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Students' Perceptions and Doubts About Menstruation in Developing Countries: A Case Study From India Vikas Chothe, Jagdish Khubchandani, Denise Seabert, Mahesh Asalkar, Sarika Rakshe, Arti Firke, Inuka Midha and Robert Simmons Health Promot Pract 2014 15: 319 originally published online 11 March 2014 DOI: 10.1177/1524839914525175 The online version of this article can be found at: http://hpp.sagepub.com/content/15/3/319
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HPPXXX10.1177/1524839914525175Health Promotion PracticeChothe et al. / Perceptions and Doubts about Menstruation
Global Health Promotion
Students’ Perceptions and Doubts About Menstruation in Developing Countries: A Case Study From India Vikas Chothe, MD1 Jagdish Khubchandani, MBBS, PhD2 Denise Seabert, PhD, MCHES2 Mahesh Asalkar, MD1 Sarika Rakshe, MD1 Arti Firke, MD1 Inuka Midha, PhD, MPH, MCHES3 Robert Simmons, DrPH, MPH, MCHES, CPH4
Menstrual education is a vital aspect of adolescent health education. Culture, awareness, and socioeconomic status often exert profound influence on menstrual practices. However, health education programs for young women in developing countries do not often address menstrual hygiene, practices, and disorders. Developing culturally sensitive menstrual health education and hygiene programs for adolescent females has been recommended by professional health organizations like the World Health Organization and UNICEF. These programs cannot be developed without understanding existing myths and perceptions about menstruation in adolescent females of developing countries. Thus, the purpose of this qualitative study from India was to document existing misconceptions regarding menstruation and perceptions about menarche and various menstrual restrictions that have been understudied. Out of the 612 students invited to participate by asking questions, 381 girls participated by asking specific questions about menstruation (response rate = 62%). The respondents consisted of 84 girls from sixth grade, 117 from seventh grade, and 180 from eighth grade. The questions asked were arranged into the following subthemes: anatomy and physiology, menstrual symptoms, menstrual myths and taboos, health and
Health Promotion Practice May 2014 Vol. 15, No. 3 319–326 DOI: 10.1177/1524839914525175 © 2014 Society for Public Health Education
beauty, menstrual abnormalities, seeking medical advice and home remedies; sanitary pads usage and disposal; diet and lifestyle; and sex education. Results of our study indicate that students had substantial 1
Maharashtra University of Health Sciences, Maharashtra, India 2 Ball State University, Muncie, IN, USA 3 Emory University, Atlanta, GA, USA 4 Thomas Jefferson University, Philadelphia, PA, USA
Associate Editors, Department
Global
Health
Promotion
Jagdish Khubchandani, MBBS, PhD, is an assistant professor of community health education at Ball State University, Indiana. He earned his doctorate in clinical medicine from India and a PhD in health education from University of Toledo. His research interests are in the areas of social epidemiology, global health, and violence prevention. Rob Simmons, DrPH, MPH, MCHES, CPH, has been a public health educator for 40 years working with local and state government, community-based health organizations, private health foundations, health care organizations, and more recently in academic public health programs. He currently serves as the program director for the Master of Public Health (MPH) program and a clinical associate professor for Thomas Jefferson University’s School of Population Health in Philadelphia. His professional background and research interests are in community health education, and health promotion and disease prevention in tobacco control, physical activity, nutrition, reducing health inequities, and global health.
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doubts about menstruation and were influenced by societal myths and taboos in relation to menstrual practices. Parents, adolescent care providers, and policy makers in developing countries should advocate for comprehensive sexuality education and resources (e.g., low-cost sanitary pads and school facilities) to promote menstrual health and hygiene promotion. Keywords: child/adolescent health; cultural competence; health education; reproductive health; school health; sexual health; women’s health
Background >> The current 10- to 19-year-old generation of females will be the largest population in history to make the transition from childhood to adolescence and adulthood, with a vast majority (>80%) living in developing countries (UNICEF, 2011; World Health Organization, 2001). During this transition, girls will experience menarche and significant changes in lifestyle, behavior, growth, and development (McMahon et al., 2011; Sommer, 2010). Menarche is a part of the complex process of growing up marked by vital biological and physical changes. With these changes comes a considerable amount of anxiety, emotional problems, and need for support. Premenstrual discomfort, menstrual symptoms, and associated gynecological disorders also have important medical and social consequences that influence adolescent females’ life in a major way (e.g., loss of school days, isolation, prolonged bed rest, reproductive tract infections, chronic sleep disturbance, and decreased appetite). In addition, lack of knowledge about menstruation is associated with profound psychological and reproductive health issues (Aniebue, Aniebue, & Nwankwo, 2009; Deo & Ghattargi, 2005; McMahon et al., 2011; Sommer, 2010). Menstrual hygiene promotion and reproductive health education in low- and middle-income countries are high priorities for national and international professional health organizations. However, menstrual hygiene promotion and reproductive health education are lacking in low- and middle-income countries (Aniebue et al., 2009; Sommer, Vasquez, Worthington, & Sahin, 2013; UNICEF, 2006). In addition, menstruation and menstrual practices in these countries are severely clouded by myths, taboos, and sociocultural restrictions. This may result in adolescent girls remaining unaware of hygienic health practices, which can influence health outcomes (Aniebue et al., 2009; Deo & Ghattargi, 2005; Sahin, 2013; Sommer et
al., UNICEF, 2006). Although menstruation has been linked to gynecological problems in adolescent females, frequently they are perceived as minor health concerns in developing countries. Unfortunately, within developing countries, female youth of low- and middle-income groups are highly vulnerable to menstrual health issues (Aniebue et al., 2009; Deo & Ghattargi, 2005; El-Gilany & Badawi, 2005; Zegeye, Megabiaw, & Mulu, 2009). Developing culturally sensitive menstrual health education and hygiene programs for adolescent females in developing countries has been recommended by professional health organizations and in scientific literature (Aniebue et al., 2009; El-Gilany & Badawi, 2005; World Health Organization, 2001; Zegeye et al., 2009; UNICEF, 2011). Understanding existing myths and perceptions about menstruation in adolescent females is essential to develop effective educational programs. Thus, the purpose of this qualitative study was to document perceptions regarding menstruation and various menstrual restrictions that have been underexplored.
