Solution Exchange Consolidated Reply: Comments on booklet on menstrual hygiene management

A consolidated reply of experiences and examples shared by various members of the Solution Exchange Water Community

Compiled by Bonani Dhar and Nitya Jacob, Resource Persons and Sarika Dhawan and Ramya Gopalan, Research Associates

Issue Date: 31 May 2008

Query:

From Lizette Burgers, United Nations Children's Fund (UNICEF), New Delhi

Posted 24 March 2008

Dear Members,

The Government of India launched the Total Sanitation Campaign (TSC), a comprehensive national program to ensure sanitation facilities in rural areas, in 1999. Despite a rapid increase in sanitation coverage, the agenda of achieving total sanitation remains incomplete without addressing the sanitation needs of women specially related to Menstrual Hygiene Management (MHM). This is rights based issue of women accessing clean hygienic methods for healthy living with dignity. The issue stems from lack of access to information and affordability.

Given   the   fact  that  adolescent  girls  face  considerable  amount  of embarrassment  due to lack of information on time, being not guided by even peers  and  lack  of  affordability  for  sanitary  napkins,  their  school attendance and over all confidence level suffers.

The Department  of Rural Development in Tamil Nadu with support of the United Nations Children’s Fund (UNICEF) has initiated comprehensive  action to deal with these issues by engaging NGOs  and  women  Self-Help Groups (SHGs) in creating awareness and building their capacities  to  manufacture  low cost sanitary napkins, adopting innovative marketing  strategies  to reach the rural women, involving adolescent girls in providing information and developing mechanisms for safe disposal at the school,  household  and at community level.

Please click on the following link to know   more   about   the   workshop on menstrual hygiene-http://www.unicef.org/india/wes_2819.htm.

UNICEF has developed a booklet on “Sharing Simple Facts: Useful Information about Menstrual Health and Hygiene” that can be downloaded from the link http://www.solutionexchange-un.net.in/gender/cr/res11030801.pdf (PDF, Size: 2.80 MB).

We would like to request suggestions and feedback on the booklet, based on members experiences and expertise, specifically we would like comments on:

Relevance of the booklet, in terms of content, approach etc.

Whether the issue of MHM should be included as an integral part of the TSC or is better taken forward by the National Rural Health Mission (NRHM)?

Additionally, please share your opinion/ experiences about making MHM or related topics compulsory in higher secondary schools- How is the issue dealt with currently, what is the adequacy of content of the curriculum used, what are the actual transactions in the classroom and constraints.

Your responses will be valuable to us in framing up our strategies.

Responses were received, with thanks, from

1.    Pravin H. Khobragade, United Nations Children’s Fund (UNICEF), Chhattisgarh

2.    K. Mahesh Kumar, School Sanitation and Hygiene Education Consultant, Bhopal

3.    Charulatha Banerjee, Terres Des Hommes Foundation, Kolkata

4.    Alka Pande, Indian Express, Lucknow

5.    Shruti Goel, Ministry of Urban Development-GoI, New Delhi

6.    Abhishek Mendiratta, Consultant, New Delhi

7.    Bhawna Vajpai, Water and Sanitation Consultant, New Delhi

8.    Hemant Khosla, Department of Drinking Water Supply-GoI, New Delhi

9.    Dhanashri Brahme, United Nations Population Fund (UNFPA), New Delhi

10.  Nirmalya Samanta, Institute of Life Long Learning, University of Delhi , New Delhi

11.  Madhu Sharma, PRIA, New Delhi

12.  Arin Basu, University of Canterbury, New Zealand 

13.  Veena Upadhyay, Sulabh International Academy of Environmental Science, Patna

14.  Lizette Burgers, United Nations Children’s Fund (UNICEF), New Delhi

15.  Vinita Sharma, Department of Science and Technology, New Delhi

16.  Biswajit Padi, SRUSTI, Orissa

17.  Maria Fernandes, WaterAid (UK) – India, Bhopal

18.  Julie Thekkudan, PRIA, New Delhi

19.  Rajesh Mehta, World Health Organization (WHO), New Delhi

20.  Yusuf Kabir, Water and Environmental Sanitation, United Nations Children’s Fund (UNICEF), Kolkata

21.  Gyanendra Mishra, Unified Development Association for the Amelioration of Neglected, Aligarh

22.  Raj Ganguly, ACDI VOCA, Jaipur

23.  Chaman Pincha, Beyond Boundaries, Chennai

24.  Prakash Nayak, Tata-Dhan Academy , Madurai

25.  Sharaf Abbas, Social Consultancy Services, Lucknow

26.  Debjani Ghosh, National Foundation for India , New Delhi

27.  Annie Namala, Program for Inclusion and Equity (PIE), New Delhi

Summary of Responses

Realizing the need to share basic facts on menstrual health and hygiene, members applauded the initiative by UNICEF to develop a booklet on Menstrual Hygiene Management (MHM) and mainstream gender They felt it was an extremely relevant document, and appreciated the unique question and answer approach.

Discussing the sanitation and hygiene needs of adolescent girls and young women, members argued the booklet would be very useful in clarifying doubts on menstrual health and hygiene. This will prove an effective tool for breaking the silence and taboos surrounding menstruation and women’s health. They highlighted that girls and women across cultures remain unaware of the facts of menstruation. For example, a study on taboos surrounding menstruation found that in some families, adolescent girls do not play with boys due to fear of pregnancy, in states like Chhattisgarh some women avoid taking a bath for first three days of their periods and women and girls are subjected to various other restrictions. Additionally the McArthur Foundation in rural areas of Uttar Pradesh and Rajasthan, did a study on the onset of menarche and related myths and misconceptions, and learned that girls have various erroneous beliefs and practices.

Discussing making MHM topics/content compulsory in higher secondary schools members felt to address the knowledge gap and attitude in this area, it was necessary to think beyond the booklet and look at converting it into a formal program. The topic could also be included in middle school curriculum as students especially girls need to be educated on MHM.

Members pointed out that MHM is often not acknowledged in India . They supported the idea of integrating it into a nationwide government programme, and reflected on the pros and cons of including it as a part of the Total Sanitation Campaign (TSC) or National Rural Health Mission (NRHM).

On integrating MHM with NRHM, discussants suggested working with social marketing projects that promote sanitary napkins and other Reproductive and Child Health (RCH) products funded by the Ministry of Health and Family Welfare (MoHFW) or NRHM. They argued NRHM has an advantage over TSC, because of the core strength of this programme- the Accredited Social Health Activist (ASHA). NRHM can train ASHAs can to incorporate MHM into reproductive health activities. Respondents also recommended field-testing the booklet in the NRHM school health programme, and then modifying it to include the perspectives of rural adolescent girlss. At the same time members cautioned, the NRHM programme may not have the capacity to focus on MHM, which would be an additional component, beyond its original mandate.

Noting the focus of NRHM is towards health service delivery, rather than preventive health and behavioral change, some respondents recommended MHM be rooted in TSC. The objective of TSC is to accelerate sanitation coverage in rural areas and promote better hygiene behavior by educating people on sanitation and safe water. Moreover, village level motivators could act as vehicles for attitude and behavior change.

Additionally, members felt there was scope for integrating MHM under the School Sanitation Hygiene Education programme (SSHE), a component of TSC and argued there was a need for better coordination and collaboration between TSC implementing partners, such as Rural Development Departments, Education Departments, and Public Health Engineering Departments (PHED). Further, they suggested that if integrated under TSC, MHM could be linked to the Gram Panchayats’ Solid and Liquid Wastes Management action plan, which is being considered as one of the criteria, along with household level toilet coverage for the Nirmal Gram Puraskar.

Discussants also recommended examining the Biomedical Wastes Management and Handling Rules 1996 (Government of India) when looking at sanitary waste disposal, especially in urban areas where sanitation workers sometimes refuse to collect and/or dispose of sanitary napkins.

Respondents opined the communities remains divided between modern and traditional menstrual management practices, and advised developing a good communication strategy with an action plan to popularize cost effective sanitary napkins among adolescents. They recommended adopting creative media strategies, like the one used to advertise emergency contraception, and advocating the issue through non-conventional channels like rural haats, melas and mahila mandals. Members highlighted successful initiatives like Sakhi in Orissa promoting sanitary napkins through SHGs, Anganwadi centres, mahila mandals, etc. and other initiatives like Hindustan Latex Family Planning Promotion Trust (HLFPPT) work on social marketing and franchising and Johnson and Johnson’s through its School Education Program booklet. Additionally, respondents argued that changing the mindsets of men and elderly family members could foster stronger psychosocial support and create an enabling environment to address the health, hygiene and sanitation needs of women.

Sharing experiences with projects addressing MHM issues, discussants mentioned the collaborative efforts by Terres Des Hommes and PRAYAS along with the state education department in Andaman Islands to improve sanitation practices among families. They also mentioned work in Maharashtra schools to educate girls on menstruation and health and the efforts of the Department of Science and Technology Government of India to produce low-cost sanitary napkins.

