'We do not know': a qualitative study exploring boys perceptions of menstruation in India

Perspectives on menstrual policymaking and community-based actions in Catalonia (Spain): a qualitative study

BACKGROUND

Menstrual research and policymaking have become imperative worldwide. It is necessary that these are informed by women and people who menstruate (PWM) alongside expert professionals and activists.

METHODS

The main aim of this study was to identify and propose policies and community-based actions to address menstrual inequity and promote menstrual health in Catalonia (Spain). This study consisted of two qualitative studies: (a) 34 individual photoelicitation interviews with women and PWM, (b) a World Café study with 22 professionals and activists. Sampling for both studies was purposive and selective. Recruitment was conducted through healthcare centres, social media, key contacts, and snowball sampling techniques. Data were collected in December 2020-September 2022, and analysed using Framework Analysis.

RESULTS

Participants considered the implementation of menstrual policies that address the taboo and stigma of menstruation to be crucial. They stressed the need for menstrual education, which should be integrated into formal education curricula. Participants, and especially women and PWM, highlighted the need to improve the access and quality of healthcare services, so that the menstrual cycle and menstruation are seen as health indicators. Health professionals should encourage agentic informed decisions, hence why both participant groups considered menstrual health education amongst health professionals to be pivotal. Taking action to improve the access and affordability of menstrual products was also imperative for participants, especially for socioeconomically vulnerable populations. Participants agreed on guaranteeing fully equipped menstrual management facilities, and and professionals discussed gender-neutral and sex-segregated bathrooms. Workplace menstrual policies to accommodate and ensure menstrual self-care were also suggested.

CONCLUSIONS

Our study highlights the need for multi-dimensional menstrual policies. These should include actions to address menstrual taboo and stigma, to promote menstrual education that goes beyond the hegemonic biomedical prism, to improve the access and quality of menstrual health services, along with policies ensuring adequate menstrual management facilities in public spaces and the access to menstrual products. Policymaking should also focus on how to ensure menstrual management and care in workplaces. Menstrual policies and community-based actions should be framed within intersectionality, to consider how societal structures of power and oppression influence menstrual experiences.

Effects of the Involvement of Male Counterparts in the Menstrual Hygiene Management of Women and Adolescent Girls With Disabilities in Selected Sub-districts of Bangladesh: Protocol for a Quasi-experimental Study

Background Women and adolescent girls with disabilities suffer the most difficulties during menstruation days in developing countries like Bangladesh. They deal with menstruation in a hazardous and unclean manner. In Bangladesh, men serve as the family's gatekeepers for health-seeking behavior. But they frequently have no idea how unpleasant and demanding menstruation can be. Menstrual hygiene care for women and adolescent girls with disabilities can be improved by involving male peers. In Bangladesh, no such intervention has been assessed. The purpose of the study is to assess the effects of male participation on menstrual hygiene management of women and adolescent girls with disabilities in Bangladesh. Methods This will be a quasi-experimental study with a sample size of 120 (60 - control, 60 - intervention). The study will be conducted in a sub-district of Bogura and Chapainawabganj in Bangladesh. Inclusion criteria for the study participants are women and adolescent girls with disabilities (intervention and control groups) and male counterparts (intervention group). The exclusion criteria for this study are women and adolescent girls with mental and intellectual disabilities. Engaging male peers in menstrual hygiene management is the key intervention in the study. No blinding or randomization will be applied. The expected primary outcome in the intervention group will be an improvement in the menstrual hygiene management of women and adolescent girls with disabilities in the selected sub-districts of Bangladesh. Two times data will be collected from the intervention and control groups using the 'Menstrual Practice Needs Scale-36', 'Perceived Stress Scale', and 'Multi-dimensional Scale of Perceived Social Support'. The analysis of variance (ANOVA) test will be applied to a two-point data series to assess statistical significance. Results The result of the study will be published in a scientific journal. The outcomes of the research will be disseminated to local policymakers and health planners. The health administrator will get evidence-based information on gender-inclusive menstrual hygiene management for women and adolescent girls with disabilities through study result dissemination events. Conclusion This protocol for a quasi-experimental study in Bangladesh highlights the potential advantages of involving male peers in the menstrual hygiene management of women and adolescent girls with disabilities. It may promote gender-inclusive behavior in selected subdistricts of Bangladesh.

