Int J Adolesc Med Health 2016; aop
Short Communication
Puja Dudeja*, Apoorva Sindhu, Pooja Shankar and Tukaram Gadekar
A cross-sectional study to assess awareness
about menstruation in adolescent girls
of an urban slum in western Maharashtra
DOI 10.1515/ijamh-2016-0079
Received July 19, 2016; accepted August 19, 2016
Abstract
Introduction: Reproductive health of adolescent girls is
crucial as it determines the health of future generations.
School girls when experiencing menarche find them-
selves in a setting without water, toilets or a supportive
female teacher to explain the changes happening in their
body. An important concern for adolescent girls is to have
adequate, correct knowledge along with facilities and the
cultural environment to manage menstruation hygieni-
cally and with dignity. Hence, the present study was done
to assess knowledge and practices about menstruation in
adolescent school girls of an urban slum.
Methodology: This was a descriptive cross-sectional study
conducted among girls of a Government School located in
an urban slum of western Maharashtra. A total of 250 girls
participated. Data collection was through a pilot-tested
questionnaire. The data thus collected were entered into
Microsoft Excel and analyzed using the SPSS 20 software.
All girls were educated about menstrual hygiene after the
study.
Results: The mean age of the students was 14.9 ± 1.75 years.
The mean age at menarche was 11.97 (95% CI: 11.94–11.99).
It was observed that only half (56.4%) had acquired prior
knowledge about attaining menarche. Out of these in a
large proportion, the knowledge was imparted to them by
their mothers (60.7%), followed by friends (31.8%). There
was no significant association between educational status
of mother and awareness in respondent about menstrua-
tion. Regarding the organ of menstrual blood flow, half
(50.7%) knew the correct answer (i.e. uterus); whereas
the rest believed that it was stomach/kidney, etc. Most of
*Corresponding author: Puja Dudeja, Department of Community
Medicine, AFMC, Pune, Phone: +9673382611,
E-mail: puja_dudeja@yahoo.com
Apoorva Sindhu, Pooja Shankar and Tukaram Gadekar: Department
of Community Medicine, AFMC, Pune
the school girls (90.5%) used sanitary pads. Almost 90%
of the young women faced physical complaints or health
problems during menstruation. Most of the participants
had some kind of restrictions on them during the men-
struation and most of these were religious restrictions
(69.7%) followed by physical (41.2%) and social restric-
tions (22.3%). All of them were unsatisfied with the toilets
and hand washing facilities available inside the school
premises.
Conclusion: Correct knowledge in adolescent young girls
regarding menstruation is lacking. Lack of awareness is a
roadblock in adopting safe and hygienic menstrual prac-
tices. It also hinders them from overcoming traditional
beliefs, misconceptions and restrictions regarding men-
struation. This will empower them as they transition into
womanhood.
Keywords: adolescents; awareness; hygiene; menstruation.
Introduction
As per World Health Organization (WHO), adolescence is
defined as age between 10 and 19 years (1). It is a vital
period of life involving the transition of physical, psy-
chological, emotional and social development (2). The
National Population Policy of India 2000 recognized
adolescents as a vulnerable group with specific needs
(3). They comprise 20% of the total Indian population,
which in actual numbers translate into 200 million
­adolescents (4).
One of the vital psychological and biological changes
in girls during adolescent period is the onset of men-
struation. The name “menstruation” comes from the
Latin word “menses” meaning moon, with reference to
the lunar month and which lasts approximately 28 days
(5). The age of attaining menarche differs by geographi-
cal region, race, ethnicity, etc., but commonly occurs in
developing countries between the ages of 8 and 16 years
with a median age of 13 years (6).
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2 Dudeja et al.: Awareness about menstruation
Reproductive health of adolescent girls is crucial as
it determines the health of future generations. A large
number of their morbidities related to menstruation are
generally unrecognized and uncared for due to the culture
of silence in Indian society. It has been documented that
menstrual problems in the majority of the adolescent girls
are mainly due to emotional maturity and psycho-social
stress (7). Though menstruation is a normal bodily func-
tion, however, attitudes to it vary substantially by culture.
In Indian culture, it is associated with several misconcep-
tions and practices. Following menarche, various myths
practiced strongly bar the woman from everyday tasks like
touching water, attending religious ceremonies, cooking/
entering the kitchen, running/participation in sports