Commenting on the booklet, members provided a number of suggestions on it’s content, style and structure along with offering ideas to ensure greater acceptance and wider dissemination:

• Add more illustrations/pictures to make the booklet self explanatory
• Provide a small “MHM do's and don'ts,” sheet, with info on individual and community health
• Include a chapter on nutrition, with information healthy foods
• Add a checklist listing the changes which occur during puberty to boys (possibly in a box format)
• Expand the scope of the booklet, to include information to address problems faced by women in rural and semi-urban areas, such as lack of privacy for changing pads and disposal issues
• Add disclaimer so the booklet is not perceived as providing prescriptive message
• Include the suggestion that schools could have shared girls’ lockers near the toilets, for girls to keep sanitary napkins, change of clothes, etc.
• Consider removing the section on sanitary napkins, because it could dilute the focus of the booklet, which is intended to serve as a self-reference guide for girls to gain information on MHM
• Do not name specific brands of sanitary napkins, and provide info on accessing locally made napkins
• Make the language simpler
• Design the booklet according with a health perspective and not just looking a hygiene and sanitation
• Translate the booklet into regional language
• Distribute at least one packet of sanitary napkin with the booklet to adolescents’ girls
• Pre-test/field test (including conducting focused group discussions) the booklet before finalizing it and disseminating widely among adolescent girls and young women
• Create a pocket sized booklet or pamphlet for wider dissemination beyond schoolgirls
• Since the booklet’s focus is MHM, a separate chapter on ‘Facts about HIV/AIDS maybe unnecessary 

Finally, some respondents suggested publishing it as a small booklet so girls could easily put it in their pocket to avoid embarrassment. At the same time, others argued instead of making the booklet discrete (small), efforts are necessary to overcome barriers faced by girls to openly discussing MHM.

Sharing a quote by the educational thinker, "… we teach a subject not to produce little living libraries on that subject, but rather to get a student to think, to take part in the process of knowledge getting... Knowing is a process, not a product,” members were hopeful that this booklet would help the adolescent girls in managing their health effectively.

Detailed comments on each section of booklet shared by members are listed below.

Growing Up - The Normal Way

• Revise the introduction to make it less lengthy and repetitive
• Avoid using the term "normal,” which hints that patterns of growing up are "abnormal"
• Change the word “from school” to “any other work” in the sentence on “that Menstruation and its management at home and in school” in the box on page one
• Stress on the booklet as a tool for teaching and learning rather than self-esteem and academic performance as stated in the box on page one
• Include on page three a diagram in the section on “What are the physical changes that happen during puberty/adolescence?”
• Clarify the sentence on page four in the section “How long does it take for breasts to be fully developed? If a girl starts later than other girls, it does not mean that her breasts will always be smaller. What does "if a girl starts later mean?”
• Reword the sub-point on self-consciousness, “Girls take growth spurt before boys” on page six to says “the growth spurt in girls starts before that of boys”
• Add on page three the section “What is puberty? Why does it happen?” the line “What should you know about puberty?”
• Rephrase on page four the section on ”What are the strategies that girls could adopt to help through puberty” as the word strategize seems inappropriate in this context.
• Include a few sentences on skincare on page four in the section on ”Why do many teenagers have skin problems during puberty?”
• Reduce the number of “should” on page four the section on “First girls should learn about the changes. Second, girls should understand that the changes are normal. Third they should learn how to adapt to the changes”
• Use illustrations and pictures to depict changes during puberty to break through the language barrier.
• Elaborate on the sub-point on future uncertainty on page six in the section on “What are the emotional changes that occur during puberty?”- this section is very important as in many familes physical changes during puberty leads to pressure and  concerns towards the safety of the young girls, influence of peers and their marriage
• Expand on the line on page seven “however households with educated parents and modern outlook seem to be changing these days” to tone down the slight bias towards educated and modern outlook families.
• Revise on page seven the section “Why is there seclusion during menstrual periods in some communities?,” because now seclusion is not as prevalent
• Elaborate on page seven in section on “Why is the onset of menarche (first menstruation) celebrated in some sections?” Give details as this ritual is culture specific and celabration of menarche may connote insensitivity to young girls

Dealing with menstruation

• Add illustrations/pictures and diagrams for better presentation of myths and realities
• Revisit the statement on page nine saying menopause occurs at forty, because age varies from women to women, instead put the average age range
• Present the information on page ten in the section on “What happens during menses?” pictorially
• Delete the line about “preparing for menstruation on a regular basis” this can be avoided as it has been mentioned in the previous answers
• Incorporate “other work” into the sentence on page thirteen ‘”can continue going to school… sports or college”
• Explain in the first paragraph on dealing with menstruation and visiting places of worship, the ration why girls and women are traditionally excluded from participating in ceremonies
• Include more information on page eleven in the section on “what is Pregnancy?”
• Add the text “any other point of time” on page eighteen in the section “Should one eat separately from family members while having periods?’’

Managing menstruation

• Include illustrations on page nineteen in the section on “What products do girls usually use during menstruation”
• Add a detailed explanation on “do’s and don’ts when using sanitary napkin”
• Change the sentence "a normal regular period is usually about 28-32 days long" to "a normal regular period is usually about three-seven days long"
• Correct on page twenty-two in the section on “How often is a women supposed to have her period? What color is the blood in your period supposed to be? Is it supposed to be red or brown?’” the sentence "Period length varies from girl to girl (twenty one to thirty five days also) and this is perfectly normal," instead make it "Interval between period varies from girl to girl (twenty one to thirty five days also) and this is perfectly normal"
• Alter the wording on pages twenty and twenty-two in the section on “What products do girls usually use during menstruation”- change “Never flush a sanitary or cloth pad down the toilet as this may cause serious plumbing problems as well as serious embarrassment after the plumber discovers what caused the problem!” to "never flush a sanitary or cloth pad down the toilet"
• Questions on page twenty-five and twenty-six must follow question one and two on page 19 and 20  as they deal with the sanitary napkins and its use, and the questions on pages twenty-one to twenty-four should come next as they cover different issues
• Add to the list of questions "What should girls carry during menstruation?"
• Provide a list of tips for managing menstruation in school like wrap spoiled pads in old newspaper, use two sanitary napkins on heavy days, carry a spare panty and a small piece of soap or soap strips for any contingency
• Include coconut oil as a way to relieve rashes on page twenty-nine in the section on “General Hygiene Measures”
• Add point on proper storage of sanitary napkins, to prevent infection and ensure clothes are properly reused on page twenty-five in the section on “How do we make cloth menstrual pads?”
• Include on page twenty-one in the section on “What if a girl suddenly bleeds through her clothes” the suggestion that a girl or woman can cover her clothes with a “chunni” or “scarf” or the end of a sari
• Add pictures on page thirty in the section on “Nutritional Requirements” of a balanced diet and the foods to be avoided then menstruating
• Add on page twenty-eight in the section on “Menstrual management is supported by schools” that all girls irrespective of their social position and caste affiliation must be allowed to use school toilet
• Change the word on page twenty-nine in the section on “How does a girl manage if she gets her periods while in school?” from “uniform” to “dress,” because not all schools have uniforms

Disposal of napkins

• Make having a garbage bin mandatory in girls’ toilets in rural government schools
• Approach members of Bal Sansad and Meena Manch to take responsibility for ensuring clean toilets
• Suggest cheap and affordable alternatives to rural and poor girls who cannot afford sanitary napkins
• Train adolescent girls to calculate their Last Menstruation Period (LMP) and inform them about the method for calculating the Expected Date of Delivery (EDD)  
• Incorporate details on designing toilets with an incinerator
• Design and construct separate toilets for boys and girls with provision for sanitary napkins disposal

Comparative Experiences

Maharashtra

Segregation by Sex of Audience and Teachers, Malvani, Mumbai 

While imparting knowledge on 'family life education' to ninth standard class male students it was inferred that a captive audience segregated by sex in schools is the best arrangement for imparting knowledge. In case of educating girls on MHM, it was found that having woman teachers in the classroom helped girls seek clarification on managing menstruation in school. Further woman teachers also helped in pushing for better facilities later during the management meetings.

Andaman Islands

Holistic Approach in Adopting Correct Sanitation Practices, Little Andaman 

Terres Des Hommes Foundation Lausanne in partnership with PRAYAS equipped all government schools with toilets and repaired existing toilets. The project also focused on improving the children's and their family’s knowledge and sanitary practices. This holistic approach adopted toward improving children’s health by improving damaged infrastructure and building the capacity of communities to maintain and use them, proved effective. 

Orissa

Users Divided Between Modern and Traditional Practices 

During 2001-05, HLFPPT promoted the use of Sanitary Napkins (Sakhi) through unconventional networks like SHGs, Anganwadi Centers, Mahila Mandals and stationery shops. Interactions with local cloth traders revealed Kandhamal tribals used sanitary napkins made by local traditional weavers. It was discovered that over time, the market share of traditional napkins decreased due to increased use of modern ones, however market penetrations of branded products was not encouraging. 

Uttar Pradesh and Rajasthan

Broad Perspective Encouraging Behavioral Change 

To address the widespread myths and misconceptions about menstruation, a foundation supported an in-depth need assessment in rural areas; highlighting the need to ensure responsible handling of menarche. The goal of the initiative was to move beyond the narrow perspective of MHM as simply a biological or physiological phenomenon towards having a more significant role in developing the self-esteem, positive self-image and responsible, healthy and clean habits among girls throughout their lives.