Method >> Participants
Convenience sampling was used to identify three girls’ schools in Pune, India, attended by students from lower or lower middle–income households. Pune is one of the fastest growing metropolitan towns of India and is highly diverse with low- and middle-income migrants from across the nation who move there to find employment. Nine to 13-year-old students in Grades 6, 7, and 8 were identified for this project. Research Design This study used a qualitative research ethnographic design. Ethnographic studies are aimed at exploring cultural phenomena, perceptions, and beliefs and pose minimum burden on participants. Participants were encouraged to pose questions regarding menstruation and were provided age-appropriate responses to their questions by a qualified pediatrician on the team. Similar methods were used in previously published studies conducted in India (Riggs et al., 2013). Given the stigma, fear, and cultural barriers, female students were ensured anonymity and a culturally sensitive approach was undertaken. Apart from researchers and panel consultants, school teachers were present during the program to listen to the girls’ questions and responses from the pediatrician. Permission was also obtained from the school administration and institutional review board at Ball State University, United States.
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Global Health Promotion
Table 1 Number of Questions Asked by Girls in Each Grade Categorized by Subthemes. Subthemes Anatomy and physiology Menstrual symptoms Menstrual myths and taboos Health and beauty Menstrual abnormalities, seeking medical advice, and home remedies Sanitary pads: use and disposal Diet and lifestyle Miscellaneous
Grade 6
Grade 7
Grade 8
45 7 11 13 6
21 29 13 20 16
28 34 40 28 32
8 3 0
5 6 1
3 5 7
Total N (%) 94 70 64 61 54
(25) (18) (17) (16) (14)
16 (4) 14 (3) 8 (2)
Data Collection
Anatomy and Physiology
The girls were given an opportunity to ask openended questions on menstruation. No names were recorded on the questions submitted to keep the identity of respondents anonymous. After collection of the students’ questions, their queries were answered by a pediatrician using simple culturally appropriate terms. The discussion was recorded and field notes were taken.
The most frequent questions were related to anatomy and physiology (25%). Students wanted to know about genitalia and reproductive organs. The questions varied in complexity (Table 2). For example, some girls from 8th grade were curious about embryonic development. Examples of such questions included the following:
Data Analysis The questions were collected and analyzed descriptively. After initial review, they were translated to English, arranged into broad subthemes, and manually coded. Data were summarized, meanings were interpreted, and inferences were drawn by three investigators. Coding inconsistencies were resolved through discussion with the research team.
Results >> Out of the 612 students invited to participate, 381 girls did so by submitting specific questions (response rate = 62%). The respondents consisted of 84 girls from sixth grade, 117 from seventh grade, and 180 from eighth grade. The questions asked were arranged into the following subthemes: Anatomy and physiology; Menstrual symptoms; Menstrual myths and taboos; Health and beauty; Menstrual abnormalities; Seeking medical advice and home remedies; Sanitary pads usage and disposal; Diet and lifestyle; and Sex education (Table 1).
Why does baby grow only in mother’s stomach (womb/uterus)? (Sixth grader) Can we remove eggs (ovum) out of the body? (Eighth grader)
Questions related to menstruation included menstrual pattern (regularity of cycle, cycle length, duration of flow, amount of flow, menarche, and menopause), physiology about menstruation, importance of menstruation, composition of menstrual flow and ovulation physiology. Some girls appeared to have only partial knowledge of reproduction and were curious to know about growth and development of the baby in the mother’s womb, reason for amenorrhea during pregnancy, and relation between menses and pregnancy. Menstrual Symptoms Eighteen percent (18%) of participants asked questions related to menstrual symptoms (Table 1). The most commonly questioned symptom was pain in the lower abdomen and backache before and after menstruation (n = 15). Other questions focused on gastrointestinal and psychological symptoms. The gastrointestinal
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Table 2 Examples of Questions Asked Under Each Subtheme. Subtheme Anatomy and physiology Menstrual symptoms Menstrual myths and taboos Health and beauty Menstrual abnormalities, seeking medical advice, and remedies Sanitary pads: usage and disposal Diet and lifestyle Miscellaneous
Examples of Questions Asked What is an egg? What is sperm? What is uterus? What is vagina? After how many months do we get next menses? How many days does menstrual flow last? Why and how do menses occur? When does menstruation begin? Why don’t pregnant women get menses? Why don’t we develop breasts when we are children? I want to be an astronaut so what should I do to get menses in space? Why do we get backache? Why do I get pain in legs? Why do I get headache? Why do I feel giddy/ fainting/ vertigo? Why do we feel angry and irritable during menses? Why do we have weakness during menses? Do we become infertile if our sanitary pad that is left in open is eaten or sniffed by a snake? Why shouldn’t we eat some type of fruits? Mother says they increase body heat causing early menses. I am not allowed to bathe my head during menses. Why? Should we stop doing household chores during menses? Why am I not allowed to visit kitchen/temple/ religious places during menses? Why do we get pimples and dandruff in hair after start of menses? I feel that my hair became bad and entangled due to menses, why? What should be done to avoid hair fall after menstruation starts? Why do we get white spots on face after menstruation? Why is my face oily? What should we do to maintain healthy skin and glow on face? Why do I have irregular menses? Why do I get scanty bleeding during menses? Why do I get white discharge? What should I do to avoid foul-smelling menses? What should I do if flow lasts more than 5 days? Should we visit a doctor if we have stomach pain during each menses? Can you suggest home remedies for pain and weakness? Why do we use sanitary pads? How do I use pads? What should I do if during menses pads and handkerchief are not available? How often should we change pads? How should we dispose pads? What type of home cloth pieces should be used? Are pads very expensive? Where do I find them? What should we eat during menses? Which clothes should we wear during menses? I do yoga sometimes, should I do yoga during menstruation? Does yoga help? Should we avoid dance classes during menses? Why do we get STDs [sexually transmitted diseases]? What is a condom? What is a French kiss? What do you mean by sex education? Should we tell our class teacher if we start menstruating in school?
