Is menstrual hygiene and management an issue for ......hygiene and management, and their...

Report

Is menstrual hygiene andmanagement an issue foradolescent school girls?

WaterAid/Anita Pradhan

A comparative study of four schoolsin different settings of Nepal

WaterAid/Marco Betti

A WaterAid in Nepal publication

March 2009

A copy of the report can be downloaded from www.wateraid.org/nepal

WaterAid’s mission is to overcome poverty by enabling the world’s poorest peopleto gain access to safe water, sanitation and hygiene education.

We would like to take the opportunityto express our sincere gratitude to allthose who have in some waycontributed to bring this study in thefinal shape it is now. In particular, wewould like to thank the adolescentschool girls who participated in thisstudy with all enthusiasm. Specialgratitude goes to Dr. Amit Bhandari &Ms. Savitri Gurung for their technicalwork & support and the Principals &teachers of all four schools (ShreeMahakali Secondary School-Dhading,Shree Devi Secondary School-Morang,Shree Bal Uddhar Secondary School-Kathmandu, Shree Devi SecondarySchool-Lalitpur) that were included inthe study for all their cooperation andsupport even at short notices.Similarly, we are very much thankful

to the Principal, teachers and thestudents of class ten of Pushpa KunjaHigh School, Samakhusi, Kathmandu fortheir participation and cooperation duringpre-testing of the instruments of thisstudy; Nepal Water for Health (NEWAH),Biratnagar and Chandra Jyoti IntegratedRural Development Society (CIRDS),Mahadevbesi, Dhading for coordinationand support for data collection in Morangand Dhading districts respectively; andBhavana Bhatta and Babu Ram Panta ofYouth Action Nepal, Kathmandu for theirassistance provided throughout thestudy. We hope that this study will servethe purpose of informing the strategiesand actions of any concernedstakeholders in improving the menstrualhygiene and management particularly ofadolescent girls.

Acknowledgement

iExecutive summary

ContentsExecutive summary ii

Background 1

Objective 3

Methodology 3

Ethical considerations 4

Limitations 5

Results 5

Knowledge and beliefs 6

Experience during menstruation 8

Practices of seclusion, exclusion and absenteeism 10

Hygiene practices 13

Discussion 17

Recommendations and conclusion 20

References 22

iiIs menstrual hygiene and management anissue for adolescent school girls?

Menstrual hygiene and management is anissue that is insufficiently acknowledgedand has not received adequate attentionin the reproductive health and Water,Sanitation and Hygiene (WASH) sectors indeveloping countries including Nepal andits relationship with and impact onachieving many Millennium DevelopmentGoals (MDGs) is rarely acknowledged.Studies that make the issue visible to theconcerned policymakers and informpractical actions are very much warranted.This small scale study was undertaken withthe objective of determining the prevailingknowledge and experiences of menstrualhygiene and management, and theirimplications, among adolescent schoolsgirls in rural and urban settings of Nepal.

This is a descriptive cross-sectional study inwhich mixed methods (quantitative andqualitative) were applied. Data wascollected from 204 adolescent school girlsfrom four government secondary schools,one in each of Dhading, Morang, Lalitpurand Kathmandu districts, using self-administered structured close-endedquestionnaires, focus group discussions(FGD), and semi-structured in-depthinterviews. Four main recurrent themes havebeen identified in the analysis: a)knowledge and beliefs b) experiencesduring menstruation c) seclusion, exclusionand absenteeism and d) hygiene practices.

The large majority of survey respondents(92%) had known about menstruationbefore their menarche, particularly from

mothers (51%) or sisters (41%). However,the information provided was mainlyabout the use of cloth and the practice ofrituals and restrictions constructed aroundthe polluting effect of menstruation.Abdominal pain is the most commonmedical problem experienced by thesurvey respondents (85%). Mental stress isalso common, particularly due to constantworry that others may know about theirmenstruation. Seclusion and exclusionpractices were widespread, particularlyamong Bahun, Chhetri and Newar castegroups. About 89% of the surveyrespondents practice some form ofrestriction or exclusion, the commonestone being abstaining from religiousactivities (68%). The socio-cultural reasonsare based on concepts of "pollution"surrounding the menstruation. Surveyshowed that about half of the respondents(53%) had been absent in school at leastonce due to menstruation. Many girlsthough physically present in the school,were unable to perform well due to poorconcentration and attention resulting fromthe constant worry. Lack of privacy forcleaning and washing (41%) was the majorreason identified by survey respondent forbeing absent during menstruation. This isusually because of lack of water or due tominor issues, such as missing door locks,even when infrastructure of toilet ispresent.

Most of the survey respondents (66%)used re-usable cloths to absorb menstrualflow during menstruation, the use being

Executive summary

iiiExecutive summary

significantly higher among rural than urbanschool girls. The use of old piece of clothwas significantly higher among rural girls.Not knowing about its availability (41%)and high cost (38%) are the majorreasons, as perceived by the surveyrespondents, for girls not using disposablesingle-use sanitary pads. The low cost andease of availability of rag cloth was seento the mostly commonly used by girls inboth rural and urban settings, howevermany of them preferred sanitary pads. Theparticipating girls wash their genitals on anaverage two to three times a day duringmenstruation. However, this may bedifficult in school due to poor facility forcleaning and washing or disposingabsorbent cloth. Only around half of therespondents have toilet with adequateprivacy at home (55%) and about two-fifthhave at school (42%). On average the girlschange the absorbent material between 2to 3 times in a day and use one re-useablecloth for 3 cycles. Disposal of used clothsand napkins was a challenge in bothurban and rural schools.

Restrictions during menstruation that limitdaily activities and routine are widelypracticed. These manifest from beliefs thata woman during her menstruation is rituallydangerous, which can result in themspoiling food and plants, biological andsocial processes. Abnormal physicalconditions, particularly dysmenorrhoea andexcessive bleeding, as well as the mentalstress during menstruation affects the dailylives and routines of adolescent schoolgirlsto a varying degree, particularly the qualityof presence at school in terms of attentionand concentration in curricular activities.

Further, lack of small things required formaintaining basic hygiene duringmenstruation, like privacy, water supply andwaste disposal compound the situation.

Conscious efforts need to be made toaddress lack of privacy, which is animportant determinant for proper practiceof menstrual hygiene and also schoolattendance. In most cases this may meanmanaging the resources thoughtfully andproblem-solving as the situation arises -small measures that can really help toprovide supportive environment formenstrual hygiene both at home and inthe school. Realizing the needs andinterest to use sanitary pads, innovativeways have to be identified for makingpads available and affordable to schoolgirls belonging to all segments of society.It is clear that the reproductive healthimplications of menstruation and itsmanagement, and its effect on quality oflife permeating school and other socialactivities are many for the adolescentschool girls. These invariably call for allstakeholders to urgently addressentrenched and incorrect menstrualperceptions, and enable proper hygienepractices amongst this segment of thepopulation. There is a significant need fororganizations working in the ReproductiveHealth and Water, Sanitation and Hygiene(WASH) sectors to work concertedlytowards developing appropriate policy andadequate actions on the hitherto neglectedissue of menstrual hygiene andmanagement.

