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Effect of menstruation on girls and their schooling, and facilitators of menstrual hygiene management in schools: surveys in government schools in three states in India, 2015

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Abstract

Background: Lack of menstrual knowledge, poor access to sanitary products and a non-facilitating school environment can make it difficult for girls to attend school. In India, interventions have been developed to reduce the burden of menstruation for school girls by government and non-governmental organizations (NGOs). We sought to identify challenges related to menstruation, and facilitators of menstrual management in schools in three states in India. Methods: Surveys were conducted among menstruating school girls in class 8-10 (above 12 years of age) of 43 government schools selected through stratified random sampling in three Indian states (Maharashtra, Chhattisgarh, Tamil Nadu) in 2015. For comparison, ten model schools supported by NGOs or UNICEF with a focussed menstrual hygiene education program were selected purposely in the same states to represent the better-case scenario. We examined awareness about menarche, items used for menstruation, and facilitators on girls' experience of menstruation in regular schools and compared with model schools. Factors associated with school absence during menstruation were explored using multivariate analysis. Findings: More girls (mean age 14.1 years) were informed about menstruation before menarche in model schools (56%, n = 492) than in regular schools (36%, n = 2072, P < 0.001). Girls reported menstruation affected school attendance (6% vs 11% in model vs regular schools respectively, P = 0.003) and concentration (40% vs 45%, P = 0.1) and was associated with pain (31% vs 38%, P = 0.004) and fear of stain or smell (11% vs 16%, P = 0.002). About 45% of girls reported using disposable pads in both model and regular schools, but only 55% and 29% of pad-users reported good disposal facilities, respectively (P < 0.001). In multivariate analysis, reported absenteeism during menstruation was significantly lower in Tamil Nadu (adjusted prevalence ratio (APR) 95% confidence interval (CI) = 0.24, 0.14-0.40) and Maharashtra (APR 0.56, CI = 0.40-0.77) compared to Chhattisgarh, and halved in model compared to regular schools (APR 0.50, CI = 0.34-0.73). Pain medication in school (APR 0.71, CI = 0.51-0.97) and use of disposable pads (APR 0.57, CI = 0.42-0.77) were associated with lower absenteeism and inadequate sanitary facilities with higher absenteeism during menstruation. Conclusions: Menstrual hygiene education, accessible sanitary products, pain relief, and adequate sanitary facilities at school would improve the schooling-experience of adolescent girls in India.
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Muthusamy Sivakami1, Anna
Maria van Eijk2, Harshad
Thakur1, Narendra Kakade1,
Chetan Patil1, Sharayu Shin-
de1, Nikita Surani1, Ashley
Bauman2, Garazi Zulaika2,
Yusuf Kabir3, Arun Dobhal3,
Prathiba Singh3, Bharathy Ta-
hiliani3, Linda Mason2, Kelly
T Alexander2, Mamita Bora
Thakkar3, Kayla F Laserson4,
Penelope A Phillips-Howard2
1
School of Health Systems Studies, Tata
Institute of Social Sciences, Mumbai,
India
2 Department of Clinical Sciences,
Liverpool School of Tropical Medicine
(LSTM), Liverpool, UK
3 Water Sanitation and Hygiene Section,
United Nations Children’s Fund, India
4 Centers for Disease Control and
Prevention (CDC) India, Atlanta,
Georgia, USA
Correspondence to:
M. Sivakami
Professor and Chairperson
Centre for Health and Social Sciences
School of Health Systems Studies
Tata Institute of Social Sciences
V N Purav Marg, Deonar
Mumbai-400088
India
sivakami@tiss.edu
Effect of menstruation on girls and their
schooling, and facilitators of menstrual hygiene
management in schools: surveys in government
schools in three states in India, 2015
Background Lack of menstrual knowledge, poor access to sanitary prod-
ucts and a non-facilitating school environment can make it difcult for girls
to attend school. In India, interventions have been developed to reduce
the burden of menstruation for school girls by government and non-gov-
ernmental organizations (NGOs). We sought to identify challenges related
to menstruation, and facilitators of menstrual management in schools in
three states in India.
Methods Surveys were conducted among menstruating school girls in class
8-10 (above 12 years of age) of 43 government schools selected through
stratied random sampling in three Indian states (Maharashtra, Chhattis-
garh, Tamil Nadu) in 2015. For comparison, ten model schools supported
by NGOs or UNICEF with a focussed menstrual hygiene education pro-
gram were selected purposely in the same states to represent the better-case
scenario. We examined awareness about menarche, items used for men-
struation, and facilitators on girls’ experience of menstruation in regular
schools and compared with model schools. Factors associated with school
absence during menstruation were explored using multivariate analysis.
Findings More girls (mean age 14.1 years) were informed about menstru-
ation before menarche in model schools (56%, n = 492) than in regular
schools (36%, n = 2072, P < 0.001). Girls reported menstruation affected
school attendance (6% vs 11% in model vs regular schools respective-
ly, P = 0.003) and concentration (40% vs 45%, P = 0.1) and was associat-
ed with pain (31% vs 38%, P = 0.004) and fear of stain or smell (11% vs
16%, P = 0.002). About 45% of girls reported using disposable pads in both
model and regular schools, but only 55% and 29% of pad-users reported
good disposal facilities, respectively (P < 0.001). In multivariate analysis,
reported absenteeism during menstruation was signicantly lower in Tamil
Nadu (adjusted prevalence ratio (APR) 95% condence interval (CI) = 0.24,
0.14-0.40) and Maharashtra (APR 0.56, CI = 0.40-0.77) compared to Ch-
hattisgarh, and halved in model compared to regular schools (APR 0.50,
CI = 0.34-0.73). Pain medication in school (APR 0.71, CI = 0.51-0.97) and
use of disposable pads (APR 0.57, CI = 0.42-0.77) were associated with
lower absenteeism and inadequate sanitary facilities with higher absentee-
ism during menstruation.
Conclusions Menstrual hygiene education, accessible sanitary products,
pain relief, and adequate sanitary facilities at school would improve the
schooling-experience of adolescent girls in India.
Electronic supplementary material:
The online version of this article contains supplementary material.
journal of
health
global
Sivakami et al.
June 2019 • Vol. 9 No. 1 • 010408 2 www.jogh.orgdoi: 10.7189/jogh.09.010408
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To achieve gender equality, it is important that girls can attend and reach their full potential in schools [1].
Inadequate options for menstrual hygiene recently received attention as a barrier to education for girls in
low and middle income countries [2]. Studies have noted poor sanitation in schools and lack of access to
good quality sanitary products can be associated with lower enrolment in schools, absenteeism, and drop-
out [3-6]. Inadequate menstrual hygiene can potentially have health consequences such as increased risk
of reproductive and urinary tract infections [5,7-11]. The problem of menstrual hygiene is multifaceted;
girls need to be aware about menarche and be able to manage their menstruation in an enabling envi-
ronment with access to hygienic menstrual materials and facilities for changing and disposal of menstru-
al items at home and school [3,12]. National and international concerns about menstrual hygiene have
been spearheaded through water, sanitation, and hygiene (WASH) programs in schools and policy and
programming frameworks to improve knowledge and infrastructure to manage menstrual hygiene [13].
According to 2011 census estimates (the latest available census data), 10% of India’s population were fe-
male adolescents aged 10-19 years, which translates into approximately 120 million girls [14]. Although
menstruation is celebrated in many parts of India, cultural taboos exist which regularly limit girls from
activities during menstruation, including religious restrictions, and freedom to leave the house [3,15].
This contributes to negative attitudes toward menstruation among women, placing a considerable phys-
ical and psychological burden on young girls [3]. A systematic review of Indian studies estimated that
barely half (48%) of adolescent girls in India were aware of menarche before their rst menstruation, and
had inadequate knowledge when attaining menarche. It also documented that the paucity of safe and hy-
gienic disposal systems for menstrual items was worrisome [3].
The government of India has recognized the importance of menstrual hygiene to the health, well-being
and educational achievements of girls and women, and has developed several programs to improve men-
strual hygiene management (MHM) in schools, targeted at improving knowledge, access and disposal of
menstrual waste, and improving sanitation in schools, with support from a number of organisations [16].
Some examples include the production and marketing of low cost sanitary pads [17], government sub-
sidized sanitary pads in rural areas [18], school vending machines for sanitary pads and pad incinerators
[17], and increasing gender separated toilet facilities [19].
In light of these government initiatives, a study was developed to evaluate progress on menstrual man-
agement in schools in India, and to identify facilitators and barriers to menstrual management in Indian
schools in 2015. This paper presents data on cross-sectional surveys conducted among girls in a repre-
sentative sample of government schools in three states in India, and a comparison with “model” schools
receiving additional/intense WASH support in the same states, which allowed us to assess if model schools
achieved improvements with regards to menstrual management.
METHODS
Study population
The study was carried out in the states Chhattisgarh, Maharashtra, and Tamil Nadu, representing the di-
verse cultural and socio-economic spectrum in India (Table S1 in Online Supplementary Document).
Chhattisgarh is a state from central India with a predominantly Tribal population with 2.7 million adoles-
cent girls. Maharashtra is a more developed state in the western part of India with 9.9 million adolescent
girls. Tamil Nadu is a southern state having one of the highest levels of development with 6.1 million ad-
olescent girls. Tamil Nadu has implemented a free sanitary pad scheme since 2011, making pads free of
cost for girls living in rural areas, those in government schools, and new mothers. Girls can receive three
packs of pads once every two months, in addition to iron tablets, and may receive education about men-
struation from an “aganwadi” (female community health) worker [20]. Similar programs in Maharashtra
and Chhattisgarh are less developed.
