Breaking the Silence: Overcoming stigma in health choices through group discussions

There are three closely intertwined, but distinct factors that contribute to suboptimal decision making in health choices. These are stigma, social norms, and taboos. Stigma relates to a person’s fear and shame of being “found out” and revealing information about themselves that somehow lessens them in the eyes of their peers and society as a whole. This can also result in self-stigma, when one feels ashamed and guilty for experiencing the stigmatized condition, even if no one else is there to observe it.¹ Social norms refer to the (unwritten) rules one expects everyone else to consider “the right thing to do” (injunctive norms), as well as the actions one expects everyone else to take in practice (descriptive norms).² Finally, taboos arise from a common agreement that a certain topic should not be discussed in public and bringing it up is frowned upon. These three concepts reinforce each other and generate a vicious cycle, in which stigmatized topics are not discussed and only executed in secret, leading to even more suspicion, even less true information about them being transmitted, and an even stronger belief that no one else engages in this practice and everyone else considers it inappropriate. This creates a hostile environment, in which personal considerations of optimal decision making are thwarted by peer pressure and social concerns.

Health concerns, and in particular reproductive and female health, are especially commonly subject to strong stigma. Take, for example, female menstruation. Almost all women, so around half the world’s population, experience menstruation for a large part of their adult lives. It is a perfectly normal, healthy and useful biological process that ensures the survival of the human race. Yet, menstruation is subject to very strong taboos, stigmas and social norms around the world. When Pixar released the movie “Turning Red” in 2022, which makes several references to a 13-year old girl’s start of her period and her need for sanitary pads, this sparked a public debate in many countries - such as the US - with people deeming this movie inappropriate for children^3,4 or targeted at a “niche” audience.⁵ This social reluctance to talk about menstruation, especially to children, can give it the appearance of something “improper”.

This can result in detrimental health effects when the extent of the taboo and restrictive social norms start to limit women’s access to modern and hygienic menstrual products and prevent them from buying the products they would need, for fear of being stigmatized and judged. This is particularly prevalent in low- and middle-income countries, where limited access to education and proper information about the topic exacerbates the problem. For example, in a survey run by Castro & Mang (2022) with 485 female Bangaldeshi garment workers, more than 80% of the surveyed women reported that the main barrier preventing them from accessing pads was that they were feeling uncomfortable when going to a store to buy pads and being potentially observed by others, in particular the usually male shopkeepers. In addition, 52% of women reported that they cover their face (e.g. with a Burka) to avoid being recognized when they do purchase pads.⁶

A big challenge about stigmatized and taboo topics, be it menstruation, mental health or AIDS and other STDs, is that they are very difficult to address from ‘within’ for several reasons. First, if no one is talking about a topic, it can seem like more people disapprove of it than is actually the case. A study by Bursztyn et al. (2020), for example, showed that the share of Saudi-Arabian men privately approving of female labor force participation was much larger than the share that the men expected to approve of it.¹⁰ Because no one openly discussed their approval of female labor force participation, the social norm was perceived as being a lot more restrictive than it actually was. Second, even if someone would themselves be comfortable discussing a certain topic, no one wants to be the one that brings it up. Think about your salary. Maybe you don’t mind sharing what you earn with your friends and you would actually be very curious to know what your friends earn. But because this is generally a taboo topic, even if you yourself would not mind discussing the topic when it came up, you would not want to be the one bringing it up in the first place, for fear of being ostracized. It therefore needs an external discussion starter to first of all generate a common understanding that talking about a topic is now ok. Third, social stigma can also lead to self-stigma, whereby people internalize the social stigma and start to feel ashamed and develop a low self-esteem even if no one else observes them. Ghosal et. al. (2022) found such an effect when talking to sex workers in India, who would not attend regular check ups with a physician or save for their future, because (among other things) they considered themselves of too little worth.¹ Finally, the lack of information transfer for a taboo topic exacerbates stigma, because false information is not countered and education initiatives do not transmit throughout society. For example, as mentioned previously, many women in Bangladesh do not discuss menstruation with their daughters. This also means that any efforts to encourage pad use, for example, will not transmit to future generations and will have only very limited local effects. All of these reasons explain why stigma, taboos and social norms have such a powerful impact on limiting optimal health choices and require an external intervention to break the silence.

