxiety, headaches.

Amenorrhea Amenorrhea is characterized by absent menstrual periods for more than three monthly menstrual cycles. There are two types of amenorrhea: Primary amenorrhea: Menstruation does not begin at puberty.

Secondary amenorrhea: Normal and regular menstrual periods that become increasingly abnormal and irregular or absent. This may be due to a physical cause typically of later onset.

Endometriosis Endometriosis is an often painful disorder in which tissue similar to the tissue that normally lines the inside of one’s uterus — the endometrium — grows outside the uterus.

Symptoms: Painful periods, Pain with intercourse, excessive bleeding

Dysmenorrhea Dysmenorrhea is characterized by severe and frequent menstrual cramps and pain associated with menstruation. The cause of dysmenorrhea is dependent on whether the condition is primary or secondary. With primary dysmenorrhea, women experience abnormal uterine contractions resulting from a chemical imbalance in the body. Secondary dysmenorrhea is caused by other medical conditions, most often endometriosis.

Symptoms: Lower back pain, Lower abdomen pain, cramping, nausea

Polycystic ovary syndrome (PCOS) Women with PCOS may have infrequent or prolonged menstrual periods or excess male hormone (androgen) levels.

The ovaries may develop numerous small collections of fluid (follicles) and fail to regularly release eggs Symptoms: Irregular periods, Painful periods, excess androgen (male hormone) Summa Health (2016) 22

Discover | Online Ethnography

Final Major Project 2020 | Ruchika Karnani

Non-Participant Online Ethnography and Online Events As a part of f\digital ethnography, the researcher joined Facebook groups and forums related to menstrual health. It was found that several women were sharing their doubts and stories online. Women rely on a support network and gain insights from each others experiences. However, there is a large part of the Indian population that does not have access to the Internet.

As per a report from the Digital Empowerment Foundation in 2018, around 90% of India’s population is digitally illiterate.

Image 14

Image 9

Image 15 Images 14-15 are screenshots from online events

Image 10 Image 12

Image 11

The COVID-19 pandemic made it possible to attend events and conferences online. Through these online events, the researcher had the opportunity to meet with people working in the Menstrual Health and Hygiene Management sector. These events gave clear a idea of the menstrual health landscape and on-field challenges in dierent parts of India.

Image 13

Images 9-13 are screenshots of posts from Facebook groups and forums. Names have been anonymized for privacy

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Discover

Final Major Project 2020 | Ruchika Karnani

Existing Government Initiatives Listed below are some government initiatives launched by the Government of India to under-privileged women.

Pradhan Mantri Matritva Vandana Yojana: Maternity benefits programme, introduced in the year, 2010 and implemented by Ministry of Women and Child Development. It is a conditional transfer scheme for both pregnant and lactating women of 19 years of age and above for 1st live births. This scheme provides, conditions for safe delivery, Child care and good nutrition. Also, the scheme covers the wage loss suered by these women during child birth. (Manjunath,2018) Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A): is a programme that essentially looks to address the major causes of

mortality among women and children as well as the delays in accessing and utilizing health care and services. (Oxfam India, 2018)

Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) was announced with objectives of correcting regional imbalances in the availability of aordable/ reliable tertiary healthcare services and also to augment facilities for quality medical education in the country by setting up of various institutions like AIIMS and upgrading government medical college institutions. (Oxfam India, 2018) Accredited Social Health Activist (ASHA):The role of an ASHA is that of a community level care provider. This includes a mix of tasks: facilitating access to health care services, building awareness about health care entitlements especially amongst the poor and marginalized, promoting healthy behaviours and mobilizing for collective action for better health outcomes and meeting curative care needs as appropriate to the organization of service delivery in that area and compatible with her training and skills. (National Health Mission, 2014).

Image 16: Contraceptives and ORS at Primary Healthcare centre

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Discover

Final Major Project 2020 | Ruchika Karnani

Existing Non-Government and Charitable Organizations Though there are several organizations working towards bettering menstrual health and hygiene in India, listed below are a few that have made a significant impact. It was observed that very few organizations are focussing on improving menstrual health for older women. Most of these organizations are working with adolescents.

WaterAid India: WaterAid India is part of the global WaterAid network which

seeks to improve access to clean water, decent toilets and good hygiene for everyone, everywhere. (1986)

Menstrupedia: Menstrupedia is a friendly guide to periods which helps girls and

women to stay healthy and active during their periods. (2012)

Goonj: A social enterprise that is addressing the gaps and challenges of

menstrual hygiene and management for the last women by engaging comprehensively with all key stakeholders. (1999)

Myna Mahila Foundation: Educates girls on usage and disposal of sanitary

napkins and openly discuss periods as a shameless bodily function, making them feel comfortable and confident while they are menstruating. (2015)

TATA Trusts: The Trusts’ interventions in RMNCHA+ are focused on programmes

in Madhya Pradesh and Rajasthan, covering 8 districts and over 80 facilities. The Trusts are involved in providing training to accredited social health activists (ASHAs) and auxiliary nurse midwives (ANMs) in identifying and treating high-risk pregnancies. (1919) RMNCHA+ is short for Reproductive, Maternal, Newborn, Child and Adolescent Health. This is a strategy developed under the national health goals by the National Health Mission (NHM) of India.(National Health Mission, 2013)

Image 17: Image from comic book Menstrupedia (2020)

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Discover

Final Major Project 2020 | Ruchika Karnani

Primary Research

Women and Menstruation To gain a deeper understanding of women and how they manage their menstrual health, the researcher started by interviewing women from all walks of life.

Even within the urban setting, India has stark dierences. The researcher connected with women that were both educated and uneducated, belonging to dierent socio-economic backgrounds. Women from mid-high income groups were via social media, forums and by leveraging personal networks.

The challenge was engaging with women living in slums as it was a hard to reach group, with lack of access to the Internet and COVID-19 guidelines made them more inaccessible. In India, it is common practice for people belonging to mid and high income groups to hire domestic help. The researcher tapped into this potential and set up an informal network with her domestic help and her friends, all living in urban slums.

Reflections: I started conducting the interviews in a formal manner. However, I soon realized that women were not opening up. I could sense the hesitance from their side. I changed my demeanor and began to empathize and express my emotions when they were sharing their stories. In some instances I even shared my own stories to make them feel more comfortable. I learnt that though it's important to not show emotions and express your opinions during interviews, for sensitive topics like menstruation, it is crucial to make the interviewees feel safe. Unfortunately, a lot of women have had traumatic experiences related to their menstrual health. This taught me to be empathetic while respecting their privacy and also getting them to speak.

27

Stories

21 Online

Interviews

6 Offline

Interviews

26

Images 18-33- Screenshots and images from some interviews

“ I suffer from heavy bleeding but it is alright because my mother and grandmother went through the same.”- Interviewee 1, 24 “My daughter kept having black outs for months together, we took her to 4-5 different doctors and they said everything was normal but she would still faint every month. It took me a while to observe that this happened before or after her periods and then we realized she had an iron deficiency.”- Interviewee 2, 33

“ I have been suffering from irregular bleeding but I’m too scared to visit the doctor.”- Interviewee 3, 20

“ Going to the doctor costs a lot of money, I don't see the value in going there”- Interviewee 4, 28

“ This one time I got my period in college and there were no pads available, none of the girls in my class had one either. I had to use tissues and I bled through my pants. I could not go back to college for a few days after that.”- Interviewee 5, 25

“ I wish someone told me that what I was going through was actually signs of PCOS.”- Interviewee 6, 26

“ The first time I was told about periods in school I thought, Woah! Am I going to be laying eggs now?”- Interviewee 7, 21 “ I have been told things like - “You go through this every month, why do you still complain about pain” and it's just devastating.”- Interviewee 8, 32

“I had a really awful experience with periods. My periods were irregular but when I got them once in 3-4 months they were very heavy and painful. I would find it hard to get out of bed even go to work. Everyone around me thought I was making excuses. I slowly stopped speaking about it and suffered quietly because talking about periods was not encouraged in our house. I want to ensure that my daughter does not go through the same. I want her to know that she can reach out to me and share her problems with me-periods or otherwise.”- Interviewee 9, 37

“ I don't know why I menstruate, it must be all the bad things in my body that are coming out.”Interviewee 10, 29

“I don't know how to explain about periods to my daughter. I don’t know what I can tell her.”, Interviewee 11, 28

Discover

Final Major Project 2020 | Ruchika Karnani

Key Takeaways

Women, regardless of their socio-economic background and literacy levels, do not know what is normal with their bodies.

