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• Published: 23 June 2022

Menstrual hygiene practices and associated factors among Indian adolescent girls: a meta-analysis

• Jaseela Majeed 1 ,
• Prerna Sharma 2 ,
• Puneeta Ajmera   ORCID: orcid.org/0000-0002-6237-2235 3 &
• Koustuv Dalal   ORCID: orcid.org/0000-0001-7393-796X 4  

Reproductive Health volume  19 , Article number:  148 ( 2022 ) Cite this article

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Menstrual hygiene management (MHM) and practices by adolescent females of low and middle-income countries (LMICs) are a severe public health issue. The current systematic review and meta-analysis aimed to estimate the pooled proportion of the hygiene practices, menstrual problems with their associated factors, and the effectiveness of educational interventions on menstrual hygiene among adolescent school girls in India.

PRISMA checklist and PICO guidelines were used to screen the scientific literature from 2011 to 2021. The Newcastle–Ottawa Scale was used to assess the quality of studies. Four themes were developed for data analysis, including hygiene practices, type of absorbent used, menstruation associated morbidities and interventions performed regarding menstruation. Eighty-four relevant studies were included and a meta-analysis, including subgroup analysis, was performed.

Pooled data revealed a statistically significant increase in sanitary pad usage “(SMD = 48.83, 95% CI = 41.38–57.62, p < 0.00001)” and increased perineum practices during menstruation “(SMD = 55.77, 95% CI = 44.27–70.26, p < 0.00001)”. Results also reported that most prevalent disorders are dysmenorrhea “(SMD = 60.24, 95% CI = 50.41–70.06, p < 0.0001)”, Pre-menstrual symptoms “(SMD = 62.67, 95% CI = 46.83–78.50, p < 0.00001)”, Oligomenorrhea “(SMD = 23.57, CI = 18.05–29.10, p < 0.00001), Menorrhagia “(SMD = 25.67, CI = 3.86–47.47, p < 0.00001)”, PCOS “(SMD = 5.50, CI = 0.60–10.40, p < 0.00001)”, and Polymenorrhea “(SMD = 4.90, CI = 1.87–12.81, p < 0.0001)”. A statistically significant improvement in knowledge “(SMD = 2.06, 95% CI = 0.75–3.36, p < 0.00001)” and practice “(SMD = 1.26, 95% CI = 0.13–2.65, p < 0.00001)” on menstruation was observed. Infections of the reproductive system and their repercussions can be avoided with better awareness and safe menstruation practices.

Conclusions

Learning about menstrual hygiene and health is essential for adolescent girls' health education to continue working and maintaining hygienic habits. Infections of the reproductive system and their repercussions can be avoided with better awareness and safe menstruation practices.

Plain language summary

Menstrual hygiene management (MHM) and practices by adolescent females of low and middle-income countries (LMICs) are severe problems for girls, parents, society, and policymakers. Menstrual-related problems are widespread among adolescent girls in India. Different menstrual abnormalities are found in different populations, suggesting socio-cultural and regional variation. Menstrual abnormalities and disorders are frequently linked to physical, mental, social, psychological, and reproductive issues, affecting adolescents' daily lives and their families lives by various psychosocial problems such as anxiety. We have the intention to compile, summarise, and critically analyse peer-reviewed and published scientific evidence from 2011 to 2021 on menstrual hygiene management methods used, most typical menstrual morbidities and their associated factors among Indian adolescent girls, and to evaluate the evidence for existing interventions like educational programs and absorbent distribution. Program planners and policymakers could use the findings of this study to build relevant initiatives to incorporate safe MHM in the country so that interventions can be designed taking into account the current needs of adolescent girls to reduce menstrual morbidities and improve their quality of life. A statistically significant improvement in knowledge and practice on menstruation was observed. Learning about menstrual hygiene and health is an essential aspect of adolescent girls’ health education to continue working and maintaining hygienic habits. Infections of the reproductive system and their repercussions can be avoided with better awareness and safe menstruation practices.

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Introduction

The onset of menstruation (menarche) is one of the most significant transformations that girls go through during their adolescent years. Menstrual hygiene management (MHM) and practices by adolescent females of low and middle-income countries (LMICs) are a severe concern [ 1 , 2 ]. Studies show that more than 50% of girls follow unsatisfactory MHM in LMICs, with rural areas having a higher percentage than urban areas [ 2 , 3 , 4 ]. Efficacious MHM requires access to clean absorbents and facilities for changing, cleaning or disposing of them as required, and soap and water for cleansing the body and the absorbents used during menstruation [ 5 ]. Hygiene-related practices during menstruation can lead to an increase in the risk of developing reproductive tract infections. Poor menstrual hygiene has a direct or indirect impact on the Sustainable Development Goals (3, 4, 5 and 6) and achieving them is critical for the overall development of these young adolescents and the country [ 6 ]. Although menstruation is a normal part of life, and it is associated with several myths and misunderstandings that might negatively affect health [ 7 ]. Menstruation is still seen as something repulsive or dirty in Indian society [ 8 ]. MHM is a severe problem in India for school-aged teenagers due to a lack of safe, sanitary facilities and limited or no sanitary hygiene products. As a result, many girls drop out of school due to a shortage of menstrual hygiene products and services [ 6 ].

Menstrual-related problems are widespread among adolescent girls in India. Different types of menstrual abnormalities are found in different populations, suggesting socio-cultural and regional variation [ 9 ]. Sixty-four per cent of girls have at least one menstrual-related issue [ 10 ]. In the age group of 10–19 years, poor menstrual hygiene and lack of self-care are critical drivers of morbidity and other problems. Some of the issues are urinary tract infections (UTI), scabies in the vaginal area, atypical abdominal pain, absence from school, and pregnancy complications [ 11 ]. Studies report that out of an estimated 113 million adolescent girls in India, around 68 million adolescent girls attend roughly 1.4 million schools. Poor MHM practices and cultural taboos are viewed to be barriers to their school attendance [ 12 , 13 ]. Menstrual abnormalities and disorders are frequently linked to physical, mental, social, psychological, and reproductive issues, affecting adolescents’ daily lives and their families' live through various psychosocial problems such as anxiety [ 14 ].

