Managing the monthly: a mixed methods study on menstrual waste management among adolescent girls from South India

Sample size

The study conducted by Veleshala et al., [10] in the Nalgonda district of Telangana, India, reported that 69.6 % of urban slum girls disposed of menstrual waste products in the dustbins or via burning, which are considered to be relatively safe practices, as suggested by the Central Pollution Control Board, Government of India, for rural areas. Assuming similar 69.6 % of safe disposal practices among rural adolescents, 80 % power, 10 % relative precision, 2 % design effect (to adjust for the cluster effects of the schools) and 95 % confidence interval, we needed 340 adolescent girls to understand the menstrual waste disposal practices. Considering a 10 % non-response rate, we calculated a sample size of 380 girls.

To explore the facilitators and barriers to MWM at schools, we conducted in-depth interviews (IDIs) among female teachers of the selected schools. The total number of IDIs was decided based on the level of information saturation.

Data collection

Three experts from public health (two faculty) and obstetrics and gynaecology (one faculty) conducted content validation of the questionnaires. The questionnaire was then pre-tested and distributed for self-administration by adolescent girls. The doubts regarding the questions were explained by the investigators to the adolescent girls and they were requested to sit separately while answering to avoid peer influence on the response.

We followed purposive sampling for IDIs and identified teachers who were vocal and involved in managing or educating adolescent girls regarding MHM. The investigator trained in qualitative research, conducted the IDIs in the local language (Telugu), and an interview guide was used to facilitate the discussion. The audio of the IDIs was recorded with consent, and these recordings were transcribed to English within 24 hours of each IDI.

Data entry and analysis

The quantitative data were entered into the EpiCollect5 mobile application and analyzed in Stata Version 18.0 (Stata Corp, College Station, Texas, USA) software. The categorical variables were summarized as percentages, and continuous variables were summarized as mean (SD) or median (IQR) based on the distribution of the data. Thematic analysis with inductive coding was done in ATLAS.ti software to identify the themes and categories to explore the current practices, cultural beliefs, challenges, and solutions for MWM in schools. The transcript documents were imported to ATLAS.ti, and two investigators coded them to reduce individual subjectivity and improve the credibility of the coding process. The disagreements regarding the categorization and coding between the investigators were resolved through discussions.

Menstrual waste management at home and school

The majority of the adolescent girls (86.6 %) disposed of their menstrual waste along with other solid waste from home, which was collected by the Gram Panchayat solid waste collection team. These bins are emptied by the waste collectors authorized by the local body on a daily or alternate-day basis. Around eight percent of adolescent girls followed local incineration at home; the rest threw the menstrual waste in open areas, canals, or buried near their homes. At schools, most participants (95 %) disposed of their menstrual waste in the disposal bin available at school, and the rest (5 %) said they threw the menstrual waste in open areas. When asked about the ideal way to dispose of menstrual waste, 63.1 % of adolescent girls said dustbin followed by burying (17 %). Only 2.9 % said burning is the ideal way of disposal of menstrual waste. Around 9 % of adolescent girls said flushing in latrines, 7 % said throwing in water bodies like lakes and rivers, and 1 % said throwing menstrual waste in open areas was the ideal method.

Nine percent of adolescent girls mentioned that they faced challenges while disposing of their menstrual waste, such as the non-availability of separate dustbins, separate washrooms, and sanitary workers at schools, and emotional apprehension due to the presence of people from the opposite sex at home and school. Around 10 % reported feeling shy when interacting with people of the opposite gender in school and at home regarding menstruation and mentioned it as a challenge.

Only 27.4 % of adolescent students were aware of menstruation prior to their menarche. The main source for their information was their mother (69.2 %) followed by female siblings (19.5 %). Around 57 % of the participants reported having their menstrual cycles regularly; 16.8 % had irregular cycles, while 24.4 % reported occasional irregular cycles.

Around one-third of the adolescent girls said they use soap to clean their genitalia, while 60 % responded that they use only water during menstruation. A small proportion (2.7 %) of adolescent girls mentioned using disinfectants like Dettol. Around 78 % of the adolescent girls mentioned that they wash their external genitalia every time they use the restroom, and the remaining wash while taking a bath or changing their menstrual product.

About 6.4 % of adolescent girls reported having health issues occasionally while using single-use disposable sanitary pads, such as white discharge, pruritus genitalia, bad odour, burning micturition, and pain in the abdomen. Around one-third of adolescents (33.5 %) reported sickness absenteeism in the past owing to the menstrual cycle associated with abdominal pain, heavy bleeding, or as per instructions from their mother.