Most women were skeptical and shy to talk about menstrual health but once they are comfortable they are willing to share all kinds of stories. Some even shared funny anecdotes and some shared their unpleasant experiences.

Interviews in pairs went well because women were building on top of each other's experiences.

Women don't like to complain or speak about their menstrual problems because they feel like it's not a big deal.

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Discover

Final Major Project 2020 | Ruchika Karnani

Charitable Organizations and Menstruation To get a complete picture of the ecosystem, the researcher interviewed charities and Non-Government Organizations working in the field of menstrual health and hygiene. This gave a better understanding of on field barriers and limitations.

The researcher interviewed individuals working at the following organizations: 1) Sukhibhava 2) Paint It Red 3) Orikalankini 4) Soroptimist International Pune Metro East 5) The Period Project- Teach for India

5 Online

Interviews

30

“It is important to build trust with the members of the community to bring about change.”

- Ananya Chachhoria, Paint It Red

“It helps to partner with ladies in the community that are curious and willing to learn, it makes sure your voice is amplified and makes women more receptive.”

- Akalya, The Period Project, Teach for India

“Important to be user centric and adapt and improve your products and services over time.

People’s views keep changing. Something you design today may not be relevant after a year.”

- Bhuvana Balaji, Sukhibhava

“Enabling conversations and stigmatizing menstruation is the core to all work done in this field. It is the stepping stone to products, services and policies to improve menstrual health and hygiene in India.”- Bhuvana Balaji, Sukhibhava

“Most females deprioritize their health because of the social conditioning of having to nurture others before we prioritize ourselves.”Dr Anupama Sen, Soroptimist International Pune Metro East

“Introducing solutions and interventions that are understood and culturally acceptable will ensure its sustainability. When we talk to women, we have to ensure that we hold separate sessions for married and unmarried women.”- Dr Sneha Rooh, Orikalankini

Discover

Final Major Project 2020 | Ruchika Karnani

Key Takeaways

Solutions and design interventions must have cultural sensitivity for them to make maximum impact. It is important to address the issue separately for married and unmarried women to be culturally appropritate.

Normalizing menstruation and encouraging people to converse about periods is the first step for women to receive better care.

Behavioural changes take a lot of time and it is important to have nudges to bring about change.

Currently, several charities and programmes are working towards imparting knowledge by speaking to women.

There is a lack of data from the government, this makes it diicult for charities to propose and bring about policy level changes

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Discover

Final Major Project 2020 | Ruchika Karnani

Doctors and Menstruation To substantiate the findings from women and charities, it was imperative to get a complete picture from doctors. This helped the researcher to understand the perspective of doctors on menstrual health as they are one of the most important stakeholders.

Reflections: The pandemic made doctors even more inaccessible than they normally are.

Leveraging my personal connections, I was able to interview four doctors. These interviews were conducted over the phone with a limitation of time. I learnt that asking specific questions and sending them in prior to the interviews helped the doctors to prepare themselves.

5 Online

Interviews

33

“Different women have different bodies and hence, they have different experiences. It is incorrect to generalize.”- Dr Aishwarya Chirla, MBBS

“People don't talk about menstrual and reproductive health. And by the time they reach the doctor, it is already too late.”- Dr Devyani, Obstetrician & Gynecologist

“Most of the problems related to periods are compounded by myths in India.”

- Dr Pratibha Narayan, Obstetrician & Gynecologist

“Women do not have access to trusted sources that can give them accurate information about their bodies.”- Dr Sarada M, Obstetrician & Gynecologist

“The biggest issue is that women do not know what is normal with their bodies. It does not matter if they are educated or uneducated.”

-Dr Sarada M, Obstetrician & Gynecologist “Reusable menstrual products are not for everyone. People in slums and villages are just about getting used to sanitary napkins and practicing menstrual hygiene. Introducing reusable products to them is like moving a step back. Moreover, not all people have access to clean water to sanitize their menstrual products.”

- Dr Anupama Sen, General Physician

“Women find it hard to accept new things. They want to believe what their mothers have told them.”

- Dr Anupama Sen, General Physician

“In one case, the gynecology team was called in during a woman's appendicitis surgery. The pain this woman was suffering from was diagnosed as appendicitis but in the middle of the surgery, they realized it was endometriosis.”

-Dr Sarada M, Obstetrician & Gynecologist

Discover

Final Major Project 2020 | Ruchika Karnani

Key Takeaways

These interviews helped the researcher to confirm the assumption that women do not know what is normal with their bodies.

The doctors do not have a complete picture of the woman's symptoms and this makes it diicult to diagnose.

Women only go to doctors when their issues are severe and it is aecting their day-to-day life.

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Discover

Final Major Project 2020 | Ruchika Karnani

Key Insights Charities

27

Women Doctors

+

5

Charities

+

5

Doctors

=

37

Interviews

and 39248092356732 92174325638491 insights

Women

Insight 1: Women don't know what's normal with their bodies. This assumption was proven by doctors who mentioned the same. Women are not aware of basic things like- How much bleeding is too much?, What does a heavy flow indicate? Women end up normalizing symptoms like painful periods and heavy bleeding assuming it is something everyone goes through. This problem is worsened as the information on the internet is not always accurate.

Insight 2: Doctors do not have a clear picture. Women often find it difficult to talk about their periods and often do not mention all the symptoms they may be suffering from. This makes it difficult for doctors to get a clear picture and provide an accurate diagnosis.

Insight 3: Women diminish their own problems and only visit doctors when it's too late. Going to the doctor means losing a day's wage for women belonging to low-income groups. This social conditioning coupled with a fear of doctors and lack of monetary resources makes menstrual healthcare more inaccessible for women living in slums.

Insight 4: Education in school is not enough as cycles change with age and the hormonal composition of our bodies. Which is why it is important to keep the conversation going for girls and women of all ages.

Insight 5: Charities mainly focus on adolescents to make them more aware of menstrual health and hygiene. This means that women are left out of this conversation and isolated further even though they could be menstruating into their late 40s.

Insight 6: Lack of empathy from employers and workplaces further aggravates the problems that women face during menstruation. Even though corporates are trying to bring about change, this is a privilege that only the privileged can avail. Unskilled and daily wage laborers cannot afford to miss a day's work to look after their health.

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4.

DeďŹ ne

Define

Final Major Project 2020 | Ruchika Karnani

DeďŹ ne During the Define stage of the project, the researcher mapped out the areas of opportunity from the key insights. The key themes emerged from the areas of opportunity which helped to define the problem space. From here, personas of the target audience were made. Through the personas, the pain points and gains of the target user became clear.

This played an important role in narrowing down the key personas of the project as the ones having more impact were highlighted. While there is significant data available on adolescent girls, there are very few research papers and services targeted to improve older married women’s menstrual health. Based on this it was evident that married women in the age group of 20-35, living in urban slums of India would have the highest impact from a design intervention around menstrual health. Following which the final research question was framed to ascertain the design direction of the project.