India

Development of Low-Cost Sanitary Napkins 

The Department of Science and Technology, Government of India has been working on developing  a low-cost sanitary napkin, with the same characteristics as the products produced by multinational corporations. The earlier technology used was based on waste rayon and was discarded since it was dependent on a single source for raw material. However, now a technology based on waste material from knit ware has been standardized and is now ready for transfer.

International

Bangladesh

Overcoming Initial Shyness and Including MHM in Toilet Designs, Dhaka 

While designing a watsan program, WaterAid undertook a baseline survey on beliefs and practices on MHM in slums followed by a sharing/action workshop among all its staff and partners who then committed to addressing the problem and giving positive messages on watsan. Female staff discussed the issue with adolescent girls/women in villages, slums and schools using flash cards, pocket books, dolls etc. and community also “built women friendly toilets.”

Related Resources

Recommended Documentation

Bio-Medical Wastes Management and Handling Rules 1998: Amended on 2000

Rules; Documentation Centre, National Institute of Health and Family Welfare; New Delhi ; 2000

Available at http://www.nihfw.org/ndc-nihfw/html/Legislations/BiomedicalWasteManagement.htm

Covers disposal of sanitary napkins as per Government of India guidelines as part of waste management and handling to ensure safe hygiene practices during menstruation

Municipal Solid Wastes (Management and Handling) Rules, 2000

Notification; by Ministry of Environment and Forests (MoEF); New Delhi; 25 September 2000

Available at http://envfor.nic.in/legis/hsm/mswmhr.html

Needs to include disposal of sanitary napkins and induce sensitivity among Gram Panchayat members for planning efficient disposal of used sanitary napkins towards MHM

School Education Program 

Booklet; Johnson and Johnson; 2003; Permission Required: Yes. Copies can be acquired from Alka Gadgil; Johnson and Johnson; AGadgil@JNJIN.JNJ.COM  

Booklet on menstrual hygiene used for class room orientation sessions, translated in regional languages and is in the form of a story line, which serves as an infotainment tool

Menstrual Hygiene and Management in Developing Countries: Taking Stock

Paper; by Sowmyaa Bharadwaj and Archana Patkar; November 2004

Available at http://www.schoolsanitation.org/Resources/Readings/Bharadwai-2004-Menstrual.doc (Doc Size: 183 KB)

Highlights the issue of what adolescent girls/women require to manage their menstrual needs in terms of materials, education and facilities for management and disposal.

Breaking the Silence on Menstrual Hygiene in Bangladesh

Article; IRC; Netherlands; 20 February 2008

Available at http://www.irc.nl/page/39141

Recounts Bangladesh's experience in incorporating menstrual management in latrine design and construction

Menstrual Hygiene and the Need for Women Friendly Toilets

Article; Sanitation Updates; 28 February 2008

Available at http://sanitationupdates.wordpress.com/2008/02/27/menstrual-hygiene-and-the-need-for-women-friendly-toilets/

Discusses how sanitation programmes and latrine design are silent about women and adolescent girls’ need to clean and change menstrual towels and menstrual management

Production of Low Cost Sanitary Napkins

Article; United Nations team For Tsunami Recovery Support; 2006

Available at http://www.un.org.in/untrs/sstories/content_01.asp?ref=ss_19

Brief on a training programme for women/adolescent girls in a Tsunami affected village in Kanyakumari on personal hygiene and production of low cost sanitary napkins

Recommended Organizations and Programmes

Total Sanitation Campaign, New Delhi

Department of Drinking Water Supply, (Rajiv Gandhi National Drinking Water Mission), Ministry of Rural Development, Govt. of India, 9th Floor, Paryavarn Bhawan, CGO Complex, Lodhi Road, New Delhi 110003; Tel: +91-11-24361043; Fax: +91-11-24364113; jstm@water.nic.in; http://ddws.gov.in/tsc_index.htm

Recommended to include as part of its program activities on MHM particularly under the School Sanitation and Hygiene Education (SSHE)

United Nations Children's Fund (UNICEF), New Delhi

73 Lodhi Estate, New Delhi 110003; Tel: +91-11-24690401/24691410; Fax: +91-11-24627521/ 24691410 newdelhi@unicef.org; http://www.unicef.org/india/health.html

Developed guidance booklet and film on MHM to serve as a self reference and support for girls and women, providing basic factual information about menstruation and hygiene

National Rural Health Mission (NRHM), New Delhi 

Ministry of Health and Family Welfare, 244-A Nirman Bhawan, Maulana Azad Marg, New Delhi; Tel: +91-11-23061195; http://www.mohfw.nic.in/NRHM.htm

Recommends including MHM activities under this program as part of efforts towards family health and hygiene focussing on women and adolescent girls

PRAYAS, Pune

Amrita Clinic, Athawale Corner, Karve Road Corner, Deccan Gymkhana, Pune 411004 Maharashtra; Tel: +91-20-25441230; Fax: +91-20-25420337; prayashealth@vsnl.net

Instituted a project, to equip all Government schools in Little Andaman with toilets and repair existing toilets to ensure safe hygienic practices particularly during menstruation

Terre des Hommes International Federation, Switzerland

Headquarters, 31 chemin Franck Thomas, CH-1223 Cologny/Geneva, Switzerland ; Tel: +41-22-736-33-72; Fax: +41-22-736-15-10; info@terredeshommes.org;

http://www.terredeshommes.org/index.php?lang=en&page=abo

Collaborated with Education Dept. and PRAYAS on a project, so all government schools in Little Andaman will have toilets, ensuring safe hygienic practices particularly during menstruation

Hindustan Latex Family Planning Promotion Trust (HLFPPT), Noida 

B-11, Sector-59, Noida 201301 Uttar Pradesh; Tel: +91-120-4231060-62; Fax: +91-120-4231065

Implements programs to encourage healthy behaviour particularly MHM and to increase access to health products and services, at affordable prices like low cost sanitary napkins

Department of Science and Technology, New Delhi 

Technology Bhavan, New Mehrauli Road, New Delhi 110016; Tel: +91-11-26567373/26962819; Fax: +91-11-26864570/26862418; dstinfo@nic.in; http://dst.gov.in/scientific-programme/s-t_scst.htm

Working on the development of a low cost sanitary napkin having the same characteristics as the MNC products

The John D and Catherine T. MacArthur Foundation, United States 

Office of Grants Management, 140 S. Dearborn Street, Chicago, IL 60603-5285 United States ; Tel: +1-312-726-8000; Fax: +1-312-920-6258; 4answers@macfound.org

Supported an in-depth needs assessment in rural areas and undertook an initiative towards addressing popular myths and misconceptions towards menstruation and hygiene

Responses in Full 

Pravin H. Khobragade, United Nations Children’s Fund (UNICEF), Chhattisgarh

I have glanced through the module.  My feedback is below:

• Can we have a handbook (which goes in the purse) instead of a big book
• The physical changes in body could be supplemented by diagram (Page no 3 of the module)
• Some corrections are necessary. Examples as below:
• On page no 4 of the module, "if a girl starts later than other girls, it does not mean that her breasts will always be smaller". What does "if a girl starts later" mean? Is the 'start' menarche or development of breasts? Needs clarification.
• On page no 6 of the module, "Girls take growth spurt before boys", could be better worded that the "The growth spurt in girls starts before that of boys"
• On page no 7 of the module, "This ritual is normally practiced". Which ritual? It is not described.
• On page 10, what happens during menstruation? Could be supplemented by diagram?
• On managing menstruation, again the use of cloths, sanitary napkins can supplemented by diagrams.
• Refer to page 22 of the module. Please correct the following from "A normal regular period is usually about 28 - 32 days long" to "A normal regular period is usually about 3 - 7 days long". Please correct the following from "Period length varies from girl to girl (21 to 35 days also) and this is perfectly normal" to "Interval between period varies from girl to girl (21 to 35 days also) and this is perfectly normal"

On the issue of whether this needs to be a part of the TSC of NRHM. I feel that NRHM is too loaded right now and is striving hard to reach the goals of reduction in IMR and MMR. I have an experience earlier on imparting knowledge on 'family life education' to 9th standard class male students during my thesis work on in Malvani, Mumbai. Drawing from this experience, I feel that the captive audience (segregated by sex) in schools are the best to impart knowledge.

In case of MHM to girls, it would be advisable to have lady teachers too in the classroom to seek clarification on the managing menstruation in school and pushing for better facilities later during the management meetings. Hence, I feel MHM could be taken up with coordination, facilitative and financial support from the Education dept with technical support from NRHM.

K. Mahesh Kumar, School Sanitation and Hygiene Education Consultant, Bhopal

Menstrual Hygiene Management (MHM) in spite of being a 'felt need' is often not acknowledged and least addressed in India for reasons that are aptly mentioned in the booklet. UNICEF's attempts to mainstream the issue and conceive such a helpful learning material is worth appreciation.