activities, cleaning, socializing or sleeping in one’s own
home or bed, etc (8). Due to these restrictions women
often adopt practices that are unhygienic or inconvenient
leading to adverse health outcomes like reproductive tract
infections including urinary tract infections.
Every day, schoolgirls around the world experi-
ence menarche and find themselves in a setting without
water, toilets or a supportive female teacher to explain
the changes happening in their body. Cultural taboos and
secrecy about menstruation compound this problem (9).
Despite growing global attention to Menstrual Health
Management (MHM), a significant gap persists in develop-
ing countries. MHM is defined as “Women and adolescent
girls are using a clean menstrual management material to
absorb or collect blood that can be changed in privacy as
often as necessary for the duration of the menstruation
period, using soap and water for washing the body as
required and having access to facilities to dispose of used
menstrual management materials” (10).
Various studies have shown that in the developing
countries girls from a poor socioeconomic background
lack adequate supplies of sanitary materials and are
forced to manage menses as best they can with cloth,
tissues or toilet paper (11). In the schools, there is a lack
of adequate means for disposal of used sanitary materi-
als and safe, ­single-sex and private toilets which can be
closed from inside and with water and soap for washing
(12). These problems along with menstrual pain are the
causes behind school absenteeism for girls.
Health promotion interventions in this area would
include improving the school’s WASH environment.
This will have an indirect impact on improving school-
ing, equity, reproductive health and well-being of girls.
An important concern for adolescent girls is to have ade-
quate, correct knowledge along with facilities and the cul-
tural environment to manage menstruation hygienically
and with dignity. Hence, the present study was done to
assess knowledge and practices about menstruation in
adolescent school girls of an urban slum.
Methodology
This was a descriptive cross-sectional study conducted among
girls of a Government School located in an urban slum of western
­Maharashtra. Data were collected during the period of January 2016.
The sample size was 217, calculated at 17% prevalence of awareness
with alpha error and precision of 5%. The study tool used was a pre-
designed, pre-tested, structured and self-administered questionnaire
which was developed and translated into local language. The study
population included all the girls studying in classes from 6th to 12th.
After taking permission from the school authorities, the class teachers
of the respective classes were explained the objectives of the study. A
good rapport was established with the girl students by the investiga-
tor. The students were explained the purpose of the study and were
briefed about the questionnaire. They were also informed about the
confidentiality of the information collected so as to get as more reli-
able answers from them. After obtaining an informed consent from
the parents of the participants, the questionnaires were administered
to them. A total of 250 girls participated but 39 questionnaires were
incomplete and hence 211 responses were analyzed. The question-
naire collected information on demographic characteristics, knowl-
edge and perceptions regarding the process of menstruation, practices
during menstrual cycles and menstrual hygiene and restrictions due
to menstruation. Specific time duration was given to answer all the
questions. The girls were allowed to enquire any clarifications with
the investigator. The data thus collected were entered into Microsoft
Excel and analyzed using the SPSS 20 software (IBM Statistics). All
girls were educated about menstrual hygiene after the study.
Results
The mean age of the students was 14.9 ± 1.75 years. Mean
years of schooling in the current school was 9.21 ± 1.97
years. The mean age at menarche was 11.97 (95% CI:
11.94–11.99).
It was observed that only half (56.4%) had acquired
prior knowledge about attaining menarche. Out of these
in a large proportion, the knowledge was imparted to them
by their mothers (60.7%), followed by friends (31.8%).
However, very few acquired this knowledge from teach-
ers (8.5%) (Table 1). There was no significant association
between the educational status of mother and awareness
in respondent about menstruation (Table 2).
The majority (88.2%) of the participants believed that
menstruation was a natural phenomenon. Regarding the
organ of menstrual blood flow, half (50.7%) knew the
correct answer (i.e. uterus); whereas the rest believed that
it was stomach/kidney, etc (Table 1). The majority (90.5%)
of them used sanitary pads. The queries on the frequency
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 Dudeja et al.: Awareness about menstruation 3