Regarding questions related to cultural beliefs, 55.3 % were not allowed to participate in religious rituals, 17.6 % said that they were not allowed to go to the temple, around 4 % mentioned that they should not enter or touch anything in the kitchen, nor are they allowed to go outside the house during menstruation (1.0 %). The remaining 24 % reported not following any cultural practices, specifically during menstruation.

Findings from qualitative data

We conducted five IDIs among the teachers from the schools (two from residential government schools, two from non-residential government schools, and one from a private school) included in the study. Figure 1 provides the conceptual diagram derived from thematic analysis related to barriers in menstrual waste management at schools as perceived by the teachers. In total, 77 codes were generated, and they were grouped into 11 categories, three subthemes, and one theme – barriers of menstrual waste management. Three subthemes were, viz., deficiency in menstrual waste disposal infrastructure, deficiency in menstrual education, and poor knowledge on reusable menstrual products.

1. Barriers related to education about menstrual hygiene: From the codes four categories were derived viz., non-availability of specific educational material or structured curriculum, poor knowledge of parents, not orienting children at young age and cultural beliefs and taboos.

Figure 1:

Conceptual diagram on barriers in appropriate menstrual waste management among school children as perceived by the teachers.

The following sections explain the barriers to menstrual hygiene-related education.

Nonavailability of specific educational materials or structured curriculum: The teachers felt that menstrual hygiene education is very limited for adolescents, as no specific curriculum or structured educational material is available at the schools. The teachers expressed that they speak to adolescents about menstrual hygiene during school assemblies (in girls-only schools) or during reproductive health classes and to needy students based on their knowledge and experience.

T2: “No separate (menstrual hygiene and safe disposal) session is there, but during the lessons (reproductive health), the teachers will explain about menstrual hygiene”

T3: “We have topics regarding reproductive cycle, at that time we discuss about menstrual hygiene”

T1 (girls-only residential school): “Yes, we tell them during morning prayer hours, about regularly changing pads every 6 hourly, proper disposal to avoid difficulty for others, etc”

Not orienting at a young age and poor knowledge of parents: Most of the teachers felt that students who attain menarche at early age do not take responsibility for menstrual hygiene due to their young age. Such young age students keep sanitary pads on washroom walls or throw them outside without wrapping them in the newspaper. Although teachers create awareness through lectures and demonstrations, these students find maintaining hygiene practices in school washrooms difficult. Teachers opined that girls should be oriented at a young age regarding menstrual hygiene and appropriate menstrual waste disposal techniques.

T3 (girls-only residential school): “Yes, we do face some issues like children who are young and new to menstruation will not dispose of the waste properly.”

Teachers felt that instead of teachers, parents should be educating their children regarding menstrual hygiene, as teachers felt that the girls were not listening to them. Paradoxically, the teachers also mentioned that the parents wanted teachers to teach their children about menstrual hygiene.

T5: “When the teacher explains, they (girls) will not listen sometimes. My personal opinion is the parents should talk to the girls regarding menstrual hygiene and menstrual waste disposal”

T3: “Parents request us to explain to their girls regarding menstrual hygiene”

T5: “Parents should be taken classes first regarding menstrual hygiene and disposal than students”

Cultural beliefs and taboos: Teachers mentioned that some parents do not agree to burn the menstrual wastes of their children and also do not agree to send their girl children to school especially during their initial few cycles after menarche due to their beliefs and myths.

T1: “Many of them here are illiterate and belong to ST (scheduled tribe caste) from Thanda’s (tribal hamlet). Parents believe and tell us that pads should not be burnt. If it is burnt our children will face childbirth difficulties.”

T5: “A few parents also tell us not to send their children out on New Moon Day during their menstrual cycle. We conduct campaigns to explain that these myths are not true and motivate the children to tell their parents as well. But there are a few parents who will not agree with us.”

T3 (residential girls-only school): “They don’t send the girls to school during the first and second day of menstruation. Remaining days they will send.”

1. Barriers related to knowledge on reusable menstrual products: From the codes five categories were derived viz. limited availability and supply of free menstrual products, adolescents unaware of reusable menstrual products, better awareness and preference for disposable products, poor awareness about environmental issues and as mentioned earlier, non-availability of specific structural curriculum.

2. Limited availability and supply of free menstrual products: The teachers said that the government provides disposable sanitary pads once a year. Some non-governmental organizations and corporate firms also provide such products free of cost to the schools. However, the supply is often once a year. Hence, the teachers are not able to provide sanitary pads to all girls throughout the year. They provide it only to those who need it at school or to those girls who forgot to bring it to school. Most of the girls buy sanitary products from shops from their own pocket. Sometimes, teachers spend their money to buy sanitary products when there is no supply.

