Inadequate menstrual hygiene management (MHM) among adolescent girls (15–19 years) is a public health problem, mainly in low and middle-income countries [1
]. With over 0.6 billion adolescent girls (8% of the world’s population), the issue of menstrual hygiene by virtue of its magnitude is an issue of global concern. More than 80 percent of these adolescents reside in the Asian and African continents [2
]. India is home to 243 million adolescents, which accounts for a quarter of the country’s total population [3
]. India has over 355 million menstruating women and girls, but millions of women across the country face uncomfortable and undignified experience with MHM [4
Menstrual hygiene is often regarded as a multi-sectoral issue that requires an integrated action from the Department of Education, Health, Women, and Child Development and Water Sanitation Hygiene (WASH) [5
]. In recent years, we have witnessed a strengthened move by the government towards addressing this public health issue. With the launch of the National Rural Health Mission in 2005, menstrual hygiene promotion was formally included as a key responsibility of the community health workers (Accredited Social Health Activist; ASHA) followed by the implementation of menstrual hygiene promotion scheme for girls in rural areas in 2011 [6
]. In 2015, another milestone was achieved when the Ministry of Drinking Water and Sanitation published guidelines on MHM [7
]. There has been a lot of national and international level push to address this issue through various social media platforms including the making of a film called Padman [8
], roll out of menstrual hygiene campaigns, performing trials on eco-friendly or biodegradable menstrual products, implementing comprehensive sexuality education in schools, etc. [4
Menstruation among school-age girls is a neglected issue on the implementation front despite the formal inclusion of a menstrual hygiene scheme under the reproductive and child health program by the government of India (in 2011) [9
]. This issue still lacks educational support from health workers, pragmatic guidelines to operationalize MHM in schools, and adequate monetary resources to implement the needed actions. Fear, shame, ongoing social taboos, ignorant unsupportive teachers, lack of water, sanitation, disposal facilities, and privacy, are some of the barriers in building an enabling environment for safe and hygienic menstrual practices within the school premises [10
]. These system-level challenges, in conjunction, not only negatively impact sexual and reproductive health outcomes of adolescent girls but also affects their self-confidence and agency (ability to make a decision and take actions for self) [11
]. The increasing enrolment of girls in secondary and senior secondary schools demands a more comprehensive approach to make schools menstrual hygiene friendly and prevent school dropouts or absenteeism [13
Given that a comprehensive approach to study MHM among schools in India was not made in previous reviews, we chose to conduct a systematic review. The review aimed to objectively summarize the evidence on the actions taken at the school (system)- and policy-level to make schools a menstrual hygiene friendly place for adolescent girls in India.
The research question was defined as “Are schools in India menstrual hygiene friendly, and what are the policy-level actions taken by the government of India to make our schools menstrual hygiene friendly?”
