International Journal of Public Health Science (IJPHS)

Vol. 11, No. 4, December 2022, pp. 1341~1349

ISSN: 2252-8806, DOI: 10.11591/ijphs.v11i4.21938  1341

Menstrual hygiene practices among adolescent schoolgirls in the

rural area of Bangladesh

Mst. Rokshana Rabeya1, Md Nazrul Islam1,2,3, Umme Hafsa1, Nadiatul Ami Nisa1,3, Gopal Kumar
Ghosh1, Afsana Yesmin1, Khairun Nahar Juthi1, Tamima Rahman1
1
Department of Public Health Nutrition, Primeasia University, Dhaka, Bangladesh
2
Department of Community Health & Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
3
Department of Public Health, North South University, Dhaka, Bangladesh

Article Info ABSTRACT

Article history: Adolescence is a time of tremendous opportunity. However, inadequate
menstrual hygiene habits are related to lower academic achievement and
Received Apr 2, 2022 enrollment at school, with possible effects on longer-term socio-economic
Revised Aug 17, 2022 status and impaired overall quality of life. Therefore, this cross-sectional
Accepted Sep 7, 2022 study was conducted among 422 adolescent schoolgirls in Bangladesh
between July 2019 and February 2020 with the aim of examining menstrual
hygiene practices. Data indicated that the mean age of menarche in 422
Keywords: adolescents was 12.71±0.97. According to the data, 47% had well and 53%
had poor hygiene practices. In multivariable logistic regression analysis, the
Adolescent educational status of respondents’ mothers at the secondary level
Menstrual hygiene [AOR=2.023, 95% CI: 1.159-3.532], fathers at the graduate and above level
Rural Bangladesh [AOR=3.150, 95% CI: 0.883-11.238], high level of household income
Schoolgirls [AOR=2.580, 95% CI: 1.480-4.495], and knowledge about the complication
of poor hygiene practice among girls [AOR=2.286, 95% CI: 1.160-4.504]
were significantly associated with the level of hygiene practices. Poor
menstrual hygiene practice was found among more than half of girls.
Attitude toward safe menstrual materials should initiate to improve good
hygiene practices. Awareness campaigns for parents and teachers to assist
their children would be a vital strategy to ensure good hygiene practices.
This is an open access article under the CC BY-SA license.

Corresponding Author:
Mst. Rokshana Rabeya
Department of Public Health Nutrition, Primeasia University
Star Tower, 12 Kemal Ataturk Ave, Dhaka 1213, Bangladesh
Email: [email protected]

1. INTRODUCTION
Adolescence is known to be between the ages of 10 and 19, and about 1.2 billion teenagers exist
around the globe, which is equivalent to 16% of the world’s population [1]. Bangladesh is one of the recently
listed developing nations with a population of over 164.7 million [2]. Among them, more than 34 million
youngsters make up one-fifth of the country's total population [2]. Menstruation is a natural and
physiological phenomenon undergone by both teenage girls and women [3]. It is important that women and
girls should be able to hygienically handle menstrual bleeding in order to live healthy, prosperous, and
dignified lives. However, in developing countries, menstrual hygiene treatment is inadequately understood
and has not gained sufficient attention in the reproductive health field [4]. In Bangladesh, a significant
portion of adolescent girls uses rags during menstruation to absorb the flow of menstrual blood. Even their
disposal and recycling methods of menstrual materials are also poor and unhygienic [5].

