title: Mapping the knowledge and understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low- and middle-income countries.
abstract: BACKGROUND
  Menstruation is a natural physiological process that requires proper management. Unlike other normal bodily processes, menstruation is linked with religious and cultural meanings that can affect the perceptions of young girls as well as the ways in which the adults in the communities around them respond to their needs.
  
  
  OBJECTIVE
  This review aims to answer the following questions: (1) how knowledgeable are adolescent girls in low- and middle-income countries about menstruation and how prepared are they for reaching menarche, (2) who are their sources of information regarding menstruation, (3) how well do the adults around them respond to their information needs, (4) what negative health and social effects do adolescents experience as a result of menstruation, and (5) how do adolescents respond when they experience these negative effects and what practices do they develop as a result?
  
  
  METHODS
  Using a structured search strategy, articles that investigate young girls' preparedness for menarche, knowledge of menstruation and practices surrounding menstrual hygiene in LMIC were identified. A total of 81 studies published in peer-reviewed journals between the years 2000 and 2015 that describe the experiences of adolescent girls from 25 different countries were included.
  
  
  RESULTS
  Adolescent girls in LMIC are often uninformed and unprepared for menarche. Information is primarily obtained from mothers and other female family members who are not necessarily well equipped to fill gaps in girls' knowledge. Exclusion and shame lead to misconceptions and unhygienic practices during menstruation. Rather than seek medical consultation, girls tend to miss school, self-medicate and refrain from social interaction. Also problematic is that relatives and teachers are often not prepared to respond to the needs of girls.
  
  
  CONCLUSIONS
  LMIC must recognize that lack of preparation, knowledge and poor practices surrounding menstruation are key impediments not only to girls' education, but also to self-confidence and personal development. In addition to investment in private latrines with clean water for girls in both schools and communities, countries must consider how to improve the provision of knowledge and understanding and how to better respond to the needs of adolescent girls.
authors.affiliation: Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1211, Geneva 27, Switzerland. chandramouliv@who.int.
authors.forename: Venkatraman
authors.initials: V
authors.lastname: Chandra-Mouli
authors.affiliation: Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA.
authors.forename: Sheila Vipul
authors.initials: SV
authors.lastname: Patel
mesh_terms: D000293:Adolescent; D000328:Adult; D001294:Attitude to Health; D005260:Female; D006266:Health Education; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D006920:Hygiene; D007182:Income; D008572:Menarche / Q000523:psychology*; D008598:Menstruation / Q000523:psychology*
keywords: Adolescent girls; Menarche; Menstrual health; Menstrual health problems; Menstrual hygiene management; Menstruation