Image 34- Work table, journey mapping

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Define

Final Major Project 2020 | Ruchika Karnani

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Define

Final Major Project 2020 | Ruchika Karnani

Problem Space The problem space became evident from the overarching themes.

Existing services are targeting adolescents and young people.

However, there are so many menstruators above the age of 18 (non-school goers) who are left out. Women may have some access to information but it is hard to tell if the information is being retained by them. Moreover, there is no assurance about the credibility of the information they receive. Women should be able to notice when something is usual, make connections and say "something is wrong here". Once they are aware of any unusual symptoms, they must be confident enough to seek help.

Image 35- Narrow alley in NBT Nagar slum

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Define

Final Major Project 2020 | Ruchika Karnani

Target Users After distilling the insights, it was evident that there are two vastly dierent user groups: Women belonging to high income groups and women belonging to low income groups living in slums.

High Income Group

Common Pain Points

Low Income Group

Shame and stigma around menstruation- though less as compared to women living in slums Lack of access to accurate information from credible sources

Larger number of women believe in myths and taboos around menstruation Access to healthcare is diicult

Women do not know what is normal with their bodies They do not know how to communicate their symptoms to doctors because of lack of knowledge and shame surrounding menstruation.

In order to narrow the focus of the project, the researcher picked the target user that would have the highest impact from this service. A majority of the 1.3 billion people in India are poor and this is evidenced by the fact that 10% of the Indian population holds 77% of the total national wealth. (Oxfam n.d.)

Thus, the researcher chose married women (in the age group of 20-35 years) belonging to the low income group and living in urban slums as the target group.

They have low levels of literacy with little to no access to the internet Little or no access to information

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Define

Final Major Project 2020 | Ruchika Karnani

Urban Slums Sometimes, urbanisation affects regions at the edges of big cities, often benefiting them because they become more connected to municipal life.

However, these communities usually aren’t prepared for the “urban lifestyle”. Life rapidly becomes too expensive for the villagers, they don’t have the skill sets required for higher paying jobs so find themselves pushed into the informal economy to survive.

With more choice but less opportunity, the pressures of urban life erode on the quality of life in general. As certain neighbourhoods become marked for the informal workers’ settlements, they begin to be identified as low-cost living areas – often leading to overcrowding. (Habitat for Humanity Great Britan, no date) As more and more people move in to cities from rural parts of India, the poplulations of the slums rise.

Slums do not have the infrastructure to support its existing inhabitants so when more people move in, this system only gets more strained.

There are efforts being made by governement, non-government and charitable organizations, to improve the quality of lives of people living in slums. Work is being done to improve sanitation facilities, electricity, permanent housing, education and skill development.

Image 36- Screenshot of aerial view of NBT nagar slum from Google Earth

The researcher interacted with women and Primary Healthcare Centre in the NBT Nagar Slum, Hyderabad, India. This slum has an approximate population of 10,000 people.

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Define

Final Major Project 2020 | Ruchika Karnani

Women in Urban Slums In order to dive deeper into the lives of the women in slums the researcher took a step backwards.

By using an educational video made by a charitable organization called Maitri(2015), the researcher tried to gauge the depth of knowledge that these women possessed about menstrual health. The video explains all the aspects of menstruation from hygiene to health management in simple words. After showing this video to the target group the researcher asked them a set of questions in order to check their understanding of the subject and identify the gaps. Two such sessions were held with four women.

Reflections: This co-discovery session was slightly challenging. The women were skeptical in the beginning. I was surprised to find that they didn't know basic things like, why they menstruate even when they have had children. I presumed that they would have made a connection between the two. I approached the situation with a lot more sensitivity and carefully explained each topic that was shown in the video. It helped to make the atmosphere more light-hearted and fun than making it seem like a classroom.

Image 37- Co-discovery session with two women from the slum

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Define

Final Major Project 2020 | Ruchika Karnani

Findings From the co- discovery, it was found that all four women did not know the following:

What are periods? Why do we bleed?

Is heavy bleeding good?

What is vaginal discharge? Is it normal?

How do I calculate the length of my cycle?

What is PMS? How does it aect me?

How do I dispose my used menstrual products?

Does the colour of my period blood mean anything?

How do I sanitize my reusable products?

Does the foul smell indicate anything?

What kind of foods are good for me?

Is it a myth/taboo or is it actually true?

It was observed that two of the four women were inquisitive and eager to learn. They even prompted their partner to ask questions.

One of the four women showed little interest and was slightly uncomfortable Two of the four women wanted to learn more but they were shy and held back from asking questions.

What kind of products are available to me?

How do I manage my period pain?

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Define

Final Major Project 2020 | Ruchika Karnani

Key Insights Even though the number of participants were less, it was observed that there were three kinds of women:

The advocate- She did not have much knowledge but she was eager to learn and make sure that her friends understood the topics well.

The learner- She did not have much knowledge but she was willing to learn and showed some eagerness. If she is given an incentive she will most likely participate.

The shy one- She did not have much knowledge but she was still reluctant to learn and engage in conversation.

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Define

Final Major Project 2020 | Ruchika Karnani

Personas “I did not know why we menstruate, but now that I know, I want to make sure that all the other women around me know as well.

We should know these basic things.”

“I did not know why we menstruate. To be honest, the details make me feel a bit awkward but I think it's important to know this information.”

Gulabo, 29 Gulabo is a sociable woman living in the slum.

She is everyone's agony aunt and other women in the community look up to her. She is a mother of two- a daughter and a son. Her daughter recently got her first period and Gulabo was shattered because she did not know how to talk about it to her daughter.

B I She does not have much knowledge about O menstruation and menstrual health but she maintains basic menstrual hygiene and uses disposable menstrual pads. When she is not at work as a domestic help, she likes to spend time with other women in the community and also stitches clothes occasionally. She wants to improve her family's quality of life by earning sufficient money and taking care of everyone's health and well-being.

P A I N S G A I N S

-Gulabo does not know how to communicate with her family.

- Does not know where she can find information and support that is reliable - Improving her life and having a positive impact on her family.

-She will be able to communicate better with those around her -Influence other women

“I don’t know why we menstruate.

It seems a bit odd, what will I do with that knowledge?”

Neelu, 24 Neelu is a shy woman living in the slum. She does not have many friends or family living close to her. She occasionally meets up with Gulabo and some other women in the courtyard when she has some time in the afternoon. Neelu is a mother to a 5 year old B I boy. After her first pregnancy she has been O having health issues. She feels very weak and faints very often. She used to use cloth pads however, of late she has been trying to use disposable pads, after she suffered from a yeast infection. She wants to look after her health but she feels shy to discuss her problems with others.

P A I N S

-Does not have a lot of support and guidance with regards to menstrual health management -De-prioritizes her health and normalizes her symptoms

G A I N S

- Will be more aware of her health -Eager to learn and bring about change in her own life

Roja, 33 Roja is a busy woman. She has two young boys aged 12 and 14. She works at four different houses as a domestic help. She rarely has time to meet her friends and she does not prioritize her health. She usually has B I very painful periods with heavy but does not O do anything about it. She has always been using a cloth pad and does not want to shift to a disposable pad.

P A I N S

-She does not realize there could be a problem and doesn't prioritize her health.

-She has no time and energy to seek guidance on menstrual health related issues.

-She is mostly isolated from other women in the slum

G A I N S

If Roja is more aware of her body, she might have a better quality of life.

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Define

Final Major Project 2020 | Ruchika Karnani

Moving Forward For the scope of this project, the researcher decided to craft a solution for women like Gulabo and Neelu. Even though women like Roja are underserved and suer from menstrual health disorders, they are diicult to out reach to. Women like Gulabo are an integral part of the Indian community. These women are friendly with most other women in the slums. Though it might seem intrusive, Gulabo has the potential to play the role of a community gatekeeper and create a ripple eect by bringing more women on board. Women like Neelu are the main end users of this service. She notices that there is a problem but she is not empowered enough to make connections and does not know where she can seek guidance. Both personas are eager to learn and bring about a change in their outlook towards menstruation.

