CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

This chapter discusses the concept of knowledge, concept of practice, concept of adolescents and

menstrual hygiene, empirical review on knowledge of menstrual hygiene, practices of menstrual

hygiene and factors influencing menstrual hygiene practices and theoretical framework

2.1 Concept of Knowledge

Knowledge is an abstract concept without any reference to the tangible world. It is a very

powerful concept, yet it has no clear definition so far. From the Greek philosophers up to present

experts in knowledge management, people tried to define knowledge but the results are still very

unclear. According to Bolisani & Bratianu, (2018) Definition of knowledge incorporates three

basic conditions, fact for which some authors call it the tripartite account of knowledge. These

conditions are:

The Truth Condition: It requires that if one knows a proposition then that proposition must be

true. If the proposition is not true, then that person does not know what he claims to know. The

truth condition makes the difference between opinion and knowledge.

The Belief Condition: This condition demands that if one knows a proposition then he believes

that proposition.

The Justification Condition: This condition requires a practical way of justifying that the belief

one has is true.

Putting together these conditions for knowing, one may conclude that “the necessary and

sufficient conditions for knowing something is this case are; first that what one is said to know to

be true, secondly that one be sure of it, and thirdly that one should have the right to be sure”.

2.1.1 Forms of Knowledge:

Bolisani & Bratianu, (2018) explained knowledge in three kinds although they are

interconnected, but have some specific features of their own. The three forms of knowledge

include:

Experiential Knowledge: Is what we get from the direct connection with the environment,

through our sensory system, and then it is processed by the brain. For instance, if we want to

know what snow is then we must go where there is snow and touch it, smell it, taste it and play

with it. We cannot get that knowledge only from books or seeing some movies with people

enjoying winter sports in beautiful mountain areas. People living in geographical zones where

there is never snow have real difficulties knowing what snow is. They lack the experiential

knowledge about snow. Experiential knowledge is personal since it can be acquired only through

direct interface of our sensory system and then processed by our brain. It is essentially based on

perception and reflection. Several people having together the same experience may acquire

different experiential knowledge since reflecting upon a living experience means actually

integrating it in some previous similar experiences and knowledge structures, if they do exist.

“Things are not always as they appear to be and our own perspectives influence our

interpretations. Still, watching out for errors in thinking can improve tremendously the quality of

our re-flection on our experiences”.

Skills: means knowledge about how to do something (know-how). It is based on experiential

knowledge but it is a well-structured and action oriented knowledge we get by performing

repeatedly a certain task and learning by doing it. This is the way of learning swimming, biking,

skiing, playing piano or doing many other similar activities. It is like learning unconsciously to

perform a certain procedure or to follow a given algorithm. We don’t learn swimming by reading

in a book about fluid mechanics and objects floating. We have to learn by doing it with the

whole body and reflecting upon it to improve coordination between breathing and moving our

arms. Know-how knowledge is often called procedural knowledge since it is about performing a

task in concordance with a given procedure. We discussed about some skills associated to

physical activities but they can be developed for any kind of task or activities, including thinking

processes. For instance, thinking skills are extremely important for knowledge workers and

decision makers. One of the most important skills in designing strategies is intuition.

Knowledge Claims: is what we know, or we think we know. We don’t know how much we

know since knowledge means both clear knowledge and understood knowledge, which means

experience existing in our unconscious zone and manifesting especially as intuition. Explicit

knowledge is something we learn in schools and reading books, or just listening to some

professors or conference speakers. Knowledge claim is what we frame in an explicit way by

using a natural or symbolic language. Thus, language is an essential component of the

transforming our emotional and spiritual experience into rational or explicit knowledge. With

explicit knowledge we are entering the zone of exchange between personal and shared

knowledge. Because ideas are stated in language, they can be examined and discussed,

questioned, evaluated, refuted, or published and passed on. Knowledge claims enable us to learn

from each other and built our shared knowledge.

2.2 Concept of Practice

According to Merriam Webster, (2018) practice is the act of performing regular activities as part

of life. This is the regular way of doing something with the use of an idea, belief or method

individual has.

Social practice

A practice is what these claims processors have developed in order to be able to do their job and

have a satisfying experience at work. It is in this sense that they constitute a community of

practice. The concept of practice connotes doing, but not just doing in and of itself. It is doing in

a historical and social context that gives structure and meaning to what we do.

