Table 2 Coding tree: Identified family environmental factors of adolescent girls’ development and performance of religio-cultural menstrual practices

Major themes Sub themes Codes Description
Individual subsystem Immediate level influence Caregivers’ observance of menstrual rituals Mothers and grandmothers practice menstrual rituals during their menstruation in a regular basis and as growing up, adolescent girls have seen their mothers and grandmothers observing the menstrual ritual restrictions. Manifested menstrual practices of the primary caregivers in the family in the local context have promoted adolescent girls to learn the cultural practices and social expectations for menstruating women. To add, observed adherence of the menstrual practices of caregivers affect the adolescents’ maintenance of menstrual practices. Caregivers’ strong adherence to menstrual practices seemed to make adolescents reluctant and cautious to questions the validity of the cultural rituals and reject the concerned traditions.
Proximal level influence Caregivers’ perceptions in regard to their religio-cultural menstrual practices Caregivers’ understanding and perspectives of menstrual rituals form the cognitive basis of the pertaining parenting practices. Motivations of mothers and grandmothers to observe menstrual practices, their understanding of the cultural changes regarding menstrual practices, and their perceptions of the contemporary menstrual practices seemed to have influence on how the caregivers interact with their menstruating daughter. Menstrual practice-related interaction in this regard includes the caregivers’ level of engagement and proactiveness in promoting menstrual health of the adolescent girls in the family context.
Distal level influence Caregivers’ personalities Caregivers’ personality has implications on adolescents’ menstrual practices as it is reflected on caregivers’ menstrual practices and pertinent perceptions. The study identified dispositional tendency to seek for others’ approval, level of agreeableness and openness to experience as relevant to the adolescents’ menstrual practices as a high-level moderator.
Interpersonal system Immediate level influence Caregiver-adolescent menstrualritual-related communications Caregivers communicate with adolescents regarding menstrual rituals. Through caregiver-child communication, family rules and restrictions on menstruating women are instructed to the adolescent girls and the caregivers monitor and supervise the child’s observance of menstrual rituals. Caregivers’ own menstrual experiences are found to be reflected on how and what kind of message the caregivers deliver to the adolescents regarding the menstrual rituals. The mothers and grandmothers reported that they mostly use punitive discipline (e.g., nagging) as they deliver the pertaining messages. They also reported that subsequently to the nagging. quarrel between caregivers-child followed with the adolescents requesting caregivers for valid explanation why they shall adhere to menstrual ritual restrictions. Caregivers’ verbal instruction on menstrual rituals would serve the adolescent as the reference for developing their menstrual practices. And, parental monitoring for adherence to the menstrual rituals would affect the adolescents’ maintenance of the menstrual practices.
Interpersonal system Immediate level influence Supports that caregivers provide to girls who observe menstrual rituals Caregivers provide menstruating girls with instrumental support when the girls observe the menstrual rituals. When performing routine task is obstructed by the rituals (e.g., not entering the kitchen during the menstruation), caregivers support them with managing the task. The most popular case reported by the caregivers was that caregivers cook food for the children and feed them during the menstruation as their menstruating daughters are not allowed to enter the kitchen. The findings indicated that the experience of menstrual rituals may be perceived as experience of social support by the adolescent girls and affect the girls’ motivation to perform the menstrual practices.
Proximal level influence Caregivers’ parental beliefs about religio-cultural menstrual practices Caregivers’ parental belief of menstrual practices is supposed to be the antecedents of the caregivers’ parenting practices regarding menstrual practices. The study identified the two prominent cognitive factors that affect pertaining caregiver-child interaction: importance of the menstrual practices perceived by the caregivers and improved menstrual health and hygiene knowledge and awareness among caregivers pertinent to their parenting practice. These factors may have indirect impact on the local adolescents’ development and maintenance of menstrual practices.
Interpersonal system Distal level influence Perceived behavioural control of the caregivers Perceived behavioural control of the caregivers has implication on the general parenting practices of the local family. The caregivers were focusing exclusively on supporting childrens’ social integration in parenting than developing their the sense of independence and self-concept. The distal level interpersonal factor is assumed to be the higher-level moderator that affects the caregivers’ parenting practices including those pertaining to adolescents’ menstrual practice.
Perceived role of the (grand)mother as caregiver Perceived role of the mothers and grandmothers as caregiver is expected to reflect the general parenting strategy of the local family. The local mothers and grandmothers presented low parental self-efficacy in parenting. The distal level interpersonal factor is assumed to be the higher-level moderator that affects the caregivers’ parenting practices including those pertaining to adolescents’ menstrual practice.
Family-as-a-whole system Immediate level influence Family level support provided to girls who are observing menstruating rituals In the local community, family members were providing support for adolescent girls as they are observing menstrual practices. It is primarily female family members including grandmother, mother, and sisters including sister-in-law and cousin-sister that share responsibility of supporting other female members when the girls have any difficulties while observing the family menstrual rituals. While the frequency may differ, nature of the support provided to the adolescent girls are the same as the one provided via caregiver-child interpersonal interaction.
Proximal level influence Family climate surrounding female members’ observance of menstrual rituals In extended family setting in the local community, grandmothers and mothers were co-developing the menstrual rules and ritual restrictions for menstruating girls and women. Grandmothers and mothers shared the responsibility for monitoring the adolescents’ adherence to the menstrual practices. However, it was predominantly mothers, who had more impact on adolescents’ menstrual practices than grandmothers, as they had more frequent interactions with the adolescents in general. The local family was ready to provide any support for adolescent girls observing the menstrual rituals and connotation of menstruating women being untouchable was no longer valid in the family. Nevertheless, some elderly presented resistance for menstruating women touching them based on the belief that it would invite misfortune.
Distal level influence Family functioning Characteristics of the extended families in the local context such as vertical family hierarchy with high parental authority and low status of women in the family have implications on adolescents’ menstrual practices. The local families demonstrating high parental authority coupled with lower youth autonomy were inclined to have adolescent girls observe stricter menstrual rules and restrictions. On the other hand, the more family responsibility and workload are imposed on girls and women (during their menstruation), the shorter the duration of the menstrual practices tended to become.
Physical co-habitation status of the extended family Physical co-habitation status of the local extended families was identifed to decide the primary decision maker of the family’s menstrual rule and restrictions. When grandmother was living with the adolescent girl and her mother, grandmother’s menstrual belief was prioritized than the mother’s in the family’s menstrual practice. However, when grandmother was living separately with the adolescent girls, menstrual belief of mother or foster mother ruled the adolescent girls’ menstrual practices almost exclusively.