Parental knowledge and communication with their adolescent on sexual and reproductive health issues in Nepal

BACKGROUND

Parental knowledge about sexual and reproductive health issues and adequate communication with their adolescent on these issues are crucial in promoting adolescent sexual and reproductive health. Although there are evidence on adolescent perceptions of their sexual health issues, research on parental perspectives of adolescent sexual health and parent-adolescent communication about sexual health issues in Nepal remains unexplored. Therefore, this study aimed to assess parental knowledge and communication practice about sexual and reproductive health with their adolescent children in Lalitpur Metropolitan City of Nepal.

METHODS

A community-based cross-sectional study was conducted between January and March 2019 among randomly selected 308 parents of adolescents (aged 10-19 years) residing in Lalitpur Metropolitan City of Nepal. Face-to-face interviews using structured questionnaires were conducted to collect the data. The collected data were entered into EpiData software v3.1, and data analysis was performed using IBM SPSS Statistics for Windows Version 21.0 (IBM Corp. Armonk, NY, USA). The statistical significance was considered at a p-value <0.05 and a 95% confidence interval (CI).

RESULTS

Of 308 parents, one-third of parents were found to have correct knowledge about safe abortion, menstrual hygiene and management, modern contraceptives, prevention of sexually transmitted infections, wet dreams among male adolescents, abstaining from sexual intercourse during the fertile period, and the possibility of a male adolescent to impregnate a girl. In addition, only 40.9% of parents were found to have communicated with their adolescent children about sexual and reproductive health issues. Parents who have knowledge about puberty (aOR = 2.2, 95% CI: 1.2-3.9), belong to Bharamin/Chhetri ethnic group (aOR = 1.2, 95% CI: 1.1-2.2), self-employed (aOR: 2.4, 95% CI: 1.3-4.0), having two or more adolescent children (aOR = 2.0, 95% CI: 1.1-3.6), and whose adolescent children were staying in school hostel (aOR = 1.7, 95% CI:1.0-3.0) were more likely to have parental communication about sexual and reproductive health with their adolescent children.

CONCLUSIONS

Most parents do not communicate with their adolescent children on sexual health topics, although they feel sexual health education is essential to adolescents. The majority of parents were found inadequately aware of adolescent sexual health issues. It is crucial to have contextual interventions that would encourage parent-adolescent communication on sexual health matters in an integrated way to promote adolescent sexual and reproductive health.

Period shaming behavior among male students in Luang Prabang Province, Lao People's Democratic Republic: A cross-sectional study

Period shaming is defined as any negative and/or disrespectful behavior in relation to the menstrual cycle and menstruating girls. It is suggested that period shaming may limit girls' potential and ability to fully participate in school and community activities. This study aims to examine the prevalence and factors associated with period shaming among male students in Luang Prabang Province, Lao People's Democratic Republic (Lao PDR). This was a cross-sectional study which was conducted during November 19-27, 2020. This study included 1,232 male students from secondary school grade 9 to 12 in Luang Prabang Province, Lao PDR. Informed consent was obtained from the participants, parents/guardians, and teachers prior to data collection. The data was collected by a self-administered questionnaire. Logistic regression was employed to examine factors associated with period shaming behavior among male students. The mean age of the participants was 16.4 years old. Of all the male students, 18.8% admitted that they had shamed girls during their menstruation at least once. Of those who committed period shaming, they shamed girls some of the times (63.2%). Male students who had consumed alcohol during the last month before the data collection day (AOR = 1.83, 95% CI 1.32-2.55, P<0.001), had heard of menstruation (AOR = 1.76, 95% CI 1.27-2.44, P<0.001), and those who had attended activities/classes about sexual reproductive health (AOR = 1.90, 95% CI 1.29-2.78, P<0.01), were significantly associated with period shaming behavior. In conclusion, a single focus on providing biological health education may not be enough to address menstrual stigmatization and taboos. The school curriculum should integrate other life skill education with reproductive health, such as respect and gender equality, to encourage behavioral changes among male students, to address menstrual stigma and to support and empower girls' menstrual health at school and in the community.

