Time of the month

Background: Menstruation is a naturally occurring monthly phenomena which affects adolescent girls and women worldwide. The last decade has highlighted how menstrual hygiene management (MHM) is a public health issue because of its link to health, social justice and human rights. Menstruation is considered a taboo topic, related to uncleanliness and impurity around the world. Menstruation related restrictions have shown to increase poor hygiene behaviors, nutritional deficiencies, gender inequality, marginalization and isolation. A Social and Behavioral Change Communication (SBCC) intervention called GARIMA was implemented in three districts of Uttar Pradesh, India to improve adequate menstrual behaviors. Therefore, the overarching question of this dissertation asked: Is SBCC an effective approach to improve adequate menstrual behaviors among adolescent girls in rural North India? To answer the overarching question, three research questions were asked: 1) what are the psychometric properties of a menstrual hygiene management scale? 2) What is the relationship between menstrual related restrictions and menstrual health and hygiene management (MHHM)? 3) How does a social and behavioral change communication intervention predict MHHM? Methods: A mixed method approach was used to analyze the overarching question. Interviewer-administered structured questionnaires were completed on tablets to understand MHHM among 2212 adolescent girls in three districts of Uttar Pradesh, India. A total of 36 Focus Group Discussions were conducted with 309 adolescent girls in the three districts. Villages and adolescent girls were matched on socio-demographic and socio-economic characteristics in the intervention and comparison sites. Results: MHHM is a multi-dimensional construct comprising of behaviors which are time bound to menstruation (menstrual health) and behaviors which not time bound to menstruation (hygiene management). Drawing from existing conceptual definitions and their operationalization in this research the author defines MHHM as "Access and use of private toilet/bathroom with soap and water to wash hands and have a bath during menstruation and use of clean menstrual management material to absorb or collect blood that is stored in a safe, clean place and changed at least three times a day for the duration of the menstruation period, and accessing facilities to ultimately dispose of used menstrual management materials". Overall, 27.58% of the adolescent girls practiced all adequate MHHM behaviors. Ninety six percent of adolescent girls stated they faced restrictions during menstruation. In general, not having restrictions had a positive relationship with adequate MHHM behaviors. The results from the evaluation showed that higher encoded exposure (dose and recall of the program) had a direct relationship with adequate MHHM. The evaluation also showed that indirectly, higher encoded exposure predicted higher knowledge about puberty, higher knowledge about reproductive parts, positive attitudes towards gender, better interpersonal communication, and thereafter, adequate MHHM. Conclusions: MHHM is a public health issue which cross-cuts through several sustainable development goals. Findings demonstrated that MHM is a multi-dimensional construct with four independent indicators corresponding to menstrual health (preparation of clean absorbent, storage of clean absorbent, frequency of changing and disposal) and one indicator corresponding to hygiene management. Therefore, the author recommends future research should use the acronym, MHHM. Restrictions were ubiquitous and mostly had a negative relationship with adequate preparation of clean absorbent, adequate storage of clean absorbent, adequate frequency of changing and disposal. A SBCC program directly improved MHHM and indirectly improved knowledge, some attitudes, interpersonal communication and therefore, adequate MHHM. These findings can be used in developing future programs and strengthening future research on MHHM.