Status of menstrual hygiene management among adolescent girls of Nepal

Abstract

Menstrual taboos are common in many low- and middle-income countries (LMICs) including Nepal. Such taboos can have direct negative impacts on psychosocial/mental health contributing to poor Menstrual Hygiene Management (MHM), which in turn leads to further negative health outcomes among girls and women. Studies have reported a wide range of negative effects from poor MHM, including shame, fear, anxiety, loneliness, and psychological distress. While a number of efforts to address adolescent issues have been initiated, there is a significant lack of data on adolescents in Nepal that are essential for programs to be properly targeted, be based on robust needs assessments, and for them to reach their intended beneficiaries and achieve desired outcomes. Only very few data sources in Nepal exist that focus on adolescents exclusively, and very few delve into the nuanced aspects of adolescent lives that can address the complex vulnerabilities they face. Recognizing these gaps in understandings, and with the support from World Vision International Nepal, the Nepal Health Research Council has undertaken a study that aims to assess knowledge, attitude and practice on menstrual hygiene, and identify negative mental health and psychosocial consequences of poor menstrual hygiene among adolescent girls (including differently-abled adolescent girls) in Nepal and make evidence-based recommendations for actions. Methods: This study adopted a mixed method design that included a population-based national representative survey of 3495 adolescent girls aged 10-19 years who had experienced their menarche by using two-staged cluster sampling. Purposively selected key informant interviews (KII) with community leaders, teachers, health coordinator and political leaders, member of school management committee of school, focus group discussion (FGD) among adolescent mothers, out-of-school adolescent girls and school going adolescent girl and in-depth interviews (IDI) with differently able adolescent girl to identify their menstrual needs. The enumerators conducted FGDs, IDIs, and KIIs among participants to obtain relevant information regarding menstrual needs. The samples were taken until no new information or themes emerged i.e. the point of saturation was met.

Data was entered into Epi-Data version 3.1. Data cleaning and editing were done subsequently after entry and descriptive statistical analysis (frequency and percentage) and cross-tabulation where necessary were done using statistical package for social sciences (SPSS) version 21.0 and data were weighted to ensure actual representativeness of the survey and descriptive analysis was carried out. For qualitative analysis, data from the IDI, KII and FGDs was simultaneously translated and transcribed into English. Then accurate data was segmented manually using Ms-Word and Ms-Excel. Thus, results were generated through thematic analysis. Background characteristics: Among total 3,495 adolescent girls who participated in this study, majority 47.5% were from upper caste groups and 0.9% from religious minorities. 84.7% were Hindu 1.1% were Muslims. The mean age of the participants were 14.53. Fifteen participants were found to be married. The mean age of menarche was 12.79 years (minimum 10 years and maximum 16 years). Knowledge regarding menstruation: Three quarter (71.7%) of the adolescent girls knew about menarche before its onset, with one quarter (28.3%) who had “no idea” about menstruation. This knowledge was found to be highest (88.9%) in Province 1 and lowest (47.4%) in Sudurpaschim province. Nearly half of the participants felt menstruation as a normal healthy process and bad blood being shed while very few also associated menstruation with illnesses, curse and supernatural reasons. Half (50%) of the adolescent girls were unaware of the physiology of menstruation that sets the stage for pregnancy. However, 22 % of the girls knew that there are certain days between two menstruation cycle when one can get pregnant under circumstances of ovulation and fertilization. Mother, elder sister and friend were the major source of information with regard to both knowledge and guidance both before and after menarche, while books and media (radio and television) provided least information. Perception and practices : Thirty six percent of the girls experienced “feeling scared” at their first menstruation. Restrictions during menstruation were highest with regard to religious activities (79.1%), followed by restrictions in household chores (51.9%), social activities (46.1%) and personal activities (36.95 %). The reasons that adolescent girls follow restrictions is because of family obligations (31.9%), felling unwell (22.3%), feeling restrictions are right (17.3%) and fearing divine retribution (16.6%). Again, mothers were the first person who suggested girls to follow restrictions, followed by grandparents and fathers. Given that there were no restrictions during menstruation, more than 90% adolescent girls preferred to continue personal activities (take a bath, sleep in their same room, eat dairy products) while the least preferred was to engage in religious activities. Similarly, one third (38.4%) had talked or done anything against restrictions at home and nearly one quarter (21.2%) had talked or done anything against restrictions in the community. Practice of Chaupadi: Chaupadi is practiced by 8.7% of adolescent girls in three provinces: Province 5 (0.9%), Karnali (20.5%) and Sudurpaschim (47.7%). The major reason behind the practice is family obligations (70.8%), fearing divine retribution (13.7%) and don’t know (11.8%). Three quarter of the girls (74.3%) of girls think chaupadi is bad practice and one tenth (9.4%) feel anxious about it. 83.9% of all girls think it is not necessary to practice chaupadi, but interestingly 22.5% of girls in Sudurpaschim thinks it is necessary. Menstrual hygiene management practices: Half (51.2%) of all girls use disposable sanitary materials, followed by reusable sanitary materials (37.7%). Majority (65%) were happy with the current use of sanitary material, while one fifth (20.9%) would prefer a different material given the option. Majority (42.6%) changed sanitary material three times or more per day, 39.7% changed twice a day and 11.9% once a day. At home, 92.9% was able to change sanitary materials as often as necessary at home. At school only 55.2% were able to change sanitary materials and three major reasons for not being able to change were: unavailability of disposal mechanism (29.1%), embarrassed (25.9%), not enough material (23.9%). Almost half of the girls (46.6%) had access to toilets for cleaning purpose, 37.7% went to well/taps and 15.6% went to river/ponds. 93.7% had access to soap for washing and it was almost similar across all provinces. 92% washed and dried sanitary materials in sunlight but away from others view. Half (54.1%) of the girls took a bath daily. 60.5% girls could easily access washing place (<15 mins) while 1.8 % had to walk more than one hour. Disposal mechanism of used sanitary materials was mostly burying and burning. Place for changing sanitary materials were toilets followed by bed room. Majority of girls stated that the place for changing are clean, private and safe. One quarter (26.7%) girls missed school over the last 12 months with dysmenorrhea and heavy bleeding/fear of leakage being the major causes. Psychosocial impact: Secrecy and shame was scored on a scale of 0-33 and the average mean score was 14. Half of the girls (45.2%) related menstruation to high secrecy and shame. Annoyance was scored on a scale of 0-36 and the mean score was 19. 45.4% experienced high levels of annoyance. Menstrual stress was scored on a scale of 0-32, and the average mean score was 10. 42.5% experienced high menstrual stress. Menstrual self-efficacy was scored on a scale of 0-27 and the average mean score was 6. 42% experienced low self-efficacy. Menstruation from differently able perspective: Experiences of differently-abled girls varied with the nature of their impairment. Major challenges were not having access to disposable sanitary materials, difficulties in disposal mechanisms, reliance on immediate female family members for changing sanitary material, reliance on female family member to oblige chaupadi and also absence of disable friendly WASH facilities outside home resulting in them staying home during menstruation. However, depending on the nature of impairment, not everyone required the same type of external support. The general needs of differently abled adolescent girls were to have access to disposable sanitary materials, disable friendly disposal mechanisms, disable friendly WASH facilities in school, distribution of free pads from government and care and support both at home and school.