A qualitative study regarding menstrual hygiene in a rural community of Haryana, India

INTRODUCTION

Adolescent girls face challenges in menstrual hygiene in routine patterns which impacts their education and health. A qualitative study was undertaken to assess the knowledge and practices regarding menstruation in a rural community of Haryana and to identify the barriers to menstrual hygiene.

METHODOLOGY

The study was conducted in the month of September 2019 among various stakeholders i.e. adolescent females, adolescent males, Accredited Social Health Activist (ASHA) workers, Anganwadi workers, school teachers and Medical Officers. The stakeholders were mapped with the help of a Multi-Purpose Health Worker and ASHA of the village. Interview guides for focus group discussion (FGD) and in-depth interview (IDI) were prepared from previous literature to understand menstrual health management among the stakeholders.

RESULTS

After IDI and FGD, we found that there is a barrier to accessibility of regular sanitary pads, a lack of education on menstrual hygiene among adolescent girls. School absenteeism was a concern due to the unavailability of mechanisms for the disposal of sanitary pads in school and poor maintenance of toilets.

CONCLUSION

Proper implementation of the Adolescent Reproductive Sexual Health program and Menstrual health education can improve the use and reduce stigma and ignorance. Free uninterrupted supply of sanitary pads through school and Anganwadi will help improving accessibility and separate toilets for girls would lead to a reduction in absenteeism.

Socio-cultural implications for women's menstrual health in the Pacific Island Countries and Territories (PICTs): a scoping review

BACKGROUND

Globally, experiences of menarche and subsequent menstruation are embedded in social and cultural beliefs, norms and practices. Menarche is an important developmental milestone in sexual and reproductive health (SRH) for females. Menarche is intertwined with socio-cultural norms, beliefs and practices, which can impact on women's ability to manage menstruation with dignity. This paper reviews the social and cultural factors that affect women's ability to effectively manage their menstrual health and hygiene (MHH) in Pacific Island Countries and Territories (PICTs).

METHODS

A scoping review was conducted following PRISMA scoping review guidelines and inclusion/exclusion criteria. An online search was conducted for peer-reviewed publications in Medline/OVID; Medline/PubMED; PsycINFO; CINAHL; Scopus and JSTOR, and Google Scholar. A search for grey literature was conducted in Google Scholar and websites of international and local organizations. Experts in the field also contributed additional references. Extracted data were summarised in an Excel spreadsheet. Searches were conducted between May and June, 2019, and then repeated in July, 2020.

RESULTS

A total of 11 studies were included; 10 qualitative and one mixed methods study. Studies were conducted in Melanesian (n = 9), Polynesian (n = 1) and Micronesian (n = 1) PICTs. All 11 studies reported elements of societal and personal factors; ten studies reported evidence relating to interpersonal factors; nine studies reported elements relating to environmental factors; and two studies presented evidence linked to biological factors. Managing menstrual health with dignity is challenging for many women and girls because menstruation is associated with menstrual taboos and shame.

CONCLUSION

This review found that the MHH experiences of women in PICTs are affected by social and cultural beliefs, norms and practices. Beliefs, norms and practices about menarche need to be incorporated in SRH planning, programs and education in order to be relevant to diverse village and urban settings.

The More You Know, the Less You Stress: Menstrual Health Literacy in Schools Reduces Menstruation-Related Stress and Increases Self-Efficacy for Very Young Adolescent Girls in Mexico

Improving the menstrual health literacy of girls and boys is a key strategy within a holistic framework of Save the Children's school health and comprehensive sexuality education programming. As menstrual health is an emerging area of study and programming, Save the Children continues to learn and adjust its interventions using program evaluations and rigorous monitoring. This paper will examine program-monitoring data from three cohorts, representing 47 public schools in Mexico City, Puebla, and Mérida, Mexico. The study focuses on female students in 5th and 6th grade who participated in We See Equal, a school-based program centered on gender equality and puberty education, between September 2018 and December 2019. This study used a cross-sectional quantitative cohort approach to document changes in girls' experiences and perceptions around managing menstruation in school. The analysis compares girls' knowledge and experiences before and after participation in We See Equal to understand how knowledge changes over the program and how those changes may contribute to menstruation-related school engagement, stress, and self-efficacy (MENSES) outcomes. Multivariate regression models explored relationships between MENSES outcomes, knowledge and socioeconomic status (SES). Overall, results show that the more knowledge girls acquired, the higher their self-efficacy score and the lower their stress score, however, certain MHH knowledge was more predictive of MENSES outcomes and varied by SES. Among girls from lower SES, we observed significant relationships between knowing what their period was prior to menarche and the three MENSES outcomes. Decreases in menstruation-related stress were driven by items related to the practical knowledge of how to dispose of sanitary pads and reduced feelings of nervousness on days they had their period at school. Increases in self-efficacy were primarily driven by girls' confidence in their ability to track their period from month to month, feelings that they could still do well on an exam if they had their period at school, and security that they could ask a friend to lend them a pad if they needed one. Implications for future menstrual health literacy programming and targeting populations for menstrual health education, as well as priorities for future research will be discussed.