Journal homepage: http://ijphs.iaescore.com

1342  ISSN: 2252-8806

Although menstruation is a common occurrence with a matter of privilege for women, people in
underdeveloped and developing countries such as Bangladesh, and India, carry misunderstandings regarding
it. Most of them even make fun of it or misinterpret it due to an inadequate sense of humor and knowledge.
This misinterpretation is found on a large scale in rural areas and people, mostly uneducated, take this as a
sign of stigmatization, which directly lowers the confidence of those girls who are already having a
biological change and do not even know whom to discuss with and how to handle it that multiplies the
problem to a great extent [6], [7]. In some remote places, it is believed that during menstruation a girl is not
allowed to sit or eat together. Even they are treated like someone who is not holy enough to be in the house
[8]. Many young girls look to their mothers or other close ones to learn about menstruation; when it comes
down to sexuality, fertility, and menstruation, these female close ones guide them with misleading
information and put them in a more unsecured phase [9]-[11]. Research in Kenya has found that menstruation
is the leading cause of teenage morbidity [12]. The detrimental impact on women's health and their re-
productivity may be the result of not following proper grooming habits during menstruation. Even in some
cases, it may be life-threatening [13]. It has become a hidden disease that devastates women's lives and is
closely connected to inadequate menstrual hygiene [14].
In addition, inadequate menstrual hygiene habits are related to lower academic achievement and
enrollment at school, with possible effects on long-term socio-economic status and hamper the overall quality
of life [15], [16]. According to the literature, about 19.7% of school-age girls in Uganda do not attend school
during menstruation [17]. A similar study also reported, that due to the shortage of safe and private sanitation
facilities, stomach, or back pain, feeling unwell, and fear of leaking blood are the significant reasons for
school absenteeism [18]. Moreover, some girls are forced to use unhygienic materials due to a shortage of
appropriate sanitary hygiene products [18].
Adolescence is a time of tremendous opportunity. At the same time, it is also a time of getting on
vulnerabilities. It is necessary to be aware that adolescent girls have adequate information and skills on crucial
issues like menstrual hygiene and management. Significant urbanization is proceeding in developing countries
such as Bangladesh, but many people live in rural settings. In this context, this study has attempted to identify
factors affecting menstrual hygiene practices among adolescents during puberty in rural areas of Bangladesh.

2. RESEARCH METHOD
2.1. Study design and setting
A cross-sectional study was conducted among adolescent girls in secondary schools aged between 12
and 16 years who experienced a menstrual cycle. The sample was obtained from five different schools in the
Kusiara and Bandar Ghat areas under the Narayanganj district of Bangladesh. The study was conducted
between July 2019 and February 2020.
The study protocol was approved by the school of science research ethics committee of Primeasia
University. A permission letter from the selected school head was then received. Each of the respondents was
told about the study's intent, and written consent was taken from respondents’ parents/teachers/guardians. The
data collection team was aware of the respondents' privacy.

2.2. Sample size and technique

The sample size was determined using the appropriate equation (n= Z2α pq/d2). Therefore, the
calculated sample was 384. An additional 10% had been added to the sample size to minimize the uncertainties
caused by losses due to uncontrollable factors. The sample size was then turned into 422 [19]. Initially, five
different schools were selected purposively from the targeted area. A simple random sampling technique was
considered among the adolescents present in the classroom by following the register. The adolescent girls who
experienced a menstrual period and agreed to the interview were selected as respondents. A well-designed
structured questionnaire was used to obtain data from participants. Trained female university students
performed all the face-to-face interviews.

2.3. Operational definition

Based on the income per month, the families were categorized into three income groups, lower group
income were Bangladeshi taka (BDT) 10,000 or less, middle (BDT 10,000-29,000), and higher-income group
(≥30,000 BDT). Family size was determined based on total family members. Consisting of a maximum of three
members was considered a small family whereas it was 4-7 members for a medium-sized one. More than that
came under a large one. To measure the menstrual hygiene practice and knowledge, there were eight questions
with proper answers that carried 1 point, and 0 for negative or do not know. The competitors with 5-9 points
were judged to have a good practice, and 0-4 points to have a poor practice as defined in similar previous
studies [20].

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2.4. Data management and analysis plan

The data for this study were analyzed by using Statistical Package Social Science (IBM SPSS)
software, version 23. Descriptive analyses were executed for each variable to measure frequency, percentage,
and mean value. Bivariate analysis was performed to see the crude association of the predictor variables with
the outcome variable. Finally, variables that showed significant association with the dependent variable on the
bivariate analysis were entered into a multivariate logistic regression model in order to identify their
independent effects on the menstrual hygiene practices of adolescent schoolgirls. The strength of the association
was also measured by the odds ratio with a corresponding 95% confidence interval. A p-value less than 0.05
was considered a significant association.