To recognise the importance of promoting menstruation hygiene practices, the Government of India is undertaking many activities to raise awareness about the pivotal role that good MHM plays in enabling adolescent girls and women to achieve their full potential. A scheme was introduced in August 2011 to provide sanitary napkins at subsidised prices to adolescent girls in rural areas [ 15 ] as their reproductive health decisions today will impact the health and well-being of future generations and their community. On May 28, Menstrual Hygiene Day is observed to raise awareness of the problems that women and girls suffer as a result of their menstruation and to promote solutions that address these problems. Despite India’s efforts, a significant portion of adolescent girls lack prior knowledge of the menstrual cycle and associated hygienic habits, resulting in poor menstrual hygiene practices [ 16 ].

Numerous studies have been undertaken across India to assess the prevalence of MHM and its associated variables among adolescent schoolgirls. The results of these investigations were inconsistent and subject to significant variations. Also, various systematic reviews and meta-analyses have been conducted on MHM, incorporating either cross-sectional, case–control or interventional studies. To the best of our knowledge, we could not find any systematic review that has included all types of studies on MHM in the Indian context. Therefore, this systematic review and meta-analysis aimed to estimate the pooled proportion of the hygiene practices, menstrual problems with their associated factors, and the effectiveness of educational interventions on menstrual hygiene among adolescent schoolgirls in India. The intention is to compile, summarise, and critically analyse peer-reviewed and published evidence from 2011 to 2021 on MHM methods used, most typical menstrual morbidities and their associated factors among Indian adolescent girls, and evaluate the evidence for existing interventions like educational programs and absorbent distribution. Program planners and policymakers could use the findings of this study to build relevant initiatives to incorporate safe MHM in the country so that interventions can be designed taking into account the current needs of adolescent girls to reduce menstrual morbidities and improve their quality of life.

The design and methodology for this systematic review and meta-analysis are developed and reported as per the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)” checklist [ 17 ]. The PICO guidelines [ 18 ] were used to determine eligibility requirements.

Data sources and search strategy

One junior researcher (PS) and one senior researcher (PA) independently searched scientific literature in July 2021 to identify peer-reviewed published studies from 2011 to 2021 on menstrual hygiene, menstrual abnormalities and their associated factors and the effectiveness of education programmes among adolescent girls in India. Various combinations of keywords, “menstruation, hygiene, abnormalities, disease, morbidity, prevalence, associated factors, education, intervention and association” were administered. These search terms were combined with Boolean operators OR and AND to broaden or narrow the search. Additional studies were included by searching randomly in the databases. We limited the search results to Indian studies and further checked the original and review articles' reference lists that the initial search yielded to identify additional full-text articles. The search strategy used for different databases is presented in Table 1 .

Eligibility criteria

Inclusion criteria Peer-reviewed journal articles written in English comprising original observational and interventional studies that reported menstrual morbidities such as dysmenorrhea, premenstrual syndrome (PMS), menorrhagia, polymenorrhagia, and oligomenorrhoea, along with articles incorporating the importance of education on menstruation from 2011 to 2021among Indian adolescent schoolgirls were included.

Exclusion criteria Systematic and narrative reviews, studies not performed on the Indian population, project reports, economic analysis, unpublished research and policy analysis have been excluded from this systematic review.

Study selection All the retrieved articles from each database found throughout the search process were noted, duplicates were deleted, and titles, abstracts, and complete publications were evaluated against eligibility criteria. The researchers screened the titles of the studies and their abstracts according to the inclusion and exclusion criteria. Two senior researchers rechecked data through repetitive meetings and all the disagreements and discrepancies were resolved by consensus. PRISMA flow diagram for data identification, screening, inclusion and exclusion is presented in Fig.  1 .

PRISMA flow chart

Data extraction

Data were extracted by designing the data extraction form, which includes the constituents like information about the publication, i.e., author(s) and year, location of study, the state of India where the study was performed, sample size, study procedure, menstrual hygiene practices, types of menstrual irregularities, common menstrual disorders and role of education on menstruation.

Data synthesis

Revman 5.4 was used for statistical analysis (The Nordic Cochrane Centre, Copenhagen, Denmark). The meta-analysis included only papers that generated sufficient data on any pre-determined outcome measures. Because it is a more traditional methodology that compensates for the fact that study heterogeneity can differ more than by chance, a random-effects model was adopted to generate pooled effect sizes since we expected much heterogeneity. This approach assumes that the studies included are selected from ‘populations’ of research systematically different from one another (heterogeneity). The prevalence estimated from the included research varied due to random error among studies (fixed effects model) and genuine variance in prevalence from one study to the next. The data at the end of the intervention were retrieved for both the intervention and control groups. MS Excel was used for data synthesis.

Quality assessment

The authors used the Newcastle–Ottawa Scale to assess the quality of studies included in the review [ 19 ]. The standard of observational and interventional studies was assessed using this scale. This scale uses a “star” system (with a maximum of nine stars for cross-sectional studies and seven stars for intervention-based studies) to rate the quality of a study in three areas: participant selection, study group comparability, and interest outcome determination.