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Define

Final Major Project 2020 | Ruchika Karnani

A day in Neelu’s life

Primary Touchpoints

(Neelu accesses these more frequently)

- at home - Primary School -Tailor Shop - Grocery Store -Friends and other women -Employers

Secondary Touchpoints (Neelu accesses these less frequently)

- ASHA workers -Primary Healthcare Centre in the slum

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Define

Final Major Project 2020 | Ruchika Karnani

Barriers and Opportunities

Barriers

Opportunities

-Low literacy rates

-Community culture

-Little to no internet access

-Willingness to learn

-Poor sanitation facilities

-Easy to grab attention with the right incentives

-Shame around menstruation -Reluctance to try something alien to their community. Anything that is considered too “modern” that questions their beliefs.

-“Each one Teach one”- create a ripple effect and infulence other women

-Language- People in the NBT Nagar slum speak three main languages- Telugu, Dakhni, Hindi

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Research Question

How Might We Empower married women (aged 20-35) in urban slums of India with knowledge and tools to manage their menstrual health and seek medical attention in a timely manner (if needed)?

5.

Develop

Develop

Final Major Project 2020 | Ruchika Karnani

Develop The researcher began the Develop stage by mapping out the areas of intervention. The Knowledge-Attitude-Practice (KAP) Model (Bano et al., 2013) was used after modification to set the expected outcomes and impact. This set the stage for brainstorming on service ideas. Based on the ideas, the user created a simple prototype in order to test the idea. The feedback received from the initial testing helped the researcher to reiterate the service elements.

After another round of testing with women and doctors, the researcher finalized on the elements of the service.

Image 38- Permanent housing in NBT Nagar Slum

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Develop

Final Major Project 2020 | Ruchika Karnani

Knowledge-Action-Practice

The Knowledge-Attitude-Practice (KAP)model was modified to Knowledge-Action-Practice.

The objective of using this modified framework was to set the expectations of the service. This helped the researcher to define both long term and short term changes the service might bring in the users behaviour.

Knowledge- what women need to know Action: Short-term changes Practice: Long term-mindset changes

53

Develop

Final Major Project 2020 | Ruchika Karnani

Ideation The main conundrum is that there are a few non-government organizations that are conducting workshops by giving talks on menstrual health and hygiene. Women are being bombarded with information but not much is being retained. This was clearly evidenced through research. They are introduced to new concepts and it almost feels like a form of colonization because the solutions often disregard their beliefs and culture. After setting the objectives, the researcher dived into brainstorming about possible solutions, keeping cultural sensitivity in mind.

Most women in slums are not literate and those who are have only completed their primary education in a regional language. It was of paramount importance to create a service that is based on visuals and experiences as these will be retained by women for a longer and make it easier to introduce behavioural changes without making them feel less abled.

Reflections: Co-designing and ideating with women was extremely diicult as I had limited access. For the first round, I reached out to people working closely with women to collect feedback from them. In the second round of testing, I reached out to women in slums from my domestic help and also one ASHA worker and doctor in the NBT Nagar Slum.

Image 39- Image of children playing on a smartphone outside a beauty salon

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Develop

Final Major Project 2020 | Ruchika Karnani

What if.....

55

Develop

Final Major Project 2020 | Ruchika Karnani

Prioritization Matrix To select the ideas that have high impact and low eort, the researcher used the prioritization matrix from the Enterprise Design Thinking Toolkit by IBM. The use of the activity is to reflect by evaluating possible ideas through the lens of user value, feasibility, or business value to inform decision making. (IBM Incorporation, 2018)

Big bets

No-Brainers

Un-wise

Utilities

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Develop

Final Major Project 2020 | Ruchika Karnani

Inspiration Inspiration struck from a book titled, Dear Data (2016), authored by Giorgia Lupi and Stefanie Posavec. It's a book written by two friends who like to collect and organize information. Both live in different continents and each week, chose a particular subject, collected data about themselves, visualized it on a postcard and mailed it.

The book showcases images of postcards with intricate shapes and a legend for them to analyze the data. This led to the first “aha moment”.

“What if women could track their periods through a physical tracker, because they do not have access to period tracker apps?”

Image 40

Image 41 Image 40: Images of postcards from book Dear Data by Giorgia Lupi and Stefanie Posavec (2016)

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Develop

Final Major Project 2020 | Ruchika Karnani

Testing Round 1 Based on the direction deciphered from the prioritization matrix and inspiration, the researcher sketched a rough journey map prototype of the service and tested it with people who have worked closely with women in slums. Reaching out to charitable organizations and designers, the researcher walked people through the journey of women in slums via Miro- An online collaborative whiteboard platform. (2011) In the museum An old bus converted to a mobile museum

a)

1

2Meets with her friends

Neelu, 24

and hears about the period museum

9

Neelu recommends her friends to visit the period museum

8 Neelu gets a few

tests at the hospital and finds that she has iron deficiency. She seeks treatment for the same.

7

Neelu sees the doctor at the primary health care clinic, who guides her to visit the hospital.

3

b)

Sees the period museum on her way back home from work

c)

4a) Swatch cards to see what your

menstrual blood can look like b) A nurse to speak to/ask questions c) Audio stories to hear other womens experiences d)A place for them to test stigmas.

d)

Physical period tracker

6Neelu tracks her periods for a few months and realizes that she has unsually heavy bleeding some months. And she faints before or after her cycle everyy month.

5

While leaving the musuem, Neelu receives a Calendar with a period tracker for her to track her symptoms.

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Feedback Round 1

It is good to have a place for women to experience periods.

However, a museum might create a barrier as women might be ashamed to enter.

Women are going to need a nudge to enter the museum and even use the tracker.

Image 42

Having a nurse as a facilitator is a good idea. However, could it be someone interacting with women already for eg, ASHA or Anganwadi (day care) workers?

Could this be converted to a workshop or pop-style to make it more accessible?

Image 43

At the initial stage, it is ok if people do not visit the hospital.

Communication cards are good cues for women to use.

As confirmed by one doctor, a physical period tracker is an extremely useful tool. It does not have to be extremely complicated, just pain, flow and duration are enough. This will be enough to notice if there is a problem and once they go to the hospital, a complete examination will be provided by the doctor.

Image 44 Images 42-44 are screenshots of online prototype testing session.

Develop

Final Major Project 2020 | Ruchika Karnani

Re-iteration of Prototype In order to tie in the elements of the service and to make the journey more cohesive, the researcher split the journey into- Before, During and After. This helped the researcher to get a clear picture of what the service could look like and what the service touchpoints could be.

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Develop

Testing Round-2 (Service Elements)

Final Major Project 2020 | Ruchika Karnani

Image 45

1) Training Programme for ASHA Workers ASHA or healthcare workers are already working on field to help women improve their reprodcutive health. Since, menstrual health and reproductive health are interconnected, the researcher thought that the ASHA workers might be a good entry point into the community.

ASHA workers can facilitate the workshops and teach women about menstruation through the experiential tools.

Objective: To check if the training is feasible for ASHA workers?

2) Experiential Tool 1- Swatch Cards Focussing on the colour and texture of menstrual blood and vaginal dsicharge, the researcher designed swatch cards.

Objective: To check if women would be able to tell what their menstrual blood looks like and how they percieve this information.

3) Experiential Tool 2- Pain Points Using bindis(a decorative dot sticker worn on the forehead by women in India), the researcher got women to mark the areas of pain.

