Knowledge and practices related to menstruation among tribal adolescent girls.

BACKGROUND: Despite the fact that every girl has to deal with menstrual hygiene, there is a lack of awareness about the process of menstruation and proper menstrual hygiene among adolescent girls, especially from tribal backgrounds. AIM: The aim of the study was to assess the knowledge and practices related to menstruation among tribal (Munda) adolescent girls.
MATERIALS AND METHODS: This was a community-based cross-sectional study. The sample for the study consisted of 150 girls belonging to Munda tribe in the age group of 13-18 years, recruited by purposive sampling from various schools of Khunti district of Jharkhand state. Interview guide was predeveloped, validated, and used to study the knowledge and practices related to menstruation among adolescent girls. The data were collected by a personal interview of the study subjects.
RESULTS: The mean age of menarche of the study subjects was 14.1 years. It was evident that only 48.67% of the participants were aware about menstruation before menarche and the most important source of the information about menstruation for them was their friends (53.33%) followed by mothers.
CONCLUSIONS: Knowledge about menstruation is poor among tribal adolescent girls and practices included various myths and misconceptions. Copyright:

Adolescence in girls has been recognized as a special period which signifies the transition from girlhood to womanhood. Menstruation is generally considered as unclean in the Indian Society. Isolation of the menstruating girls and restrictions imposed on them in the family have reinforced negative attitudes toward this phenomenon in girls. The perception of menstruation is different in different cultures and religions.[1] Several studies have reported restrictions in daily activities such as not being allowed to take bath, change clothes, comb hair, and enter holy places. Apart from these, dietary restrictions (taboo on consumption of food such as rice, curd, milk, lassi, potato, and onion sugarcane) during the menstrual period are also imposed. This gives rise to avoidable anxiety and fear and may also lead to undesirable practices.[2345] A study found that 43.7% of the girls did not take part in ceremonies and 36.2% did not take part in the social activities with family during menstruation.[6] Along with cultural constructs which lead to the formation of a certain preconception, the reaction to menstruation also depends on awareness and knowledge about the subject. A survey of 160 girls in West Bengal found that 67.5% were aware about menstruation and 67.5% were aware about menstruation before menarche, but 97.5% did not know the source of menstrual bleeding.[7] In Nepal, 92% of 204 adolescent girls surveyed had heard about menstruation, but the majority of respondents reported that they were not prepared in any way for their first period.[8] A common belief among Gujjar girls (a Semi-nomadic tribal group in Jammu and Kashmir) was that menstruation was removal of bad blood from the body necessary to prevent infection.[9] Social prohibitions and the negative attitude of parents in discussing the related issues openly have blocked the access of adolescent girls to right kind of information, especially in rural and tribal communities. Further, their strong bondage with the traditional beliefs, taboos, and misconceptions during menstruation has led to many serious health problems. Poor personal hygiene and unsafe sanitary conditions result in the girls facing many gynecological problems.[10] Infections due to a lack of hygiene during menstruation have been reported in many studies.[111213] Repeated use of unclean cloth and improper drying of used cloth before its reuse results in harboring of microorganisms, resulting in the spread of vaginal infections among adolescent girls.[14] In one survey, the reasons given by girls for not using sanitary pads included a lack of awareness about them (41%), high cost (39%), the fact that they were not easily available (33%), and lack of disposal facilities (24%). Focus group discussion suggested that girls would prefer to use disposable pads as they were more comfortable, less smelly, and easier to use and carry.[8]

Very little literature can be found on the health and social issues related to menstruation in developing countries like ours. There is also a dearth of information regarding hygiene related to menstruation. Keeping above in view, the present study about knowledge and practices about menstruation among (Munda) adolescent girls was planned. The study was conducted on the sample of adolescent girls of Munda Tribe from Khunti district of Jharkhand. One of the tribes was known for being educationally backward and unexposed to modern influences. Munda tribe mainly inhabits the region of Jharkhand. Although they are well spread in the states of west Bengal, Chhattisgarh, Orissa, and Bihar, Mundas speak Mundari language, which belongs to the family of Austro-Asiatic. Christianity is the main religion followed among the Mundas. Apart from that, Mundas have their own religion known as Sarna. Mundas have remained hunters for centuries, but now, they have started farming. This study aimed to provide an insight into the cultural setup of the tribal community with regard to most sensitive issues of menstruation which would help in promoting improved awareness level and increase in right knowledge about menstruation.

MATERIALS AND METHODS

The study was done in the upgraded high school of Khunti district of Jharkhand state. The sample was selected from the Munda tribe of Khunti District. Ten villages were selected for the research purpose. Institutional ethical committee approval was obtained before starting the study.

Written informed consent was obtained from the parents of the students.

Sample

A total of 150 students were recruited by purposive sampling for the present study. The sample consisted of girls in the age range of 13–18 years and studying in 8th, 9th, and 10th grade. Exclusion criteria were students having major psychiatric or physical illness or with family history of mental illness.

