Mapping the knowledge and understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low- and middle-income countries

Our paper maps the knowledge, attitudes, beliefs and practices surrounding menarche, menstrual hygiene and menstrual health among adolescent girls in low and middle income countries in order to inform the future design of relevant policies and programming.

Our study of over 80 journal articles from a number of low and middle income countries confirmed that:

Efforts to respond to girls’ needs are fragmented and piece-meal. There is growing acknowledgement that efforts are more likely to be successful if they come together in a whole-of-community approach that involves schools, health facilities, and homes and communities to:

Girls in many low- and middle-income countries (LMIC) enter puberty with knowledge gaps and misconceptions about menstruation, unprepared to cope with it and unsure of when and where to seek help. This is because the adults around them, including parents and teachers, are themselves ill-informed and uncomfortable discussing sexuality, reproduction and menstruation (which frequently comes laden with dirty, polluting and shameful connotations).

To respond to the increased international attention on empowering girls through the United Nation’s Sustainable Development Goals, this review aims to map the knowledge, attitudes, beliefs and practices surrounding menarche, menstrual hygiene and menstrual health among adolescent girls in LMIC in order to inform the future design of relevant policies and programming. To do this, our objectives are to answer the following questions: (1) how knowledgeable are girls in LMIC about menstruation and how prepared are they for reaching menarche, (2) who are their sources of information regarding menstruation, (3) how well do the adults around them respond to their information needs, (4) what negative health and social effects do adolescents experience as a result of menstruation, and (5) how do adolescents respond when they experience these negative effects and what practices do they develop as a result?

Our literature search aimed to identify articles that evaluated the knowledge of girls regarding menstruation, their information sources, the health and social effects of menstruation, and how adolescents and adults responded to these effects. We searched Google Scholar, PubMed and EBSCO’s Global Health database for articles in peer-reviewed journals published between 2000 and 2015. To identify relevant literature, we used the following search strategy: (menarche or menstruation or menstrual health or menstrual hygiene or menstrual management) and (adolescence or adolescent or youth or young) and (female or girl or women) and (knowledge or belief or practice or experience).

Through a title and abstract review, papers in English that addressed the experiences of adolescent girls (ages 10–19) in LMIC were retained. Full text articles were reviewed to determine whether studies addressed one or more of our five questions. Given the limited research available, descriptive overviews and interventions using quantitative, qualitative, or mixed methods of any sample size were all included.¹ While the focus of this paper is on menstrual experiences, studies that reported on the preparedness and attitudes of pre-menarcheal girls were included so long as data were stratified by those who had and had not reached menarche. To complement our search, we reviewed the reference lists of the included articles and identified a small number of additional studies that met these broad criteria. Finally, we searched and included publications by United Nations agencies and international non-governmental organizations that responded to how organizations and their LMIC partners are responding to the needs of girls.

A total of 81 articles were identified after discarding duplicate articles and those that did not meet inclusion criteria (Table 1).

An important limitation of this review is that vague measures are often used to describe the menstrual experiences of girls, which impede data aggregation and direct comparisons. For instance, studies used different yardsticks for adequate or inadequate knowledge, and used the terms premenstrual syndrome and dysmenorrhea loosely. Further, many studies had small sample sizes and relied heavily on self-report. Some studies had low response rates due to discomfort or limitations to discussing menstruation. Another limitation is that a majority of relevant data from included studies come from a limited number of countries and are not representative of all LMIC. Among the included countries and across all LMIC is great cultural variation, and the results presented here should be considered in light of these unique perspectives. Despite these limitations, the evidence presented allows for the following conclusions:

It is clear that far too many girls across LMIC are struggling with nearly complete ignorance of their normal biological maturation and its consequences, and when they do receive education, still struggle with inadequate sanitary materials and insufficient physical and emotional support. Although there is no convincing evidence that poor menstrual hygiene management leads to ascending reproductive tract infections [81] or causes lasting sequelae, this review underscores that coming to terms with menarche and navigating the shame and practical challenges associated with its management may cause girls great anxiety and sadness. There remains a need for further research into the physical, mental and social impacts of such distress. For example, being unprepared for menarche, being excluded and shamed during monthly periods, being hindered in self-care and uncared for when unwell, undermines a girl’s sense of being in charge of her life, her sense of self-worth and her sense that the individuals and institutions around her are responsive to her needs. The huge and lasting impacts this can have on girls’ lives remain to be studied.

In the short term, however, there are intervention studies that demonstrate the ability to improve girls’ menstrual knowledge and hygiene management. Health education interventions like school-based sessions tested in India have resulted in improved understanding post-intervention [17], and similar programs in Egypt [80] and Iran [79] have improved the bathing practices of girls during their periods. Additionally, a quasi-experimental study in India that involved training of medical officers and providing reference tools led to statistically significant improvements in their case management of menstrual health problems for female patients between the ages of 15 and 24 [82].

Some exciting initiatives led by academics, international agencies and the private sector are also under way. Educating and encouraging parents to communicate with their daughters and sons about puberty and menstruation is being implemented by the Families Matter Program [83]. A five-year initiative by Columbia University has launched locally designed puberty booklets for girls and for boys in Tanzania, Ghana, Ethiopia, and Cambodia; these have been embraced by the Ministries of Education and of Health in all four countries [84]. Save the Children has also developed workbooks, modeled on those by Columbia University, for girls and boys in Nepal, Uganda and Malawi and is carrying out puberty education programs in multiple countries [85]. Similar efforts, such as CycleSmart^TM [86] and GrowUp Smart [87], are being implemented by Georgetown University’s Institute of Reproductive Health in Rwanda and Guatemala. In 2014, UNESCO published a policy booklet with guidance to improve school administrators and teachers’ abilities to educate and support girls and boys in classrooms [88]. Procter & Gamble, a major producer of sanitary products, has launched communication programmes in several of the countries where it sells products with marketing approaches aimed at legitimizing family discussion of menstruation, and engaging and educating girls while building their self-esteem [89]. During its Celebrating Womanhood event in 2013, the Water Supply & Sanitation Collaborative Council defined menstrual hygiene as a priority and outlined a 3-pronged approach that includes breaking the silence around this topic, ensuring hygienic management, and identifying mechanisms for safe reuse and disposal of materials [90]. Linking menstruation education with efforts to improve water, sanitation and disposal facilities in schools has also been actively promoted and implemented by UNICEF at the country and global levels [91].

While these initiatives are important and promising first steps, greater uptake and commitment is needed to fulfill the rights of girls related to menstrual knowledge, health and hygiene. Concerted multi-level efforts are required to achieve this. At the individual level, girls and boys need to be educated about puberty. At the family level, girls need support during their menstrual cycles. At the community level, we must improve access to sanitary products, running water, functional toilets and privacy. We need competent and caring health care workers who can respond to girls’ questions and concerns, and to provide care when they have menstrual health problems. Finally, we need leaders who can change the perception of menarche and menstruation to one of normalcy and promise rather than of shame.