How can mHealth help in developing an effective national framework for

Menstrual Health?

Background
The status of women in India has undergone a sea-change over the centuries. Women
have successfully risen above various socio-cultural confines and progressed in all walks
of life. Unfortunately, amidst this encouraging trend womens menstrual health and
hygiene condition in this country present a deplorable picture. The taboos, myths, stigma
and negative cultural attitude towards this normal female biological process all combine
to deny menstrual health the visibility and recognition that it deserves.
Menstruation is a monthly occurrence that requires access to appropriate materials and
facilities, without which, girls and women suffer from poor menstrual hygiene which
restricts their movement, affects their health and lowers their self-confidence. Therefore
the use of sanitary napkins and adequate clean water for washing of the genitals are
good hygiene practices that are absolutely essential during menstruation. Besides,
females should have appropriate private space like proper toilets for females (, sanitary
pad disposal facilities, proper information about menstruation, and a clear understanding
about ways of hygienically managing it.
In India, like in several other parts of the world, menstruating females are considered to
be impure and dirty, and menses are believed to be a curse on women. Such beliefs are
coupled with various restrictions on womens daily activities. For instance, menstruating
girls and women are prohibited from entering the temple, kitchen and sometimes even
their house. They also face restrictions on washing their hair and taking part in cultural
and religious practices, etc. These negative attitudes and practices not only violate
womens rights but also have serious implications for their health and wellbeing. The
shroud of secrecy and shame associated with this social stigma limits their knowledge
and awareness about menstrual health as also impedes their access to hygienic
materials and facilities to manage their menses.
As a consequence of taboo and the culture of silence around menstruation, an estimated
200 million women have a poor understanding of menstrual hygiene practices (WSSCC,
2013).Moreover, only 12% of India's 355 million menstruating women use sanitary
napkins in contrast to 73-92% in developed countries (Singh, A. and Sinha, S., 2013).
Although sanitary napkins are abundant in the markets, lack of information about their
availability, the high cost and inaccessibility compel 88% of the menstruating populace
to resort to home-grown alternatives like unsanitised cloth, ashes, sand and sawdust
(Dhar, A.,2010). The women either use old rags or cloths alone or wrap ashes, sand, etc
on a piece of cloth and then use them as menstrual absorbents.
Social taboos associated with menstruation, coupled with the lack of facilities like, ample
clean water, soap and private toilets result in inadequate washing of womens cloths and
drying them in well-hidden places (away from the gaze of the men, as it is too
embarrassing) in their homes which are often dark, damp and poorly ventilated. As a
result, many girls and women end up wearing damp, poorly cleaned cloth. Such
unhygienic menstrual practices have serious health consequences as they raise the risk
of vaginal infections that suppress the reproductive tracts natural defenses.
Approximately 70% of all reproductive diseases in India are caused by poor menstrual
hygiene and it may increase the probability of maternal mortality (Venema, V., 2014;
Garg, R. et al., 2012). Unclean and unsanitised menstrual protection increases the
chances of Reproductive Tract Infections (RTIs) including urinary, vaginal and perineal
infection (Garg, R. et al., 2011). If neglected and left untreated RTIs may sometimes lead
to potentially fatal toxic shock syndrome (Bheenaveni, R. 2010). Untreated RTIs are
responsible for 1015% of foetal wastage and 3050% of prenatal infection. Increasingly
RTIs are also linked with the incidence of cervical cancer, HIV/AIDS, infertility, ectopic

