|Year : 2020 | Volume
| Issue : 3 | Page : 117-123
Social determinants of menstrual hygiene among school-going girls in a rural area of Southern Haryana, India
Avinash Surana1, DR Rajesh2, Rakesh Tank3, Abhishek Singh4, Vikas Gupta5, Deepika Agrawal6, Virender Kumar Chhoker7
1 Additional Health Director, Infantry Division, 14 Coprs, Bareilly, India
2 Department of Forensic Medicine, Indira Gandhi Medical College, Puducherry, India
3 Department of Internal Medicine, SHKM Government Medical College, Nalhar, Haryana, India
4 Department of Community Medicine, SHKM Government Medical College, Nalhar, Haryana, India
5 Department of Community Medicine, Government Medical College, Shahdol, Madhya Pradesh, India
6 Department of Community Medicine, Santosh Medical College, Ghaziabad, Uttar Pradesh, India
7 Department of Forensic Medicine, Santosh Medical College, Ghaziabad, Uttar Pradesh, India
|Date of Submission||19-May-2020|
|Date of Decision||06-Jul-2020|
|Date of Acceptance||11-Jul-2020|
|Date of Web Publication||27-Jul-2020|
Department of Community Medicine, Government Medical College, Shahdol, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Several factors associated with menstrual hygiene are modifiable and if such factors are identified and addressed, it can go a long way in promoting good menstrual hygiene practice among adolescent girls. The present study was conducted with an aim to investigate the social determinants for menstrual hygiene-related knowledge and practices among rural school-going girls. Methods: This cross-sectional study included 649 school-going girls (12–19 years) from two government schools. A pretested, predesigned, standardized questionnaire was prepared which included demographic details such as age, sociodemographic characteristics, knowledge regarding menstruation, restrictions practiced, absenteeism during menstruation, the practice of menstrual hygiene. Multiple logistic regression model at a significant level of 0.05 was used. Results: The mean age of menarche in the study population was 12.8 ± 1.73 years. Mother's education and family socioeconomic status showed a trend with poor menstrual hygiene. The study participants belonging to the age group of 12–14 years were nearly 2.3 times more likely to have poor hygiene practices than the study participants belonging to the age group of 18 years or more. Absence of sanitary latrines (adjusted odds ratio [OR]: 2.34, 95% confidence interval [CI]: 1.65–3.31, P = 0.000), lower class in school (adjusted OR: 11.65, 95% CI: 7.19–18.86, P = 0.010), and joint families (adjusted OR: 2.19, 95% CI: 1.42–3.32, P = 0.022) also showed a high positive association with the odds of practicing poor menstrual hygiene. Conclusion: This study reveals that adolescent girls in rural area had ignorance, false perceptions, and unsafe practices regarding menstruation. Thus, the above findings reinforce the need to encourage safe and hygienic practices among the adolescent girls and bring them out of the traditional beliefs, misconceptions, and restrictions regarding menstruation.
Keywords: Determinants, factors, girls, menstrual hygiene, school
|How to cite this article:|
Surana A, Rajesh D R, Tank R, Singh A, Gupta V, Agrawal D, Chhoker VK. Social determinants of menstrual hygiene among school-going girls in a rural area of Southern Haryana, India. Soc Health Behav 2020;3:117-23
|How to cite this URL:|
Surana A, Rajesh D R, Tank R, Singh A, Gupta V, Agrawal D, Chhoker VK. Social determinants of menstrual hygiene among school-going girls in a rural area of Southern Haryana, India. Soc Health Behav [serial online] 2020 [cited 2021 Jan 19];3:117-23. Available from: https://www.shbonweb.com/text.asp?2020/3/3/117/290980
| Introduction|| |
Menstruation is a natural phenomenon among matured females who experience shedding of blood for 1–7 days every month from the age of maturity until menopause. Every year, May 28 is considered the Global Menstrual Hygiene Day. Although menstruation is a normal biological process and a key sign of reproductive health, in various cultures, it is treated as something negative, shameful, or dirty, and it is often not discussed openly in our society, considering menstruation to be an inconvenient or embarrassing topic to discuss. Menstrual practices are still shrouded by taboos and sociocultural restrictions. Various aspects such as the physiology, pathology, and psychology of menstruation have been found to associated with the health and well-being of women; hence it is an important issue concerning the morbidity and mortality of female population.
