Abstract
Menstruation is a natural and essential biological process that affects adolescent girls’ physical, emotional, and social well-being. In many low- and middle-income countries (LMICs), menstruation is surrounded by misconceptions and inadequate management practices. This study aims to assess the knowledge, perceptions, and practices regarding menstruation and menstrual hygiene among school-going adolescent girls in North East India. The study employed a cross-sectional design and was conducted over a period of one year in schools which were randomly selected under the Kamalpur block of Kamrup district of Assam. Data were collected through an awareness program using a pre-tested proforma. A total of 176 adolescent girls who had attained menarche participated. Data analysis included descriptive statistics and Chi-square tests. The mean age of participants was 14.00 years, and the mean age at menarche was 11.89 years. A significant portion, 60% (106 girls), were well aware of the menstruation process, while 40% (70 girls) lacked adequate knowledge. Most participants (72.2%) reported always having access to menstrual materials. Concerns about leakage and disposal were highly prevalent, with 64.2% sometimes worrying about leakage and 67.0% about disposal. Cramps were the most common menstrual problem (63.1%). The majority (93.2%) used sanitary pads, while 3.4% used cloth or a combination. Disposal methods varied, with 47.2% using dustbins and 36.9% burying the pads. Chi-square tests indicated no significant association between the type of menstrual material used and menstrual problems (χ² =8.012, P = 0.628). This study emphasizes the need for targeted interventions and educational programs to address menstrual hygiene challenges. Future studies should explore longitudinal data and broader geographical scopes to enhance menstrual health management.
Keywords: Adolescent, hygiene, knowledge, menstrual, practices
INTRODUCTION
Menstruation is a natural and essential biological process that affects the physical, emotional, and social well-being of adolescent girls. However, in many low- and middle-income countries (LMICs), menstruation is surrounded by misconceptions, stigma, and inadequate management practices. Adolescents often enter puberty with limited knowledge and understanding of menstruation, leading to challenges in managing their menstrual health effectively.[1] This lack of awareness is compounded by the reluctance of parents and educators to discuss menstruation, often viewing it as a taboo subject. Consequently, many girls experience restrictions during their menstrual periods, such as being prohibited from participating in regular activities or being isolated from their communities.[2]
Research indicates that proper menstrual hygiene management is crucial for the health, education, and overall well-being of adolescent girls.[3] Studies have shown that inadequate menstrual hygiene can lead to adverse health outcomes, including infections and reproductive tract diseases.[4] Furthermore, the lack of access to sanitary products and appropriate facilities can hinder girls’ participation in school and other activities, thereby affecting their educational attainment and social development.[5]
Though various studies have been conducted on menstrual hygiene, the importance of the study lies in its focus on the unique cultural and social dynamics of North East India, providing targeted insights to improve menstrual health management in this under-researched region. By providing comprehensive insights into menstrual hygiene practices and challenges, this research will contribute to the development of policies and programs that promote better menstrual health management among adolescent girls, ultimately enhancing their health, education, and social participation. These interventions can empower girls with accurate knowledge and create a supportive environment, enabling them to manage their menstrual health with confidence and dignity.[6,7]
With this background, the present study has been conducted with the following objectives:
To assess the knowledge, perceptions, and practices regarding menstruation and menstrual hygiene among school-going adolescent girls.
To explore the socio-demographic and cultural factors influencing menstruation and identify gaps and misconceptions that need to be addressed.
MATERIALS AND METHODS
The study employed a cross-sectional design to assess the knowledge, perception, and practices regarding menstruation and menstrual hygiene among school-going adolescent girls in North East India. The study was conducted over a period of one year (March 2023–March 2024)
Study area
Schools (Both government and private) within the Kamalpur block of Kamrup rural district of Assam. A list of both private and government high schools in the Kamalpur block was obtained. Simple random sampling was employed to select the schools from the list provided.
Study participants
All adolescent girls (10–19 years) who had attained menarche and were willing to provide consent were included in the study. Considering the prevalence of awareness regarding menstruation as 51.6% from a study conducted by Jain R et al.[8] in a government school in India and taking 10% as absolute error, the sample size was calculated using the formula z2pq/d2. The calculated sample size was 99 but since we included all the adolescent girls who fulfilled the inclusion criteria from all the three schools, so our total sample size was 176.