T4: “They (Government or NGOs or firms) give a large box once a year. We will give it to those who need it in school only.”

T3: “Sponsors (firms) will provide sanitary pads, if anyone doesn’t get their pads we will give them… not every month, they provide (sanitary pads) every year up to 3–4 huge boxes”

Preference for disposable products and lack of awareness on reusable menstrual products:

The teachers opined that all school girls use single-use disposable sanitary pads and are unaware of reusable cloth pads or any other reusable methods. They perceived that reusable cloth pads are old methods for managing the menstrual cycle and are not preferred nowadays. The teachers are also not aware of any program related to menstrual hygiene.

T1: “No, since the generation has been changing, everyone will have awareness. So, no one will use clothes (as menstrual products). In 2010–11, students who were poor and unable to afford sanitary pads used to get cotton clothes. But later, we created awareness and requested “Whisper” for help, so they provided sanitary pads for one year. From then on, they (girls) continued to use sanitary pads.”

T3 (girls-only residential schools): “No, I don’t have any idea about it (menstrual hygiene-related programs). In the name of the Swachh Bharat program, all children will participate in campus cleaning every Saturday for one hour, they also clean their dormitories and trunk boxes.”

Poor awareness about environmental issues:

In terms of environmental issues related to menstrual products, most of the teachers were concerned about the unpleasant smell and unsightly appearance associated with the improper disposal of menstrual products. Some also mentioned that there will be a nuisance from pigs, dogs, and rats if the menstrual waste is not disposed of properly. However, there was no further expression related to other environmental problems associated with menstrual waste.

T4: “Yes, there are some cases where we get bad smell due to improper and delayed burning (of menstrual wastes).”

T3: “If the dustbin gets filled and if it is there for a long time, it leads to a bad smell”

T1:“We teach them to dispose waste properly, otherwise there are issues with pigs and dogs. Also urinary tract infections are often reported by these students”

1. Barriers related to menstrual waste disposal infrastructure: Four categories were derived from the codes: lack of sanitary workers to collect and dispose waste, menstrual waste disposal not being a priority for PTA/Panchayat Raj institutions, limited availability and supply of free reusable menstrual products, electricity challenges and limited incinerators.

2. Lack of sanitary workers to collect and dispose of waste: A few schools did not have any helpers or sanitary workers. In those situations, the teachers dispose of menstrual waste with or without the students’ help. A few teachers reported that the school’s housekeeping staff collects the menstrual waste thrown in the dustbins and disposes of it. They also thought that the government paid less for housekeeping work, so it wasn’t easy to find labor.

T3 – “I expect housekeeping staff should be employed for these kinds of work.”

T4- “We tried to employ housekeeping staff on a contract basis, but who will come for less salary? Even in villages nowadays people don’t do this type of work unless 2000 rupees is paid. Hence, our students are doing it.”

T4: “We want housekeeping staff because now we are doing all these works (disposal).”

MHM is not given priority in parent-teacher meetings, committees, or Panchayat Raj Institutions:

All the teachers opined that menstrual hygiene is not discussed during parent-teacher meetings, and these meetings mainly focus on the student’s academic performance. They also felt that parent-teacher meetings could be a good opportunity to discuss menstrual hygiene and clear misconceptions. Most teachers felt that the parents should be aware of it. The teachers also expressed that Panchayat Raj is not involved in discussing MWM.

T2 – “These things (menstrual hygiene management) are not discussed during parent-teacher meetings. Only administrative issues are discussed. But if any personal problems are mentioned, then we will discuss them.”

T3 – “Meetings are held once a month, but parents attend during vacations like Dusshera, Sankranti, and summer mostly.”

T2 – “We don’t have these (school committee meetings with Panchayat Raj members) often; during Independence Day and Republic Day, they (Panchayat Raj members/ Village leader) visit the school.”

Electricity challenges and non-availability of incinerators:

Most residential schools had electricity-based incinerators, and non-residential schools burned menstrual waste in open places using conventional firewood. However, manpower for such waste disposal was limited, and often, teachers, with the help of the students, carried out the waste disposal activities. Teachers also felt that the challenges with fluctuations in electricity and low-voltage electricity, limiting the usage of incinerators at school.

T2 – (nonresidential school) – “We have an open place behind the school where we will collect the waste (including menstrual waste) and burn it. Since this is not a residential school, we don’t get much waste”

T5 – “We wanted to buy an incinerator for our school through donors, but the electrician told us its maintenance will be difficult as we don’t get enough power supply to run it”

T1 (Residential girls-only school) – “We run the incinerator once in every two days. As they (girls) wrap the waste in the paper, the weight of each menstrual waste will be more and the incinerator gets filled easily, so we have to use it every two days.”