About one-fifth (21.4% or 243 million) of the India's population is constituted by the adolescents who can transform the social and economic fortunes of the country. Adolescent girls constitute a vulnerable group not only with respect to their social status but also in relation to health. Girls experience menstruation for the first time during adolescence. Adolescent girls are restricted due to various social misconceptions, low socioeconomic conditions, and lack of proper health education either at home or at school. These affect their health and educational attainment. Adolescent girls are often reluctant to discuss the topic regarding menstruation with their parents and often hesitate to seek medical help regarding menstrual problems.
Hygiene-related practices during menstruation are of considerable importance for reproductive health because poor practices increase vulnerability to reproductive and urinary tract infections. Good hygiene, such as use of sanitary pads and adequate washing of the genital area, is essential during menstruation. Moreover, inadequate and inappropriate water, sanitation, and hygiene facilities in schools, especially in rural areas, hinders menstruation practices healthily, safely, and with dignity. Primarily, poor personal hygiene and unsafe sanitary conditions result in gynecological problems such as ectopic pregnancy, infertility, and chronic pelvic inflammatory disease. Repeated use of unclean napkins or the improperly dried cloth napkins before their reuse results in harboring of microorganisms causing vaginal infections. Infections due to lack of hygiene during menstruation are often not reported.
Many studies have been done in India focusing on menstrual hygiene, but so far, very few studies on this topic have been done in the rural area of Haryana as rural areas have inadequate and inappropriate water, sanitation, and hygiene facilities in schools, which hinders menstruation practices healthily, safely, and with dignity. With this background, the present study was conducted among school-going adolescent girls in a rural area of Haryana with objectives to study the sociodemographic profile of the school-going adolescent girls including those aged 18 years or above, to find out the menstrual hygiene practices among the study participants, and to determine the factors affecting the existing poor menstrual hygiene practices.
| Methods|| |
Study area and study period
The present study was conducted during January to March 2019 in the service area of rural health center, Nalhar, which also happens to be the field practice area under the aegis of the Department of Community Medicine, SHKM Government Medical College (GMC), Nalhar, Haryana.
Study design and participants
This cross-sectional study included school-going girls (12–19 years) as participants.
A total of 15 secondary schools including ten government and five private schools were listed in the study area and the school principals were approached to obtain permission for conducting the study. Only two government schools provided permission for conducting study and following which interview dates of study were fixed. Both schools granted permission to conduct study only from ninth standard onward. The line listing of students from the 9th standard to 12th standard was done for both the schools; the total number of students was about 840. After satisfying the inclusion criteria (students who had attained menarche at the beginning of the study period, studying in the 9th–12th standards, and having current age between 12 and 19 years) and exclusion criteria (students who were seriously ill such as malaria [fever in the evening hours associated with chills], severe anemia [extreme paleness of either palm or tongue or lower inner side of the eyelids], high-grade fever [temperature of 39.4°C or more], present history of urinary or vaginal discharge or burning micturition, and psychological distress [a score of 3 or more on General Health Questionnaire-12]), out of 840 participants, 649 students were included in the study.
The sample size was calculated (n = 601) considering the proportion of adolescents having poor hygiene practices as 50% (studies not found in rural Haryana) with a confidence level of 95% and 5% absolute allowable error by applying the following formula: N = (Z1−a/2)2 × p (1 − p)/d2, where Z = standard normal variate for level of significance (at 5% type I error [P < 0.05], Z = 1.96 for two-sided test), a = level of significance (0.05), P = prevalence (proportion – 50%), d = absolute allowable error (4%), and n = sample size. Though the calculated sample size came out to be 601, a sample of 649 study participants was included in the study.
A pretested, predesigned, standardized questionnaire was prepared. The questionnaire included demographic details such as age, sociodemographic characteristics, knowledge regarding menstruation, restrictions practiced, absenteeism during menstruation, and the practice of menstrual hygiene. The questionnaire was first prepared in English. Then, it was translated into Hindi by an expert in that language keeping semantic equivalence. To check the translation, it was back translated into English by two independent researchers who were unaware of the first English version.