Necessary permissions were obtained from the school authorities before initiating the study. On the day of the visit, informed consent was obtained from the participants who were above 18 years of age. For children less than 18 years of age assent was obtained from them and informed consent was obtained from their parents or legal guardians through the school authorities. Data were collected using a pre-tested and validated proforma, which included both close-ended and open-ended questions. The proforma was designed to capture various aspects of menstrual hygiene, including the availability of menstrual materials, worry regarding leakage, disposal of used materials, and common menstrual problems faced by the girls. The questionnaire consisted of both open-ended and closed-ended questions. An awareness program on menstrual hygiene was also conducted after the data collection procedure. The awareness program provided information on menstrual hygiene and management of health issues during menstruation. The program aimed to address any prevailing taboos, stigma, or misconceptions about menstruation identified during the study through educational initiatives. Each session lasted for almost 1 hour. The following topics were covered in the session
Physiology and biological process of menstruation.
Common problems during menstruation and how to tackle it.
Common myths and misconceptions of menstruation
Menstrual hygiene and safe disposal of menstrual materials.
A total of 2–3 visits were made per school for data collection followed by the awareness program. The days of awareness program and data collection were fixed after a discussion with the school authorities.
Institutional ethics committee approval was obtained before the commencement of the study from the IEC of the respective Institute.
SPSS v. 27.0 was used for analysis of data. Data were analyzed using descriptive statistics to summarize the demographic characteristics and responses. Differences in the frequencies of categorical data were compared using appropriate statistical tests, including Chi-square test. Qualitative data were coded and thematically analyzed to identify recurring themes and patterns in the data. The study adhered to ethical guidelines, ensuring minimal risk to participants and maintaining the confidentiality of the collected data.
RESULTS AND DISCUSSION
The study included a sample of 176 adolescent girls from three schools in Kamrup rural district, comprising two government schools and one private school. The descriptive statistics revealed that the mean age of the participants was 14 years (SD = 1.38), with age ranging from 12 to 18 years. The mean age at menarche was 11.89 years (SD = 1.55), with the youngest reporting menarche at 9 years and the oldest at 17 years. The frequency distribution of various aspects related to menstrual hygiene provided insightful data.
The level of understanding regarding the menstruation process varied among the participants. A significant portion, 60% (106 girls), were well aware of the menstruation process, while 40% (70 girls) lacked adequate knowledge. This discrepancy highlights the need for improved menstrual education in schools to ensure all girls have a clear understanding of the biological phenomenon and health aspects of menstruation. Regarding perceptions during menstruation, 55% of the participants reported feeling dirty during their menstrual periods. This negative perception underscores the prevailing stigmas and misconceptions surrounding menstruation, which can adversely affect girls’ self-esteem and social participation.
A significant majority of the participants (72.2%) reported always having access to adequate menstrual materials like sanitary pads and cleaning materials, while 21.6% sometimes had enough, and 6.3% never had sufficient access to materials. Concerns regarding leakage to outer garments were prevalent, with 64.2% of the girls sometimes worrying about this issue and 27.8% always being worried. Only 8.0% reported never having this concern. A significant majority (93.2%) of the girls used sanitary pads, while a small number relied on cloth (3.4%) or a combination of both (3.4%). Disposal methods varied, with nearly half (47.2%) using dustbins, 36.9% resorting to burying the pads, and 15.3% employing other methods, including burning. Similar trends were observed for worries about the disposal of used materials, with 67.0% sometimes worried, 10.8% always worried, and 22.2% never worried [Table 1].
Table 1.