Key words: Menstruation, Hygiene,Adolescent Girls, Water, Sanitation

ivIs menstrual hygiene and management anissue for adolescent school girls?

1Background

BackgroundNepal, being a signatory to the DelhiDeclaration 2008: "Sanitation for Dignityand Health", in the Third South AsianConference on Sanitation (SACOSAN),needs to make major efforts to ensurethat "the special needs of women (e.g.menstrual hygiene management) areintegrated in planning, implementation,monitoring and measurement of(sanitation) programme outcomes" (TheDelhi Declaration, SACOSAN-III 2008).Although often not acknowledged, it isclear that measure to adequately addressmenstrual hygiene and management willdirectly contribute to MDG-7 onenvironmental sustainability. Additionally,due to its indirect effects on schoolabsenteeism and gender discrepancy, poormenstrual hygiene and management mayseriously hamper the realization of MDG-2on universal education and MDG-3 ongender equality and women empowerment(Ten, 2007). However, the attention onthis issue is far from sufficient. Even theliterature on gender mainstreaming insanitation sector is silent on the issues ofmenstrual management. The objective ofmany environmental health programmesin Nepal, like in most developingcountries, is to reduce morbidity andmortality caused by exposure to agents ofdisease and exacerbated by environmentalhazards. Priority areas include watersupply and sanitation, solid wastemanagement and hygiene education(Bhardwaj & Patkar, 2004). Better excretadisposal facilities benefit men, women,

girls and boys. They offer privacy,convenience and safety. But mostsanitation programmes necessarily do notmention the special needs of women andadolescent girls who use latrines tomanage menstruation. It's a need that hasbeen excluded from latrine design/construction as well as hygiene educationpackages. Even reproductive andpreventive health programmes indeveloping countries like Nepal often donot address the issue and moreover theyfocus mainly on the reproductive functionsof married women.

Menstruation, though a natural process,has often been dealt with secrecy in manyparts of Nepal. Hence, knowledge andinformation about reproductivefunctioning and reproductive healthproblems amongst the adolescent is poor(Adhikari, 2007). A great deal of womens'and girls' scant knowledge is informed bypeers and female family members. A studyof Indian women shows that young girlsare generally told nothing aboutmenstruation until their first experience(Narayan et al, 2001). Several traditionalnorms and beliefs, socio-economicconditions and physical infrastructure canand do influence the practices related tomenstruation. For example, a Hindu Nepaliwoman abstains from worship, cookingand stays away from her family as hertouch is considered impure during thistime. Women and girls in poor countriescan't afford sanitary pads or tampons,

2Is menstrual hygiene and management anissue for adolescent school girls?

which would normally be changed aroundtwo to four times a day duringmenstruation. Instead, the vast majority ofwomen and girls in Nepal use rags, usuallytorn from old saris. Rags are washedquickly inside the latrine or in public bathearly in the morning and used severaltimes. There is no private place to changeand clean the rags and often no safe waterand soap to wash them properly. Thegender unfriendly schools andinfrastructure, and lack of adequatemenstrual protection alternatives and / orclean, safe and private sanitation facilitiesfor female girls and teachers, underminethe right of privacy, which results in afundamental infringement of the humanrights of female students and teachers(Ten, 2007). Even in the homes, a cultureof shame forces women to find well-hidden places to dry the rags. These placesare often damp, dark and unhealthy. Ragsthat are unclean can cause urinary, vaginaland perineal infection. Very often seriousinfections are left untreated and maysometimes lead to potentially fatal toxicshock syndrome.

Literature review indicates that thepractices coupled with poor knowledge isresponsible for a significant proportion ofschool absenteeism, seclusion from socialactivities, illness and infection associatedwith female reproductive health of schoolgoing adolescents in developing countries.Expectedly, the scenario is common inNepal. Though many of the healthprogrammes have taken significant steps

forward, particularly as they ensuredcommunity participation in developingsustainable and effective hygiene andsanitation programme, usually these havefailed to include the issues related tomenstrual hygiene and management. Thisexclusion is undoubtedly due to theprevailing culture of shame, which createssilence and inability of young girls toarticulate demand.

Above all, studies documenting suchsituation in Nepal are lacking. The typesand frequency of problems related tomenstruation among adolescent girls andthe effect of these problems on daily livesmight be different in Nepal andimplications may vary. In the currentsituation, where there is an absence ofmenstrual hygiene and management issuesin the policy debate, and hence ininvestments and actions (Bhardwaj &Patkar, 2004), studies that garner support,confidence and an enabling environmentin order to make the voices on this issueis very much warranted - particularly tomake the issue visible to concernedpolicymakers and to inform practicalactions.

Menstrual hygiene and management is yetto be integrated effectively in overallhygiene promotion interventions in Nepal.Evidences from the field are imperative toemphasize the issues. Hence this smallscale descriptive cross-sectional study wascommissioned by WaterAid Nepal with theobjectives given below.

3Objective and Methodology

ObjectiveThe broad objective of this study is todetermine the prevailing knowledge andexperiences of menstrual hygiene andmanagement, focusing on the implicationsin the daily lives and routines, amongadolescent schools girls in rural and urbansetting of Nepal

Specific objectivesTo assess the prevailing knowledge andsources of information of adolescentschool girls about menstrual hygiene andmanagement,To elaborate the experiences and factorsthat determine the prevailing practices ofadolescent school girls vis-à-vismenstrual hygiene and management,To identify issues and challenges faced(including health) by adolescent schoolgirls due to their menstruation, andTo propose specific measures to improvemenstrual hygiene knowledge andmanagement

MethodologyThe research was carried in betweenDecember 2008 and February 2009.

Study site and populationThe study was conducted in four districtsof Nepal - Dhading, Morang, Lalitpur andKathmandu. The districts were selectedpurposively - to represent different terrainsas well as rural-urban areas of the country,

and also to keep it within WaterAid'sprogramme implementation area. Dhadingis a hill District, Morang a Terai District,and Lalitpur and Kathmandu are within thewider Kathmandu valley. The study unitwas one government secondary school ineach of these four districts. The schools inDhading, Morang and Lalitpur were in ruralarea and the one in Kathmandu was in theurban context. The study population was204 adolescent girls studying in grade 8, 9or 10 at the time of study. Girls of thesethree classes who attended the school onthe day of survey and were willing toparticipate in the study were included.Girls from those classes who had not yethad menarche were excluded.