In this sense, practice is always social practice. Such a concept of practice includes both the

explicit and the tacit. It includes what is said and what is left unsaid; what is represented and

what is assumed. It includes the language, tools, documents, images, symbols, well-defined

roles, specified criteria, codified procedures, regulations, and contracts that various practices

make explicit for a variety of purposes. But it also includes all the implicit relations, tacit

conventions, subtle cues, untold rules of thumb, recognizable intuitions, specific perceptions, and

well-tuned sensitivities, embodied understandings, underlying assumptions, and shared world

views. Most of these may never be articulated, yet they are unmistakable signs of membership in

communities of practice and are crucial to the success of their enterprises.

2.3 Concept of Adolescence

According to WHO, (2019) Adolescence is a transitional phase of growth and development

between childhood and adulthood. And is defines as person between ages of 10 and 19.

According to American Academics of pediatrics, AAP, (2019) Adolescence is divided into 3 age

groups – early (ages 11-14), middle (ages 15-17) and late (ages 18-21)

2.3.1 Characteristics of Adolescents

According to Stanford Children Health, (2019) Sexual and other physical maturation that occurs

during puberty is a result of hormonal changes.

In boys, it is difficult to know exactly when puberty is coming. There are changes that occur, but

they occur gradually and over a period of time, rather than as a single event. While each male

adolescent is different, the following are average ages when puberty changes may occur:

 Beginning of puberty at 10 to 14 years old.

 First pubertal change: enlargement of the testicles.

 Penis enlargement: begins approximately 1 year after the testicles begin enlarging.

 Appearance of pubic hair at 13.5 years old.

  Nocturnal emissions (or "wet dreams") at 14 years old.

 Hair under the arms and on the face, voice change, and acne at 15 years old.

Girls also experience puberty as a sequence of events, but their pubertal changes usually begin

before boys of the same age. Each girl is different and may progress through these changes

differently. The following are average ages when puberty changes may occur:

 Beginning of puberty at 8 to 13 years.

 First pubertal change: breast development.

 Pubic hair development: shortly after breast development.

 Hair under the arms at 12 years old.

 Menstrual periods at 10 to 16.5 years old.

According to Stanford Children Health, (2019) There are specific stages of development that

both boys and girls go through when developing secondary sexual characteristics (the physical

characteristics of males and females that are not involved in reproduction such as voice changes,

body shape, pubic hair distribution, and facial hair). The following is a brief overview of the

changes that occur:

 In boys, the initial puberty change is the enlargement of the scrotum and testes. At this

point, the penis does not enlarge. Then, as the testes and scrotum continue to enlarge, the

penis gets longer. Next, the penis will continue to grow in both size and length.

 In girls, the initial puberty change is the development of breast buds, in which the breast

and nipple elevate. The areola (dark area of skin that surrounds the nipple of the breast)

increases in size at this time. The breasts then continue to enlarge. Eventually, the nipples
 and the areolas will elevate again, forming another projection on the breasts. At the adult

state, only the nipple remains elevated above the rest of the breast tissue.

 Pubic hair development is similar for both girls and boys. The initial growth of hair

produces long, soft hair that is only in a small area around the genitals. This hair then

becomes darker and coarser as it continues to spread. The pubic hair eventually looks like

adult hair, but in a smaller area. It may spread to the thighs and, sometimes, up the

stomach. (Stanford Children Health, 2019)

2.4 Concept of Menstrual Hygiene

2.4.1 Menstruation and menstrual cycle

Menstruation is an important biological process that occurs when blood and tissue from the

uterus comes out of the vagina. It happens every month. Menstrual cycle is the period at which

the uterus undergoes changes under the influence of hormones such as follicle stimulating

hormone, luteinizing hormones estrogen and progesterone. The length of menstrual cycles varies

from 21- 35 days with average of 28 days. Some women are regular while other women may find

their cycles frequently change. There are medical condition such as polycystic ovarian syndrome

and thyroid conditions which can cause fluctuation in cycle lengths. (Gray, 2019)

According to Thiyagarajan, Basit & Jeanmonod, (2019) Phases involve in menstrual cycle

includes the following:

PHASE 1: This is the follicular or proliferative phase. It occurs from day 0 to day 14 of

menstrual cycle, based on the average of 28 days cycle. The main hormone during this phase is

estrogen. There is release of follicle stimulating hormone which act on the primordial follicles
for their maturation to graafian follicle whereby the developing ova response by releasing

estrogen. The increase of estrogen occurs by regulation of follicle stimulating hormone receptors

within the follicle at the beginning of this phase. The estrogen function in the growth of the

endometrial lining of the uterus to create environmental that is helpful for fertilized ovum. The

surrounding follicles begins to degenerate which is when the graafian follicle becomes mature

follicle and is set up for ovulation. Ovulation is the release of matured ovum, it occurs at 14th

day of menstrual cycle.