I wish to share few suggestions that might help enhance the effort:

• Relevance of this booklet is unquestionable and Q&A approach adopted to narrate the content is appropriate. However, the chapter on 'Facts about HIV/AIDS' could be avoided. My intention is not to undermine the relevance or the need to educate students about HIV/AIDS. But looking at previous reactions met by UNICEF's 'sex education' material by 'cultural police' and 'right-wing state government’s’. In this context I feel, by avoiding one chapter if we can make this useful material reach to the maximum audience, I am all for it and further there are other programmes that address HIV/AIDS at schools.
• Adding sanitary napkin making process (including cost estimates and pictorial depictions ) In the chapter 'Managing Menstruation' could be of a great help, if anyone want to start such an initiative with the help of their family or friends. 
• Disposal detailing at school such as design of the toilet with incinerator etc. could have added more meaning to the chapter 'Disposal of Napkins'.
• SSHE is part of TSC and MHM can become an extension of the same and promoting it through TSC makes better sense. Further NRHM and its implementation structure is more inclined towards promotive and curative health rather than preventive health and behavioral change sphere of MHM. The issue we got to deal with will be of coordination, in most of the states TSC is implemented either by Rural Development Department or PHED and Education Department is often sidelined resulting in lack of ownership. So attempts should be made to coordinate these efforts from State to School level.

Charulatha Banerjee, Terres Des Hommes Foundation, Kolkata

This booklet is a good effort that addresses an issue that is almost always discussed as an afterthought in a life skills session and worse still, often forgotten. Some of respondents to the mail have done a great job in actually proofreading the manual - I have just a few observations.

A detailed step by step section on making of cost effective sanitary napkins would be extremely useful. This should include the specifications of type of cotton/ any other absorbent material and also the lining etc.

In my opinion Menstrual Hygiene should form a component of Sanitation campaigns   run by any agency. School Health is an important component of the NRHM and within this Menstrual Hygiene should form an important component.

It would be interesting to know the feedback from field testing processes in different urban and rural contexts.   

Terres Des Hommes Foundation Lausanne in partnership with PRAYAS which in collaboration with the ANI Education Dept has instituted a project, through which all Government schools in Little Andaman will be equipped with toilets or in schools where toilets exist but need repairs, will be repaired. This programme also focuses strongly on improving children's and their family’s knowledge and practice on correct sanitation practices. A holistic approach towards improving children’s health through improving damaged infrastructure and supplementing where necessary and also building capacity of communities to maintain and use them effectively is the guiding principle. 

I am sure that this manual will be a useful guide for us to introduce the topic of Menstrual Hygiene. We look forward to the final version of this and translated versions also.

Alka Pande, Indian Express, Lucknow

The effort of UNICEF in bringing this informative booklet is indeed commendable. I am no authority to give any suggestions. But since I am a mother of a girl whom I taught about female anatomy, menstruation, STD, HIV, AIDS and child birth etc. when she attained puberty, and since I am in a profession where we come across the gross realities of life, I would like to point out certain points which come instantly into my mind after going through this discussion and the material provided with it.

The book is in English - which is a drawback. Reason is simple - most of the girls coming from English speaking families, either know more or less about menstruation and hygiene related to it, or are told by their parents and family members;

If the book had more pictures and fewer words, or if it can be translated in regional languages, it would become more useful for those who actually need to be educated on the issue;

Secondly, as one of the members has wisely pointed out, that, if the book is small which can be kept in a bag, it would reach more girls by way of sharing. Also many a girls feel shy talking openly about such issues, for them the small booklet would serve better purpose;

Coming from a Hindi speaking state which is also stricken with illiteracy and poverty, I also must point it out that majority of girls in Uttar Pradesh cannot afford sanitary napkins. Here, I would like to appreciate the endeavor of Tamil Nadu government and UNICEF, who have come up with affordable alternatives. I was wondering if the same effort can be replicated in this state and other states as well!!

Shruti Goel, Ministry of Urban Development-GoI, New Delhi

I am working with Hindustan Latex Family Planning Promotion Trust (HLFPPT) a national level NGO working in the area of social marketing and social franchising, maternity and child health and HIV-AIDS.

I feel this booklet should become an integral part of all social marketing projects funded by Ministry of Health and Family Welfare (MOHFW) or National Rural Health Mission (NRHM), that promote sanitary napkins and other RCH products. This would enable product support to go along with the information provided and hence I feel, the booklet will come in direct implementation.

The idea is that the issue of access, acceptance and affordability towards sanitary napkin can be tackled by Social Marketing and hence such communication material/aid should strengthen this innovative strategy.

Hence, my suggestion is to link it up and provide adequate information to the reader in accessing the product for practicing safe and hygienic methods of Menstruation management.

Abhishek Mendiratta, Consultant, New Delhi

MHM should not be included as an integral part of the TSC. MHM should be part of NHRM campaign. TSC is a people centered, participatory and demand driven approach, which is being implemented in a campaign mode, taking district as a unit. This new paradigm is a shift from allocation based and supply driven program to a demand driven program; from a top down to participatory approach; from a high to low subsidy regime trying to generate a campaign in the entire district to highlight issues related to sanitation by involving all stakeholders.

This implies that strong emphasis is placed on information, education and communication (IEC) and social marketing, which will increase people’s awareness in terms of enhancing capacity to choose appropriate options. The objective of TSC and communication plan is to increase toilet coverage and adoption of better hygiene behavior. This requires that the stakeholders have some understanding of issues around sanitation, safe water and hygiene. Moreover, in many districts intervention related to the above issues are being carried out at larger scale and longer span of time. For any intervention to be effective, it needs to incorporate the aspects of comprehension, complexity, coverage, coherence and continuity.

But by including MHM, the complexity of the campaign will increase and message we want to communicate will not be coherent. We should keep the campaign as simple as possible so as to make it effective.

Complexity – The program complexity – How to define and deliver the most cost effective mix of information, persuasion, skills-building and enabling interventions

Coherence – across program components. Implying that the communication program must have a binding string within the district plan as well as with the Communication design and messages at the national level should flow in coherence.

Having said that, I would like to point out in context of the document, that

• It is a well presented with clear communication flowing through, however, it needs to be more pictorial
• It should be more user friendly for the young girls to understand, without much help as they would like their privacy protected and given the fact that the adolescent girls are shy by nature.
• It should be in local languages.

Bhawna Vajpai, Water and Sanitation Consultant, New Delhi

This is an undeniably indispensable initiative, although we have been talking about this in bits and pieces but this manual will be a holistic package for young girls and their parents. I completely agree with the valuable suggestion by members like translation in local language, more pictorial etc., but I would like to put forth two more point:

Manual in large book shape is good to keep at Schools, Community centers, SHG groups, Mahila Mangal Dal groups etc. with larger size drawing, design and text, where target group can refer in without hesitation. But it can be published briefly as a mini book let or pamphlet form to provide young girls and their mother.

One important point is on the chapter for Parents (especially mothers) on 'communication between young girls and Mothers' about menstruation. Based on my experience with rural area and small cities as well with friends, even girls informed by their friends and schools do not practice healthy aspect as they hesitate to talk with their Mothers. The chapter for Mothers should focus on the importance of communication and sharing on menstruation for better physical and emotional health of their daughters.

Access to the sanitary napkins is an issue as girls do not purchase themselves, nor ask their mothers, as a result they keep practicing the age old unhygienic methods. To this the affordability factor adds up as barriers to practicing MHM. The last is the safe and dignified disposal of the napkins. The book therefore, needs to cover all these aspects to present a complete information base to the users.

Next important aspect is, the reach of this book to Parents, where role of teachers is important. Once this manual reaches to School, every school should call mothers meeting to discuss and explain this manual. Reach of this book to non-school going young girls (dropouts) should also be ensured.

Hemant Khosla, Department of Drinking Water Supply-GoI, New Delhi

This is in response to your query regarding the Booklet on Menstrual Hygiene, conceptualized and developed by UNICEF India Country Office. I would like to reply presenting my views:

English is the widely accepted language not even across the globe but also, when it comes to pass on information across various States and UTs in a diverse country like India . Your point on "The book is in English - which is a drawback", I would like to state that when it comes to gaining information (from the angle of the needy community), "LANGUAGE NEVER BECOMES A BARRIER". Looking at the efforts of UNICEF India Country Office's efforts in at least coming forward for producing such a material as an "Eye Opener" for highlighting and addressing the "unfelt need" of the adolescent girls, the efforts of the UNICEF Office is very positive and needs appreciation

The suggestion for inclusion of more pictures by many members is a good idea and pictures do add value in arresting the attention of the reader. In this case, the rural populations and in semi-urban areas, young girls, can benefit by seeing pictorial demonstrations.

Also I do agree that the book should be small that can fit in a bag.