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Global Health Promotion symptom questions related to loss of appetite, nausea, vomiting, anorexia, and bloating sensation in abdomen. The psychological symptom questions focused on depression, irritability, inability to concentrate in school, and anger. Other questions asked by students related to general fatigue, body pain, burning sensation, and itching in body parts. Examples of specific questions asked by participants include the following: Why do we feel depressed during menses? (Seventh grader) Why do we get backache during menses? (Eighth grader)
Myths and Taboos More than one in six (17%) girls asked questions that were categorized as myths and taboos (Table 1). Attitudes such as refraining from bathing, poor perineum care, and restrictions on touching anything and leaving the house were cultural and social constraints associated with menstruation among participants. Some also avoided school, dance classes, outdoor games, and visiting temples and doing daily chores during menses and wished to know the reason behind these restrictions. On further probing about restrictions, girls mentioned mothers, sisters, family members, and friends as the most common source of information about restrictions. A few girls raised questions about cultural restrictions imposed by their mothers and family and expressed myths related to disposal of sanitary pads. A few students stated that certain foods were regularly restricted in their households during menstruation, such as hot spicy food, pickles, onion, potato, and adding pinch of salt to fruits. Examples of questions addressing myths include the following: Do we get pregnant by kissing? (Sixth grader) Do we become infertile if our sanitary pad that is left in open is eaten or sniffed by a snake? (Seventh grader) Do we get menses only after development of breasts? (Eighth grader)
Health and Beauty Almost one in six girls (16%) asked questions about health and beauty symptoms. Girls reported development
of pimples, white spots, oily face, dandruff, loss of hair, and low body weight and mentioned that these problems were affecting their beauty and self-confidence. In addition to seeking remedies for the aforementioned health and beauty concerns, they raised questions to increase their height, gain weight, and have long, black, and strong hair and healthy, shiny skin. Menstrual Abnormalities, Home Remedies, and Seeking Medical Advice The majority of the questions asked by girls in this category pertained to amenorrhea, abnormal/excessive uterine bleeding, irregular menses, dysmenorrhea and associated symptoms like white discharge and foulsmelling discharge. What will happen if a girl never menstruates? (Eighth grader)
Out of the total questions (n = 54) asked by girls on treatment for various menstrual abnormalities, only one asked about seeking medical help from a qualified health professional for menstrual abnormalities. The rest of the questions in this category were about homebased treatments. Girls inquired about symptom relief for various menstrual abnormalities and abdominal pain, giddiness, foul discharge, body ache, generalized weakness, breast engorgement, irregular menses, and mental stress. Diet and Lifestyle Fourteen girls asked about lifestyle and diet during menstruation. For example, girls inquired about different fruits to be consumed during menses and amount of water intake necessary to maintain good health. Lifestyle questions included appropriate clothes to be worn during menses and optimum frequency to wash genital area. A lifestyle-related question asked was the following: I do yoga sometimes, should I do yoga during menstruation? Does yoga help? (Eighth grader)
Miscellaneous Although the theme for discussion was on menstruation, sexuality and sexual relations arose in nearly all sessions for girls in higher grades. Students wanted to know about contraceptives, condoms, kissing, sex education, and pregnancy.
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Discussion >> Little is known about the type of menstrual health education provided to young girls in India. However, to provide such education, baseline assessments of perceptions and knowledge could assist in development of menstrual education programs. This study highlights the perspectives of adolescent girls from low-income households and indicates a lack of critical knowledge that could aid in healthy growth and development. A few menstrual health education programs are implemented formally or informally in Indian schools or schools of many developing countries. However, functions of reproductive organs, menstrual abnormalities, sexually transmitted diseases, and contraception are not formally taught (Deo & Ghattargi, 2005; Garg, Goyal, & Gupta, 2012; Khanna, Goyal, & Bhawsar, 2005). Adolescent Indian girls may not understand the importance of menstrual hygiene in daily life, which in part, could be due to inadequate education and awareness and unhealthy social norms and customs. In one study, it was reported that awareness about menstruation prior to menarche was very low among Indian adolescents. The limited knowledge available was often passed down informally from mothers, who were themselves lacking in knowledge of reproductive health and hygiene due to low literacy levels (Deo & Ghattargi, 2005). Projection of menarche as a traumatic experience, development of misconceptions, and fear among adolescent girls have been noted in other studies also (Deo & Ghattargi, 2005; Garg et al., 2012; Khanna et al., 2005). Our findings support previous studies that adolescent girls in low- and middle-income countries may silently suffer some degree of pain, cramping, and discomfort associated with dysmenorrhea (Deo & Ghattargi, 2005; El-Gilany & Badawi, 2005; Sule, Umar, & Madugu, 2007). Without appropriate pain relief, girls with dysmenorrhea may not be able to carry out their normal activities or pursue formal education. In the present study, it was also surprising to note that girls had few questions on sanitary pads, and the questions submitted provided an indication that girls did not know about usage and disposal of sanitary pads. Interestingly, just before our study began, the government of India proposed funding for low-cost sanitary napkins to promote menstrual hygiene in rural areas for girls 10 to 19 years in 20 Indian states (Ministry of Health & Family Welfare, Government of India, 2012). Although a positive step in menstrual hygiene promotion, program and outreach implementation to young adolescent girls may be challenging due to lack of menstruation awareness.
Students from higher grades in the study sought more information and had more questions about menstrual symptoms, abnormal menstruation, myths, health, and beauty. Also, adolescent girls posed more questions about self-medication and home remedies than about seeing a health professional for common menstrual abnormalities. Consequently, there could be underdiagnosis and treatment of menstrual abnormalities, which may lead to reproductive problems during adulthood. This is in contrast to previous reports of women with more education who reported better awareness of health issues and were more likely to seek medical attention (Kirk & Sommer, 2006; Sule et al., 2007). In early puberty, adolescents’ most significant preoccupation is their bodies, during the rapid physical changes they experience. Educating adolescents such as those in our study should be a key initiative for reduction of reproductive health problems (Kirk & Sommer, 2006; Shah et al., 2013; Sule et al., 2007). Illiteracy along with poverty has been indicated as a cause of sociocultural beliefs and taboos regarding menstruation leading to ill health and ignorance among adolescent girls (Deo & Ghattargi, 2005; Khanna et al., 2005; Kirk & Sommer, 2006). Adolescents who cannot talk to their parents and teachers about menstruation comfortably and do not receive sexuality education in school might receive inaccurate information. In our study, cultural restrictions on discussing reproductive health and sex education issues could have resulted in misperceptions and beliefs about menstruation and sexuality-related topics. This is a critical issue that warrants strategic thinking and comprehensive planning on adolescent sexuality education in developing countries. In our study there are some indicators that suggest that sequential sexuality education based on grade level of students is required. Based on the differences in questions asked by students in lower grades compared to students in upper grades, a grade-specific Family Life/Sex Education curriculum should be designed. Regarding implementation, there are many sociopolitical, cultural, and religious issues to consider. For example, we must consider the Indian scenario of school-based Family Life/Sex Education. In 2007, the Indian government National AIDS Control Organization and Ministry of Human Resource Development proposed a sex education program for adolescents. Within a few days of the proposed initiatives, major controversy erupted and opponents from religious and social groups argued for a prohibition of any such education, citing that such education would lead to the moral downfall of youth, excessive sexual behavior, promiscuity, and experimentation at a tender age (Tripathi & Sekher, 2013).