3. RESULTS AND DISCUSSION

A total of 422 adolescent girls aged between 12 to 16 years experiencing menstruation were
interviewed in this study. Table 1 displays that approximately 98.6% of the girls were Muslim in religion.
There were 36.7% of respondents were in class nine, which marks the highest class among study participants.
The majority of the respondents (79.6%) came from a nuclear family, and 83.4% were from medium-sized
families. Parents ' education showed that most fathers and mothers (36.5% vs. 27.7%) did not have formal
education. Nevertheless, higher education was found in greater numbers among fathers’ relatives to teenage
mothers. In terms of occupation, 36% of fathers were engaged in business, and the remaining were occupied
in various occupations. The current study also found that 83.5% of mothers were housewives. 33.9% were
found to have a family income below 10,000 BDT per month. On the other hand, the income of about 19.9%
was found at more than 29,000 BDT per month, and 61.4% of the households had a single earner.
Table 2 indicates approximately more than half (54.5%) of the participants did not have sufficient
menstrual information. Approximately 32.2% of adolescents were aware that menstruation is a physiological
process. However, according to a study conducted in Ethiopia, more than two-thirds of adolescents are aware
that menstruation is a physiological process [21]. Nearly 81.7% of respondents received information
regarding menstruation and its management from their mothers', while the remaining respondents received
information from other sources. The study participants reported that they had experienced menstruation by
the age of 10 (2.6%). Although, 38.9% experienced their first menstrual cycle at 13 years. The menarche age
of adolescents is found shorter in this study than the outcomes of other research performed in another country
[17]. More than half (57.8%) of the respondents’ menstrual duration was between 3-5 days in this study,
which is somewhat similar to an Indian survey [13], [22]. About 77.5% of the respondents had a menstrual
cycle interval between 24-35 days. However, the previous research shows a shorter interval of menstrual
cycle than current study [22]. During menstruation, 77.7% thought their blood flow was normal, and 72.7%
of participants reported painful menstruation that is very distinct from previous similar study [23]. There
were 79.9% of participants were not used to taking any drug during menstruation. Absenteeism of school due
to menstruation was found among 23.7% of girls. Although, more prevalent absenteeism of school during
menstrual period (Approximately one in ten) found in former research [23]. Others research reported school
absenteeism is 40% due to menstruation [24], [25].
Table 3 indicates that only 33.1 % of 422 respondents used commercially manufactured sanitary
pads as a menstrual absorbent, though Indian surveys showed the attitude toward using sanitary pads is
higher among Indian adolescents [26]-[28]. There were 76.3% of girls changed menstrual absorbent more
than two times a day, which is much higher than the Nigerian study [29]. The current study also found that
88.6% of participants cleaned their genitalia twice or more per day. The percentage is higher than the
previous study conducted in India by Rana (40%) [13]. Another survey identified around half of the
participants only cleaned external genitalia separately while taking a bath during menstruation [30]. Nearly
64.2% of respondents used the school toilet during menstruation, and 89.6 % of girls had reproductive tract
disease. Among teenagers, 32.7% retained the correct form of disposal, 7.3% tossed into the open field, and
60.0% reused cloth. 94.1% of cloth re-users cleaned clothes with soap and water, and 5.9% of the
respondent’s washed cloths with only water. In addition, due to lack of privacy, 66.8% of the girls did not dry
rags under the sunlight. Whereas, a Nepalese study found that nearly half of the adolescent girls do not dry
reusable clothes under the direct sunlight [31].

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Table 1. Socio-demographic characteristics of respondents (n=422)

Variables Categories Frequency Percentage
Age 12 14 3.3%
13 53 12.6%
14 127 30.1%
15 151 35.8%
16 77 18.2%
Religion Muslim 416 98.6%
Hindu 6 1.4%
Level of education Seven 59 14%
Eight 138 32.7%
Nine 155 36.7%
Ten 70 16.6%
Family size Small 27 6.4%
Medium 352 83.4%
Large 43 10.2%
Family type Nuclear 336 79.6%
Joint 86 20.4%
Fathers’ education No formal education 154 36.5%
Primary level 93 22%
Junior school level 72 17.1%
Secondary level 68 16.1%
Higher secondary level 24 5.7%
Graduate and above 11 2.6%
Mothers’ education No formal education 117 27.7%
Primary level 116 27.5%
Junior school level 81 19.2%
Secondary level 91 21.6%
Higher secondary level 12 2.8%
Graduate and above 5 1.2%
Fathers’ occupation Jobless 13 3.1%
Farmer 11 2.6%
Daily labor 89 21.1%
Business 152 36.0%
Service holder 112 26.5%
Others 45 10.7%
Mothers’ occupation Housewife 352 83.5%
Service holder 39 9.2%
Business 14 3.3%
Others 17 4.0%
Monthly income Low income 143 33.9%
Middle income 195 46.2%
High income 84 19.9%
Earning members One person 259 61.4%
Two persons 124 29.4%
More than two 39 9.2%