A total sample size of 1800 adolescent girls (600 girls per state, about 75 girls per school), would be suf-
cient to measure a state-based prevalence of 50% with 95% condence interval and 5% of margin error,
taking clustering into account and using a design effect of 1.5. Multi-level stratied sampling was used
for each state, by rst randomly selecting one district in each of the three states. In each of the select-
ed districts, one block was then randomly selected, and then in each of the selected blocks, a list of all
schools was prepared in collaboration with the state government education department in the respective
districts. In each of these, schools were then randomly selected from all government middle and high
Menstrual hygiene management in schools in India
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schools (regular) after excluding boys’ only schools, solely residential, and private schools (Figure S1 in
Online Supplementary Document). Adolescent girls above 12 years of age in class (called grade in In-
dia) 8-10 (comparable to school year 8-10 in the United States) were selected to maximise the likelihood
they had reached menarche and could provide information on menstrual management and water sani-
tation and hygiene. One class was randomly selected if there was more than one class in grades 8-10. In
Tamil Nadu, more schools were included than in the other states because girls were younger and fewer
girls had reached menarche compared to the other states. In addition to regular schools, schools that re-
ceived support on menstrual hygiene from external sources (“better practice” or model schools) to rep-
resent the best case scenario in MHM were purposively chosen with the help of the UNICEF team in the
respective state to assess if this resulted in signicantly better menstrual management practices. In the
model schools, external experts (from UNICEF or other NGOs) regularly provided information sessions
on puberty, menstrual hygiene and on how to use menstrual pads.
Schools were visited, and meetings were held with the head teachers. Parental consent forms were then
distributed by study staff with the help of school staff. Meetings with target girls who had parental con-
sent were conducted to discuss the study and respond to questions before girls assented. Pre-tested struc-
tured self-administered questionnaires in the local languages of each state were used to elicit information
on the sanitation status of the school, knowledge about menstruation, pre-menarche, menstrual practices
and beliefs, and the effect of menstruation on school life. The data collection was carried out from June
to December 2015. Three senior research ofcers supervised the eld data collection team who received
intensive one-week training before the start of the study.
Analysis
For this analysis, only girls who reported they had started menstruating were included. We tabulated
results for model and regular schools by state for the following themes: awareness about menarche and
source of information, menstruation-related restrictions, menstrual absorbents, effect of menstruation on
the school experience, and barriers and facilitators of menstrual management at the school level. Missing
data was included as a separate category of the variables of interest. Signicant differences were explored
at the state level and model vs regular schools overall and within states (χ2 test). To assess factors associ-
ated with school absence during menstruation, we used generalized linear regression with a log link and
binomial distribution for multivariate analyses. Poisson regression with a robust variance estimator was
used for models which did not converge (Stata v14.2, StataCorp LLC, College Station, USA). The follow-
ing factors were explored in univariate analysis: age, state, model vs regular school, menstrual item used,
education or program on menstrual hygiene in school and factors related to sanitary situation in school.
Factors with a P-value <0.1 in the univariate model and model vs regular schools as a focus of interest
were included in the multivariate model, whereby factors with a P-value >0.05 were removed from the
multivariate model using backward elimination. Univariate and multivariate models were adjusted for
clustering at the school level, and interactions between signicant variables were examined.
Ethical considerations
The study was approved by the Tata Institute of Social Sciences, Mumbai, and the Liverpool School of
Tropical Medicine, UK, after fullling all the ethical requirements. Participant information sheets, describ-
ing the study and the activities involved for study participants were prepared. Written informed consent
from the parents and assent from the girls was obtained before the study, in compliance with national
and international ethical committee requirements. The survey questionnaire had ID numbers and had no
names on it. Consent forms and questionnaires were translated into local languages of the states involved.
RESULTS
Characteristics of schools and participating girls
Of the 3617 girls who participated, 2564 (70.9%) reported they had begun menstruating and were in-
cluded in this analysis. These menstruating girls attended 43 randomly selected regular schools (N = 2072)
and 10 model schools (N = 492) in the 3 states (Table 1). Over half of schools were co-educational (58%),
a third (31%) were girls’ only, and the remaining had some girls and some mixed classes. Girls’ average
age was 14.1 years (standard deviation (SD) = 1.1), with girls from Tamil Nadu slightly younger than oth-
er states, and girls in model schools slightly older (14.2 vs. 14.0 years, P < 0.01). Most girls were in grade
Sivakami et al.
June 2019 • Vol. 9 No. 1 • 010408 4 www.jogh.orgdoi: 10.7189/jogh.09.010408
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10 (51%), while 35% were in grade 9, and 13% in grade 8. Participating girls were mostly Hindu (93%),
with 3% Muslims, and 2% other religions.
Girls’ awareness and knowledge about menstruation
Nearly all (93%) menstruating girls had received some information about menstruation (Table 2). Par-
ents or guardians were the major source (68%), with friends the next most reported source. There were
striking differences by state and type of school; approximately 1 in 10 girls said teachers were a common
source, the highest proportion were in model schools in Tamil Nadu (51%), and lowest in regular schools
in Maharashtra (3%). Half (48%) of girls did not hear about menstruation until their rst period began;
the proportion of girls who were informed before menarche was signicantly higher in model schools
compared to regular schools (56% vs 36%, P < 0.001).
Cultural taboos and restrictions during menstruation
Religious restrictions (not going to temple, etc.) were common, affecting 88% of girls overall, and nearly
all (91%) girls in regular schools (Figure 1, and Table S2 in Online Supplementary Document); girls
reported less restrictions in the model schools in Maharashtra (64%) and Tamil Nadu (76%) compared
to the regular schools (94% and 93%, respectively, P < 0.001). Restrictions during exercise were prevalent
(83% overall); again this was signicantly lower in model schools in Maharashtra (89% vs 50%, P < 0.001)
and Tamil Nadu (92% vs 69%, P < 0.001) but not in Chhattisgarh (78% vs 84%, P = 0.205). Other re-
ported restrictions due to cultural traditions were less common (Figure 1); thus one in ve reported dif-
Table 1. Characteristics of participating schools and girls by state and school type, India 2015
Maharashtra Chhattisgarh taMil Nadu all 3 states
Regular
school,
n (%)
Model
school,
n (%)
Regular
school,
n (%)
Model
school,
n (%)
Regular
school,
n (%)
Model
school,
n (%)
Total,
n (%)
Characteristics of schools:
Number of schools 12 412 419 253
Type of school:
-Co-education 10 310 018 041
-Girls only 2 1 2 4 1 2 12
Participants:
-Not menstruating 169 (19.9) 119 (40.6) 143 (16.9) 56 (18.9) 480 (40.1) 50 (37.6) 1017 (28.1)
-Menstruating 664 (78.2) 173 (59.0) 691 (81.5) 236 (79.7) 717 (59.9) 83 (62.4) 2564 (70.9)
-No answer 16 (1.9) 1 (0.3) 14 (1.7) 4 (1.4) 1 (0.1) 036 (1.0)
Median number of menstruating
participants per school, range 48, 16-109 45, 22-61 50, 14-149 58, 8-112 24, 15-113 42, 24-59 45, 8-149
Characteristics of school girls (only menstruating girls included):
Total number of participants 664 173 691 236 717 83 2564
Average age of participant (SD)* 14.4 (1.0)
n = 645
14.2 (0.9)
n = 169
14.3 (1.0)
n = 685
14.4 (1.1)
n = 236
13.5 (0.9)
n = 715
13.6 (0.8)
n = 83
14.1 (1.1)
n = 2533
Grades of participants:†
-8 97 (14.6) 31 (17.9) 66 (9.6) 27 (11.4) 104 (14.5) 9 (10.8) 334 (13.0)
-9 230 (34.6) 65 (37.6) 225 (32.6) 92 (39.0) 246 (34.3) 26 (31.3) 884 (34.5)
-10 327 (49.3) 73 (42.2) 389 (56.3) 113 (47.9) 366 (51.1) 48 (57.8) 1316 (51.3)
-Missing 10 (1.5) 4 (2.3) 11 (1.6) 4 (1.7) 1 (0.1) 0 (0.0) 30 (1.2)
Religion:‡
-Hindu 619 (93.2) 128 (74.0) 686 (99.3) 232 (98.3) 641 (89.4) 79 (95.2) 2385 (93.0)
-Muslim 33 (5.0) 11 (6.4) 1 (0.1) 4 (1.7) 31 (4.3) 0 (0.0) 80 (3.1)
-Other§ 12 (1.8) 33 (19.1) 0 (0.0) 0 (0.0) 44 (6.1) 4 (4.8) 93 (3.6)
- No answer 0 (0.0) 1 (0.6) 4 (0.6) 0 (0.0) 1 (0.1) 0 (0.0) 6 (0.2)
SD – standard deviation
*P < 0.01 for comparison by state (Tamil Nadu vs schools in the other states) and model schools (mean 14.2, SD = 1.1) vs regular schools (mean 14.0,
SD = 1.0, P = 0.005, t test).
P < 0.05 comparing schools in Chhattisgarh vs schools in the other states, no difference by model schools vs regular schools (χ2 test).
P < 0.001 comparing schools by states and model schools vs regular schools (χ2 test).
§Other: Christian, Buddhist, Jain etc.
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ferent sleeping arrangements, 16% reduced social
interactions within the home, 12% reduced social
interactions outside the home, and 7% had restrict-
ed food choices.