Now on to the good news - it may only take a small spark to break the silence, get the discussions going and translate into real and lasting health impact! Discussion-based interventions can be the kick-starter that transforms perceptions and health practices. These interventions aim at providing individuals with a safe space to discuss a stigmatized topic. They generally consist of one or more group sessions, led and facilitated by a trained moderator, in which groups of approximately 15-20 participants share their thoughts and experiences on a stigmatized topic. The key of these sessions is to create the common understanding that discussing the topic in this context is approved of and desirable. Unlike many other interventions that have been tested in similar contexts, discussion-based interventions do not require the provision of any education, training or information, but solely rely on the common knowledge already present within the group, allowing the individuals to share their thoughts. 

In the study by Castro & Mang (2022),⁶ for example, the authors conducted such a discussion-based intervention to increase the uptake of sanitary pads and reusable menstrual underwear in a Bangaldeshi garment factory. Half of the female study participants joined a 1h discussion session, and were encouraged to share their experiences and thoughts about menstruation. While the sessions were moderated by two trained facilitators, there was no formal education or training. The sessions relied on the women sharing their personal experiences and opinions, focusing in particular on the menstrual products they used and the experience they had made with different methods. Subsequently, the willingness to pay for a pack of sanitary pads was measured, as well as the pickup rates of a reusable menstrual underwear made available to the women for free. The crucial feature of the experiment design was that the sanitary pads and the reusable menstrual underwear had to be picked up in a small convenience store on the factory premises that was run by a male shopkeeper. The previous survey had identified the presence of the usually male shopkeeper as one of the main barriers to why women felt uncomfortable with the idea of buying sanitary pads in a regular store or pharmacy. The hypothesis for the discussion-based intervention was that participation would boost the women’s confidence and change their perceptions of the stigma and social norms surrounding the topic, empowering them to pick up the products even from a male shopkeeper.

Indeed, participating in the 1h discussion session increased the women’s willingness to pay for sanitary pads by more than 25% compared to a control group without the discussion session, and the pickup rate of the menstrual underwear increased by 14%. Further analyses showed that the effect was not driven by a change in the perceived value-for-money, but by fewer concerns about having to pick up the product from a male shopkeeper. In addition, explicit measures of the perceived stigma and taboo surrounding the topic decreased significantly. Moreover, while a majority of women had reported viewing the purchase of pads from a male shopkeeper as “socially inappropriate” before the intervention, a majority viewed it as “socially appropriate” after the intervention. These changes were persistent over 6 months and also led to increased use of the menstrual underwear after 6 months. 

The success of this intervention went far beyond its impact on the treatment group. The effects reverberated throughout the entire garment factory of more than 6000 employees. The study observed significant “spillover effects”, meaning that changes were observed also in the behavior and perceptions of women who were not part of the treatment group, as the women started to discuss the topic also with colleagues who had not been part of the initial discussion sessions. In addition to the discussion sessions themselves, another key success factor of the project was that the factory was providing the space and also the workers’ time to participate in the research, which gave an air of institutional approval to the project and to menstruation as a topic more generally. Even the female members of the senior leadership team and the senior trade union leaders reported feeling more comfortable to openly address menstruation and felt empowered to push for more initiatives making menstrual products available to their workers. Word about the reusable underwear also spread as a result of the project, with other female employees not part of the study asking for them. The factory management subsequently made the menstrual underwear available to female workers across several of its factories in other countries as well.