A total of 43 collected questions were subjected to content validation by a panel of ten medical experts. The purpose was to identify the items with a high degree of agreement among experts. Aiken's V was used to quantify the concordance between experts for each item. Only 26 questions that had an Aiken's V > 0.7 were selected for the study. All efforts were made to keep the questions simple and unambiguous according to the objectives of the study.
The questionnaire focusing on baseline menstrual hygiene practices details consisted of nine questions, i.e., type of absorbent used, absorbent changing time, cleaning of genitalia during last menstrual cycle, material used for genitalia cleaning, reutilizing the clothes, place for washing the re-utilizable clothes, use of soap for washing clothes, drying the re-utilizable clothes in sunlight, and disposal of menstrual absorbent. Every question was compulsory and consisted of different sets of responses for various questions, and scoring was done on the basis of response to each of the question which ranged between 9 and 24. Equal or more than median of the attained score was considered good, whereas less than median of the attained score was considered poor.
Socioeconomic status (SES) was obtained using the modified B. G. Prasad Socioeconomic Status Classification (revised for the year 2019, CPI 2001 as base). It is based on per capita monthly income and based on it has five categories such as Class I (Rs. 7008 and above), Class II (3504–7007), Class III (2102–3503), Class IV (1051–2101), and Class V (1050 and below).
Day-to-day activity included briefing of the study through face-to-face interaction among students of different classes. After that, the questionnaires were self-administered by participants under the direct supervision of the investigator and also care was taken that no consultations were made with the fellow students by strict vigilance with the help of school teachers. The participants took part in the batches of 12–15 counts per se ssion so that day-to-day academic activities of school are not hampered. In this way, all the selected students were covered in the study during the defined period. The questionnaire required 30–45 min per batch to be completed. The completed questionnaires were then collected and checked for completeness.
The collected data were entered in the MS Excel spreadsheet, coded appropriately, and later cleaned for any possible errors. The analysis was carried out using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA). During data cleaning, more variables were created so as to facilitate the association of variables. Clear values for various outcomes were determined before running frequency tests. Categorical data were presented as percentages (%), whereas continuous data were presented as median and interquartile range. Multivariable logistic regression was done to find out the strength of association between dependent variables and independent variables. First, a univariate regression was done to ascertain the relationship of the dependent variables with other independent variables. Only those found to be significant were entered into the multiple logistic regression model. All tests were performed at a 5% level of significance; thus, an association was statistically significant if P < 0.05.
Ethical approval was obtained from the SHKM GMC Institutional Ethical Committee, Nalhar (approval letter number: EC/OA-10/2018). Written informed consent from the parents and assent from the student were obtained, and anonymity and confidentiality of the participants was maintained throughout the study.
| Results|| |
The present study was conducted in two government schools with a total of 649 participants studying in 9th to 12th standards. Overall mean age (±standard deviation [SD]) of the study participants was 15.5 ± 1.09 years. The mean age (±SD) of menarche in the study population was 12.8 ± 1.73 years. Mothers of more than two-fifth of the participants (43.5%) were illiterate, and majority of the participants (82.2%) belonged to Muslim religion. More than half of the participants (58.1%) were staying in joint families, and no sanitary latrine was available at home among more than two-third of the participants (67.5%). Nearly one-fourth of the participants (26.3%) were never exposed to advertisements in mass or social media regarding the usage of sanitary pads [Table 1].
Out of every five participants, only three of them (59.9%) were having knowledge about menstruation before their onset of menarche and their primary source of that knowledge was their mother or sister (44.7%). Nearly two-fifth of the participants (39.4%) were having awareness regarding causation for menstruation and more than half of the participants (59.3%) were aware that uterus was the source of blood in menstruation [Table 2].
|Table 2: Knowledge about menstruation among the study participants (n=649)|
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In majority of the participants (88.1%), restrictions during menstruation were noticed, and restricting cooking food (84.1%) and religious activities (86.7%) were the most common restrictions. More than two-third of the participants (67.8%) were absent from school during their last menstrual period and the major reasons for their absence were lack of proper disposal facility of sanitary napkins (79.6%) and continuous water supply for washing (70.1%) in their school [Table 3].