Items used for menstrual hygiene
management by girls
Overall, 45% of girls used disposable sanitary pads,
28% used cloths, and 21% reusable pads. Menstrual
cups and tampons were reported by 1% each, 2%
of girls said they did not use anything, and 3% did
not respond. There were considerable differences by
state and school (Figure 2 and Table S3 in Online
Supplementary Document). The majority of girls
in Chhattisgarh used cloths (61%), whereas the ma-
jority of girls in Maharashtra and Tamil Nadu used
disposable pads (47% and 66%, respectively). Re-
usable pads were mainly used in Maharashtra (37%)
and Tamil Nadu (21%). Only in Chhattisgarh signif-
icant differences were present between model and
regular schools; cloths were used less frequently in
model schools where disposable pads were more
common.
Effect of menstruation on school experience
The majority of girls reported going to school during their menstruation (87%, Table 3), and this was
higher among model schools (92% vs 86% in regular schools, P = 0.003). One out of ve girls in regular
schools in Chhattisgarh reported missing school during their period. The majority (65%) of girls reporting
Table 2. Girls’ awareness of menarche and source of information by state and school type, India 2015
Maharashtra Chhattisgarh taMil Nadu all 3 states
Regular
school, n (%)
Model
school, n (%)
Regular
school, N (%)
Model
school, n (%)
Regular
school, n (%)
Model
school, n (%) Total
N = 664 N = 173 N = 691 N = 236 N = 717 N = 83 N = 2564
Who informed you about menstruation?*
Mother, father, caretaker† 598 (90.1) 87 (50.3) 347 (50.2) 128 (54.2) 517 (72.1) 65 (78.3) 1742 (67.9)
Other relative‡ 13 (2.0) 2 (1.2) 78 (11.3) 32 (13.6) 55 (7.7) 9 (10.8) 189 (7.4)
Friends§ 79 (11.9) 40 (23.1) 233 (33.7) 76 (32.2) 73 (10.2) 32 (38.6) 533 (20.8)
School teacher (lesson/private)20 (3.0) 38 (22.0) 22 (3.2) 18 (7.6) 89 (12.4) 42 (50.6) 229 (8.9)
Other (eg, doctor, warden)‡ 10 (1.5) 3 (1.7) 5 (0.7) 4 (1.7) 0 (0.0) 0 (0.0) 22 (0.9)
No one¶ 22 (3.1) 4 (2.3) 22 (3.2) 6 (2.5) 35 (4.9) 0 (0.0) 89 (3.5)
No response 6 (0.9) 7 (4.1) 73 (10.6) 0 (0.0) 0 (0.0) 0 (0.0) 86 (3.4)
When did you learn about
menstruation?§,** N = 636 N = 162 N = 596 N = 230 N = 682 N = 83 N = 2389
Before start 242 (38.1) 99 (61.1) 257 (43.1) 119 (51.7) 204 (29.9) 50 (60.2) 971 (40.6)
When 1st period 352 (55.4) 52 (32.1) 244 (40.9) 84 (36.5) 393 (57.6) 29 (34.9) 1154 (48.3)
After 1st period 17 (2.7) 6 (3.7) 46 (7.7) 15 (6.5) 51 (7.5) 3 (3.6) 138 (5.8)
No answer 25 (3.9) 5 (3.1) 49 (8.2) 12 (5.2) 34 (5.0) 1 (1.2) 126 (5.3)
*More than one option was allowed.
P < 0.05 for comparison by state, model schools vs regular schools, and in Maharashtra model vs regular school.
P < 0.05 for comparison by state.
§P < 0.05 for comparison by state, model schools vs regular schools, and in Maharashtra and Tamil Nadu model vs regular school.
P < 0.05 for comparison by state, model schools vs regular schools, and within states model vs regular school.
P < 0.05 for comparison in Tamil Nadu model vs regular school.
**Among girls who were informed by persons mentioned above about menstruation (so excluding girls who reported to have not been informed about
menstruation and girls with no response to the question).
Figure 1. Restrictions (%) during menstruation among school girls in
three states in India, 2015. Religious restrictions: P < 0.05 comparing
model schools vs regular schools, and in Maharashtra and Tamil Nadu
model vs regular school. Sleeping arrangements: P < 0.05 comparing by
state, model vs regular schools, and in Chhattisgarh and Tamil Nadu
model vs regular school. Behave different inside house: P < 0.05 compar-
ing by state, and in Maharashtra model vs regular school. Behave differ-
ent outside house: P < 0.05 comparing by state, model vs regular school,
and in Maharashtra model vs regular school. Eating/exercise: P < 0.05
comparing by state, model schools vs regular schools, and in Maharash-
tra and Tamil Nadu model vs regular school.
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absence stated it was for 1 day, 22% said 2-3 days
and 13% responded that it was throughout men-
struation. Concentration problems at school during
menstruation were common (45%), with differenc-
es noted by state (Table 3). Other frequently men-
tioned problems in school included pain (stomach,
head, hips and limbs, 36%), fear of staining or smell
or losing the cloth or pad in school (15%), feeling
unwell, tired, dizzy, and weak (11%). A few (5%)
reported reduced mobility and comfort resulting
in problems with sitting, walking, bicycling, and
reaching school. Girls who used disposable pads
were signicantly more likely to report attending
school during menstruation (95%), and less fre-
quently reported concentration or other problems
during menstruation (39%, and 47%, respectively)
than girls who used cloths (81%, 53%, and 68%,
respectively, P < 0.001 for all comparisons, Figure
S2 and S2 in Online Supplementary Document).
Facilitation of schools of menstrual hygiene management
Toilet and wash facilities reported by girls
About half of girls thought there were enough toilets in the school to deal with their menstruation, with
the lowest proportion in the regular schools in Maharashtra (33%), and the highest in model schools
in Tamil Nadu (99%; Table 4). Only 37% of girls stated their school had toilets exclusively for them,
with the highest proportion in Tamil Nadu (60%). Access to toilets differed by state, with 48% of girls in
Chhattisgarh stating they could use them any time, while the majority of girls in other states were only
Figure 2. Items (%) used to deal with menstruation in three states in In-
dia, 2015. Disposable pads: P < 0.05 by state, and in Chhattisgarh model
vs regular schools. Reusable pads: P < 0.05 by state, and in Chhattisgarh
model vs regular schools. Cloth/rag: P < 0.05 by state, and in Chhattis-
garh model vs regular schools. Tampon: no differences. Cup: P < 0.05 by
state, and in Chhattisgarh model vs regular schools.
Table 3. Effect of menstruation on school experience
Maharashtra Chhattisgarh taMil Nadu all 3 states
Regular
school, n (%)
Model
school, n (%)
Regular
school, n (%)
Model
school, n (%)
Regular school
n (%)
Model school
n (%)
Total
N = 664 N = 173 N = 691 N = 236 N = 717 N = 83 N = 2564
Go to school during period:*
Yes 587 (88.4) 162 (93.6) 520 (75.3) 206 (87.3) 684 (95.4) 82 (98.8) 2241 (87.4)
No 67 (10.1) 7 (4.1) 143 (20.7) 23 (9.8) 25 (3.5) 0265 (10.3)
No response 10 (1.5) 4 (2.3) 28 (4.1) 7 (3.0) 8 (1.1) 1 (1.2) 58 (2.3)
Concentration problems at school during menstruation:†
Yes 336 (50.6) 68 (39.3) 343 (49.6) 107 (45.3) 263 (36.7) 24 (28.9) 1141 (44.5)
No 316 (47.6) 97 (56.1) 333 (48.2) 125 (53.0) 445 (62.1) 59 (71.1) 1374 (53.6)
No response 12 (1.8) 8 (4.6) 15 (2.2) 4 (1.7) 9 (1.3) 0 (0.0) 48 (1.9)
Do you have other problems when attending school during menstruation?‡
Yes 439 (66.1) 119 (68.8) 477 (69.0) 109 (46.2) 279 (38.9) 15 (18.1) 1438 (56.1)
No 217 (32.7) 40 (23.1) 176 (25.5) 107 (45.3) 431 (60.1) 68 (81.9) 1039 (40.5)
No response 8 (1.2) 14 (8.1) 38 (5.5) 20 (8.5) 7 (1.0) 0 (0.0) 87 (3.4)
Specication of some problems when attending school during menstruation:
Pain during menstruation§ 242 (36.5) 69 (40.0) 209 (44.7) 69 (29.2) 228 (31.8) 13 (15.7) 930 (36.3)
Fear of stains, smell, loss of item152 (23.0) 25 (14.5) 125 (18.1) 25 (10.6) 60 (8.4) 2 (2.4) 389 (15.2)
Feeling tired, dizzy, weak, unwell¶ 127 (19.1) 38 (22.0) 57 (8.3) 18 (7.6) 46 (6.4) 7 (8.4) 293 (11.4)
Discomfort when moving or sitting¶ 24 (3.6) 3 (1.7) 54 (7.8) 23 (9.8) 18 (2.5) 2 (2.4) 124 (4.8)
*P < 0.05 comparing by state, model schools vs regular schools, and in Maharashtra and Chhattisgarh model vs regular school.
P < 0.05 comparing by state, and in Maharashtra model vs regular school.
P < 0.05 comparing by state, model schools vs regular schools, and within states model schools vs regular schools.
§P < 0.05 comparing by state, model schools vs regular schools, and in Chhattisgarh and Tamil Nadu model vs regular school.
