Knowledge, attitudes, and practices on menstrual hygiene among school-going adolescent students in the rural areas of Wardha district, Maharashtra: A cross-sectional study.

Background

Menstruation is an important phase that changes the life of girls.¹ Menarche starts between 10 to 16 years (12 and 13 years) old, and menopause occurs between 45 to 50 years old.² As an outcome, puberty is a difficult period for girls as the body undergoes many neurological and biochemical changes.³ Yet, many girls are unprepared for puberty, and the information they receive are often incomplete and considered taboo. Menstruation is an anxiety-provoking phenomenon for adolescent girls and a social phenomenon focused on concealment, menstrual laws, and perceived norms.⁴ In 2019, Nath and John showed the social stigma many girls felt about menstruation, explaining how girls believed that menstrual blood and menstrual products should be kept invisible.⁵ The belief that menstrual blood and other menstrual products have to be hidden is a way of explaining the social humiliation many girls feel about their menstrual cycles.⁶

Adolescents and those in the reproductive age need access to sanitary products that are clean, gentle, and absorbent to maintain their health in the long run.⁷ However, there is an inadequate focus on this issue. A paramount concern for girls is whether they have the necessary information, facilities, and environment to manage menstruation in a healthy and dignified manner.⁴

In occidental cultures, menstrual taboos have unintentionally and negatively impacted girls' perceptions of menstruation, as seen by the constraints linked with menstruation: communication, activity, and concealment. Girls in India are considered “filthy” or “impure” throughout their menstrual cycle.⁷ They are prohibited from participating in any religious activity or social gatherings and are bound by restrictions on working, eating, and bathing. Similarly, research in Hong Kong found that popular religious beliefs continue to foster the concept that menstruation brings "bad luck." For example, among Nepali Hindus during the menstrual period, girls have to follow various rituals and limitations like living separately in mud huts.³

There is some openness regarding menstruation, thanks to social media and films like Pad Man (2018), yet significant differences exist in attitudes, experiences, and behaviors.⁷ Although menstruation is a natural physiological phenomenon, it is rarely widely discussed, and is still considered taboo between mother and daughter in many homes today in India.¹ Furthermore, several regulations remain to surround menstruation practice. Globally, menstrual hygiene habits are impacted by the many constraints that impede daily living activities, insufficient awareness, a lack of resources, and social and economic factors.^4,8

Men and Boys’ role in menstruation hygiene

Although it is uncommon for studies on the menstruation cycle to include boys, worldwide research has shown how important it is to include boys and men in sexual and reproductive health (SRH) since their participation may positively impact girls' health.⁹

Improving men and boys’ knowledge and attitudes about menstruation health have been emphasized as the first essential step to menstrual health and menstrual hygiene management by the United Nations International Children's Emergency Fund (UNICEF).³ Menstrual health and hygiene programs require a theory of change. This may be translated into boys and men having a beneficial impact on girls and women's actions and societal conventions about menstruation, helping to create supportive conditions for girls and resulting in a culture where there is gender equality.¹⁰ This impact may also assist boys in comprehending the relationship between menstruation and the different physical changes that adolescents go through, which is crucial to fully comprehending reproductive health.³

In a patriarchal country like India, men have a larger influence over decisions. Typically, girls do not talk to boys or men about their periods.¹⁰ The majority of boys are unaware of the basic physiology of menstruation, including the menstrual cycle.⁶ Men and boys can help women and girls manage their periods well in various social contexts, such as the home, neighborhood, school, and workplace.⁹ Men and boys play a variety of roles that have an impact on how women and girls experience menstrual hygiene management (MHM), including those of fathers, husbands, brothers, students, teachers, peers, community leaders, business owners, employers, practitioners of development and humanitarian aid, and policymakers.¹¹ While it is important to speak about men and boys in all of these positions, this article will concentrate on those relevant to the home, community, and educational settings.³

Effect of menstruation on education

Puberty accounts for the largest gender gap in schooling. Menstruation has an effect on school absences, ranging from zero to three days throughout the menstrual cycle, with greater rates in rural areas of India and Sub-Saharan Africa.¹² Important reasons for absences include embarrassment, lack of sanitary pads, lack of adequate and separate changing rooms at school, and concerns about leakage.¹¹ Various studies^10,11 have found that girls have experienced mocking from boys, younger children, instructors, and other girls. The shame of being observed by other students in blood-stained clothing was the first factor cited for dropouts related to menstruation, typically due to experiencing the first menses at school without prior preparation.^10,11