Dhanashri Brahme, United Nations Population Fund (UNFPA), New Delhi

I would like to present my observations and comments on the book:

• The issue of menstrual health needs to be better linked to the aspects of personal hygiene and improved RH. Use of the manual through the NRHM school health program is necessary after having pre-tested it and adjusted for rural girls as well.
• The information is organized keeping in mind largely the urban/metro audience. Information on use of panties, privacy to change pads in rural areas and also about disposal can be included.
• There is much repetition throughout the document which can be avoided. There are too many references on duration, amount and timings etc.
• Some brand names of the pads are used in the document. Can be avoided in promoting specific brands.
• For locally made pads, it will be useful if the manufactures in SME sector can be contacted and prices can be given along with the contact points.
• Seclusion and isolation can often also mean restriction on engaging in normal activities - also merging from the belief that the girl/woman is impure when she is menstruating. A section on myths and misconceptions will be useful.
• The manual needs to be pre-tested for use in rural areas/rural schools, with questions such as; ‘can I play engage in sports and exercise during periods’; need to be suitably modified for the rural situation/circumstances.
• In the context of the section on HIV, may also add a question on whether it is safe to engage in sexual relations during periods, linkage of menstrual hygiene and RTIs, etc. would be useful;
• Personalized way of answering queries such as done in the question on; ‘what when a girl suddenly bleeds through her clothes’; can be adopted in other answers too.
• Somewhere  a box item can be added giving a checklist of changes in boys too to ensure that girls are aware that both boys and girls go through changes but just that the changes are different.

Overall, good amount of information has been put together which can be further strengthened, especially from the perspective of rural girls and used in the context of NRHM.

Nirmalya Samanta, Institute of Life Long Learning, University of Delhi, New Delhi

I have been following the discussion and suggestions regarding the booklet on `Sharing Simple Facts: Useful Information about Menstrual Health and Hygiene' have been included in the short and simple book. However, I have the following observations to make:

I am glad that this subject about menstrual hygiene is being openly discussed and is not being considered a `taboo’. But this issue does not concern women only and need not be `secretly’ kept within the domain of the feminine. Suggestion for the booklet to be small enough so that it can be hidden in the bag only perpetuate the `embarrassing four days’ concept that today defines the woman’s periodic natural biological process. Hence, it needs to be in the hands of men and boys to enable them to understand, that it is a natural biological process and a women needs hygienic management during the ‘four days’ of menstruation;

I also think that the words `sanitary’ and `hygiene’ have negative implications in this context and reinforces the idea of the menstrual blood as dirty and unclean. Thus, for a large number of women, menstruation remains a traumatic experience they have to live with for most of their lives. Often married women, away from their paternal home and are unable to share with their husbands the physiological problems that they may undergo during menstruation. So they suffer it out alone, silently;

Men and women need to be made aware of each other’s bodily functions. I do agree that the menstrual cycle is something special but it needs to be brought out from the exclusive domain of women and be made a part of general awareness as something natural for which the women do not have to be ashamed or apologetic.

Father’s, brothers, husbands should not feel helpless and embarrassed to deal with the menstrual cycles of their daughters, sisters and wives. If a man can clip his nails, shave his beard, cut his hair, so can the woman have her periods.   

We need to develop a new vocabulary, a new approach to this issue so that mind sets may change. The woman’s experience of her body and her life needs to be understood by men as much as it should be by women. 

This book is an excellent tool and can be placed in the hands of both men and women, provided the following are added:

Please include a chapter, preferably in the beginning to orient the reader to change the mindset;

MHM is important and the book conveys significantly. However, please include the messages on hygienic conditions not just in one place, but may be several times in the book as this is crucial to enable women to be healthy.

Madhu Sharma, PRIA, New Delhi

The need to address the issue of menstrual health has been felt for quite some time now as it has important bearing on the health and development of Adolescent girls.  Under a McArthur Foundation supported initiative, an in depth need assessment was done in rural areas of Uttar Pradesh and Rajasthan, which clearly highlighted the need to ensure responsible handling of menarche. This is not to be seen in the narrow perspective of just as a biological or physiological phenomenon having bearing on the   health or specifically “reproductive health” of girls.  This is an important  phase of girls' "growing up", which has significant   role in developing  healthy self  esteem,  positive self image and  responsible and clean habits  for  whole of life.

The need for timely information given with a “personalized” caring attitude cannot be underestimated in any manner. There have been instances where bright young, scholastically well performing girls not having information on ‘what, when a girl suddenly bleeds through her clothes’ had to undergo traumatic experiences.  In rural  areas  where there are not much  support mechanisms  in the form of  very  communicative mothers, supportive and understanding teachers or easy availability of sanitary pads , girls   are  suddenly  taken  aback and  have to  face  not only the physical pain or discomfort  but much more harassing guilt  and public shame. The psycho social impact in certain cases are quite serious ranging from withdrawal, depression,  self  stigmatization, loss of  self esteem and  confidence. These have bearing on her continuity of education, participation in social activities and thus overall personality and performance. 

Some of the myths and misconceptions that came across uniformly in rural areas of Uttar Pradesh and Rajasthan are:

• Girls are not allowed to enter the cooking space;
• Girls are not allowed to touch the drinking water container
• Girls are not allowed to water the “Tulsi” plant  normally present in most of the houses;
• Girls are not allowed to “touch” the pickle, as it is supposed to be getting spoiled, if touched; Girls are  not allowed to play  outside;
• Girls are sometimes not allowed to sleep on their normal bed;
• Girls are not allowed to eat certain foods
• Girls are not allowed to come near worship corner in the house
• Girls are not allowed to care/feed cows

Some of the above activities may have the intentional or unintentional "bonus" benefit of rendering some rest to girls, but all the activities necessarily result in “identification” or “segregation” of the menstruating persons in the large joint families. This “identification” or “segregation” for the young and impressionable girls reinforce values of being somewhat ashamed or apologetic. The booklet needs to address these myths and misconceptions in rationalized manner, so that menstruation is seen in more normative manner.

Then even if the booklet has mentioned the need to dry the cloths in the “sun”, but it needs to be strongly emphasized, as it is the most abundant, practically inexpensive, and reasonably safe methods to disinfect. But sometimes even simple things are also not simple to adopt in practice.  Sometimes as seen that even though the mothers and daughters knew that the clothes needed to be dried in sun, the normally practice still was to cover the undergarments with the towel or some other clothes.  Perhaps elder generation needs to take lead. 

Arin Basu, University of Canterbury, New Zealand (response 1)

The concept of the booklet is good, but I feel for an educational program to be successful to bring about a change in knowledge, and attitude towards a sensitive topic, a booklet alone is not good enough. Also, if I may add:

I did not see anywhere in the book any disclaimer that the information presented here is based on currently available best evidence or data and that advices in the book do not represent medical advice in any form. Is this book meant to be prescriptive? Also, I did not understand the basis of the claim in the preface, "this book will enhance self-esteem and academic performance". I'd greatly appreciate if you (and indeed, any of the members in the discussion group) can kindly direct to literature about the impacts of books being drivers of self-esteem and academic performance. I thought it was more to do with teaching and learning;

The title of the first chapter, "Growing up the normal way" -- I'd avoid the term "normal" (the word, "normal" is repeated several times in the text), since it hints at other patterns of growing up as "abnormal";

In what order are the bullet points of the "emotional changes" presented? Are they based on the frequency of occurrences? This might be non-trivial because girls may access the book to find responses to their specific problems and if the items in the list are ordered in line with current research or derived from focus groups, that may increase the acceptability of the booklet as a resource;

Although it's not possible to comment how the booklet may appear in other Indian languages, at least the readability of the English version appeared to be inappropriate for an eighth grader. The English language was not very lucid (did not flow well, too many long words, terminology not well explained, verbose, etc, it needs some editing at places. Several editing remarks are already well pointed out by others in this thread). Overall, there is a need to improve on the English of the booklet. You need to produce simpler, shorter expressions, and better yet, use more pictures. It'd be better if it were a comic book format;

Be careful of advices! (Page 30 of the PDF, where you highlight: Never flush a sanitary or cloth pad down the toilet as this may cause serious plumbing problems as well as serious embarrassment after the plumber discovers what caused the problem!). I thought just "never flush a sanitary or cloth pad down the toilet" would be enough. The extra fluff adds to confusion (surely embarrassment after being found out cannot be a reason why a napkin should not be flushed down a toilet! it's the effect).

At this point, I stopped looking at the booklet. Sorry, if it sounds like too critical, but I thought this was an important booklet.

Veena Upadhyay, Sulabh International Academy of Environmental Science, Patna

I am glad that a serious attempt has been made to familiarize a young adolescent girl with all that she needs to know about a difficult phase in her young life. Being a mother of a 12nyear old, I asked my daughter to read this booklet. Observing her reactions and having gone through it myself, I feel that the information on various issues should be presented in short, crisp sentences and repetition of information should be avoided. I wonder if a young adolescent would go through a 40 page booklet!

My feedback on the chapters is as follows:

Growing up

The introduction is lengthy, please avoid repetition. This can be put across in maybe a short paragraph.

The first question, "What is puberty?" should be followed by, "What should you know about puberty?" The answer for this should be the one for the question "What are the strategies…puberty?" This question does not sound good as a girl does not need to strategize herself in order to prepare for this period! Therefore my suggestion is to rephrase it.

The questions starting from, "What are the physical changes.....adolescence?" should follow the first two as given above.

The question, "Why do many teenagers have skin problems during puberty?" In the answer it would be advisable to insert a line on how and with what to wash her face and how best she can avoid acnes and pimples. A young girl’s face is a very sensitive issue for her particularly when she is discovering her body and naturally she is very conscious of her looks. The appearance of a pimple is absolute horror for her. Therefore, if we could advise her on the do's and do not, it would be great.