Menstrual hygiene practices and concerns among adolescent girls in North East India
| Parameter | Yes | No |
|---|---|---|
| Adequate knowledge of menstruation | 106 (60%) | 70 (40%) |
| Attended school during menstruation | 105 (59.3%) | 71 (40.6%) |
| Knowledge of how to manage cramps | 62 (35%) | 114 (65%) |
| Access to adequate sanitary materials | 127 (72.2%) | 49 (27.8%) |
| Access to proper support system at school | 88 (50.0%) | 88 (50.0%) |
| Access to adequate disposal of menstrual pads | 79 (44.9%) | 97 (55.1%) |
| Fear of leakage during menstruation | 162 (92.0%) | 14 (8.0%) |
| Access to adequate washing/sanitary facilities | 168 (95.5%) | 8 (4.5%) |
| Having abdominal cramps during menstruation | 111 (63.1%) | 65 (36.9%) |
The study also assessed the adequacy of support available to the participants. 46 (25.4%) of girls were never comfortable going to school during menstruation whereas 96 (54.2%) reported that they were sometimes comfortable. Only 35 (19.8%) reported that they were always comfortable going to school during menstruation. A significant percentage of the girls, approximately (71) 40%, reported missing school during their menstrual periods due to a lack of adequate facilities and support. Regarding the disposal facilities, about 79 (45%) of the respondents indicated that their schools provided adequate facilities for disposing of used menstrual products. However, the provision of sanitary materials in schools was reported to be insufficient, with only 62 (35%) of the girls stating that their schools supplied sanitary pads. Support from teachers varied, with 88 (50%) of the participants feeling that they received adequate support from their teachers during menstruation. Despite these challenges, a relatively high percentage, around 105 (60%), of the girls reported that they continued to participate in social events during their menstrual periods, suggesting resilience and the importance of social inclusion in their communities.
Concerns about other people noticing the area of disposal were also notable, with 97 (55.1%) sometimes worried, 38 (21.6%) always worried, and 41 (23.3%) never worried. Access to sufficient water was reported by 134 (76.7%) of the participants as always available, while 33 (18.8%) had access sometimes, and 8 (4.5%) never had enough water for cleaning.
The responses to open-ended questions revealed several key themes regarding the menstrual experiences of adolescent girls. The most common menstrual problem reported was cramps, affecting 111 (63.1%) of the participants. Other issues included mood swings 19 (10.8%), various unspecified problems 17 (9.7%), irregular periods 5 (2.8%), and heavy bleeding 3 (1.7%). Only 62 (35%) of girls were aware of how to manage abdominal cramps while the rest 114 (65%) were not aware. These themes underscore the diverse challenges and practices in menstrual hygiene management among girls.
The analysis aimed to determine whether significant differences existed in menstrual problems (cramps, mood swings, irregular periods, heavy bleeding) across the type of menstrual material used (sanitary pads, cloth, both). The Chi-square test between the type of menstrual material used and common menstrual problems faced yielded no statistically significant association (χ² =8.012, P = 0.628). Chi-square analysis indicates significant variations in menstrual problems across socio-demographic variables. Notably, students from government schools reported higher menstrual problems (73.0%) compared to private schools (54.0%), with a significant P value of 0.024. Age, menstrual material used, and prior knowledge regarding menstruation showed no significant impact, with P values of 0.785, 0.226, and 0.594, respectively [Table 2].
Table 2.
Association between menstrual problems and socio-demographic variables
| Category | Menstrual problems |
Chi-square | P | |
|---|---|---|---|---|
| Yes (%) | No (%) | |||
| Age of the participant | 0.075 | 0.785 | ||
| <14 | 46 (65.7%) | 24 (34.3%) | ||
| >14 | 73 (68.9%) | 33 (31.1%) | ||
| Type of school | 5.075 | 0.024* | ||
| Govt | 92 (73.0%) | 34 (27.0%) | ||
| Private | 27 (54.0%) | 23 (46.0%) | ||
| Menstrual material used | 1.639 | 0.226 | ||
| Cloth | 6 (100%) | 0 (0%) | ||
| S. Pads | 109 (66.5%) | 55 (33.5%) | ||
| Prior knowledge regarding menstruation | 0.284 | 0.594 | ||
| Yes | 44 (71.0%) | 18 (29.0%) | ||
| No | 75 (60.0%) | 39 (40.0%) | ||
*: P<.05 is considered significant
The results emphasize the importance of addressing the menstrual hygiene needs of adolescent girls. Despite the high availability of menstrual materials, significant concerns about leakage, attending school and social events, disposal, and social visibility of disposal practices persist. These findings highlight the need for targeted interventions, educational programs, and awareness campaigns to address the concerns and challenges faced by adolescent girls regarding menstrual hygiene.