Characteristics and quality assessment of studies

The studies conducted from 2011 to 2021 intending to evaluate the menstrual hygiene practices, were screened and the most typical menstrual morbidities and their associated factors among young girls were identified. A total of 84 relevant studies reporting hygiene practices during menstruation by adolescent girls and menstrual morbidities and associated factors in India were obtained after removal of duplication and studies that did not fulfil inclusion criteria. Data collected from 84 studies were scrutinised and codes were created based on our objective and heterogeneity. Codes were again analysed and patterns among them were identified. Also, we thoroughly reviewed the literature on menstrual hygiene and associated factors to identify existing and emerging themes. Finally, we developed the following four themes for the final data analysis:

Type of absorbent used during menstruation

Hygiene practices during menstruation, mhm associated morbidities.

Interventions performed to improve knowledge and practices regarding menstruation

A complete description of all the studies, including demographic details, setting, interventions, methodology and outcomes based on four themes, are presented in Additional file 1 : Tables S1–S3. Quality assessment of included studies using Newcastle–Ottawa Assessment Scale shows that studies mainly were of low to moderate quality (Additional file 1 : Table S4).

Fifty-three studies with adequate information were included in the meta-analysis to study the use of sanitary pads by Indian adolescent girls during menstruation. Pooled data revealed a statistically significant increase in sanitary pad usage as an absorbent “(SMD = 48.83, 95% CI = 41.38–57.62, p < 0.00001)” (Fig.  2 ).

Pooled usage of sanitary pad as absorbent by Indian adolescent girls

Pooled data from fifteen studies reported a statistically significant “(SMD = 55.77, 95% CI = 44.27–70.26, p < 0.00001)” increase in perineum practices by adolescent girls during menstruation (Fig.  3 ). The random-effect model was used as the heterogeneity was statistically significant (p < 0.00001) and the inconsistency was too high (100%).

Pooled hygiene practices by Indian adolescent girls

Pooled data reported that most prevalent morbidities among Indian adolescent girls are dysmenorrhea “(SMD = 60.24, 95%, CI = 50.41—70.06, p < 0.0001)”, Pre-menstrual symptoms “(SMD 62.67, 95% CI = 46.83–78.50, p < 0.00001)”, Oligomenorrhea “(SMD 23.57, CI = 18.05–29.10, p < 0.00001)”, Menorrhagia “(SMD = 25.67, CI = 3.86–47.47, p < 0.00001)”, Hypomenorrhea “(SMD = 9.00, CI = 4.72–22.72, p < 0.00001)”, PCOS “(SMD = 5.50, CI = 0.60–10.40, p < 0.00001)”, and Polymenorrhea “(SMD = 4.90, CI = 1.87–12.81, p < 0.0001)”. Subgroup analysis was conducted to examine probable sources of between-study heterogeneity. The heterogeneity was statistically significant (p < 0.00001) and the inconsistency was high (100%). Figure  4 depicts a subgroup analysis of pooled data on prevalent morbidities among Indian girls. Various menstrual morbidity-associated factors, including modifiable factors, have been reported in the studies. Common modifiable associated factors include poor nutritional status, lower physical activities by girls, poor menstrual hygiene, education, and mother’s occupation. Other reported associated factors are family history, socioeconomic status, late menses, amount and duration of blood flow.

Subgroup analysis for Menstrual morbidities

Fifteen studies have found an association between nutritional status, BMI, Junk food, meals skip during menses, dieting by girls, dietary habits, and Nutritional deficiency with menstrual morbidities. However, one study found no association of BMI with menstrual morbidities among Indian young girls. Five studies found that girls had a family history of menstrual morbidities are more prone to develop dysmenorrhea. Out of 21 studies, five reported that a family’s socioeconomic status could be responsible for menstrual abnormalities among adolescent girls . Four studies reported lower physical activity among girls with more menstrual disorders. Three studies presented the association of practices during menstruation with menstrual morbidities. Two studies reported that girls with late-onset of late menstruation and low education level have higher chances of developing menstrual problems. One study found the association with the mother’s occupation; another study has reported the association of menstrual morbidities with bleeding duration and the girl’s age. It is also found that the mother’s education has been directly associated with the menstrual problems her daughter faces.

Interventions are performed to improve knowledge and practices regarding menstruation

A total of fourteen interventional studies were retrieved, out of which seven were excluded due to insufficient data. Subgroup analysis was conducted to examine possible sources of between-study heterogeneity. Pooled data from three two group intervention studies revealed a statistically significant improvement in knowledge “(SMD = 2.06, 95% CI = 0.75–3.36, p < 0.00001)” and practice “(SMD = 1.26, 95% CI = 0.13–2.65, p = 0.00001)” on menstruation (Fig.  5 ). Pooled data from four one group pre-post interventional studies also revealed an overall improvement in knowledge “(SMD = − 16.77, 95% CI = 16.80 − 16.74, p < 0.00001)” and practice “(SMD = -0.72, 95% CI − 0.92 to − 0.52, p < 0.00001)” on menstruation among Indian adolescent girls. The heterogeneity was statistically significant (p < 0.00001) and the inconsistency was high Fig.  6 .

Subgroup analysis for overall changes in standardized mean difference indices for the knowledge and practice on menstruation in intervention based studies

Subgroup analysis for pooled changes in standardized mean difference indices for knowledge and practice on menstruation in one group Pre-post interventional based studies

The present study aimed to find studies that looked into menstrual hygiene, morbidities prevalence, and its factors, focusing on modifiable factors. Our search was susceptible to various potential biases, and it is critical to understand the type and prevalence of menstrual morbidities and their associated factors based on the result we have reported. We hoped that limiting our search and utilising broad search keywords would reduce the risk of bias in our literature selection. Hand scanning recognised articles for relevant references was added as an extra step. Given our time and resource limits, we believe we have broadened our search as far as possible. Numerous studies have been published on menstruation knowledge, awareness, and practice in low-income settings. Although each study focuses on a different context with different variables, one thing is clear: Menstrual disorders are a common problem in adolescents; at least one the menstrual morbidity is prevalent among Indian young girls, which is the source of anxiety for the patients and the families that are associated with various modifiable and non-modifiable factors [ 20 ].