Dealing with menstruation

The introduction is superfluous as it has been dealt with in the last two questions of the 1st chapter;

"What happens during menstruation?" Could we support it with a diagram for better understanding?

"Preparing for menstruation on a regular basis", this can be avoided as it has already been mentioned in the earlier answers.

Managing menstruation

Question number 1&2 talk about sanitary napkins, although this information is very useful to her yet it would be advisable to explain it through pictures especially on how to make pads at home and what do these different type of pads look like;

A couple of simple pictures on the do's and don’ts of washing the soiled cloth and disposal of pads would make it clearer for her;

Questions on page 25 &26 should follow Q1&2 on page 19&20 as they deal with the sanitary pad and its usage. Therefore questions on pages 21, 22, 23 & 24 should follow these as they deal with a different issue;

Could we please have a question such as, "What should you carry during your menstrual period?" The answer should include necessary things like 2 pads (for heavy days), an old newspaper to wrap the soiled pad, a spare panty, a small piece of soap or soap strips.

Managing menstruation in school

"What are some hygienic practices related to menstruation?" In this answer, I feel that the soreness and chafing along the inner thighs (around the vaginal area) is often a painful experience. Therefore my suggestion is to suggest application of an ointment or maybe a home remedy like coconut oil.

Nutritional requirement

It maybe better explained with pictures of a balanced diet consist and the foods that should be avoided during this time.

Disposal of napkins

Could we please make a garbage bin mandatory in girl’s toilets in rural government schools? During the course of my field visits in Vaishali district in Bihar , I have not seen this anywhere. In fact the availability of a bin raises an important question of "Who would clean the school toilet"-Members of Bal Sansad, Meena Manch? We must understand and accept that today the problem of cleaning of toilets is an issue which needs to be addressed at the ground level since the parental pressure does not allow BAL Sansad to clean them. Services of a local sweeper are linked with availability of funds. Therefore, we either ensure the process of making the sanitation funds easily available to the rural government schools or we look at alternatives.

I suggest this book on menstrual health and hygiene should be made a part of SSHE under TSC as SSHE covers safe hygienic practices.

Lizette Burgers, United Nations Children’s Fund (UNICEF), New Delhi

Due to the overwhelming response to the query FOR COMMENTS: “Booklet on Menstrual Hygiene Management” and the valuable concerns being raised on the booklet, I am writing to clarify some of them which are already under consideration at our level.

The booklet has already been translated to Hindi and will be finalized after incorporating responses from the knowledge groups and other experts. There are plans to further translate it to other Indian languages. The concern of having it more pictorial is of course valid and the final version will have a lot more illustrations at appropriate places. The suggestion on textual changes in terms of simplifying the language and making it less verbose is noted and all these suggestions will be met with as far as possible. Pre-testing of the booklet is also planned in select states before it is further disseminated widely among adolescent girls and young women.

The suggestion of adding a chapter on sanitary napkin production process may dilute the real issue because the objective of the booklet is to serve as a self reference guide for girls to answer their questions regarding menstruation. Production is a different issue altogether and there shall be a separate business plan and production manual on setting up low cost sanitary napkin production units which will be beneficial for Self Help Groups (SHGs) and other groups interested in taking up this activity. We will wait till the end of the query to consolidate the comments / feedback and then work on them.

Thanks again for the very useful and insightful responses,

Vinita Sharma, Department of Science and Technology, New Delhi  

The Department of Science and Technology Government of India (GOI) has been working on development of a low cost Sanitary napkin having the same characteristics as the MNC products. These could be produced as an entrepreneurship activity by women groups. The earlier technology based on waste Rayon was discarded being dependent on a single source for raw material. However now a technology based on waste material from knit ware has been standardized and is now ready for transfer. Groups interested in being trained will need to get in touch.

On the book I would like to say, considering the girls of this age are shy and hesitate to ask questions:

This MHM could then be an integral part of the popularization program if it could be in local languages and pictorial

The contents could be simple, informative and more pictorial than reading material

A condensed version of the book can be slipped into the packets of sanitary napkins.

Biswajit Padi, SRUSTI, Orissa

I would like to congratulate the team for the idea. We needed this long ago. I would like to suggest the following:

Most rural & poor girls don't use pads as they can't afford it. So we have to suggest cheap & affordable alternatives as well, like disposing off the used cloth after single use. We have found this kind of solutions has been well received;

There is also a need to give a pictorial account of menstruation. It is less discussed because over a period of time we have equated it with pure & not so pure. Women are not allowed into the Puja rooms etc. this kind of social belief has to be removed through discussion on it scientifically to dispel the wrong idea;

Recently in a training for our field staff, we used their own Last Menstruation Period (LMP) dates for calculating the Expected Date of Delivery (EDD). They work in a Reproductive and Child Health (RCH) project. We found that, there was more vibrant discussion on the topic. So girls should be given a number table to calculate their cycle.

The book should be small, concise with picture and a chapter on what to do and what not to do during the periods. 

While I am presenting my immediate expressions, however, I would like to be more specific in my next response, which I will be sending shortly. 

Maria Fernandes, WaterAid (UK) – India, Bhopal

Accept my congratulation for bringing out this booklet on Menstrual Hygiene Management; this is really an important need of the sector. Water Aid is also addressing this need with the help of Grass root level partner NGOs. Based on my rural, urban and tribal area experience I am attaching my few comments for this booklet. This Booklet has definitely covered the maximum part of menstruation but it would be good if it is short and with more of pictures to retain interest of adolescent girls and women. My comments on the chapters are:

Growing up:  In this chapter if you can explain the puberty or changes through charts or diagrams. This will help girls from rural / tribal / slum area to understand the subject. Different type of charts /diagrams will play as important tools for teachers, trainers and Anganwadi workers to explain adolescent girls and even mothers as to what is puberty, changes occurred during puberty, etc. Illiterate women can also easily understand the concept

Dealing with Menstruation:  This is a very important chapter and raising very genuine questions, even now many literate women are not aware about the facts of menstruation. It will be good if you can present this chapter in the form of Myths against Realities. This kind of presentation will clarify the target audience as to what are the myths and what is fact. Water Aid has recently conducted a survey. The findings indicate that 41% of 3000 respondents considered-it is a taboo and many of the respondents shared their responses that menstruation means flow of impure blood. Adolescent girls shared that they stop playing with boys due to fear of pregnancy. In States like Chhattisgarh women avoid taking bath for first three days and they follow much restriction about their diet during menstruation. This clearly indicates the unhygienic conditions; women continue to live for three days, when hygienic living is crucial. Also controlling the diet impacts health. Hence, focusing on these aspects will bring in changes in the mind set

Managing Menstruation: Management of menstruation is the most critical one as due to many of the unhygienic practices women and girls suffering from different kinds of diseases. This chapter should explain “Dos & Don’ts” clearly. It should cover about what are the unhygienic practices and what kind of diseases may occur due to unhygienic practices. Similarly treatment methods also need to be discussed as it was observed, in our survey, that women do not normally, referring to the doctors in case of any problem, mainly because of shyness and non availability of lady doctors;   

Disposal of napkin/soiled cloth: This is a growing problem as it is always observed, that, all soiled napkins are thrown around along roadside, in drain, near dustbin area. Therefore promotion of safe disposal of menstrual waste is essential to protect our environment. Please suggest under incineration that wash/ squeeze napkin before burning as it is not advisable to burn blood. Mainly in case of community toilet/girls hostel toilet where quantity is more. Similarly for sanitary pit case ask users to put a mug of water mixed with dung at least once in a day for fast decomposing of waste. Designs of incinerator and sanitary pit attached with latrine can also be included;

This booklet should be more of pictorial and one booklet can not be applied to all. This booklet can be divided in two; for example the first booklet can focus more on subject (Menstruation) where as the other booklet can be on Menstrual Hygiene and disposal of menstrual waste. I suggest supporting tools like Flip charts, pictures (Urban & rural specific), pocket charts can be developed;

For promotion of menstrual hygiene special trainings must be given to school teachers as in many cases teachers avoid to deal with this topic.  Under the TSC program, school toilets must be designed in respect of Adolescent Girls Friendly where separate toilet for girls and boys should be constructed, provision for disposal of waste and availability of water inside the toilet is essential. Middle and high school should also keep sanitary napkins / homemade napkin in a school as we see first aid box in every school.  

Julie Thekkudan, PRIA, New Delhi

I completely agree with Arin that the concept is good. It will have a better outreach if it is the contents of the book are disseminated to adolescent girls in various Indian languages. I also agree with him on some of the points that he has raised. If I were to go back to that age and what I had gone through, I feel that maybe the booklet needs to speak to me in the first person and not in the third person!!! This booklet is also sounding as if it is preaching. For instance the page 4 'First girls should learn about the changes.' Second, girls should understand that the changes are normal. Third they should learn how to adapt to the changes. It comes across sounding like a strict school teacher. A more conversational tone might be more helpful in connecting with the girls.