PHASE 2: This is luteal or secretive phase. This occurs from 14- 28 days of the cycle. There is

release of luteinizing hormone that act on the corpus luteum. After ovulation there is corpus

luteum formed in the ovary at the site of mature follicle rupture to produce progesterone, which

is predominate at the end of the phase due to negative feedback system. The endometrial

prepares by increasing its vascular supply and stimulating more mucous secretions. Contrary to

the cervical mucous changes seen during the proliferative phase and ovulation, progesterone

decreases and thicken the cervical mucous making it non elastic. However if no fertilization

occurs then the corpus luteum regresses.

PHASE 3: This is menstrual phase. When the hormone levels decrease, the endometrium layer

sheds and the menstrual bleeding involve the sloughing of the endometrial lining and the blood.

2.4.2 Menstrual Hygiene

Menstrual hygiene occurs when women and adolescent girls are using clean absorbable materials

to take in or collect blood that can be changed in privacy as often as necessary for the duration of

the menstruation period, using clean water to wash the vaginal and soap and water for washing
the body as required, having access to facilities to dispose used menstrual management materials.

(Sommer, 2018)

Essential Components of Menstrual Hygiene includes; Information & Support, materials &

Supplies, Facilities (Toilets with water, bathing & laundering/drying spaces) and Disposal &

Waste Management.

2.4.3 Source of information for Adolescent girls regarding Menstrual Hygiene

Mothers were most often reported as the first and main source of information. Sisters and peers

were the next most common sources. Nearly all studies reporting on teachers and health

professionals reported them as the least common source (Egypt, Ghana, India, Jordan, Malaysia,

Nepal, Nigeria, Sri Lanka, and Turkey). Some girls have access to media and the Internet.

2.4.4 Types of Absorbents used during Menstruation

The preference of sanitary material is based on personal choice, cultural acceptability, economic

status, and availability in the market. Also availability basic sanitation facilities, one should be

also provided with soap and water and menstrual absorbents to manage menstruation hygiene.

(Kaur et. al, 2018) The choice of absorbents varies among rural and urban women and girls. In

rural areas, the most preferred absorbents are reusable cloth pads and in urban areas women

prefer to use commercial sanitary pads. There are:

 COMMERCIAL SANITARY PADS: These are rectangular hygiene absorbent products

that are preferred by women on light-flow days or when spotting is present. The absorbent

pad is the most important component of a sanitary napkin, which is made of wood pulp

mixed with super absorbent polymers for enhancing fluid holding capacity (Meštrović,

2019). They are easily available at many stores, chemist shops, or online. They are
 expensive compared to cloth pads, non-reusable, and not very environment-friendly. The

cotton used in their making is not 100% natural and may contain pesticides. (Kaur 2018)

 REUSABLE AND WASHABLE CLOTH PADS: These cloth pads are reusable so they

are cost-effective, easily available, and are economic friendly. (Kaur et. al, 2018) They

may be sustainable sanitary option but must be hygienically washed and dried in the

sunlight. The sun’s heat is a natural sterilizer and drying the cloths/cloth pads under it

sterilizes them for future use it can also be ironed (Meštrović, 2019). They also need to be

stored in a clean dry place for reuse to avoid contamination.

 TAMPONS: They are the type of absorbent that provides internal protection. They are

kind of plugging of soft material (cotton) which is inserted into the vagina to absorb the

menstrual flow before it leaves the body. They are expensive, not easily degradable in

nature and, hence, not very environmental friendly. Nowadays, sea sponge tampons are

available in the market which is a natural alternative to synthetic tampons. (Kaur, Kaur,

Kaur,2018)

 REUSABLE TAMPONS: Tampons absorb the menstrual fluid inside the body (vagina)

after it has left the uterus, thus offering very discreet protection. They are mainly

composed of rayon or cotton cellulosic absorbent material, or a mixture of these fibers

(Meštrović, 2019).These are washable tampons made up of natural materials like bamboo,

wool, cotton, or hemp. They are also knitted or crocheted using the natural absorbent

material like cotton or wool. They are inserted into the vagina to absorb menstrual flow

same as the disposable tampons. (Kaur, Kaur, Kaur, 2018)

 MENSTRUAL CUPS: Menstrual cups are small, flexible items worn inside the vagina

that capture the menstrual fluids during menstruation (Meštrović, 2019). They may be a
 new technology for poor women and girls and an alternative to sanitary pads and tampons.

They are like cups made of medical grade silicone rubber which makes the cup easy to

fold and get inserted into the vagina to collect menstrual blood. They can be worn up to 6–

12 hours depending upon the amount of menstrual flow, so it needs to be removed and

emptied less frequently. They are reusable and environment-friendly. It offers sustainable,

practical, and cost-effective alternative where sanitation conditions are not good.

