Background: Ensuring respectful maternity care is crucial to promote positive childbirth experiences among women. Globally, 22-100% women report experiencing at least one form of disrespect and abuse during facility-based birth, with a study in Nepal reporting 100% prevalence. Thus, interventions like Forum Play are needed to promote respectful maternity care but remain scarce. Forum Play is a participatory theatre technique which encourages the participants to create scenes based on their own experiences illustrating a situation of oppression. This study aimed to assess the effectiveness of a pilot Forum Play intervention in promoting respectful maternity care by investigating self-reported perception and behaviour among care providers.

Methods: A quasi-experimental pre-post study with a control group was conducted among doctors and nurses in two tertiary hospitals in Nepal. Participants involved in providing care or interacting with women during labour and delivery were purposively selected for the intervention and control groups. The intervention group comprised 25 care providers (14 nurses and 11 doctors), while the control group included 75 care providers (42 nurses and 33 doctors). Two half-day Forum Play workshops were conducted separately for nurses and doctors in the intervention hospital. Data were collected using a self-administered structured questionnaire at baseline and two months post-intervention in both groups; however, the design was not strictly parallel. In the control hospital, data were collected later at the same intervals to provide contextual comparison. Data were analysed using IBM statistical package for social sciences version 20. Descriptive statistics (frequency, percentage, mean and standard deviation) were used to measure the self-reported perception and behaviour on disrespect and abuse and perceptions of respectful maternity care. Mann Whitney U test was used to compare groups and Wilcoxon Signed Rank test was used to assess within-group changes before and after the intervention.

Results: There were no differences in background characteristics between intervention and control groups (p=>0.05), nor in the overall disrespect and abuse of women at baseline (p = 0.09 to 0.35) whereas significant differences were observed at follow-up (p=<0.001 to 0.004, r = 0.33 to 0.61). There were no significant differences in perception scores towards respectful maternity care between the groups at baseline while significant differences were found at follow-up (z = -3.25, p = 0.001 and r = 0.32). The perception score was significantly higher in the intervention group after the intervention (z = -3.073, p = 0.002 and r = 0.61) while no significant difference was observed in the control group (z = -0.120, p = 0.90 and r = 0.05).

Conclusion: Forum Play as a method of participatory intervention has the potential to enhance positive perception and behavioral change among care providers towards respectful maternity care. Scaling up the Forum Play intervention and systematically exploring women's experiences are essential to determine its actual effectiveness.

Background: Promoting respectful maternity care is a crucial indicator of quality maternal healthcare. However, evidence from global studies indicates that 22% -100% women experience at least one form of disrespect and abuse during facility-based births, with research conducted in Nepal reporting a prevalence of 100%. Therefore, implementing targeted interventions for healthcare providers is essential to reduce instances of disrespect and abuse of women and to foster respectful maternity care. Forum Play represents a promising approach in this regard.

Objectives: To explore the staff perspectives on disrespect and abuse of women during facility-based births and to assess the feasibility and acceptability of a Forum Play intervention in promoting respectful maternity care in Nepal.

Methods: Three half-day Forum Play workshops were conducted among hospital staff of a tertiary hospital in Kathmandu, Nepal, in November 2023. Eleven doctors, 14 nurses and 11 administrative staff were recruited for the workshops by using purposive sampling. Separate workshops were organized for the respective groups. At the end of each workshop, a focus group discussion was conducted using a semi-structured interview guide. All discussions were audio-recorded and non-verbal cues were noted by two note-takers. A total of 27 hospital staff participated in the discussions, including seven administrative staff, 10 doctors, and 10 nurses. Data analysis utilized inductive qualitative content analysis, allowing codes and categories to be developed directly from participants' responses as guided by Graneheim and Lundman.

Results: Data derived from the focus group discussions was divided into two parts: (i) staff perspectives on disrespect and abuse of women during facility-based births and (ii) Staff reflection on Forum Play in promoting respectful maternity care. Four categories were generated from the data: (1) Structural and systemic drivers of disrespect and abuse, (2) Social and interpersonal determinants of disrespect and abuse, (3) Personal and professional transformation through Forum Play, (4) Acceptance and institutional feasibility of Forum Play. These categories were extracted based on 11 subcategories classified from the codes derived from the data. Participants' reflections on the Forum Play workshop were very promising. Forum Play was identified as an innovative, interesting and acceptable method of intervention.