I congratulate UNICEF in conceptualizing this book. Involvement of the Solution Exchange, in consulting the members, is a unique way of getting stakeholders’ consultations. The book will certainly be an improved version, once the comments are incorporated.

Rajesh Mehta, World Health Organization (WHO), New Delhi

I suggest the following:

• This manual is a resource book for detailed knowledge transmission and skills building. There should be an accompanying folder that is more pictorial with direct bulleted messages that can remain with the beneficiary/client;
• The issue should be promoted through NRHM and TSC and other opportunities. This topic is well covered in the ARSH training package or healthcare provided under NRHM-RCH II. Such training is expected to influence attitudinal change in the care providers so that they become more sensitive to this need of the adolescent girls and also improve their communication skills to facilitate comfortable discussion on this issue with adolescent clients;
• In addition to enabling adolescents/young people to keep them dry and clean, knowledge about better menstrual management also empowers them by making them realize that they are in full control of their body and function and free to participate in most activities. This may be addressed upfront as empowerment opportunity;
• Boys should be made aware of ‘girl issues’ to make them more empathic and sensitive to the biological differences. It is also applicable to girls and they should be made aware of the biological changes in both sexes. Such awareness about each other would facilitates communication and understanding  among partners and hopefully, will enable the next generation to  lead better lives with health-seeking behaviors;
• States Governments should take initiatives in translating  the book into local language;
• A similarly useful pamphlet for illiterate adolescents is also required, for example, a more pictorial version;
• Knowledge and skills building must be supported by ensuring supplies – social marketing, through school health etc. and disposal of used material

Yusuf Kabir, Water and Environmental Sanitation, United Nations Children’s Fund (UNICEF), Kolkata

The Guidance Booklet on Menstrual Hygiene Management has been published with a notion to be applied and used at field level.

The book covers all the aspects, extensively. However, we can add a chapter on the present behavioral practices of rural women, particularly where sanitary pads are not available or are not being used. Attitudes of men, primarily the rural men and older generations towards menstrual hygiene and myths can also be discussed.

We can give a small fact sheet on do's and don'ts of the MH practices, and its individual and community health significances. Regarding the disposal of napkin, it is often seen in urban India and municipalities, sanitary workers generally refuse to collect and they are not being disposed properly. Therefore, disposal needs to be tackled carefully. Recently, Solid and Liquid Wastes Management (SLWM) has been introduced under Total Sanitation Campaign (TSC) where each and every Gram Panchayat (GP) has to prepare a GP level SLWM action plan. It is now being considered as one of the indicators along with individual household level toilet coverage to be qualified for Nirmal Gram Puraskar.

Though disposal of Sanitary Napkins is covered under the Bio-medical Wastes Management and Handling Rules 1996 as per Government of India guidelines, it needs to be implemented. Hence any SLWM planning within a Gram Panchayat needs to include the disposal of sanitary napkins. There is a need to induce sensitivity among the GP members for planning of efficient disposal of the used sanitary napkins.

I find the booklet ending suddenly. This should be completed with access to the sanitary napkins at affordable price. The production may not be within the preview of this book, but, there should be efforts to build up capacities of the Self Help Group members to produce the napkins locally at low prices. This information needs to be a part of this book as, after reading the book, the girls would want to access the napkins. Hence, this issue is linked to the orientation that the book is designed for.

Gyanendra Mishra, Unified Development Association for the Amelioration of Neglected, Aligarh

The issue taken by you is the need of hour. Since the women in rural areas do not use sanitary napkins, they suffer from various ailments resulting from unhygienic conditions. This impacts their health. Since hygiene is one of the important issues, it should be made in integral part of the NRHM or TSC. NRHM has the advantage of the placement of ASHA as a health volunteer and she can facilitate to promote the use of sanitary napkins. Hence, the book needs to be in the hands of ASHA in every village. However, the TSC also has a component of placing Motivators at the village level, but the network of ASHA is much stronger, visible and is more organized.

The inclusion of MHM is essential in the middle school curriculum. The girls in the middle school need to know about the hygienic management of menstruation at this age. The education and information at this age would make them confident to manage it more efficiently. The need for efficient and hygienic disposal methods is crucial in every middle and high school where girls are enrolled.

In my opinion, the book is:

• An excellent effort of the UNICEF and the Government to educate young girls;
• It should be in many more languages, at least in Hindi and some South Indian Languages;
• It should be more pictorial;
• The Book should be in form of simple questions and answers.

Arin Basu, University of Canterbury, New Zealand (response 2)

Thanks for considering all responses and posting to the mailing list your plans for redrafts, With respect to the messages I have seen in this discussion group and your recent notes about incorporating changes in the text but leaving out napkin making from the scope of this text, etc. Further to my previous response, here are some more thoughts on the booklet:

Looks to me that the content in the text is mainly from the perspective of the teacher who wants to transmit information (about menstruation, etc, in this case) to the recipient (the adolescents in the rural areas and urban centers in India ). Implicit in the idea of this booklet (but leaving out other components of health educational intervention from the scope of this booklet) is that as long as a booklet with colored pictures, good readable text, and appropriate size is delivered to the intended recipients, learning will happen, and behavior change will occur. Conceptually, you follow something like: Input (this booklet) --> {Black box} --> adolescents learn the content of this book + demonstrate intended behavior and skills + [? improvement in their academic performance? as a secondary objective](Outputs).If that does not happen as intended, surely the failure to learn can be attributed to the adolescents?

De-Tagging napkin making and issues related to more hands-on, active approach and making it separate (as you indicated, "...Production is a different issue  altogether and there shall be:

(i) a separate business plan and production manual on setting up low cost; (ii)sanitary napkin production units which will be beneficial for Self-Help Groups (SHGs) and other groups interested in taking up this activity"

(ii) it's obvious that the focus is more towards the teacher than the student.

Jerome Bruner wrote in 1966, that "we teach a subject not to produce little living libraries on that subject, but rather to get a student to think,.., to take part in the process of knowledge getting... Knowing is a process, not a product". Bereft of any activity or any associated program with the book (like the booklet is a stand-alone product that reaches in the hands or is displayed in the shelf), the booklet becomes a source of declarative knowledge. That's fine, teaching's done, but is learning taking place?

In order for learning to take place in the context of what primarily looks like functional knowledge (that of behavior modification and attitude formation), the book treats it like its declarative knowledge (the theory of menstruation and so on). I think there is a need to learn from existing evidence (narrative/qualitative/quantitative data) as to what are the key barriers for an adolescent in India to learn about menstruation and taking the intended actions, tailor the messages accordingly in the sections of the book, and align the teaching/learning for a wide variety of context-sensitive situations so that "learning" happens.

Good to see that you have decided to make changes to make the English friendlier, add more pictures, translate and pilot the book, but surely more needs to be done. Addressing the barriers to adoption of the book as an instrument of change in attitude and practice can be a challenge. How about shifting the target of the book as it is, i.e, rather than focusing on teenagers, how about teaching the teachers to use the book as an agent of change in behavior modification?

Raj Ganguly, ACDIVOCA, Jaipur

I believe the effort to develop this guidance book on Menstrual Hygiene Management should add two perspectives:

It should be developed from health perspective than from 'Hygiene' and sanitation. The body undergoes tremendous hormonal changes and balanced nutrition is vital, during this critical period. A chapter presenting details of criticality of nutrition such as uptake of iron pills and vital nutrition through commonly available fruits and vegetables should add value to the reader;

The age old 'sanitation' perspective to this has always acted as barriers to women’s mobility and has made them socially vulnerable. For example, during this period the women cannot enter kitchen, temples etc. Social discrimination shall further find ground if only Hygiene perspective is highlighted than the health care needs, that, the adolescent girls require. I believe the implementation and introduction of the booklet should be a part of NRHM than TSC, thus positioning it as an 'adolescent girls’ health guidebook;

It will act as a tool for the mothers to educate their children, as we should remember that it is the 'Mother' who introduces a child to her adulthood and guides her. Thus the script if creatively put in a mother to child dialogue will be very lively and intimate.

Chaman Pincha, Beyond Boundaries, Chennai

Thanks for sharing the booklet on the network. It was interesting to go through the discussions on various aspects of the manual. I have just a few things to point out. If some discussion has already covered them, I apologize for being repetitive.

In one of the sections it is mentioned that to avoid embarrassment from stains on clothes and being seen with the napkins, the girls can adopt several ways like keeping the napkin in purse etc.

I would suggest that we need to address this sense of shame and embarrassment at being seen with an unavoidable stain or a girl seen carrying the napkins to the toilet. Girls and boys as well as men and women teachers need to be sensitized on the issue. A girl may bleed through her clothes, when she menstruates-it is natural and there is nothing to feel ashamed about. One just needs to change and that's all about it. This attitudinal change would instill confidence in girls and avoid a major cause of worry for her both at home and school. 

It may be considered to include a chapter on: the school to have some shared lockers near the toilets for keeping napkins, fresh clothes and soap etc. This will eliminate the stress among girls of soiled and stained clothes;

It may be a good idea to have focused group discussions with the adolescent girls, before finalizing the manual to realistically look into their needs in the school at the time of menstruation.

