• Should cover product use, disposal, and stigma reduction, with workshops engaging male and female students
• Teacher training and student feedback mechanisms would enhance menstrual hygiene support 
• Zonal Edu. Directorates should institutionalise menstrual hygiene policies, fund facility upgrades, implement regular monitoring and evaluation
• PPPs needed to subsidise reusable menstrual products 

Menstrual hygiene education should be integrated into the local school curriculum, covering product use, disposal, and stigma reduction, with workshops engaging both male and female students, and teacher training and student feedback mechanisms to enhance menstrual hygiene support. Further, Zonal Education Directorates should institutionalise menstrual hygiene policies, fund facility upgrades, and implement regular monitoring and evaluation. 

These findings were made in an original article on "Menstrual hygiene practices among school students in a District of the Northern Province: A cross-sectional study" which was authored by P. Kanagaratnam (a Postgraduate Scholar at the Kelaniya University's Medical Faculty's Public Health Department, and a Medical Officer at the Jaffna Teaching Hospital's Radiology Department) and P.A.D. Coonghe (Senior Lecturer at the Jaffna University's Medical Faculty's Family and Community Medicine Department), and published in the ReproSex: International Journal on Sexual and Reproductive Health's First Volume.

Materials and methods

Kanagaratnam et al.'s study subjects were 16-year-old girls in a District of the Northern Province. The study was a cross-sectional one. This descriptive study was conducted over a five-month period in 2024. The study population included students who had attained menarche at least six months prior, and were regularly attending school. 

This said District comprises 82 secondary schools distributed across four administrative divisions. The Government schools were stratified by division and type (National, Type 1AB, Type 1C), and 17 schools were selected as multistage cluster samples. Within each selected school, eligible students were systematically sampled from the class registers. A total of 385 students participated.

Results

The sample is predominantly Hindu (289, 75.1 per cent), followed by Christian (93, 24.2%) and Muslim (three, 0.8%). Hindu cultural norms likely shape menstrual hygiene practices, influencing attitudes and taboos. Most fathers (172, 44.7%) and mothers (182, 47.3%), have General Certificate of Education (GCE) Ordinary Level education, with 154/40% fathers and 109/28.3% mothers having primary education.

Mothers show higher attainment, with 73/19% at the GCE Advanced Level and 12/3.1% with university degrees, compared to 38/9.9% and three/0.8% for fathers, respectively. Maternal education may enhance health literacy, benefiting daughters' hygiene practices.

A majority of families (283, 73.5%) earn less than Rs. 25,000 monthly, reflecting economic hardship. Only 81/21% earn Rs. 25,000-50,000, with minimal representation in the higher brackets (more than Rs. 200,000).

The low income restricts access to menstrual products, potentially leading to less hygienic alternatives and impacting attendance. The study sample is a group of young individuals, predominantly adolescents, with an average age of 15.3 years.

The mean age at menarche, 12.97 years, reflects a typical range for the onset of menstruation, though with some variation. The average duration of the menstrual periods is 5.38 days, indicating moderate consistency in the cycle length.

Family composition shows an average of 1.14 sisters and 1.2 brothers, suggesting slightly larger numbers of male siblings in relatively small families.

A total of 355/92.2% students have covered toilets at home, aiding hygienic menstrual management, while 30/7.8% without such facilities face privacy and infection risks. Nearly all 383/99.5% have attained menarche, highlighting the need for menstrual hygiene support, with only two/0.5% yet to reach it.

Menstrual cycles vary, with 252/65.5% shorter than 28 days, 129/33.5% between 28-32 days, and four/1% longer than 32 days, indicating diverse product needs. Comfort discussing menstrual hygiene is moderate, with 273/70.9% somewhat comfortable, 94/24.4% very comfortable, and 18/4.7% not comfortable, suggesting persistent stigma and a need for fostering open conversations.

All students - 385/100% - use sanitary pads, indicating strong accessibility or cultural preference, though the lack of cloth use may reflect distribution programmes while raising environmental concerns due to disposable waste.

Only 135/35.1% change pads every few hours, while 44/11.4% change once daily, 114/29.6% less frequently, and 92/23.9% unsure, suggesting that limited facilities or supplies may contribute to infrequent changes, increasing infection risks. When cloths were used, 58/15.1% would dry them indoors, risking bacterial growth, and 221/57.4% would not store them cleanly, underscoring the need for education on reusable absorbents. Disposal practices are varied, with 129/33.5% using trash, 129/33.5% burning, 69/17.9% flushing, 22/5.7% burying, and 36/9.4% using other methods; flushing and burning pose environmental and infrastructural challenges, highlighting the need for improved disposal facilities.

Students exhibit strong hygiene practices: 385/100% bathe daily, 382/99.2% clean the genitalia before sleep, 369/95.8% use water for genital cleaning, 99.5% wash hands after toilet use, 381/99% wash hands with soap after changing absorbents, and 383/99.2% use separate undergarments. The small minority not in adherence may face resource or awareness gaps, but, overall, the practices are robust.

School menstrual hygiene facilities (students’ perspectives)

A total of 367/95.3% students reported that health and physical education were included in their school curriculum, suggesting the broad coverage of menstrual health topics, though the 18/4.7% gap may reflect inconsistent implementation or awareness.

Despite this, only 263/68.3% students had access to clean water and sanitation facilities during menstruation at school, While 294/76.4% perceived no deficiencies in menstrual hygiene resources, 91/23.6% identified existing gaps.

Reported challenges included inadequate water and toilet cleanliness (200/52%), stigma and shame (85/22%), school absenteeism (60/15.8%), and the fear of sudden leakage (40/10.2%), revealing both structural and socio-cultural barriers.