Page 1 of 6

pregnancy and a myriad of other symptoms (Garg, R. et al., 2011; Ranjan, R. et all, 2002
& Juneja, A. et al, 2003).
Apart from the profound health implications, unhygienic menstrual practices have
considerable socio-economic repercussions. Inadequate and unsanitised menstrual
protection, lack of proper toilet and water facilities at school causes 23% of adolescent
girls (12-18 years of age) to dropout every year. Working women in India lose around 50
days of work which leads to considerable economic losses for the country (WSSCC,
2013). Besides, the negativity and social taboo related to the topic of Menstruation
violates women and girls dignity, productivity, and participation in their community
(Khatri, R. 1978; Singh, M et al., 1999; Aggarwal, K. et al., 1997).
Despite being a fundamental aspect of female reproductive and basic health, menstrual
hygiene has not received adequate attention. Any progressive initiative towards this
issue is impeded by the culture of taboo and silence surrounding the subject. The
tremendous social stigma attached to the topic can be gauged from the fact that Indias
main source for detailed health statistics, the National Family Health Survey (NFHS), does
not include any questions related to menstrual health. Moreover, this fundamental
female health issue has long been neglected by Indias public health policy, namely- The
National Health Mission. If we look at the Indian Sexual and Reproductive Health Policies
we find that the nation has come a long way from its exclusive focus on demographic
goals and population control objectives (National Family Planning Program in 1952) to
broader reproductive, maternal, newborn child and adolescent health (RMNCH+A).
However, despite the evolution of health policies over the years, the National Health
Mission did not have any program dedicated to Menstrual Health until recently. In the
year 2010 the Union Health Ministry finally woke up to its importance and announced a
Rs 150-crore scheme to increase access to and use of Sanitary Napkins to adolescent
girls in rural areas (Times of India, 2011). Consequently, a Menstrual Hygiene Scheme
was launched in 2011 under the National Health Mission where a packet of 6 sanitary
napkins is made available to girls in the age group of 10-19 years in rural areas at a
highly subsidized price of INR 6. The pilot is being implemented in 152 districts across 20
States in the country (National Health Mission).
Although the above-mentioned national program on social marketing of sanitary napkins
among adolescent rural girls (Menstrual Hygiene Scheme) is a laudable step towards the
recognition of menstrual health, a lot needs to be done in order to adequately and
effectively address this fundamental womens health issue in terms of dissemination of
relevant information and knowledge, provision of appropriate sanitary protection facilities
like private space with a safe disposal method for used pads and a water supply for
washing hands; and active involvement of women and girls in the decision-making and
management processes. The Existing Policy fails to focus on Behavioural and
Communication Change and unless it is addressed it is unlikely to improve the existing
menstrual hygiene situation.
Given the serious adverse health implications of unhygienic menstrual practices it
becomes imperative for the Indian government to develop a comprehensive policy on the
issue or else it will compound the existing sexual and reproductive health (SRH) problems
and considerably increase the nations public health burden. Indias progress in SRHrelated Millennium Development Goals (MDGs) has been below the mark on the
parameters of maternal and child mortality and access to improved sanitation- While the
global maternal mortality ratio (MMR) dropped by 45 per cent between 1990 and 2013,
India still accounts for 17 per cent of maternal deaths; India accounted for highest
number of under-five deaths in the world in 2012, with 1.4 million children in the country
dying before age five. Besides, the country has the worlds largest population that
defecates in the open (Sharma, M. 2014). All these have serious direct and spill over
effects on basic health in general and SRH in particular. Looking at the grim SRH scenario
in India and the consequent dismal performance towards MDGs it is high time the
government recognised that we cannot ameliorate our SRH and public health situation
without adequately addressing a fundamental women health issue-Menstrual hygiene.

Page 2 of 6

Given the serious adverse health implications of unhygienic menstrual practices it

becomes imperative for the Indian government to develop a comprehensive policy on the
issue or else it would compound sexual and reproductive health problems and
considerably increase the nations public health burden. However, the issue cannot be
addressed efficaciously unless the social stigma and secrecy clouding menstrual
practices are dispelled. In this regard, the existing menstrual hygiene program run by the
government of India requires a strong and effective Behavioral and Communication
Change (BCC) tool. BCC can motivate the target population towards improved menstrual
health and wellbeing by fostering positive behaviour, promoting and sustaining
individual, community and societal behavioural change (Maitra, A. 2007:2). Information
and Communication Technologies (ICTs) is a powerful BCC instrument that has the
potential to clear doubts and dispel myths through dissemination of knowledge and
awareness creation. It can also contribute to strengthening the service delivery and
capacity building systems of the existing national Menstrual Hygiene Program.

Over the past two decades India has been witnessing a phenomenal growth in the use of
new ICTs, in particular mobile phones (Population Council, 2010). In November 2014,
there were 937.06 million mobile subscribers in the country with rural populations share
being 41.62%, making mobile technology perhaps the most accessible ICT media in rural
India (Telecom Regulatory Authority of India, 2015 ; Garai, A., 2011: 2). Some of the
more attractive features of mobile phones include short message service (SMS) which
enables immediate dissemination of information,
assures a certain level of
confidentiality, confirmation of delivery, and is cost effective (Tilly, A. et al., 2012; Atun R.
A., et al., 2006).

