• Economic barriers in the North  
• Lack of separate, clean and lockable toilets for girls, equipped with covered disposal bins, water and soap
• Lack of infrastructure such as ramps and adapted facilities for disabled students 
• Menstrual hygiene education should be integrated into the curriculum
• PPPs needed to subsidise reusable menstrual products 
• Zonal Edu. Directorate should institutionalise menstrual hygiene policies, fund facility upgrades, implement regular monitoring and evaluation
• Teacher training and student feedback mechanisms would enhance menstrual hygiene support 

Inadequate school facilities – the lack of separate, clean and lockable toilets for girls, equipped with covered disposal bins, water and soap, along with infrastructure such as ramps and adapted facilities to accommodate disabled students - and economic barriers remain significant impediments to the optimal menstrual health and personal hygiene of adolescent girls in the Northern Province.

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's First Issue.

Menstrual hygiene is a vital component of adolescent health, profoundly impacting physical health, educational attainment, and gender equity worldwide. Menstruation, a natural biological process signaling the onset of womanhood, involves a sophisticated hormonal cascade orchestrated by the hypothalamus, the pituitary gland, the ovaries, and the uterus. The median age at menarche in urban Sri Lankan girls is now approximately 13-13.5 years, with girls in better socioeconomic and nutritional environments experiencing it even earlier (11.8 years). These figures suggest a downward secular trend compared to earlier decades (per a Bangladeshi study). Menstruation is a natural biological process marking reproductive maturity in adolescent girls. Its management is influenced by a range of socio-cultural, economic, and infrastructural factors, which are critical to adolescent health, education, and overall well-being (per a Bangladeshi study). Globally, menstruation is often steeped in cultural taboos, myths, and stigma, fostering shame and misunderstanding. These societal attitudes shape menstrual hygiene practices, which remain an under-addressed public health concern (V. Chandra-Mouli and S.V. Patel's "Mapping the knowledge and understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low-and middle-income countries [LMICs]", and E. Coutinho and S. Segal's "Is menstruation obsolete?"). Challenges in menstrual management vary significantly due to socio-economic disparities, cultural norms, and inadequate infrastructure. In LMICs, limited access to hygienic menstrual products, clean water, and sanitation facilities hinders effective menstrual hygiene, increasing the risks of urinary tract infections (UTIs), reproductive tract infections (RTIs), and other gynecological issues (per a Ghanian study, and W. Fernando and P. Jayawardana's "Knowledge, attitudes and practices on menstrual hygiene and associated factors among Grade 10 schoolgirls in the District of Kalutara"). Such health challenges can impair long-term reproductive health, potentially contributing to infertility (A. Geetz, L. Iyer, P. Kasen, F. Mazzola and K. Peterson's "An opportunity to address menstrual health and gender equity"). Menstrual hygiene also intersects with education and gender equality (per a Ugandan study). The absence of adequate sanitation facilities, coupled with stigma and the lack of affordable menstrual products, leads to school absenteeism among girls. This disrupts academic progress, increases dropout rates, and perpetuates gender disparities (A. Hettiarachchi, T. Agampodi and S. Agampodi's "Period poverty in rural Sri Lanka: Understanding menstruation hygiene and related health issues to empower women"). Economically, the cost of menstrual products strains household budgets in impoverished communities, forcing many to resort to unsafe alternatives like rags or leaves. Infrastructure gaps, such as the lack of private toilets and waste disposal systems, further complicate hygienic menstrual management (S. House, T. Mahon and S. Cavill's "Menstrual hygiene matters: A resource for improving menstrual hygiene around the world", and C. Jasper, T.T. Le and J. Bartram's "Water and sanitation in schools: A systematic review of the health and educational outcomes"). Global initiatives, including those by the United Nations (UN) Children's Fund, the World Health Organisation, and non-Governmental organisations (NGOs), advocate for improved menstrual health through education, product access, and policy reform. Events like the Menstrual Hygiene Day (28 May) aim to destigmatise menstruation and foster an inclusive dialogue (per a Kenyan study). Innovations such as menstrual cups and reusable pads, alongside digital platforms for education, are transforming menstrual hygiene management, offering sustainable and accessible solutions (per a Nicaraguan study, and D. Joshi, D. Gonzalez and G. Buit's "Menstrual hygiene management education and empowerment for girls?"). In Sri Lanka, menstruation is deeply entwined with cultural traditions, shaping perceptions and practices. Often viewed as a taboo, menstruation lacks open discussion, perpetuating misconceptions and inadequate hygiene practices. Socio-economic barriers exacerbate these issues, particularly for low-income families who struggle to afford sanitary products, in turn resorting to unhygienic alternatives (per an Indian study, and I. Kandauda, S. Bandara, S. Tennakoon and T. Gunathilake's "Awareness of menstrual symptoms and related problems among schoolgirls in the Kandy Municipal area: A descriptive study"). Educational institutions frequently lack proper sanitation facilities and menstrual health education, hindering effective management (R. Kaur, K. Kaur and R. Kaur's "Menstrual hygiene, management, and waste disposal: Practices and challenges faced by girls/women of developing countries").