(Kaur,kaur,Kaur,2018)

2.4.5 Tips to maintain Menstrual Hygiene

According to Satpathy, (2019) Nigeria still has a long way to go as several thousand women

still use cloths, reusable pads other unsanitary substances during their periods. Even the use of

sanitary pad requires proper personal hygiene to prevent any complications as it affect their

health. Here are some tips every woman should follow to maintain menstrual hygiene practices:

CHANGE PADS EVERY FOUR HOURS: Change sanitary napkins or tampons every 4-6

hours to reduce the chance of having irritation, rashes or urinary tract infections. (Srivastava,

2019) If sanitary pad is used to soak the flow during your periods, remember to change it often.

Ideally, changing it every four hours is good. If not every day, do this on the first two days when

the flow is heavier. On other days too, don’t wear the same pad for more than eight hours.

(Satpathy, 2019)

CLEAN REUSABLE PADS PROPERLY: There are sanitary napkins that can be reused for

several menstrual cycles. If used ensure that you clean them thoroughly after every use so that

they are free from germs. (Srivastava, 2019)

KEEP YOUR VAGINAL AREA CLEAN: It is important to keep vagina and the surroundings

clean especially during periods. The vagina also has a self-cleaning mechanism. Wash your

vagina regularly with lukewarm water to avoid organisms clinging to your body after you have

removed your sanitary napkin or tampon. (Srivastava, 2019) Don't use vagina hygiene products

during menses as during these days the self-cleaning mechanism of the vagina activates and

these artificial hygiene products can hamper the natural process, leading to infections and growth

of bacteria.

NEVER USE TWO PADS SIMULTANEOUSLY: Fix to one method of sanitation. Using

tampons and sanitary napkins, or two sanitary napkins simultaneously may keep you dry and

stain free but can cause severe infections. (Srivastava, 2019) No, two is not better than one.

Some women who experience heavy flow and tend to use two sanitary pads at one go to control

the flow and prevent staining of clothes. This, however, is a bad idea as it can cause infections in

the vaginal region. Stick to one and keep changing it often if the flow is more. (Satpathy, 2019)

WEAR COMFORTABLE, CLEAN UNDERWEAR: While changing your sanitary pad is

essential, it is also important to wear something comfortable during these days. Tight thongs or

underwear made of fabric that doesn’t allow your skin to breathe will also lead to infections.

Stick to clean and comfortable cotton underwear that do not stick to your skin.

HAVE A BATH REGULARLY DURING YOUR MENSES: To get relief from those monster

backaches and cramps.

WASH YOUR HANDS BEFORE AND AFTER CHANGING YOUR PAD, TAMPON, OR

CUP: To ensure maximum cleanliness as your hands come in contact with all kinds of stuff

throughout the day.

2.4.6 Menstrual Waste Disposal Techniques Used By Girls and Women

The menstrual material used was disposed according to the type of product, cultural beliefs and

location of disposal such as urban and rural area. (Kaur, Kaur, Kaur, 2018)

Appropriate disposal of used menstrual material is still lacking in many countries of the world

especially developing countries. Most of the countries have urbanized techniques to manage their

fecal and urinary wastes but lack of menstrual management practices in the world which make

most of the women to dispose their sanitary pads or other menstrual articles into domestic solid

wastes Bins even sewage system. Most Toilets facilities in schools, work places lack Bins for the

disposal of sanitary pads and hand washing facilities for menstruating girls and women to handle

menstrual hygiene. (Kaur, Kaur, Kaur, 2018)

In urban areas, where modern disposable menstrual products are used they dispose of them by

flushing in Toilets and throwing in dustbins or through solid waste management, while In rural

areas, mostly women use reusable and noncommercial sanitary materials like reusable pads or

cloths. Thus, they generate lesser amount of menstrual waste as compared to women in urban

areas who rely on commercial disposable pads. There are many options for disposing menstrual

waste such as by burying, burning, and throwing in garbage or in pit latrines.

In schools, due to lack of sanitary facilities, girls throw their pads in Toilet. In some cases, girls

threw away their used menstrual clothes without washing them. Also many were reported being

absent from school due to lack of disposal system, broken lock/doors of Toilet, lack of water tap,
bucket, and poor water supply. In some schools, incinerators or “feminine hygiene Bins” are

used for disposing menstrual waste material but due to shyness or fear of being seen by others

they refrained from using it.

2.4.7 The behavior of women regarding disposal is different when being at home and away

from home.