Table 1: Awareness in adolescent girls about various aspects of of change during the time of menstruation revealed that
menstruation. 50.2% changed sanitary pads or cloth 1–2 times a day,
32.2% 3–4 times a day and 6.6% 5 times a day. The major-
Number Percentage
ity (88.2%) of the respondents were disposing the sanitary
Did you know about menstruation before menarche? absorbent in the correct way (i.e. wrapping it in paper and
Yes 119 56.4 disposing into a dustbin). Only 9% were reusing the used
No 92 43.6
cloths after cleaning it.
If you knew about it, then from whom did you come to know?a Almost 90% of the young women faced physical
Mother 72 60.7
complaints or health problems during menstruation.
Friends 37 31.8
The perceived symptoms are given in Figure 1. The most
Teacher 10 8.5
common problem faced during menstruation was pain
By which organ does menstruation occur?
in the abdomen (dysmenorrhoea) followed by backache
Stomach 25
Kidney 52 and headache. Most of the participants had some kind of
Uterus 107 restrictions on them during the menstruation and most of
Do not know 27 12.9 these were religious restrictions (69.7%) followed by phys-
What do you use during your menstrual cycles? ical (41.2%) and social restrictions (22.3%). All of them
Sanitary pad 191 90.5 were unsatisfied with the toilets and hand washing facili-
New cloth 16 7.6 ties available inside the school premises.
Old cloth 4 1.9
How often do you change the sanitary pad?
0–1 times per day 24 11.4
1–2 times per day 106 50.2 Discussion
3–4 times per day 68 32.2
Above 5 times per day 13 6.2
Adolescence is a crucial phase of development which
How do you destroy the sanitary pad? encompasses transition from childhood to adulthood or
Rapping it in the paper and throw it in 186 88.2
girl to a woman. This period is considered to be critical
the dustbin
Without wrapping it in the paper and 7 3.3 as these are formative years where pubertal, psychologi-
throw it in the dustbin cal and behavioral changes take place. The foundation of
Cloth by cleaning it and using it again 18 8.5 sound reproductive health is also laid during this period
What kind of daily problems are faced by you during menstruation? of life.
Avoid walking, running and cycling 87 41.2 It is known that age at menarche varies across differ-
Avoid some kind of foods 32 15.2 ent cultures, regions and places. Esimai et al. found this
Avoid roaming out with family and 47 22.3 age to be 14.18 years, which is much higher than that of
friends
our study. Another study by Thakre et al. conducted in
Avoid to attend school 14 6.6
Avoid housework 28 13.3
Maharashtra in the year 2011 documented the mean age
Avoid visiting holy places 147 69.7

