INTRODUCTION

Menstrual hygiene practices refer to maintaining a specific hygiene by women and adolescent girls during the menstruation cycle, including sanitary material to absorb or collect menstrual blood and facilities for disposing them, in order to effectively manage the menstrual period^1,2. Adolescent girls from low- and middle-income countries face different challenges to maintain proper hygiene during menstruation³. Low quality sanitary materials, the social culture related to menstruation hygiene management, inadequate water, sanitation and hygiene (wash) facilities, lack of guidance and privacy for changing and washing at school or home are common issues related to inadequate menstrual hygiene practices that have adverse effects on education, health and economic outcomes⁴.

School absenteeism means missing school due to excused or unexcused reasons. School absenteeism may also occur during the menstrual cycle due to poor menstrual hygiene practices attributed to the improper school setting, lack of gender-specific wash facilities, insufficient sanitary material, and bad response/attitude by male teachers and students, etc.^5,6 Menstrual fatigue and pain are also responsible for school absenteeism. As a result, reduced school performance, drop-out from school, and lower educational attainment appear to have long-term effects on gender equality, education, sexual and reproductive health, and economic outcomes^6,7.

In Bangladesh, adolescent girls have negative attitudes towards menstrual hygiene practices. Many adolescent girls lack scientific knowledge about the menstrual cycle. They feel hesitant to discuss menstruation with their parents, relatives, friends and others⁸. The majority of adolescent girls in Bangladesh do not know about menarche or maintain menstrual hygiene. The Bangladesh Demographic Health Survey 2014 reported that only 33.7 % of adolescent girls (aged 15–19 years) had heard about menstruation before menarche⁹. A study conducted among adolescent girls in a rural area in Bangladesh reported that about 69% used an unhygienic cloth or even no protection during menstruation. Only about 24% of school settings fulfil basic wash facility criteria, which is a challenge to improve these facilities in Bangladesh¹⁰. According to the National Baseline Survey 2014 in Bangladesh, there is on average 1 toilet per 187 students with insufficient water and soap facilities in nearly two-thirds of the bathrooms. In addition, there is a lack of light and ventilation facilities¹¹.

Knowledge, attitudes, and practices on menstrual hygiene management and its impact among Bangladeshi adolescent girls are not well known, with little evidencebased intervention programs to reduce school absenteeism among adolescent girls during menstrual periods. To address this information gap, a cross-sectional study was conducted among Bangladeshi adolescent girls aimed to assess the prevalence of school absenteeism during menstrual periods and to explore the association of menstrual hygiene practices with school absenteeism, which can help governmental and non-governmental organizations to design programs to reduce school absenteeism and so improve the educational status of women.

METHODS

RESULTS

Sociodemographic characteristics of school-going adolescent girls in Bangladesh are shown in Table 1. Of 442 participants, about one-third (35.1%) of adolescent girls were absent from school, and more than half (62.3%) of the adolescent girls were aged ≥15 years, with a mean (±SD) age of 16.8 (±5.3) years. Most of the respondents (94.3%) were Muslims. About half of the respondents’ mothers (54.1%) had secondary or above education level, and for the majority of (74.8%) respondents, their mother was a housewife. Moreover, about half of the respondents’ fathers were employed (53.4%) and had secondary or above education level (52.3%). About 43.2% of respondents did not know about the menstruation cycle before menarche; more than half (54.9%) of the respondents knew from their mother and 12.4% from a school-based program. The majority (67.2%) of the respondents did not know the reason for menstruation, only 30.3 % of respondents knew that it is a physiological process, and 2.9% believed that it is a curse of God.

Table 2 shows the bivariate regression analysis used to identify sociodemographic factors associated with school absenteeism among school-going adolescent girls. The Hosmer and Lemeshow test (χ²=8, df=6, p=0.76) was used to express the goodness-of-fit. The adjusted regression model showed that the following sociodemographic factors were statistically significant with school absenteeism among adolescent girls: older age (AOR=2.97; 95% CI: 1.66–5.24, p<0.05); illiterate mother (AOR=5.36; 95% CI: 1.91–12.44, p<0.05) and illiterate father (AOR=4.66; 95% CI: 1.79–11.24, p<0.001); from single families (AOR=2.54; 95% CI: 1.45–4.47, p<0.001); did not know about the menstruation cycle before menarche (AOR=2.14; 95% CI: 1.32–3.48, p<0.001); and poor hygiene management (AOR=5.66; 95% CI: 2.73–15.32, p<0.001). Moreover, school absenteeism was less frequent among adolescent girls who received information about the menstrual cycle from school-based programs (AOR=0.17; 95% CI: 0.04–0.69, p<0.001).