Effect of menstruation on health

Globally it is seen that adolescent girls are frequently unprepared for handling the menstrual cycle in terms of knowledge, skills, and attitudes.^4,13 This ignorance and poor personal hygiene habits throughout the menstrual cycle have been linked to significant illnesses such as vaginal tract infections, urinary tract infections, and foul breath.⁶ Unhealthy menstruation behaviors include not frequently cleansing the genitalia, using dirty cloths, neglecting to wash hands after changing menstrual products and infrequently changing a sanitary pad. To prevent the long-term adverse effects of poor menstrual hygiene practices, which can result in miscarriages, premature births, stillbirths, infertility issues, toxic shock syndrome, and cervix carcinoma as a complication of recurrent reproductive tract infections, menstruating girls must learn about menstrual hygiene.⁶ A study by Benshaul-Tolonen (2020) presents direct and indirect evidence in favor of the notion that gender differences and sociocultural factors significantly impact how girls experience their periods.¹⁰ However, there are still many myths and stigmas associated with menstruation. The attitudes of adolescent boys and girls are distorted by old beliefs which make their way into debates and teaching about menstruation.¹⁰ The goal of this study will be to thoroughly examine how young pubescent girls and boys build and interpret their menstrual knowledge and experiences.⁴

Economic factors

Economic conditions can also hinder girls from using good and hygienic puberty products.¹⁴ As mentioned earlier, the study by Gundi and Malaika (2020) showed that social and cultural norms changed the attitudes towards menstruation only when girls’ behavior around menstruation changed.¹⁴

Study design

The study will be a descriptive cross-sectional study of school-going adolescents (both girls and boys) in the rural Wardha district of Maharashtra, India.

According to the National Family Health Survey (NFHS-5),¹⁵ the prevalence of rural areas of India is 72.3%. Hence to observe presences of any variations in the prevalence in rural districts, Wardha district was chosen.

Study settings/place

A study will be conducted to assess the knowledge, perception, and attitude towards menstruation and menstruation hygiene among school-going adolescent students in the rural area of a government school in Wardha, Maharashtra, India.

The study will be conducted using simple random sampling, and two government schools in rural Wardha will be picked randomly. The cross-sectional study will be conducted in rural areas of Wardha district from June 2023 to November 2023, and the recruitment period is six months. The minimum number of visits will be six to seven times to gather all the data.

Participants

The study participants will be school-going adolescent students (girls and boys) aged 10–19 years in a rural area of Wardha.

Eligibility criteria

Inclusion criteria:

Exclusion criteria:

Data sources

Variables:

The study variables in questionnaires²¹ will include the socio-demographic information and background of the participants and the knowledge of adolescent students on attitudes, practices, and perceptions regarding menstruation.

The study tool will consist of a self-made structured online questionnaire²¹ with a quantitative component for the data collection on socio-demographic variables and on the knowledge, attitude, perception, and practices on menstruation and menstrual hygiene. In the study, the questionnaire we will be using is validated as before creating the questionnaire, we conducted a thorough literature review to identify existing validated questions used in previous studies.¹³ This ensures that the questionnaire covers all relevant aspects and includes well-established items. By going through this robust validation process, the questionnaire can be considered validated. The results obtained from a well-validated questionnaire will be more credible and provide valuable insights for the research study.

The questions cover knowledge, attitude, and practices related to menstruation. It includes information on what menstruation is, the age at which it typically starts, and why some girls may not attend school during menstruation. It also explores attitudes towards menstruation, such as the belief that it should be kept secret and considered exclusively a topic for girls. Additionally, it touches upon menstrual practices, specifically asking about preferred menstrual products and bathing frequency during menstruation.

The questions in the knowledge, attitude, and practices questionnaires are publicly available.²¹

Table 1 also shows the data sources. The questionnaire will be administered with the following three sections.

Section A: Questions on socio-demographic characteristics.

Section B: Questions regarding perception on menstruation.

Section C: Questions about hygiene during menstruation and the restrictions participants face during their menstrual cycle.

Measurements

Through this study, the primary outcomes measured will be the knowledge about menstruation among adolescent students and how boys play essential part in effective feminine hygiene programs and girls menstrual hygiene practices.

Secondary outcomes include understanding gender sensitization needed to make practical changes in knowledge, attitude and deep-rooted cultural and practices during menstruation. Figure 1 presents the plan of work.

Figure 1. Plan of work.