Study design, techniques and toolsThis was a descriptive cross-sectionalstudy in which mixed methods(quantitative as well qualitative) wereapplied. A self-administered structuredclose-ended questionnaire survey(quantitative), and focus group discussions(FGD), and semi-structured in-depthinterviews (qualitative) were applied tocollect the information. The tools, surveyquestionnaire and guide checklist for FGDand in-depth interview were first preparedin English and then translated into Nepali.All three tools were pre-tested in a schoolin Kathmandu valley and revisedaccordingly before using it for the studypopulation.

Data collectionData collection was carried out at theschool site during school hours with dueverbal consent from respective schoolPrincipals. The self administered survey


was carried out in a classroom without thepresence of male students or teachers.Female member(s) from the research teamexplained the purpose of the study andmethod of completing the questionnaireand took verbal affirmation from therespondents to participate in the study.The survey was conducted with a total of204 respondents. An FGD was conductedin each of the four schools with nine tothirteen articulate and willing girls, whowere selected out of the surveyrespondents with the help of teachers. FGDwas carried out with a total of forty-sevengirls. Semi-structured in-depth interviewswere carried out with one or two girls ineach of the four schools. A total of fivegirls who have had some noteworthyexperience of school absenteeism or otherproblems due to their menstruation wereselected with the help of teachers for theinterview. To make the respondents feel atease and express freely on the littlediscussed issue of menstrual practices,only female member(s) were involved toconduct FGD and interviews.

Data analysisQuantitative data from the survey wasanalyzed using SPSS 12.0 software.Descriptive statistics were generated toshow the socio-demographiccharacteristics as well as the distribution ofknowledge and practices regardingmenstrual hygiene and management.Cross-tabulation and Chi-square tests wererun to see the association between somesocio-demographic variables withknowledge or practice variables.Qualitative data were gathered through in-

depth interviews and four focus groupdiscussions in order to gain anunderstanding of the patterns andpractices around menstruation. Influencingfactors to menstruation management andhealth seeking behavior were alsoexplored. Data from FGD and in-depthinterview was transcribed verbatim fromthe audio record in Nepali and translatedlater into English. The data was thenanalyzed manually; based on recurrentthemes and patterns.

Rights, anonymity and confidentiality ofthe respondents were respected in allphases of the study. Informed verbalconsent with the respective school'sPrincipal and the respondents were takenbefore data collection. Through verbalconsent process, the type and purpose ofthe survey, discussion or interview; issuesof anonymity and confidentiality;voluntary participation and freedom todiscontinue the interview/discussion atany stage; and absence of any known riskor benefit for participating in the studywas explained beforehand. Photo andaudio records were made with due verbalpermission from the respondents. Topreserve anonymity, all findings arepresented without ascribing names oridentifiable personal description.

Ethicalconsiderations

5Limitations and Results

LimitationsThe selection of study units andrespondents was purposive and may notreflect the population distribution of thegeographical terrains covered. So, thefindings of this study should not begeneralized, however the key issuesidentified from the community will be anassets for management of menstrualhygiene. The language was a barrier,particularly in Terai as most students therewere not well versed in Nepali language.The survey questionnaires were in Nepaliand many respondents had difficultyunderstanding parts of it. The researcherteam had to explain with the help offemale teacher, who acted as translator.

ResultsThe findings obtained through differentmethods and tools used in the study havebeen organized and presented in thissection under four main themes arisingfrom the quantitative and qualitative data.The main themes are:

Knowledge and beliefsExperiences during menstruationSeclusion, exclusion and absenteeismHygiene Practices

Socio-demographic characteristics ofrespondentsThe study was carried out with adolescentgirls studying in government secondaryschools. A total of 204 girls participated inthe survey, and out of them 47participated in the FGD and 5 in the in-depth interview. Out of 204 respondents,42% are from Kathmandu, 15% fromLalitpur, 22% from Dhading and 21% fromMorang.

The age of the respondents ranges from12 to 20 years, with mean age being 16years. Only 2 (1%) of the respondentsare married. Caste/ ethnicity-wise mostof the respondents belong to uppercaste group (45%) and disadvantagedJanajati (38%). Large majority of therespondents are Hindu by religion(84%), followed by Buddhist (13%). Theoccupation of the parents of majority ofthe respondents is agricultural activities(father's - 53%, mother's - 61%).Geographically, 57% of the respondentsare from the valley (Kathmandu andLalitpur), 22% from hill (Dhading) and21% from Terai (Morang). Of them 58%are from rural locality (Lalitpur, Dhadingand Morang) and 42% from urban(Kathmandu). The respondents hadattained menarche between 10 and 16years, the mean age of menarche being13.3 years.


Knowledge and beliefsThe survey indicates that about 92% ofthe participants had heard aboutmenstruation before their menarche(figure-1). However, FGD reveals a moreintricate pattern. Young girls shared thatthey were not told anything specific aboutmenstruation, especially the physiologicalbasis - e.g. where the menstrual flowcomes from - until their first personalexperience of it. Majority of the girls werenot prepared in any way for their firstmenstruation. Girls described the onset ofmenarche as a shocking or fearful event.Information was mainly provided aboutthe use of cloth, the practice of rituals inthe form of restrictions on theirmovements and behavior, and cautionsabout behavior towards males and, ofcourse, the possible effects of her"polluting touch" and the equallypolluting potential of the menstrual cloth.

As shown in the table 1, the surveyidentified that mother (51%), sisters (41%)and friends (36%) are the main source ofinformation about menstruation beforemenarche. The result is fairly consistentwith the source of information aboutmenstrual hygiene and management. Onlyabout one-fifth respondents mentionedthat they learnt about these issues fromteachers. However, many respondents inFGD expressed that the teachers usuallyavoided teaching lessons related toreproductive health. A respondent fromLalitpur exemplified it by quoting what herteacher had said:

"This topic need not be taught, you canself study at home. It's like knowing to goto toilet with slippers/shoes."

When asked who do they feel comfortablewith talking openly about menstruation,more than half said with friends/peers(55%), followed by mother (47%) andsister (40%). Only 3% mentionedteachers.

TABLE 1: Source of knowledge related to menstruation

(n = 204)

Mother 51.0 58.8

Sister 40.7 38.7

Other relatives 9.8 6.9

Teacher 17.2 20.6

Friends 36.3 32.8

Radio/TV 16.7 27.0

Newspaper 7.4 10.8

Textbook 16.2 25.0

Others 1.0 2.5

Source of Menstruation Menstrualinformation before Hygiene(%)*

menarche (%)*

8% Didn’t know

92% Knew

FIGURE 1: Distribution of knowledge about menstruation

before menarche (n = 204)

Knowledge: About menstruation before first menstruation

* Total may add to more than 100% due to multiple responses.