Conclusion: Adolescent girls’ knowledge around menstruation is inadequate as one quarter are unware about menstruation before menarche and one half are unaware of the link between menstruation and pregnancy. This may have direct implications on the level of reproductive health knowledge among adolescent girls and subsequent reproductive health programs. Adolescent girls continue to face restrictions during menstruation ranging from restrictions in religious activities, issues of touchability to food consumption. Mothers are the primary source of information and guide for menstrual management as well as major bearers to continue restrictions during menstruation. Chaupadi continues to be practiced in three of seven provinces with Sudurpaschim practicing most. Three fourth of adolescent girls know chaupadi is bad but cultural practice is deep rooted.

Menstruation management among adolescent girls were found to be good: majority had access to disposable sanitary materials, half of the girls were able to change pads thrice or more per day, more than 90% had access to soap for washing and was able to dry menstrual materials, majority had a safe and private place to change. However, home was more comfortable place for menstruation management compared to schools. One quarter of girls missed school due to menstruation related issues.

Menstrual needs of differently abled adolescent girls is largely neglected. Their needs are related to availability of menstrual material and disable friendly WASH beyond home. Their needs are largely fulfilled within household only. Majority of girls felt sacred during their first menstruation. Almost half of the girls experienced high menstrual stress, high annoyance and low self-efficacy.

Recommendation: School education and MHM programs should focus on educating adolescents about physiology of menstruation and the linkage to reproductive health. Restriction around menstruation is deep rooted and therefore should engage primary bearers and influencers including mothers and grandparents to change malpractices including chaupadi. Schools need to ensure an enabling environment for menstruation management including; access to gender friendly toilets, access to water and soap, access to menstrual materials, proper disposal mechanisms and pain management in order to reduce absenteeism. Menstrual needs of differently abled girls should be addressed at all levels including household, community, public places and schools. Given the high levels of menstrual stress, support mechanisms should be provided to adolescent girls at community and schools.