|Table 3: Restrictions practiced and absenteeism during menstruation among the study participants (n=649)|
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More than half of the study participants (57.3%) were using only cloth as absorbent during menstruation, and in nearly three-fourth of the participants (72.5% and 73.8%), the absorbent changing and genital cleaning frequency was <4 times a day during menstrual cycle, respectively. Majority of the participants (68.3%) used only water for cleaning genital area. Practice of reutilization of cloth was observed in more than four-fifth of the participants (83.9%), and pond water was used for washing the cloth in more than three-fourth of the participants (75.5%). More than one-third of the participants (37.7%) disposed menstrual absorbent in latrine. The median score for practicing menstrual hygiene was 12 with interquartile range between 10 and 15. Out of the 649 study participants, 283 participants (43.6%) had a median score <12, which means that 43.6% were practicing poor menstrual hygiene [Table 4].
|Table 4: Practice of menstrual hygiene among the study participants (n=649)|
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The step-wise logistic regression analysis in [Table 5] reveals the poor menstrual hygiene practices using sociodemographic variables, of which majority were found to be statistically significant. The study participants belonging to the age groups of 12–14 years and 15–17 years were nearly 2.3 and 1.3 times more likely to be have poor hygiene practices, respectively, than the study participants belonging to the age group of 18 years or more (adjusted odds ratio [aOR]: 2.29, 95% confidence interval [CI]: 1.52–3.42, P = 0.022, and aOR: 1.35, 95% CI: 0.90–2.02, P = 0.124), respectively.
|Table 5: Independent association of variables and menstrual hygiene among the study participants (logistic regression analysis) (n=649)|
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Mother's education and family's SES showed a trend with poor menstrual hygiene, where the study participants with illiterate mothers and lower SES class families had 3.1 and 9 times more odds of practicing poor menstrual hygiene, respectively, than the study participants with mother's higher education level and family with upper SES class (aOR: 3.13, 95% CI: 1.71–5.7, P = 0.031, and aOR: 9.00, 95% CI: 2.27–35.64, P = 0.000), respectively.
| Discussion|| |
In the present study, only 59.9% of the study participants were having premenarchial knowledge about menstruation, which was similar to the studies conducted by Dasgupta et al., Ray et al., and Deo et al., where 32.5%, 42%, and 42.5% of the study participants had premenarchial knowledge about menstruation, respectively.,, It is desirable that awareness about menstruation shall be universal to each and every girl, as it is a vital event at the threshold of adolescence and ideally before the attainment of menarche. Before bringing any change in menstrual practices, the girls should be educated about the facts of menstruation, physiological implications, the significance of menstruation, and, above all, proper hygienic practices with selection of disposable sanitary menstrual absorbent.
Mothers must play a very important role for their health education by freely discussing all aspects of menstrual matters including clean practices without any hesitation with her daughter before her attainment of menarche. The next best are the teachers who may conduct classes on menarche, menstrual hygiene, reproductive tract infection, or sexually transmitted infection under the routine school curriculum. However, mother was the first informant only in case of 44.7% of study participants, which is similar to the findings of studies by Dasgupta et al., Ray et al., and Sarkar et al., where in 37.5%, 45%, and 50% of cases, mother was the first informant.,,
In addition, studies conducted by Jailkhani et al., Damor et al., and Jogdand et al. found that the main source of information regarding menstruation was mother.,, However, the present study findings are in contrast to the studies conducted by Yasmin et al. and Juyal et al., where it was reported that in most cases their first informant regarding menstruation was their friend., This observed gap in the present study suggests that poor literacy and SES of mothers have fueled the inhibitions that a mother has to talk to her daughter regarding menarche and the significance of menstrual hygienic. This will play a long way in maintaining a healthy reproductive tract for each and every girl child who, after she becomes a mother, percolates the healthy message to her female offspring.