7Results

81% Normal physiological process

17% Didn’t know

2% Abnormal pathoological process

FIGURE 2: Distribution of knowledge about menstrual process

(n = 204)

Knowledge: Menstruation is a....

1% Disease

1% Curse/sin

4% Others

39% Didn’t know

55% Hormones

FIGURE 3: Distribution of knowledge about cause of menstrua-

tion (n = 204)

Knowledge: Cause of menstruation is ...

12.7% Don’t know

0%

20%

40%

60%

80%

100%

2.0% Urinary bladder

72.5% Vagina

12.7% Uterus

FIGURE 4: Distribution of knowledge of where menstrual blood comes from (n = 204)

Knowledge: Menstruation blood comes from...

In the survey, 81% recognized menstruationas normal physiological process (figure 2),only little more than half (55%) recognizedthe cause of menstruation to be hormones(figure 3). Very few respondents (2%)mentioned disease or curse/sin as the cause

of menstruation. The findings of the FGDare also in the similar lines. In the survey,majority of the respondents (73%)identified vagina, and only 13% identifieduterus, as where the menstrual bloodcomes from (figure 4).


Experience duringmenstruation

Pain and moreAbout 90% of the survey respondentsmentioned experiencing some kind ofabnormal physical condition during thelast menstrual episode (figure-5).Abdominal pain or discomfort is thecommonest medical problem experiencedby the respondents. Only 85% reportedabdominal pain, followed by excessivebleeding (8%) and breast pain (5%)(figure 6).

From the FGD it is evident that participantssought out both pharmacological and non-pharmacological interventions,Pharmacological interventions includedtaking pain-killers and visiting healthworkers. Participants also visitedtraditional healers and tried variousalternative medicines including ayurveda.Some girls shared their experiences withhealthcare providers which they did notfind positive or encouraging - some ofthem were told that they need uterusremoval, that they will be never be able tobear children or that their problems withmenstruation will fade away once theywere married. Case Study 1 given belowhighlights the consequences of excessivebleeding during menstruation for aschoolgirl.

In the FGD, many girls shared that inaddition to these physical symptoms theyfeel mentally stressed now and thenduring menstruation. They become verycautious about their mobility especially in

FIGURE 6: Distribution of type of abnormal physical condition in

last menstruation (n = 185)

Experience: Type of abnormal physical condition suffered

5% Breast pain/discomfort

8% Excessive bleeding

4% Others

83% A bdominal pain/discomfort

15% Didn’t suffer/Don’t remember

85% Suffered

FIGURE 5: Distribution of experience of abnormal physical

condition during last menstruation (n = 204)

Experience: Abnormal physical condition in last menstruation

the classroom. They take a lot of carewhen they stand, sit and walk - all due tothe fear of accidental blood stain in theuniform or the place where they sit on.FGD participants in Dhading consistentlyshared the effects of the pain on regular

9Results

Case Study- 1

Miss A is 19 year old studying in class ten and she had attained menarche at 15. She currently has lower thanaverage body weight and is suffering from anemia. Miss A comes from religious minority and follows Islam faith.During her last menstruation, she suffered heavy bleeding for continuous six days and this has been consistent forthe last two years. According to Miss A “menstruation is a disease”. It has affected her life tremendously. It was notalways like this. Since her menarche, “things and life were ok” at least for the next 2 consecutive years – it hasbeen only for last two years that experience with menstruation has been very bad.

Menstruation has affected her wellbeing both physically and mentally. Physically, she has suffered due to heavybleeding, loss of appetite and loss of weight resulting into a sense of lethargy, which in turn influences her volitionto be physically active and support mother in household chores. Mentally, it has been the constant fear of theassociated pain, discomfort and the effects associated with menstruation – academic performance and especiallygetting through class ten. She shared that as a class ten student with looming Iron Gate SLC exams she has hadsleepless nights over the possible pain perpetuated by her menstruation and thought of not being able to makeit through her class ten along with her peers. Her worst fear became exactly true when she had to forego herschool exams once because of menstruation. According to her, she fainted in the classroom in the midst of theexams and then had to discontinue all her forthcoming exams. Miss A along with her mother has tried many placesand people to bring relief to her situation. She has been to many faith-healers, sought alternative medicine fromeast to west, but of no avail. It has cost the family money, time and energy. The faith-healers claim that evil spirithas cast an eye on her that has made her weak and her “body shrink”.

In all these excruciating times, “Mother” has been a pillar of support and she feels, it would have helped her moreif only she knew where she could rightly go to a place or person, where she might be informed about the causeof her sufferings and means to relieve it. There are not many long wish lists, but places and people who can makeher life less painful and “disease-free”.

studies and specifically during exams andthis is expressed through one of theparticipants' view -

"Menstruation badly affects studies. Theschool does not give lesson notes.

Students are expected to develop theirown notes and hence when a studentmisses a class it can affect them a lot. Wecannot miss the exams - but even whenwe come for the exams the excruciatingpain can blank us out"


Practices of seclusion,exclusion andabsenteeism

Seclusion and exclusionIn the FGD, most of the girls expressedthat first menstruation is often traumaticand very negative experience. Culturallygirls of Bahun, Chhetri and Newar castegroups are put in seclusion in specialplace in one’s own or relatives’ house(usually kept dark) where they areconfined for seven to 11 days. During thisseclusion they are not allowed to see sunand male relatives (brothers and father).

Both survey and FGD findings clearlyindicate that there are still large number oftraditional beliefs and restrictionssurrounding menstruation. Only 11% of thesurvey respondents mentioned notpracticing any form of restriction orexclusion (table 2), and this was notsignificantly different amongst rural andurban respondents. It was evident in theFGD that restrictions and other traditionalbeliefs and practices affecting adolescentgirls are stronger in Bahun, Chhetri and

Newar caste groups. The commonestrestriction practiced by the surveyrespondents is abstaining from religiousactivities (68%), which are followed byabstaining from cooking (46%) as well asnot touching the male family members(24%) (table 2). The socio-cultural beliefsbehind are based on concepts of“pollution” surrounding the conditions ofmenstruation and usually mothersimparted these beliefs to the girls asimportant know how related to thepractices during menstruation. This isevident in what a class IX participant fromDhading said –

“A woman is ritually impure duringmenstruation and anyone or anything shetouches becomes impure as well. It isusually the mothers who enforce theserestrictions”

It was stressed in all four FGD that fathersand brothers are increasingly becominglenient in these matters. A girl fromDhading in FGD reflected how girls turn totheir fathers for rescue particularly whenthey are not provided with enough warmclothes during winter, thinking that it will“pollute” the clothes –

“During winter it is very difficult, we haveto sleep alone, and there is not enoughwarm clothes at night. Many times I haveto ask father for quilt.”