Practices by adolescent girls during menstruation

Cloths have historically been used to absorb menstrual flow; they are less expensive and less polluting, but pads are progressively replacing them, especially in urban areas. If females do not have access to water, privacy, or a drying area, cleaning and drying clothes might be challenging [ 21 ]. Commercial pads were preferred by the authors of the reviewed studies and the participants, but cost prohibits widespread usage, particularly in rural regions. Compared to a national community-based study done in 2007–2009, our pooled estimate of pad use was greater than that in a separate report from 2010, in which 12% of 1033 females sampled across India used pads [ 22 ]. Our pooled data found that more adolescents clean their perineum during menses. This is in line with findings of other studies that reported a large percentage of females to use sanitary pads, bathe every day, and cleanse their genitalia with soap and water [ 23 , 24 ]. However, Only 4.6% of students in Andhra Pradesh, 11% of Haryana found washing their genitalia with soap and water during menses which could be a lack of awareness and facilities in the school.

Menstrual disorders

In this review study, we have reported the various menstrual disorders in which dysmenorrhea has been recorded as high, premenstrual syndrome (PMS), oligomenorrhea, Mennorhagia, Polymenorrhea, Polycystic ovary syndrome (PCOS), and Hirustusmus. Many studies have also reported the same various menstrual irregularities among young girls [ 21 , 25 ]. Dysmenorrhea, a medical ailment defined by intense uterine pain during menstruation presenting as the recurrent lower abdomen or pelvic discomfort that may also radiate to the back and thighs, has been recognised as the most frequent disorder [ 21 ]. There are two types of dysmenorrhea: primary dysmenorrhea and secondary dysmenorrhea. Primary dysmenorrhea occurs when there is no co-existing pathology, and secondary dysmenorrhea occurs when there is an identified and modifiable cause [ 26 ]. After dysmenorrhea, other menstrual abnormalities noted were polymenorrhea which is the condition where the gap between two consecutive cycles is 21 days, but in oligomenorrhea, it can be up to 35 days. [ 27 ] The premenstrual syndrome, also reported in various studies, is a collection of cyclic, repeating physical, emotional, and behavioural symptoms that appear during the late luteal phase of the menstrual cycle and disappear when menses begin. Symptoms range is comprehensive and affects all aspects of life (family, social, occupational). The condition for PMS diagnosis is the existence of two consecutive periods accompanied by annoying changes [ 27 , 28 ]. Various factors were associated with menstrual morbidities. The main reason for morbidity prevalence could be not using the sanitary pads due to cost considerations. Other reasons included were absorbent disposal issues, lack of awareness about hygiene, and personal choice among girls.

Common modifiable factors

Poor nutritional status, a high BMI, junk food consumption, meal skipping during menses, female dieting, decreased physical activity, low socioeconomic status and anaemia have all been identified as contributing causes to menstrual problems. Junk foods are low in micronutrients such as vitamin B6, calcium, magnesium, and potassium, which may be responsible for initiating premenstrual symptoms [ 14 ]. Another study found a link between frequent junk food consumption and irregular menstrual periods, abnormal flow, dysmenorrhea, and PMS [ 29 ]. According to Fujiwara et al., the frequency of fast food consumption was linked to dysmenorrheal [ 30 ]. To improve the menstrual health of young college girls, a study has suggested emphasising the reduction of junk food consumption and promoting healthy eating practices [ 31 ]. Also, it is essential to avoid skip of meals and diet to maintain good menstrual health. In earlier research, the lower socioeconomic level was linked to higher illness severity, morbidity, mortality, and barriers to accessing more advanced medical treatments [ 29 , 32 ]. However, in the one study, the prevalence of menstruation disorders was higher in females with a middle socioeconomic class due to a sedentary lifestyle and junk food intake than in females with a low socioeconomic position owing to a sedentary lifestyle and junk food consumption [ 29 ]. Higher socioeconomic status (SES) could also be because of menstrual problems as high SES is more at high risk of consumption of fast food and a sedentary lifestyle [ 20 ].

According to the study, menorrhagia has a strong negative link with salad consumption and socioeconomic status, whereas oligomenorrhea has a favourable link with socioeconomic status. The contradictory relationship with socioeconomic level could be attributed to high socioeconomic level individuals' increased consumption of junk food, sedentary lifestyles, and lack of knowledge about healthy eating habits [ 29 ]. Good nutrition and a healthy lifestyle induce puberty earlier. As menstruation is the last process of puberty, it delays adolescence with stress, poor nutrition, and an unhealthy lifestyle [ 33 , 34 ]. Physical activity and menstrual irregularities have been found to have a strong link. Compared to students who did not exercise regularly for more than 3 days a week, regular students had fewer menstrual irregularities in cycle length, flow, dysmenorrhea, and PMS. Regular physical activity helps maintain optimal body weight, enhance insulin sensitivity, enhance BMR, and release endorphins, which aid in menstrual cycle regularisation, PCOS and hypothyroidism improvement, PMS reduction, and overall well-being [ 14 , 35 ].

Adolescent gynecologic problems are unique in the spectrum of gynecologic illnesses of all ages, as 75% of women suffer from menstrual issues. A statistically significant link between a girl’s educational level and reproductive morbidity has been reported. As one's level of education rises, so does one’s age in years, and as one’s age rises, so does reproductive morbidity [ 36 ]. Girls with a lower educational level may be unwilling to discuss reproductive morbidity. This could explain the current study’s findings. It is suggested that an aware girl and a mother continue with girl education could improve the family’s well-being and quality of life. Poor menstrual hygiene practices are closely linked to reproductive tract morbidities, damaging a woman’s life. According to research, a large information gap exists among adolescent girls in terms of prior awareness of menstruation and menstrual cleanliness, which impacts menstrual practices and associated gynaecological morbidities [ 37 ]. Different cultures in India have different types of limitations during menstruation, which could be a factor in the lack of compliance with proper menstrual hygiene [ 38 , 39 ]. PCOS was linked to a higher incidence of diabetes mellitus and hypothyroidism in the family. According to previous research, the likelihood of discovering a metabolic problem in the families of PCOS patients is 2.7 times higher than in the control group [ 40 ]. As a result, PCOS is more common in girls whose parents and grandparents had metabolic abnormalities than in girls whose parents and grandparents did not. Hypertension is three times more common in women with PCOS than in those without the condition, according to previous research [ 20 ].

