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Initiation rites at menarche and self-reported dysmenorrhoea among indigenous women of the Colombian Amazon: a cross-sectional study

Objectives To investigate the association between self-reported dysmenorrhoea and patterns of female initiation rites at menarche among Amazonian indigenous peoples of Vaupés in Colombia. Design A cross-sectional study of all women in seven indigenous communities. Questionnaire administered in local language documented female initiation rites and experience of dysmenorrhoea. Analysis examined 10 initiation components separately, then together, comparing women who underwent all rites, some rites and no rites. Settings Seven indigenous communities belonging to the Tukano language group in the Great Eastern Reservation of Vaupés (Colombia) in 2008. Participants All women over the age of 13 years living in the seven communities in Vaupés, who had experienced at least two menstruations (n=185), aged 13–88 years (mean 32.5; SD 15.6). Primary and secondary outcome measures The analysis rested on pelvic pain to define dysmenorrhoea as the main outcome. Women were also asked about other disorders present during menstruation or the precedent days, and about the interval between two menstruations and duration of each one. Results Only 17.3% (32/185) completed all initiation rites and 52.4% (97/185) reported dysmenorrhoea. Women not completing the rites were more likely to report dysmenorrhoea than those who did so (p=0.01 Fisher exact), taking into account age, education, community, parity and use of family planning. Women who completed less than the full complement of rites had higher risk than those who completed all rites. Those who did not complete all rites reported increased severity of dysmenorrhoea (p=0.00014). Conclusions Our results are compatible with an association between traditional practices and women's health. We could exclude indirect associations with age, education, parity and use of family planning as explanations for the association. The study indicates feasibility, possible utility and limits of intercultural epidemiology in small groups.


Key messages
• Association between abandoning initiation rites and dysmenorrhoea.
• Suggests an effective traditional practice.
• Suggests feasibility and usefulness of intercultural epidemiology.

Strengths and limitations of this study
• No epidemiological studies of indigenous initiation and dysmenorrhoea.
• Even with all eligible women participating the small numbers problem is recognized. to cultural contexts. This cultural adaptation is less common in epidemiology, which is often perceived as unreceptive to alternative epistemologies. [1] Yet inter-cultural epidemiology can be useful to identify potential health benefits of traditional health practices, many of which are being lost as globalization erodes indigenous cultures.
This loss of culture is a concern for Amazon indigenous communities, where every year people have less to do with traditional medical practices. [2] The Tatuyo, Bará, Carapana, Tuyuca y Tukano ethnicities in Tukano language group live between the Papurí and Yapú rivers in the Great Eastern Reservation of Vaupés. [3,4] In collective reservations, the seven communities with very similar customs in a subsistence economy. [5] In the context of a decade long partnership with the traditional health systems group at Universidad del Rosario in Colombia, the indigenous authorities of these communities requested scientific support to study their loss of cultural practices and the effect of this on women's reproductive health, particularly dysmenorrhoea.
Problems related to women's reproductive cycle are increasing worldwide. [6][7][8] Western medicine has few satisfactory solutions to offer women with dysmenorrhoea, offering an interesting case in point as the World Health Organization calls to explore possible contributions of traditional medicine. [9][10][11] A sparse epidemiological literature addresses the links with dysmenorrhoea and cultural influences, [12,13] ethnicity and religiosity. [14,15] Better documented risk factors are diet, exercise, psychological or emotional episodes, and use of alcohol and tobacco. [16][17][18][19][20] We found no epidemiological studies of indigenous initiation rites and dysmenorrhoea.

METHODS
Study population: All women over the age of 13 years living in the seven communities in Vaupés, who had experienced at least two menstruations.
Outcome: Interviewers asked if, during menstruation, women suffered pelvic pain, dizziness, headache, bodily pains, and problems in the days prior to menstruation. They also asked about the interval between menstruation and duration of menstruation. The analysis rested on pelvic pain to define dysmenorrhoea. [21][22][23] Because pain perception is subjective, we used a well established graphic approach showing faces with different grades of discomfort ( Figure 1). [24] Respondents simply pointed to the face that reflected their experience during menstruation. Exposure: Traditional healers described initiation rites at the onset of menarche, lasting three to five days, during which time the young women completed a number of discrete activities: each initiate had a god-mother (madrina); each had a mentor during the initiation; the initiate spent 3-5 days away from others; she received a diet limited to specific foods; she received a blessing or prayer from the traditional healer; she applied powdered carayurú, a vegetable stain (Arrhabidea chica); her hair was cut; her body was painted with we, another vegetable stain (Bignoniaceae sp.); she inhaled ají, a hot spice mix (Capsicum spp.); and water or a plant precipitated emesis. The questionnaire documented exposure to each component rite (yes/no) separately. Without understanding the exact workings of the initiation rites, we followed the WHO guideline to handle the component activities as a "black box" [25]: we do not always have to understand exactly how a traditional therapy works to measure its effect. We also analyzed complete and incomplete initiation using sequential stratification by age of the woman, community of origin (some had more access to Western ways), education, parity, family planning and menopause. We analysed trend using the Mantel extension of the Mantel-Haenszel test. [26] We report results as adjusted odds ratios (ORa) with 95% confidence intervals. The two-tailed Fisher exact test served for estimation of confidence with the resulting sparse numbers comparisons.
Without any prior basis for weighting importance of different activities in the initiation, we calculated the average effect across the ten components as though each was a separate exposure; this relied on Meta, an R program. A Forest plot summarises this ( Figure 2). Compared with occurrence among women who completed all ten rites of initiation, a sensitivity analysis dropped each initiation rite in turn to test relevance of each in initiation. The questionnaire documented type of family planning (none, plants, pill, injection, condom, pessary, surgery, partner-managed contraception), and duration of use of each method, as this could affect dysmenorrhoea; hormonal pills can diminish pain and IUDs can increase pain. Use of Western contraceptive methods also coincides with Western acculturation. We stratified by contraceptive use to separate between the effect of the contraceptive and the initiation rites. To avoid an acculturation bias from interviewing only women who did not go to nearby towns for work, we conducted the study in December when most return to their homes. We took age, menopause and education into account by stratification to limit the differential influence of these on responses. The average age of menarche was 13.8 years (sd 1.16). Some 52% (97/185) reported dysmenorrhoea and 88.6% (164/185) reported undergoing at least some rite of initiation during menarche. Table 1 shows the proportion involved in each of ten activities identified by traditional healers as the initiation rites. Considering each rite separately, only emesis retained a significant association on its own with dysmenorrhea, after taking into account age of the woman, community of origin (some had more access to Western ways), parity, family planning by sequential stratification and adjusting for menopause and education. The   To understand the role of each rite in relation to dysmenorrhoea, a sensitivity analysis compared dysmenorrhoea rates among women who did all ten rites (n=32) with women who participated in less than the ten, dropping each rite in turn. Figure 3 shows the unadjusted odds of dysmenorrhoea for all rites compared with failing to do specific rites, and those who did no rites.
The contrast was more stark between those who did no rituals at all (10/14), and those who completed the ten activities (8/32) (Fisher p 0.01). Those who did some but not all rites were somewhere in-between (89/153) (p-Fisher 0.001).
Most respondents with dysmenorrhoea (92/97) reported severity using the Wong-Baker Faces Pain Rating Scale. Table 2 shows a statistically significant increase across five levels of severity for those who completed all rites compared with those who did any or no rites (p=0.0014), and compared with those who did no rites (p= 0.0039).