The proliferation of mobile phone technology in rural India presents a promising

communication channel that offers the potential to improve health care delivery and
promote BCC among underserved populations (Tilly, A. et al., 2012: 82).
There is growing evidence from different parts of the developing world confirming the
success of employing mobile telecommunication technologies in the health arena (known
as mobile health or mHealth) for several healthcare projects.
My study, which aims to look at the effectiveness of the existing national menstrual
hygiene program and address the gaps in it, will seek to know whether mHealth can be
used as a decisive and efficacious BCC tool to strengthen the program and to make it
more comprehensive in nature.
Health is a crucial stepping stone for building a better existence and creating a way out
of poverty. In order to meet the Health related SDGs the Indian government should
recognise that sexual and reproductive health, in particular and public health, in general
cannot be addressed successfully unless menstrual health matters are taken into
consideration. The neglect of menstrual health and hygiene in national health programs
will have strong ramifications for the nations development as half of Indias populationthe females can only go to school, engage in work and contribute positively to their
community, when they are not affected by lack of access to proper menstrual protection
or not plagued by menstrual disorders, morbidity and reproductive diseases.
Objective of the Research
The objective of the proposed research will be to see how the existing menstrual hygiene
program run by the Government of India can be strengthened and made effective by
addressing the gaps in the program. The research will therefore attempt to look at how
the Indian government can develop a comprehensive and effective menstrual health
policy in order to better address the nations sexual and reproductive health.

Page 3 of 6

To address this I want to explore multiple roles and effectiveness of mobile

communications in menstrual health in low resource settings of rural India because rapid
adoption of mobile telephony in rural India and absence of other information and
communication technology media have prompted the social sector to exploit mobile
communication as a dependable and effective ICT media. I will analyse the existing Policy
Framework and then conduct a Situational Assessment and on the basis of that will
design the mHealth framework.
Research Methodology
The thesis will use both qualitative and quantitative research methods: it will combine
semi-structured in-depth interviews; participant observation, cohort study and study of
secondary sources.
Participant Observation: It will be applied because it is deemed as an important data
collection method that enables a researcher to develop a holistic understanding of the
phenomena under study (DeWALT and DeWALT 2002:92). It attempts to study social life
as it unfolds in the practices of day to day life and enables the researcher to collect
unexpected findings which help in broadening his vision (Desai and Potter 2006:180).
Immersion into the field of study as a participant allows one to decipher the influence of
social and cultural norms on policy making - an insight that other more direct methods
may not extend (Desai and Potter 2006:180).
Interviews: I will conduct semi-structured in-depth interviews with state and non-state
SRH policy actors like government institutions, UN agencies, donor institutions, research
and academic institutions, non-governmental organisations working on SRH issues, and
religious institutions. Qualitative interviews will be conducted as they afford research
respondents the opportunity to reflect on their roles and experiences in policymaking
processes, their relationships with other actors, and their views on the ways in which
decisions are made (Erasmus and Gilson 2008).
Cohort Study: I will conduct a Cohort Study on 100 Households focusing on Knowledge
and Practice related behaviour on Menstrual health, based on which I will try to
implement a formative research using Bangladesh mHealth model. I would like to look
at the various aspects of the Bangladesh mHealth model like the recommended
technology specifications, design of BCC messages and the evaluation processes. I will
then attempt to contextualise it in relation to menstrual health scenario in India.I will
attempt to contextualise it in relation with menstrual health and disseminate the
information, then again revisit those households at the end of next year. The women will
get the same message related to practice and knowledge on Menstrual health and
hygiene. At the end of the study I will look at the effectiveness of mHeath on knowledge
and practices related to menstrual health? IF yes, then can we replicate the model in the
Indian context?
Study of Secondary Data Sources: I plan to conduct secondary analysis using subsamples from two large-scale datasets namely, The National Family Health Survey
(NFHS)-4 and District Level Household and Facility Survey (DLHS)-3. Both NFHS and DLHS
are large-scale household sample survey providing detailed health statistics on fertility
and mortality, reproductive health, contraceptive use and violence against women
among other indicators.

