Breaking the Taboo: Addressing Menstrual Health Challenges in India
Pratiksha Jadhav1*, Ashok Hajare2, Madhuranjan Vatsa3,
Shiju Sebastian4, Syeda Unnisa5, Manisha Paliwal6
1Krishna institute of pharmacy, Krishna Vishwa Vidyapeeth, Karad, Maharashtra.
2Bharati Vidyapeeth College of Pharmacy, Palus, Maharashtra, India 416310.
3Akhildev IPR and Research Services, Greater Noida, UP, India.
4School of Business and Management, Christ University.
5Department of Environmental Science, Osmania University, Hyderabad, Telangana, India.
6Sri Balaji University, Pune. Maharashtra, India.
*Corresponding Author E-mail: pratikshapjadhav@outlook.com
ABSTRACT:
Although, menstrual hygiene is a topic as ancient as mankind, it has recently garnered attention because society is more willing to face its difficulties. Adolescents seldom talk about issues related to menstruation, menstruation disorders, menstrual cleanliness, and customs of their culture. There is little data on the hardships that teenage females bear from menstruation and their social norms. Adolescent health education must include information about menstruation. Menstrual behaviors are often greatly influenced by culture, awareness, and social condition. However, periods, behaviors, and problems are seldom included in health education programs for the younger girls in impoverished nations. International health organizations such as WHO and UNICEF have advised developing culturally responsive menstrual health management (MHM) as well as water, sanitation and hygiene (WASH) programs for the adolescent girls. Without an awareness of the preconceived notions and prejudices that teenage girls in poor nations currently have about menstruation, these programs cannot be implemented. The goal of this review from India was to record the myths that are currently in circulation concerning menstruation, menarche, and other understudied menstrual constraints. Our goal in conducting this review was to characterize and assess the effectiveness of menstruation education programs designed to provide early teenage girls the information and abilities they need to support menstrual health.
KEYWORDS: Menstruation, Menstrual Health Management, Menstrual Health, Sexually Transmitted Diseases.
INTRODUCTION:
Despite being an inevitable part of life, many cultural norms and beliefs are linked to menstruation, and they can at times possess a detrimental effect on women health1. A woman's life is bound to involve maintaining good hygiene throughout her period. The relationship between women's health and well-being and several factors, including the physiology, psychology and pathology, of menstruation, makes this a significant problem in terms of the morbidity and mortality rate among the female population.
It is believed that a woman is most susceptible to contracting urinary tract infections, sexually transmitted diseases (STDs), also reproductive tract infections (RTIs) at this time2,3. The menstrual cycle, often known as the period/monthly cycle, is a special phenomenon that is exclusive to women. It is more than just a term; it refers to a crucial time during which a woman goes through several reproductive changes, beginning with menarche and concluding with menopause. Adolescence is a period of physical, female reproductive, as well as psychological development that normally lasts from puberty until the achievement of legally recognized adulthood4.
With support from several organizations, the Indian government has put together multiple initiatives focused on enhancing menstrual hygiene management (MHM) in schools. These programs aim to improve knowledge, access to, and facilities for disposal of menstrual waste, as well as sanitation in schools. The government recognizes the value of menstrual hygiene to girl's wellbeing, health, and academic success of the girls. Increasing the number of restrooms with separate facilities for both men and women, WASH (water, sanitation and hygiene) programmes, producing and selling inexpensive sanitary pads, government-subsidized feminine hygiene products in rural areas, and installation of school vending systems for hygienic pads as well as pad incinerators are a few examples4,5. However, due to a lack of understanding of the scientific basis of menstruation, there are a number of psychological, cultural and religious hurdles around it. It is significant to note that a lot of females living in impoverished communities may even not know what the menstrual cycle is all about.6
Adolescent girls in low- and middle-income countries (LMICs) struggle with managing their menstrual hygiene, particularly while they are in school1,2. Girls see menstruation as embarrassing in addition to unpleasant due to a shortage of sanitary MHM products (absorbents), sanitation, poor WASH (water, sanitation, and hygiene) amenities in schools, and insufficient puberty education. Few statistical findings support the qualitative research that describe girls' nervousness and shame over body odor and blood leaks, which causes menstruation girls to skip school3-8.