Dietary habit (iron and vitamin-containing food) is essential during menstruation when unnecessary
blood losses are already happening. This study found that 64.5% of the girls did not consume iron and
vitamin-rich food during menstruation as shown in Table 4. However, the percentages are lower than in the
Indian study [32]. About two-thirds of adolescents were not permitted to go to certain places, and more than
half were restricted to religious activities. Moreover, 61.8% could not participate in outdoor games.
Furthermore, 35.5% of the girls used separate utensils during menstruation in this study. The possible reasons
for these findings would be social stigma and taboos related to menstruation [33], [34].
Menstrual hygiene practices among adolescent girls were classified as good and poor practices as
presented in Table 5. According to the overall respondents' data, 47% had well, and 53% had poor hygiene
practices. Adolescent girls whose maternal education status was secondary level were 2.023 times more
likely to have healthy menstrual hygiene than mothers who did not attend formal education [AOR=2.023,
95% CI: 1.159-3.532]. Likewise, girls whose father’s educational achievement graduated or above were
3.150 times more likely to have good menstrual hygiene practices than their counterparts [AOR=3.150, 95%
CI: 0.883-11.238]. The potential cause may be the awareness of the educated parents’ menstrual hygiene

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habits. Previous research also revealed similar findings [35]-[37]. Girls whose households were at a high-
income level are 2,580 times more likely to have healthy hygiene behaviors than their peers [AOR=2.580,
95% CI: 1.480-4.495]. The likelihood of having well menstrual hygiene practice among respondents who had
an idea or knowledge about infection compared to those who did not know about infection [AOR=2.286,
95% CI: 1.160 -4.504].

Table 2. Experiences of menstruation among study participants (n=422)

Variables Categories Frequency Percentage
Knowledge about the reason for menstruation Physiological process 136 32.2%
Hormonal change 56 13.3%
Not known 230 54.5%
Information sources Mother 345 81.7%
Sister 38 9.0%
Friend 14 3.3%
Teacher 18 4.3%
Mass media 7 1.70%
Onset of menarche 10 years 11 2.6%
11 years 31 7.3%
12 years 122 28.9%
13 years 164 38.9%
14 years 94 22.3%
Average duration of menstruation 3-5 days 244 57.8%
More than five days 178 42.2%
Flow of bleeding More 76 18.0%
Usual 328 77.7%
Less 18 4.3%
Interval between menstrual cycle <24 days 56 13.3%
24-35 days 327 77.5%
>35 days 39 9.2%
Sufferings of abdominal pain Yes 307 72.7%
No 115 27.3%
Taking medications Yes 85 20.1%
No 337 79.9%
Attend school during menstruation Yes 322 76.3%
No 100 23.7%

Table 3. Menstrual hygiene practice among the study subjects (n=422)

Variables Categories Frequency Percentage
Protection materials Sanitary pad 140 33.1%
Cloth 156 37.0%
Sanitary pad or cloth 126 29.9%
Frequency of changing pad Single time/day 100 23.7%
≥ 2 time/day 322 76.3%
Cleaning of genitalia Single time/day 48 11.4%
≥2 time/day 374 88.6%
Use school toilet during menstruation Yes 271 64.2%
No 151 35.8%
Knowledge about infectious disease Yes 378 89.6%
No 44 10.4%
Method of disposal Open field 31 7.3%
Others proper disposal 138 32.7%
Cloth reused 253 60.0%
Cloth cleaning materials Only water 15 5.9%
(n=253) Soap with water 238 94.1%
Drying method Not drying sunlight 169 66.8%
(n=253) Drying sunlight 84 33.2%

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Table 4. Several common restrictions related to menstruation (n=422)

Taboos Categories Frequency Percentage
Keeps separately from other family members Yes 90 21.3%
No 322 78.7%
Touches of religious book Yes 16 3.8%
No 406 96.2%
Uses of separate utensils Yes 150 35.5%
No 272 64.5%
Plays outdoor games Yes 161 38.2%
No 261 61.8%
Food restriction Yes 272 64.5%
No 150 35.5%

Table 5. Factors associated with good menstrual hygiene practices among adolescent girls (n=422)
Menstrual hygiene
Factors Categories AOR 95% CI p-value
Good (47%) Poor (53%)
Educational status of mother’s Illiterate 44 73 1
Primary level 53 63 1.396 [ 0.827-2.354] 0.211
Junior school level 40 41 1.619 [ 0.912-2.874] 0.100
Secondary level 51 40 2.023 [ 1.159-3.532] 0.013
Higher secondary level 8 4 3.318 [ 0.944-11.665] 0.061
Graduate & above 4 1 2.489 [ 0.4-15.481] 0.328
Educational status of Father’s Illiterate 55 99 1
Primary level 54 39 2.385 [1.409-4.038] 0.001
Junior school level 38 34 1.611 [ 0.913-2.842] 0.100
Secondary level 37 31 2.148 [ 1.203-3.837] 0.010
Higher secondary level 12 12 1.800 [ 0.758-4.277] 0.183
Graduate & above 6 5 3.150 [ 0.883-11.238] 0.077
Monthly Income Low income 57 86 1
Middle income 88 107 1.241 [ 0.801-1.922] 0.334
Higher income 53 31 2.580 [ 1.480-4.495] 0.001
Idea about reproductive tract Yes 185 193 2.286 [ 1.160-4.504] 0.017
infection No 13 31 1
Use of school toilet Yes 134 137 1.330 [ 0.890-1.986] 0.164
No 64 87 1
Key = statistically significant value is p-value <0.05; 1= reference category