Measures

Data were collected using an interview guide. Detailed interviews were conducted with the selected sample to obtain information regarding their knowledge and practices related to menstruation. The major components of the interview guide were: The terminology used for menstruation, prior information level about menstruation, and the level of personal hygiene during the menstruation cycle. Individual interviews conducted. Wherever necessary, important information and feedback were provided to the girls.

Statistical analysis

The present study is mainly qualitative in nature, and the data obtained using an interview guide was analyzed through content analysis. The quantitative data obtained through clinical assessment were analyzed by calculating frequencies and computing percentages.

RESULTS

Age distribution at menarche and length of menstrual cycle of the subjects is given in Table 1.

Table 1

Age distribution and length of menstrual cycle of the study subjects

Variables	Number of subjects (n=150), n (%)
Age at menarche (years)
Average	14.1
Range	13-18
13	28 (18.67)
14	83 (55.33)
15	23 (15.33)
16	9 (6.0)
17	5 (3.33)
18	2 (1.33)
Menstrual cycle (days)
15-30	7 (4.67)
30-45	97 (64.67)
45-60	32 (21.33)
60-75	9 (6.0)
90-105	5 (3.33)

It is observed that a vast majority of females attain puberty at the age of 14 irrespective of the nature of tribe. Among the Munda tribe, 18.67% of them attain puberty below 14 years of age which tells on their healthy physical growth. Most of them 55.33% attain puberty at 14 years of age and 15.33% are 15 years of age. Only 1.33% above 17 years is recorded.

Menstrual cycle

Figures point out that, though a large majority of girls were having normal menstrual cycles, some of them had their periods with longer than usual gaps [Table 1]. This could be due to some medical reasons, which need further investigation.

Prior information about menstruation and its related complaints

It was found that none of the sample girls had complete information about the process of menstruation before they started menstruating. They started that, “it was the removal of dirty blood from the body, and otherwise a female would develop any infection or disease.”

A large number (51.33%) of the girls were unaware about menstruation before they experienced it. The respondents were asked to reveal the major sources of information about menstruation, and it was found that 53.33% of the respondents had received information from friends, while the source of information for others was mothers 21.33%, magazines 16%, movies 2.67%, relatives 8.5%, and 0% reported form T.V. because in Munda villages, there is a scarcity of electricity and so they are not exposed to television [Table 2].

Table 2

Prior information about menstruation and its related symptoms

Categories	Number of responses (n=150), n (%)
Prior - information
Aware	73 (48.67)
Partially aware - unaware	77 (51.33)
Source of information about menstruation
Mothers	32 (21.33)
Friends	83 (53.33)
Magazines	24 (16.0)
Relatives	7 (8.5)
Movies	4 (2.67)
TV	0
Physical complaints during menstruation
Stomach ache	127 (84.67)
Loss of appetite	41 (27.33)
Nausea	29 (19.33)
Pain in legs	28 (18.67)
Headache	9 (6.0)
Psychological tension/stresss/palpitation
Yes	107 (71.33)
No	43 (28.67)
Less interest in work/study
Yes	79 (52.67)
No	71 (47.33)
Felt weakness
Yes	107 (71.33)
No	43 (28.67)
Sleep problem during menstruation
Yes	106 (7.67)
No	44 (29.33)
Problem in school going
Yes	101 (67.33)
No	49 (32.67)

Regarding the physical complaints during menstruation, majority 84.67% of girls experienced stomach ache, followed by loss of appetite 27.33%, nausea 19.33%, pain in legs 18.67%, and very few 6% started having headache. On being questioned about psychological complaints such as tension/stress/palpitation, majority of samples 71.33% experiencing palpitation and stress and 28.67% did not have such complaints. It was found that, during the menstruation, 52.67% sample experienced less interest in work and study. On another issue asked regarding weaknesses during menstruation. Nearly 71.33% of subjects felt weaknesses. A large number (70.67%) of the girls faced sleep problems during menstruation. On the issue of work/study or school going was affected or not, 67.33% girls accepted that they have a problem in school going.

Practices during menstruation

There were many social and religious restrictions on girls during menstruation. Girls received these instructions for do's and don'ts from mothers, elder sisters, and friends. The questioned being asked regarding the hygiene during menstruation; it was generally found to be lacking. In this study, all subjects use reusable cloths to absorb menstrual blood and they are usually torn from old saris. No one was using sanitary napkins. Restrictions particularly related to prohibitions in going to religious places, offering prayers and keeping fast, and other taboos/myth were also reported by maximum subjects [Table 3].