Some of the common beliefs reinforcedwere that pickles go bad, seeds becomesterile, plants will wither – they might wiltwhen touched by a menstruating person.

None 10.8

Don’t attend religious function 67.6

Don’t go to school 3.4

Don’t cook 46.1

Don’t do household work 20.6

Don’t touch males 23.5

Don’t play 9.8

Don’t eat certain food 13.2

Sleep separately 28.4

Restriction Percent*

* Total may add to more than 100% due to multiple responses.

TABLE 2: Restrictions practiced during menstruation (n = 204)

11Results

Even under Islamic law, a menstruatingwoman is not allowed to pray or fast nor isshe allowed to touch the Koran. The girlsare relieved from exclusion only after apurification ritual. One interesting not-to-do activity during menstruation was sharedby one of the FGD participant fromKathmandu –

“I was told that ‘Dashain/Tihar’ will beobstructed if one sees herself in the mirrorduring menstruation. I did it and guesswhat – the following Dashain wasobstructed; I had my menstruation duringDashain. Yes, now this has happened tome. I think it is true and now I don’t seemirror anymore during menstruation.”

Despite these enforced superstitiousrestrictions, encouragingly one pattern hasbeen observed consistently in all four FGD.Amidst all these restrictions girls, both inurban and rural areas are challenging theserituals in one way or other either throughreflection or straight away defying it in theirways. A girl from Dhading shared –

“I grew up being told of what to do andwhat not to do. I know of what I amsupposed to do …but then when no one isaround I do everything that I am notsupposed to... I touch water, I touch foodin the kitchen, I enter every room… I havealso touched many fruit trees and none ofthem have wilted so I think it is not true.”

AbsenteeismHalf of the survey respondents (53%)mentioned being ever absent due tomenstruation (figure 7). However, many

girls in the FGD shared that thoughphysically present in the school theyperformed poorly in terms of concentrationand attention. This was particularly due toconstant worry that boys might figure outabout their status by their movements andfacial expressions. Many also expressedfeeling exhausted and weak duringmenstruation. Another major worryexpressed by the girls was having theirmenstruation coinciding with exams asthey would not get adequate time andopportunity to clean and change timely. Agirl of class IX from Lalitpur shared herutter despair by stating:

“I wish I did not have to have thismenstruation! But I know this is notpossible.”

Among reasons highlighted by surveyrespondents for being absent in schoolduring menstruation, lack of privacy for

2% Don’t know

53% Yes

45% No

FIGURE 7: Distribution by experience of absenteeism due to

menstruation (n = 204)

Experience: Ever absent due to menstruation


Case Study 2

Miss B is a 16 year old Chettri girl studying in class nine. She had her first menstruation when she was 15. Hermenstruation is regular except that she has experiences of heavy bleeding on 2nd and 3rd day of her menstrua-tion. Similar to many experiences shared by girls of her age, she has had a frightening first experience withmenstruation. Gradually, she got to know about menstruation and its management through her mother and sister-in-law.

At home, she experiences several restrictions of what she can do and what she cannot do. She is not allowed toparticipate in puja and most of her daily activities are confined to outdoor. Her mother even suggests that duringmenstruation she avoid the road which passes through temple. She claims that she does not heed to her mother’ssuggestions but restricts herself from performing puja. At home, she is fortunate enough to have some privacy –the family has their private toilet with water supply. It is in the bathroom that she manages to change the clothused for menstruation, to clean and take shower. However, unfortunately this is not possible in school, as theschool environment is not very conducive – when she has menstruation she usually misses classes. She misses herclasses especially during the 2nd or 3rd day because that is when she bleeds heavily and needs to regularlychange the pad. The school has a lavatory but lacks basic amenities. The door even does not have a latch, neitheris there a water supply. She has to carry water from the tap outside and there have been occasions when thebucket to transport water from the tap to the lavatory was missing. To avoid all these inconveniences anddifficulties, she prefers to stay at home and continue missing classes. She expresses that if basic amenities wereensured such as a bucket, a lock system at the toilet door, and water, managing menstruation at school would bemuch easier and she need not miss her classes.

cleaning/ washing (41%) ranks highfollowed by lack of availability of disposalsystem (28%) and water supply (23%).Pain/discomfort was also mentioned by16% (figure 8). With regards to privacy girlsnoted in the FGD that even if infrastructureof toilet is present, in many instancesbasic lock system is missing or notfunctioning. So they usually go in pairs bytaking turns to go to the toilet and wait oneach other. The following quotes from FGDin Kathmandu and Lalitpur aptlysummarize the challenges of a girl duringher menstruation when she attends schoolwhich lacks basic infrastructural amenitiesand also the recurrent effect onattendance:

“In our school there is no water facility inthe toilet - it is so difficult.., sometimes Ihave to miss schools. The water supply isoutside the bathroom. There is only onetap. We have to carry water to the toilet.

Also there is no arrangement of disposingthe cloth. Sometime the used cloth has tobe disposed off in the toilet-pan.”

“Some days we bleed heavily, and weneed to change clothes at least 2 or 3times during the school hours. There is noplace to change and dispose the cloth –there is question of putting back thoseused cloth in our pockets. So we just bunkclasses when we have to change theclothes.”

41.422.7 28.2

4.5 9.116.2

5.40

20406080

100

Lack

ofpriva

cyfo

rcl

eanin

g/w

ash

ing

Lack

ofw

ate

rsu

pply

forcl

eanin

g

Lack

ofdis

posa

lsy

stem

for

pads/

cloth

s

Fearofm

enst

rual

acc

ident(le

akage)

Sham

e

Pain

/dis

com

fort

Soci

o-c

ultura

lbeliefs

Resp

ondent(%

)

FIGURE 8: Distribution of reasons for school absenteeism

during menstruation (n = 107)*

Reasons for absenteeism during menstruation

13Results

Hygiene practices

Absorbent materialOf the survey respondents, 17% usedsingle use material only, 40% used re-usable cloths only and 35% used bothtypes during last menstruation. Regardingthe actual material used, 33% useddisposable sanitary pad, 40% used newcloth whereas as about a fourth (26%)used old piece of cloth from sari or scarf(figure 9). The use of sanitary pad is higheramong girls in urban schools (50%) incomparison to rural (19%), and the use ofold piece of cloth was higher among rural(35%) than urban (14%). This difference issignificant on chi-square test with p valueless than 0.05 (table 3).