DISCUSSION
Our results support the idea that abandoning traditional initiation rites, or adopting practices that go along with abandoning these rites, is a risk factor for dysmenorrhoea. Emesis was the single strongest protective rite on its own, but sensitivity analysis showed a consistent effect of the other rites for those who did not abandon the initiation practices. The apparent lack of specific effects of each component rite supports the idea that synergy between all components completes the protective effect.
This study faced several common challenges in inter-cultural epidemiology. Even with all eligible women participating, the small numbers problem is well recognised [28][29][30][31] and has no easy solution. As anticipated, we found it difficult to untangle issues like use of contraceptives and reporting of age, given the effect of acculturation on these. Despite this interdependence of exposures, we believe we were able to show an independent effect of initiation rites.
Inter-cultural approaches have received little attention in the epidemiological literature, and these need further investment. In this study, the indigenous leaders of the seven communities requested the study and set the research question; they specified the cultural exposures of interest; they participated in the design and testing of instruments; they led the interpretation of results; and they are the primary research users, sharing the results with their communities in support of traditional health practices.
In these important dynamics, the research was culturally safe. Even so, cultural issues probably reduced the effectiveness of the study and reduced the numbers further. The 14.6% (27/185) of women who could not give their age in calendar years is testimony to their distance from Western culture. Analysing only those who mention an age included a cultural filter, limiting our conclusions to those with some measure of Western acculturation.
The average age of menarche of our sample was higher than typically reported in the literature, [32][33][34][35][36][37] possibly indicating a relatively low level of secular change. [38,39] That one half of the women reported dysmenorrhoea (97/185) is lower than reported in international studies. [40][41][42][43][44] Although the local definition (facial expressions) was useful for internal comparisons, it is of limited value in international comparisons.
We tried to take account of other acculturation issues, beyond initiation rites, by stratifying for education, age, parity, community of residence (some had greater access to modern towns) and use of family planning. The lower risk associated with initiation rites might still be due to unmeasured lifestyle issues associated with maintaining initiation rites. Resolving this requires a randomised controlled trial that supports initiation rites in some communities and not in others, measuring decrease in dysmenorrhoea as the outcome.
Since the 1950s, public health programmes have contemplated primary, secondary and tertiary prevention.
[45] More recently, primordial prevention identified social, economic and cultural patterns that affect risks.
[46] Albeit with limitations, our study suggests that primary or primordial prevention of dysmenorrhoea might be possible for indigenous women who are increasingly in contact with Western ways.

CONCLUSIONS
Without adding insight into exact mechanisms, this cross-sectional study shows an association between abandoning initiation rites and dysmenorrhoea. No one of the rites on its own explains this association. The study suggests feasibility and usefulness of inter-

COMPETING INTERESTS
We, the authors, declare that there are no conflicts of interest in this study regarding the Indigenous communities that took part, the recognised rights of the Indigenous Peoples, or the financing institutions.    Sensitivity analysis compared dysmenorrhoea risk among women who did all ten rites (n=32) compared with women who did not do at least one rite, and those who did no rite (listing shows excluded rites) 180x117mm (300 x 300 DPI)

Preámbulo
El presente convenio reconoce y respeta el derecho a la autodeterminación de los pueblos indígenas de la zona de Yapú, en el marco de los cinco derechos fundamentales de los pueblos indígenas reconocidos por la Constitución Política de 1991, la Ley 21 de 1991 de la República de Colombia, aprobatoria del Convenio # 169 de la Organización Internacional del Trabajo, y su naturaleza jurídica de entidad de derecho público de carácter especial, que incluye la potestad para tomar decisiones sobre investigación en sus comunidades. Se considera que los beneficios a las comunidades, a cada región y al esfuerzo nacional se deben fortalecer por medio de la investigación, culturalmente sensible. La investigación tiene que facilitar la propiedad y el manejo por parte de las comunidades de la información sobre su salud y contribuir con la promoción de estilos de vida saludables, prácticas y planeación efectiva de programas, en el marco de sus Planes de Vida.

Propósito
El presente convenio define los términos para compartir información entre Asatrizy y el GESTS, en relación con los datos recogidos en el Estudio epidemiológico para un programa de intervención en atención primaria de salud para la promoción y prevención de las enfermedades relacionadas con el ciclo reproductivo de las mujeres indígenas en comunidades del Vaupés, (en adelante el Proyecto). El propósito del presente convenio es formalizar un acuerdo entre ASATRIZY y el GESTS, respecto de la ejecución del proyecto de investigación, incluyendo la propiedad y el manejo de todos los datos recogidos como parte del proyecto.

Meta
Realizar un estudio epidemiológico para un programa de intervención en atención primaria de salud para la promoción y prevención de las enfermedades relacionadas con el ciclo reproductivo de las mujeres indígenas en comunidades de Asatrizy, Vaupés.

Objetivos
a. Fortalecer, recuperar y promover los conocimientos tradicionales y la cultura de las comunidades de Asatrizy. b. Adelantar un estudio transversal con la participación de las mujeres pertenecientes a las siete comunidades de Asatrizy. c. Estudiar la prevalencia de problemas de salud relacionados con el ciclo vital de la mujer. d. Estudiar la frecuencia de prácticas tradicionales relacionadas con el cuidado de los ciclos vitales de la mujer. e. Determinar las posibles asociaciones entre enfermedades propias de la mujer y la pérdida de las prácticas tradicionales y culturales de salud. f. Divulgar los resultados del estudio a las mujeres participantes, miembros de las comunidades, líderes, agentes sanitarios y educativos y la Junta Directiva de Asatrizy. g. A partir de los resultados, realizar un programa de intervención en autocuidado y atención primaria en salud para la promoción y prevención de enfermedades relacionadas con el ciclo vital de la mujer. h. A partir de los resultados, incluir un proceso de formación específica en salud tradicional en el proceso de educación propia que adelanta Asatrizy. i. Compartir los resultados del estudio con las entidades de carácter municipal, departamental y nacional que tienen responsabilidad en los programas de salud, educación y desarrollo adelantados en las comunidades de Asastrizy, de manera que los programas tengan mayor sensibilidad cultural.

Principios
a. El proyecto mejorará la capacidad y habilidades de miembros de la comunidad en investigación basada en la comunidad. b. Las comunidades se involucrarán como socios en todos los aspectos de la investigación, desde el diseño hasta la implementación. c. Se guardará el anonimato de los encuestados en todas las etapas y su identidad será protegida cuando los datos sean recogidos y los resultados presentados. d. Asatrizy retiene la propiedad de los datos y será la primera en recibir los resultados. e. Para proteger la identidad de los encuestados, el Gests guardará los datos en nombre de Asatrizy en un lugar seguro. f. Todos los datos serán recogidos y guardados según lo establecido en este convenio. g. Los datos de este proyecto sólo serán utilizados para alcanzar los objetivos y la meta establecida.
• Epidemiology and cultural safety.

Key messages
• There is an association between abandoning initiation rites and dysmenorrhoea.
• The study suggests effectiveness of traditional practice.
• The study proposes the feasibility and usefulness of intercultural epidemiology.

Strengths and limitations of this study
• There are no epidemiological studies of indigenous initiation and dysmenorrhoea.

METHODS
Study population: All women over the age of 13 years living in the seven communities in Vaupés, who had experienced at least two menstruations in their lifetime.
Compared with occurrence among women who completed all ten rites of initiation, a sensitivity analysis dropped each initiation rite in turn to test relevance of each in initiation.

Control of biases:
Involvement of healers and elders in the design guaranteed cultural fit.
The questionnaire inquired for current family planning, and if so, which is the method used (plants, pill, injection, condom, pessary, surgery, partner-managed contraception), and duration of use of each method, as this could affect dysmenorrhoea; hormonal pills can diminish pain and IUDs can increase pain. Use of Western contraceptive methods also coincides with Western acculturation. We stratified by contraceptive use to separate between the effect of the contraceptive and the initiation rites. To avoid an acculturation bias from interviewing only women who did not go to nearby towns for work, we conducted the study in December when most return to their homes. We took age, menopause and education into account by stratification to limit the differential influence of these on responses.  Table 1 shows the proportion involved in each of ten activities identified by traditional healers as the initiation rites. Considering each rite separately, only emesis retained a significant association on its own with dysmenorrhea, after taking into account age of the woman, community of origin (some had more access to Western ways), parity, family planning by sequential stratification and adjusting for menopause and education. The Forest plot ( Figure 2) shows dysmenorrhoea associated with each component rite compared with women who did no rites. The average effect size was OR 1.66 (95%CI 1.35-2.04). To understand the role of each rite in relation to dysmenorrhoea, a sensitivity analysis compared dysmenorrhoea rates among women who did all ten rites (n=32) with women who participated in less than the ten, dropping each rite in turn. Figure 3 shows the unadjusted odds of dysmenorrhoea for all rites compared with failing to do specific rites, and those who did no rites. Those who completed the 10 rites (8/32) contrasted sharply with those who completed some or no rites (89/153) (p-Fisher 0.001).  Table 2 shows a statistically significant increase across five levels of severity for those who completed all rites compared with those who did any or no rites (p=0.0014). It also contrasts those who did no rites with those who completed all rites (p= 0.0039).