Bias

The study may include bias where participants may not recall previous events or experiences correctly. This occurs when participants in a study may selectively remember certain events or experiences more easily than others. In the context of adolescents, their emotional state and the turbulent nature of adolescents can influence their memory and recollection of events. This bias can affect the accuracy of the data collected and the conclusions. The KAP (knowledge, attitudes and practices) study relies on self-perception. For example, what each individual sees, feels and understands can create potential bias. Overall, these biases highlight the importance of careful study design, participant selection and data collection techniques when studying adolescents. The research will take into full consideration the problems which might arise and how to minimize them.

Sample size

According to the National Family Health Survey (NFHS-5),¹⁵ the prevalence of rural areas of India is 72.3%, with confidence the limit is 10%; this total sample size calculated is 154 (77 girls and 77 boys).¹⁵ This sample size was estimated from Epi-info software.

The sample size was calculated using the following formula:

In the mentioned study, the required sample size (n) and the design effect accounts for the potential clustering or correlation within the data (DEFF). The population size (N) is given as 100,000 in this case, and the frequency of the outcome factor in the population (p) is given as 72.3%. The desired confidence limit (d) is given as a percentage of 100 and is specified as 10% in this case. The critical value of the standard normal distribution corresponding to the desired confidence level (Z[1-α/2]), is 95%. (W) represents a weighting factor. Based on the given values and the formula, it is stated that a sample size of 154 will be used for data collection.

Population size = 100,000

Frequency of outcome factor in the population = 72.3%

Confidence limits as % of 100(absolute +/-%) (d)-10%

Design effect (DEFF) = 2

Confidence levels = 95%

Hence a sample size of 154 will be used for data collection.

Statistical methods

The study will be conducted using simple random sampling, and two government schools in rural Wardha will be picked randomly. The first school for data collection will be selected randomly and based on population. This method of selection will be used in another school as well. Adolescent students (both girls and boys) between 10 to 19 years of age are eligible to participate in the study. The data will be gathered in the form of a KoboToolBox (https://ee.kobotoolbox.org/x/mOWRQnSB) (https://ee.kobotoolbox.org/x/rAuAMdbi) (Ver. 2022.4.4.9/3/2023). The questionnaires are also available through the online repository.²¹ The data will be stored in Excel tabular form and presented using tables and graphs. The information will be coded into an Microsoft Excel 2019 MSO (Ver.2305 Build 16.0.16501.20074) spreadsheet. Epi-info (Ver. 7.2.5.0) software and SPSS (Ver.1.0.0.1406) will also be used for analysis. Descriptive data will be calculated in the form of percentages and frequencies. Data will be entered into SPSS version (1.0.0.1406) for Windows and analyzed using descriptive statistics (frequencies and percentages) for sociodemographic information, knowledge about menstrual hygiene, practices regarding menstrual hygiene and availability of menstrual hygiene management facilities. Inferential statistics (chi square) will be used to measure the association between level of knowledge and practice with selected variables.

Ethical considerations

Data collection will take place at a time that is convenient for instructors and students, with the written approval of the head of the relevant institution. The institutional ethics committee of the Datta Meghe Institute of Higher Education and Research (DMIHER) has approved the research proposal with the approval number DMIHER (DU)/IEC/2023/641. The researcher will access the required papers and records solely with the consent of the relevant authorities, and the parents of the adolescent students have provided written informed consent due to their minor status. After parents of the participants fill out the consent forms, we started the data collection. Furthermore, verbal informed consent is sought directly from the adolescent students themselves before they participate. Verbal consent procedure included the researchers firstly introducing themselves, speaking about the motivation behind the research and asking the questions from the questionnaire. Participants will then fill out a sheet related to the questionnaire and return it to the researchers. The researchers will then enter the participants’ answer into the Kobotool box. Data will be collected using a questionnaire on socio-demographic information, knowledge, attitude, practices, and perceptions about menstruation.

Expected outcomes and results

The study will examine knowledge about menstruation among adolescent students, how boys play an essential part in effective feminine hygiene programs, and girls' menstrual hygiene practices. Once the study is completed, the outcome will be presented in seminars or conferences.

Study status

The study is currently in process of data collection.

The implication of the study

The study’s findings will give insights that may be used to enhance menstrual hygiene practices in the target group and will also show the knowledge of both the boys and girls about the menstrual cycle. The findings will also indicate how men and boys help their menstruating family members and women colleagues.

Limitations

The survey will be carried out exclusively in government schools in the Wardha district. Thus, the study will be focused only on two schools’ pupils and will not capture drop-out students as well as students of the whole district. Another limitation of KAP (knowledge, attitudes and practices) is that it provides access to quantitative and qualitative information and relies on self-perception.