Teenage years are unique, marked by significant changes in the emotional, physical, psychological, and social domains7. According to a research there was little knowledge about menstruation before to menarche in India. Because of their own poor literacy rates and socioeconomic backgrounds, moms passed on the little information that was accessible to them informally. These mothers were also ignorant about reproductive health and cleanliness8.
In one of the research studies by Gultie et al.9 on teenagers' understanding of menstruation in Ethiopia, 33% of participants had never discussed menstruation with anybody. In an interactive survey, girls said that their menstruation had an impact on their attention (40 vs 45%, P = 0.1), punctuality at school (6% vs 11% in model versus conventional schools, as well, P = 0.003), and pain (31% vs 38%, P = 0.004) as well as their dread of stains or smells (11% vs 16%, P = 0.002). In both private and government schools, almost 45% of girls admitted to using disposable sanitary pads; however, only 55% and 29% of sanitary pad users, specifically, reported having adequate disposal facilities (P<0.001)10. According to a phenomenological investigation of menarche experiences conducted in Jordan, girls felt that discussing menstruation was “rude”11 Men and women were equally involved in the menstrual stigma's perpetuation, according to a research on puberty communications in China and Czech Republic. Mothers were telling their daughters to keep their monthly status “secret”12.
Cultural taboos compound females' struggles by keeping them from asking for assistance, and restricting their food and activities during menstruation13. Health problems pertaining to the vaginal and urinary systems may arise from inadequate MHM114. Choudhary discovered that although 61.3% of teenage girls in India had crippling dysmenorrhea, only 1.6% of them had ever seen a doctor. Instead, they believed they had to "tolerate" the condition as a normal part of growing up15. It was reported that around 52.52 percent of a survey participants were well-versed on menstrual hygiene. Few students (20.57%) thought that menstruation was a result of a divine curse, whereas the majority of students (64.07%) acknowledged that it was a natural process16.
According to a different survey, the majority of respondents were ignorant about menstruation cleanliness and habits because of societal norms and a lack of understanding of the reproductive system's physiology17.
According to reports, 84% of the girls learned about menses from their mother, whereas the majority of them (76%) had no idea what a menstrual cycle was before they reached menarche. Of the girls, 84% were unaware of the organ from which bleeding originates, and only 16% recognized that it is the uterus. The greatest percentage of girls (76%) had no idea that the menstrual cycle had a physiological explanation, whereas very few girls (20%) knew this18.
Significant Changes in Girlhood:
The adolescent years are a time when children start developing into adults. This is the critical time in a girl's life when changes in behavior, psychology, and physical attributes occur. The World Health Organization (WHO) defines adolescence as the age range between 10 and 17. Adolescence in females is a distinct time of life that requires special treatment, as is well recognized. At this point, the menarche begins14. In several civilizations, menstruation is still considered disgusting or dirty. The way one responds to menstruation relies on their level of awareness and expertise. How a girl responds to the menarche event may depend on how she is taught about menstruation and the changes that go along with it.
Sociocultural norms may make it difficult for teenage females to get proper knowledge regarding menstruation and menstrual hygiene at the outset of menarche, which makes adolescence a particularly concerning time. Adolescent girls' long-term health and socioeconomic consequences may result from menstruation's role in school dropout, absenteeism, as well as other sexual and reproductive health issues (UNICEF). Adolescents should be more knowledgeable of menstruation, good cleanliness during their periods, and safe behaviors to prevent infections of the reproductive tract (RTI) and the associated risks. Growing awareness about menstruation from an early age might improve safe practices and lessen their discomfort. Due to the negative social connotation associated with menstruation, many women and girls engage in risky personal hygiene behaviors15.
Without a forum to discuss issues related to menstrual hygiene, girls often experience pain and illness, refrain from urinating in public when they are menstruating, and use whatever old or unclean clothing that they can find.
Socio-Economic Factors and Poor Hygiene:
With each passing year, a new group of females enters the teenage period, which means there is a constant need to be prepared to handle the difficulties associated with puberty. There is a belief that social, cultural, and economic factors—such as the absence of women’s private rooms for changing sanitary products in schools, the lack of water and sanitation facilities, the restriction of foods, taboos, and the acceptance of discussing menstrual hygiene management with friends, family, and the community—constrict and undervalue MHM.
Although the menstrual cycle is a natural event, it is also linked to a variety of societal as well as cultural misconceptions and practices that may be harmful to the girls’ health. The family's isolation of the menstrual girls and the limitations placed on them have contributed to the bad perception of this event. The social and cultural taboos around menarche and menstruation practices prevent adult females from learning about the scientific information and hygienic health behaviors that are essential to preserving good reproductive health.