With intervention, the post-test and experimental groups significantly improved menstrual hygiene compared to the pre-test and control groups. This study is backed by various studies that found a need for health education and behaviour change programmes in this area [ 41 , 42 , 43 ]. This type of intervention in schools can eradicate preconceptions, prejudices, and improper familial behaviours. So imparting the proper knowledge, changing attitudes and practices, and reducing the likelihood of developing morbidities like RTI [ 44 ]. A study conducted in Egypt also found that a menstrual education programme for first and second-year girls at a secondary school was adequate and that the programme needed to be expanded to elementary, preparatory, and other secondary schools [ 45 ]. A similar study by Chang et al. on primary school girls in grades 5 and 6 found that educational programmes in schools for students and their parents were effective [ 43 ]. Another study conducted in Bangladesh found a 31.4 per cent improvement in follow-up knowledge scores, identical to the current study but with only one intervention group [ 46 ].

By examining replies and gauging retention after the intervention, our study offers evidence to support the efficacy of education training in producing a lasting influence on knowledge levels. Furthermore, few studies have looked at changes in views immediately after intervention and several months later. The importance of family life education in the school health programme has been recognised. We can increase knowledge by including themes on specific physiological aspects of menstruation and pregnancy in health education programmes offered by health professionals for adolescent girls [ 47 ].

We recommend that public health programmes strengthen menstrual hygiene management and associated factors. Evidence-based research, particularly research targeting the most underserved to assess the actual impact and outcomes of programmes targeting MHM should be conducted in the country. Support for learning from the implementation of government programmes and policies to share across country governments, longitudinal research to measure relevant impact and outcomes; increased investment in the evidence base for addressing MHM in schools, particularly research targeting the most underserved; and a better understanding of costs and effectiveness, as well as the benefits of comprehensive, cross-sectoral addressing MHM in schools are among the key recommendations for actions that will advance the agenda. All of these efforts will help the young girls to become aware of and comfortable with their menstrual cycle and will be able to manage their periods in a pleasant, safe, and dignified manner.

Implications

The results of this study can be helpful in future studies to prevent and treat menstrual disorders such as dysmenorrhea, oligomenorrhea, and premenstrual syndrome to promote menstrual health by modifying lifestyle and improving the quality of life of young Indian girls. Furthermore, this study suggests the need for research on associated factors of specific menstrual problems and the role of comprehensive intervention on menstruation among adolescent girls.

Menstruation-related problems are widespread among adolescent girls in India. Studies show that menarche results in feelings of stress, anxiety, depression, and anger. Our findings estimate that most Indian adolescent girls began menarche unaware of the reason, with very few knowing the source of bleeding. Learning about menstrual hygiene and health is an essential aspect of adolescent girls’ health education to continue working and maintaining hygienic habits. Infections of the reproductive system and their repercussions can be avoided with better awareness and safe menstruation practices. The ideal menstrual health education programme would teach students to consider the connections between knowledge, behaviour, and improved human health. It would also assist in the improvement of maternal health. There is a need to address the menstrual morbidities in young girls’ initial stages of life. Therefore workshops, adding a chapter to some course’s literature focusing on improving the lifestyle and associated modifiable factors with raising girls’ general information about the following: physiology of menstruation, the relationship between hormonal changes, symptoms and menstrual disorders and their associated factors.

Strengths and limitations

There is the possibility of selective reporting bias or publication prejudice in any review. Our review found many outcomes, ranging from substantially positive associations to the inverse. We attempted to broaden our review to include these studies, given the time and resources available. However, this was not possible due to time and resource constraints. With these constraints in mind, we have concluded that most studies on menstrual hygiene practices, morbidities, and their associated factors focus on determining the prevalence of exposure. We conducted a systematic search for articles and included research based on explicitly specified criteria to reduce selection bias, which strengthened this review.

Furthermore, between-study high heterogeneity is observed in the present review as depicted by I 2 statistic. This may be due to different methodologies and study settings. We developed four themes to analyse and interpret our results and conducted subgroup analysis by type of morbidity and study design.

Availability of data and materials

All data relevant to the study are included in the article and additional sheets. No additional data is available.

Abbreviations

Body mass index

Basic metabolic rate

Low and middle-income countries

• Menstrual hygiene management

Polycystic ovary syndrome

Population intervention comparison of outcome

Premenstrual syndrome

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Socioeconomic status

Standardized mean difference

Urinary tract infections

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Additional file 1. table 1..

Morbidities and Associated factors. Table 2. Use of absorbent and perineum cleaning during menses. Table 3. Intervention based studies on menstruation. Table 4. Quality assessment of included studies by using Newcastle – Ottawa Assessment Scale

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Majeed, J., Sharma, P., Ajmera, P. et al. Menstrual hygiene practices and associated factors among Indian adolescent girls: a meta-analysis. Reprod Health 19 , 148 (2022). https://doi.org/10.1186/s12978-022-01453-3

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Menstrual hygiene management practice among adolescent girls: an urban–rural comparative study in Rajshahi division, Bangladesh

• Md. Abu Tal Ha 1 &
• Md. Zakiul Alam 1  

BMC Women's Health volume  22 , Article number:  86 ( 2022 ) Cite this article

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Introduction

Adolescence is a critical period characterized by significant physical, emotional, cognitive, and social changes, including the monthly occurrence of menstruation of adolescent girls. Despite being an inevitable natural event, most societies consider menstruation and menstrual blood as taboos and impure. Such consideration prevents many adolescent girls from proper health education and information related to menstrual health, which forces them to develop their ways of managing the event. This study attempted to explore the pattern, the urban–rural differences, and the determinants of menstrual hygiene management practices (MHMP) among adolescent girls in the Rajshahi division, Bangladesh.

