Menstrual hygiene management in Indonesia

There is increasing recognition of the impact that menstrual hygiene management (MHM) practices can have on health, education and psychosocial outcomes for women and girls in developing countries. Significant challenges exist for women in these settings to manage their menstruation safely and effectively and without adverse consequences such as behavioural restrictions, reduced school-attendance, or loss of dignity.

Objective

The period of adolescence is of particular concern as socio-cultural norms can create a barrier for adolescent girls to obtain accurate information about menstruation and menstrual hygiene at the onset of menarche. Menstruation can also contribute to school-drop out, absenteeism, and other sexual and reproductive health concerns that can have substantial and long-term health and socioeconomic ramifications for adolescent girls.

Schools are a potentially important setting in relation to MHM: a lack of appropriate facilities in schools may prevent adolescent girls from managing their menstruation safely and hygienically or may result in increased absence from school. Moreover, education settings may present an opportunity to reach adolescent girls to improve their knowledge, attitudes and practices in relation to MHM.

While there is an emerging body of research into MHM and the impact of menstruation and MHM practices on girls’ health and psycho-social outcomes, there are still significant knowledge gaps, particularly in relation to school settings. This includes limited investigation of broad impacts on education participation and outcomes, lack of in-depth analysis of challenges and determinants across cultural contexts, and limited rigorous evaluation of interventions. Addressing these knowledge gaps is crucial to inform effective policy and programming. 

In Indonesia, there is little context specific research about MHM among adolescent girls, including in the school setting. Consequently, the determinants and impacts of MHM among girls and women in Indonesia are not well understood and an evidence-base for programming and interventions to improve MHM is lacking. This study aimed to explore factors related to MHM knowledge, attitudes, practices and impacts amongst adolescent school girls in Indonesia.

The overall goal of this study was to improve MHM among adolescent girls in Indonesia.

The aims of this study were to:

• understand current MHM practices, their determinants, and impacts among adolescent girls in Indonesia
• identify key targets for intervention to strengthen policy and programs, particularly in schools.

The specific objectives were to:

• identify current knowledge, attitudes and practices related to menstruation and MHM among adolescent girls in Indonesia
• explore the underlying determinants of MHM practices
• investigate the health, education and social impacts of menstruation and current MHM practices 
• examine the barriers and enablers to improved MHM practices in schools.

Timeline

2014–2015.

Approach

To address these objectives, a school-based convergent parallel mixed methods study was conducted in 16 urban and rural secondary schools in four provinces in Indonesia (East Java, South Sulawesi, NTT and Papua).

The quantitative component included a self-administered, structured questionnaire exploring knowledge, attitudes, practices and self-reported health and education impacts of menstrual hygiene completed by 996 school-going girls aged 12-19 years. In addition, a structured observation checklist was completed at each school to document current water, sanitation and hygiene resources and provision of education related to menstruation.

The qualitative component explored in depth the attitudes, beliefs and misconceptions related to menstruation and menstrual hygiene, determinants of current MHM practices, impacts on adolescent girls, and the barriers and opportunities to improve MHM in school settings.

Focus group discussions were conducted with adolescent girls, adolescent boys and mothers of adolescents, in-depth interviews with adolescent girls who have reached menarche, and key informant interview with teachers and health providers.

Additionally, a desk-review of Indonesian policies, guidelines and programs was conducted to identify current approaches, gaps and lessons learned related to MHM.

Community impact

The findings of our study were used to inform a basic package of interventions that can be delivered and tested in school settings in Indonesia. UNICEF, the national WASH Reference Group and the Ministry of Health and Ministry of Education are key stakeholders.