Objective: To check if women are able to identify where they feel pain during their periods and how it impacts them.

Image 46

4) Experiential Tool 3- Period Tracker-calendar A physical period tracker to help women keep track of their cycles and symptoms.

Objective: To check if women are able to mark the dates of their flow, how heavy their flow is, days they feel pain and their moods.

5) Communication tools Tools that will help them to communicate their feelings and emotions clearly.

Objective: To check if women can commincate their feelings or experiences through pictures.

Image 47 Image 45- Photograph of prototype testing session with doctor at Primary Healthcare Centre Images 46-47- Photograph of prototype testing session with women from slums

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Develop

Final Major Project 2020 | Ruchika Karnani

Key Testing Moments

Orange- emotion-crying because of pain Green- No of days she was in Pain Red- Flow- Larger circles indicate heavy flow and smaller circles indicate little flow Blue- Duration of flow

Period Tracker Calendar

Swatch card

The Users were able to pinpoint the colour of their menstrual fluids but slightly confused because the colours were scattered.

Period Tracker Calendar

The user intuitively made larger circles for a heavier flow.

They required some guidance and prompts but both participants were able to fill out the tracker.

Image 48

The user intuitively made larger circles for a heavier flow.

They required some guidance and prompts but both participants were able to fill out the tracker.

Image 49

Image 50

Girl feeling emotional because of PMS Girl

Boy

Girl with stomach cramps during periods

Girl feeling sad and crying

Emotions and feelings behind it

Undergarment

Excessive bleeding

Vaginal Discharge

Little Bleeding

Communication Tool

Only one of the two women was able to draw her emotions and objects based on the prompts given. Expressing themselves visually seemed to be challenging for both.

Image 51

Images 48-52: Photographs of prototypes

Image 52

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Feedback Round 2 The service elements and training program was tested with a doctor at the Primary Healthcare Clinic. The doctor has direct contact with ASHA workers. Whereas, only experiential tools were tested with two women.

Training Programme for ASHA Workers

Experiential Tool 3- Period tracker-calendar

ASHA workers also conduct workshops for adolescents in school, making this service easy to develop and deliver for older married women. However, it might also add to their workload

Women were able to use the tracker easily. However, a few prompts were required. It will take them some time to get used to the tool. It might make sense to replace the markers with stickers as women may not have dierent coloured pens at hand.

Experiential Tool 1- Swatch Cards

Communication tools

The doctor attested that this tool would be very helpful for women and the visual ques can be strong.

The tool can be in the form of Pantone (1962) swatch cards for better usability.

Only one of the two women were able to translate their emotions into drawing. Even after they converted it to a drawing, they were not able to talk about how they were feeling.

Experiential Tool 3- Pain Points

It is easy for women to stick stickers instead of writing with pens or pencils. They were able to identify the pain points without much diiculty.

Develop

Final Major Project 2020 | Ruchika Karnani

Learnings and Insights Apart from the feedback on the training programe and experiential tools, the researcher learned two crucial things: 1) Accredited Social Health Activists (ASHA workers) are a good entry point into the community. They already have access to women and can identify their pain points. As they too live in slums with these women, it will not be seen as an intrusion.

3) Nudge- In order to get people on board the service will need incentives and behavioural nudges. This will also help to break the barrier of shame and stigma around menstruation

mage

mage of omen gathered outside their house in the a ernoon

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6.

Deliver

Modifying the Research Question

How Might We Empower married women (aged 20-35) in urban slums of India with knowledge and tools to manage their menstrual health by leveraging existing government, non-government and social networks?

Deliver

Final Major Project 2020 | Ruchika Karnani

The Service

SURKHi My red friend

Surkhi is a blend of two words- Surkh meaning red in Urdu and Sakhi meaning female friend in Hindi. Literally making up Surkhi-My red friend. The idea behind it is that the service acts as a friend who is always there to support women for all their menstrual needs.

WHAT

HOW

WHO

WHY

Surkhi is a proposed training

Through the programme ASHA workers will be trained to conduct fortnightly workshops to teach women about menstrual health through experiential tools.

After the education stage, women are encouraged to track their periods on the Period Tracker Calendar designed by Surkhi. These women speak to the ASHA workers during the workshop in case they notice something unusual with their bodies. The ASHA workers further guide them to seek help from the Primary Healthcare Clinics (PHC) that are located in every slum.

For: The training programme offered by Surkhi is currently targeting married women in the age group of 20-35.

Menstrual health can only be promoted if more women start advocating for it.

Since ASHA workers already reach out to expectant mothers and provide care, it’ll be easier for them to include menstrual health in the conversation as menstrual health and reproductive health are interconnected. Moreover, ASHA workers are already in close contact with women in the slums making it easier for them to reach out to women. This service will help women be more aware of their bodies and empower them to communicate about menstruation with those around them.

programme for Accredited Social Healthcare Activists (ASHA) designed to impart knowledge about menstrual health management to women living in slums.

Led by: The service will be led by ASHA workers and the staff at Surkhi Supported by:This programme is a collaboration between Tata Trusts(1919) and NUHM National Urban Health Mission)(2013) Telangana, India.

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Systems Map

2.SERVICE ENABLER TRAINING ASHA WORKERS

Accredited Social Health Activists (ASHA) as they already have access to the community and work towards improving their reproductive health.

CONDUCT WORKSHOPS

1.SERVICE PROVIDER:

Government- National Urban Health Mission(NUHM) The key role of NUHM is to uplift the under-privileged in urban areas of India.

Non-Government- Tata TrustsCurrently working with a human-centred approach to uplift marginalized communities in India.

(This collaboration is hypothetical.)

MAINTAINING DATABASE

Primary Healthcare clinics or hospitals

DATA COLLECTION GATHERING FEEDBACK GUIDING END USER TO HOSPITA S IF NEEDED

}

RECRUITING GATEKEEPERS

3.COMMUNITY GATEKEEPER

The agony aunt of the community, recruited by ASHA to help her bring more women on board.

GET WOMEN ONBOARD

4.END USER

Married women in the age-group of 20-35 living in urban slums.

PROVIDING RESOURCES FOR WORKSHOPS

ATTEND WORKSHOPS

DESIGN EXPERIENTIAL TOOLS

TRACK SYMPTOMS AWARE OF OWN BOD SEEK GUIDANCE AND MEDICAL ATTENTION

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Service Nudges

To encourage the users to use the service, the researcher proposes the following nudges: 1) The workshops will be promoted as Free Tea and Snacks�sessions. This will ensure that women feel less ashamed to attend.

2) Community Gatekeeper- She plays a crucial role is nudging and bringing more women onboard 3) For woman the gatekeeper brings, she will get Rs.500 and her guest will get Rs.250. (Rs.500 5 approx.)

4) ASHA workers will nudge women to use the trackers

Deliver

Final Major Project 2020 | Ruchika Karnani

Service Deliverables The outcome of months of research and interviewing women, is a service that empowers women with knowledge and tools to manage their menstrual health.

This is achieved by leveraging Government (NUHM, ASHA), Non-government (Charitable Organizations) and social (women in slums) networks. Through the design process it was found that all the stakeholders around women need to make a collective eort to achieve the desired result. The service, Surkhi-My red friend, hopes to fulfill this collaboration and ensure that women bleed with dignity. The programme for ASHA will train them to educate women through experiential tools. Women will then use the tracker to become more aware of their bodies and later seek medical attention if needed. Even though the service could create hypochondriacs at first, this would mean that the education is working. However, during the workshops, it will be crucial to communicate with women clearly without inducing panic.

Image 54- Mockup of training manual

The training manual (Appendix 1)includes a set of basic guidelines for the training programme for ASHA workers. This will help them deliver the workshops eiciently and guide women when needed.