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Global Health Promotion Limitations of the Study The results of our study should be viewed in light of several potential limitations. All study subjects were low-income students in one county of western India. Thus, our results cannot be generalized to students in other regions of India or other low-income countries. There were several confounding demographic and background characteristics of the students that could not be gathered. This was an ethnographic observational study, and therefore the inferences are limited. Finally, even though our response rate was more than 50%, we might have missed important perceptions and beliefs as many girls opted out of asking questions.
Conclusions >> The present study has revealed a low level of menstruation knowledge and various misconceptions among adolescent schoolgirls in India. This speaks to the urgent need for girls to receive more guidance on menstruation and to the importance of good menstrual health and hygiene practices. The information from this study could be useful in modifying existing health education programs and improving reproductive health services in India. Our study also suggests that teachers and parents in developing countries should be educated to conduct routine screening for menstrual problems, provide counseling, and offer guidance about reproductive health issues. The governing bodies such as the Ministry of Education in India should consider menstrual health education and should revise existing health education materials according to Indian local context to implement a multigrade sequential education program for Grades 6 to 8. Live examples, case scenarios, three-dimensional models, manikins, and videos should be used while explaining complex topics like menstruation, pubertal changes, functions of reproductive organs, and use of sanitary pads (House, Mahon, & Cavill, 2012; Ministry of Health & Family Welfare, Government of India, 2012; Shah et al., 2013). Mothers should also be educated to communicate with their daughters regarding menstruation before menarche. Schools should be encouraged to provide basic facilities such as water, bathrooms, and safe private spaces where girls can follow hygienic practices. Schools and parents can play an important role in shaping healthy menstrual attitudes. Community-based adolescent-friendly health services will help begin open discussions on reproductive health, menstrual abnormalities, and psychosocial problems (House et al., 2012; Mahon & Fernandes, 2010; McMahon et al.,
2011; Shah et al., 2013; Sommer, 2010; Sommer et al., 2013). Further research should be conducted on menstrual health and hygiene in adolescents in low- and middle-income countries to meet the cultural, emotional, and social needs of girls. The adolescent girls of today are the mothers of tomorrow and the forebears of the future of their family, community, and nation. References Aniebue, U. U., Aniebue, P. N., & Nwankwo, T. O. (2009). The impact of pre-menarcheal training on menstrual practices and hygiene of Nigerian school girls. Pan African Medical Journal, 2(9), 1-9. Deo, D. S., & Ghattargi, C. H. (2005). Perceptions and practices regarding menstruation: a comparative study in urban and rural adolescent girls. Indian Journal of Community Medicine, 30, 33-34. El-Gilany, A. H., & Badawi, K. (2005). Menstrual hygiene among adolescent school girls in Mansoura, Egypt. Reproductive Health Matters, 13,147-152. Garg, R., Goyal, S., & Gupta, S. (2012). India moves towards menstrual hygiene: subsidized sanitary napkins for rural adolescent girls-issues and challenges. Maternal and Child Health Journal, 16, 767-774. House, S., Mahon, T., & Cavill, S. (2012). Menstrual hygiene matters: A resource for improving menstrual hygiene around the world. London, England: WaterAid. Khanna, A., Goyal, R. S., & Bhawsar, R. (2005). Menstrual practices and reproductive problems: a study of adolescent girls in Rajasthan. Journal of Health Management, 7, 91-107. Kirk, J., & Sommer, M. (2006). Menstruation and body awareness: Linking girls’ health with girls’ education. Amsterdam, Netherlands: Royal Tropical Institute. Mahon, T., & Fernandes, M. (2010). Menstrual hygiene in South Asia: a neglected issue for WASH (water, sanitation and hygiene) programs. Gender & Development, 18, 99-113. McMahon, S. A., Winch, P. J., Caruso, B. A., Obure, A. F., Ogutu, E. A., Ochari, I. A., & Rheingans, R. D. (2011). “The girl with her period is the one to hang her head”: Reflections on menstrual management among schoolgirls in rural Kenya. BMC International Health and Human Rights, 11(7), 1-10. Ministry of Health & Family Welfare, Government of India. (2012). Two year (2009-2011) achievements of Ministry of Health & Family Welfare unveiled. Retrieved from http://pib.nic.in/ newsite/erelease.aspx?relid=72307 Riggs, N., Tewari, A., Stigler, M., Rodrigues, L., Arora, M., Khubchandani, J., . . .Pentz, M.A. (2013). Indian students’ perspectives on obesity and school-based obesity prevention: A qualitative examination. Health Promotion Practice, 14, 816-823. Shah, S. P., Nair, R., Shah, P. P., Modi, D. K., Desai, S. A., & Desai, L. (2013). Improving quality of life with new menstrual hygiene practices among adolescent tribal girls in rural Gujarat, India. Reproductive Health Matters, 21(41), 205-213. Sommer, M. (2010). Where the education system and women’s bodies collide: The social and health impact of girls’ experiences
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of menstruation and schooling in Tanzania. Journal of Adolescence, 33, 521-529. Sommer, M., Vasquez, E., Worthington, N., & Sahin, M. (2013). WASH in schools empowers girls’ education: Proceedings of the Menstrual Hygiene Management in Schools Virtual Conference 2012. New York, NY: United Nations Children’s Fund and Columbia University.
UNICEF. (2006). Adolescent development in East Asia and the Pacific: Realizing their potential. A summary of trends, programming and policy experiences (Learning Series No. 2). New York, NY: Author. UNICEF. (2011). Progress for children: A report card on adolescents. New York, NY: Author.
Sule, S. T., Umar, H. S., & Madugu, N. H. (2007). Premenstrual symptoms and dysmenorrhoea among Muslim women in Zaria, Nigeria. Annals of African Medicine, 6, 68-72.