Conclusion: Disrespect and abuse during facility-based births arise from structural, social, and interpersonal factors and violate women's fundamental human rights. Participants' reflections indicate that Forum Play is an innovative and acceptable intervention that can raise awareness and support personal and professional growth among healthcare providers, suggesting its potential as a practical approach for promoting respectful maternity care. However, further testing is needed to confirm its feasibility and effectiveness.

Background Gender inequality and violence are not mutually exclusive phenomena but complex loops affecting each other. Women in Nepal face several inequalities and violence. The causes are diverse, but most of these results are due to socially assigned lower positioning of women. The hierarchies based on power make women face subordination and violence in Nepal. The study aims to explore participants' understanding and experience to identify the status of inequality for women and how violence emerges as one of its consequences. Furthermore, it explores the causes of sex trafficking as an example of an outcome of inequality and violence. Method The study formulated separate male and female groups using a purposive sampling method. The study used a multistage focus group discussion, where the same groups met at different intervals. Six focus group discussions, three times each with male and female groups, were conducted in a year. Thirty-six individuals, including sixteen males and twenty females, were involved in the discussions. The study used constructivist grounded theory for the data analysis. Results The study participants identify that a power play between men and women reinforce inequality and increases the likelihood of violence for women. The findings suggest that the subjugation of women occurs due to practices based on gender differences, constricted life opportunities, and internalization of constructed differences among women. The study identifies that interpersonal and socio-cultural violence can result due to established differences between men and women. Sex trafficking, as an example of the outcome of inequality and violence, occurs due to the disadvantageous position of women compounded by poverty and illiteracy. The study has developed a concept of power-play which is identified as a cause and consequence of women's subordination and violence. This power play is found operative at various levels with social approval for men to use violence and maintain/produce inequality. Conclusion The theoretical concept of power play shows that there are inequitable power relations between men and women. The male-centric socio-cultural norms and practices have endowed men with privilege, power, and an opportunity to exploit women. This lowers the status of women and the power-play help to produce and sustain inequality. The power-play exposes women to violence and manifests itself as one of the worst expressions used by men.

Gender inequality and violence against women are present in every society and culture around the world. The intensities vary, however, based on the local guiding norms and established belief systems. The society of Nepal is centered on traditional belief systems of gender roles and responsibilities, providing greater male supremacy and subordination for the females. This has led to the development and extensive practices of social gender hierarchal systems, producing several inequalities and violence toward women. This study has utilized Forum Theater interventions as a method of raising awareness in 10 villages in eastern Nepal. The study aimed to understand the perception and changes in the community and individuals from the interactive Forum Theater performances on pertinent local gender issues. We conducted 6 focus group discussions and 30 individual interviews with male and female participants exposed to the interventions. The data analysis utilized the constructivist grounded theory methodology. The study finds that exposure and interactive participation in the Forum Theater provide the audience with knowledge, develop empathy toward the victim, and motivate them to change the situation of inequality, abuse, and violence using dialogues and negotiations. The study describes how participation in Forum Theater has increased individual’s ability for negotiating changes. The engagement by the audience in community discussions and replication of efforts in one of the intervention sites show the level of preparedness and ownership among the targeted communities. The study shows the methodological aspects of the planning and performance of the Forum Theater and recommends further exploration of the use of Forum Theater in raising awareness.

Worldwide, a large number of women experience disrespectful and abusive behavior from care providers during childbirth. This violates the rights of women to attain respectful care. This study aimed to find out the women's experience of disrespect and abuse during institutional delivery. A cross-sectional study was conducted in two hospitals of Morang district situated in eastern Nepal. Two hundred eighteen women from a public hospital and 109 women from a private hospital (N = 327) with normal vaginal delivery were selected purposively for this study. Data were collected through face-to-face interviews using a structured questionnaire based on the Disrespectful and Abusive Scale by Bowser and Hill. All women had experienced at least one type of disrespect and/or abuse during labor and delivery, most common being non-consented care (100%), non-dignified care (72%), and non-confidential care (66.6%), respectively. Discriminatory care and physical abuse were experienced by 32.33% and 13.23%, respectively. Ethnicity, religion, place of delivery, and numbers of living children were the main predictors of reporting disrespect and abuse. Overall, the occurrence of disrespect and abuse during institutional delivery was found to be very high.