Misconceptions, misinformation, and negative mindsets toward menstruation may lead to a low self-image among girls who are going through their first menstrual period. Moreover, the stigma associated with menstruation and the need to keep it private might be reinforced by the culture of silence around menstrual hygiene6–10. In order to effectively manage menstrual hygiene and overcome the stigma around it, teenagers must recognize the physiological transition they are going through and develop coping mechanisms.
Period Poverty:
“Period poverty” has been recently identified as a problem in high-income countries (HICs) for specific groups, like homeless women. However, a whitepaper published by PHS Group, UK, a UK provider of hygiene services, indicates that period poverty is more widespread, especially among school going girls, in addition is a contributing factor to menstrual anxiety along with absenteeism from school19. Menstruation and involvement have been the subject of much less study in HICs, despite the general knowledge that girls stop playing sports around puberty.
Girls who attend school and come from low-income homes find it difficult to manage their menstruation. Practical, social, economic, and cultural reasons limit them. Because most girls don’t know about the physiology of menstruation, their first feelings of dread, humiliation, and disgust are often associated with the period.
Menstrual Health:
An expanding field of health study is "menstrual health." It is a general phrase that includes aspects of psychological well-being including confidence, dignity, along with self-esteem as well as the sanitary control of menstruation8 9. It is a development of the idea of MHM, which is mostly used in environments related to LMIC to explain the difficulties in maintaining menstruation hygienically when resources are few, particularly soap, pads, and water14–16.
As per many of the theories, using filthy rags to absorb menstrual blood might lead to cervical cancer followed by RTIs because the materials can harbor infectious organisms that enter the reproductive system. Certain fabrics may cause chafing and discomfort, and even clean supplies that are not replaced often may smell3. Females may experience discomfort and anxiety if there is not enough water to wipe the blood off their hands or genitalia17.
Many research conducted in low- and middle-income countries have shown a link between menstruation and higher rates of school absences and decreased activity engagement14,18,19. Menstruation still remains taboo, making it difficult to have an honest conversation about it and leading to misconceptions and misunderstanding. For optimal reproductive health, one must be well-informed about menarche, menstruation, as well as the scientific evidence supporting these concepts.
Menstrual Hygiene Management (MHM):
Menstrual hygiene management, or MHM, is a part of larger programs that support the rights of women and adolescent girls to improved sexual and reproductive health. These rights are founded on everyone's capacity and right to control their own bodies and to have healthy reproductive lives. Every woman and girl has the right to basic hygiene, sanitation, as well as reproductive health care; menstrual hygiene is essential to these services as well as to the dignity and well-being of women and girls. Menstrual hygiene pertains to the unique health care demands and requirements that girls and women experience throughout their monthly menstrual cycle. The goal of menstruation hygiene management, or MHM, is to provide useful coping mechanisms for monthly periods. MHM describes how women get, utilize, and discard blood-absorbing products as well as how they maintain their personal hygiene and health during menstruation. Cervical neoplasia and infections of the reproductive tract are associated with poor menstrual hygiene. For teenage girls, a crucial component of their health education is learning about menstrual hygiene.
Risks Related to Inadequate Knowledge and Poor Hygiene:
Poor or inadequate knowledge about menstrual hygiene management (MHM) leads to
Health related risk - Utilizing unclean and unsafe materials for absorption of blood during periods may result in vaginal infections, which may have long-term implications for reproductive health.
Psycho-social effects: Menstrual constraints imposed by society and culture are often linked to feelings of disgust and humiliation, which induces negative attitudes.
Educational thrashing: Girls are more likely to skip school during their menstrual cycles when there are insufficient or poor WASH (water, hygiene, and sanitation) facilities availability.
Environment: Commercial along with non-reusable materials are frequently dumped into the surroundings due to inadequate or nonexistent waste management.
Due to a lack of hygienic restrooms and seclusion, young girls consider it challenging to manage menstruation hygiene in schools. For teenage girls, knowing and practicing good hygiene throughout menstruation is crucial since it affects health by making them more susceptible to reproductive tract infections12
Adolescent females need education because it affects their health in a way that makes them more susceptible to RTIs and its side effects, which may include persistent pelvic discomfort, dysmenorrhea, and, in extreme circumstances, infertility because of inadequate hygienic conditions and behaviors. Suggestions backed by research might be useful in addressing these issues and suggesting effective program interventions. A well-defined set of evidence-based treatments is necessary, according to key MHM members.