World Health Organization. (2001). The second decade: Improving adolescent health and development. Geneva, Switzerland: World Health Organization.
Tripathi, N., & Sekher, T. V. (2013). Youth in India ready for sex education? Emerging evidence from national surveys. PLoS One, 8(8), e71584.
Zegeye, D. T., Megabiaw, B., & Mulu, A. (2009). Age at menarche and the menstrual pattern of secondary school adolescents in northwest Ethiopia. BMC Women’s Health, 9, 29.
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Students' Perceptions and Doubts About Menstruation in Developing Countries: A Case Study From India Vikas Chothe, Jagdish Khubchandani, Denise Seabert, Mahesh Asalkar, Sarika Rakshe, Arti Firke, Inuka Midha and Robert Simmons Health Promot Pract 2014 15: 319 originally published online 11 March 2014 DOI: 10.1177/1524839914525175 The online version of this article can be found at: http://hpp.sagepub.com/content/15/3/319
Published by: http://www.sagepublications.com
On behalf of: Society for Public Health Education
Additional services and information for Health Promotion Practice can be found at: Email Alerts: http://hpp.sagepub.com/cgi/alerts Subscriptions: http://hpp.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
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525175
research-article2014
HPPXXX10.1177/1524839914525175Health Promotion PracticeChothe et al. / Perceptions and Doubts about Menstruation
Global Health Promotion
Students’ Perceptions and Doubts About Menstruation in Developing Countries: A Case Study From India Vikas Chothe, MD1 Jagdish Khubchandani, MBBS, PhD2 Denise Seabert, PhD, MCHES2 Mahesh Asalkar, MD1 Sarika Rakshe, MD1 Arti Firke, MD1 Inuka Midha, PhD, MPH, MCHES3 Robert Simmons, DrPH, MPH, MCHES, CPH4
Menstrual education is a vital aspect of adolescent health education. Culture, awareness, and socioeconomic status often exert profound influence on menstrual practices. However, health education programs for young women in developing countries do not often address menstrual hygiene, practices, and disorders. Developing culturally sensitive menstrual health education and hygiene programs for adolescent females has been recommended by professional health organizations like the World Health Organization and UNICEF. These programs cannot be developed without understanding existing myths and perceptions about menstruation in adolescent females of developing countries. Thus, the purpose of this qualitative study from India was to document existing misconceptions regarding menstruation and perceptions about menarche and various menstrual restrictions that have been understudied. Out of the 612 students invited to participate by asking questions, 381 girls participated by asking specific questions about menstruation (response rate = 62%). The respondents consisted of 84 girls from sixth grade, 117 from seventh grade, and 180 from eighth grade. The questions asked were arranged into the following subthemes: anatomy and physiology, menstrual symptoms, menstrual myths and taboos, health and
Health Promotion Practice May 2014 Vol. 15, No. 3 319–326 DOI: 10.1177/1524839914525175 © 2014 Society for Public Health Education
beauty, menstrual abnormalities, seeking medical advice and home remedies; sanitary pads usage and disposal; diet and lifestyle; and sex education. Results of our study indicate that students had substantial 1
Maharashtra University of Health Sciences, Maharashtra, India 2 Ball State University, Muncie, IN, USA 3 Emory University, Atlanta, GA, USA 4 Thomas Jefferson University, Philadelphia, PA, USA
Associate Editors, Department
Global
Health
Promotion
Jagdish Khubchandani, MBBS, PhD, is an assistant professor of community health education at Ball State University, Indiana. He earned his doctorate in clinical medicine from India and a PhD in health education from University of Toledo. His research interests are in the areas of social epidemiology, global health, and violence prevention. Rob Simmons, DrPH, MPH, MCHES, CPH, has been a public health educator for 40 years working with local and state government, community-based health organizations, private health foundations, health care organizations, and more recently in academic public health programs. He currently serves as the program director for the Master of Public Health (MPH) program and a clinical associate professor for Thomas Jefferson University’s School of Population Health in Philadelphia. His professional background and research interests are in community health education, and health promotion and disease prevention in tobacco control, physical activity, nutrition, reducing health inequities, and global health.
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doubts about menstruation and were influenced by societal myths and taboos in relation to menstrual practices. Parents, adolescent care providers, and policy makers in developing countries should advocate for comprehensive sexuality education and resources (e.g., low-cost sanitary pads and school facilities) to promote menstrual health and hygiene promotion. Keywords: child/adolescent health; cultural competence; health education; reproductive health; school health; sexual health; women’s health
Background >> The current 10- to 19-year-old generation of females will be the largest population in history to make the transition from childhood to adolescence and adulthood, with a vast majority (>80%) living in developing countries (UNICEF, 2011; World Health Organization, 2001). During this transition, girls will experience menarche and significant changes in lifestyle, behavior, growth, and development (McMahon et al., 2011; Sommer, 2010). Menarche is a part of the complex process of growing up marked by vital biological and physical changes. With these changes comes a considerable amount of anxiety, emotional problems, and need for support. Premenstrual discomfort, menstrual symptoms, and associated gynecological disorders also have important medical and social consequences that influence adolescent females’ life in a major way (e.g., loss of school days, isolation, prolonged bed rest, reproductive tract infections, chronic sleep disturbance, and decreased appetite). In addition, lack of knowledge about menstruation is associated with profound psychological and reproductive health issues (Aniebue, Aniebue, & Nwankwo, 2009; Deo & Ghattargi, 2005; McMahon et al., 2011; Sommer, 2010). Menstrual hygiene promotion and reproductive health education in low- and middle-income countries are high priorities for national and international professional health organizations. However, menstrual hygiene promotion and reproductive health education are lacking in low- and middle-income countries (Aniebue et al., 2009; Sommer, Vasquez, Worthington, & Sahin, 2013; UNICEF, 2006). In addition, menstruation and menstrual practices in these countries are severely clouded by myths, taboos, and sociocultural restrictions. This may result in adolescent girls remaining unaware of hygienic health practices, which can influence health outcomes (Aniebue et al., 2009; Deo & Ghattargi, 2005; Sahin, 2013; Sommer et
al., UNICEF, 2006). Although menstruation has been linked to gynecological problems in adolescent females, frequently they are perceived as minor health concerns in developing countries. Unfortunately, within developing countries, female youth of low- and middle-income groups are highly vulnerable to menstrual health issues (Aniebue et al., 2009; Deo & Ghattargi, 2005; El-Gilany & Badawi, 2005; Zegeye, Megabiaw, & Mulu, 2009). Developing culturally sensitive menstrual health education and hygiene programs for adolescent females in developing countries has been recommended by professional health organizations and in scientific literature (Aniebue et al., 2009; El-Gilany & Badawi, 2005; World Health Organization, 2001; Zegeye et al., 2009; UNICEF, 2011). Understanding existing myths and perceptions about menstruation in adolescent females is essential to develop effective educational programs. Thus, the purpose of this qualitative study was to document perceptions regarding menstruation and various menstrual restrictions that have been underexplored.