This is one of several recent examples in the academic literature that demonstrates the power that discussion based interventions can have in improving personal health choices. However, it does not always need to be academics running formal studies that provide safe spaces for individuals to share their experiences and overcome the barriers to health choices. The key elements required are an external spark to get a discussion going and a safe space to express your honest opinion freely. In fact, there are many ways in which businesses, policymakers and public figures can contribute to creating such an environment and several successful examples of past campaigns exist. For example, extensive awareness campaigns targeted at sparking more public debate about mental health in Britain have led to a widespread acceptance of mental health illnesses as “an illness like any other”.¹¹ Here are 5 actions to take by policy makers and businesses in order to break the silence and reduce stigma to encourage better individual health choices.

1. Encourage discussion starters. A poster in the underground train station, a TV commercial, or a radio show can all act as a discussion starter. The options are endless. As mentioned earlier, a movie such as “Turning Red” can spark public debates about the taboos surrounding menstruation. Similarly, TV and radio shows and soap operas have been used in past research to address social norms and stigma, for example around HIV,¹² domestic violence¹³ or prejudices towards other ethnic groups.¹⁴ Similarly, a hashtag on social media such as #LetsTalkPERIOD(s) can serve as a way to promote discussion and raise awareness.
2. Provide institutional endorsement. As described above, one of the major success factors of the discussion-based intervention in the Bangladeshi garment factory was the women’s perception that the factory, their employer, was endorsing the effort to promote menstrual health. This is something employers around the world can adopt. Providing resources to employees such as access to mindfulness apps or tips on improving your mental health in the company newsletter, or providing free menstrual products in the bathrooms are just a few examples of how employers can foster a feeling of institutional endorsement.
3. Create safe discussion spaces. Allowing people to discuss a taboo topic without the fear of negative social repercussions is a key success factor of discussion-based interventions. This requires that facilitators are present that can moderate the discussion and keep the conversation in check. Such opportunities could be offered by community centers or companies, for example. Both in-person, but also online discussion sessions can do the trick. An important opportunity is also provided by schools. Schools can provide safe spaces for children to learn about important health topics and teachers can serve as facilitators, simultaneously using the opportunity to educate the children (e.g. about basic biological facts of their bodies and brains) and encourage discussion and engagement with the topic. This can be controversial, though - if adults already have issues with discussing a stigmatized topic, they may consider it harmful to discuss these topics with children (especially if it concerns reproductive health - see the discussion on the appropriateness of “Turning Red” for children mentioned above). Nevertheless, schools as a place of education and learning and a safe space for the children to engage with the health of their bodies and brains, can play a crucial role in tackling stigma and norms around health topics in the long-run.
4. Give information. Factual information, both about the stigmatized health conditions themselves as well as on the actual true beliefs and opinions that people in the community hold, can be powerful tools to reduce stigma. The research on perceptions of male approval of female labor force participation in Saudi-Arabia¹⁰ showed that sharing the actual approval rates of their peers caused Saudi-Arabian men to adjust their beliefs about the prevailing social norms and made them feel more confident to support their women in taking on jobs. In addition, providing information, for example about the biological basis of menstruation or of mental health issues, can serve to demystify the conditions, counters misinformation and helps provide the language individuals affected might lack in order to talk about the conditions.
5. Engage role models. Role models can serve as a discussion starter and can also help shift the perceptions on what is considered socially appropriate by the majority. If public figures, such as movie stars, sports stars or politicians speak up and advocate for a certain topic, this can change public opinion and spark the conversations necessary. For example, the Prince and Princess of Wales have successfully spearheaded campaigns to destigmatize mental health problems in Britain.¹¹

While it is important, first and foremost, to ensure that making beneficial health choices is available and affordable, it is almost equally important to ensure that taboos and social norms around stigmatized health topics are addressed. Reducing fears of being stigmatized and ostracized is a vital prerequisite for ensuring that people actually access what is available to them and make privately optimal health decisions. Often, it just needs a small spark to break the silence and get the discussion going. So let’s get talking!