Role of Intervention Programmes:
Moms are often the ones who have the most knowledge about menstruation, however several studies have shown that moms may not have all the information they need and may even spread false information and cultural beliefs. Menstruation may be discussed at school as part of sexual awareness instruction in HICs like Australia as well as the UK, if it is taught at all, however, it is reported many girls fail to receive the necessary practical knowledge. Non-governmental organizations have intervened to attempt to close the gap by offering menstruation education initiatives in both HIC and LMIC.
Simple "menstrual education" interventions, such as teaching boys and girls about anatomy, puberty, and hygiene via the hands of teachers or other qualified educators. Interventions offered by nurses or other key workers that focused on skill development, including proper menstrual cup insertions, were also eligible. Programs that provided resources or locations (physical and virtual) for learning were also eligible for inclusion, as long as they promoted peer or self-guided learning.
Managing menstrual hygiene or MHM need to be a key component of medical health awareness. The UN11 defines adequate menstrual hygiene management as having access to resources for the disposal of used sanitation materials, soap and water for body washing as needed, and a sterilized sanitary material to absorb or collect blood that can be changed within privacy as often as necessary for the duration of the menstrual period. However, particularly in LMICs, girls and women have major challenges in accessing effective menstrual management8. The Fig. 1 represents WASH facilities provided for adolescent girls and MHM awareness in tribal schools of Gujarat.
Instructors have a good effect and have a big mental influence on adolescents. However, there is seldom a discussion of menstruation hygiene in the curriculum. The Millennium Development Goals include it as well. Therefore, it is critical to research existing menstrual hygiene behaviors in order to understand the implications and significance of these practices for teenage girls and to design future treatments appropriately.
In India, the Adolescent Reproductive and Sexual Health (ARSH) and the Adolescence Education Programme (AEP) under the RCH-II, which address adolescent health as the major components, introduced the menstrual hygiene promotion program. The goal of the program, "Promotion of Menstrual Hygiene Among Adolescent Girls (10-19 Years), is to empower girls for greater socialization, enhance their awareness of menstrual hygiene, and ensure that they can easily access and use high-quality sanitary napkins. Additionally, the program aims to build self-esteem and ensure the ecologically responsible and safe disposing of the sanitary napkins.
Figure 1: Facilities for adolescent girls and MHM awareness in tribal schools of Gujarat17.
One of the unique life experiences and puberty stages is the menstrual cycle in a girl’s life. Adolescents girls made up 20% of the global population, and 85% of them resided in developing nations.5 Girls must have the opportunity to attend school and fully develop possible, in order to succeed in gender parity. Recently, there has been focus on the way insufficient menstrual hygiene alternatives hinder girls' access to school in low- and middle-income nations. Researches have shown that decreased student enrollment, absence, and dropout rates might be linked to inadequate hygiene facilities in schools as well as a lack of access to high-quality sanitation supplies. Menstrual hygiene issues may have negative effects on one's health, including an elevated risk of UTIs along with reproductive disorders. Menstrual hygiene is a complex issue; girls must understand menarche as well as be able to manage their period in a supportive setting with access to sanitary items and spaces for changing especially discarding menstrual products at home as well as at schools7-9,18-21.
Consequently, menstruation before menarche is not well known in India, where it is also socially stigmatized as filthy or unclean. Menstrual hygiene management in adolescent girls who are starting menstruation is limited by social, practical, and financial factors, such as the cost of sanitary pads, the absence of water facilities, the lack of private spots for changing clean hygienic pads, as well as the lack of education regarding menstrual hygiene facts18.
It has been noted that cultural restrictions, the idea that menstruation should not be discussed with other people, being shy, and other factors contribute to teenage girls' decreased conversation about menstruation and cleanliness. Therefore, only during their menstrual period, most conversations about health issues, napkin use and disposal, especially the length of the menstrual cycle popped up. Such adolescent girls constitute the majority of people who have periods that are irregular and suffer from abdominal discomfort. Adolescent girls, however, are keen to learn more about menstruation-related topics including period hygiene. They would want to know the causes of the following symptoms: white discharges, itchiness in the genitalia and around the vulva, heavy and sparse bleeding, stomach discomfort, body ache, and heaviness throughout the menstrual cycle. In addition to the physiological issues, females need education and solutions to the cultural limitations on dietary restriction, movement restriction, and segregation19.