Method >> Participants
Convenience sampling was used to identify three girls’ schools in Pune, India, attended by students from lower or lower middle–income households. Pune is one of the fastest growing metropolitan towns of India and is highly diverse with low- and middle-income migrants from across the nation who move there to find employment. Nine to 13-year-old students in Grades 6, 7, and 8 were identified for this project. Research Design This study used a qualitative research ethnographic design. Ethnographic studies are aimed at exploring cultural phenomena, perceptions, and beliefs and pose minimum burden on participants. Participants were encouraged to pose questions regarding menstruation and were provided age-appropriate responses to their questions by a qualified pediatrician on the team. Similar methods were used in previously published studies conducted in India (Riggs et al., 2013). Given the stigma, fear, and cultural barriers, female students were ensured anonymity and a culturally sensitive approach was undertaken. Apart from researchers and panel consultants, school teachers were present during the program to listen to the girls’ questions and responses from the pediatrician. Permission was also obtained from the school administration and institutional review board at Ball State University, United States.
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Global Health Promotion
Table 1 Number of Questions Asked by Girls in Each Grade Categorized by Subthemes. Subthemes Anatomy and physiology Menstrual symptoms Menstrual myths and taboos Health and beauty Menstrual abnormalities, seeking medical advice, and home remedies Sanitary pads: use and disposal Diet and lifestyle Miscellaneous
Grade 6
Grade 7
Grade 8
45 7 11 13 6
21 29 13 20 16
28 34 40 28 32
8 3 0
5 6 1
3 5 7
Total N (%) 94 70 64 61 54
(25) (18) (17) (16) (14)
16 (4) 14 (3) 8 (2)
Data Collection
Anatomy and Physiology
The girls were given an opportunity to ask openended questions on menstruation. No names were recorded on the questions submitted to keep the identity of respondents anonymous. After collection of the students’ questions, their queries were answered by a pediatrician using simple culturally appropriate terms. The discussion was recorded and field notes were taken.
The most frequent questions were related to anatomy and physiology (25%). Students wanted to know about genitalia and reproductive organs. The questions varied in complexity (Table 2). For example, some girls from 8th grade were curious about embryonic development. Examples of such questions included the following:
Data Analysis The questions were collected and analyzed descriptively. After initial review, they were translated to English, arranged into broad subthemes, and manually coded. Data were summarized, meanings were interpreted, and inferences were drawn by three investigators. Coding inconsistencies were resolved through discussion with the research team.
Results >> Out of the 612 students invited to participate, 381 girls did so by submitting specific questions (response rate = 62%). The respondents consisted of 84 girls from sixth grade, 117 from seventh grade, and 180 from eighth grade. The questions asked were arranged into the following subthemes: Anatomy and physiology; Menstrual symptoms; Menstrual myths and taboos; Health and beauty; Menstrual abnormalities; Seeking medical advice and home remedies; Sanitary pads usage and disposal; Diet and lifestyle; and Sex education (Table 1).
Why does baby grow only in mother’s stomach (womb/uterus)? (Sixth grader) Can we remove eggs (ovum) out of the body? (Eighth grader)
Questions related to menstruation included menstrual pattern (regularity of cycle, cycle length, duration of flow, amount of flow, menarche, and menopause), physiology about menstruation, importance of menstruation, composition of menstrual flow and ovulation physiology. Some girls appeared to have only partial knowledge of reproduction and were curious to know about growth and development of the baby in the mother’s womb, reason for amenorrhea during pregnancy, and relation between menses and pregnancy. Menstrual Symptoms Eighteen percent (18%) of participants asked questions related to menstrual symptoms (Table 1). The most commonly questioned symptom was pain in the lower abdomen and backache before and after menstruation (n = 15). Other questions focused on gastrointestinal and psychological symptoms. The gastrointestinal
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Table 2 Examples of Questions Asked Under Each Subtheme. Subtheme Anatomy and physiology Menstrual symptoms Menstrual myths and taboos Health and beauty Menstrual abnormalities, seeking medical advice, and remedies Sanitary pads: usage and disposal Diet and lifestyle Miscellaneous
Examples of Questions Asked What is an egg? What is sperm? What is uterus? What is vagina? After how many months do we get next menses? How many days does menstrual flow last? Why and how do menses occur? When does menstruation begin? Why don’t pregnant women get menses? Why don’t we develop breasts when we are children? I want to be an astronaut so what should I do to get menses in space? Why do we get backache? Why do I get pain in legs? Why do I get headache? Why do I feel giddy/ fainting/ vertigo? Why do we feel angry and irritable during menses? Why do we have weakness during menses? Do we become infertile if our sanitary pad that is left in open is eaten or sniffed by a snake? Why shouldn’t we eat some type of fruits? Mother says they increase body heat causing early menses. I am not allowed to bathe my head during menses. Why? Should we stop doing household chores during menses? Why am I not allowed to visit kitchen/temple/ religious places during menses? Why do we get pimples and dandruff in hair after start of menses? I feel that my hair became bad and entangled due to menses, why? What should be done to avoid hair fall after menstruation starts? Why do we get white spots on face after menstruation? Why is my face oily? What should we do to maintain healthy skin and glow on face? Why do I have irregular menses? Why do I get scanty bleeding during menses? Why do I get white discharge? What should I do to avoid foul-smelling menses? What should I do if flow lasts more than 5 days? Should we visit a doctor if we have stomach pain during each menses? Can you suggest home remedies for pain and weakness? Why do we use sanitary pads? How do I use pads? What should I do if during menses pads and handkerchief are not available? How often should we change pads? How should we dispose pads? What type of home cloth pieces should be used? Are pads very expensive? Where do I find them? What should we eat during menses? Which clothes should we wear during menses? I do yoga sometimes, should I do yoga during menstruation? Does yoga help? Should we avoid dance classes during menses? Why do we get STDs [sexually transmitted diseases]? What is a condom? What is a French kiss? What do you mean by sex education? Should we tell our class teacher if we start menstruating in school?