Menstrual health promotion in schools remains an issue of concern in India. Limited evidence was available on the different components of menstrual hygiene friendly school. Most of the evidence was available on two components, primarily girls’ awareness about MHM, and sanitation facilities in schools, leaving other components unaddressed. MHM in schools, although it was conceptualized comprehensively with different components as documented in guidelines, the data on its implementation was limited. There was a dearth of literature on education programs focusing on MHM in schools and knowledge, attitude, practices of mentors (teachers) who acted as an immediate source of information to girls. Although the data were available for the source of information about MHM (teachers), the studies on whether teachers as a source of information to girls had adequate knowledge about MHM were not available. We estimated that more than half of the girls did not have information about menstruation prior to menarche. Only 7% of girls reported teachers as a source of information for MHM. Menstruation hygiene education in school has most often being outsourced to non-governmental agencies [197
]. Discrimination against female teachers to continue teaching in schools during periods was another example of a social barrier against menstruation. Not only did this practice disrupt the learning process, but it also perpetuated negative images among young minds and society [199
Research evidence revealed that lack of sanitation facilities in schools hindered the ability of girls to manage menstruation healthily, safely, and with dignity. Evidence showed how this aspect affected coping strategies of girls during menstruation [5
]. Only 56% of schools had the facility of a separate toilet for girls. Appropriate menstrual waste disposal facilities were still lacking in the majority of the schools in the country. Studies reported that because of a lack of awareness and sanitation facilities, most of the girls did not change pads in schools [23
]. Despite being emphasized in the education policies, display of MHM messages through information, education, and communication (IEC) materials were not routinely practiced in schools [200
]. IEC materials such as posters, leaflets helped to reinforce the health promotion messages and supporting behavior change at large [201
]. Although online monitoring of some of the WASH indicators in schools was done, MHM components were not included [202
]. A lack of evidence on MHM management information system (MIS) data takes away the system of their efficacy in dealing with this social health problem at a large scale [203
]. Other reviews have reported similar findings on one or more of the eight components of MHM friendly schools in India [15
Our review highlighted minimal rural-urban differences in menstrual hygiene practices in schools. However, in the national-level survey, it was reported that more than 50% of the rural girls did not use hygienic methods of menstrual protection (girls who use locally prepared napkins, sanitary napkins, or tampons during their menstrual period) compared to 23% in urban areas [206
]. The plausible explanation for this could be the heterogeneity in the included studies in our review. Furthermore, most of the studies had low quality scores.
It is imperative to emphasize the four primary considerations to build effective evidence on MHM friendly school aspect. These are discussed further, below.
Firstly, pre-service training of teachers on MHM with knowledge assessment at regular intervals is a crucial step in this regard since teachers are viewed as health promoters [195
]. Teachers’ knowledge assessment can be a part of the regular school education surveys [13
]. Furthermore, the sensitization of male teachers and boys on MHM is equally important. The provision of MHM-related education materials in schools such as booklets, flipcharts, and modules can be the cornerstone in enhancing the knowledge of teachers and girls [208
The second major issue is the urgent need for improvement in the sanitary facilities at schools. MHM was missing in the majority of the schools [194
]. We found data that highlighted the poor sanitation facilities across the school, and effective implementation and monitoring on this aspect were awaited. Previously published meta-synthesis highlighted that the poorly supportive physical infrastructure, such as a lack of water and sanitation facilities, made it difficult for girls to practice MHM safely [208
]. Waste disposal is of equal concern to make the school environment clean and healthy. The widespread reality of poor sanitary facilities and ignorance about menstruating girls’ needs in schools can make its experience a negative one resulting in increased dropout rates among girls [209
The third major area is the efficient working of the school management committee with an emphasis on MHM services in schools. Regular monitoring and timely actions are crucial to transform poor MHM practices in schools. Lastly, an efficient MIS is paramount in constructing evidence-based planning for the policymakers and the education leaders. Improved management of supplies and data generation demands an MIS software to update school authorities and concerned departments in the government at regular intervals. The MIS software may generate monthly data regarding the menstrual supplies stock, availability of sanitation facilities across schools, count of the menstruating adolescent girls, and school preparedness towards maintaining sanitation friendly status [210
]. The Education MIS under UNICEF’s WASH programs (Wins) in schools across 194 countries provides a classic example of robustness and usefulness of data monitoring [211
