The hidden burden: Understanding the causal link between menstrual health and hygiene and mental health outcomes in Nepal.

Inadequate menstrual health and hygiene (MHH) has significant implications for women's well-being, potentially affecting health, education, and economic productivity, particularly in low- and middle-income countries. While the link between unmet basic needs and mental health is recognized, the causal impact of MHH on mental health remains largely unexplored due to endogeneity concerns. This study addresses this critical gap by investigating the causal effect of improved MHH practices on the likelihood of experiencing anxiety and depression among women aged 15-49 in Nepal. Nepal presents a relevant context due to both prevalent MHH challenges and significant mental health burdens. In our sample, the prevalence of moderate-to-severe anxiety is 9.45 % and depression is 5.45 %. To address endogeneity concerns, I employ an instrumental variable approach, leveraging women's perceived barrier of distance to the nearest health facility as an exogenous source of variation in MHH access. Using data from 6480 women from the 2022 Nepal Demographic Health Survey, I find that women with better MHH practices experience substantial reductions in the likelihood of adverse mental health outcomes. Specifically, improved MHH practices lead to an 17.4 percentage point (pp) reduction in the likelihood of experiencing anxiety and a 10.8 pp reduction in the likelihood of experiencing depression. These findings highlight the substantial mental health burden associated with inadequate MHH, suggesting that investments in MHH could yield significant improvements in mental well-being. These results provide strong empirical support for policies promoting comprehensive MHH programs, including expanded access to period products, private sanitation facilities, and educational initiatives.