P < 0.05 comparing by state, model schools vs regular schools, and in Maharashtra and Chhattisgarh model vs regular school.
P < 0.05 comparing by state.
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allowed during break-time. For accidental leaking
of blood during lessons, a higher proportion of girls
in model schools stated they were allowed to leave
the class (63% in regular vs 76% in model schools,
P < 0.001). Most girls thought there was enough
time for changing their menstrual item during
break (55% in regular and 73% in model schools,
P < 0.001). Washing facilities in schools were insuf-
cient, with overall just 51% of girls reporting wash-
ing was always possible.
Disposal facilities as reported by girls
Only 27% of girls reported that their schools had
good disposal facilities for menstrual waste, and op-
tions varied widely across states and schools (Figure
3, and Table S4 in Online Supplementary Docu-
ment). The most frequently mentioned option for
disposal was taking the soiled item home (21%),
with 41% of girls in regular schools in Maharashtra
saying this. Burn pits (20%), rubbish pits (17%),
or bins (16%) were the next most common, with
a low proportion (7%) reporting an incinerator for
waste. Incinerators were more common in model
schools; for example 2% of girls in Tamil Nadu reg-
ular schools reported incinerators, whereas this was
64% in model schools (P < 0.001). In Tamil Nadu,
19% of girls reported throwing menstrual waste
down the toilets, compared with <5% in the other
two states where free napkins were less available.
When limiting analysis specically to the 1153 girls
using disposable pads, 37% reported disposal in
burning or rubbish pits, 17% in buckets, 9% in an
incinerator, 11% in toilets, and 19% reported taking
the used pad home.
Additional facilitation (pain relief, pad
provision, point person for menstrual hygiene
management)
Overall, 21% of girls reported they could get pain
relievers for menstrual cramps in the school when
needed, with a signicantly higher proportion in
model (39%) compared with regular schools (17%)
in all states (P < 0.001, Figure 4, and Table S4 in
Online Supplementary Document). Overall, 37%
of girls said absorbents were made available to them
in school. This was almost exclusively due to pad
provision in Tamil Nadu, with 81% of girls saying
they were regularly given pads. Pad distributions
were signicantly more common in model schools
than in regular schools (overall 46% vs 35%, P < 0.001), and, within states, in Maharashtra (47% vs 9%,
respectively, P < 0.001) and Chhattisgarh (30% vs 13%, respectively, P < 0.001). Overall, 51% of girls re-
ported they knew a point person in the school they could approach for problems with menstrual hygiene
management, mostly (75%) this was a female teacher (Table S4 in Online Supplementary Document).
Education in schools on menstruation and menstrual hygiene
Overall, 34% of girls reported to have received education about menstrual hygiene in school; the propor-
tion differed signicantly by state, type of school and within states (Table S5 in Online Supplementary
Figure 3. Disposal options (%) of menstrual items in schools in three
states in India, 2015. *Excluding participants who used reusable pads or
cups. Pit: P < 0.05 for comparison by state, and for Maharashtra and Ch-
hattisgarh model vs regular school. Bucket/dustbin: P < 0.05 for compar-
ison by state and model vs regular school, and in Tamil Nadu model vs
regular school. Take back home: P < 0.05 for comparison by state, model
vs regular school, and in Maharashtra and Tamil Nadu model vs regu-
lar school. Rubbish pit for burning: P < 0.05 by state and in Maharash-
tra, Chhattisgarh, and Tamil Nadu comparing model vs regular schools.
In toilet/latrine: P < 0.05 by state and type of school. School incinerator:
P < 0.05 by state, type of school, and in Maharashtra, Chhattisgarh and
Tamil Nadu model vs regular school.
Figure 4. Facilitators of menstrual hygiene (%) in schools in three states in
India. Good disposal facilities: P < 0.05 for comparison by state, model vs
regular school overall and within states. Providing pain relief: P < 0.05 for
comparison by state, model vs regular school overall and within states.
Regularly given pads: P < 0.05 for comparison by state, model vs regu-
lar school overall and within states. Teaching about menstrual hygiene:
P < 0.05 for comparison by state, model vs regular school overall and
within states.
Sivakami et al.
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Table 4. Facilitators by schools of menstrual hygiene management
Maharashtra Chhattisgarh taMil Nadu all 3 states
Regular school,
n (%)
Model school,
n (%)
Regular
school, N (%)
Model
school, n (%)
Regular
school n (%)
Model
school n (%) Total
N = 664 N = 173 N = 691 N = 236 N = 717 N = 83 N = 2564
Are there enough toilets to deal with menstruation in the school?‡
Yes 220 (33.1) 104 (60.1) 268 (38.8) 94 (39.8) 494 (68.9) 82 (98.8) 1262 (49.2)
No 399 (60.1) 54 (31.2) 376 (54.4) 128 (54.2) 214 (29.9) 1 (1.2) 1172 (45.7)
No answer 45 (6.8) 15 (8.7) 47 (6.8) 14 (5.9) 9 (1.3) 0130 (5.1)
Toilets for girls:§
For female staff & girls 166 (25.0) 34 (19.7) 79 (11.4) 95 (40.3) 195 (27.2) 29 (34.9) 598 (23.2)
For girls only 123 (18.5) 47 (27.2) 183 (26.5) 90 (38.1) 441 (61.5) 50 (60.2) 934 (36.5)
For boys and girls 188 (28.3) 61 (35.3) 242 (35.0) 5 (2.1) 62 (8.7) 4 (4.8) 562 (21.9)
For all staff & students 154 (23.2) 15 (9.7) 108 (15.6) 35 (14.8) 11 (1.5) 0323 (12.6)
No response 33 (5.0) 16 (9.3) 79 (11.4) 11 (4.7) 8 (1.1) 0147 (5.7)
When can you use the toilet?
Any time 215 (32.4) 41 (23.7) 323 (46.7) 125 (53.0) 175 (24.4) 22 (26.5) 901 (35.1)
Only during breaks 395 (59.5) 115 (66.5) 213 (30.8) 75 (31.8) 527 (73.5) 60 (72.3) 1385 (54.0)
Other responses* 30 (4.5) 2 (1.2) 38 (5.5) 4 (1.7) 11 (1.5) 1 (1.2) 86 (3.4)
No response 24 (3.6) 15 (8.7) 117 (16.9) 32 (13.6) 4 (0.6) 0192 (7.5)
Is there enough time in breaks for change of menstrual item?
Yes 307 (46.2) 132 (76.3) 301 (43.6) 147 (62.3) 532 (74.2) 80 (96.4) 1499 (58.5)
No 343 (51.7) 30 (17.3) 342 (49.5) 84 (35.6) 175 (24.4) 3 (3.6) 977 (38.1)
No response 14 (2.1) 11 (6.4) 48 (6.9) 5 (2.1) 10 (1.4) 089 (3.4)
Are you allowed to leave class if leaking?¶
Yes 354 (53.3) 133 (76.9) 367 (53.1) 162 (68.6) 593 (82.7) 77 (92.8) 1686 (65.8)
No 295 (44.4) 34 (19.7) 266 (38.5) 64 (27.1) 114 (15.9) 6 (7.2) 779 (30.4)
No response 15 (2.3) 6 (3.5) 58 (8.4) 10 (4.2) 10 (1.4) 099 (3.9)
Can you wash yourself in school when leaking?
Can always wash in school 230 (34.6) 131 (75.7) 317 (45.9) 114 (48.3) 443 (61.8) 72 (86.8) 1307 (51.0)
Can sometimes wash 47 (7.1) 12 (6.9) 113 (16.4) 50 (21.2) 209 (29.2) 11 (13.3) 442 (17.2)
Can never wash in school 375 (56.5) 18 (10.4) 219 (31.7) 60 (25.4) 48 (6.7) 0720 (28.1)
No response 12 (1.8) 12 (6.9) 42 (6.1) 12 (5.1) 17 (2.4) 095 (3.7)
*Other included responses such as queuing before toilet, toilet unusable, no toilet present, go home for change
P < 0.05 for comparison by state, model vs regular school, and Maharashtra and Tamil Nadu model vs regular school.
§P < 0.05 for comparison by state, model vs regular school, and Maharashtra and Chhattisgarh model vs regular school.
P < 0.05 for comparison by state, model vs regular school, and Maharashtra model vs regular school.
P < 0.05 for comparison by state, model vs regular school overall and within states.
Document). The majority of girls heard about it in a hygiene lesson (58%), during lessons separate from
boys (82%). Written materials about menstruation were infrequently available (19%) and mainly present
in model schools. Of the 1742 girls who heard about menstrual hygiene from their parents or guardians,
586 (34%) had lessons at school as well.
Factors associated with missing school during menstruation
Numerous factors were associated with missing school during menstruation in univariate analysis (Ta-
ble 5); however, six remained in the multivariate model. State and type of school affected absence rates,
and were signicantly lower in Tamil Nadu (adjusted prevalence ratio (APR) = 0.24, 95% condence
interval (CI) = 0.14-0.40) and Maharashtra (APR = 0.56,95% CI = 0.40-0.77) compared to Chhattisgarh,
and halved in model compared to regular schools (APR = 0.50, 95% CI = 0.34-0.73) The use of dispos-
able pads, the availability of pain medication, and a space to wash in school were all associated with
less absenteeism during menstruation. Dysfunctional toilets or long queues for toilets were associated
with increased absenteeism. In a separate multivariate analysis including only variables related to san-
itary facilities at school, “clean toilets”, “toilet breaks”, and “can wash in school” remained signicant;
however, “gender-separate toilets” was not signicant in the multivariate analysis (Table S6 in Online
Supplementary Document).