Background

Gender inequality and violence are prevalent globally affecting women withdiscriminatory practices and victimizations. The oppressions majorly arise due tosystemic inequalities and power hierarchies. Interventions targeting to endinequality and violence are increasing and this thesis compares the outcomes ofparticipatory Forum Theater.

Aim

This thesis aimed to develop and test the efficacy of Forum Theater for promotinggender equality and reducing violence against women in the Morang district ofeastern Nepal.

Method

This thesis stands on the findings from epidemiological studies. Study I wasconducted with sex trafficking survivors using focus group discussion and theanalysis used a content analysis method. The baseline study (II) reached 2000samples in twenty randomly selected villages. Quantitative data collection used amethod of self-administered Color-Coded Audio Computer-Assisted Self-Interviews. A total of thirty Forum Theater, three times each over a year wereorganized in ten randomly selected intervention villages. Qualitative studies (III andIV) conducted between the interventions used six focus group discussions and thirtyindividual interviews. The evaluation study (V) reached 1210 samples in bothgroups. Quantitative analysis used descriptive and inferential statistical methods andqualitative analysis used constructivists grounded theory.

Results

Study I find social stigma and lack of opportunities as major challenges for thereintegration of sex trafficking survivors. Study II identifies the prevalence of gender 

inequitable beliefs and violence influenced by norms, attitudes, and practices. StudyIII develops a theoretical model of power-play to exhibit nurturers of genderinequitable beliefs and resulting violence. Study IV finds Forum Theaterinterventions have increased the ability of audiences to negotiate for change. StudyV finds that intervention groups compared to the comparison groups havedeveloped more gender-equitable beliefs and stronger opinions on equality.

Conclusion

The use of Forum Theater has motivated and increased the ability of participantsto develop opinions and negotiate for establishing equitable beliefs. Forum Theaterenables the inclusion of oppressed voices and provides a safer environment to endoppressions providing multiple solutions. This thesis informs academicians andpractitioners on the nuances of efforts required in establishing equality and reducingviolence. Further testing of Forum Theater is recommended

Background Gender inequality and gender based violence is more established in societies with stratification and stronger gender norms. Objective To determine prevalence of gender violence, perception on gender issues and awareness on sexual trafficking and rights among men and women in Morang district of Nepal. Method This cross sectional study was conducted among 810 men and 1190 women in twenty different VDCs of Morang district using self-administered computer based self-interview methods during October-November 2016. Result Male in comparison to female reported more physical abuse during their lifetime. Females (n=259, 21.7%) reported more severe lifetime emotional abuse (n=148, 18.2%) compared to the males. Lifetime severe sexual abuse was reported by a close to five percent (n=95) of both sexes. The severe forms of partner violence include choking, threat or use of weapon and setting on fire was identified to be perpetrated by both the sexes. More than 50% (n=1095) of the respondents had known someone using physical violence against their partner in the community. The involvement of female in key economic decision-making was reported by less than 12%. Nearly 72% (n=1441) were aware of occurrence of sexual trafficking from Nepal while only 46% (n=918) were aware of sexual trafficking occurring from their vicinity. Conclusion The study confirms that despite awareness on gender equality and sexual trafficking, the prevalence of violence and adherence to stronger gender stereotypes, stigmas and roles indicates much need of awareness for establishing equalities and reducing gender violence. © 2019, Kathmandu University. All rights reserved.

Background: The successful reintegration of sexual trafficking survivors into Nepalese society is challenging. This paper aims to explore the trafficking process, abuses faced during sexual slavery, and the challenges faced by women and girl survivors for successful reintegration. Method: This exploratory study used qualitative methods to identify that poverty, illiteracy, lack of opportunities, and varied social stigma initiate the victimization process, and continuity of this vicious circle increases the risk for (re) entrapment. Result: The reasons for sexual trafficking have also become the reasons for restricting survivors from opportunities for growth and mainstreaming. Conclusion: Non-existent support systems, detachment from familial ties, being outcast by society, and an uncertain livelihood make reintegration difficult for survivors.