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.
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.
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,
Menstrual hygiene education, accessible sanitary products, pain relief, and adequate sanitary facilities at school would improve the schooling-experience of adolescent girls in India.
To achieve gender equality, it is important that girls can attend and reach their full potential in schools [
According to 2011 census estimates (the latest available census data), 10% of India’s population were female adolescents aged 10-19 years, which translates into approximately 120 million girls [
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 menstrual 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 [
In light of these government initiatives, a study was developed to evaluate progress on menstrual management 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 representative 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.
The study was carried out in the states Chhattisgarh, Maharashtra, and Tamil Nadu, representing the diverse cultural and socio-economic spectrum in India (Table S1 in
A total sample size of 1800 adolescent girls (600 girls per state, about 75 girls per school), would be sufficient to measure a state-based prevalence of 50% with 95% confidence interval and 5% of margin error, taking clustering into account and using a design effect of 1.5. Multi-level stratified sampling was used for each state, by first randomly selecting one district in each of the three states. In each of the selected 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 schools (regular) after excluding boys’ only schools, solely residential, and private schools (Figure S1 in
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 consent were conducted to discuss the study and respond to questions before girls assented. Pre-tested structured 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 officers supervised the field data collection team who received intensive one-week training before the start of the study.
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. Significant differences were explored at the state level and model vs regular schools overall and within states (χ2 test). To assess factors associated 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 following 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
The study was approved by the Tata Institute of Social Sciences, Mumbai, and the Liverpool School of Tropical Medicine, UK, after fulfilling all the ethical requirements. Participant information sheets, describing 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.
Of the 3617 girls who participated, 2564 (70.9%) reported they had begun menstruating and were included in this analysis. These menstruating girls attended 43 randomly selected regular schools (N = 2072) and 10 model schools (N = 492) in the 3 states (
Characteristics of participating schools and girls by state and school type, India 2015
Maharashtra |
Chhattisgarh |
Tamil Nadu |
All 3 states | ||||
---|---|---|---|---|---|---|---|
|
|
|
|
|
|
|
|
|
|||||||
Number of schools |
12 |
4 |
12 |
4 |
19 |
2 |
53 |
Type of school: |
|||||||
-Co-education |
10 |
3 |
10 |
0 |
18 |
0 |
41 |
-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) |
0 |
36 (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 |
|
|||||||
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
*
†
‡
§Other: Christian, Buddhist, Jain etc.
Nearly all (93%) menstruating girls had received some information about menstruation (
Girls’ awareness of menarche and source of information by state and school type, India 2015
Maharashtra |
Chhattisgarh |
Tamil Nadu |
All 3 states | ||||
---|---|---|---|---|---|---|---|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
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) |
|
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.
†
‡
§
‖
¶
**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).
Religious restrictions (not going to temple,
Restrictions (%) during menstruation among school girls in three states in India, 2015. Religious restrictions:
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 (
Items (%) used to deal with menstruation in three states in India, 2015. Disposable pads:
The majority of girls reported going to school during their menstruation (87%,
Effect of menstruation on school experience
Maharashtra |
Chhattisgarh |
Tamil Nadu |
All 3 states | ||||
---|---|---|---|---|---|---|---|
|
|
|
|
|
|
|
|
|
N = 664 |
N = 173 |
N = 691 |
N = 236 |
N = 717 |
N = 83 |
N = 2564 |
|
|||||||
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) |
0 |
265 (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) |
|
|||||||
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) |
|
|||||||
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) |
|
|||||||
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 item‖ |
152 (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) |
*
†
‡
§
‖
¶
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%;
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 |
|
|||||||
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) |
0 |
130 (5.1) |
|
|||||||
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) |
0 |
323 (12.6) |
No response |
33 (5.0) |
16 (9.3) |
79 (11.4) |
11 (4.7) |
8 (1.1) |
0 |
147 (5.7) |
|
|||||||
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) |
0 |
192 (7.5) |
|
|||||||
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) |
0 |
89 (3.4) |
|
|||||||
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) |
0 |
99 (3.9) |
|
|||||||
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) |
0 |
720 (28.1) |
No response | 12 (1.8) | 12 (6.9) | 42 (6.1) | 12 (5.1) | 17 (2.4) | 0 | 95 (3.7) |
*Other included responses such as queuing before toilet, toilet unusable, no toilet present, go home for change
‡
§
‖
¶
Only 27% of girls reported that their schools had good disposal facilities for menstrual waste, and options varied widely across states and schools (
Disposal options (%) of menstrual items in schools in three states in India, 2015. *Excluding participants who used reusable pads or cups. Pit:
Overall, 21% of girls reported they could get pain relievers for menstrual cramps in the school when needed, with a significantly higher proportion in model (39%) compared with regular schools (17%) in all states (
Facilitators of menstrual hygiene (%) in schools in three states in India. Good disposal facilities:
Overall, 34% of girls reported to have received education about menstrual hygiene in school; the proportion differed significantly by state, type of school and within states (Table S5 in
Numerous factors were associated with missing school during menstruation in univariate analysis (
Factors associated with missing school during menstruation by adolescent girls, 3 states in India, 2015
Factor |
Univariate analysis |
Multivariate analysis |
|||
---|---|---|---|---|---|
|
|
|
|
|
|
|
|||||
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 |
|
|
|
|||||
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 |
|
|
|
|
|||||
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 |
|
|||||
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 |
|
|
|||||
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 |
|
|
|
|||||
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 |
|
|
|
|||||
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 |
|
|
|
|||||
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 |
|
|
|
|||||
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 |
|
|||||
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 |
|
|
|
|||||
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 |
|
|
|
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 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 |
|
|||||
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 – confidence interval, MH – menstrual hygiene, NR – not reported, NS – not significant
*All analyses adjusted for school as cluster. Factors explored but not significant included class, time of transport to school, and means of transport to school. No interactions of interest were noted between significant variables.
†Tampons or menstrual cups.
§Other included responses such as queuing before toilet, toilet unusable, no toilet present, go home for change.
This study explored the current progress of both government and external agencies to reduce the barriers menstruation causes for schoolgirls in India, and identified 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) compared 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 Tamil 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 five 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 [
Approximately half of girls reported using disposable pads. The high use in Tamil Nadu reflects the implementation of the free sanitary pads scheme in this state [
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 findings 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 questionnaires were pre-tested to get accurate information. Despite our efforts, there is a possibility that some girls had difficulty 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 management by schools. Focused national policies and budget support for menstrual hygiene would facilitate schools to improve this in a continuous and sustainable way. Ensuring sufficient gender specific private toilet facilities with water for changing and washing, and provision of sanitary materials would help reduce 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 implications 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 development of environmentally-friendly materials and disposal systems is also called for.
We thank all the school girls, head teachers and teachers who provided the information. We also thank field staff who collected data, UNICEF officials from Chhattisgarh, Maharashtra and Tamil Nadu for facilitating the study in the respective states.