Improving menstrual hygiene management among adolescent girls in tribal areas of Gujarat: an evaluation of an implementation model integrating the government service delivery system

Figures & data

Figure 1. Theory of change

Figure 2. Flow chart menstrual health management study

Table 1. Socio-demographic characteristics of adolescent girls in tribal areas of Gujarat (N=1057)

	Baseline (N=507)		Endline (N=550)		P-Value
	F	%	F	%
Age  10 to 14  15 to 19	81 426	16.0 84.0	121 429	22.0 78.0	0.01
Religion  Hindu  Muslim	500 7	98.60 1.40	537 13	97.60 2.40	0.24
Caste  Tribal  Non-Tribal	458 49	90.30 9.70	487 63	88.50 11.50	0.35
Education  Illiterate  1 to 8  9 to 12  More than 12	10 117 377 3	2.00 23.1 74.40 0.60	2 184 363 1	0.40 33.50 66 0.20	<0.001
Mother’s education  Illiterate  Primary1-8  Secondary & above  Do not know  Mother died	139 240 105 9 14	27.40 47.30 20.70 1.80 2.80	167 273 100 1 9	30.40 49.60 18.20 0.20 1.60	0.03
Ration card  Antyodaya*  BPL†  APL**  No Card	45 332 122 8	8.90 65.50 24.10 1.60	29 417 101 3	5.30 75.80 18.40 0.50	0.017
Study participants  School going  Out of school	271 236	53 47	307 243	56 44	0.44
Having pukka bathroom	220(219)	43.39	226	41.09	0.68
Having functional toilets and utilized	165	32.54	206	37.45	0.04

Note: *Antyoday-extremely poor; BPL** Below poverty line; APL†- Above poverty line.

Table 2. Output indicators: adherence to intervention among adolescent girls in tribal areas of Gujarat

	Planned	Executed
Capacity building of frontline workers	900	892 (99%)
MHM awareness sessions attended by  Adolescent girls from school  Boys  Out-of-school adolescent girls	10098 10000 2964	9284 (92%) 7200 (72%) 2647 (90%)
MHM corners in  Schools  AWCs	215 325	215 325
MHM team formation in schools (one teacher and two adolescent girls)	215	200
Facilitation field visits to support schools and AWCs**	900	1332
Participants in stakeholders’ meeting at the beginning of the project for convergence between different departments of government	60	56
Monitoring meetings with government officials	4	4
Sanitary pad production unit by SHG*	2	2

* MHM-Menstrual Hygiene Management

**AWC-Aganwadi Centers

***SHG-Self Help Group

Table 3. School-level facilities among adolescent girls in tribal areas of Gujarat (N=578)*

	Baseline school-going (N= 271)		Endline school-going (N= 307)
	N	%	N	%
Availability of separate toilet for girls	250	92	297	96.74
Availability of changing room	94	35	117	38.11
Availability of water	237	87	283	92.18
Availability of any type of disposal facility	106	39	211	68.73
Availability of sanitary material	79	29	193	62.87
Awareness sessions conducted on MHM (M-Menstrual Hygiene Management)	161	59	292	95.11

Note: MHM, Menstrual Hygiene Management.

*Unit of analysis was school going girls.

Table 4. Sanitary material used, knowledge on menstruation and preparedness among adolescent girls in tribal areas of Gujarat (N = 1057)