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Global Health Promotion symptom questions related to loss of appetite, nausea, vomiting, anorexia, and bloating sensation in abdomen. The psychological symptom questions focused on depression, irritability, inability to concentrate in school, and anger. Other questions asked by students related to general fatigue, body pain, burning sensation, and itching in body parts. Examples of specific questions asked by participants include the following: Why do we feel depressed during menses? (Seventh grader) Why do we get backache during menses? (Eighth grader)
Myths and Taboos More than one in six (17%) girls asked questions that were categorized as myths and taboos (Table 1). Attitudes such as refraining from bathing, poor perineum care, and restrictions on touching anything and leaving the house were cultural and social constraints associated with menstruation among participants. Some also avoided school, dance classes, outdoor games, and visiting temples and doing daily chores during menses and wished to know the reason behind these restrictions. On further probing about restrictions, girls mentioned mothers, sisters, family members, and friends as the most common source of information about restrictions. A few girls raised questions about cultural restrictions imposed by their mothers and family and expressed myths related to disposal of sanitary pads. A few students stated that certain foods were regularly restricted in their households during menstruation, such as hot spicy food, pickles, onion, potato, and adding pinch of salt to fruits. Examples of questions addressing myths include the following: Do we get pregnant by kissing? (Sixth grader) Do we become infertile if our sanitary pad that is left in open is eaten or sniffed by a snake? (Seventh grader) Do we get menses only after development of breasts? (Eighth grader)
Health and Beauty Almost one in six girls (16%) asked questions about health and beauty symptoms. Girls reported development
of pimples, white spots, oily face, dandruff, loss of hair, and low body weight and mentioned that these problems were affecting their beauty and self-confidence. In addition to seeking remedies for the aforementioned health and beauty concerns, they raised questions to increase their height, gain weight, and have long, black, and strong hair and healthy, shiny skin. Menstrual Abnormalities, Home Remedies, and Seeking Medical Advice The majority of the questions asked by girls in this category pertained to amenorrhea, abnormal/excessive uterine bleeding, irregular menses, dysmenorrhea and associated symptoms like white discharge and foulsmelling discharge. What will happen if a girl never menstruates? (Eighth grader)
Out of the total questions (n = 54) asked by girls on treatment for various menstrual abnormalities, only one asked about seeking medical help from a qualified health professional for menstrual abnormalities. The rest of the questions in this category were about homebased treatments. Girls inquired about symptom relief for various menstrual abnormalities and abdominal pain, giddiness, foul discharge, body ache, generalized weakness, breast engorgement, irregular menses, and mental stress. Diet and Lifestyle Fourteen girls asked about lifestyle and diet during menstruation. For example, girls inquired about different fruits to be consumed during menses and amount of water intake necessary to maintain good health. Lifestyle questions included appropriate clothes to be worn during menses and optimum frequency to wash genital area. A lifestyle-related question asked was the following: I do yoga sometimes, should I do yoga during menstruation? Does yoga help? (Eighth grader)
Miscellaneous Although the theme for discussion was on menstruation, sexuality and sexual relations arose in nearly all sessions for girls in higher grades. Students wanted to know about contraceptives, condoms, kissing, sex education, and pregnancy.
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Discussion >> Little is known about the type of menstrual health education provided to young girls in India. However, to provide such education, baseline assessments of perceptions and knowledge could assist in development of menstrual education programs. This study highlights the perspectives of adolescent girls from low-income households and indicates a lack of critical knowledge that could aid in healthy growth and development. A few menstrual health education programs are implemented formally or informally in Indian schools or schools of many developing countries. However, functions of reproductive organs, menstrual abnormalities, sexually transmitted diseases, and contraception are not formally taught (Deo & Ghattargi, 2005; Garg, Goyal, & Gupta, 2012; Khanna, Goyal, & Bhawsar, 2005). Adolescent Indian girls may not understand the importance of menstrual hygiene in daily life, which in part, could be due to inadequate education and awareness and unhealthy social norms and customs. In one study, it was reported that awareness about menstruation prior to menarche was very low among Indian adolescents. The limited knowledge available was often passed down informally from mothers, who were themselves lacking in knowledge of reproductive health and hygiene due to low literacy levels (Deo & Ghattargi, 2005). Projection of menarche as a traumatic experience, development of misconceptions, and fear among adolescent girls have been noted in other studies also (Deo & Ghattargi, 2005; Garg et al., 2012; Khanna et al., 2005). Our findings support previous studies that adolescent girls in low- and middle-income countries may silently suffer some degree of pain, cramping, and discomfort associated with dysmenorrhea (Deo & Ghattargi, 2005; El-Gilany & Badawi, 2005; Sule, Umar, & Madugu, 2007). Without appropriate pain relief, girls with dysmenorrhea may not be able to carry out their normal activities or pursue formal education. In the present study, it was also surprising to note that girls had few questions on sanitary pads, and the questions submitted provided an indication that girls did not know about usage and disposal of sanitary pads. Interestingly, just before our study began, the government of India proposed funding for low-cost sanitary napkins to promote menstrual hygiene in rural areas for girls 10 to 19 years in 20 Indian states (Ministry of Health & Family Welfare, Government of India, 2012). Although a positive step in menstrual hygiene promotion, program and outreach implementation to young adolescent girls may be challenging due to lack of menstruation awareness.