DISCUSSION
Our results support the idea that abandoning traditional initiation rites, or adopting practices that go along with abandoning these rites, is a risk factor for dysmenorrhoea. Emesis was the single strongest protective rite on its own, but sensitivity analysis showed a consistent effect of the other rites for those who did not abandon the initiation practices. The apparent lack of specific effects of each component rite supports the idea that synergy between all components completes the protective effect. This study faced several common challenges in inter-cultural epidemiology. Even with all eligible women participating, the small numbers problem is well recognised [28][29][30][31] and has no easy solution. As anticipated, we found it difficult to untangle issues like use of contraceptives and reporting of age, given the effect of acculturation on these. Despite this interdependence of exposures, we believe we were able to show an independent effect of initiation rites.
Inter-cultural approaches have received little attention in the epidemiological literature, and these need further investment. In this study, the indigenous leaders of the seven communities requested the study and set the research question; they specified the cultural exposures of interest; they participated in the design and testing of instruments; they led the interpretation of results; and they are the primary research users, sharing the results with their communities in support of traditional health practices.
In these important dynamics, the research was culturally safe. Even so, cultural issues probably reduced the effectiveness of the study and reduced the numbers further. The 14.6% (27/185) of women who could not give their age in calendar years is testimony to their distance from Western culture. Analysing only those who mention an age included a cultural filter, limiting our conclusions to those with some measure of Western acculturation.
The average age of menarche of our sample was higher than typically reported in the literature, [32][33][34][35][36][37] possibly indicating a relatively low level of secular change. [38,39] That one half of the women reported dysmenorrhoea (97/185) is lower than reported in international studies. [40][41][42][43][44] Although the local definition (facial expressions) was useful for internal comparisons, it is of limited value in international comparisons.
We tried to take account of other acculturation issues, beyond initiation rites, by stratifying for education, age, parity, community of residence (some had greater access to modern towns) and use of family planning. The lower risk associated with initiation rites might still be due to unmeasured lifestyle issues associated with maintaining initiation rites. Resolving this requires a randomised controlled trial that supports initiation rites in some communities and not in others, measuring decrease in dysmenorrhoea as the outcome.

COMPETING INTERESTS
We, the authors, declare that there are no conflicts of interest in this study regarding the Indigenous communities that took part, the recognised rights of the Indigenous Peoples, or the financing institutions.     Women not completing the rites were more likely to report dysmenorrhoea than those who did so (p=0.01 Fisher exact), taking into account age, education, community, parity, and use of family planning. Women who completed less than the full complement of rites had higher risk than those who completed all rites. Those who did not complete all rites reported increased severity of dysmenorrhoea (p=0.00014).

Conclusions:
Our results are compatible with a protective effect of initiation rites. We could exclude indirect associations with age, education, parity and use of family planning as explanations for the association. The study indicates feasibility, possible utility and limits of inter-cultural epidemiology in small groups. • Female initiation rites and dysmenorrhoea.
• Epidemiology and cultural safety.

Key messages
• There is an association between abandoning initiation rites and dysmenorrhoea.
• The study suggests an effectiveness of ity of atraditional practice.
• The study proposes theuggests feasibility and usefulness of an intercultural epidemiology.

Strengths and limitations of this study
• There are nNo epidemiological studies of indigenous initiation and dysmenorrhoea.
• The small numbers problem is recognized, eEven with all eligible women participating the small numbers problem is recognized.  [12,13] ethnicity and religiosity. [14,15] Better documented risk factors are diet, exercise, psychological or emotional episodes, and use of alcohol and tobacco. [16][17][18][19][20] We found no epidemiological studies of indigenous initiation rites and dysmenorrhoea.

Study population: All women over the age of 13 years living in the seven communities in
Vaupés, who had experienced at least two menstruations in their lifetime.
Outcome: Interviewers asked if, during menstruation, women suffered pelvic pain, dizziness, headache, bodily pains, and problems in the days prior to menstruation. They also asked about the interval between menstruation and duration of menstruation. The analysis rested on pelvic pain to define dysmenorrhoea. [21][22][23] Because pain perception is subjective, we used a well-established graphic approach showing faces with different grades of discomfort  Figure 1). [24] Respondents simply pointed to the face that reflected their experience during menstruation.
Exposure: Traditional healers described initiation rites at the onset of menarche, lasting three to five days, during which time the young women completed a number of discrete activities: each initiate had a god-mother (madrina); each had a mentor during the initiation; the initiate spent 3-5 days away from others; she received a diet limited to specific foods; she received a blessing or prayer from the traditional healer; she applied powdered carayurú, a vegetable stain (Arrhabidea chica); her hair was cut; her body was painted with we, another  Without any prior basis for weighting importance of different activities in the initiation, we calculated the average effect across the ten components as though each was a separate exposure; this relied on Meta, an R program. A Forest plot summarises this ( Figure 2).
Compared with occurrence among women who completed all ten rites of initiation, a sensitivity analysis dropped each initiation rite in turn to test relevance of each in initiation.

Control of biases:
Involvement of healers and elders in the design guaranteed cultural fit.
The questionnaire documented inquired for type ofcurrent family planning, and if so, which is the method used (none, plants, pill, injection, condom, pessary, surgery, partner-managed contraception), and duration of use of each method, as this could affect dysmenorrhoea; hormonal pills can diminish pain and IUDs can increase pain. Use of Western contraceptive methods also coincides with Western acculturation. We stratified by contraceptive use to separate between the effect of the contraceptive and the initiation rites. To avoid an acculturation bias from interviewing only women who did not go to nearby towns for work, we conducted the study in December when most return to their homes. We took age, menopause and education into account by stratification to limit the differential influence of these on responses.  Table 1 shows the proportion involved in each of ten activities identified by traditional healers as the initiation rites. Considering each rite separately, only emesis retained a significant association on its own with dysmenorrhea, after taking into account age of the woman, community of origin (some had more access to Western ways), parity, family planning by sequential stratification and adjusting for menopause and education. The Forest plot ( Figure 2) shows dysmenorrhoea associated with each component rite compared with women who did no rites. The average effect size was OR 1.66 (95%CI 1.35-2.04). To understand the role of each rite in relation to dysmenorrhoea, a sensitivity analysis compared dysmenorrhoea rates among women who did all ten rites (n=32) with women who participated in less than the ten, dropping each rite in turn. Figure 3 shows the unadjusted odds of dysmenorrhoea for all rites compared with failing to do specific rites, and those who did no rites. Those who completed the 10 rites (8/32) contrasted sharply with those who  Most respondents with dysmenorrhoea (92/97) reported severity using the Wong-Baker Faces Pain Rating Scale. Table 2 shows a statistically significant increase across five levels of severity for those who completed all rites compared with those who did any or no rites (p=0.0014). It also contrasts those who did no rites with those who completed all rites (p= 0.0039).

DISCUSSION
Our results support the idea that abandoning traditional initiation rites, or adopting practices that go along with abandoning these rites, is a risk factor for dysmenorrhoea. Emesis was the single strongest protective rite on its own, but sensitivity analysis showed a consistent effect of the other rites for those who did not abandon the initiation practices. The apparent lack of Comment [Germán Zu15]: KEM: Table 3  (assuming it is the table below table 2 as there is no label) results were singled out to no rites compared with all rites. This would introduce bias to the result Table 2 and 3. The number of those with severe intensity was only 1. There will be problem with the significance analysis >> Tables have been consolidated. The sparse data do affect the analysis, but the trend is still significant however we set the contrast.  This study faced several common challenges in inter-cultural epidemiology. Even with all eligible women participating, the small numbers problem is well recognised [28][29][30][31] and has no easy solution. As anticipated, we found it difficult to untangle issues like use of contraceptives and reporting of age, given the effect of acculturation on these. Despite this interdependence of exposures, we believe we were able to show an independent effect of initiation rites.