In the survey 41% of the respondentsperceived that many may not know aboutthe availability of the single-use disposablesanitary pad resulting into its non-use.Many also reported high cost (39%), noeasy availability (33%) and difficulty ofdisposal (24%) as the other reasons for notusing such pads (figure 10). This finding isalso consistent with the FGD findings.

In the FGD it was clearly identified that thefamily income affects the use or the non-use of sanitary pads. The low cost andease of availability of rag cloth make it theindispensable choice for the girls in bothrural and urban, more in the former. Somegirls in the FGD explicitly mentioned thatthey prefer cloths to pad for use duringmenstruation because it is cheap and canbe reused as well. However, manyparticipants made it clear that if they hadthe option to choose between sanitarypads and rag cloth they would want to usethe sanitary pad, like one FGD participantfrom Morang highlighted:

“If I had an option to choose betweensanitary pad and rag cloth (piece of clothfrom sari or other cloth)… of course, Iwould choose the sanitary pad.”

FIGURE 9: Distribution by absorbent material used in last


Practice: Absorbent material used in the last menstruation

32.840.2

25.9

0

20

40

60

80

100

Sanitary pad New cloth piece Piece of old cloth(sari/scarf )

Resp

ondent(%

)

FIGURE 10: Distribution of perceived reasons for girls not using single-use sanitary pads (n = 204)*

Reasons for girls not using single-use, disposable sanitary pad

41.2

38.7

23.6

32.5

10.8

0 20 40 60 80 100

Not knowing about it

High cost

Difficulty of disposal

Not easily available

Don't know

Respondent (%)


These girls would prefer pad because thecloth is thick and causes discomfort,especially during summer. As oneparticipant from Dhading shared –

“Cloth is ok during winter, however duringsummer it is very uncomfortable. It rubsagainst the skin and becomes smelly.”

Sanitary pad on the other hand is seen aseasy to use and easy to carry as well.However, because they cannot affordsanitary pad always, most of them usuallyuse cloth material when staying at homeand use sanitary pad only when they needto go out.

Cleaning and changingHygiene practices were found to be not sosatisfactory. In the survey, only half of therespondents (51%) mentioned having

taken bath everyday, and about two-fifth(43%) on alternate days, during their lastmenstruation. In the FGD, however, mostof the girls told that it is difficult to takebath daily in winter and usually take bathon alternate days while in summer they doso daily. Many respondents mentionedthat, even if not on other days, theyusually take bath on the third or fourthday of menstruation as a purifying ritual.Most participants in FGD told that theywash their genitals with water only whenthey go to toilet. Many of them wereconfused whether soap could be used ornot. Most of them told that they wash theirgenitals two to three times a day; sometold that they wash every time when theygo to toilet. Survey also revealed that onan average, the girls clean their genitalsthree times a day during menstruation(table 4). However, girls particularly inurban school said that they refrain fromgoing to toilet when they are at school

TABLE 4: Frequency related to menstrual hygiene

Change of absorbent

in last menstruation 1 9 2.7

Cleaning of genitalia

in last menstruation 1 10 3.1

Cycles of use of a

re-useable cloth 1 12 3.2

Absorbent use &cleaning (averagefrequency) Minimum Maximum Mean

Sanitary New cloth Piece of

pad piece old cloth

Rural-

Urban

Rural 18 (19%) 42 (44%) 34 (35%)

Urban 39 (50%) 28 (36%) 11 (14%)

Types of absorbent material

TABLE 3: Cross tabulation of type of absorbent material used

among rural and urban respondents (n = 174)

2= 22.7, p value = .000 (p value < .05 is significant.)

3% Don’t know

51% Everyday

3% Less than that

43% Alternate day

FIGURE 11: Distribution by practice of bath taken in last


Practice: Bath taken in last menstruation

15Results

TABLE 5: Cross tabulation of availability of toilet at home

with adequate privacy among rural and urban respondents

(n = 204)

Rural-Urban Rural 55 (46%) 61 (51%)

Urban 59 (69%) 25 (29%)

Yes No

Availability of toilet athome with privacy

because it is not well managed forcleaning and washing or disposingabsorbent cloth – particularly due to theproblems of lock, lack of water anddisposal facility. More than half of thesurvey respondents (56%) mentioned thatthey had access to a toilet with adequateprivacy at home and only about two-fifth(42%) mentioned having access to thisservice at school (figure 12). On cross-tabulation, clear differences are seenbetween rural and urban respondents andstatistical data show that these differencesare significant (p value less than 0.05).The survey shows that on average the girlschange the absorbent material between 2to 3 (2.7) times in a day (table 4), whichwas also confirmed in the FGD. The surveyfinding that on an average one re-useable

cloth is used for 3 cycles (table 4) alsocoincides with what most participants inFGD shared – they reuse a single cloth fortwo to three menstrual cycles. However,the girls clarified that the number of timesof use also depends on the nature ofblood stain on the cloth – if the stain isstrong they don’t use it again.

In survey majority of the respondents(59%) indicated that they dried theirwashed re-useable absorbent material(cloth) outside the house and undersunlight (figure 13). However, participants

FIGURE 12: Distribution by availability of toilet with adequate

privacy at home & school (n = 204)

Availability of toilet with adequate privacy

55.9

41.7 42.2

55.9

2.0 2.5

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Resp

ondent(%

)

Yes No Don't know

Home (%) School (%)

23.0

10.8

59.8

1.0

0.0 10.0 20.0 30.0 40.0 50.0 60.0

Respondent (%)

Inside house with direct sunlight

Inside house without direct sunlight

Outside house with sunlight

Outside house without sunlight

TABLE 13: Distribution by practice of drying washed re-usable absorbent material (n = 193)

Experience: Drying of washed re-useable absorbent material


in the FGD clarified that even if they drytheir cloth outside it is usually in aseparate place which can not be noticedeasily by others and many of them stillcontinue to put over a thin piece ofanother cloth so that others cannot notice.This practice is unanimously voiced bymost of the FGD participants in Dhading.The girls jointly voiced giggling:

“Yes, we dry the cloth under the sunlight.But most of the time we place it undersome clothes. When we do it directly thenit is in a “kolte” (slanted) place - so noone can see it.”