4. CONCLUSION
Menstrual hygiene practices were associated with parents’ education, income, and knowledge of
study participants. The current research suggests that safe menstrual material should be available, accessible
and ensure utilization for the girls, especially in rural settings, to improve good hygiene practices. The results
recommend that the required awareness campaign for parents and teachers to assist their children should be
coordinated by government and non-government organizations. Furthermore, we propose further research on
obstacles to healthy menstrual habits, like menstrual taboos based on geographical area.
Like every research, our research has some limitations. This cross-sectional study is limited by the
fact that it provides only a snapshot in time and does not provide information on cause-and-effect correlations
between study variables. Furthermore, because the sample was collected from a specific location in
Bangladesh, it is not appropriate to extrapolate the results to the entire population.

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BIOGRAPHIES OF AUTHORS

Mst. Rokshana Rabeya is an an Assistant Professor in the Dept. of Public Health

Nutrition at Primeasia University. Basically, I am a Biochemist and have research experience
as a research fellow in the study of mammalian DNA repair mechanisms related to Cancer and
Aging in the Dept. of Molecular Genetics at the Institute of Development, Aging and Cancer
(IDAC) affiliated with Tohoku University Graduate School of Medicine, Japan. I am very
much interested in Public Health and Nutrition field-related research work. She can be
contacted at email: [email protected]

Md Nazrul Islam is a nutritionist/epidemiologist working on a school food

program to improve access to nutritious foods at school, build food skills, change food
behavior, and connect students to their local food systems. He is interested in working on
public health nutrition, maternal and child health, mental health, and other emerging public
health issues. He can be contacted at email: [email protected].

Umme Hafsa is a Lecturer/Nutritionist who has been completed a post-graduation

in Applied Nutrition and Food Technology. She has a keen interest in research and education
in the field of Nutrition and Food Science, Public Health, Obesity & Fitness, and Food Product
Development. She is currently working as a lecturer in the department of Public Health
Nutrition at a well-known private university in Bangladesh. Alongside, she has a working
experience of four years as a nutritionist in a multinational wellness organization. Now she is
engaged in developing a ready to drink food product for adolescent girls in reducing mineral
deficiency. She can be contacted at email [email protected].

Nadiatul Ami Nisa is a Public Health Nutritionist and Public Health specialist
working as a research intern in Binary Data lab organization which is committed to conducting
research in statistics, health and biology, industry, education, and social sciences; training
people in statistics, and collaborating with industries to handle data problems. She is very
interested in public health and human nutrition field-related research work. She can be
contacted at email: [email protected].

Int J Public Health Sci, Vol. 11, No. 4, December 2022: 1341-1349
Int J Public Health Sci ISSN: 2252-8806  1349

Gopal Kumar Ghosh is a registered Medical Assistant and Public Health

Nutrition worker, focusing on public health nutrition research areas. He is enthusiastic about
working on the sustainability of the intervention program to improve people’s nutritional
status. He can be contacted at email: [email protected].

Afsana Yesmin holds BSc. degree in Public Health Nutrition. Her study focusing
a research topic on nutritional status, dietary diversity, and food security of adolescent girls in
rural Bangladesh. She is interested in exploring and understanding the factors of food
insecurity that can directly or indirectly affect our health through nutritional status. She can be
contacted at email: [email protected].

Khairun Nahar Juthi is a Public Health/Nutrition Expert have working

experience with adolescent girls in rural areas of Bangladesh. Her study focuses on Nutritional
status, dietary diversity, environmental hazards, and food security of Bangladesh. I’m
interested in researching public health problems and issues that affect health and lifestyle. She
can be contacted at email: [email protected].

Tamima Rahman completed her bachelor’s in public health nutrition from

"Primeasia University,” Bangladesh, and has completed a course on "Nutrition and Dietetics"
in India. She is currently, pursuing a master’s degree in food and Nutrition from "Bangladesh
Home Economics College,” Bangladesh. I am a nutritionist whose mission is to make healthy
living easier and even create awareness of the most common misconceptions about nutrition
among people in our country and around the world. She can be contacted at email:
[email protected].

Menstrual hygiene practices among the adolescent schoolgirls … (Rokshana Rabeya)