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Deliver

Final Major Project 2020 | Ruchika Karnani

Service Deliverables

Image 55- Mockup of period tracker

The period tracker-calendar (Appendix 2)includes a yearly calendar with stickers for women to mark their flow, pain and duration of their period. It also has a figure of the human body for them to mark the areas of pain.

This tool will help women to be more aware of their menstrual cycles.

Image 56- Mockup of swatch cards

The swatch cards (Appendix 3) are designed to help women identify what the colour of their menstrual blood says about their menstrual health.

Women will be guided on how to use the ASHA workers during the workshop.

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Deliver

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Business Model Canvas KEY PARTNERS

Government services and departments- Sanitation, Health and Hygiene, Women’s empowerment

SYSTEMIC ISSUE

- Shame and stigma around menstruation -Lack of interventions for women. There are a few for adolescents.

-Not involving men and others in the conversation.

CUSTOMER RELATIONSHIPS SERVICE USER - Support Network

SERVICE ENABLER - Support from government - Network with other women

Doctors and nurses Friends and family of women Charitable organizations working in the field of menstrual health and hygiene

KEY RESOURCES

KNOWLEDGE AND EXPERTISE Doctors and professionals to make the training for ASHA more impactful Researchers and data to further develop experiential tools Designed and printed experiential tools and physical period tracker and Posters Experts that will take the feedback from ASHA and guide them to deliver the workshops TECHNICAL RESOURCES Primary schools Tablets for ASHA to log feedback digitally Monetary incentive for women who attend the workshop.

KEY ACTIVITIES SERVICE USER

Onboarding - User finds out about the service from posters and word of mouth.

Education- The user learn about menstrual health and hygiene management through experiential tools at the fortnightly workshops conducted by ASHA. Self-Awareness- Women track their periods and symptoms on the physical period tracker Treatment: If the women will notice something unusual, they will be guided to get medical attention

SERVICE ENABLER

Training - Enabler gets trained by experts Education- Enabler recruits community gatekeeper and conducts workshops every fortnight. Where she shows the women to use the experiential tools.

Feedback and re-training: ASHA collects feedback digitally and reports to SURKHI where the data bases are updated.

Guidance: In case women experience some unusual symptoms, ASHA will guide them to seek medical attention

PAIN POINTS OR NEEDS

- Women don’t know what is normal with regards to menstruation.

- Women need to track their learnings and be more aware of their cycles and symptoms in order to make connections and detect menstrual health disorders (if there are any) in a timely manner.

-Women do not know how to communicate about periods because of the shame and stigma attached to it

CHANNELS SERVICE USER

- Informal network of other women - Primary Healthcare Centers in slums

VALUE PROPOSITION SERVICE USER - SURKHI is a service that empowers women with tools and knowledge about their menstrual health.

- Leveraging government, social networks non-government and to destigmatize Menstruation

SERVICE ENABLER - everage the existing network of ASHA workers to help women to manage and learn about their menstrual health.

IMPACT ON NON-HUMAN FACTORS POSITIVE NEGATIVE - Digitally logging feedback makes it - Waste generated from the tracker easier for people to analyze and and other paper tools assimilate whilst also saving paper.

COST STRUCTURE Hiring experts to train ASHA workers Creating and designing experiential tools Conducting the workshops - monetary incentive for women who attend Maintaining the databases

SERVICE ENABLER

- Primary Healthcare Centers - Auxiliary Midwife Nurse (ANM) - Government channels

CUSTOMER SEGMENTS SERVICE USER

Married women in the age group of 20-35 from under privileged backgrounds living in urban slums of India.

SERVICE ENABLER

Government Accredited Social Health Activists (ASHA) workers working in these slums.

IMPACT ON CUSTOMER SEGMENTS & PEOPLE NEGATIVE POSITIVE - Normalizing menstruation from - Misinterpretation of information as women and also their male friends it will be traveling through many and family actors.

- Streamlining the activities of the government and non-government initiatives to enable better collaboration to increase the impact - Women are more aware of their bodies and can get care in a timely manner.

REVENUE STREAMS

Tata Trusts: This project will run as a part of their (CSR) Initiative Government of India: Under the National Urban Health Mission

(Adapted Business Model Canvas, originally modified by Laura Duarte, LCC Student 2021)

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Final Major Project 2020 | Ruchika Karnani

Service Blueprint

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Final Major Project 2020 | Ruchika Karnani

SWOT Analysis Strengths

# tapping into community culture # culturally appropriate # begins a conversation about menstruation #Collaboration between government and non-government sectors

# Has the potential to be modified and adapted in dierent languages so it can be implemented in dierent parts of India

Opportunities

Weaknesses

# Interdependecnies and information could be misinterpreted # overburdening ASHA workers # Women may not show up or even if they do they might not use the trackers. # Create hypochondriacs

# Not self-sustaining, relies heavily on funding

Threats 74

Deliver

Final Major Project 2020 | Ruchika Karnani

Future Suggestions 1) Scalability This project can be scaled and adapted in different regional languages to implement in other slums across the country.

2) Experiential toolkit The experiential tools can be developed further. By looking into other areas of menstruation and menstrual health management. There can be so variants: 1) a physical toolkit for women to learn at their own time and 2) a digital toolkit so that other developing communities over the world can adapt it to their audiences.

3) Hidden Women Women like Roja (persona 3) that work multiple jobs and have several children have very limited touchpoints. These women are hidden and underserved. They often end up suffering in silence. For this, the scope of the service can be broadened by including Roja’s employers who are women belonging to middle and upper class communities. Not only will it help Roja but it will also help these women to fill the gaps in their knowledge about menstrual health.

4) Other non-government organizations Not just Tata Trusts, the service can be implemented as a collaboration between the government and other organizations working in the Menstrual health and hygiene management sector. Corporates can also be roped in and this service can be a part of their CSR activities.

5) Data points for the government The service can be used to conduct research and gather data and statistics on women’s menstrual health in India.

Image 57- Semi-permanent house in NBT Nagar slum

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7.

Reflections & Bibliography

Reflections

Final Major Project 2020 | Ruchika Karnani

Reflections The past seven months have been challenging and thrilling at the same time.

With every roadblock I encountered, my heart sank a little at first. I’d ask rhetorically, “Could it get any worse?”. To my despair it did get worse, so I stopped asking the question eventually. For a person that despises uncertainty and likes to have at least a loose plan, it was very difficult for me to deal with all the uncertainty COVID-19 brought to the project. In the initial few months, I would hit a slump with every roadblock but towards the end, I learned to take charge and pushed myself over the hurdles. This taught me a very valuable lesson as a designer- to put my stubbornness to good use and to tackle each problem head on and just PIVOT! I guess “embracing uncertainty” is not so bad afterall.

Apart from COVID-19, working on a topic like menstruation in India was a challenge in itself. It was heartbreaking to hear stories of so many women having to deal with trauma due to their menstrual illnesses just because no one would listen to them. It enraged me to think that a woman has to suffer just because her body is performing its functions. But this also motivated me to power through the difficult days. After the interviews, several women came back to me and thanked me for normalizing periods through the project, one of them even went to see a doctor after pushing it off for months and was diagnosed with Polycystic Ovarian Syndrome (PCOS). As a victim of PCOS myself, I was relieved to find that she was finally getting the care she deserved. Women told me that this was the first time they had ever spoken about their periods in such detail- they were either too shy or no one ever bothered listening before. I thought if a small student project is able to create this impact, what would it be like on a large scale? I felt like I had the power to uplift other women around me.

Conducting socially-distanced and online research was another challenge.