Disposal of absorbent materialIn the survey, nearly 43% of therespondents reported that for disposalthey bury their absorbent material, 35%throw with other waste and 19% burntthe material (figure 14). FGD revealedthat in rural areas where there is nogarbage collection system girls evendumped it in the stream. Disposal ofused cloths and napkins was a challengein both urban and rural schools. ManyFGD participants said that they wrap it

19% Burnt

38% Thrown with other waste

43% Buried

FIGURE 14: Distribution by practice of disposing single-use

absorbent material (n = 136)

Experience: Disposal of used absorbent material

and carry it home with them either tothrow it with other waste or to burn it.Some also mentioned flushing it in theirhome and school toilets. Some of thegirls have even disposed it in schooltoilets, at times causing the toilet toclog. A FGD participant from Moranginformed that:

“In our school there is no specific place todump the cloth, wish there was a dustbin.Many times we just throw it in the toiletpan.”

17Discussion

DiscussionGiven the findings in the study andreflecting on the objective of the study, itis clear that menstrual hygiene andmanagement is an issue for adolescentschool girls both in rural and urbansettings. In this section, factors thatdirectly or indirectly influence menstrualhygiene and management have beenidentified for discussion.

Knowledge about menstruation that largemajority of girls participating in this studyhad before attaining menarche, and latertoo, was not correct. Their perceptionswere heavily influenced by socio-culturalbeliefs and symbolisms. Mothers havebeen identified as an important source ofinformation on menstruation for theadolescent girls, as also shown by someother studies to a varying degree(Dasgupta and Sarkar, 2008; El-Gilany etal, 2005). However, information onmenstruation given by mothers is oftenincomplete and incorrect, usually beingbased on cultural myths, and thereforeprobably perpetuating negative anddistorted perceptions and practices ofmenstruation (Adinma and Adinma, 2008).In view of the little information that thegirls are equipped with, usually frommothers, family members and peers, it isnot surprising that only about one in tenof the participating girls knew correctlythat the menstrual blood came fromuterus. This already reflects that teachersdo not sufficiently impart the knowledge,and seemingly girls themselves also do not

make a self effort to learn, even thoughsuch basic anatomical issues are part oftheir school curriculum. School teachers’hesitation in conducting the health classesand provide reproductive healthinformation including menstruationconfidently is evident in this study – whichcan be said to mirror the lack of skills andattitude of teachers to handle sensitivetopics. It was clear that the level ofawareness on menstruation amongst therespondents, though secondary schoolstudents, reflect that the majority still doesnot have right information to makedecisions, and to take appropriate steps interms of managing menstruation andrelated problems.

Practice of ritual seclusion particularly at orbefore the attainment of menarche hasbeen identified in this study. Though thepractice of sleeping in separate room wasfound in this study, seclusion in menstrualhuts during each menstrual period aspracticed by some groups or in some areasof Ethiopia, Nigeria and Nepal (Ten, 2007)was not evident. As observed by theresearchers, the practice, called chhaupadi,in which menstruating females have tosleep in such menstrual huts (calledchhaupadi goth) that are often unhealthfuland dangerous is common in far-westernregion of Nepal. None of the schoolsstudied was from this region.

Nine out of ten girls in the study observedat least one or the other restrictions during


menstruation, which is consistent with astudy done in India where 86% practicedsome form of restriction (Dasgupta andSarkar, 2008). Such restrictions, thoughvaried, are practiced across the groups ofdifferent religion and culture – includingHindu, Muslims, Christians and Jews – andin most cases are related to the “impurity”of the females during menstruation (Ten,2007). Restrictions symbolize a woman’sritually dangerous status (Narayan et al,2001) that, as fuelled by myths,misconceptions, superstitions and taboos,is believed to have the potential to spoilfood, plant, biological and social processesas exemplified by the respondents of thisstudy. All pervasive the phenomenon ofrestrictions may be, however it wasencouraging to note in this study thechanging attitude of the adolescentschoolgirls in terms of challenging therestrictions that limit their daily lives androutines.

Dysmenorrhoea manifesting as abdominalpain or discomfort has been found as thecommonest medical problem, the findingbeing consistent with some other studies(Adinma and Adinma, 2008; Narayan et al,2001). The abnormal physical conditionduring menstruation not only affects theirdaily lives and routines to a varyingdegree, it also makes the girls try differentremedial measures from self medication tovisiting different types of health providers.As is evident in the study, girls many timesdo go through negative experiences withhealth worker in terms of the responseand advice they provide, and this clearlyhighlights on the need for sensitivity onthe part of the health workers to provide

friendly health services taking into accountthe needs of this group of population.

One in two girls in this study reportedhaving been absent from school due to acause related to menstruation. More thanphysical absence during menstruation, thisstudy pointed out an important aspect thatcan affect school performance equally –the quality of presence at school,particularly the attention andconcentration in the curricular activities.This facet of the implications ofmenstruation on school girls could not befound in the literature referred to in thisstudy. Lack of small things required formaintaining the menstrual hygiene, likeprivacy, water supply and waste disposal,have been found as major reasons forabsenteeism, though abnormal physicalconditions (pain, discomfort, heavybleeding) are also one. Lack of privacy hasbeen pointed out by other studies also asa major problem (El-Gilany et al, 2005)and there’s conclusive evidence that girls’attendance at school is increased throughimproved sanitation (Bhardwaj and Patkar,2004).

Three out of four girls in this study usedre-usable clothes as menstrual absorbent.This figure is comparable with otherstudies in Nepal (Adhikari et al, 2007) andIndia (Narayan et al, 2001; Dasgupta andSarkar, 2008) where large majority of theparticipants used re-usable cloth. Thestudy clearly pointed out that the lack ofinformation about disposable sanitary pad,its high cost and limited availability are themain reasons for school girls not usingthem. Similar observation that poverty,

19Discussion

high cost of disposable sanitary pads andto some extent ignorance dissuaded theadolescent girls from using the menstrualabsorbents available in the market wasmade in an Indian study (Dasgupta andSarkar, 2008). The use of sanitary padswas found to be significantly higheramong urban school girls, whereas the useof old cloth was significantly high amongrural, which is consistent with an Egyptianstudy which found the correlation betweenrural residence and low socio-economicclass with the use of unsanitaryabsorbents (El-Gilany et al, 2005). It’sevident in this study that those who knewabout the sanitary pads are likely to usethem instead of cloth if they could accessand afford it. The disposable pads usuallyhave better absorption, are meant forsingle use and, hence are consideredsanitary. However, with the cloths there isa tendency towards reuse and have thepotential of harbouring infection agentsthat can cause pelvic infections. However,this study didn’t delve much into theaspect of infections. Proper washing anddrying of re-used cloth does minimize thechance of infection, but it was explicit inthe study that the drying practices werenot optimal as they had to hide the clothfrom others view.