	Baseline**		End line**		P-Value	Unadjusted OR (95% CI)	Adjusted* OR (95% CI)
	N	%	N	%
A) Total adolescent girls (school-going and out-of-school)	507		550
Sanitary material use
Sanitary pads and flannel cloth pad	350	69.00	498	90.50	<0.001	4.63 (3.25 – 6.6)	5.19 (3.61-7.47)
Old cloth	157	31.00	52	9.50
Knowledge about Menstruation
Reason for menses (hormones+puberty)	38	7.50	401	72.90	<0.001	33.21 (22.70-48.58)	47.84 (31.14-73.48)
Origin of menstruation (uterus)	32	6.30	362	65.80	<0.001	28.58 (19.17-42.59)	39.6 (25.66-61.10)
Reproduction and menstruation are related to each other	224	44.2	533	96.90	<0.001	39.61 (23.69-66.21)	50.21 (29.13-86.55)
B) School-going adolescent girls	271		307
Sanitary material use
Sanitary pads (any type) and flannel	198	73.07	285	92.80	<0.001
Old cloth	73	26.93	22	7.20		4.86 (2.92-8.09)	5.94 (3.46-10.21)
Knowledge about menstruation
Reason menses (hormones, puberty)	22	8.10	252	82.08	<0.001	51.85 (30.69-87.62)	87.87 (46.26-166.90)
Origin menstruation (uterus)	17	6.30	239	77.90	<0.001	52.51 (29.99-91.93)	68.32 (36.72-127.10)
Knows that reproduction and menstruation are related to each other	125	46.5	295	96.00	<0.001	28.71 (15.37-53.62)	39.59 (19.90-78.76)
Preparedness of menstruation
Had information regarding menstruation before menarche	139	51.3	306	99.7	0.005	1.60 (1.15-2.24)	1.55 (1.10-2.19)
Menstrual practices
Do not exchange sanitary material with family members	215	79.3	296	96.40	<0.001	7.00 (3.58-13.69)	8.09 (4.04-16.20)
Cleaning of genitals during menstruation	262	96.7	302	98.40	0.196	2.07 (0.68-6.26)	2.36 (0.75-7.39)
Washing hands with soap before and after changing sanitary material	267	98.5	306	99.70	0.17	0.21 (0.02-1.96)	0.22 (0.02-2.08)
Change sanitary material 3-4 times a day	31	11.4	118	38.40	<0.001	4.38 (3.11-7.49)	5.65 (3.35-9.01)
Washing material with soap & water	195	97.9	211	99.30	<0.001	4.32 (0.48-39.06)	2.98 (0.27-32.16)
Drying in sunlight	128	64.3	184	86.8	0.002	1.67 (1.20-2.32)	1.61 (1.14-2.27)
School absenteeism
Remain absent	66	24.4	42	13.7	0.001
Remain present during menses	205	75.6	265	86.30		0.49 (0.32-0.75)	0.48 (0.31-0.75)
Menstrual disorder and care seeking
Having any type of menstrual disorder	115	42.3	125	40.7	0.676	1.07 (0.77-1.49)	0.97 (0.69-1.37)
Treatment taken of any type	27	23.5	66	52.8	0.003	2.14 (1.29-3.54)	2.43 (1.43-4.11)
Having no treatment	88	76.5	59	47.2
Disposal
Burn + bury + dustbin (Safe disposal)	226	83.40	285	92.80	0.0002
Unsafe disposal (drainage, throw away, others)	45	16.60	22	7.20		4.16 (2.23-7.78)	4.76 (2.49-9.10)
Source of information
Mother	96	35.4	129	66.8	0.23	0.81 (0.57-0.1.14)	0.81 (0.52-1.16)
Teacher	19	7	55	28.5	<0.001	0.31 (0.18-0.56)	0.33 (0.18-0.59)
Frontline Health Worker (ASHA/AWW)	13	4.8	14	7.3	0.45	1.37 (0.81-3.12)	1.36 (0.59-3.13)
Friends (relatives)	41	8.8	65	39.7	0.032	0.62 (0.39-0.95)	0.59 (0.37-0.94)
C) Out-of-school adolescent girls	236		243
Sanitary material use
Sanitary pads (any type) and flannel	133	64.84	213	87.70	<0.001
Old cloth	83	35.16	30	12.30		3.85 (2.41-6.14)	4.77 (2.87-7.91)
Knowledge about menstruation
Reason for menses (hormones + puberty)	16	6.80	149	61.30	<0.001	21.79 (12.33-38.51)	28.09 (15.21-51.87)
Origin of menstruation (uterus)	15	6.40	`123	50.60	<0.001	15.10 (8.45-26.98)	20.27 (10.94-37.56)
Knows that reproduction and menstruation are related to each other	99	41.9	238	97.90	<0.001	65.87 (26.18-165.72)	73.64 (28.68-189.06)
Preparedness of menstruation
Had information regarding menstruation before menarche	99	41.9	243	100.00	<0.001	1.94 (1.35-2.79)	1. 88 (1.14-3.10)
Menstrual practices
Do not exchange sanitary material with family members	186	78.8	237	98	<0.001	10.62 (4.45-25.30)	10.82 (4.49-26.05)
Cleaning of genitals during menstruation	225	95.3	242	99.60	<0.001	11.83 (1.51-92.38)	11.55 (1.46-91.65)
Washing hands with soap before and after changing sanitary material	235	99.6	241	99.20	0.587	1.95 (1.18-21.65)	1.67 (0.15-18.88)
Change sanitary material 3-4 times a day	37	15.7	77	31.70	<0.001	2.49 (1.60-3.88)	2.69 (1.69-4.29)
Washing material with soap & water	190	97.9	205	100	0.473	0.84 (0.52-1.36)	0.88 (0.53-1.47)
Drying in sunlight	121	62.4	177	86.3	<0.001	2.55 (1.74-3.73)	2.54 (1.72-3.74)
Menstrual disorder and care seeking
Having any type of menstrual disorder	91	38.6	97	39.9	0.761
Treatment taken of any type	24	26	51	52.6	0.008	1.05 (0.73-1.53)	1.031 (0.71-1.50)
Having no treatment	67	74	46	47.4		2.07 (1.21-3.54)	2.14 (1.23-3.74)
Disposal
Burn + bury + dustbin (safe disposal)	200	84.70	220	90.50	0.012
Unsafe disposal (drainage + throw away + others)	36	13.30	23	9.50		2.12 (1.18-3.82)	2.19 (1.19-4.04)
Source of information
Mother	68	28.8	102	71.8	0.004	0.57 (0.38-0.83)	0.56 (0.37-0.82)
Teacher	11	4.7	21	14.8	0.086	0.51 (0.23-1.10)	0.47 (0.22-1.03)
Frontline Health Worker (ASHA AWW)	6	2.5	11	7.7	0.447	0.66 (0.23-1.91)	0.63 (0.21-1.83)
Friends Other (Relatives)	27	11.5	47	32.1	0.028	0.56 (0.33-0.94)	0.51 (0.29-0.87)
Washing and drying practices among reusable cloth pads (flannel and old cloth)	N = 194	%	N = 205	%
Washing material with soap &water	190	97.9	205	100	0.473	0.84 (0.52-1.36)	0.88 (0.53-1.47)
Drying in sunlight	121	62.4	177	86.3	<0.001	2.55 (1.74-3.73)	2.54 (1.72-3.74)

*Adjusted with age, education, mother’s education, family poverty status.

**Baseline - Data collection done before the intervention started. Endline - Data collection at the end of the project (after implementing interventions).