Schools preparedness for menstrual hygiene management: a descriptive cross-sectional study in the West Gonja Municipality, Savannah Region of Ghana

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.

Gender and Sanitation: Women’s Experiences in Rural Regions and Urban Slums in India

Without adequate sanitation facilities, environmental, social, and health risks are common and worsen as the state of sanitation stagnates. Vulnerable groups, specifically women, are unequally affected by poor sanitation. Attitudes towards and perceptions of gender and menstruation have created a health and social discrepancy between women and men. Women must undergo additional obstacles when practicing proper sanitation and managing menstruation. This article utilizes the sanitation insecurity measure to assess the lived experience of women in rural and urban India. This article also discusses accounts of women’s experiences managing menstruation in both the rural regions and urban slums of India and discusses the social implications of the state of sanitation. Examining the issue of sanitation by focusing on menstruation and the dichotomy of men’s and women’s experiences with sanitation and hygiene will indicate that achieving gender equity requires sanitation to be viewed as a human rights, social justice, and education issue.

The persistent power of stigma: A critical review of policy initiatives to break the menstrual silence and advance menstrual literacy

Menstruation is shrouded in stigma and shame-that is the common refrain in burgeoning initiatives on menstrual health and hygiene. Public policies alone cannot undo stigma and enact social change, but they do interact with social norms. They can reflect and adopt stigmatizing attitudes and, as a result, institutionalize, formalize, and legitimize stigma; or they can actively challenge and denounce it and mitigate existing discrimination. Against this background, we explored whether and how policies on menstrual health and hygiene address menstrual stigma and advance menstrual literacy based on an analysis of 34 policy documents and 85 in-depth interviews with policy-makers and advocates in four countries: India, Kenya, Senegal, and the United States. We found that policies recognized menstrual stigma and set out to break the silence surrounding menstruation and advance menstrual education, but they did not contribute to dismantling menstrual stigma. Policy-makers seemed constrained by the very stigma they sought to tackle, resulting in hesitancy and missed opportunities. Policies raised awareness of menstruation, often with great noise, but they simultaneously called for hiding and concealing any actual, visible signs of menstruation and its embodied messiness. Educational initiatives mostly promoted bodily management and control, rather than agency and autonomy. As a result, policies might have succeeded in breaking the silence around menstruation, but stigma cannot be broken as easily. We first need to recognize its (invisible) power and its impacts in all spheres of life in order to actively challenge, dismantle, and redefine it.

Perceptions of Frontline Workers, Female Health Workers, and School Teachers in Menstrual Hygiene Promotion among Adolescent Girls of Delhi, India: A Qualitative Study

Background:

Government schemes for the promotion of Menstrual Hygiene Management (MHM) among adolescent girls in India are underpinned by crucial implementation efforts from the frontline health workers, community health workers, and school teachers.

Aim:

The aim of the study is to identify the perspectives on menstrual health and hygiene management with regard to government schemes for sanitary pad distribution to adolescent girls among the frontline workers and the government school teachers located in urban resettlement colonies in Delhi.

Methods:

In-depth interviews were conducted with 30 accredited social health activisits, 30 Anganwadi Workers (AWW), and 30 auxiliary nurse midwives (ANMs) and five focus group discussions among 28 government school teachers from the middle, high, and secondary standard.

Results:

Most participants recognized the phenomenon of menstruation-related problems in adolescent girls and were aware of some of the common sociocultural, religious, and hygiene-related menstrual restrictions prevalent in their communities. All the participants believed that the pad distribution scheme was highly beneficial. However, in spite of inclusion of menstrual health promotion in the school curriculum, teachers often lacked self-efficacy in discussing challenges and health concerns related to MHM with their students.