Comment [Germán Zu16]: HGP:
Inter-cultural approaches have received little attention in the epidemiological literature, and these need further investment. In this study, the indigenous leaders of the seven communities requested the study and set the research question; they specified the cultural exposures of interest; they participated in the design and testing of instruments; they led the interpretation of results; and they are the primary research users, sharing the results with their communities in support of traditional health practices.
In these important dynamics, the research was culturally safe. Even so, cultural issues probably reduced the effectiveness of the study and reduced the numbers further. The 14.6% (27/185) of women who could not give their age in calendar years is testimony to their distance from Western culture. Analysing only those who mention an age included a cultural filter, limiting our conclusions to those with some measure of Western acculturation.

COMPETING INTERESTS
We, the authors, declare that there are no conflicts of interest in this study regarding the Indigenous communities that took part, the recognised rights of the Indigenous Peoples, or the financing institutions.

Preámbulo
El presente convenio reconoce y respeta el derecho a la autodeterminación de los pueblos indígenas de la zona de Yapú, en el marco de los cinco derechos fundamentales de los pueblos indígenas reconocidos por la Constitución Política de 1991, la Ley 21 de 1991 de la República de Colombia, aprobatoria del Convenio # 169 de la Organización Internacional del Trabajo, y su naturaleza jurídica de entidad de derecho público de carácter especial, que incluye la potestad para tomar decisiones sobre investigación en sus comunidades. Se considera que los beneficios a las comunidades, a cada región y al esfuerzo nacional se deben fortalecer por medio de la investigación, culturalmente sensible. La investigación tiene que facilitar la propiedad y el manejo por parte de las comunidades de la información sobre su salud y contribuir con la promoción de estilos de vida saludables, prácticas y planeación efectiva de programas, en el marco de sus Planes de Vida.

Propósito
El presente convenio define los términos para compartir información entre Asatrizy y el GESTS, en relación con los datos recogidos en el Estudio epidemiológico para un programa de intervención en atención primaria de salud para la promoción y prevención de las enfermedades relacionadas con el ciclo reproductivo de las mujeres indígenas en comunidades del Vaupés, (en adelante el Proyecto). El propósito del presente convenio es formalizar un acuerdo entre ASATRIZY y el GESTS, respecto de la ejecución del proyecto de investigación, incluyendo la propiedad y el manejo de todos los datos recogidos como parte del proyecto.

Meta
Realizar un estudio epidemiológico para un programa de intervención en atención primaria de salud para la promoción y prevención de las enfermedades relacionadas con el ciclo reproductivo de las mujeres indígenas en comunidades de Asatrizy, Vaupés.

Objetivos
a. Fortalecer, recuperar y promover los conocimientos tradicionales y la cultura de las comunidades de Asatrizy. b. Adelantar un estudio transversal con la participación de las mujeres pertenecientes a las siete comunidades de Asatrizy. c. Estudiar la prevalencia de problemas de salud relacionados con el ciclo vital de la mujer. d. Estudiar la frecuencia de prácticas tradicionales relacionadas con el cuidado de los ciclos vitales de la mujer. e. Determinar las posibles asociaciones entre enfermedades propias de la mujer y la pérdida de las prácticas tradicionales y culturales de salud. f. Divulgar los resultados del estudio a las mujeres participantes, miembros de las comunidades, líderes, agentes sanitarios y educativos y la Junta Directiva de Asatrizy. g. A partir de los resultados, realizar un programa de intervención en autocuidado y atención primaria en salud para la promoción y prevención de enfermedades relacionadas con el ciclo vital de la mujer. h. A partir de los resultados, incluir un proceso de formación específica en salud tradicional en el proceso de educación propia que adelanta Asatrizy. i. Compartir los resultados del estudio con las entidades de carácter municipal, departamental y nacional que tienen responsabilidad en los programas de salud, educación y desarrollo adelantados en las comunidades de Asastrizy, de manera que los programas tengan mayor sensibilidad cultural.

Principios
a. El proyecto mejorará la capacidad y habilidades de miembros de la comunidad en investigación basada en la comunidad. b. Las comunidades se involucrarán como socios en todos los aspectos de la investigación, desde el diseño hasta la implementación. c. Se guardará el anonimato de los encuestados en todas las etapas y su identidad será protegida cuando los datos sean recogidos y los resultados presentados. d. Asatrizy retiene la propiedad de los datos y será la primera en recibir los resultados. e. Para proteger la identidad de los encuestados, el Gests guardará los datos en nombre de Asatrizy en un lugar seguro. f. Todos los datos serán recogidos y guardados según lo establecido en este convenio. g. Los datos de este proyecto sólo serán utilizados para alcanzar los objetivos y la meta establecida.

Confidencialidad
Asatrizy y Gests se comprometen a salvaguardar la privacidad y seguridad de toda la información que contenga identificaciones personales y/o comunitarios. Se obtendrá consentimiento informado, culturalmente adecuado, según los requerimientos de la Junta  Women not completing the rites were more likely to report dysmenorrhoea than those who did so (p=0.01 Fisher exact), taking into account age, education, community, parity, and use of family planning. Women who completed less than the full complement of rites had higher risk than those who completed all rites. Those who did not complete all rites reported increased severity of dysmenorrhoea (p=0.00014).

Conclusions:
Our results are compatible with an association between traditional practices and women's health. We could exclude indirect associations with age, education, parity and use of family planning as explanations for the association. The study indicates feasibility, possible utility and limits of inter-cultural epidemiology in small groups.

Article summary
Article focus • Female initiation rites and dysmenorrhoea.
• Epidemiology and cultural safety.

Key messages
• There is an association between what women say about abandoning initiation rites and dysmenorrhoea.
• The study suggests an association between traditional practices and women's health.
• The study proposes the feasibility and usefulness of intercultural epidemiology.

Strengths and limitations of this study
• There are no epidemiological studies of indigenous initiation and dysmenorrhoea.
• The small numbers problem is recognized, even with all eligible women participating.
INTRODUCTIONThe Tatuyo, Bará, Carapana, Tuyuca y Tukano ethnicities in Tukano language group live between the Papurí and Yapú rivers in the Great Eastern Reservation of Vaupés. [1,2] In collective reservations, the seven communities with very similar customs in a subsistence economy. They share traditional rituals around childbirth, management of the umbilicus, rites of sexual début, marriage, pregnancy, menopause and death but, like many traditional cultures, they have abandoned much of this with urbanisation and globalisation of culture. [3] According to traditional wisdom, young women will be healthy if they complete initiation rites and follow traditional practices during menstruation. Young women in the region go to residential schools outside their communities. The school year follows a national standard, making it difficult for schoolgirls to participate in traditional rites. [4] This loss of culture is a concern for Amazon indigenous communities, where every year people have less to do with traditional medical practices. [5] This research began with the express concern of community elders who, in the course of a decade long partnership with the traditional health systems group at Universidad del Rosario in Colombia, asked if loss of their cultural practices could affect women's reproductive health, particularly dysmenorrhoea.
Qualitative research methods, like unstructured conversations, are relatively easily adapted to address cultural issues like this. Cultural adaptation is less common in epidemiology,  [12,13] ethnicity and religiosity. [14,15] Better documented risk factors are diet, exercise, psychological or emotional episodes, and use of alcohol and tobacco. [16][17][18][19][20] We found no epidemiological studies of indigenous initiation rites and dysmenorrhoea. A retrospective survey using a questionnaire evaluated this possible association.