The majority of the girls/participants in various studies adhered to various limitations as a result of their incorrect views and inaccurate ideas regarding menstruation. Teenage girls or their families follow customs and superstitious beliefs that are rooted in tradition because they lack basic understanding. Every teenage female complied with a number of certain rules, such as refraining from going to temples and staying out of the kitchen20.
The review examined the relationship between adolescent girls' socio-economic background and their knowledge of menstruation as well as menstrual hygiene management. It was discovered that there were no notable differences in the knowledge of menstruation before puberty, personal hygiene/genital hygiene practices, along with difficulties suffered during menstruation at school among students in rural and urban areas, government and private school students, as well as students from coeducational schools. Even social and cultural elements and stigma like caste and religion do not really matter20,21.
A growing global concern for MHM has been sparked by efforts to enhance WASH in schools, and it has centered on the need for privacy and dignity, breaking the taboo of MHM usage by increasing awareness, providing access to safe and efficient MHM absorbents, and enhancing the school WASH environments. The latter offers females' only restrooms, water and cleaning supplies, and secure trash disposal for filthy items. The distribution of adolescent school girls from a survey report based on their hygiene practices during menstruation is presented in Table 1.
Table 1: Distribution of adolescent school going girls based on hygiene practices during menstruation22
|
Hygiene practices during menstruation |
Rural (n=132) |
Urban (n=112) |
||
|
Frequency |
% |
Frequency |
% |
|
|
Type of sanitary material used: |
||||
|
Sanitary pad |
68 |
52.22 |
74 |
66.37 |
|
New cloth |
14 |
18.84 |
22 |
28.64 |
|
Old cloth |
51 |
39.94 |
16 |
13.06 |
|
Frequency of change of sanitary material: |
||||
|
Every 4-6 hrs |
25 |
24.91 |
51 |
45.53 |
|
6-8 hrs |
21 |
22.91 |
38 |
34.82 |
|
8-10 hrs |
74 |
54.16 |
09 |
08.03 |
|
>10 hrs |
12 |
09.09 |
14 |
11.60 |
|
Cleaning of privates: |
||||
|
Twice a day |
89 |
67.42 |
55 |
49.10 |
|
Once |
35 |
26.05 |
51 |
45.53 |
|
Irregular |
08 |
06.06 |
06 |
05.35 |
|
Method of disposal: |
||||
|
Hide/others |
52 |
40.14 |
25 |
20.74 |
|
Flush in toilet |
07 |
05.30 |
10 |
08.82 |
|
Dustbin |
72 |
54.54 |
79 |
72.52 |
|
Proper privacy/facilities at Home: |
||||
|
Yes |
52 |
41.25 |
97 |
85.60 |
|
No |
78 |
58.75 |
15 |
14.40 |
|
Proper privacy/facilities at School: |
||||
|
Yes |
42 |
34.14 |
96 |
87.50 |
|
No |
81 |
65.86 |
15 |
12.50 |
The influence that MHM hygiene practices have on teenage girls' health, education, as well as psychosocial outcomes is becoming more widely acknowledged. Adolescents have significant obstacles in managing their menstruation in a safe, effective manner, but that should not result in negative outcomes like lower school attendance, behavioral constraints, or loss of confidence21-25.
It is determined that the girls' and students' menstrual hygiene habits in rural regions were unsatisfactory. Our review research demonstrates that most girls experience significant physical and psychological burdens and lack enough understanding about menstruation. Restrictions and false ideas exacerbate this as unpleasant experience. It is also quite uncommon for females to learn regarding menstruation and understand what is natural or when to need assistance since talking about it is considered taboo. If these girls get enough health information, they will begin to practice good hygiene and will also assist in lifting some of the limitations. In addition to teaching girls, moms should be urged to end the taboo and begin talking about the significant parts of menstruation and other bodily changes that girls are going through. Various intervention programmes and MHM practices have come up as aid, however, religious and cultural stigma in certain underprivileged regions remains that needs reformation and education.
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Received on 05.06.2024 Modified on 17.08.2024
Accepted on 21.10.2024 © RJPT All right reserved
Research J. Pharm. and Tech 2024; 17(11):5653-5659.