Table 3

Practices during menstruation

Categories	Number of responses (n=150), n (%)
Using sanitary napkins	0
Reusable clothes	150 (100)
Prohibition to go to religious place/read religious book/offer prayers to keep fast
Yes	111 (74.0)
No	39 (26.0)
Not taking both regularly
Yes	83 (55.33)
No	67 (44.67)
Not to look in the mirror
Yes	96 (64.0)
No	54 (36.0)
Avoid going to some other’s home
Yes	99 (66.0)
No	51 (34.0)
Stay away from flowing water (river, channel etc.)
Yes	77 (51.33)
No	73 (48.67)
Is plantation being done during menstruation
Yes	71 (47.33)
No	79 (52.67)
Is fruit preservation activities done (pickles, sauce etc.)
Yes	68 (45.33)
No	82 (54.67)

DISCUSSION

The results of the study showed that there is a low level of knowledge about menstruation and its related issues among Munda adolescent girls. The age of menarche in most of the subjects under study show 14 years. In agreement with our study, some earlier studies also reported that the mean age of menarche was 13–14 years in various communities (urban, rural, and tribal) across various parts of the country.[91516]

Although India has a long history of child marriages, this phenomenon is not common in all sections of the society and particularly among the tribal populations. A marriage for the biologically premature girls among the tribes is uncommon for the simple reason that marriage should allow for sexual gratification of the couple. Therefore, attainment of puberty is an important phase in the life of a girl and her role in the progeny. Generally, it is observed that not much gap is given between marriages within 2–6 years after menarche. Hence, attainment of menarche at 14 years may lead to early marriage. However, in the Munda tribe, the marriage and menarche are not close to each other. Late marriage after the age of 35 years is common in this tribe.

It was observed that study subjects lacked conceptual clarity about menstruation. Similar results were found in many other studies.[17] In Hong Kong, a study revealed that problems related to menstruation become more as our age advances, but a small percentage of people suffering from these problems actually took any medical help.[18] Research from New Zealand suggests that a lot of teenage girls suffered from pain during their menses which also disrupted their daily activities.[19] A research done in Taiwan included teenage girls aged 10–12 years. It revealed that the study subjects suffered from both physical and psychological problems during their menses.[20] A study showed that girls are mostly directed negatively about the cultural beliefs about menstruation and how they are supposed to act in accordance to these beliefs.[21]

The most common source of information issues was friends 53.33% relatively and very few mothers in this group appeared to have an open communication with their daughters about menstruation and its related issues. Majority of girls reported stomach ache during this period. The health problems and complaints are the result of inaccurate and incomplete information provided to the girls through limited sources. Many studies have revealed that mothers, teachers, friends, relatives, television, and books are the main source of providing information about menstruation to the adolescent girls.[2223] At times, even the mother does not have adequate information about the details regarding menstruation, leading to reluctance in discussing the problems faced by their daughters.[24] Studies from other countries such as Egypt[25] and Pakistan[26] also reported that there was no proper source of information regarding menstruation being passed to adolescent girls. Teachers were given as a source of information on menstruation only in the Nepal Study, and this was by 150 respondents.[8] The girls in this study also practice rituals. The concept of (cultural) pollution and cautions about behavior toward men and boys very little information was shared regarding the physiological process involved. Data about their level of knowledge and practices followed by them regarding menstruation are beneficial for planning programs for improving awareness level regarding life processes and promoting their quality of life.

Menstrual hygiene is a taboo subject; a topic that many women in south Asia are uncomfortable discussing. There are so many cultural and beliefs followed by adolescent girls. The various factors affecting practices related to menstruation include education, family environment, culture, and belief according to a study done in Ranchi.[27] Religion was found to play a major role affecting the practices related to menstruation.[28] In agreement with previous studies,[4] the present research has also documented similar results about several restrictions related to menstruation. Research done in Nepal showed that the inability of the rural adolescent girls were to follow proper hygienic practices related to menstruation.[29] A study showed that some girls have a belief that they cannot use the same cloth as “it is a kind of disease” and different kinds of germs are being expelled out.[30] The level of personal hygiene practiced by sample subjects was unsatisfactory. A study done by WaterAid Nepal and WaterAID West Bengal[31] supported this study; they also found that, in Bangladesh, India, and Nepal, majority of women in rural areas use reusable clothes to abort menstrual Blood. In Bangladesh, these are usually torn from old saris and known as “Nekra.” Reuse of used cloth for the absorption of menstrual blood was found in the overall subject in the study. Similar observations were found in other studies.[1112] In a study done in rural Gujarat which studied menstrual hygiene practices among adolescent tribal girls, it was found that the girls would have to take bath and wash their used clothes early in the morning before their family could wake up.[32] It has been recommended that the sanitary napkins should not be worn for more than 4 h, especially when the blood flow is heavy during the first few days. Leakage leads to unpleasant odor, therefore changing pads and maintaining hygiene during these days is especially important.[33] Moreover, it is necessary to maintain proper hygiene in the genital area. Research has shown that not washing the perineal region regularly during menses may lead to higher risk of cervical cancer.[34]

CONCLUSIONS

Majority of teenagers do not have adequate information about menstruation. The parents are apparently not very keen to talk about these issues. It is important to educate adolescents about issues related to menstruation so that they can safeguard themselves against various infections and diseases. This could further help them to lead a healthy life. The data of the study can be used for planning programs, making new policies for improving the level of information especially, for tribal adolescent girls.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.