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Table 5. Factors associated with missing school during menstruation by adolescent girls, 3 states in India, 2015
FaCtor
uNivariate aNalysis Multivariate aNalysis
Missing school:
n/N (%)
Prevalence ratio,
95% CI*
P-value Prevalence ratio,
95% CI*
P-value
Age (years):
13 and below 47/665 (7.1) Reference NS
14 97/981 (9.9) 1.43, 0.97, 2.10 0.068
15 and above 118/832 (14.2) 2.03, 1.44-2.85 <0.001
State:
Chhattisgarh 166/892 (18.6) Reference Reference
Maharashtra 74/823 (9.0) 0.48, 0.31-0.75 0.001 0.56, 0.40-0.77 <0.001
Tamil Nadu 25/791 (3.2) 0.17, 0.10-0.28 <0.001 0.24, 0.14-0.40 <0.001
Model school
Yes 30/480 (6.3) 0.54, 0.26-1.13 0.104 0.50, 0.34-0.73 <0.001
No 235/2026 (11.6) Reference
Menstrual item used:
Nothing or NR 15/94 (16.0) 0.84, 0.49-1.44 0.523 1.19, 0.73-1.95 0.490
Cloth 131/688 (19.0) Reference Reference
Reusable pads 48/525 (9.1) 0.48, 0.32-0.72 <0.001 0.98, 0.74-1.31 0.893
Disposable pads 58/1140 (5.1) 0.27, 0.19-0.39 <0.001 0.57, 0.42-0.77 <0.001
Insertables† 13/59 (22.0) 1.16, 0.70-1.91 0.569 2.51, 1.54-4.07 <0.001
Pain medication in school:
Yes 25/528 (4.7) 0.39, 0.26-0.59 <0.001 0.71, 0.51-0.97 0.031
No or not reported 240/1978 (12.1) Reference Reference
Pads given in school:
Yes 50/943 (5.3) Reference NS
No 181/1329 (13.6) 2.57, 1.74-3.80 <0.001
Don’t know 17/153 (11.1) 2.10, 1.11-3.95 0.022
Not reported 17/81 (21.0) 3.96, 2.40-6.54 <0.001
Education MH in school:
Yes 47/824 (5.7) Reference NS
No 197/1432 (13.8) 2.41, 1.65-3.53 <0.001
Don’t know 11/188 (5.9) 1.03, 0.57-1.86 0.935
Not reported 10/62 (16.1) 2.83, 1.43-5.60 0.003
MH program in school:
Yes 522 (20.4) Reference
No 1565 (61.0) 3.01, 1.77-5.12 <0.001 NS
Don’t know 363 (14.2) 1.51, 0.75-3.02 0.246
Not reported 114 (4.5) 3.30, 1.54-7.06 <0.001
Enough toilets in school:
Yes 93/1240 (7.5) 0.55, 0.39-0.78 0.001 NS
No 156/1153 (13.5) Reference
Not reported 16/113 (14.2) 1.05, 0.52-2.09 0.898
When can you use the toilet?:
Any time 100/887 (11.3) Reference Reference
Only during breaks 106/1365 (7.8) 0.69, 0.49-0.96 0.029 0.95, 0.71-1.27 0.744
Other responses§ 21/85 (24.7) 3.18, 1.70-5.95 <0.001 1.61, 0.98-2.66 0.062
No response 38/169 (22.5) 2.90, 1.91-4.38 <0.001 1.42, 1.01-1.99 0.045
Toilets clean:
Always clean 73 (1128 (6.5) Reference NS
Sometimes clean 122/978 (12.5) 1.93, 1.32-2.80 0.001
Never clean or NR 70/396 (17.7) 2.73, 1.74-4.29 <0.001
Toilets for girls:
For female staff & girls 60/582 (10.3) 1.40, 0.94-2.07 0.096 NS
For girls only 68/921 (7.4) Reference
Sivakami et al.
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FaCtor
uNivariate aNalysis Multivariate aNalysis
Missing school:
n/N (%)
Prevalence ratio,
95% CI*
P-value Prevalence ratio,
95% CI*
P-value
For boys and girls 79/549 (14.4) 1.95, 1.07-3.55 0.029
For all staff & students 38/320 (11.9) 1.61, 0.96-2.71 0.073
No response 20/134 (14.9) 2.02, 1.10-3.72 0.024
Can wash in school:
Can always wash 95/1287 (7.4) Reference Reference
Can sometimes wash 47/437 (10.8) 1.46, 1.07-1.98 0.017 1.44, 1.07-1.92 0.015
Can never wash or NR 123/778 (15.8) 2.14, 1.56-2.94 <0.001 1.49, 1.13-1.95 0.004
Disposal options at school:
In pits 92/927 (9.9) 3.07, 0.96-9.85 0.059 NS
In buckets 44/389 (11.3) 3.47, 1l06-11.36 0.040
Take home 65/515 (12.6) 3.96, 1.23-12.72 0.021
Throw in toilet 17/202 (8.4) 2.60, 0.78-8.60 0.119
Incinerator 6/186 (3.2) Reference
Other or no answer 38/259 (14.7) 4.50, 1.29-15.72 0.019
CI – condence interval, MH – menstrual hygiene, NR – not reported, NS – not signicant
*All analyses adjusted for school as cluster. Factors explored but not signicant included class, time of transport to school, and
means of transport to school. No interactions of interest were noted between signicant variables.
†Tampons or menstrual cups.
§Other included responses such as queuing before toilet, toilet unusable, no toilet present, go home for change.
Table 5. Continued
DISCUSSION
This study explored the current progress of both government and external agencies to reduce the barriers
menstruation causes for schoolgirls in India, and identied where actions can be taken to improve this
further. Menstruation was not only shown to impact absenteeism (among 10% of girls) but also affected
the quality of school time, with close to half of the girls complaining of an inability to concentrate when
in school, and about a third complaining of pain (36%); other worries included fear of staining, smell,
or feeling unwell, and discomfort with movement and sitting. These problems were affected by the type
of menstrual item used, eg, they were more common among users of cloth (used by 28% of girls) com-
pared to disposable pad users (used by 45%). The status of sanitary facilities was reported to be often
inadequate, compromising girls’ ability to manage their menstruation in school. Model schools had half
the reported menstrual-related absence, and compared to Chhattisgarh absence was 75% lower in Tam-
il Nadu where sanitary napkin schemes predominate. Simply providing sanitary pads would clearly not
resolve girls’ menstrual issues, however. Comparison of regular against `model’ schools highlighted that
additional activities reach girls and improved their knowledge, and ability to cope with menstruation in
school. Variations between states displayed a need to tailor interventions to address differing cultural and
socio-geographical challenges; eg, in regions where cloths are routinely used, girls would need information
on how to hygienically clean and dry them. This study also demonstrated the ongoing need for improving
sanitary and disposal facilities at the schools (eg, one in ve girls using disposable pads had to take the
used napkin home for disposal), and encouraging (development and) use of biodegradable pads. Gains
can be achieved from simple measures such as pain relief in school or relaxation of school-break rules.
Most girls were not aware of menarche and faced barriers and restrictions when menstruating, consistent
with past studies across India [3,6]. While health education is a common thread across the Government
of India schemes, our study found no evidence of menstrual education offered systematically in regular
schools. Model schools’ focused programmes signicantly improved girls’ awareness of menstrual hygiene
suggesting this provides a template to reframe girls’ understanding that menstruation is a normal phys-
iological process [21,22]. However, parents were the main source of information about menstruation,
and efforts to equip families with information to prepare daughters on menarche and menstrual hygiene
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would add value to school-based initiatives, and are included in government guidelines [6,23]. While
differences exist across states, it was an interesting and encouraging observation that some restrictions re-
lated to menstruation were less in model schools (with more attention to menstrual hygiene) compared
to regular schools. The education of girls might have a wider effect on family and society. As our study is
cross-sectional, it is not possible to clarify this.
Approximately half of girls reported using disposable pads. The high use in Tamil Nadu reects the imple-
mentation of the free sanitary pads scheme in this state [20]; it is notable that about 20% of girls choose
to use reusable pads in Tamil Nadu, which may be because of the disposal issues for disposable pads. A
preference for reusable pads has also been reported among women living in slums in Hyderabad [24].
The wider reported experience of differing menstrual products suggests other products, currently deemed
to be unacceptable due to the many taboos, may indeed be welcomed by girls and women in India. Al-
though girls clearly seem to benet from a scheme as implemented in Tamil Nadu and envisioned for
the rural areas in India [20], inadequate disposal hinders success. Incinerators have been promoted as an
option, but there are concerns about the environmental impact [25]. According to solid waste manage-
ment rules of the Government of India, sanitary pad manufacturers must provide a wrapper with each
pad, and must be deposited in landlls as non-biodegradable waste [26,27]. For the environment, the
reusable options for menstruation may be preferable; biodegradable menstrual pads, now being tested in
India, may be another option. It is unclear if girls are aware of all the options available to deal with men-
struation, and very likely that their access to some of them will be limited (eg, reusable pads, menstrual
cup, or tampons). Lack of adequate toilet facilities emerges as one of the major reasons for girls’ absen-
teeism which has been demonstrated by others [3]. While government systems suggest that all schools
have enough gender specic toilets [28], girls’ responses do not corroborate this with 46% of girls saying
there were not enough toilets, and only 37% saying they were for girls only. Even when toilets were pres-
ent, the functionality could be doubted when girls responded the toilets were unusable so they preferred
to go outside or stay home. In addition, only 35% of the girls reported they could use the toilets anytime
(not only during breaks) and only 51% reported they could always wash themselves in school (51%). The
time during break was too short for a change of the menstrual item for one third of the girls (38%), and
thirty percent responded they could not leave the class when leaking. A more exible approach of school
rules with allowance of toilet visits during lessons may better facilitate girls’ menstrual hygiene and reduce
absenteeism. About one third of girls had some form of pain during menstruation; it is encouraging that
the ability of provision of pain relief in school may assist in keeping girls in school during their period.