Methodology

Using a cross-sectional study design with multistage random sampling, we collected data from 586 adolescent girls (aged 14–19 years) from the Rajshahi division of Bangladesh. The MHMP was measured using eight binary items, where the value from zero to five as ‘bad,’ six as ‘fair,’ and seven-eight as ‘good’ practices. Finally, we employed bivariate analysis and multinomial logistic regression analysis.

Only 37.7% continuously used sanitary pads. Among the cloth users, nearly three-fourths reused cloths, and about 57% used water and soap to wash them. About 49% changed menstrual absorbent, and 44% washed their genitalia three times daily. About 41% used water only to wash genitalia, and 55% buried sanitary materials under the soil. Around 36.9% of the girls practiced bad, 33.4% fair, and 29.7% good menstrual management. We found significant differences in MHMP among adolescent girls between urban and rural areas (32.3% vs. 27.7% good users, p  ≤  0.05 ). Multinomial logistic regression found that place of residence, age, family size, parental education, and age at first menstruation were the significant determinants of MHMP.

Although there are some cases of sanitary pad use, still menstrual hygiene management is unhealthy in most cases. The continuous supply of sanitary pads at affordable cost, change in existing social norms about menstruation, proper education, information, and services are essential for achieving health-related SDG goals in both rural and urban areas of Bangladesh.

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Adolescence is a critical period in women’s lives characterized by first menstruation, a natural and beneficial biological event, and significant physical, emotional, cognitive, and social changes [ 1 , 2 ]. Despite being an inevitable and natural process, most societies consider menstruation a taboo [ 1 , 2 , 3 , 4 , 5 , 6 ]. Many of the norms and stigma associated with the event are based on discriminatory gender roles and cultural restrictions, making it a silent and invisible issue [ 1 , 2 , 3 , 4 , 5 , 6 ]. As a result, it prevents many adolescent girls from receiving proper menstrual health and hygiene-related information and education. Furthermore, it also exposes them to challenges of managing menstruation and menstrual blood properly and forces them to develop their ways of managing it depending on existing traditional and cultural beliefs, level of knowledge on menstruation, and personal preferences [ 1 , 2 , 3 , 4 , 5 , 6 ].

In a country like Bangladesh, mothers and other female relatives are the primary sources of information on menstruation; however, they can provide very little information, which is often misconceptions, thereby affecting adolescent girls’ response to menstrual management [ 7 , 8 , 9 , 10 ]. Studies show that unhealthy practices of menstrual management among adolescent girls are highly prevalent in Bangladesh [ 1 , 7 , 11 , 12 ]. Globally, poor menstrual management affects girls’ school attendance and academic progress through psychological (for example, discomfort, high stress, fear of leakage of menstrual blood, and fear of leaving signs of menstrual blood inside the school latrine) and physical (for example, Dysmenorrhoea, Headache, and excessive bleeding) factors [ 2 , 12 , 13 ]. At the same time, it affects their maternal and reproductive health through increased risk of reproductive tract infections (RTI), sexually transmitted diseases (STD), Human Papillomavirus (HPV) infection, and adverse pregnancy outcomes [ 1 , 2 , 14 ]. Understanding the menstrual hygiene management practices (MHMP) of adolescent girls is therefore crucial for informing strategies to promote equitable education, gender equality, women’s empowerment, health, and environment in line with the Sustainable Development Goals (SDGs) [ 10 ].

Despite being a significant public health issue, there is limited understanding of the extent of proper MHMP in low and middle-income countries, including Bangladesh [ 11 ]. Studies on menstrual management practices conducted in Bangladesh have, for instance, focused on narrow topics such as the prevalence of the practices or the relationship between menstruation and girls’ school attendance, with no consideration of the broader dimensions of menstrual hygiene management and its socioeconomic determinants [ 1 , 7 , 8 , 10 , 12 ]. This paper examines the menstrual management practices of adolescent girls in the Rajshahi Division (randomly selected) of Bangladesh and the socioeconomic determinants of such practices.

Data and methods

Data collection process.

We used a multistage random sampling procedure to identify the research location. In the first stage, we randomly selected the study area, the Rajshahi division, among Bangladesh's eight administrative divisions. One of the administrative districts, Chapainawabganaj, was then randomly selected among the eight districts of the Rajshahi division. In the third stage, four administrative sub-districts ( Upazila in Bangladesh) were selected randomly out of the five sub-districts. In the final stage, eight secondary schools (four located in the urban area and the other four in the rural area) were randomly selected with the help of key informants to locate the schools., The target sample size was 589 adolescent girls in order to detect 10% prevalence of use of sanitary pad (based on the 2014 Bangladesh National Hygiene Baseline Survey) at a 95% confidence interval, 5% non-response rate, and 1.5 design effect for homogeneity among learners sampled from the same school. The current cross-sectional study was conducted on 17–25 November 2018 among adolescent girls aged 14 to 19 years studying in eight secondary schools in the Rajshahi Division of Bangladesh. In each school, an average of 37 adolescent girls (total sample divided by two classes of each school) in Standards 9 and 10 were randomly selected from the registrar. The initial target was to have 60% of the sample from rural areas and 40% from urban areas, as most (more than 60%) of the population lives in rural areas. However, the final sample size stands at 586 adolescent girls comprising 57% from rural areas and 43% from urban areas (Fig.  1 ).