Conclusions:

Despite their potential as community resources for adolescent girls, FHWs, ANMs, and school teachers often fail to impart crucial menstrual hygiene information and skills-building needed toward achieving effective, safe, and optimal MHM.

Menstrual health: a definition for policy, practice, and research

The term “menstrual health” has seen increased use across advocacy, programming, policy, and research, but has lacked a consistent, self-contained definition. As a rapidly growing field of research and practice a comprehensive definition is needed to (1) ensure menstrual health is prioritised as a unified objective in global health, development, national policy, and funding frameworks, (2) elucidate the breadth of menstrual health, even where different needs may be prioritised in different sectors, and (3) facilitate a shared vocabulary through which stakeholders can communicate across silos to share learning. To achieve these aims, we present a definition of menstrual health developed by the Terminology Action Group of the Global Menstrual Collective. We describe the definition development process, drawing on existing research and terminology, related definitions of health, and consultation with a broad set of stakeholders. Further, we provide elaboration, based on current evidence, to support interpretation of the definition.

Exploring young women's menstruation-related challenges in Uttar Pradesh, India, using the socio-ecological framework

Menstruation frequently poses psychological, social, and health challenges for young women living in low- and middle-income countries. In countries such as India, where menstruation is stigmatised, it can be particularly difficult. This paper examines challenges related to menstruation for young women living in slums in Lucknow, Uttar Pradesh, India. The research was informed by the socio-ecological model. Life course interviews were conducted with 70 young women ages 15-24 living in the slums of Lucknow. Thematic analysis was used to identify salient themes regarding individual, social, and systemic challenges related to menstruation. On the individual level, young women lack knowledge about menstruation. In the social sphere, young women experience stigma around menstruation, lack opportunities to discuss menstruation, and experience limitations around mobility and other activities during menstruation. At the institutional level, for example in school, there are few resources to support menstruating young women as toilets are dirty and doors are broken. Therefore, menstruating adolescents and young women in Lucknow, Uttar Pradesh, India, face an array of challenges at multiple levels. These findings suggest that multi-level interventions are warranted to create a supportive context for menstruation.

Period teasing, stigma and knowledge: A survey of adolescent boys and girls in Northern Tanzania

Emerging evidence suggests that menstruation-related teasing is a common experience among adolescent girls with ramifications on their school participation, yet empirical evidence on the prevalence and determinants of period teasing in schools remain scarce. Menstrual hygiene research and policies almost exclusively focus on girls and women, leading to a dearth of knowledge of male attitudes. We conducted the first quantitative survey of period teasing in schools in sub-Saharan Africa, focusing on 432 male and 524 female students in four co-educational secondary schools in northern Tanzania. Period teasing is prevalent; 13% of girls have experienced period teasing, and more than 80% fear being teased, especially by male classmates. Girls’ fears are associated with insufficient menstrual hygiene management resources and practices. Girls cope by reducing school attendance, participation, and concentration in the classroom during periods. Boys engage in period teasing because they perceive periods as embarrassing, especially visible markers of periods (odor or stains). Social norms, such as peer behavior and home restrictions on menstruating women, are associated with more teasing. Boys believe it is strongly inappropriate for girls to reveal period status or to discuss periods with males, including male teachers. In contrast, boys are well informed about basic biological facts of menstruation (scoring 60% on a knowledge quiz, not statistically different from the girls) and have received information from school curricula and health workers. Lack of suitable menstrual hygiene practices and restrictive social norms is correlated with period teasing, which hinders gender equality in educational opportunities. Providing narrowly bio-medical focused education about menstruation may not be enough to reduce period teasing in contexts with period stigma.