India is a country of contrasts with strong gender-related disparities; a strength of this study is that we
adopted the same methodology across three geographical locations. We are aware that this still would not
allow us to generalize the ndings to government schools in other States of India, or to private schools.
Nonetheless, it gives an opportunity to understand menstrual management in-depth with a large sample
size across the country. Some girls in the study did not respond to questions, especially in Chhattisgarh;
for example, 10% of girls in the overall sample and 20% in Chhattisgarh did not give any response about
disposal of menstrual waste in the school. Great care was taken with the use of local words, and question-
naires were pre-tested to get accurate information. Despite our efforts, there is a possibility that some girls
had difculty in understanding some questions, and self-reported responses may suffer from “desirability
bias”. Model schools were selected so they may have been prone to bias; however they may illustrate the
“best case scenario”. Researchers were not aware of the type of interventions which had occurred in the
model schools or regular schools involved. Studies were cross-sectional, so causality cannot be inferred.
In conclusion, our study further strengthens the case for national investment in menstrual hygiene man-
agement by schools. Focused national policies and budget support for menstrual hygiene would facilitate
schools to improve this in a continuous and sustainable way. Ensuring sufcient gender specic private
toilet facilities with water for changing and washing, and provision of sanitary materials would help re-
duce girls’ absenteeism in schools during menstruation. Providing pain relief, and adapting school rules
(to facilitate toilet visits) may further help to facilitate menstrual care in schools. Broader policy impli-
cations include the responsiveness of the education sector to enhance girls’ reproductive health and life
skills, and modify social norms to diminish menstrual restrictions. International investment in the devel-
opment of environmentally-friendly materials and disposal systems is also called for.
Sivakami et al.
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Acknowledgements: We thank all the school girls, head teachers and teachers who provided the information.
We also thank eld staff who collected data, UNICEF ofcials from Chhattisgarh, Maharashtra and Tamil Nadu
for facilitating the study in the respective states.
Disclaimer: The ndings and conclusions in this report are those of the authors and do not necessarily repre-
sent the views of the Centers for Disease Control and Prevention.
Ethical approval: The study protocol, consent forms and data collection instruments were reviewed and ap-
proved by the Tata Institute of Social Sciences, Mumbai, India, and the Liverpool School of Tropical Medicine, UK.
Funding: This study was funded by the Department of Foreign Affairs, Trade and Development (DFAD), Gov-
ernment of Canada through a grant to UNICEF. MS, AMvE and PAP-H had full access to all data and had nal
responsibility for the decision to submit for publication.
Authorship declaration: PAP-H is the LSTM PI; and MS, HT, NK were Indian Institutional CO-PIs of the origi-
nal eld work study from which this paper is derived; they all contributed to the conceptualization and develop-
ment of the research study and its implementation. MS, NK, CP, SS, NS, GZ, and AB supervised data collection
for the study. MS and AMvE analysed and interpreted the data. MS and AMvE wrote the rst draft of the paper.
PAP-H, HT, NK, MBT, YK, AD, PS, BT, LM, KA, GZ and KFL critically revised subsequent drafts of the paper.
All authors approved the nal version.
Competing interests: The authors have completed the Unied Competing Interest form at www.icmje.org/
coi_disclosure.pdf (available on request from the corresponding author) and declare no competing interests.
Additional Material
Online Supplementary Document
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2 Sommer M, Caruso BA, Sahin M, Calderon T, Cavill S, Mahon T, et al. A Time for Global Action: Addressing Girls’ Men-
strual Hygiene Management Needs in Schools. PLoS Med. 2016;13:e1001962. Medline:26908274 doi:10.1371/jour-
nal.pmed.1001962
3 van Eijk AM, Sivakami M, Thakkar MB, Bauman A, Laserson KF, Coates S, et al. Menstrual hygiene management
among adolescent girls in India: a systematic review and meta-analysis. BMJ Open. 2016;6:e010290. Medline:26936906
doi:10.1136/bmjopen-2015-010290
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... Although participation and concentration are integral in developing a comprehensive picture of girls' educational attainment, few studies, thus far, (e.g. [14,29]) quantify menstruation's effects on these subjective outcomes. Third, very few quantitative studies, to date, have examined the reasons behind absenteeism and decreased participation (e.g. ...
... Biological constraints can range from dysmenorrhea (menstrual cramps) to more severe disorders like endometriosis. In particular, dysmennorhea is a common gynecological complaint among adolescents in developing countries [8,29]. A systemic review of 50 studies [45], and various single case studies [15,31,46], have reinforced the finding that cramps are a common cause of school absenteeism and reduced participation. ...
... Biological constraints. This study contributes rare quantitative findings to a nascent body of evidence that menstrual cramps and pain are major causes of girls' absenteeism [8,13,15,19,29,30,66] and their impaired participation/concentration in school activities [31]. Among our sample of 524 girls, cramps and pain are consistently the most or second-most prevalent reason for all four adverse educational outcomes: absenteeism, leaving early, and reduced participation and concentration. ...
Article
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Menstrual hygiene management is an important determinant for girls’ educational outcomes. We develop a method of cross-sectional analysis that quantifies the relative importance of four distinct mechanisms: material, biological, social and informational constraints and consider four main schooling outcomes: absenteeism, early departure, concentration and participation. We use survey data from 524 female students enrolled in four co-educational secondary schools in Northern Tanzania. Average age at first period is 14.2 years (standard deviation = 1.1, range 9-19). Information is the least binding constraint: 90-95% of girls report they received information about menstruation and how to manage it. In contrast, biological constraints are hindering: (i) the distribution of menstrual cramps and pain is bifurcated: most girls report very light or very strong pain (rather than moderate) with considerable educational impacts for girls in the latter group, (ii) irregular cycles (62%) and difficulty predicting the cycle (60%) lead to stress and uncertainty. Socio-cultural constraints are binding as 84% would feel shame if male peers knew their menstrual status, and 58% fear being teased over periods. Material constraints include prohibitive costs: girls spending between 12-70% of the daily national poverty line (6,247 TSH per day) on pads during their period. However, we discern no statistically significant relationship between access to pads and absenteeism. In contrast, biological and socio-cultural constraints as well as lack of sanitary infrastructure have significant effects on absenteeism. The results have several implications. First, sanitary pad interventions should consider participation and concentration as main outcomes, in addition to absenteeism. Second, biological (menstrual cramps and pain) and socio-cultural (fear, stigma) constraints are drivers of menstruation-related absenteeism and participation in the classroom and need to be evaluated in trials. We suggest exploring analgesic use, alternative pain-management techniques, menstrual cycle tracking technologies, and social programming in future trials.
... After 4 years, compared with unimproved schools, school attrition had fallen from 11% to 6% (p<0.003). 51 The effect of menstrual education alone cannot be separated out. ...
Article
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Objectives To systematically review interventions that include an element of menstrual education delivered to young adolescent girls. Design This was a systematic review and meta-analysis. Selected articles were quality assessed using the Mixed Methods Appraisal Tool quality appraisal checklist. A meta-analysis was conducted on a subset of articles, and the effect size of the intervention was calculated using Cohen’s d. A logic model was constructed to frame the effect of menstrual education interventions on menstrual health. Setting Papers reporting on interventions in high-income and low-income and middle-income countries were sought. Information sources Seven electronic databases were searched for English-language entries that were published between January 2014 and May 2020. Participants The interventions were aimed at younger adolescent girls aged 10–14 years old. Interventions The interventions were designed to improve the menstrual health of the recipients, by addressing one or more elements of menstrual knowledge, attitude or practices (KAP). Eligibility criteria Interventions that had not been evaluated were excluded. Primary and secondary outcomes The most common type of output was a difference in knowledge or skill score ascertained from a pre and post test. Some studies measured additional outcomes, such as attitude or confidence. Results Twenty-four eligible studies were identified. The number of participants varied from 1 to 2564. All studies reported improvements in menstrual KAP. The meta-analysis indicates that larger effect sizes were attained by those that encouraged discussion than those that distributed pamphlets. Conclusions Education interventions are effective in increasing the menstrual knowledge of young adolescent girls and skills training improves competency to manage menstruation more hygienically and comfortably. Interactive interventions are more motivating than didactic or written. Sharing concerns gives girls confidence and helps them to gain agency on the path to menstrual health. Trial registration number For this review, a protocol was not prepared or registered.
... However, since reusable cloth pads require sufficient water to wash, this level of maintenance may be difficult to maintain. Cloth pad cleanliness might be compromised in populations where water supply is highly constrained, including where water is unavailable in the toilet area when changing, especially when women and girls are in public places such as in school [20,21] or in a slum [22][23][24]. ...