All those who knew about it before menarche.

a
250
No Yes

200

Table 2: Association between the educational status of mother and

150 118 128
awareness about menstrual hygiene in the respondent.
170
191 193
100 206
Education status of mother Awareness about menstruation

Absent Present Total

50 93 83
Illiterate 27 21 48 41
Primary 32 26 58 20 18
0 5
Secondary 33 35 68 Stomach Headache Acidity Vomiting Back pain Excessive
Senior secondary and above 15 22 37 pain bleeding
Total 107 104 211
Figure 1: Symptoms experienced by adolescent girls during
χ2: 2.712 p-Value: 0.438
menstruation.

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4 Dudeja et al.: Awareness about menstruation
of menarche in the adolescent girls as 12.85 ± 0.867 years
(13). However, the mean age at menarche in our study
was lower (11.97 years). This difference could be because
of secular trends with better nutrition and decreased
infection.
Our study revealed that more than 44% of adolescent
girls had no prior knowledge about menstruation. The
prevalence of awareness was lower in our study (56.4%)
as compared to other studies: West Bengal (67.5%) and
Uttarakhand (64.5%). This could be due to the cultural
difference in the population studied (14, 15). A literature
search highlights the importance of awareness and states
that ignorance and lack of preparation around puberty
and menstruation propagate false beliefs and taboos
which leaves young girls vulnerable to feelings of embar-
rassment and low confidence. Our study corroborated the
finding that girls are ill-prepared for menstruation.
Mothers and friends have been identified in this study
as the main source of information to the girls. This fact
has been proved in other similar studies to be of foremost
influence on the menstrual health of adolescent girls (16,
17). However, mothers and families themselves are often
inhibited to discuss teenage matters with their young
children and incomplete knowledge of mother is hence
passed on to their daughters. It is, therefore, important
that mothers have appropriate information on reproduc-
tive health matters so as to pass the same information to
their growing girl child. After mother comes the role of
female teachers, who in school interacts with adolescent
girls on a day-to-day basis. Unfortunately, teachers were
found to constitute only a small proportion from whom
the menstrual information was received. Similar findings
were also seen in a study conducted in rural Kenya (18).
In our study, 50% of the girls identified uterus as the
organ of menstrual bleed. This was better than a study
conducted among adolescent girls in Varanasi district
(UP), where 43.5% of the girls correctly responded uterus
as the organ from where the menstrual blood comes (19).
This improvement is mostly because of inclusion of life
skills workshops in schools of Maharashtra. However,
there is still scope for improvement which can be achieved
by inclusion of life skills education in the teaching
curriculum.
An important component of menstrual hygiene is
the type of menstrual absorbent used as unsanitary and
cheap materials like rags and, toilet tissue paper can
harbor infectious agents which often thrive under blood
culture medium, and may, therefore, constitute a source
of pelvic infection. More than 90% of the participants in
our study used sanitary pads. This can be attributed to
the Government of India project on social marketing of
sanitary napkins which has been implemented in letter
and spirit in the state of Maharashtra. Other factors that
can be ascribed are media exposure and interpersonal
communication that has adequately enhanced their
awareness about sanitary napkins. The national cam-
paign of Swachh Bharat: Swachh Vidyalaya in India has
also played a key role in improving hygiene and sanitary
awareness of adolescent girls by providing hand washing,
toilet and soap facilities.
Half (50.2%) of the girls in our study reported that
they change the pad only twice a day, while a change is
recommended every 8 h (20). This shows the lack of sci-
entific knowledge among the girls which can predispose
them to poor hygiene and later infections. This issue can
be addressed by health promotion and education. With
regard to final throwing away of the pad, most of the
girls used the correct method. This is a matter of concern
because of their high content of non-biodegradable com-
ponents. The Government of India has also made avail-
able sanitary pad destroyers at certain places and has
mandated their installation in teaching institutions.
The commonest symptom during menstruation in
our study was dysmenorrhoea which has been high-
lighted in a similar study in Delhi by Sharma et al. (21).
This affects the daily routines of the majority of the girls
leading to absenteeism from school. Demedicalizing
women’s health approach can be used to relieve these
symptoms by using other non-pharmacological remedies
like spices (garlic, bitter kola), salted water and abdomi-
nal hot water compress. These measures along with some
exercises have been studied and are found to be effective
(22); these are no cost interventions which can be done
at household level and reduce morbidity in young girls.
A study in Rajasthan also shows that 92% were restricted
in religious and social activities, which is also consistent
with our findings (23).
To work toward achieving SDGs 6 and 4, UNICEF has
suggested a common vision which states “Girls in 2024
around the world would be knowledgeable about and
comfortable with their menstruation, and able to manage
their menses in school in a comfortable, safe and dignified
way” (24).
Conclusion
Correct knowledge in adolescent young girls regarding
menstruation is lacking. Lack of awareness is a road-
block in adopting safe and hygienic menstrual practices.
It also hinders them from overcoming traditional beliefs,
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misconceptions and restrictions regarding menstrua-
tion. This will empower them for their transition into
womanhood.
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