Students from higher grades in the study sought more information and had more questions about menstrual symptoms, abnormal menstruation, myths, health, and beauty. Also, adolescent girls posed more questions about self-medication and home remedies than about seeing a health professional for common menstrual abnormalities. Consequently, there could be underdiagnosis and treatment of menstrual abnormalities, which may lead to reproductive problems during adulthood. This is in contrast to previous reports of women with more education who reported better awareness of health issues and were more likely to seek medical attention (Kirk & Sommer, 2006; Sule et al., 2007). In early puberty, adolescents’ most significant preoccupation is their bodies, during the rapid physical changes they experience. Educating adolescents such as those in our study should be a key initiative for reduction of reproductive health problems (Kirk & Sommer, 2006; Shah et al., 2013; Sule et al., 2007). Illiteracy along with poverty has been indicated as a cause of sociocultural beliefs and taboos regarding menstruation leading to ill health and ignorance among adolescent girls (Deo & Ghattargi, 2005; Khanna et al., 2005; Kirk & Sommer, 2006). Adolescents who cannot talk to their parents and teachers about menstruation comfortably and do not receive sexuality education in school might receive inaccurate information. In our study, cultural restrictions on discussing reproductive health and sex education issues could have resulted in misperceptions and beliefs about menstruation and sexuality-related topics. This is a critical issue that warrants strategic thinking and comprehensive planning on adolescent sexuality education in developing countries. In our study there are some indicators that suggest that sequential sexuality education based on grade level of students is required. Based on the differences in questions asked by students in lower grades compared to students in upper grades, a grade-specific Family Life/Sex Education curriculum should be designed. Regarding implementation, there are many sociopolitical, cultural, and religious issues to consider. For example, we must consider the Indian scenario of school-based Family Life/Sex Education. In 2007, the Indian government National AIDS Control Organization and Ministry of Human Resource Development proposed a sex education program for adolescents. Within a few days of the proposed initiatives, major controversy erupted and opponents from religious and social groups argued for a prohibition of any such education, citing that such education would lead to the moral downfall of youth, excessive sexual behavior, promiscuity, and experimentation at a tender age (Tripathi & Sekher, 2013).
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Global Health Promotion Limitations of the Study The results of our study should be viewed in light of several potential limitations. All study subjects were low-income students in one county of western India. Thus, our results cannot be generalized to students in other regions of India or other low-income countries. There were several confounding demographic and background characteristics of the students that could not be gathered. This was an ethnographic observational study, and therefore the inferences are limited. Finally, even though our response rate was more than 50%, we might have missed important perceptions and beliefs as many girls opted out of asking questions.
Conclusions >> The present study has revealed a low level of menstruation knowledge and various misconceptions among adolescent schoolgirls in India. This speaks to the urgent need for girls to receive more guidance on menstruation and to the importance of good menstrual health and hygiene practices. The information from this study could be useful in modifying existing health education programs and improving reproductive health services in India. Our study also suggests that teachers and parents in developing countries should be educated to conduct routine screening for menstrual problems, provide counseling, and offer guidance about reproductive health issues. The governing bodies such as the Ministry of Education in India should consider menstrual health education and should revise existing health education materials according to Indian local context to implement a multigrade sequential education program for Grades 6 to 8. Live examples, case scenarios, three-dimensional models, manikins, and videos should be used while explaining complex topics like menstruation, pubertal changes, functions of reproductive organs, and use of sanitary pads (House, Mahon, & Cavill, 2012; Ministry of Health & Family Welfare, Government of India, 2012; Shah et al., 2013). Mothers should also be educated to communicate with their daughters regarding menstruation before menarche. Schools should be encouraged to provide basic facilities such as water, bathrooms, and safe private spaces where girls can follow hygienic practices. Schools and parents can play an important role in shaping healthy menstrual attitudes. Community-based adolescent-friendly health services will help begin open discussions on reproductive health, menstrual abnormalities, and psychosocial problems (House et al., 2012; Mahon & Fernandes, 2010; McMahon et al.,
2011; Shah et al., 2013; Sommer, 2010; Sommer et al., 2013). Further research should be conducted on menstrual health and hygiene in adolescents in low- and middle-income countries to meet the cultural, emotional, and social needs of girls. The adolescent girls of today are the mothers of tomorrow and the forebears of the future of their family, community, and nation. References Aniebue, U. U., Aniebue, P. N., & Nwankwo, T. O. (2009). The impact of pre-menarcheal training on menstrual practices and hygiene of Nigerian school girls. Pan African Medical Journal, 2(9), 1-9. Deo, D. S., & Ghattargi, C. H. (2005). Perceptions and practices regarding menstruation: a comparative study in urban and rural adolescent girls. Indian Journal of Community Medicine, 30, 33-34. El-Gilany, A. H., & Badawi, K. (2005). Menstrual hygiene among adolescent school girls in Mansoura, Egypt. Reproductive Health Matters, 13,147-152. Garg, R., Goyal, S., & Gupta, S. (2012). India moves towards menstrual hygiene: subsidized sanitary napkins for rural adolescent girls-issues and challenges. Maternal and Child Health Journal, 16, 767-774. House, S., Mahon, T., & Cavill, S. (2012). Menstrual hygiene matters: A resource for improving menstrual hygiene around the world. London, England: WaterAid. Khanna, A., Goyal, R. S., & Bhawsar, R. (2005). Menstrual practices and reproductive problems: a study of adolescent girls in Rajasthan. Journal of Health Management, 7, 91-107. Kirk, J., & Sommer, M. (2006). Menstruation and body awareness: Linking girls’ health with girls’ education. Amsterdam, Netherlands: Royal Tropical Institute. Mahon, T., & Fernandes, M. (2010). Menstrual hygiene in South Asia: a neglected issue for WASH (water, sanitation and hygiene) programs. Gender & Development, 18, 99-113. McMahon, S. A., Winch, P. J., Caruso, B. A., Obure, A. F., Ogutu, E. A., Ochari, I. A., & Rheingans, R. D. (2011). “The girl with her period is the one to hang her head”: Reflections on menstrual management among schoolgirls in rural Kenya. BMC International Health and Human Rights, 11(7), 1-10. Ministry of Health & Family Welfare, Government of India. (2012). Two year (2009-2011) achievements of Ministry of Health & Family Welfare unveiled. Retrieved from http://pib.nic.in/ newsite/erelease.aspx?relid=72307 Riggs, N., Tewari, A., Stigler, M., Rodrigues, L., Arora, M., Khubchandani, J., . . .Pentz, M.A. (2013). Indian students’ perspectives on obesity and school-based obesity prevention: A qualitative examination. Health Promotion Practice, 14, 816-823. Shah, S. P., Nair, R., Shah, P. P., Modi, D. K., Desai, S. A., & Desai, L. (2013). Improving quality of life with new menstrual hygiene practices among adolescent tribal girls in rural Gujarat, India. Reproductive Health Matters, 21(41), 205-213. Sommer, M. (2010). Where the education system and women’s bodies collide: The social and health impact of girls’ experiences
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