Significant associations were demonstrated between access to water and sanitation facilities and key hygiene behaviours, including absorbent changing practices, pad changing frequency, and disposal methods, underscoring the need to improve school infrastructure to support effective menstrual hygiene management.

While 13/76.5% schools provide adequate separate toilets, only 11/64.7% have locks, nine/52.9% maintain cleanliness, and eight/47.1% offer disposal bins, compromising hygiene and privacy.

The majority of schools, 15/88.2%, provide access to clean and safe water near toilet facilities, supporting menstrual hygiene management, though two/11.8% lack this resource. However, only 11/64.7% schools offer soap and hand-washing facilities with running water, leaving six/35.3% without adequate means for proper hygiene, which could increase health risks for students during menstruation.

While 14/82.4% provide privacy features, only 10/58.8% have changing spaces, 12/70.6% offer adequate lighting and ventilation, and nine/52.9% provide seating, indicating gaps in comfort. Only seven/41.2% schools have sanitary napkin dispensers or vending machines, limiting access to menstrual products, while 14/82.4% offer emergency supplies, indicating stronger support for addressing unexpected menstruation, though three/17.6% still lack such provisions.

Just over half of the schools, nine/52.9%, have proper disposal systems for used sanitary materials and regular hygienic waste collection, while eight/47.1% lack these facilities, posing hygiene risks. Additionally, 10/58.8% provide clear instructions for students on the disposing of sanitary materials, but, seven/41.2% do not, indicating significant gaps in effective waste management practices.

Only one/5.9% displays menstrual hygiene education materials, and five/29.4% offer training or library resources, highlighting a critical lack of educational support.

The majority of schools demonstrated strong support for menstrual hygiene infrastructure, with 15/88.2% to 16/94.1% of the respondents affirming the availability of essential provisions, including access to facilities for female staff, regular maintenance, collaboration with the local health authorities, availability during school events, accommodations for menstrual discomfort, and the promotion of a non-stigmatising environment.

Furthermore, 13/76.5% reported that the school infrastructure was accessible to students with disabilities. However, notable gaps remain: only seven/41.2% schools had systems in place for student feedback on menstrual hygiene facilities, and four/23.5% lacked infrastructure that is fully accessible to students with disabilities. These findings highlight the need for targeted improvements to ensure inclusive and responsive menstrual hygiene support within school settings.

Discussion

The universal use of disposable sanitary pads (100%) during school hours, indicates the widespread availability, accessibility, and cultural acceptance of these products among adolescent girls in this post-conflict region. This represents a marked improvement in menstrual hygiene product usage and signals meaningful progress in ensuring menstrual health in school environments.

While the data confirmed 100% pad use during school hours, this does not necessarily imply exclusive pad use in all settings, particularly in home environments or during emergencies. 

Despite this, challenges remain in actual hygiene practices and facility related adequacy. For example, only 35.1% changed pads every few hours, while a notable proportion changed pads less frequently or were unsure of their changing habits, suggesting barriers to optimal menstrual hygiene management.

Additionally, although 95.3% received menstrual hygiene education, the effectiveness of these programmes is likely compromised by deficiencies in school sanitation infrastructure. Only 68.3% of schools provided clean water and sanitation, 52% had unclean toilets, and less than half (47.1%) had adequate disposal facilities, echoing infrastructure concerns. 

The sample predominantly reflected regional socio-cultural characteristics, with 75.1% identifying as Hindu and 4.7% reporting discomfort discussing menstruation, underscoring the persistence of cultural stigma that may hinder open menstrual hygiene dialogue. Parental education, especially maternal, was positively associated with better menstrual hygiene practices, while lower paternal education correlated with limited resource access.

Economic constraints were evident, with 73.5% of families earning below Rs. 25,000 monthly, significantly linked to the use of less hygienic menstrual products (the United Nations Population Fund's "Annual report. 2015"), though this was not observed here due to the universal pad use.

Individual hygiene behaviours were strong; 100% reported daily bathing, and 99.5% practiced hand-washing after toilet use. However, gaps in home sanitation persist, as 7.8% lacked access to covered toilets, increasing the infection risk (per a South Asian study).

Finally, while disposable pad use is near universal, environmental concerns arise from improper disposal amid inadequate waste management systems. Overall, there is substantial progress in menstrual product use but there is a need to improve sanitation infrastructure and address socio-cultural barriers to optimise menstrual hygiene practices in schools.

Conclusion

In terms of limitations, the study did not include specific questions on the degree of absorbent saturation (e.g., whether pads were soaked or leaking). Menstrual hygiene education should be integrated into the curriculum, covering product use, disposal, and stigma reduction, with inclusive workshops engaging both male and female students.

Public-private partnerships (PPPs) are needed to subsidise reusable menstrual products, such as menstrual cups, coupled with hygiene education and support programmes. The Zonal Education Directorate should institutionalise menstrual hygiene policies, allocate funding for facility upgrades, and implement regular monitoring and evaluation. Training for teachers and feedback mechanisms for students would further enhance menstrual hygiene support in schools.

The reliance on self-reported data introduces potential biases, particularly underreporting due to stigma. 

Adolescent girls in this District demonstrate commendable personal hygiene practices. 

Addressing these challenges requires coordinated efforts among the educational authorities, public health stakeholders, non-Governmental organisations, and communities. Sustainable infrastructure development, comprehensive menstrual hygiene education, and equitable access to menstrual products are essential to safeguarding the health, dignity, and educational attainment of schoolgirls in resource-limited settings.

(This is the final Part of a two-Part article. Part I was published in a previous edition.)