Process of sample selection for the study

Adolescent girls studying in Standard 9 and 10 were targeted; they were considered mature enough to talk about a socially sensitive issue like menstruation and could provide their consent for participation in the research. Before the commencement of data collection, permission was obtained from the head of each school over the phone after informing the study's objectives. As permission was received, we collected detailed information of the potential respondents from those schools, randomly selected them, contacted their parents, and managed to receive their permission as the potential participants were minors. After getting permission from both heads of institutions and parents, one of the female teachers from each school was trained on the data collection process to oversee. On the interview day, randomly selected girls from Standard 9 and 10 were gathered in a classroom and were seated in-class environment. A questionnaire was given to students who voluntarily agreed to participate in the study after a short description of objectives and roles as respondents. After that, participants self-administered the questionnaire. The responsible female teacher collected the completed questionnaires.

Variable definitions and measurements

Outcome variable.

The dependent variable, “Menstrual Hygiene Management Practice (MHMP),” had three categories, namely ‘good,’ ‘fair,’ and ‘bad.’ A total of 8indicators, identified based on existing literature [ 7 , 12 , 15 , 16 , 17 , 18 , 19 , 20 ], were used to measure menstrual hygiene management practices (Table 1 ).

For measurement purposes, healthy practices for each indicator were coded one, and unhealthy practices as zero. The first indicator was related to absorbent use for managing menstrual blood, where the use of sanitary pads and new cloth was regarded as healthy practices. However, the questions on washing cloth before re-using, materials used to a washcloth, place of drying and storing washed cloth (indicators 2.1 to 2.4 in Table 1 ) were only asked those who used the cloth to manage their menses [ 12 , 19 , 20 , 21 ]. The positive response of all the four indicators about using old cloth was also considered healthy practices for indicator one. The other seven indicators included frequency of changing absorbent, washing of genitalia during menstruation, frequency of washing genitalia, the material used for washing genitalia, taking a bath during menstruation, frequency of bathing during menstruation, and ways of disposal of sanitary materials [ 7 , 12 , 15 , 16 , 17 , 18 , 19 , 20 ] and were applicable for all participants. Therefore, a score for the sum of eight indicators was used to measure MHM practices, with values ranging from zero to eight. The indicator was then categorized into bad (score of zero to five: up to 50%), fair (score of six: 50–75%), and good (score of seven and eight: 75–100%) MHM practices.

Socioeconomic and demographic variables were used as the independent variables, including age, family size, religion, wealth index, fathers’ and mothers’ education, fathers’ and mothers’ income, age of first menstruation, social connectivity, and information on menstruation before reaching menarche based on the existing literature [ 1 , 10 , 12 , 15 , 19 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. Age was categorized as ≤ 15 and ≥ 16 years old considering the year of schooling (class 9 and 10) and mean age (15.1) of the participants. Since mother and other female relatives were the primary sources of information on menstruation in Bangladesh [ 8 ], adolescent girls from small families may have a lower chance of receiving menstrual information; as the number of female relatives tends to be lower in these families. Thus, we decided to assess the relation between family size and menstrual hygiene management. Families with five or fewer members were defined as small, and more than five members as large families based on the average family size (4.4) in Bangladesh [ 30 ].

We used ten items on household possessions to generate an indicator of an individual’s family wealth status. Questions included flooring type of the respondent’s household, electricity connection, steel/wooden Almirah, smartphone, toilet, type of toilet, color television, refrigerator, air conditioner, and availability of transport used for a non-business purpose. All variables had binary responses (yes or no) except the type of toilet and transport. Positive responses were assigned value one, and negative answers were attributed zero. Type of toilet facility and transport were recoded into dummy variables. The availability of a motorcycle and/or cars/micro/bicycle was considered a positive response. Similarly, the availability of open and/or kancha (mud) toilets was considered a negative response, while sanitary toilets (with or without water slab) were considered a positive response. One was attributed for both variables for a positive response and zero for a negative response. The principal component analysis (KMO = 0.71) was used to measure the wealth index and categorized poor (bottom 40%), middle (next 40%), and rich (top 20%) following existing literature [ 24 ].

The perceived socioeconomic class was measured by two questions that asked participants about their perceptions of the specific class to which they belonged, with the response of very poor, poor, middle, upper, and uppermost. For analytical purposes, those who responded very poor and poor were assigned value one, the middle was attributed two, and the upper and uppermost were attributed three. The two variables were then summed to generate a variable with values ranging from two to six. Respondents attaining value 1–2 were defined as low, 3–4 as middle, and 5–6 were defined as a high socioeconomic class. As existing literature suggests, although there is a high unmet need for sanitary pads, many adolescent girls and women do not use them because of high costs [ 8 ]. At the same time, many women and adolescent girls still consider sanitary pads as a luxury item [ 31 ]. Thus, we incorporated this variable to assume that perceived socioeconomic class may affect sanitary pad use and other menstrual hygiene management practices. We also measured the fathers' income as low (up to BDT 10,000), middle (BDT 10,001 to 20,000), and high (BDT 20,001+); mothers’ income as yes and no.

We used three variables to measure respondents' social connectivity: physical mobility, passing the time with friends outside the school, and internet use. Respondents who could travel more than one kilometer alone from home during the daytime without parental consent were defined as physically mobile, and those who could travel less than one kilometer as non-mobile. We considered a minimum distance of one kilometer based on the assumption that sanitary pads may not be available within this one square kilometer area, thus limiting the chance of buying sanitary pads by respondents themselves. Physical mobility was attributed value one, and non-mobility was attributed zero. Similarly, passing the time with friends other than school period and using the internet regularly had two possible responses; yes and no; positive answers were assigned value one, and negative answers were assigned zero. The three variables were summed to generate a score with values ranging from zero to three. Those who scored zero were considered not socially connected, those with 1–2 as moderately connected, and those scoring three as highly connected.