Menstrual knowledge, sociocultural restrictions, and barriers to menstrual hygiene management in Ghana: Evidence from a multi-method survey among adolescent schoolgirls and schoolboys

On a daily basis, schoolgirls in low and middle-income countries discover blood on their clothing for the first time in school environments without toilets, water, or a supportive teacher, mentor, or role model to help them understand the changes happening in their bodies. This study aimed to examine the menstrual knowledge, sociocultural restrictions, and barriers to menstrual hygiene management in school environment among adolescent schoolgirls in a rural community. We collected quantitative data from 250 adolescent schoolgirls and qualitative data from thirty schoolboys and five schoolteachers in five Junior High Schools in the Kumbungu district of northern Ghana. Binary logistic regression models were fitted to determine the predictors of poor menstrual knowledge. Qualitative data were transcribed verbatim, coded, and organized into themes. Overall, 53.6% of the girls had poor knowledge about menstruation. Most of the boys had heard about menstruation and had an idea about what menstruation is with most of them describing it as "the flow of blood through the vagina of a female." The boys revealed that terms such as "Vodafone," "Red card," and "Palm oil" are used to describe menstruation in the schools and within the community. After adjusting for the effect of other sociodemographic factors, we found evidence that girls in their late adolescents were less likely to have poor menstrual knowledge compared to those aged 10-14 years (aOR 0.20, 95%CI 0.08-0.48). Maternal education was protective against poor menstrual knowledge. When compared to adolescents whose mothers were illiterates, those whose mothers had basic education (aOR 0.62, 95%CI 0.28-1.40) and those whose mothers had secondary or higher education (AOR 0.22, 95%CI 0.06-0.76) were less likely to have poor knowledge about menstruation. Adolescents from homes with no television and radio sets were more likely to have poor menstrual knowledge compared to those from homes with television and radio sets (aOR 2.42, 95%CI 1.41-4.15). Comfort, safety, and cost were the major factors that influenced their choice of sanitary products. Most of the teachers said the schools do not provide students with sanitary products, even in emergencies. We found that girls were not to prepare some local dishes (e.g. Wasawasa) during their periods and are forbidden from participating in religious activities (i.e. read the Holy Quran or pray in the mosque) during the period of menstruation. Open discussions about menstruation and its management are not encouraged and girls are considered unclean and impure during the period of menstruation. None of the schools had a regular supply of water in WASH facilities, a mirror for girls to check their uniforms for bloodstains or soap in the toilet facilities for handwashing. Menstrual education through the standard school curriculum, starting from primary school, could prepare girls for menarche, improve their knowledge on menstruation, and teach boys how to support girls and women during the period of menstruation. This could also eliminate the sociocultural misconceptions surrounding menstruation.

Menstrual Hygiene Preparedness Among Schools in India: A Systematic Review and Meta-Analysis of System-and Policy-Level Actions

With increasing girl's enrolment in schools, school preparedness to ensure a menstrual friendly environment is crucial. The study aimed to conduct a systematic review regarding the existing evidence on menstrual hygiene management (MHM) across schools in India. It further aimed to highlight the actions that have been taken by the government to improve the MHM situation in India. We conducted the systematic literature search using PubMed, EMBASE, and Web of Science for searching the peer-reviewed articles and Google Scholar for anecdotal reports published from inception until 30 October 2019. Of 1125 publications retrieved through the search, 183 papers were included in this review, using a priori created data-extraction form. Meta-analysis was used to estimate the pooled prevalence (PP) of MHM practices in schools. Less than half of the girls were aware of menstruation before menarche (PP 0.45, 0.39 to 0.51, I2= 100.0%, n = 122). Teachers were a less common source of information about menstruation to girls (PP 0.07, 0.05 to 0.08, I2 = 100.0%, n = 86). Separate toilets for girls were present in around half of the schools (PP 0.56, 0.42 to 0.75, I2 100.0%, n = 11). MHM in schools should be strengthened with convergence between various departments for explicit implementation of guidelines.

Menstrual health communication among Indian adolescents: A mixed-methods study

BACKGROUND

Research in health communication frequently views it as an information dissemination strategy, thus neglecting the intricacies involved in communicating a sensitive topic such as menstruation. The social patterning in menstrual communication, a taboo in India, and its consequent health-effects on adolescents are under-studied.

METHODS

We studied the social determinants of menstrual communication influencing menstrual- health through semi-structured interviews of 21 boys and girls each, 12 key-respondent interviews, followed by a cross-sectional survey of 1421 adolescents from Nashik district, India. We thematically analysed the qualitative data and fit multivariable logistic regression to model risk ratios.