Efforts by NGOs, international agencies, and local groups aim to address these challenges through education, product distribution, and advocacy. Despite progress, rural and marginalised communities often remain underserved (per a South Asian study). Cultural beliefs imposing restrictions on menstruating girls, such as limiting social or educational participation, further entrench gender inequality (O. Lusk-Stover's "Globally, periods are causing girls to be absent from school", and a Tanzanian study). Recent advancements, including affordable reusable products and digital education platforms, are fostering greater awareness and accessibility, yet, sustained efforts are needed to ensure that all girls manage menstruation with dignity (per a Kenyan study).

The Northern Province, scarred by decades of civil conflict, faces unique challenges in menstrual hygiene management. The war disrupted healthcare and education infrastructure, particularly in areas of the said Province, leaving schools without adequate sanitation or clean water (per a Ugandan study, and an Indian study). Cultural stigmas surrounding menstruation limit open dialogue, contributing to poor hygiene practices and health risks (per an Indian study). Poverty and economic instability restrict access to menstrual products, while limited healthcare services hinder menstrual health education and support (K. Piyadasa and C. Goonewardene's "An insight to menstrual hygiene and practices among adolescent girls aged above 15 years in the Tangalle Education Division").

The lack of proper facilities leads to school absenteeism among girls, undermining educational outcomes. NGO and Government initiatives strive to improve conditions, but, funding and logistical barriers persist (S. Raguraman, B. Balagobi, Y. Shanmuganathan, U. Powsiga, S. Kanesamoorthy, T. Kiruththiga, G. Rajeev and S. Kumaran's "Prevalence of sub-fertility and associated factors in the Jaffna District: A cross sectional study"). Rebuilding infrastructure and enhancing menstrual health education are critical to improving menstrual hygiene in the Northern Province.

The study District, at the heart of the Northern Province, grapples with the legacy of conflict, poverty, and inadequate infrastructure. Schools often lack separate, well-maintained toilets and clean water, making menstrual management challenging for adolescent students. Cultural stigma and methods, and limited education foster poor hygiene practices, compounded by psychological stress from post-conflict trauma (per a South African study, and an Indian study). Many girls rely on unhygienic absorbents due to financial constraints, facing social isolation and emotional distress during menstruation.

By addressing infrastructural, cultural, and educational barriers, girls can be empowered to navigate menstruation confidently in a post-conflict context (S.M.N. Samarakoon, S.M.P. Samarakoon and P. Pelenda's "Exploring women's hygiene practices in underserved communities: A case study in the Elapatha rural area, the Sabaragamuwa Province").

Menstrual hygiene practices depend on the choice of absorbents, and are influenced by cost, availability, and cultural preferences. Reusable cloth pads are common in rural areas for their affordability and sustainability, requiring proper washing and drying (U. Sekaran and R. Bougie's "Research methods for business: A skill-building approach"). Commercial sanitary pads dominate urban settings for convenience but are costlier and less eco-friendly (per a Gambian study). Menstrual cups and reusable tampons offer sustainable alternatives, though awareness and initial costs limit adoption. Innovative products like bamboo, banana fibre, and water hyacinth pads provide eco-friendly options, while disposable products contribute to environmental waste (per an Indian study). Promoting access to sustainable absorbents is key to improving hygiene and reducing the environmental impact (M. Sommer and M. Sahin's "Overcoming the taboo: Advancing the global agenda for menstrual hygiene management for schoolgirls").

Menstrual hygiene is a critical public health issue with far-reaching implications for adolescent girls’ health, education, and empowerment, particularly in the Northern Province, a region marked by post-conflict challenges. Poor hygiene practices increase risks of infections like UTIs and RTIs, which can lead to sub-fertility and long-term health issues (N. Sommer, J. Hirsch, C. Nathanson and R. Parker's "Comfortably, safely, and without shame: Defining menstrual hygiene management as a public health issue", and M. Sommer, B.A. Caruso, M. Sahin, T. Calderon, S. Cavill, T. Mahon and P.A. Phillips-Howard's "A time for global action: Addressing girls' menstrual hygiene management needs in schools"). Absenteeism due to inadequate facilities and stigma hinders academic progress and perpetuates gender inequality. 

Menstrual hygiene involves using clean menstrual products (e.g. pads, tampons, cups), maintaining personal hygiene through regular changes and washing, and ensuring the hygienic disposal of menstrual waste. Access to clean water, sanitation facilities, and private spaces is essential to manage menstruation with dignity, minimising health risks and the environmental impact (M. Sommer, C. Figueroa, C. Kwauk, M. Jones and N. Fyles's "Attention to menstrual hygiene management in schools: An analysis of education policy documents in LMICs", an African study, an Indian study, and the UN Education, Scientific and Cultural Organisation's "Education for people and the planet: Sustainable Development Goals").

Menstrual hygiene is a vital component of adolescent health and education.

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%), 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 UN 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, NGOs, 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.