Prakash Nayak, Tata-Dhan Academy, Madurai

At the outset of this discussion, let me take this opportunity to congratulate those who have made it possible in bringing out "Sharing Simple Facts: Useful Information about Menstrual Hygiene Management". I have been closely following the discussion from the very beginning. Except a couple of contributions by the members, all other responses are focused on the content. It is a very interesting and focused discussion. While I appreciate the effort in conceptualizing and producing this book, I feel, it is important to device a communication strategy linked to the availability of the product. Hence, my comments are not totally focused on the contents of the book, but it goes beyond this. Addition of this would widen the horizon of this book. I present my comments below: 

I do agree with Shruti Goel, Ministry of Urban Development, and would like to add few more questions to think of a marketing communication strategy for the Sanitary napkins. Before freezing on the content, let’s ask few questions to ourselves:

What would be the media outlets for this Manual? How the manual is going to reach out to the intended community, and in which form? Can we think of variations in the content, text and visuals, looking at different segment of the users? What are the media outlets thought of for the influencers?

A book let of this kind can be made available in all schools (middle school onwards) with at least a packet of sanitary napkins. This would help the girls tremendously as they would find the pack handy, probably at the first arrival of their menstruation.

Media plays a very crucial role and in this case, it can be used in spreading messages for benefits of using a sanitary napkin. This would influence non-users as well.Is there any mechanism to link the manual to counseling? Is it going to be an effective Inter-Personal Communication tool for the counselor? What would be the training capsule for the counselors to address Menstrual Health & Hygiene?

Counseling adolescent girls has longer term impact on their behavior. It may be more effective to train counselors in inducing hygienic behaviors among the adolescent girls.

In this connection, I feel it is imperative to design a media strategy to have more effective campaigns. I would like to refer to the media strategy of I-Pill by Cipla. Can we think of reaching out to the adolescent population by service delivery mechanism of TSC, NRHM and the likes? Could we think of maximizing access to sanitary napkins and its use? It seems there is an urgent need to promote the products through more non-conventional channels like Rural Haats, Melas, and Mahila Mandals etc. The list is indicative but not exhaustive. Ensuring regular supply, making the napkins affordable and offering them conveniently are all important enhancing service delivery mechanism. All these answers could be captured in a suitable communication strategy that could be region and culture specific. There is no fit-to-all strategy for the entire country; however, we can try to localize it.

During 2001-05, for four more years, I had the opportunity to work with Hindustan Latex Family Planning Promotion Trust in Orissa as Communications Manager where we promoted Sanitary Napkins (Sakhi) through unconventional networks like SHGs, Anganwadi Centers, Mahila Mandals, Stationery shop etc. While interacting with some of the cloth traders in the locality, we came to know that the tribal people of Kandhamal were acquainted of locally made sanitary napkins. These items are made locally by traditional weavers and had a good market catering to local needs. Over the years, the market share of the traditional sanitary napkins has been decreasing, giving ways to modern napkins. But, the market penetrations of all the branded sanitary napkins are not that encouraging. Users are still divided along modern and traditional practices. There is a demand for the unmet need of the adolescent girls. Hope at this juncture, a good communication strategy with an action plan will popularize sanitary napkins among the adolescents.

Sharaf Abbas, Social consultancy Services, Lucknow

We are a development consultancy organization and working on the issue of Menstrual Hygiene since 2003. I can refer to a School Education Program (SEP) supported by Johnson & Johnson. A booklet is used for the class room orientation sessions, which is duly translated in regional languages as per the requirement.

This booklet is in the form of a story line, which makes it an infotainment tool for the target group. So I would suggest that the persons or the organizations interested in having access to the booklet can get in touch with Ms. Alka Gadgil of J&J through her email ID AGadgil@JNJIN.JNJ.COM

Debjani Ghosh, National Foundation for India, New Delhi

The manual looks very efficient and I believe girls will feel happy to have it. I agree with one of our friend that the booklet should be small in size so that it can fit into the bag. While I appreciate this tremendous effort on the part of the UNICEF to educate young adolescent girls to make informed choices, I would like to share my comments in the following paragraphs:

On pg.9, it is mentioned that women attend menopause at 40, but we need to revisit this statement. It varies from individual to individual;

On Pg10, “what happens during menses?” It will be better to represent pictorially otherwise when translated it will be complicated;

On Pg33, as mentioned for disposal of the napkins, it is observed that in rural areas, dogs & other animals dig out the napkins buried and make the surroundings unhygienic. We can clarify this with more grass root organizations;

On Pg 25, How to make pads? We need to mention also how to store them. In rural areas, there is always scarcity of clothes. They do reuse, therefore, we can always suggest for safe storage, like in clean plastic pack with Neem leaves to prevent germination of bacteria.

Annie Namala, Program for Inclusion and Equity (PIE), New Delhi

Congratulations to UNICEF on the bringing out of this booklet on Menstrual Hygiene Management, which will in some ways help break the silence and taboos on menstruation and women's health issues too. I find the book very useful and am sure will go a long way to discuss these issues with facts and dignity.

I agree with feedback on the issues on repetition and diagrams.

A few issues for consideration:

In some ways we find that there is a slight bias towards 'educated, middle class, modern' families. The following sections gave me this feel:

• Sec.1:1. Menstruation and its management at home and in school in a hygienic manner – feel that the sentence can also include 'any other work'.
• Sec.1:7 –"However households with educated parents and modern outlook seem to be changing these days"
• Sec. 1:8 - In the modern era, the practice of seclusion during menstrual periods is given up.
• Sec.1:13–one can continue going to school….sports or college. Can also add 'also do any other work one is engaged in'.
• Sec.1:6 – Future Uncertainty – It is not clear. The issue seems to be – this is a time when the family and the person is concerned about their future most. Time for many decisions – what is the future course of study –where can it be done – how far is it from home – is it safe to go so far? Family also begins to think about marriage of the girl and finding suitable matches. Concerns about the safety of the girl are all of a sudden a great anxiety with the family which begins to put more pressure. A time of greater uncertainty and also a time of decision making and heightened sensitivity and concern. The new attention and anxiety also makes the girl feel less at ease.
• Sec.1:7–celebration of menarche–'Get the feeling that communities that celebrate are in some ways not so modern or sensitive about young girls'.
• Sec.1:8–'visiting places of worship is still avoided by most. This statement is not expanding the rationale – or giving solutions. I feel, it is better we can avoid this as this is very much related to excluding girls and women from participation in religious sphere.
• Sec.1: 9–It will be good to have a pictorial representation of the urinary opening and vaginal opening as being separate as this may not be known to many children of this age.
• Sec.1:11–In what is Pregnancy? It Will be good to give the information that pregnancy happens somewhere in the middle of two periods.
• Sec. 1:18–There is no need for girls and women to eat separately from their families, during the time they are menstruating. Can also add 'at any other point in time' as this is also a cultural practice.
• Sec.1:21-Suddenly bleed through your clothes – cover it with chunni, end of the half saree.
• Sec.1:28–All girls irrespective of their social position and caste affiliation are allowed to use the toilet without any barriers.
• Sec 1:29 –uniform stained to dress stained as some children may not be having uniforms

Congratulations once again on bringing this booklet out. Hope it will get translated to all languages and circulated widely, not only through schools but also the Anganwadis and health centers.

Moderator's Note: We are pleased to share this response from one of our members as an instant response to the MHM Consolidated Reply. We are tremendously encouraged to see that Mr. Yadav has mailed the booklet to all the TSC implementers. This will have a longer term impact. While we thank Mr. Yadav for this spontaneous effort in sharing this booklet in applying knowledge to increase development effectiveness, we encourage other members to take action in their areas and share on this platform. Please read on the response:

Dear Ms. Dhar & Mr. Jacob, 

I have gone through this beautifully prepared Guidance booklet on Menstrual Hygiene Management. I hope this booklet will go a long way in addressing the problem of women and particularly adolescent girls, if translated in local languages and circulated to all the schools and colleges in sufficient number. 

I would like to further point out a small printing error occurred at Page No 17 "from taking bath during the period" should have been this period. 

Some demonstration of making cloth pads could have really helped the users. There could have been details of low cost Sanitary Napkin production process like shredding of cotton is a simple mixer, pressing, wrapping and labelling and sealing etc. with simple machines being adopted by SHGs in Tamil Nadu. I would like to share that, the Roja Malar SHG in Thiruchampally of Sambanarkoil Block of Nagapattinam District is involved in producing low cost sanitary napkins. The SHGs, therefore, can promote manufacturing and use of Sanitary Napkins for large number of women.
Disposal of Sanitary napkins is really an issue. As I learnt from the villagers in Kameshwaram Village of Keeliyur Block that Sanitary Incinerator installed adjacent to the girls toilet in the school is hardly used. 
The promotion of Sanitary Napkins should be taken up not only under both NRHM and TSC but convergence should be done with SGSY s an income generation activity.

I have mailed this booklet to all our TSC implementers at the district level unofficially.

The efforts on the part of this booklet maker are appreciable. Though I know the moving spirit behind this initiative is Madam Santha Sheela Nair who is making all efforts to make sanitation a way of life.

With regards,

Puran Singh Yadav

Haryana Institute of Rural Development &

Department of Development and Panchayats, Haryana.

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