FINDINGS

We found social disparities in adolescents' experiences of communication taboo regarding menstruation. While boys curbed their curiosity about the topic, girls too faced resistance to their experience-sharing and treatment-seeking for menstrual illnesses. The inequality in menstruation-related communication was evident as more boys than girls faced avoidance to their questions [IRR at 95%CI: 2.75 (2.04, 3.71)]], and fewer tribal than rural girls were communicated severe taboos (OR at 95% CI: 0.18 (0.09, 0.36))]. Girls who had been communicated severe (versus no/mild) taboos reported greater stress about menstrual staining (IRR at 95% CI: 1.31 (1.10, 1.57)], emphasizing the health consequences of such communication inequalities.

CONCLUSIONS

Our study highlights the need to address gender and setting-specific communication experiences of adolescents in India, a patriarchal society. The inequality in communication needs attention as it creates unequal patterns in Indian adolescents' menstrual health and experiences, which may manifest as inequities in reproductive health-related outcomes even in their adult-lives.

A rite of passage: a mixed methodology study about knowledge, perceptions and practices of menstrual hygiene management in rural Gambia

BACKGROUND

Appropriate menstrual hygiene management (MHM) is impeded by taboos and secrecy surrounding menstruation. Unhygienic menstrual practices and unpreparedness for managing menstruation has been associated with adverse health and social outcomes among adolescent girls. In The Gambia, there is limited data on menstrual practices among girls and women in rural communities and the sources of information about menstruation for the adolescents. This study aimed to explore knowledge, preparedness and practices of menstruation and its management among adolescents, mothers and teachers in rural Gambia.

METHODS

A mixed methods study was conducted in the rural Kiang West district of The Gambia. Twenty focus group discussions and thirteen in-depth interviews were conducted among mothers, adolescents and teachers to explore their views on menstruation, cultural beliefs, sources and level of knowledge on menstruation and MHM practices. In addition, a survey was done among 331 school girls to assess their knowledge, practices and attitudes of menstruation and its management. Inductive content analysis was used to analyse the qualitative data, and descriptive analysis and chi-squared tests were used to analyse quantitative data.

RESULTS

All participants had different levels of knowledge about menstruation. Knowledge score was higher among post-menarche girls compare with pre-menarche girls (p = 0.0001). All groups expressed difficulties, embarrassment and shame in relation to discussing menstruation. Two thirds of the surveyed girls reported having learnt about menstruation before menarche, however at menarche most felt unprepared. Teachers were the main source of information, but when asking for advice most girls preferred to ask their mothers. Mothers reported facing difficulties in discussing menstruation with their children and felt that boys did not need to be taught about it, however boys were very curious to know about. Most girls used reusable cloth unless they are given free pads from school.

CONCLUSION

Taboos, secrecy and embarrassment associated with discussing menstruation hinder adolescents from seeking advice from parents and teachers on appropriate MHM practices. Strategies to encourage positive social norms towards menstruation would help to promote more open discussions about it at the family, community and national level, which will support improvements in MHM in this and similar communities in low and middle income settings.

Do Water, Sanitation and Hygiene Conditions in Primary Schools Consistently Support Schoolgirls' Menstrual Needs? A Longitudinal Study in Rural Western Kenya

Many females lack access to water, privacy and basic sanitation—felt acutely when menstruating. Water, sanitation and hygiene (WASH) conditions in schools, such as access to latrines, water, and soap, are essential for the comfort, equity, and dignity of menstruating girls. Our study was nested within a cluster randomized controlled pilot feasibility study where nurses provided menstrual items to schoolgirls. We observed the WASH conditions of 30 schools from June 2012–October 2013 to see if there were any changes in conditions, to compare differences between study arms and to examine agreement between observed and teacher-reported conditions. Data came from study staff observed, and school teacher reported, WASH conditions. We developed scores for the condition of school facilities to report any changes in conditions and compare outcomes across study arms. Results demonstrated that soap availability for students increased significantly between baseline and follow-up while there was a significant decrease in the number of “acceptable” latrines. During the study follow-up period, individual WASH indicators supporting menstruating girls, such as locks on latrine doors or water availability in latrines did not significantly improve. Advances in WASH conditions for all students, and menstrual hygiene facilities for schoolgirls, needs further support, a defined budget, and regular monitoring of WASH facilities to maintain standards.