Article
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Girls’ menstrual experiences impact their social and educational participation, physical and psychological health. We conducted a pilot study to assess the acceptability and feasibility of a multi-component intervention intended to support menstruating girls; improve menstrual care knowledge, practices, and comfort; and increase school attendance. We conducted a pre/post evaluation of a 6-month pilot intervention in four schools (2 urban, 2 rural) in Dhaka, Bangladesh. We selected 527 schoolgirls (grades 5 to 10; aged 10 to 17 years) for a baseline survey and 528 girls at endline. The intervention included: 1) Menstrual Hygiene Management (MHM) packs– reusable cloth pads, underwear, carry bags and menstrual cycle tracking calendars, 2) education curriculum- pictorial flipcharts, puberty related-booklets, and teachers’ training to deliver puberty and MHM sessions, 3) maintenance- improvements to school sanitation, provision of disposable pads in the school office, provision of chute disposal systems for disposable pads, and gender committees to promote a gender-friendly school environment and maintenance of intervention facilities. We estimated intervention uptake and intervention effect by calculating prevalence differences and 95% confidence intervals using fixed-effects logistic regression. The intervention uptake was more than 85% for most indicators; 100% reported receiving puberty education, 85% received MHM packs, and 92% received booklets. Reusable cloth pads uptake was 34% by endline compared with 0% at baseline. Knowledge about menstrual physiology and knowledge of recommended menstrual management practices significantly improved from baseline to endline. Reported improvements included more frequent changing of menstrual materials (4.2 times/day at endline vs. 3.4 times/day at baseline), increased use of recommended disposal methods (prevalence difference (PD): 8%; 95% Confidence Interval: 1, 14), and fewer staining incidents (PD: − 12%; 95% CI: − 22, − 1). More girls reported being satisfied with their menstrual materials (59% at endline vs. 46% at baseline, p < 0.005) and thought school facilities were adequate for menstrual management at endline compared to baseline (54% vs. 8%, p < 0.001). At endline, 64% girls disagreed/strongly disagreed that they felt anxious at school due to menstruation, compared to 33% at baseline (p < 0.001). Sixty-five percent girls disagreed/strongly disagreed about feeling distracted or trouble concentrating in class at endline, compared to 41% at baseline (p < 0.001). Self-reported absences decreased slightly (PD: − 8%; 95% CI: − 14, − 2). Uptake of cloth pads, improved maintenance and disposal of menstrual materials, and reduced anxiety at school suggest acceptability and feasibility of the intervention aiming to create a supportive school environment.
... Among these factors, there was an association found among menstrual hygiene practices of girls with menarche age, religion, and caste. [14][15][16] It was found that mothers were the main source of information. Also, in the present study, significant association was found among information received, source of information, and menstrual hygiene. ...
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This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. For reprints contact: reprints@medknow.com How to cite this article: Pal M, Devi S, Taywade M. Experiences of menstruation with factors influencing menstrual hygiene practices among adolescent girls attending outpatient department of secondary care hospital setting: A cross-sectional study. Amrita J Med 2022;18:20-5. Abstract Background: Menstruation is a physiological process as it brings changes in a young woman's life. In this process, menarche is the most important phase in menstruation. It is the onset of first menstruation in girls. In today's time also, menstruation is confused by different perceptions, myths, and misconceptions, which later affect their menstrual hygiene practices. Materials and Methods: The mixed method approach is adopted for the study. A qualitative approach using an in-depth interview was adopted for exploring the experiences of adolescent girls, and a quantitative approach was used for assessing factors influencing menstrual hygiene practices. Results: Adolescent girls had various experiences regarding their menarche. Seventy-four percent of girls had average menstrual hygiene practices. Several influencing factors were found and after applying binary logistic analysis four risk factors were found, which are caste, problems faced by girls during menses, frequency of changing pads, and method of disposal. Conclusion: The present study shows that girls had various experiences at the time of their menarche. They are having average menstrual hygiene practices, and there are various factors found which influence menstrual hygiene practices. Though there are several modules to maintain menstrual hygiene, still many adolescent girls lack resources such as a supply of clean water, availability of toilets, and use of sanitary pads.
... [26] In a recent survey from Maharashtra, Chhattisgarh, Tamil Nadu reported that 2564 (70.9%) menstruating girls, only 45% of female students were using disposable sanitary pads, while 28% used clothes. [41] Along with use, it is also important how frequently the soiled sanitary pad was changed. In the present study, students who changed their soiled sanitary pad during the menstruation period more frequently had significantly lower rates of UTI. ...
Article
Full-text available
BACKGROUND: Urinary tract infections (UTIs) are more common in females than males and predominantly based on their unhealthy practices in their day to day lives. This study is trying to assess the occurrence of UTI and strategies used by female student to prevent UTI. MATERIALS AND METHODS: A cross‑sectional descriptive study carried out in a tertiary care teaching institute. A total of 338 conveniently selected B. Sc. Nursing and MBBS Medical students were surveyed. The data were collected by using a pretested, self‑structured questionnaire related to occurrence and practices to prevent UTI along with necessary demographic details. Descriptive (frequency, percentage, mean and standard deviation) and inferential (Chi‑square test) statistics was used to compute the data. RESULTS: The result of this study shows that 10.05% female students reported of having UTI. The proportion was higher in nursing students (67.6%) than medical (32.4%) but did not show a significance difference (P = 0.61). Age, duration of hostel life, and marital status were significantly associated with the status of UTI (P = 0.001). To prevent UTI, students were using commercial product with Tea Tree Oil, soap, drinking 3–4 l water/day, increased frequency of peri‑wash during menstruation period, and use of Citrus Fruits. The use of western toilet was also significantly associated with status of UTI (P = 0.04). CONCLUSION: The occurrence of UTI was more among nursing students. Most of the perineal hygienic practices by the female students were associated with occurrence of UTI; hence, it is necessary to emphasize on preventive practices to minimize re‑occurrence.
... 13 14 Various studies provide evidence that school going girls are usually absent during their menstrual period due to inadequate facilities in schools, which have adverse implications on their lives and Ghana as a whole. [15][16][17][18] In schools where these essential environments including waste dumping facilities are not available, girls experience discomfort while at school which affects learning. 19 Over 260 schools in Ghana are benefiting from the World Bank initiative to provide sanitation infrastructure and hygiene education. ...
Article
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Objective This study aimed to investigate schools’ preparedness for menstrual hygiene management in the West Gonja Municipality of Ghana. Design This was a cross-sectional study with a mixed-methods approach. Setting Junior high schools in the West Gonja Municipality. Participants Twenty-six schools were randomly selected, and 13 schoolgirls were purposively chosen for qualitative interviews. Analysis of data The quantitative and qualitative data were analysed using Microsoft Excel and thematic content analysis, respectively. The transcriptions were printed out and read repeatedly to identify similar wordings, phrases, concept and meanings. Outcomes Presence of menstrual hygiene facilities in basic schools. Results Majority (69.2%) of the schools were poorly prepared towards menstrual hygiene management. Only 38.5% schools had water, most schools (61.5%) did not have waste bins, 30.8% of the schools had designated places for changing of menstrual materials. No school had menstrual hygiene materials available for emergency use. All participants acknowledged inadequate hygiene facilities in their schools. During menses, adolescent girls often absent themselves from school. Girls tend to be very inactive during their menstrual period for fear of embracement from their male counterparts. The following themes were obtained ‘unavailability of hygiene material’, ‘involvement in class during menses’ and ‘absence from school’. Conclusion Schools in West Gonja Municipality have inadequate menstrual hygiene management facilities that could be a major setback to the health and educational attainment of young girls. The Ministry of Sanitation and Water Resources should expand menstrual hygiene and its management to reach the West Gonja Municipality as part of the National Sanitation and Hygiene Strategy.
... 47 Schooling can be interrupted by this work burden, as well as by the absence of school toilet facilities adequate for coping with menstrual hygiene. 48 A study in an urban slum in Madhya Pradesh found that more than half the sample of adolescent girls missed school when they were menstruating. 49 This can result in both school drop-out and lower literacy rates. ...
Article
To identify the extent of menstrual disorders and relation to various aspects of life in 100 women of age group 12-25 years. This is a cross-sectional study. Data is collected using questionnaire on demographics, medical history, personal habits, academic performance and menstrual pattern. Results analyzed using EPI info and SPSS software. 40% have no idea of menstruation prior to menarche, 28% of all were scared at menarche. 15% of menstrual education is contributed by schools. 60% had HMB, 83% had PMS. 91% had menstrual disorders and 37% had severe dysmenorrhea on day 1. Irregular cycles has significant association with BMI and medical history. PMS has significant association with food habits and alcohol intake. 64% with menstrual disorders did not seek medical help. Adolescent period in women can be quite difficult especially in view of menarche; understanding of menstruation and facing menstrual disroders.it needs preparation which is lacking in India. Menstrual education should be included in school study curriculum. Awareness should be increased about menstrual disorders, hygiene, personal habits and support should be given during menstruation in schools to avoid skipping of schools and to decrease academic stress during periods and medical help should be taken.
Article
There has been a growth in menstrual equity policy advancements in the U.S.A. in recent years; with much of the new legislation prioritizing the needs of adolescent girls in schools. New York City, a predecessor of this movement, was the first U.S.A. locality to pass such legislation in 2016. The aim of this case study was to better understand the various factors which led to the development, passage and initial implementation of New York City's Menstrual Equity in Schools Policy. Data collection methods included a desk review and qualitative assessment with several actors involved across the policy and introduction phases. Key findings included (1) the utility of community narratives and a pilot project as a means for overcoming initial skepticisms, proving feasibility, and generating support; (2) the importance of policy champions for overcoming fiscal objections and navigating political discourse; and (3) lessons learned from early implementation efforts, including variance in awareness and distribution models. This case study yields valuable insights into the practical considerations when designing or implementing policies aimed at tackling issues of menstrual equity within school settings.