In the present study, it was observed that 44.4% of the study participants were not aware of the mechanism or natural phenomenon of menstruation, which is similar to the study done by Ray et al., where 34% of the study participants were unaware about the natural phenomenon of menstruation. However, their awareness about menstruation has a wide range in various studies as a study conducted by Khanna et al. showed that nearly 70% of the participants considered that menstruation was not a natural process, whereas in studies done by Sarkar et al., Yasmin et al., and Kamath et al., it was observed that 87%, 72.8%, and 68.9% of girls believed menstruation to be a physiological process and natural phenomenon.,,,
It was very unfortunate to observe in the present study that most of the girls did not know about the source of menstrual bleeding, and only 59.9% knew that the source of blood was uterus, which is consistent with the finding of Yasmin et al., which elicited that 63.3% of the respondents knew that bleeding occurs from the uterus, whereas studies by Singh et al., Sarkar et al., and Ray et al. showed that only 32%, 28.3%, and 17.9% of the study participants had a correct knowledge about the source of menstrual blood as uterus. The above observation might be due to poor literacy level of mothers or absence of proper health education programs in schools focusing on menstrual hygiene.,,,
In the present study, 57.3% of the girls preferred cloth pieces rather than sanitary pads as menstrual absorbent, only 11.6% of girls used only sanitary pads during menstruation, and around 31.1% used both reusable cloth pieces and sanitary pads. Apparently, poverty, high cost of disposable sanitary pads, and to some extent ignorance dissuaded the study participants from using the menstrual absorbents available in the market. The present study findings are consistent with the studies conducted by Khanna et al., Ray et al., and Sarkar et al., where nearly 75%, 62.6%, and 31.3% of the girls used old cloth during their periods. In contrast, studies done by Yasmin et al., Damor et al., and Singh et al. showed that 82.3%, 52.34%, and 38% of the study participants used only sanitary napkins as menstrual absorbent.,,,,,
Many restrictions were imposed on the participants in the present study, such as not performing religious activities, not cooking food, not washing head, and avoiding sour food, with not attending school being the most common. This is very similar to the studies conducted by Dasgupta et al., Ray et al., Sarkar et al., and Jogdand et al., where not performing religious rituals was found to be the most common restriction observed. In the present study, 67.8% of the study participants restricted school during menstruation, which is in contrast to the findings of Dasgupta et al. and Ray et al., where only 16% and 39% of the participants reported school absenteeism, respectively. Therefore, it is strongly felt that it should be mandatory for all schools to have separate, private clean toilets for the girl students with running water and proper disposal facility for sanitary pads. Moreover, periodic health checkups with special emphasis on RTI is the need of the hour.,,,
The median score for practicing menstrual hygiene was 12 with interquartile range between 10 and 15. Out of the 649 study participants, 283 participants (43.6%) had a median score <12, which means that 43.6% were practicing poor menstrual hygiene. It was observed in the present study that the usual practice was to wash the cloth with soap in the pond after use and keep it at some secret place till the next menstrual period. To keep the cloth away from prying eyes, these were sometimes hidden in unhygienic places. Privacy for washing, changing, or cleaning purpose is something very important for proper menstrual hygiene, but in this study, lack of privacy was an important problem both at home and at school. The lack of privacy may be enhanced due to the absence of sanitary latrines at home and school and due to belonging to mostly joint or extended families. Similarly, studies conducted by El-Gilany et al., Ray et al., and Sarkar et al. showed that the different aspects of personal hygiene were generally found to be poor, such as using only cloth as absorbent during menstruation, less frequently changing the absorbent and cleaning the genital during menstrual cycle, using only water for cleaning genital, reutilizing the cloth, using pond water for washing the cloth, and disposing menstrual absorbent in latrine.,,
The major determinants of poor menstrual hygiene practice have been found to be illiteracy of the mothers, lower educational status of the adolescent girls, no exposure to mass or social media in the form of advertisements promoting the use of sanitary pads, joint or extended families, lower SES, and absence of proper sanitary latrine at home. Similarly, studies conducted Khanna et al., Ray et al., Sarkar et al., and Jailkhani et al. found that schooling, residential status, occupation of father, caste, and exposure to media were found to be the major predictors of safe menstrual practices.,,,
| Conclusion|| |
This study reveals that adolescent girls in rural area are the most deprived and underprivileged, while ignorance, false perceptions, unsafe practices regarding menstruation, and reluctance of the mother to educate her child are also quite common among them. Improving education level of the mothers can go a long way in improving menstrual hygiene practice. Thus, the above findings reinforce the need to encourage safe and hygienic practices among the adolescent girls and bring them out of the traditional beliefs, misconceptions, and restrictions regarding menstruation.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]