METHODS
Study population: All women over the age of 13 years living in the seven communities in Vaupés, who had experienced at least two menstruations (n=185), aged 13 to 88 years (mean 32,5; SD 15,6).
Outcome: Interviewers asked if, during menstruation, women suffered pelvic pain, dizziness, headache, bodily pains, and problems in the days prior to menstruation. They also asked about the interval between menstruation and duration of menstruation. The analysis rested on pelvic pain to define dysmenorrhoea. [21][22][23] The interviewer asked directly about pain and its severity, without asking about duration of pain, proportion of menstruations affected or activities that could not be completed due to the pain. Because pain perception is subjective, we used a well-established graphic approach showing faces with different grades of discomfort ( Figure 1). [24] Respondents simply pointed to the face that reflected their experience during menstruation.  We also analysed complete and incomplete initiation using sequential stratification by age of the woman, community of origin (some had more access to Western ways), education, parity, family planning and menopause. We analysed trend using the Mantel extension of the Mantel-Haenszel test. [26] We report results as adjusted odds ratios (aOR) with 95% confidence intervals. The two-tailed Fisher exact test served for estimation of confidence with the resulting sparse numbers comparisons.
Without any prior basis for weighting importance of different activities in the initiation, we calculated the average effect across the ten components as though each was a separate exposure; this relied on Meta, an R program. A Forest plot summarises this ( Figure 2).
Compared with occurrence among women who completed all ten rites of initiation, a sensitivity analysis dropped each initiation rite in turn to test relevance of each in initiation.

Control of biases:
Involvement of healers and elders in the design guaranteed cultural fit.
The questionnaire inquired for current family planning, and if so, which is the method used coincides with Western acculturation. We stratified by contraceptive use to separate between the effect of the contraceptive and the initiation rites. To avoid an acculturation bias from interviewing only women who did not go to nearby towns for work, we conducted the study in December when most return to their homes. We took age, menopause and education into account by stratification to limit the differential influence of these on responses.   Table 2 shows the proportion involved in each of ten activities identified by traditional healers as the initiation rites. Considering each rite separately, only emesis retained a significant association on its own with dysmenorrhea, after taking into account age of the woman, community of origin (some had more access to Western ways), parity, family planning by sequential stratification and adjusting for menopause and education. The Forest plot ( Figure 2) shows dysmenorrhoea associated with each component rite compared with women who did no rites. The average effect size was OR 1.66 (95%CI 1.35-2.04). To understand the role of each rite in relation to dysmenorrhoea, a sensitivity analysis compared dysmenorrhoea rates among women who did all ten rites (n=32) with women who participated in less than the ten, dropping each rite in turn. Figure 3 shows the unadjusted odds of dysmenorrhoea for all rites compared with failing to do specific rites, and those who did no rites. Those who completed the 10 rites (8/32) contrasted sharply with those who completed some or no rites (89/153) (p-Fisher 0.001).  Table 4 shows a statistically significant increase across five levels of severity for those who completed all rites compared with those who did any or no rites (p=0.0014). It also contrasts those who did no rites with those who completed all rites (p= 0.0039).

DISCUSSION
Our results support the idea that abandoning traditional initiation rites, or adopting practices that go along with abandoning these rites, is a risk factor for dysmenorrhoea. Emesis was the single strongest protective rite on its own, but sensitivity analysis showed a consistent effect  This study faced several common challenges in inter-cultural epidemiology. Even with all eligible women participating, the small numbers problem is well recognised and has no easy solution. [41,42] As anticipated, we found it difficult to untangle issues like use of contraceptives and reporting of age, given the effect of acculturation on these. Despite this interdependence of exposures, we believe we were able to show an independent effect of initiation rites.
Cultural issues probably reduced the effectiveness of the study and reduced the numbers further. The 14.6% (27/185) of women who could not give their age in calendar years is testimony to their distance from Western culture. Analysing only those who mention an age included a cultural filter, limiting our conclusions to those with some measure of Western acculturation. Recall bias might have affected the results as some women had to remember rites that took place decades earlier; a social desirability bias (not wanting to be culturally different, wanting to avoid disapproval) might also have influenced the results. We have no additional information to clarify the directions of these biases.
Within these constraints and the stringent limits imposed by our population size, we tried to take account of other acculturation issues, beyond initiation rites, by stratifying for education, age, parity, community of residence (some had greater access to modern towns) and use of family planning. The lower risk associated with initiation rites might still be due to unmeasured lifestyle issues associated with maintaining initiation rites. Solving this issue may require a randomised controlled trial where the differential support for the fulfilment of the rite among communities be contrasted with the occurrence of dysmenorrhoea.

Key messages
• There is an association between what women say about abandoning initiation rites and dysmenorrhoea.
• The study suggests an association between effectiveness of traditional practices and women's health.
• The study proposes the feasibility and usefulness of intercultural epidemiology.

Strengths and limitations of this study
• There are no epidemiological studies of indigenous initiation and dysmenorrhoea.
• The small numbers problem is recognized, even with all eligible women participating.  This loss of culture is a concern for Amazon indigenous communities, where every year people have less to do with traditional medical practices. [2] The Tatuyo, Bará, Carapana, Tuyuca y Tukano ethnicities in Tukano language group live between the Papurí and Yapú rivers in the Great Eastern Reservation of Vaupés. [1,2] In collective reservations, the seven communities with very similar customs in a subsistence economy. They share traditional rituals around childbirth, management of the umbilicus, rites of sexual début, marriage, pregnancy, menopause and death but, like many traditional cultures, they have abandoned much of this with urbanisation and globalisation of culture. [3] According to traditional wisdom, young women will be healthy if they complete initiation rites and follow traditional practices during menstruation. Young women in the region go to residential schools outside their communities. The school year follows a national standard, making it difficult for schoolgirls to participate in traditional rites. [4] This loss of culture is a concern for Amazon indigenous communities, where every year people have less to do with traditional medical practices. [5] This research began with the express concern of community elders who, in the course of a decade long partnership with the traditional health systems group at Universidad del Rosario in Colombia, asked if loss of their cultural practices could affect women's reproductive health, particularly dysmenorrhoea.

INTRODUCTION
Qualitative research methods, like unstructured conversations, are relatively easily adapted to address cultural issues like this. Cultural adaptation is less common in epidemiology, which is often perceived as unreceptive to alternative epistemologies. [6] Yet intercultural epidemiology can be useful to identify potential health benefits of traditional health practices, many of which are being lost as globalization erodes indigenous cultures.
Problems related to women's reproductive cycle are increasing worldwide. [7][8][9] Western medicine has few satisfactory solutions to offer women with dysmenorrhoea, offering an interesting case in point as the World Health Organization calls to explore possible contributions of traditional medicine. [10,11] [12,13] ethnicity and religiosity. [14,15] Better documented risk factors are diet, exercise, psychological or emotional episodes, and use of alcohol and tobacco. [16][17][18][19][20] We found no epidemiological studies of indigenous initiation rites and dysmenorrhoea. A retrospective survey using a questionnaire evaluated this possible association.

METHODS
Study population: All women over the age of 13 years living in the seven communities in Vaupés, who had experienced at least two menstruations (n=185), aged 13 to 88 years (mean 32,5; SD 15,6).
Outcome: Interviewers asked if, during menstruation, women suffered pelvic pain, dizziness, headache, bodily pains, and problems in the days prior to menstruation. They also asked about the interval between menstruation and duration of menstruation. The analysis rested on pelvic pain to define dysmenorrhoea. [21][22][23] The interviewer asked directly about pain and its severity, without asking about duration of pain, proportion of menstruations affected or activities that could not be completed due to the pain. Because pain perception is subjective, we used a well-established graphic approach showing faces with different grades of discomfort ( Figure 1). [24] Respondents simply pointed to the face that reflected their experience during menstruation. Exposure: Traditional healers described initiation rites at the onset of menarche, lasting three to five days, during which time the young women completed a number of discrete activities: each initiate had a god-mother (madrina); each had a mentor during the initiation; the initiate spent 3-5 days away from others; she received a diet limited to specific foods; she received a blessing or prayer from the traditional healer; she applied powdered carayurú, a vegetable stain (Arrhabidea chica); her hair was cut; her body was painted with we, another vegetable stain (Bignoniaceae sp.); she inhaled ají, a hot spice mix (Capsicum spp.); and water or a plant precipitated emesis. The questionnaire documented exposure to each component rite (yes/no) separately. Without understanding the exact workings of the initiation rites, we followed the WHO guideline to handle the component activities as a "black box" [25]: we do not always have to understand exactly how a traditional therapy works to measure its effect. We thus documented each of the individual rites.  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  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  We also analysed complete and incomplete initiation using sequential stratification by age of the woman, community of origin (some had more access to Western ways), education, parity, family planning and menopause. We analysed trend using the Mantel extension of the Mantel-Haenszel test. [26] We report results as adjusted odds ratios (aOR) with 95% confidence intervals. The two-tailed Fisher exact test served for estimation of confidence with the resulting sparse numbers comparisons.
Without any prior basis for weighting importance of different activities in the initiation, we calculated the average effect across the ten components as though each was a separate exposure; this relied on Meta, an R program. A Forest plot summarises this ( Figure 2). Compared with occurrence among women who completed all ten rites of initiation, a sensitivity analysis dropped each initiation rite in turn to test relevance of each in initiation.