At home, they dispose the waste by wrapping and throwing in the dustbin along with other

domestic waste. In public places, prior to having knowledge about the consequences of flushing

the pads, they flush them in the Toilets or wrap and throw them in the dustbins. Where dustbins

are not placed they leave the soiled pads wrapped or unwrapped in the Toilets corners. This

makes the Toilets dirty, breeding place for flies and mosquitoes, and also unhygienic for other

Toilets users and cleaners. In many cities, the persons who manage the public Toilets always

complain of blockage of sewage system because of flushing of sanitary pads or rags in the

Toilets.

(Kaur, Kaur, Kaur., 2018)

2.4.8 Consequences of Inappropriate Menstrual Waste Disposal

According to Womena, (2019) one estimate is that menstrual products form around 6.3% of the

sewage-related debris along rivers and beaches. In the European Union, plastics in products like

tampons and pads were among the five most commonly found items in marine debris. One

estimate is that 252 million menstrual pads will clog European seas and beaches by 2030.

These absorption materials clog the gutter pipelines as they are unable to pass through and cause

backflow of the system. Materials like tampons, cotton wool, Toilets paper, and other organic

materials used for menstrual management might be decomposed in pit latrines except the plastic
inlay of the commercial sanitary pads. Sanitary napkins might decompose over a period of about

one year except its plastic lining in on-site sanitation.

In rural areas, pit latrines once full they were covered with soil and new pit was dug but due to

space limitations this was not practiced in urban areas. It was reported that some women and

girls wrap their used menstrual cloths and packs in polythene bags before disposing in pit latrines

which prevents them from decomposition.

Nowadays, mostly women/girls prefer commercial sanitary pads and tampons which are made up

of super absorptive materials like polyacrylate. Disposable menstrual pads and tampons made

from super absorbent polymers (SAP) cause problems because they swell up once they are

saturated with fluid and when flushed down the Toilets can block pipes Moreover, when

disposed of, used menstrual products are often wrapped in plastic which further reduces

decomposition. (Womena, 2019)

Deodorized sanitary products used by women/girls contain chemicals used in bleaching such as

organochlorines which when buried in the soil disturb the soil microfora and decomposition

takes time.

People living alongside river banks throw menstrual waste into water bodies which contaminate

them. These materials soaked with blood were breeding places for germs and pathogenic

microbes.

Sanitary products soaked with blood of an infected women/girl may contain hepatitis and HIV

viruses which retain their infectivity in soil and live up to six months in soil. The clogged

drainage with napkins has to be unblocked and cleaned manually by conservancy workers with

their bare hands without proper protection and tools. This exposes the workers to harmful
chemicals and pathogens. Incineration is a better technique to dispose of menstrual waste but

burning of pads releases harmful gasses that affects health and environment. (Kaur, et. al., 2018)

2.4.9 Role of School Authority and Teachers in Creating Awareness Regarding

Menstruation and Menstrual Waste Management

Teachers should make the school environment friendly to girl to handle menstruation with

dignity through sex education. It helps adolescents to discover their sexual identity, to protect

themselves from sexual abuse, unwanted pregnancies, and sexually transmitted diseases, and to

know physiological changes occurring in the body and how to take care of personal hygiene.

Sex education is often neglected from the school curriculum which have harmful impacts on the

student’s life in such that information about puberty, sexual intercourse, menstruation, and other

physiological changes in one’s body are getting from books, friends, and Internet which may be

imperfect or incorrect. Due to lack of knowledge and social interaction, teasing and taunting with

hurtful nicknames are common in schools and makes it difficult for a girl student to survive in

this environment, so they remain absent from school. . (Kaur, Kaur, Kaur, 2018)

The teacher need to do proper education on how to avoid all sort of stain and the duration of

using one material related to the type of material use.

In some reported cases, parents do not allow girls to go to schools upon reaching puberty in fear

of sexual harassment by boys and male teachers in schools. To overcome these issues the

following should be done:

 Male teachers and employees in the schools and institutes should be well educated on

menstruation and menstrual hygiene management so that they support girls and women

by providing safe environment and privacy.

 Also committee of teachers including both male and females should be made in schools

to collect funds for providing sanitary napkins, soaps, water, and Toilets facilities in

schools so that girls manage their menstruation with ease and safety.

 Committee should also provide dustbins for menstrual waste disposal.

 Provision of separate Toilets for girls and boys with proper doors and locks should be

built in the schools.

 Teachers should educate girls about menstrual health management and its link to their

health.

 They should also make girl students aware of how to dispose of used menstrual products

at home and in schools

 They should also let them know the consequences of throwing them in open or flushing

them in Toilets.

