Menstrual Management among Adolescent Girls in Uttar Pradesh, India: An Examination of Interpersonal and Mediated Communication as Delivery Mechanisms for Practical Guidance

"There is urgent need to create positive, sustainable changes to address menstrual health and hygiene management. This study introduces an... approach that utilizes interpersonal and mediated communication as mechanisms to deliver practical guidance on menstrual management."

Menstruation is stigmatised and neglected in many parts of the world, and, as a result, many adolescent girls are left in the dark with regard to the procurement, use, and disposal of absorbents. This study examines the impact of providing menstrual health and hygiene management (MHHM) practical guidance to adolescent girls in GARIMA, a social and behaviour change communication (SBCC) intervention in Uttar Pradesh, India, that intended to break the silence surrounding menstruation. Broadly, SBCC interventions recognise the necessity of effective communication at each level of the social-ecological model (SEM). Strategies include interpersonal communication (IPC), mediated communication through print and media materials, and more.

This study defines interpersonal practical guidance (IPG) as face-to-face communication and mediated practical guidance (MPG) as SBCC-intervention-driven communication through print and media materials. IPC components included peer-educator-facilitated girl group meetings, peer-educator- and health-worker-facilitated one-on-one discussions, mothers' group meetings, and small fathers' groups. Mediated communication included girl group film and video watching, storybooks, and posters. The study examines the impact of these two delivery mechanisms of practical guidance on adolescent MHHM knowledge, attitudes, and practices (KAP) following the implementation of GARIMA (2013-2016) in three districts of rural Uttar Pradesh, India: Mirzapur, Jaunpur, and Sonbhadra. GARIMA (described in more detail at Related Summaries, below) reached approximately 64,000 adolescent girls.

GARIMA underwent a case-comparison evaluation between December 2017 and January 2018 within 240 villages (120 comparison and 120 intervention). GARIMA measured IPC exposure in intervention and comparison groups because IPC could occur naturally through family members, peers, teachers, and other professional and non-professional acquaintances. Accordingly, IPC could be informal, non-evidence based, and can provide inconsistent information. However, only girls in the intervention villages had received mediated communication from GARIMA that was consistent and accurate information on the subject matter. Multivariate logistic regression assessed associations between practical guidance and KAP variables. Responses from 2,384 adolescent girls (n = 1,162 comparison and n = 1,222 intervention adolescent respondents) are included.

To begin, the study's findings show that girls who receive both IPG and MPG tend to be more educated, especially when compared with girls who did not receive any form of practical guidance. This education is essential because girls have reported being unaware and with feelings of shock, fear, anxiety, guilt, and frustration at menarche. Furthermore, girls who received both IPG and MPG also were more likely to have a private place to bathe and change at home when compared with those who received neither. These disparities highlight the physical barriers that adolescents may face while managing their menstruation. Otherwise, there were no substantial differences regarding each KAP area and sociodemographic and socioeconomic characteristics such as age, district, and type of house.

IPG on the procurement and use of menstrual products were similar among the intervention and comparison groups. However, a higher proportion of adolescent girls in the intervention group received IPG on the disposal of menstrual products (52.5% vs. 39.7%). In addition, attitudes towards the procurement and use of menstrual products were similar across all groups. However, a higher proportion of adolescent girls in the intervention group reported agreeable attitudes towards the correct ultimate disposal of products (86.5% vs. 79.4%). Lastly, a higher proportion of intervention group girls reported correct knowledge and practices on the use and disposal of menstrual products compared to the comparison group.

The study found significant associations between adolescent girls' KAP depending on whether they received IPG, SBCC-driven MPG, or both. IPG and MPG delivered together has greater odds of predicting correct menstrual management KAP than when delivered separately. For instance, those who received only MPG had 1.4 (95% confidence interval (CI), 1.1-1.8) times the odds of reporting correct storage practices compared to girls who received no form of practical guidance, and those who received IPG and MPG had 2.2 (95% CI, 1.7-2.8) times the odds. Moreover, girls who received only IPG or MPG had similar odds of reporting correct washing and drying practices compared to girls who did not receive anything. In contrast, those with IPG and MPG had 4.0 (95% CI, 3.1-5.1) times greater odds of reporting correct washing and 4.2 (95% CI, 3.3.1-5.4) times greater odds of correct drying practices.

To cite another example, in relation to KAP practices on the correct ultimate disposal of products, receiving one form of practical guidance - only IPG or only MPG - is significantly associated with an adjusted odds ratio of 2.0 (95% CI, 1.6-2.6) - 2.2 (95% CI, 1.7-2.7), respectively, compared to receiving neither. However, receiving both doubles the adjusted odds ratio (AOR) to 4.3 (95% CI, 3.3-5.5) - 4.4 (95% CI, 3.4-5.7) compared to receiving none. This finding may suggest that the pathways of influence of IPG and MPG on KAP practices are different and complement each other.

Per the researchers, next steps include designing and validating an instrument to effectively capture key practical guidance components related to menstrual management KAP and to implement this tool during an SBCC intervention where IPG and MPG are delivered together. The instrument should also seek to capture how practical guidance is being provided rather than solely focusing on whether it is occurring. For example, pertinent questions for future interventions to consider include: who delivers the practical guidance; how they can provide the necessary skills to provide practical guidance in a timely, accurate, and comfortable manner; and what barriers and facilitators girls and women face within their specific contexts.