Control of biases: Involvement of healers and elders in the design guaranteed cultural fit.
The questionnaire inquired for current family planning, and if so, which is the method used (plants, pill, injection, condom, pessary, surgery, partner-managed contraception), and duration of use of each method, as this could affect dysmenorrhoea; hormonal pills can diminish pain and IUDs can increase pain. Use of Western contraceptive methods also coincides with Western acculturation. We stratified by contraceptive use to separate between the effect of the contraceptive and the initiation rites. To avoid an acculturation bias from interviewing only women who did not go to nearby towns for work, we conducted the study in December when most return to their homes. We took age, menopause and education into Comment [GZR dic1213]: ECh: "…The questionnaire was piloted, but were these images piloted too?" >>Done    Table 2 shows the proportion involved in each of ten activities identified by traditional healers as the initiation rites. Considering each rite separately, only emesis retained a significant association on its own with dysmenorrhea, after taking into account age of the woman, community of origin (some had more access to Western ways), parity, family planning by sequential stratification and adjusting for menopause and education. The Forest plot ( Figure 2) shows dysmenorrhoea associated with each component rite compared with women who did no rites. The average effect size was OR 1.66 (95%CI 1.35-2.04). To understand the role of each rite in relation to dysmenorrhoea, a sensitivity analysis compared dysmenorrhoea rates among women who did all ten rites (n=32) with women who participated in less than the ten, dropping each rite in turn. Figure 3 shows the unadjusted odds of dysmenorrhoea for all rites compared with failing to do specific rites, and those who did no rites. Those who completed the 10 rites (8/32) contrasted sharply with those who completed some or no rites (89/153) (p-Fisher 0.001).  Table 4 shows a statistically significant increase across five levels of severity for those who completed all rites compared with those who did any or no rites (p=0.0014). It also contrasts those who did no rites with those who completed all rites (p= 0.0039).

DISCUSSION
Our results support the idea that abandoning traditional initiation rites, or adopting practices that go along with abandoning these rites, is a risk factor for dysmenorrhoea. Emesis was the single strongest protective rite on its own, but sensitivity analysis showed a consistent effect of the other rites for those who did not abandon the initiation practices. The apparent lack of specific effects of each component rite supports the idea that synergy between all components completes the protective effect.
The average age of menarche of our sample was higher than typically reported in the literature, [28][29][30][31][32][33] possibly indicating a relatively low level of secular change. [34,35] That one half of the women reported dysmenorrhoea (97/185) is lower than reported in international studies. [36][37][38][39][40] Although the local definition (facial expressions) was useful for internal  This study faced several common challenges in inter-cultural epidemiology. Even with all eligible women participating, the small numbers problem is well recognised and has no easy solution. [41,42] As anticipated, we found it difficult to untangle issues like use of contraceptives and reporting of age, given the effect of acculturation on these. Despite this interdependence of exposures, we believe we were able to show an independent effect of initiation rites.
Cultural issues probably reduced the effectiveness of the study and reduced the numbers further. The 14.6% (27/185) of women who could not give their age in calendar years is testimony to their distance from Western culture. Analysing only those who mention an age included a cultural filter, limiting our conclusions to those with some measure of Western acculturation. Recall bias might have affected the results as some women had to remember rites that took place decades earlier; a social desirability bias (not wanting to be culturally different, wanting to avoid disapproval) might also have influenced the results. We have no additional information to clarify the directions of these biases.
Within these constraints and the stringent limits imposed by our population size, we tried to take account of other acculturation issues, beyond initiation rites, by stratifying for education, age, parity, community of residence (some had greater access to modern towns) and use of family planning. The lower risk associated with initiation rites might still be due to unmeasured lifestyle issues associated with maintaining initiation rites. Solving this issue may require a randomised controlled trial where the differential support for the fulfilment of the rite among communities be contrasted with the occurrence of dysmenorrhoea.
Since the 1950s, public health programmes have contemplated primary, secondary and tertiary prevention. More recently, primordial prevention identified social, economic and cultural patterns that affect risks. [43] Within its limitations, our study is compatible with the idea that primary or primordial prevention of dysmenorrhoea might be possible for indigenous women who are increasingly in contact with Western ways.

CONCLUSIONS
Without adding insight into exact mechanisms, this cross-sectional study shows an association between abandoning initiation rites and dysmenorrhoea. No one of the rites on its own explains this association.
Inter-cultural approaches have received little attention in the epidemiological literature, and Comment [GZR dic1217]: ECh: "discuss the subgroup analyses with caution, as the numbers are very small and the overall study design is relatively weak" >>Done Comment [ISC18]: ECh: "recall bias (some of the women had to remember rites that took place decades earlier) and social desirability bias…" >>Done Comment [ISC19]: ECh: "presumably it wasn't possible to conduct a prospective study -say why not" >>Done >>We believe it can be a second step in the research process.

Y:
El Grupo de Estudios en Sistemas Tradicionales de Salud de la Facultad de Medicina de la Universidad del Rosario (GESTS) y el Centro de Estudios Médicos Interculturales (CEMI), representados por su director.

Preámbulo
El presente convenio reconoce y respeta el derecho a la autodeterminación de los pueblos indígenas de la zona de Yapú, en el marco de los cinco derechos fundamentales de los pueblos indígenas reconocidos por la Constitución Política de 1991, la Ley 21 de 1991 de la República de Colombia, aprobatoria del Convenio # 169 de la Organización Internacional del Trabajo, y su naturaleza jurídica de entidad de derecho público de carácter especial, que incluye la potestad para tomar decisiones sobre investigación en sus comunidades. Se considera que los beneficios a las comunidades, a cada región y al esfuerzo nacional se deben fortalecer por medio de la investigación, culturalmente sensible. La investigación tiene que facilitar la propiedad y el manejo por parte de las comunidades de la información sobre su salud y contribuir con la promoción de estilos de vida saludables, prácticas y planeación efectiva de programas, en el marco de sus Planes de Vida.

Propósito
El presente convenio define los términos para compartir información entre Asatrizy y el GESTS, en relación con los datos recogidos en el Estudio epidemiológico para un programa de intervención en atención primaria de salud para la promoción y prevención de las enfermedades relacionadas con el ciclo reproductivo de las mujeres indígenas en comunidades del Vaupés, (en adelante el Proyecto). El propósito del presente convenio es formalizar un acuerdo entre ASATRIZY y el GESTS, respecto de la ejecución del proyecto de investigación, incluyendo la propiedad y el manejo de todos los datos recogidos como parte del proyecto.

Meta
Realizar un estudio epidemiológico para un programa de intervención en atención primaria de salud para la promoción y prevención de las enfermedades relacionadas con el ciclo reproductivo de las mujeres indígenas en comunidades de Asatrizy, Vaupés.

Objetivos
a. Fortalecer, recuperar y promover los conocimientos tradicionales y la cultura de las comunidades de Asatrizy. b. Adelantar un estudio transversal con la participación de las mujeres pertenecientes a las siete comunidades de Asatrizy. c. Estudiar la prevalencia de problemas de salud relacionados con el ciclo vital de la mujer. d. Estudiar la frecuencia de prácticas tradicionales relacionadas con el cuidado de los ciclos vitales de la mujer. e. Determinar las posibles asociaciones entre enfermedades propias de la mujer y la pérdida de las prácticas tradicionales y culturales de salud. f. Divulgar los resultados del estudio a las mujeres participantes, miembros de las comunidades, líderes, agentes sanitarios y educativos y la Junta Directiva de Asatrizy. g. A partir de los resultados, realizar un programa de intervención en autocuidado y atención primaria en salud para la promoción y prevención de enfermedades relacionadas con el ciclo vital de la mujer. h. A partir de los resultados, incluir un proceso de formación específica en salud tradicional en el proceso de educación propia que adelanta Asatrizy. i. Compartir los resultados del estudio con las entidades de carácter municipal, departamental y nacional que tienen responsabilidad en los programas de salud, educación y desarrollo adelantados en las comunidades de Asastrizy, de manera que los programas tengan mayor sensibilidad cultural.