The multi-sectoral approach to MHM gaps in schools calls for convergence among various Departments such as Health and Family Welfare, Human Resource Development, Tribal Affairs, Woman and Child Development beyond the Department of Drinking Water and Sanitation. We need to leverage the use of resources and concentrated efforts to support school-based interventions for MHM. The different components to make schools menstrual hygiene friendly have been prioritized in other resources [212
The ad-hoc grant-based projects or pilot initiatives by external agencies on MHM in schools are essential for evidence generation, which can be scaled-up as cost-effectiveness solutions at the national or state level. WaterAid India and Vatsalya (Breaking the Silence program) in Uttar Pradesh were working with the schools and service providers to change the perception around MHM [213
]. The program proactively engaged with boys, school teachers, and management committees. Another intervention called ‘the MHM curriculum’, implemented by WASH United India, adopted game-based approaches across schools to empower girls in overcoming the stigma around menstruation [214
]. Under the broad school health-promoting framework, knowledge and perceptions around menstruation were addressed with the support of lay counsellors in the SEHER (Strengthening Evidence base on scHool-based intErventions for pRomoting adolescent health) project from Bihar. This randomized control trial advocated for the involvement of lay counsellors in transforming the school climate and improving adolescent health outcomes [105
Multiple non-peer reviewed anecdotal evaluation reports and articles documented that the implementation of such school-based MHM interventions was imperative to construct evidence. One such evidence was from a large-scale study covering 15 districts in India, called project JAGRITI
, with menstrual hygiene promotion among adolescent girls as one of the components [215
]. The program, run by the MAMTA-health Institute for Mother and Child, made a 10-step pragmatic guideline towards transforming schools into menstrual hygiene friendly with essential and desirable components (adapted from the National guidelines). Other national and state-level menstrual health players active in India are contributing to the availability of low-cost disposable sanitary material, MHM education to girls through comic books, training of facilitators, and researching on MHM behavior and practices [4
Poor menstrual hygiene practices can lead to potential long-term consequences such as dropping out of school, early marriage, restriction of mobility, agency development (capacity to act independently), menstrual irregularities, and other reproductive and mental health problems. Moreover, menstrual irregularities during reproductive age group are common in many gynecological diseases, such as endometriosis, which may affect mental and psychological well-being in long-term [216
]. There are multiple challenges girls face in managing menstruation due to poor awareness about safe practices, limited access to sanitary products, sanitation, and lack of support from teachers or family members. Schools have emerged as an important delivery platform for health promotion interventions, which needs more consistent efforts to improve the health outcomes of young girls.
Limitations of the Study
The results of the review should be interpreted in view of some limitations. This review aimed to provide an overview of menstrual hygiene practices in schools. We could not produce a critically appraised and synthesized results for all the components of menstrual hygiene friendly schools. Heterogeneity between the included studies was very high, which might affect the validity of the pooled results. Most of the included studies were of low quality. The reports and peer-reviewed journal articles, which were publicly available, were included in our study. This limits our access to published literature in the public domain only. The study results might be considered in lieu of publication bias for positive findings because negative findings might not have been placed in the included reports and papers or papers and reports with negative findings may not have been published or made publicly available.
MHM practices in schools are poor in India. Furthermore, we lack sufficient data to conclude the MHM situation in schools. The government has developed national level guidelines on all the aspects of MHM friendly school. However, its effective implementation on the ground is lacking. Still, MHM in schools is largely supported by outside agencies. Research on MHM in schools is mainly focused on observational studies to assess the knowledge and practices of girls regarding MHM. Moreover, research on the other aspects, such as waste management, teacher’s knowledge assessment, and management information, is limited.
There is a wide scope of integrating various curriculum or non-curriculum-based actions on menstrual health education and establish schools as an ideal forum to disseminate MHM information. There is a need for transforming the existing infrastructure into menstrual hygiene friendly, which needs to be the priority area for all the schools (government or private). Simplifying the elaborated guidelines into pragmatic action points would help authorities and management committees to implement the program easily in all the schools. The increased momentum from international donors, small and medium-sized enterprises, and non-governmental organizations could be synergized and channeled into constructive outcomes for attaining improved menstrual health outcomes. The emerging scientific and innovative solutions from MHM projects could help policymakers in strategizing concentrated efforts in this direction. Moreover, expanding MHM accountability from sanitation and health ministries to other departments will help to improve menstrual hygiene conditions in the country multilaterally. To better understand the problems surrounding MHM for adolescent girls in school, the impact of MHM interventions, we need new research studies with expanded range of methodologies.