References:

Page 4 of 6

 Aggarwal K, Kannan AT, Puri A, Sharma S. (1997) Dysmenorrhea in adolescent

girls in a rural area of Delhi: a community-based survey. Indian J Pub Health;
41:84 85.
Atun, R. A., Greene, S. A., Morris, S., Thomas, L., McKee, M., Franklin, V., Soalen, R.
(2006). The role of mobile phones in increasing accessibility and efficiency in
healthcare.
http://www.mobileactive.org/files/file_uploads/vodafone_policy_paper_4_march06.
pdf. accessed on 31st October 2014
Bheenaveni, R. (2010). Beliefs and practices in women health. Promote healthy
life. Available at: http://promote-healthy life.info/beliefs-and-practices-in-womenhealth.php. Accessed on 3rd November, 2014.
Desai, V. and R. Potter (2006). Doing Development Research, Thousand Oaks,
SAGE Publications.
DeWalt, K.M. and R.B. DeWalt (2002). Participant observation: a guide for
fieldworkers. Walnut Creek, CA: AltaMira Press.
Erasmus, E., L. Gilson (2008) How to start thinking about investigating power in
the
organisational settings of policy implementation, Health Policy and Planning,
23:361-368.
Garai, A. (2011) Role of mHealth in rural health in India and opportunities for
collaboration. In, ICCP Technology Foresight Forum: Developments in Mobile
Communication, Paris, 26 October 2011.
Garg, R., Goyal, S. & Gupta, S. (2012) India Moves Towards Menstrual Hygiene:
Subsidized Sanitary Napkins for Rural Adolescent GirlsIssues and Challenges,
Maternal Child Health J. 16(4):767-74.Geertz, C. (1973). The Interpretation of
Culture New York, Basic Books
Juneja A, Sehgal A, Mitra AB, Pandey (2003) A Survey on Risk Factors Associated
with Cervical Cancer.Indian Journal of Cancer, Vol. 40, No. 1 , pp. 15-22.
Khatri R, Gupta AN. Effect of childbirth on menstrual pattern. Indian J Med Res
1978;67:6672.
Maitra,
A.
(2007)
Safe
motherhood
and
ICT
tools
in
BCC,
http://unpan1.un.org/intradoc/groups/public/documents/un/unpan036503.pdf.
accessed on 6th June, 2014.
May 2014.National Health Mission (NHM) Scheme for Promotion of Menstrual
Hygiene among Adolescent Girls in Rural India
http://nrhm.gov.in/nrhmcomponents/rmnch-a/adolescent-health/menstrual-hygiene-schememhs/schemes.html accessed on 30th January, 2015
Population Council. (2010) Role of information and communication technologies
(ICTs) in behaviour change communication, Policy Brief No. 12. New Delhi:
Population Council.
Ranjan, R., & Sharma, R. K. (2002). Gender differentials in the knowledge of RTI
and STI in India: Evidence from RCH-RHS IIsurvey. Inter-regional seminar on
reproductive health, unmet needs and poverty: Issues of access and quality of
service, Bangkok, Committee for International Cooperation in National Research in
Demography.
Available
at:
http://www.cicred.
org/Eng/Seminars/Details/Seminars/Bangkok2002/28Bangkok
Ranjan.pdf.
Accessed on 10th January, 2015
Sharma, M. (2014) MDG Report 2014: India among worst performers in poverty
reduction,
maternal
death
and
sanitation.
http://www.downtoearth.org.in/content/mdg-report-2014-india-among-worstperformers-poverty-reduction-maternal-death-and-sanitation. Accessed on 12th
October, 2014.
Singh, A and Sinha, S. (2013) Adolescent Health- Tackling Menstrual Hygiene Issue
through Social Marketing of Sanitary Napkins scheme: an evaluation study from
Haryana, Journal of Postgraduate Medicine, Education and Research, 47(3):127130.
Singh MM, Devi R, Gupta SS. Awareness and health seeking behaviour of rural
adolescent school girls on menstrual and reproductive health problems. Indian J

Page 5 of 6

Med Sci1999; 53:439443.Rubin DB (2006). Matched Sampling for Causal Effects.

Cambridge University Press, NewYork.
Telecom Regulatory Authority of India (TRAI) (2015) Highlights of Telecom
Subscription Data as on 30th November, 2014. New Delhi: January, 2015
Tilly A. Gurman , Sara E. Rubin & Amira A. Roess (2012) Effectiveness of mHealth
Behavior Change Communication Interventions in Developing Countries: A
Systematic Review of the Literature, Journal of Health Communication:
International Perspectives, 17:sup1, 82-104
Venema, V. (2014) The Indian sanitary pad revolutionary. BBC World Service.
http://www.bbc.com/news/magazine-26260978 accessed 3rd December, 2014
Water Supply and Sanitation Collaborative Council (WSSCC), (2013) Menstrual
Hygiene
Management:
Training
of
Master
Trainers
http://www.wsscc.org/sites/default/files/publications/mhm_training_report.pdf
accessed on 24th May, 2014

Page 6 of 6