Table 3 depicts the findings of multiple logistic regression analysis used to identify the association of menstrual hygiene practices with school absenteeism among schoolgoing adolescent girls. The adjusted regression analysis revealed that the following menstrual hygiene practices were significant with school absenteeism: use of a homemade cloth for sanitary protection (AOR=2.14; 95% CI: 1.23–5.79, p<0.01); underwear instead of a sanitary pad (AOR=2.54; 95% CI: 1.43–2.82, p<0.01); reuse of sanitary material (AOR=1.74; 95% CI: 1.21–2.31, p<0.005); washing reusable cloth with only water (AOR=3.78; 95% CI: 1.27–11.14, p<0.001); bathing using only water in this period (AOR=1.93; 95% CI: 1.09–3.69, p<0.001); unsatisfactory cleaning of external genitalia (AOR=4.37; 95% CI: 1.19–7.54, p<0.005); and sanitary pad/cloth changed once per day (AOR=3.14; 95% CI: 1.36–7.45, p<0.01).

DISCUSSION

We found that about one-third (35.1%) of school-going adolescent girls were absent from school during menstrual periods, which is in accordance with a study conducted among adolescent girls in India (40%)¹². Another study conducted in Nepal reported that girls were more likely to be absent from school during menstruation than on other days¹⁴. This study identified that the older adolescent girls, whose mother was illiterate, and came from a nuclear family were significantly associated with higher school absenteeism during menstrual periods. Older adolescent girls were more absent from school compared with younger girls, and this was consistent with previous studies^4,15. Overall, school absenteeism was higher among the older age group, indicating that age may be a significant factor associated with school absenteeism. School absenteeism was higher among the adolescent girls whose parents were illiterate, a result also found in a study conducted among Nigerian school-going girls¹⁶. Literate mothers play an important role in motivating their daughters regarding hygiene practices and a healthy attitude toward menstruation¹⁷. Thus, school absenteeism was high among adolescent girls with illiterate mothers. Adolescent girls who come from a nuclear family and had no knowledge about menstrual hygiene management before menarche were more absent from school. A study conducted in Dibrugarh town¹ reported that adolescent girls from single/nuclear families were more absent from school during menstruation. It also found that girls from an extended family had good knowledge of menstrual hygiene management, as found in previous studies^18,19. School absenteeism among the adolescent girls was lower for those who received information about menstrual hygiene management from school-based programs, as found in a previous study²⁰. Hence, this study suggests that school-based menstrual hygiene practice intervention programs should be increased to reduce school absenteeism among school-going adolescent girls.

The present study revealed that poor menstrual hygiene practices were significantly associated with absenteeism among school-going adolescent girls during menstrual periods, in line with previous studies^4,21. A study conducted in India reported that poor hygiene management was associated with reproductive tract infections²¹. In our study poor hygiene management was considered if: the frequency of change of sanitary pad/cloth was greater than eight hours; not cleaning hands before and after changing MHM materials; not washing external genitalia at least once per day; and using reusable sanitary pads/cloths without washing them with soap/antiseptic. This type of poor hygiene is intricately linked with risks of infection, such as urogenital infections, yeast infection, fungal infection, and urinary tract infection^21-23, leading to increased school absenteeism during menstrual periods.

This study found that school absenteeism was higher among adolescent girls who used homemade cloths or underwear, reused sanitary materials, washed reusable cloths with only water and dried these inside the house or outside without sunlight. School absenteeism was less among the girls who use sanitary pads during this period. School absenteeism was significantly associated with the reuse of sanitary materials, consistent with results found with a study conducted in Northeast Ethiopia³. The adolescent girls who used sanitary pads were more concern about menstruation and hygiene practices¹⁷. Due to proper hygiene maintenance and concern about menstruation, they had less reproductive tract infections and less school absenteeism. Reusable sanitary cloth washing with soap or antiseptic results in properly disinfected or less contaminated cloths that inhibit several genitival problems and less infection²⁴. Improper drying of reusable cloths may be associated with contamination and responsible for reproductive tract infections found in a previous study²⁵. Unsatisfactory cleaning or cleaning without soap/antiseptics also leads to less school participation by adolescent girls during menstrual periods. This issue is responsible for reproductive infections^26,27and pain during menstruation²⁸.

CONCLUSIONS

The major finding of this study was that the lack of knowledge and the lack of wash facilities and soap/antiseptic equipment for washing sanitary pads, for bathing and cleaning external genitalia were responsible for school absenteeism among school-going adolescent girls. Menstrual hygiene management knowledge and adequate mother’s education level prevent school absenteeism. This study’s findings may help governmental and nongovernmental organizations to design programs to reduce school absenteeism during menstrual periods by improving education on health hygiene practices during the menstrual cycle.