The findings of this study provide significant insights into the menstrual hygiene practices and challenges faced by adolescent girls in North East India. The mean age at menarche among participants was consistent with global trends, underscoring the onset of puberty around the early teenage years.[1] The high prevalence of menstrual cramps (63.1%) as the most common problem aligns with a study conducted by Amatya P et al.[2] from Nepal, indicating that dysmenorrhea is a widespread issue affecting the majority of adolescent girls. This finding is critical as it emphasizes the need for effective pain management strategies to enhance the quality of life and school attendance among these girls.
The use of sanitary pads by 93.2% of the participants reflects an encouraging trend towards the adoption of safer menstrual products. However, the reliance on cloth by a small percentage (3.4%) indicates that economic and accessibility barriers still exist for some girls, echoing findings from other low- and middle-income countries.[3] The variation in disposal methods, with a significant number using dustbins (47.2%) and burying pads (36.9%), highlights the lack of uniformity in sanitary disposal practices. This inconsistency could be attributed to differences in local infrastructure and cultural practices, similar to observations made in rural Kenya where disposal practices varied widely due to infrastructural limitations.[4]
The study also revealed substantial concerns about leakage and disposal visibility, with 64.2% and 67.0% of girls sometimes worried about these issues, respectively. These concerns are reflective of the broader stigmatization and cultural taboos surrounding menstruation, which have been documented in various cultural contexts, including Nepal and Ethiopia.[5,6] Addressing these worries through education and improving sanitary facilities can significantly enhance menstrual hygiene management and reduce associated anxiety among adolescent girls.
The Chi-square analysis indicated no significant association between the type of menstrual material used and the common menstrual problems faced. This suggests that while the type of menstrual product may not directly influence menstrual problems, the overall menstrual hygiene practices and access to adequate materials are critical for managing menstrual health effectively. This finding is consistent with studies that emphasize the importance of comprehensive menstrual hygiene management over the mere availability of sanitary products.[7]
The responses to open-ended questions provided qualitative insights into the lived experiences of these girls. Thematic analysis revealed that cramps, mood swings, and irregular periods were prevalent issues, with many girls expressing a need for better menstrual health education and support. These qualitative findings align with data from several studies in India and highlight the multifaceted nature of menstrual health challenges, encompassing physical, emotional, and social dimensions.[9]
Despite the relatively high availability of menstrual materials and access to water reported by participants, the persistent concerns about leakage, disposal, and social stigma indicate that merely providing sanitary products is insufficient. There is a critical need for holistic interventions that address the socio-cultural barriers to effective menstrual hygiene management as highlighted from a systematic review conducted in low- and middle-income countries.[10] Educational programs that dismantle myths and stigmas, coupled with infrastructural improvements in schools, can create a supportive environment for adolescent girls.
This study adds valuable insights to the existing literature by highlighting the unique cultural and social dynamics influencing menstrual hygiene practices among adolescent girls in North East India, a region previously under-researched in this context. It underscores the high prevalence of menstrual cramps and widespread use of sanitary pads, highlighting concerns about leakage, disposal practices, and social stigma. The study highlights the need of a targeted intervention and educational programs through a comprehensive approach combining quantitative and qualitative insights. However, the study has limitations, including a relatively small sample size and the potential for response bias, as data were collected through self-reported questionnaires. Additionally, the cross-sectional design limits the ability to establish causal relationships. Despite these limitations, the study’s insights are crucial for developing policies and interventions to enhance menstrual hygiene management and overall well-being among adolescent girls in this region.
CONCLUSION
This study provides a comprehensive analysis of the menstrual hygiene practices and challenges faced by adolescent girls in North East India, highlighting significant issues such as the high prevalence of menstrual cramps, persistent concerns about leakage, disposal practices, social stigma and a lack of supportive environment during menstruation. By offering a nuanced understanding through both quantitative and qualitative data, this research contributes valuable insights for policymakers, healthcare professionals, and educators aiming to improve menstrual health management. There is a need for targeted interventions, educational programs, and infrastructural improvements to address these challenges effectively. Future studies should explore longitudinal data to establish causal relationships and assess the long-term impact of implemented interventions, as well as broaden the geographical scope to include diverse socio-cultural settings within India.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
To the school authorities for the permission and the support to conduct the study.
Funding Statement
Nil.
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