Even though the response I received was overwhelming, I really missed seeing people's faces, catching their fleeting expressions and interacting with them in person. A sensitive topic like menstruation requires extra sensitivity and I was always afraid that the crackling internet connection or the fogging on my spectacles because of the mask was hindering that. It would have been great if I could work more closely with women in the slums and interact with them in their own environments - just sit under a tree and have a nice conversation whilst drinking tea from earthen cups.

Seven months of working alone has been difficult, even though I had support from my friends, I really missed the spirit of teamwork. Building on top of each other's ideas, exploring more avenues, learning from teammates and people with different skill sets. Having said this, after working on a project of this scale on my own I feel confident and empowered to take on anything.

However, I must learn to improve my organizational skills to survive on my own. *abandoned Trello Board glares at me* The entire masters journey has been a wonderful adventure. One that I am always going to be grateful for. I didn’t get to spend time in London with my friends and classmates and learn in a studio. However, I feel everyone-from my tutors to classmates, did the best they could to recreate the studio set up and made the best of what we had.

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Bibliography

Final Major Project 2020 | Ruchika Karnani

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Geertz, A. , Iyer, L. et.al. (2016) Menstrual Health in India-Country Landscape Analysis. Available at: https://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- andscape India.pdf (Accessed: 01/10/2020) https://nhm.gov.in/index4.php?lang 1 level 0 linkid 445 lid 38 (Accessed: 09/10/2020). https://www.instagram.com/theperiodprince/?hl=en (Accessed 12/09/2020) https://youtube.com/watch?v=ePL8adXjS4c

I.C.E (2015) Indian Center for Endometriosis. Available at: https://www.endometriosis-india.com/indian-centre-for-endometriosis/ (Accessed: 31//08/2020).

IBM (year) Prioritization Grid. Available at: https://www.ibm.com/design/thinking/page/toolkit/activity/prioritization (Accessed: 07/01/2021).

Kapadia M. (201 ) She Says She's Fine Podcast . 21 Februaryat: https://open.spotify.com/show/0l7ADPc5AkPsmFhB1 5zaQ (Accessed: 3/07/2020).

Kathuri, A. (2018) 'Challenges to Healthcare in India - The Five A's' Indian Journal of Community Medicine 43(3), pp. 141-143. doi: 10.4103/ijcm.IJCM_194_18.

Laksham, K., Selvaraj, R and et al. (2019) 'Menstrual disorders and quality of life of women in an urban area of Puducherry: A community-based cross-sectional study', ournal of Family Medicine and Primary Care, 8(1), pp. 137-140. doi: 10.4103/jfmpc.jfmpc_209_18.

Lohani, P. and Nikita (2019) ‘Prevalence and determinants of menstrual disorders and napkin usage among women in India using DLHS-4 date’, ournal of Family Medicine and Primary Care, 8(6), pp. 2106-2111.

Available at: https://www.jfmpc.com/article.asp?issn=2249-4863;year=2019;volume=8;issue=6;spage=2106;epage=2111;aulast=Nitika (ACCESSED 23/11/2020).

Lupi, G. Posavec, S. (2016) Dear Data. United Kingdom: Penguin.

Hutt, R. (2016) These are the world's five biggest slums. Available at: https://www.weforum.org/agenda/2016/10/these-are-the-worlds-five-biggest-slums/ Mayo Clinic Endometriosis. Available at: https://www.mayoclinic.org/diseas(Accessed: 19/12/2020. es-conditions/endometriosis/symptoms-causes/syc-20354656 (accessed: 15/07/2020) 78

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Bibliography Mayo Clinic Polycystic Ovary Syndrome (PCOS). Available at: https://www.mayoclinic.org/diseases-conditions/pcos/symptoms-causes/syc-20353439#:~:text=Polycystic%20ovary%20syndrome%20 (PCOS)%20is,fail%20to%20regularly%20release%20eggs (Accessed: 14/09/2020) McWeeney, C. (2019) Period blood color: brown, black or dark - does it matter. Available at: https://helloclue.com/articles/cycle-a-z/period-blood-color-brown-black-dark-does-it-matter (accessed: 02/12/2020).

McWeeney, C. (2021) Vaginal Discharge: What’s normal? Available at https://helloclue.com/articles/cycle-a-z/what-is-normal-vaginal-discharge (accessed: 02/12/2020) Muralidharam, A. (2016) Let’s talk menstruation. Available at: https://www.wateraidindia.in/blog/lets-talk-menstruation (accessed: 15/8/2020).

Revol, M. and Hulley N. (2018) How Bodyform revolutionised normality.

Available at: https://www.campaignlive.co.uk/article/bodyform-revolutionised-normality/1492354 (accessed: 12/12/2020).

Sambyal, S. and Henam S. (2019) Is Green Menstruation Possible? Available at: https://www.downtoearth.org.in/blog/waste/is-green-menstruation-possible--64796 (accessed: 5/08/2020).

Shukla, S. (2020) Period Health: Everything You Need to Know About Endometriosis. Available at: https://www.grazia.co.in/beauty-and-health/lets-not-normalise-period-pain-5175-1.html (Accessed: 27/07/2020).

Stickdorn, M. et al. (2018) This is service design doing. Sebastopol: O’ Reilly Media, Inc.

Nesta (2021) Women. Available at: https://www.nesta.org.uk/search/?search=women (Accessed: 21/11/2021)

Summa Health Menstrual Disorders. Available at: https://www.summahealth.org/medicalservices/womens/aboutourservices/gynecological-services/menstrual-disorders (accessed: 08/01/2021)

Omidvar S., Amiri F and et. al. (2018) 'A study on menstruation of Indian adolescent girls in an urban area of South India', Journal of Family Medicine and Primary Care, 7(4), pp. 698-702. doi: 10.4103/jfmpc.jfmpc_258_17.

The Borgen Project (2019) Top Five Fact about Period Poverty in India. Available at: https://borgenproject.org/top-five-facts-about-period-poverty-in-india/ (Accessed: 16/07/2020).

Oxfam International ( ear) India: Extreme inequality in numbers. Available at: https://www.oxfam.org/en/india-extreme-inequality-numbers : :text et's%20look%20at%20the%20numbers text The%20top%20 10%25%20of%20the,1%25%20increase%20in%20their%20wealth. text The re%20are%2011 %20billionaires%20in%20India (accessed: 31/7/2020).

Tingle C. and Vora S. (2018) Break the Barriers: Girls' Experiences of Menstruation in the UK. Available at: https://plan-uk.org/file/plan-uk-break-the-barriers-report-032018pdf/download?token Fs-H P3v (Accessed: 05/07/2020)

Penin, L. (2018) An introduction to service design: designing the invisible.

London: Bloomsbury Visual Arts.

United Nations Development Programme (2015) What are the Sustainable Development Goals?. Available at: https://www.undp.org/content/undp/en/home/sustainable-development-goals.html : :text The%20Sustainable%20Development%20Goals %20(SDGs,peace%20and%20prosperity%20by%202030 (Accessed: 22/07/2020).

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8.

Appendix

Appendix 1- ASHA Training Manual

SURKHi My red friend

Empowering married women (aged 20-35) in urban slums of India with knowledge and tools to manage their menstrual health through leveraging existing government, non-government and social networks.

ASHA TRAINING MANUAL

Content Abbreviations Background 2.1 What is Surkhi?

2.2 Why this programme?

2.3 How to promote menstrual health?

2.4 How can ASHA Workers Help?

2.5 Who is this training for?

Objective for training Note for the trainer 4.1 Training schedule 4.2 Training checklist ASHA Roles and Responsibility 5.1 Key Mindsets Training Sessions 6.1 Week 1 6.2 Week 2 6.3 Week 3 6.4 Week 4 Workshop Ideas for women

Abbreviations

ASHA: ACCREDITED SOCIAL HEALTH WORKER AWW: Anganwadi workers PHC: Primary healthcare clinic MHM- Menstrual Hygiene Management NUHM- National Urban Health Mission NHM- National Health Mission

Background 2.1 What is Surkhi?

