Resilience Among Nepali Widows After the Death of a Spouse: "That Was My Past and Now I Have to See My Present".

Responses to the death of a spouse vary; although some are at increased risk of poorer physical and mental health outcomes, others have more resilient responses. In light of the limited scope of research on widows' experiences in Nepal, a setting where widows are often marginalized, we explore themes of resilience in Nepali widows' lives. Drawing from a larger qualitative study of grief and widowhood, a thematic narrative analysis was performed on narratives from four widows that reflected resilient outcomes. Individual assets and social resources contributed to these widows' resilient outcomes. Forgetting, acceptance, and moving forward were complemented by confidence and strength. Social support and social participation were key to widows' resilient outcomes. These four narratives reflect the sociocultural context that shape widows' resilient outcomes in Nepal. Future studies on the emergent themes from this exploratory study will help identify how best to encourage resilient outcomes among widows.

Persistent Complex Bereavement Disorder and Culture: Early and Prolonged Grief in Nepali Widows.

OBJECTIVE: Persistent complex bereavement disorder (PCBD) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), has not been well studied in socioculturally diverse populations. Thus, this qualitative study examined (a) how widows in Nepal understand grief, (b) whether a local construct of PCBD exists, and (c) its comparability with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), terminology. METHODS: Using an adapted Explanatory Model Interview Catalogue (EMIC) framework, semistructured interviews with 25 widows and 12 key informants, as well as three focus-group discussions (n = 20), were conducted between October 2014 and April 2015. Through an inductive grounded theory-based approach, we used the constant comparative method, iteratively coding transcripts to identify themes and patterns in the data. Also, we created two lists of grief responses, one of early reactions and another all reactions to grief, based on the frequency of mention. RESULTS: No single term for grief was reported. Widows reported a local construct of PCBD, which was broadly compatible with DSM-5 terminology but with important variation reflecting societal influence. Surviving torture during conflict, economic and family stressors, and discrimination were mentioned as important determinants that prolong and complicate grief. Suicidal ideation was common, with about 31% and 62% of widows reporting past-year and lifetime suicidality, respectively. Findings may not be generalizable to all Nepali widows; participants were recruited from a non-governmental organization, from Kathmandu and its neighboring districts, and were primarily of reproductive age. CONCLUSIONS: While PCBD symptoms proposed in DSM-5 were mentioned as relevant by study participants, some components may need adaptation for use in non-Western settings, such as Nepal.

Social isolation and health in widowhood: A qualitative study of Nepali widows' experiences.

Little research exists on social isolation and health among widows despite their marginalization in South Asia. Using a conceptual framework that delineates distinct forms of social support, our results provide a preliminary analysis of the role social support plays in the well-being of Nepali widows. Between 2011 and 2012, we conducted 42 in-depth interviews in the Kathmandu valley and Surkhet district. Low social support was a common theme, principally lacking in the domains of emotional and instrumental support and was described as increasing women's vulnerability to mistreatment and economic insecurity. Policies and programs that foster these types of support may have positive effects on widows' well-being.

Violence Against Widows in Nepal: Experiences, Coping Behaviors, and Barriers in Seeking Help.

Widows are a vulnerable population in Nepal. This study examined Nepalese widows' experiences of violence, their coping strategies, and barriers faced in seeking help. Study participants were recruited from Women for Human Rights, an NGO in Nepal. A stratified purposive sampling approach was used to select 51 widows and 5 staff members for in-depth interviews. Twenty-seven women who experienced violence were included in this analysis. Data were analyzed and synthesized using a thematic analysis procedure. Widows reported a range of violent experiences perpetrated by family and community members that spanned psychological, physical, and sexual abuse. Women dealt with abusive experiences using both adaptive (e.g., attempting to move ahead, seeking social support, using verbal confrontation) and maladaptive coping strategies (e.g., suicidal thoughts or self-medication). However, they faced barriers to seeking help such as insensitivity of the police, perceived discrimination, and general lack of awareness of widows' problems and needs. Findings highlight the need for interventions across the individual, family, community, and policy levels. Avenues for intervention include creating awareness about widows' issues and addressing cultural beliefs affecting widows' lives. Furthermore, efforts should focus on empowering widows, promoting healthy coping, and addressing their individual needs.

Non-disclosure of widowhood in Nepal: implications for women and their children.

Non-disclosure of significant or emotionally charged information can have psychological and physical health consequences. Widowhood in Nepal is highly stigmatised and therefore is a sensitive topic. This study sought to understand why and to whom women do not disclose their status as widows. Thematic content analysis of 31 in-depth interviews and 6 focus groups was conducted with primarily high-caste widows of reproductive age from the Kathmandu Valley, Surkhet, Chitwan and Kavre districts of Nepal. A codebook was developed based upon recurring concepts and applied to all transcripts using Atlas.ti. Due to discomfort or stigmatisation, many women concealed their status as widows in the community through behaviours impacting their daily lives. Non-disclosure to children was frequently described, often as a way to protect them from psychological sequelae. Concealment of widowhood is a coping strategy Nepali women use to shield themselves against societal stigma and to manage bereavement in their children. Efforts are needed to support widows in dealing with mental health issues related to disclosure and the psychosocial impact on their children.

Barriers to sexual and reproductive health care among widows in Nepal.

OBJECTIVE: To investigate how the social status of high-caste Nepali widows of reproductive age impacts their sexual and reproductive health care. METHODS: Twenty-one in-depth interviews and 1 focus group (n=6) were conducted between September and November 2012 in the Kathmandu, Kavre, and Chitwan districts of Nepal. Participants were members of Women for Human Rights, Single Women Group. Interviews and the focus group with widows followed a semi-structured interview guide designed to elicit information on sexual and reproductive health problems, knowledge about them, and barriers to care. Two researchers used inductive and deductive coding to analyze transcripts for themes using ATLAS.ti. RESULTS: Widows reported facing substantial obstacles to accessing sexual and reproductive health care. Widows suspected of having sexual and reproductive health problems, or who discussed or tried to access these services, could be ostracized by their families and experience severe economic and psychological consequences. Additionally, widows feared discrimination, lack of confidentiality, and sexual harassment by male providers if their status was known. These barriers appeared to stem from the perception that sexual relationships are necessary for widows to require care for gynecologic problems. CONCLUSION: Widows expressed a need for sexual and reproductive health care and described cultural and systematic barriers to accessing this care; these barriers need to be addressed.