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Background Menstruation is a natural physiological process that requires proper management. Unlike other normal bodily processes, menstruation is linked with religious and cultural meanings that can affect the perceptions of young girls as well as the ways in which the adults in the communities around them respond to their needs. Objectives This review aims to answer the following questions: (1) how knowledgeable are adolescent girls in low- and middle-income countries about menstruation and how prepared are they for reaching menarche, (2) who are their sources of information regarding menstruation, (3) how well do the adults around them respond to their information needs, (4) what negative health and social effects do adolescents experience as a result of menstruation, and (5) how do adolescents respond when they experience these negative effects and what practices do they develop as a result? Methods Using a structured search strategy, articles that investigate young girls’ preparedness for menarche, knowledge of menstruation and practices surrounding menstrual hygiene in LMIC were identified. A total of 81 studies published in peer-reviewed journals between the years 2000 and 2015 that describe the experiences of adolescent girls from 25 different countries were included. ResultsAdolescent girls in LMIC are often uninformed and unprepared for menarche. Information is primarily obtained from mothers and other female family members who are not necessarily well equipped to fill gaps in girls’ knowledge. Exclusion and shame lead to misconceptions and unhygienic practices during menstruation. Rather than seek medical consultation, girls tend to miss school, self-medicate and refrain from social interaction. Also problematic is that relatives and teachers are often not prepared to respond to the needs of girls. ConclusionLMIC must recognize that lack of preparation, knowledge and poor practices surrounding menstruation are key impediments not only to girls’ education, but also to self-confidence and personal development. In addition to investment in private latrines with clean water for girls in both schools and communities, countries must consider how to improve the provision of knowledge and understanding and how to better respond to the needs of adolescent girls.
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A number of programmes have recently been initiated to popularise the use of sanitary pads among poor women in developing countries. In this light, we review the prevailing menstrual practices in different contexts across India, as well as the initiatives undertaken to improve sanitary care. We also report findings from a study amongst women in slums of Hyderabad. We find high usage of sanitary pads (56 to 64 percent), suggesting that development initiatives have percolated down to the urban poor. Furthermore, we find that although a large number of cloth users (57 percent) are willing to change practice, an overwhelming number of them (94 percent) elicit a preference for re-usable cloth pads. This suggests a disengagement with public policy discourses on menstrual care that have so far focused singularly on promotion of sanitary pads. We draw upon these results to comment on better sanitary care for women slum dwellers in a rapidly urbanising context. Copyright © 2017 John Wiley & Sons, Ltd.
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Objectives Conduct a feasibility study on the effect of menstrual hygiene on schoolgirls' school and health (reproductive/sexual) outcomes. Design 3-arm single-site open cluster randomised controlled pilot study. Setting 30 primary schools in rural western Kenya, within a Health and Demographic Surveillance System. Participants Primary schoolgirls 14–16 years, experienced 3 menses, no precluding disability, and resident in the study area. Interventions 1 insertable menstrual cup, or monthly sanitary pads, against ‘usual practice’ control. All participants received puberty education preintervention, and hand wash soap during intervention. Schools received hand wash soap. Primary and secondary outcome measures Primary: school attrition (drop-out, absence); secondary: sexually transmitted infection (STI) (Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoea), reproductive tract infection (RTI) (bacterial vaginosis, Candida albicans); safety: toxic shock syndrome, vaginal Staphylococcus aureus. Results Of 751 girls enrolled 644 were followed-up for a median of 10.9 months. Cups or pads did not reduce school dropout risk (control=8.0%, cups=11.2%, pads=10.2%). Self-reported absence was rarely reported and not assessable. Prevalence of STIs in the end-of-study survey among controls was 7.7% versus 4.2% in the cups arm (adjusted prevalence ratio (aPR) 0.48, 0.24 to 0.96, p=0.039), 4.5% with pads (aPR=0.62; 0.37 to 1.03, p=0.063), and 4.3% with cups and pads pooled (aPR=0.54, 0.34 to 0.87, p=0.012). RTI prevalence was 21.5%, 28.5% and 26.9% among cup, pad and control arms, 71% of which were bacterial vaginosis, with a prevalence of 14.6%, 19.8% and 20.5%, per arm, respectively. Bacterial vaginosis was less prevalent in the cups (12.9%) compared with pads (20.3%, aPR=0.65, 0.44 to 0.97, p=0.034) and control (19.2%, aPR=0.67, 0.43 to 1.04, p=0.075) arm girls enrolled for 9 months or longer. No adverse events were identified. Conclusions Provision of menstrual cups and sanitary pads for ∼1 school-year was associated with a lower STI risk, and cups with a lower bacterial vaginosis risk, but there was no association with school dropout. A large-scale trial on menstrual cups is warranted. Trial registration ISRCTN17486946; Results
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Objectives To assess the status of menstrual hygiene management (MHM) among adolescent girls in India to determine unmet needs. Design Systematic review and meta-analysis. We searched PubMed, The Global Health Database, Google Scholar and references for studies published from 2000 to September 2015 on girls’ MHM. Setting India. Participants Adolescent girls. Outcome measures Information on menarche awareness, type of absorbent used, disposal, hygiene, restrictions and school absenteeism was extracted from eligible materials; a quality score was applied. Meta-analysis was used to estimate pooled prevalence (PP), and meta-regression to examine the effect of setting, region and time. Results Data from 138 studies involving 193 subpopulations and 97 070 girls were extracted. In 88 studies, half of the girls reported being informed prior to menarche (PP 48%, 95% CI 43% to 53%, I2 98.6%). Commercial pad use was more common among urban (PP 67%, 57% to 76%, I2 99.3%, n=38) than rural girls (PP 32%, 25% to 38%, I2 98.6%, n=56, p<0.0001), with use increasing over time (p<0.0001). Inappropriate disposal was common (PP 23%, 16% to 31%, I2 99.0%, n=34). Menstruating girls experienced many restrictions, especially for religious activities (PP 0.77, 0.71 to 0.83, I2 99.1%, n=67). A quarter (PP 24%, 19% to 30%, I2 98.5%, n=64) reported missing school during periods. A lower prevalence of absenteeism was associated with higher commercial pad use in univariate (p=0.023) but not in multivariate analysis when adjusted for region (p=0.232, n=53). Approximately a third of girls changed their absorbents in school facilities (PP 37%, 29% to 46%, I2 97.8%, n=17). Half of the girls’ homes had a toilet (PP 51%, 36% to 67%, I2 99.4%, n=21). The quality of studies imposed limitations on analyses and the interpretation of results (mean score 3 on a scale of 0–7). Conclusions Strengthening of MHM programmes in India is needed. Education on awareness, access to hygienic absorbents and disposal of MHM items need to be addressed. Trial registration number CRD42015019197.
Article
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• There is an absence of guidance, facilities, and materials for schoolgirls to manage their menstruation in low-and middle-income countries (LMICs). • Formative evidence has raised awareness that poor menstrual hygiene management (MHM) contributes to inequity, increasing exposure to transactional sex to obtain sanitary items, with some evidence of an effect on school indicators and with repercussions for sexual, reproductive,and general health throughout the life course. • Despite increasing evidence and interest in taking action to improve school conditions for girls, there has not been a systematic mapping of MHM priorities or coordination of relevant sectors and disciplines to catalyze change, with a need to develop country-level expertise. • Columbia University and the United Nations Children's Fund (UNICEF) convened members of academia, non governmental organizations, the UN, donor agencies,the private sector, and social entrepreneurial groups in October 2014 (“MHM in Ten”) to identify key public health issues requiring prioritization, coordination, and investment by 2024. • Five key priorities were identified to guide global, national, and local action.
Article
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Menstrual hygiene management (MHM) practices vary worldwide and depend on the indi-vidual's socioeconomic status, personal preferences, local traditions and beliefs, and access to water and sanitation resources. MHM practices can be particularly unhygienic and inconvenient for girls and women in poorer settings. Little is known about whether unhygienic MHM practices increase a woman's exposure to urogenital infections, such as bacterial vaginosis (BV) and urinary tract infection (UTI). This study aimed to determine the association of MHM practices with urogenital infections, controlling for environmental drivers. A hospital-based case-control study was conducted on 486 women at Odisha, India. Cases and controls were recruited using a syndromic approach. Vaginal swabs were collected from all the participants and tested for BV status using Amsel's criteria. Urine samples were cultured to assess UTI status. Socioeconomic status, clinical symptoms and reproductive history, and MHM and water and sanitation practices were obtained by stan-dardised questionnaire. A total of 486 women were recruited to the study, 228 symptomatic cases and 258 asymptomatic controls. Women who used reusable absorbent pads were more likely to have symptoms of urogenital infection (AdjOR=2.3, 95%CI1.5-3.4) or to be diagnosed with at least one urogenital infection (BV or UTI) (AdjOR=2.8, 95%CI1.7-4.5), than women using disposable pads. Increased wealth and space for personal hygiene in the household were protective for BV (AdjOR=0.5, 95%CI0.3-0.9 and AdjOR=0.6, 95% CI0.3-0.9 respectively). Lower education of the participants was the only factor associated with UTI after adjusting for all the confounders (AdjOR=3.1, 95%CI1.2-7.9). Interventions that ensure women have access to private facilities with water for MHM and that educate women about safer, low-cost MHM materials could reduce urogenital disease among women. Further studies of the effects of specific practices for managing hygienically
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