 Open discussions on puberty, sex education, menstruation, and the likes should be

organized by schools in every class to make students aware of it. And also it will solve

their uncertain queries by providing them correct knowledge, promote social interaction,

and also develop a trust relationship with fellow friends and teachers.

 School-level health policies should be made by school management committee to

promote and educate students regarding health and safety and ensure adequate water and

sanitation facilities.

 Protect female students and staff from bullying and sexual harassment. .

(Kaur,Kaur,Kaur, 2018)
2.4.10 Strategies for the Management of Menstrual Waste

Disposal of menstrual waste is of major concern as it affects health and environment. There is a

need for effective menstrual materials which is needed to be cost-effective and body pleasant.

Manufacturing companies of sanitary pads should disclose information on the pads regarding the

chemical composition of the pads so that appropriate technologies could be used for their

disposal and treatment. . (Kaur, Kaur, Kaur., 2018)

The Toilets must be designed and built to be girl friendly for instance, In Kerala, some schools

have installed sanitary napkin vending machines in Toilets which are semiautomatic and operate

by inserting a coin in it. It contains 30–50 sanitary napkins to meet the emergency needs of the

girls/women in schools.

There should be a separate collection system for the menstrual wastes without affecting the

privacy and dignity of women. Also there should be sufficient space for washing, cleaning

private parts and hands and for changing or dealing with stained clothes through adequate water

availability, Toilets paper, dustbin, and a sink to wash menstrual products. Dustbins should be

covered by lid and emptied from time to time to keep the Toilets clean from flies, mosquitoes,

and bad odor. Covered containers and dustbins have advantage of hiding the waste being seen by

others. They are placed in a place that offers privacy. . (Kaur, Kaur, Kaur,2018)

Gloves and proper safety tools should be provided to the cleaners so that they are not exposed to

pathogenic organisms and harmful gasses.

Government should introduce new rules for the safe disposal and treatment of menstrual wastes,

Incinerator installed in the Toilets for easy sanitary products disposal. Appropriate policy and

legal framework is necessary for the management of menstrual wastes. Government and non-
Government organizations should come forward for making the people aware of management of

menstrual wastes. Government should give the funds to the Municipal Corporation or NGOs for

the construction of women friendly Toilets.

Financial support should be given to the institutions to carry out the research in the management

of menstrual wastes. Scientific research should be encouraged for the most suitable techniques of

disposal of sanitary pads or other menstrual products also allocation of budget in schools to

support menstrual hygiene management studies should be conducted. Collaborative efforts (trash

Bins) should be made.

2.4.11 Appropriate Ways of Disposing Menstrual Wastes

According to Kaur, Kaur, Kaur (2018) the following are the appropriate ways of disposing

menstrual wastes.

 INCINERATORS: Incinerators are a better option for disposal when commercial

sanitary pads are used but should be operated in a controlled environment so that harmful

gasses emitted will not harm larger area. They should be operated at certain specific

temperature around 800∘ C so that they emit less harmful gasses. They should be

installed in schools, institutions, and slum areas and at community level

 LATRINES WITH CHUTES: These are special kind of Toilets in which a shoulder

level Chute was made in the usual deep pit. A chemical agent was added to the pit five

times in a month to enhance the decomposition process of used napkins.

 REUSABLE CLOTH PADS: Using these reusable cloth pads is a better option as they

have less chemical and plastic content. So they are easily decomposable as compared to

other commercial products.

  BIODEGRADABLE PRODUCTS: Commercial sanitary product manufacturing

companies must manufacture products having lesser chemical and plastic content. Pads

made from bamboo fibre, banana fibre, water hyacinth, and sea sponges should be

encouraged.

 CLAY OR CEMENTED INCINERATORS: Clay and cement incinerators used in

Gujrat villages by “Vatsalya Foundation” are a welcomed step in menstrual hygiene

management. A lady named “Swati” designed this incinerator and named it

“Ashudhinashak” which burns many sanitary napkins at a time without creating any

smoke. This economic friendly and cheap innovation is appreciated by rural women who

find it difficulty in disposing them.

 BETTER DISPOSAL TECHNIQUES: Special covered Bins should be installed to

handle menstrual waste. Disposal bags should be provided by manufacturing companies

with color indication for disposing these products. These bags should be freely

distributed among schools and institutions. Menstrual waste should not be disposed of

along with domestic waste. Pads should be properly wrapped in newspaper and then

thrown in the dustbins. By this it should also be safe for rag pickers as it does not expose

them to any disease-causing pathogens.