Principios
a. El proyecto mejorará la capacidad y habilidades de miembros de la comunidad en investigación basada en la comunidad. b. Las comunidades se involucrarán como socios en todos los aspectos de la investigación, desde el diseño hasta la implementación. c. Se guardará el anonimato de los encuestados en todas las etapas y su identidad será protegida cuando los datos sean recogidos y los resultados presentados. d. Asatrizy retiene la propiedad de los datos y será la primera en recibir los resultados. e. Para proteger la identidad de los encuestados, el Gests guardará los datos en nombre de Asatrizy en un lugar seguro. f. Todos los datos serán recogidos y guardados según lo establecido en este convenio. g. Los datos de este proyecto sólo serán utilizados para alcanzar los objetivos y la meta establecida.

Conclusions:
Our results are compatible with an association between traditional practices and women's health. We could exclude indirect associations with age, education, parity and use of family planning as explanations for the association. The study indicates feasibility, possible utility and limits of inter-cultural epidemiology in small groups. • Female initiation rites and dysmenorrhoea.
• Epidemiology and cultural safety.

Key messages
• There is an association between what women say about abandoning initiation rites and dysmenorrhoea.
• The study suggests an association between traditional practices and women's health.
• The study proposes the feasibility and usefulness of intercultural epidemiology.

Strengths and limitations of this study
• There are no epidemiological studies of indigenous initiation and dysmenorrhoea.
• The small numbers problem is recognized, even with all eligible women participating.

INTRODUCTION
The Tatuyo, Bará, Carapana, Tuyuca y Tukano ethnicities in Tukano language group live between the Papurí and Yapú rivers in the Great Eastern Reservation of Vaupés. [1,2] In collective reservations, the seven communities with very similar customs in a subsistence economy. They share traditional rituals around childbirth, management of the umbilicus, rites of sexual début, marriage, pregnancy, menopause and death but, like many traditional cultures, they have abandoned much of this with urbanisation and globalisation of culture. [3] Initiation rites at the onset of menarche last three to five days, involving a number of discrete activities: each initiate has a god-mother (madrina) and a mentor; she spends 3-5 days in isolation on a strict diet; she receives a blessing or prayer from the traditional healer; she applies powdered carayurú, a vegetable stain (Arrhabidea chica), to her skin; her hair is cut and her body painted with we, another vegetable stain (Bignoniaceae sp.); she inhales ají, a hot spice mix (Capsicum spp.); and undergoes water-or plant-precipitated emesis.
According to traditional wisdom, young women will be healthy if they complete initiation rites and follow traditional practices during menstruation. Young women in the region go to residential schools outside their communities. The school year follows a national standard,  [4] This loss of culture is a concern for Amazon indigenous communities, where every year people have less to do with traditional medical practices. [5] We were unable to confirm a decline or otherwise of initiation rituals from published sources in Colombia. Our research began with the express concern of community elders who, in the course of a decade long partnership with the traditional health systems group at Universidad del Rosario in Colombia, asked if loss of their cultural practices could affect women's reproductive health, particularly dysmenorrhoea.
Cultural adaptation is less common in epidemiology than it is in some qualitative approaches, [6] yet intercultural epidemiology can be useful to identify potential health benefits of traditional health practices, many of which are being lost as globalization erodes indigenous cultures.
Problems related to women's reproductive cycle are increasing worldwide. [7][8][9] Western medicine has few satisfactory solutions to offer women with dysmenorrhoea, offering an interesting case in point as the World Health Organization calls to explore possible contributions of traditional medicine. [10,11] A sparse epidemiological literature addresses the links with dysmenorrhoea and cultural influences, [12,13] ethnicity and religiosity. [14,15] Better documented risk factors are diet, exercise, psychological or emotional episodes, and use of alcohol and tobacco. [16][17][18][19][20] We found no epidemiological studies of indigenous initiation rites and dysmenorrhoea. A retrospective survey using a questionnaire evaluated this possible association.   We also analysed complete and incomplete initiation using sequential stratification by age of the woman, community of origin (some had more access to Western ways), education, parity, family planning and menopause. We analysed trend using the Mantel extension of the Mantel-Haenszel test. [26] We report results as adjusted odds ratios (aOR) with 95% confidence intervals. The two-tailed Fisher exact test served for estimation of confidence with the resulting sparse numbers comparisons.

METHODS
Without any prior basis for weighting importance of different activities in the initiation, we calculated the average effect across the ten components as though each was a separate  Compared with occurrence among women who completed all ten rites of initiation, a sensitivity analysis dropped each initiation rite in turn to test relevance of each in initiation.

Control of biases:
Involvement of healers and elders in the design guaranteed cultural fit.
The questionnaire inquired for current family planning, and if so, which is the method used (plants, pill, injection, condom, pessary, surgery, partner-managed contraception), and duration of use of each method, as this could affect dysmenorrhoea; hormonal pills can diminish pain and IUDs can increase pain. Use of Western contraceptive methods also coincides with Western acculturation. We stratified by contraceptive use to separate between the effect of the contraceptive and the initiation rites. To avoid an acculturation bias from interviewing only women who did not go to nearby towns for work, we conducted the study in December when most return to their homes. We took age, menopause and education into account by stratification to limit the differential influence of these on responses.   Table 2 shows the proportion involved in each of ten activities identified by traditional healers as the initiation rites. Considering each rite separately, only emesis retained a significant association on its own with dysmenorrhoea, after taking into account age of the woman, community of origin (some had more access to Western ways), parity, family planning by sequential stratification and adjusting for menopause and education. The  To test the role of each rite in relation to dysmenorrhoea, a sensitivity analysis compared dysmenorrhoea rates among women who did all ten rites (n=32) with women who participated in less than the ten, dropping each rite in turn. Figure 3 shows the unadjusted odds of dysmenorrhoea for all rites compared with failing to do specific rites, and those who did no rites. Those who completed the 10 rites (8/32) contrasted sharply with those who completed some or no rites (89/153) (p-Fisher 0.001).  Table 4 shows a statistically significant increase across five levels of severity for those who completed all rites compared with those who did any or no rites (p=0.0014). It also contrasts those who did no rites with those who completed all rites (p= 0.0039).

DISCUSSION
Our results show that women who reported having no initiation rite were more likely to report dysmenorrhoea than women who said they had such a rite. Emesis was the single strongest protective rite on its own, but sensitivity analysis showed a consistent effect of the other rites for those who did not abandon the initiation practices. The apparent lack of specific effects of each component rite supports the idea that synergy between all components completes the The average age of menarche of our sample was higher than typically reported in the literature, [28][29][30][31][32][33] possibly indicating a relatively low level of secular change. [34,35] That one half of the women reported dysmenorrhoea (97/185) is lower than reported in international studies. [36][37][38][39][40] Although the local definition (facial expressions) was useful for internal comparisons, it is of limited value in international comparisons.
This study faced several common challenges in inter-cultural epidemiology. Even with all eligible women participating, the small numbers problem is well recognised and has no easy solution. [41,42] As anticipated, we found it difficult to untangle issues like use of contraceptives and reporting of age, given the effect of acculturation on these. Despite this interdependence of exposures, we believe we were able to show an independent effect of initiation rites.
Cultural issues probably reduced the effectiveness of the study and reduced the numbers further. The 14.6% (27/185) of women who could not give their age in calendar years is testimony to their distance from Western culture. Analysing only those who mention an age included a cultural filter, limiting our conclusions to those with some measure of Western acculturation. Recall bias might have affected the results as some women had to remember rites that took place decades earlier; a social desirability bias (not wanting to be culturally different, wanting to avoid disapproval) might also have influenced the results. We have no additional information to clarify the directions of these biases.
Within these constraints and the stringent limits imposed by our population size, we tried to take account of other acculturation issues, beyond initiation rites, by stratifying for education, age, parity, community of residence (some had greater access to modern towns) and use of family planning. The lower risk associated with initiation rites might still be due to unmeasured lifestyle issues associated with maintaining initiation rites. Solving this issue may require a randomised controlled trial where the differential support for the fulfilment of the rite among communities be contrasted with the occurrence of dysmenorrhoea. One problem with prospective studies in this setting is that it would take many years to accumulate the numbers necessary to make the case.
• Epidemiology and cultural safety.