The frequency of cleaning the genitaliaand changing absorbent material aboutthree times a day in average has been

quite similar to the findings of an Egyptianstudy where the frequency was 2.5 times aday (El-Gilany et al, 2005). Each womandecides for herself what is comfortable butfor optimal hygiene menstrual absorbentshould be changed at least three to fivetimes a day, and more frequent may benecessary (Salem and Setty 2006). Thecleaning should also be at least equal tothe number of times the pad is changed.Though the practice of cleaning andchanging sounds fairly okay, girls havepointed out that at school this is notalways possible. Fortunately, all theschools in which the study was undertakenhad provision of toilet, which is not thecase across most of Nepal, but small issuelike a broken lock or lack of tap or abucket to carry water did result in poorhygiene and in some cases schoolabsenteeism as well. The problem of nothaving toilet with adequate privacy formanaging menstrual hygiene also existedfor many participant girls at home.Environmental impact of menstrualhygiene in the form of a growing wasteproblem has been noted (Ten, 2007). Inthat line, the problem of properlydisposing the menstrual absorbent, mainlydue to the lack of proper or no garbagecollection system, both at school andhome was evident in this study too – attimes causing problems like clogging oftoilet and polluting the local environmentlike streams in villages.


Recommendations andconclusionThe study has highlighted the needs of theadolescents to have accurate andadequate information about menstruationand its appropriate management. Formalas well as informal channels ofcommunication, such as mothers andpeers, need to be emphasized for thedelivery of such information – particularlylinking instructions on menstrual hygieneto an expanded programme of healtheducation in schools and in tandem withmore informal means of disseminationchannels. In view of the vital role of themothers, it is utmost important that themothers be armed with the correct andappropriate information on reproductivehealth, to give to their growing girl childon a ‘dose-related’ continuous basis. It isalso essential for the teachers, who maynot have necessary skills to impartreproductive health education includingmenstrual hygiene to their student, to begiven requisite skills – usually throughworkshops or training.

Conscious efforts need to be made toaddress lack of privacy, which is animportant determinant for proper practiceof menstrual hygiene and also schoolattendance. The efforts does not alwaysmean large investments in infrastructures,but in many instances it suffices with

attention given to minute issues of basicsanitation infrastructures like toilet, watersupply and waste management. It is justabout managing the resources thoughtfullyand problem-solving as the situationarises. Such small measures can definitelyprovide supportive environment formenstrual hygiene both at home and inthe school. The interesting aspecthighlighted by the school girls regardingthe quality of attendance in schoolsuggests that further studies are needed toexplore more at the qualitative aspects ofthe effect on the daily activities aroundmenstruation, particularly schoolattendance.

Realizing the needs and interest to usesanitary pads, innovative ways have to beidentified for making the pads availableand affordable to school girls belonging toall segments of society. Minimal effort hasgone into the production and socialmarketing of low-cost napkins indeveloping countries (Bhardwaj and Patkar,2004). However the example of BRAC, oneof the world’s largest NGOs, inmanufacturing and retailing low-costsanitary pads through extensive network ofsocial mobilizers in Bangladesh and similarexamples in Tamil Nadu do point out adoable solution in similar settings like ours.

21Recommendations and Conclusion

Additionally, the use of locally producedsanitary pads stimulates local economy too.

The reproductive health implications ofmenstruation and its management, andits effect on quality of life permeatingschool and other social activities aremany for the adolescent school girls.These invariably call for an urgentaddress by all stakeholders – family,school, community, civil society, andservice providers to entrench correctmenstrual perceptions and enable properhygiene practices amongst this segmentof the population. In Nepal, allorganizations, state and non-state,working on reproductive health as well ason water, sanitation and hygiene shouldwork concertedly towards appropriatepolicy and adequate actions on hithertoneglected issue of menstrual hygiene andmanagement to achieve “Sanitation forDignity and Health” for all women (The

Delhi Declaration, SACOSAN-III 2008).This essentially will contribute to theattainment of some MDG, particularly 2, 3and 7.

In conclusion, it can be said that amongthe adolescent school girls both in urbanand rural areas, menstrual knowledge andperceptions are poor and practices oftennot optimal for proper hygiene. Oftenignored issues of privacy affect thehygienic practices and daily lives,particularly school attendance, of theadolescent girls. The know-how, availabilityand affordability of sanitary products tomanage menstruation are far fromsatisfactory. Schools, home, society andorganizations of reproductive health aswell as water, sanitation and hygienesectors need to make an effort towardsmaking menstrual hygiene andmanagement better for adolescentpopulation.


ReferencesAdhikari P et al (2007) Knowledge and practice regarding menstrual hygiene in ruraladolescent girls of Nepal, Kathmandu University Medical Journal, pp 382-386, Vol 5, No 3,Issue 19

Adinma E and Adinma J (2008) Perceptions and practices on menstruation amongst Nigeriansecondary school girls, African Journal of Reproductive Health, pp 74-83, Vol 12 (1)

Bhardwaj S and Patkar A (2004) Menstrual hygiene and management in developingcountries: taking stock, Junction Social.

Dasgupta A and Sarkar M (2008) Menstrual hygiene: how hygienic is the adolescent girl inIndian, Journal of Community Medicine, pp77-80, Vol 33(2)

El-Gilany A Badawi K and El-Fedawy S (2005) Menstrual hygiene among adolescentschoolgirls in Mansoura, Egypt in Reproductive Health Matters, pp-147-152, Vol.13(26)

Narayan K A, Srinivasa D K Pelto, P J and Veeramal S (2001) Puberty rituals, reproductiveknowledge and health of adolescent schoolgirls in South, Asia Pacific Population Journal,pp 225–238Vol 16(2)

Ten V TA (2007) Menstrual hygiene: a neglected condition for the achievement of severalmillennium development goals, Europe External Policy Advisors

SACOSAN III (2008) The Delhi declaration: sanitation for dignity and health

Salem R and Shetty V (2006) Key facts about the menstrual cycle, INFO Reports No 7Baltimore, Johns Hopkins Bloomberg School of Public Health, The INFO Project

23Glimpses of the study

Interaction with student after survey

Responding to interviewers

Glimpses of the study


Briefing about the study

Focus group discussion

Individual questionnaire survey

Is menstrual hygiene andmanagement an issue foradolescent school girls?

This study was undertaken with the objective ofdetermining the prevailing knowledge andexperiences of menstrual hygiene and management,and their implications, among adolescent schoolsgirls in rural and urban settings of Nepal.

WaterAid's mission is to overcomepoverty by enabling the world's poorestpeople to gain access to safe water,sanitation and hygiene education.

For more information please contact;WaterAid in NepalKupondole, Lalitpur, NepalGPO Box No.: 20214, Kathmandu, NepalTelephone: 00977-01-5552764/ 5/ 5011625Fax: 00977-01-5547420EMail: [email protected]/nepal

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