2.5 Empirical Review

2.5.1 Knowledge on Menstrual Hygiene

A descriptive survey was conducted on knowledge and practice of menstrual hygiene among 150

adolescent girls residing in selected orphanages of Haryan, which showed that more than half of

adolescent girls (62.7%) were in age group of 12-15 year. half (50.7%) of adolescent girls had
age of menarche at 12 year. only 16% adolescent girls had good knowledge regarding menstrual

hygiene. 95.3% were using sanitary pad during menstruation. This finding showed that

adolescent girls had poor knowledge of menstruation and menstrual hygiene. (Kumari, Sheoran

& Siddiqui, 2018)

This cross-sectional study on knowledge, attitude, and practice on menstrual hygiene

management among school adolescents in Doti district, Nepal was carried out by Yadav, Joshi,

Poudel & PPandeya, (2017). This study was done among 276 students from grade seven and

eight of 11 schools. The study showed that 67.4% respondents had fair knowledge and 26.4%

respondents had good knowledge on menstrual hygiene management. However, out of 141

female adolescent respondents, only 56 (40%) were engaged in good menstrual hygiene

practices. Around half of the respondents had positive attitude towards menstrual hygiene

management related issues and concluded that knowledge on menstrual hygiene management

among school adolescents is fair, still attitude and practice need to improve.

2.5.2 Practice on menstrual hygiene

A community based, cross sectional study was conducted on menstrual attitude and practices

among 150 adolescent girls in tribal area of faqeergujari, district Srinagar and the study showed

that (83.9%) of study participants use cloth as an absorbent during menstruation and (78.2%)

reuse it in subsequent periods. Only 16.3% of participants took bath during menstruation and

93.3% of participants miss school during periods. (Nelofar, Choudhary & Masoodi, 2018) This

concluded that the knowledge and practice of menstrual hygiene is low. Awareness regarding the

need for information about good menstrual practices is very important. Menstrual hygiene is an

issue needs to be addressed at all levels.

A cross-sectional study was conducted in the rural field practice area of the Department of

Community Medicine, Andhra Medical College, Visakhapatnam among 400 high school

adolescent girls who had attained menarche and were present in the schools during the days of

survey by Madhavi & Paruvu (2019) shows that Mean age of study participants was 14.2yrs

±1.05. About 206 (48.4%) knew about menstrual cycle before their menarche. Majority of study

participants (78.3%) used sanitary pad as protective material. Regarding hygienic practices

during menstruation 78.8% had daily bath. Awareness before menarche was still poor in rural

areas but the practices is still fair.

2.5.3 Factors Influencing Menstrual Hygiene Practices

A cross sectional study was carried out in two schools of Udaipur on menstrual hygiene practices

and problems among 440 adolescence girls by Tundia & Thakrar, (2018). The study revealed

that 68.41% girls gave history of abdominal pain as premenstrual symptoms (PMS). School

absenteeism was found 44.54% due to menstruation related problems. Sanitary Napkins were

used by 50.22% girls. And 66.54% girls were using water to clean genitals during menstruation.

Restriction from attending religious functions was high (91.59%). Associations of absorbents

used by participants with absorbents used by their mothers and sisters were statistically

significant.

An explorative study design was conducted by Lahme, Stern & Cooper (2018) with 51

respondents, aged 13–20 years, from three secondary schools. Their age at menarche was 11–15

on factors impacting on menstrual hygiene and their implications for health promotion revealed

that the girls suffer from poor menstrual hygiene, originating from lack of knowledge, culture

and tradition, and socio-economic and environmental constraints, leading to inconveniences,

humiliation and stress. This leads to reduced school attendance and poor academic performance,

or even drop outs, and ultimately infringes upon the girls’ human rights.

A community based comparative cross-sectional study design was employed in urban and rural

Kebeles of Bahir Dar city administration. By Azage, Ejigu, &Mulugeta, (2018) revealed that

Safe Menstrual Hygiene Management practice was 24.5% and did not show significant variation

between urban and rural adolescent girls. However, significantly higher numbers of adolescent

girls in the urban area used sanitary pads than the rural adolescent girls. Being older, attending

formal education and educational status of participants’ mother were factors associated with safe

MHM practice.