Key messages
• There is an association between what women say about abandoning initiation rites and dysmenorrhoea.
• The study suggests an association between traditional practices and women's health.
• The study proposes the feasibility and usefulness of intercultural epidemiology.

Strengths and limitations of this study
• There are no epidemiological studies of indigenous initiation and dysmenorrhoea.
• The small numbers problem is recognized, even with all eligible women participating.

INTRODUCTION
The Tatuyo, Bará, Carapana, Tuyuca y Tukano ethnicities in Tukano language group live between the Papurí and Yapú rivers in the Great Eastern Reservation of Vaupés. [1,2] In collective reservations, the seven communities with very similar customs in a subsistence economy. They share traditional rituals around childbirth, management of the umbilicus, rites of sexual début, marriage, pregnancy, menopause and death but, like many traditional cultures, they have abandoned much of this with urbanisation and globalisation of culture. [3] Initiation rites at the onset of menarche last three to five days, involving a number of discrete activities: each initiate has a god-mother (madrina) and a mentor; she spends 3-5 days in isolation on a strict diet; she receives a blessing or prayer from the traditional healer; she applies powdered carayurú, a vegetable stain (Arrhabidea chica), to her skin; her hair is cut and her body painted with we, another vegetable stain (Bignoniaceae sp.); she inhales ají, a hot spice mix (Capsicum spp.); and undergoes water-or plant-precipitated emesis.
According to traditional wisdom, young women will be healthy if they complete initiation rites and follow traditional practices during menstruation. Young women in the region go to residential schools outside their communities. The school year follows a national standard,  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  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59 [4] This loss of culture is a concern for Amazon indigenous communities, where every year people have less to do with traditional medical practices. [5] We were unable to confirm a decline or otherwise of initiation rituals from published sources in Colombia. Our research began with the express concern of community elders who, in the course of a decade long partnership with the traditional health systems group at Universidad del Rosario in Colombia, asked if loss of their cultural practices could affect women's reproductive health, particularly dysmenorrhoea.
Cultural adaptation is less common in epidemiology than it is in some qualitative approaches, [6] yet intercultural epidemiology can be useful to identify potential health benefits of traditional health practices, many of which are being lost as globalization erodes indigenous cultures.
Problems related to women's reproductive cycle are increasing worldwide. [7][8][9] Western medicine has few satisfactory solutions to offer women with dysmenorrhoea, offering an interesting case in point as the World Health Organization calls to explore possible contributions of traditional medicine. [10,11] A sparse epidemiological literature addresses the links with dysmenorrhoea and cultural influences, [12,13] ethnicity and religiosity. [14,15] Better documented risk factors are diet, exercise, psychological or emotional episodes, and use of alcohol and tobacco. [16][17][18][19][20] We found no epidemiological studies of indigenous initiation rites and dysmenorrhoea. A retrospective survey using a questionnaire evaluated this possible association.

METHODS
Study population: All women over the age of 13 years living in the seven communities in Vaupés, who had experienced at least two menstruations (n=185), aged 13 to 88 years (mean 32,5; SD 15,6).

Control of biases:
Involvement of healers and elders in the design guaranteed cultural fit.
The questionnaire inquired for current family planning, and if so, which is the method used (plants, pill, injection, condom, pessary, surgery, partner-managed contraception), and duration of use of each method, as this could affect dysmenorrhoea; hormonal pills can diminish pain and IUDs can increase pain. Use of Western contraceptive methods also coincides with Western acculturation. We stratified by contraceptive use to separate between the effect of the contraceptive and the initiation rites. To avoid an acculturation bias from interviewing only women who did not go to nearby towns for work, we conducted the study in December when most return to their homes. We took age, menopause and education into account by stratification to limit the differential influence of these on responses.   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  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59 Table 2 shows the proportion involved in each of ten activities identified by traditional healers as the initiation rites. Considering each rite separately, only emesis retained a significant association on its own with dysmenorrhoea, after taking into account age of the woman, community of origin (some had more access to Western ways), parity, family planning by sequential stratification and adjusting for menopause and education. The Forest plot (Figure 2) shows dysmenorrhoea associated with each component rite compared with women who did no rites. The average effect size was OR 1.66 (95%CI 1.35-2.04). To test the role of each rite in relation to dysmenorrhoea, a sensitivity analysis compared dysmenorrhoea rates among women who did all ten rites (n=32) with women who participated in less than the ten, dropping each rite in turn. Figure 3 shows the unadjusted odds of dysmenorrhoea for all rites compared with failing to do specific rites, and those who did no rites. Those who completed the 10 rites (8/32) contrasted sharply with those who completed some or no rites (89/153) (p-Fisher 0.001).  Table 4 shows a statistically significant increase across five levels of severity for those who completed all rites compared with those who did any or no rites (p=0.0014). It also contrasts those who did no rites with those who completed all rites (p= 0.0039).

DISCUSSION
Our results show that women who reported having no initiation rite were more likely to report dysmenorrhoea than women who said they had such a rite.Our results support the idea that abandoning traditional initiation rites, or adopting practices that go along with abandoning these rites, is a risk factor for dysmenorrhoea. Emesis was the single strongest protective rite on its own, but sensitivity analysis showed a consistent effect of the other rites for those who
This study faced several common challenges in inter-cultural epidemiology. Even with all eligible women participating, the small numbers problem is well recognised and has no easy solution. [41,42] As anticipated, we found it difficult to untangle issues like use of contraceptives and reporting of age, given the effect of acculturation on these. Despite this interdependence of exposures, we believe we were able to show an independent effect of initiation rites.
Cultural issues probably reduced the effectiveness of the study and reduced the numbers further. The 14.6% (27/185) of women who could not give their age in calendar years is testimony to their distance from Western culture. Analysing only those who mention an age included a cultural filter, limiting our conclusions to those with some measure of Western acculturation. Recall bias might have affected the results as some women had to remember rites that took place decades earlier; a social desirability bias (not wanting to be culturally different, wanting to avoid disapproval) might also have influenced the results. We have no additional information to clarify the directions of these biases.
Within these constraints and the stringent limits imposed by our population size, we tried to take account of other acculturation issues, beyond initiation rites, by stratifying for education, age, parity, community of residence (some had greater access to modern towns) and use of family planning. The lower risk associated with initiation rites might still be due to unmeasured lifestyle issues associated with maintaining initiation rites. Solving this issue may require a randomised controlled trial where the differential support for the fulfilment of the rite among communities be contrasted with the occurrence of dysmenorrhoea. One problem with prospective studies in this setting is that it would take many years to accumulate the numbers necessary to make the case.

COMPETING INTERESTS
We, the authors, declare that there are no conflicts of interest in this study regarding the Indigenous communities that took part, the recognised rights of the Indigenous Peoples, or the financing institutions.   Sensitivity analysis compared dysmenorrhoea risk among women who did all ten rites (n=32) compared with women who did not do at least one rite, and those who did no rite (listing shows excluded rites) 180x117mm (300 x 300 DPI) (e) Describe any sensitivity analyses Para 3 of Results ( Figure 3 and Table 3) (p8)

Results
Participants 13* (a) Report numbers of individuals at each stage of study-eg numbers potentially eligible, examined for eligibility, confirmed eligible, included in the study, completing follow-up, and analysed Other analyses 17 Report other analyses done-eg analyses of subgroups and interactions, and sensitivity analyses Table 3 and 4 and Figure 2 Discussion Key results 18 Summarise key results with reference to study objectives Paras 2, 4, 5 of Results (p6 and p7), para 5 of Discussion (p10)