Surkhi is a training programme for ASHA workers designed to impart Snowledge about menstrual health management to women living in slums.

This programme is a collaboration between Tata Trusts and NUHM Telangana, India.

During its initial stage, the programme will be launched in the slums of Hyderabad, India and will be delivered in regional languages such as Dakhni, Telugu, Urdu & Hindi.

The programme has the potential to be adapted to dierent regional languages and launched in slums across the country.

2.2 Why this programme?

The training programme oered by Surkhi is currently targeting married women in the age group of 20-35. Through the programme ASHA workers will be conducting fortnightly workshops that teach women about menstrual health through experiential tools. After the education stage, women are encouraged to track their periods on the Period Tracker Calendar designed by Surkhi. These women speak to the ASHA workers during the workshop in case they notice something abnormal with their bodies. The ASHA workers further guide them to seek help from the Primary Healthcare Clinics (PHC) that are located in every slum.

2.3 How do we promote menstrual health and hygiene?

Experiential Tools Setting up a support system Education Tracking- actions for women after these workshop Normalizing menstruation

3

2.4 Who Can do it?/Why ASHA? Menstrual health can only be promoted if more women start advocating for it.

Since ASHA workers already reach out to expectant mothers and provide care, it’ll be easier for them to include menstrual health in the conversation.

Seeing as menstrual health and reproductive health are interconnected.

Moreover, ASHA workers are already in close contact with women in the slums. Making it easier for them to reach out to women.

Community gatekeepers will be recruited by ASHA workers and this will help to get more women on board. Every community in India has “chatty women” that play the role of a real life agony aunt. Concerted efforts made by the ASHA workers and the community gatekeepers will help to bring about a change in attitude towards menstruation and menstrual health.

2.5 Who is this training for ?

The training is for ASHA workers to help married women in the age group of 20-35 in urban slums of India to understand more about their menstrual health.

4

Objective of the training Key tasks required to deliver the service : Basic conversation around menstrual health and hygiene Enable ASHA to facilitate workshops to help women understand about their menstrual health with the help of educational tools Recording and reporting the progress made by women

5

Note for the trainer The purpose of this training is to broaden the scope of the ASHA workers to enable them to help women learn about their menstrual health and manage it eectively. Even though this training programme is designed to support ASHA workers they know the women best as they have access and connections within the community. Keeping this in mind, any modifications could be made on the field with regards to delivery of the information.

However, all modification and changes must be recorded. It is important for trainers to keep the information cycle in check to ensure that misinformation is not being spread.

4.1 Training schedule The initial training will last for 4 weeks consisting of one hour sessions twice a week.

Tentative training schedule: 10 mins- ice breakers 40 mins- training based on weekly curriculum 10 mins- Q and A After the initial training is complete, ASHA workers will receive weekly training on the topic that will be covered in the workshops for women. For example, if the first week ASHA workers are going to teach women about why they menstruate, they will receive training from Surkhi on the knowledge that needs to be shared. Once the programme begins and ASHA workers begin to interact with women, there will be re-training based on the feedback gathered from the workshops.

4.2 Training checklist The trainers must make the following preparations before each training session: Secure space for the session, arranging schedule with local primary school All educational tools must be kept ready Feedback forms for ASHA workers to improve the training session

6

ASHA Roles and Responsibilities

1) Recruiting community gatekeepers- women that are popular in the community.

Leveraging the community gatekeepers networks is a crucial step as it will help to bring more women onboard.

2) Being aware of menstrual health disorders to help other women out 3) Facilitating workshops and report to Surkhi workers after each session 4) Being alert of women's reactions and ensuring that they have understood the facts.

5) Encouraging women to use the trackers and swatch cards to be more mindful of their symptoms.

6) Encouraging them to learn through experience.

7) Keeping a track of the participants progress and health 8) Guiding women to Primary healthcare clinics if they notice something abnormal 9) Create an atmosphere where sharing experiences is encouraged- women will relate and learn from each other 5.1 Key mindsets 1) Empathy: This will help women to feel more comfortable during the sessions Ask and listen 2) Encouraging women to speak up 3) Motivating them to use trackers 4) Understanding when they speak up about their menstrual health issues 5) Women must feel like they are in a safe space

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Training sessions

6. Training Sessions 6.1 Week 1- Introduction Why this is important and how this is going to change their daily schedules and workflow Key tasks Selection of community gatekeepers Getting women on board 6.2 Week 2 Conducting Workshops How to conduct workshops Facilitation tips for workshops Possible questions women might ask and their answers 6.3 Week 3 Educational Tools How to best use the educational tools designed by Surkhi.

Tool 1: Period Swatch Cards Objective: The objective of the period swatch cards is for women to understand what their menstrual blood signifies. Women can use these cards and inform the ASHA workers if they spot anything abnormal. These swatch cards will be used during the workshops facilitated by the ASHA workers.

Tool 2: Period Tracker Calendar Objective: For women to track their symptoms and be more aware of their menstrual cycles.

6.4 Week 4 Monitoring and Evaluation What needs to be tracked How to use tablets for digital documentation of feedback Grievance redressal- Guiding women with complaints

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Workshop Ideas

Based on the feedback gathered from women and doctors, it was found that there is a lack of knowledge and misinformation about several factors related to menstrual health.

Here are some of the topics that women have little to no knowledge about and would like to learn more about the same: 1) What is menstruation 2) How to calculate the length of the menstrual cycle 3) What is PMS and how to manage its symptoms 4) How much bleeding is ok?

5) What does the colour of your blood signify?

6) What is vaginal discharge? How to tell if there’s something unusual?

7) How to dispose of menstrual products?

8) How to sanitize reusable menstrual products?

9) What kind of menstrual products are available to them?

10) DI makeshift menstrual products for emergencies 11) How to manage painful periods?

12) What kind of food are good during periods?

13) What kind of exercises help during periods?

14) Common myths and taboos ASHA workers can be trained by professionals like doctors to conduct workshops for women on these topics in the future.

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Appendix 2- Period Tracker Calendar

January 2021 S

M

T

W

T

F

S

27

28

29

30

31

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

1

2

3

4

5

6

Use these stickers to mark the number of days you bleed and the ow.

Spotting Light Medium Heavy

Spotting Light Medium Heavy

Mark Areas where it pains during your menstural cycle

Appendix 3- Swatch Cards

My red friend

SWATCH CARD

Beginning or end of period Beginning or end of period

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Heaviest days of periods Beginning or end of period Heaviest days of periods

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Information can be found online on helloclue.com

CLEAR -Healthy discharge -Pregnancy -Ovulation -Hormonal imbalance WHITE -Healthy discharge If the discharge is smelling o, check for signs of yeast infection YELLOW-GREEN (with foul smell) -Sexually transmitted infection

RED -During period- menstrual blood

PINK -Cervical bleeding

GRAY (with fishy or foul smell) -Bacterial vaginosis

Vaginal Discharge

SURKHi

Instructions: 1) Ask women to identify the colour of the bleeding.

2) If answer is no need for action.

3a) If answer is , check for other symptoms like excessive bleeding, fever, pains etc.

3b) Report to supervisor

Mid cycle (ovulatory bleeding) Irregular or non-cyclical bleeding Irregular or non-cyclical bleeding McWeeney (2019)

Menstrual Blood

Beginning or end of period

RUCHIKA KARNANI Final Major Project MA Service Design 2020 London College of Communication

IT’S A NATURAL BODILY FUNCTION. PERIOD SURKHi My red friend

Empowering married women (aged 20-35) in urban slums of India with knowledge and tools to manage their menstrual health by leveraging existing government, non-government and social networks.