2.6 Theoretical Framework

2.6.1 Health Belief Model

The Health Belief Model (HBM) is one of the first theories of health behavior. It was developed

in the 1950s by a group of U.S public Health service social psychologists in order to understand

the failure of people to adopt disease prevention strategies or screening tests for early detection

of diseases. Later uses HBM were patients’ responses to symptoms and compliance with medical

treatments. (Lamorte, 2018)

HBM is derived from psychological and behavioral theory with the foundation that the two

components of health related behavior are: the desire to avoid illness, or conversely get well if

already ill and the belief that a specific health action will prevent, or cure, illness. Ultimately, the

individual’s course of action often depends on the person’ perceptions of the benefits and

barriers related to health behavior. There are six construct of the HBM. The first four constructs
were developed as original tenets of HBM. The last two were added as research about the HBM

evolved. (Lamorte, 2018)

 Perceived Susceptibility

 Perceived severity

 Perceived benefit

 Modifying variables

 Cue to action

 Self-efficacy

HBM is popular model applied in nursing especially in issues focusing on patient compliance

and preventive health care practices. It postulate health seeking behavior is influenced by the

person’s perception of a threat posed by the health problem and the value associated with actions

aimed at reducing the threat. It addresses the relationship between a person’s behavior and belief.

It provides a way to understanding and predicting how clients will behave in relation to their

health and how they comply with health care therapies.

The major concepts of Health Belief Model are:

 Perceived susceptibility: refers to patient perception that a health problem is personally

relevant or that a diagnosis of illness is accurate. This means people will not change their

behavior unless they believe that they are at risk. There is wide variation in a person’s

feelings of personal vulnerability to an illness or diseases. (Lamorte, 2018)

 Perceived severity: even when one recognizes personal susceptibility, action will not

occur unless the individual perceives the severity to be high enough to have serious
 organic or social complications. Meaning there will be increase probability of changing

their behavior when they are aware of the severity of the disease.

 Perceived benefits: refers to the patient’s belief that a given treatment will cure the illness

or help to prevent it. That is, is difficult to convince people to change a behavior if there

isn’t something in it for them.

 Perceived barriers: refers to the complexity, duration and accessibility and accessibility of

the treatment. One of the major reason people don’t changes their health behavior is that

they think that doing it is going to be hard. Sometimes it’s not just a matter of physical

difficulty as well. Changing your health behavior can cost effort, money, and time.

 Cues to action or motivation: the external events that prompt a desire to make a health

change. A cue to action is something that helps to move someone from wanting to make a

health change to actually making the change. It includes the desire to comply with the

treatment and belief that people should do what.

 Modifying variables: individual characteristics, including demographic, psychosocial,

and structural variables, can affect perceptions (perceived seriousness, susceptibility,

benefits and barriers) of health related behaviors. Demographic variables includes: age,

sex, race, ethnicity and education among others.

Self-efficacy: this refers to the level of a person’s confidence in his or her ability to successfully

perform a behavior. It directly relates to whether a person performs the desired behavior. This

construct was added to the model most recently in mid “1980”

Individual Modifying factors Likely hood of
action
perception

Demographic factor
Perceived benefits
Age, sex, ethnicity, versus
socio economics
Perceived barriers

Perceived
severity/
Perceived threat of
disease Likelihood of
Perceived
behavioral changes
susceptibility

Cues to action
 Education
 symptoms
Perceived
 media
information efficacy

Figure 2.1: Health belief model

2.6.2 Application of the Model

The health belief model has been used to develop effective interventions to change health- belief

related behaviors by targeting various aspects of the health belief model of aim to increase

perceived susceptibility to and perceived seriousness of health condition by providing education

about prevalence and incidence of disease, individualized estimation of risk, and information

about the consequences of diseases (Wikipedia, 2019)

The model involves assessment of menstrual hygiene practices among adolescents, to identify

the factors (girls’ socio economic characteristics such as low socioecomic status and high socio

economic, level of education) influencing menstrual hygiene practices among adolescent girls

and the implication of inappropriate menstrual hygiene that may prone the girls to UTI, BV even

death. The cues to action are adequate knowledge on menstrual hygiene from teachers, health
personnel, friends, family and media and so on, which increase the likelihood that the girls will

take necessary action regarding menstrual hygiene practice to prevent the implication of

inappropriate menstrual hygiene practices.

Also if the perceived benefits is more than the barriers there would be likelihood that the

necessary action to assess the level of practices menstrual hygiene by the girls and initiate proper

menstrual hygiene practices will be taken by the girls to prevents the UTI, BV and complication

on pregnancy. In other word, the adolescence girls are likely to adopt positive health practice

such as to timely changing of soaked pad, proper securing of used pad before throwing away,

proper washing of vaginal (front to back) and hand after using Toilets with adequate soap and

water.

Furthermore interventions based on health belief model may provide cues to action to remind

and encourage Individual to engage in health- promoting behaviors. Intervention may also aim to

boost self- efficacy by providing training in specific health- promoting behaviors, particularly for

complex life style changes (frequent bathing, washing of reusable pads and spread under

sunlight). Intervention can be aimed at individual level to increase engagement in health-related

behaviors. (Wikipedia, 2019).