Respondents’ perception towards pad use was measured using a set of four statements: (1) use of old clothes rather than pads to manage menses may increase the risk of reproductive tract infections , (2) use of sanitary pads to manage menses may prevent reproductive tract infections , (3) use of sanitary pads helps to regular menstruation , and (4) use of sanitary pads protects one from the fear of unwanted drop out of it . Each statement had five options; strongly agree, agree, do not know/not sure, disagree, and strongly disagree. Responses ‘agree’ and ‘strongly disagree’ were coded as positive responses, while the rest were negative responses.

Analytical approach

We used cross-tabulation with the Chi-square test to examine urban–rural differences in various menstrual hygiene practices. We then estimated a multinomial logistic regression model to examine the factors associated with hygiene management practices. The results from cross-tabulations are presented as percentages, while those from multinomial logistic regression analysis are presented as [coefficient estimates/relative risk ratios (RRR)] with 95% confidence intervals (CI).

Socio-demographic characteristics of respondents

Table 2 represents the socio-demographic characteristics of respondents. Data show that the mean age of the respondents in this study was 15.5 (standard deviation is 0.71 years). Out of 586 girls, 254 (43.3%) lived in urban areas and the rest in rural areas. Most (71.8%) girls lived in small families with five members or fewer. Data regarding parents’ education indicated that 7.8% of fathers and 5.1% of mothers did not have formal education. The majority of the respondents (81.1%) were from middle-class families. About a third (32.8%) of the adolescent girls did not have social connections, while 31.7% reported having high social connectivities.

Menstrual knowledge of respondents

Results on menstrual knowledge are presented in Table 3 . The mean age at first menstruation was 12.8 (standard deviation of 0.97 years), slightly higher in rural than urban areas (12.9 and 12.6 years, respectively; p  = 0.008). Three-quarters (75%) of the respondents reported that they received information about menstruation before reaching menarche, while the rest did not receive any information before their first menstruation. Sources of information about menstruation were mothers (42.1%), female friends (22.9%), female teachers (18.5%), sisters (13.2%), and others (3.2%). Results further show that half (50.2%) of the girls had positive perceptions about the use of sanitary pads. There were statistically significant variations in availability and sources of information and perception about the use of sanitary pads between adolescent girls in urban and rural settings. For instance, urban adolescents were more likely to receive information before menarche, specifically from female teachers, than their counterparts.

Menstrual hygiene management practices of adolescent girls

Table 4 presents the findings and shows that the highest 37.7% of adolescent girls used sanitary pads and 27.1% used old/new cloth only to manage their menstrual blood. The use of absorbent does not vary statistically ( p  = 0.47) between urban and rural areas. Among the cloth users (n = 363, including occasionally cloth users), nearly three-fourths (71.1%) reused the same cloth, and almost all (97.7%) washed these cloths before reusing. Water and soap were used as the main ingredient (57%) in urban and rural areas. In 51.6% of cases, the washed cloth was dried in open sunny places, and after drying, nearly three-fourths (74.7%) of them were stored in hidden places in the room. Nearly half (48.5%) of girls changed menstrual materials three times a day, and only 0.4% changed it four or more times. These practices did not vary based on place of residence. Almost all (98.8%) washed their genitalia during menstruation. Data show that 44.2% of girls washed their genitalia three times, 33.7% four or more times, and 8.4% once a day. Around 41% of girls used only water to wash genitalia, which was higher in urban areas than rural areas. Both washing frequency and materials varied significantly between the two areas. Urban girls were more likely to wash their genitalia four or more times a day than rural girls, while rural girls were less likely to use water only to wash external genitalia than urban girls. More than three-fourths of the girls (77.5%) took a bath regularly during menstruation. After use, 55.3% of the girls buried their sanitary materials under the soil, and 20.2% threw them in the pond or river—the practice of disposing of sanitary materials varied between the two areas. Rural girls were more likely to throw their used sanitary materials into ponds or rivers; on the other hand, more urban girls buried them under the soil.

Barriers to continuous use of sanitary pad

Table 5 presents barriers to the continuous use of sanitary pads. Among the sanitary pad users, including mixed users (sometimes cloth and sometimes pad users), respondents (45.5%) and their parents (25.1% by mothers and 20.6% by fathers) were the primary buyers of sanitary pads. However, these sources varied based on place of residence. More girls in urban areas relied on their parents to buy sanitary materials, while more rural girls themselves bought them. More than one-third of girls felt shy to buy sanitary materials from male shopkeepers (36.1%), and this shyness increased in the presence of a male in the shop other than the shopkeeper (60.1%). More than three-fourths (76.1%) of adolescent girls could not use sanitary pads continuously due to their absence at home during their menstruation. In this circumstance, they either used old/new clothes (66.2%) or borrowed sanitary pads (28.4%) from others or took other measures to manage this. Among all-time cloth users, including old and new cloth, 71.8% wished to use sanitary pads but could not because of high cost (35.6%), feeling of embarrassment to buy sanitary pads (37.5%), unavailability of sanitary pads at nearby shops (10.6%) and other (16.3%) causes. Adolescent girls' unwilling to use sanitary pads mentioned relaxation to use cloths (60%), unnecessary money expending (27.5%), rashes (10%), and other (2.5%) causes as a reason.

Association between socioeconomic factors and menstrual hygiene management practices

The classification of menstrual hygiene management practices indicated that 36.9% of respondents followed bad, 33.4%, and 29.7% followed fair and good practices (Table 6 ). Variations in menstrual hygiene management practices show that urban adolescent girls had more good and fair practices ( p  = 0.05) than rural girls. Similarly, girls from small families had more good practices than girls from large families ( p  = 0.030). Parental education, parental income, and age at first menstruation were also statistically significant (Table 6 ). At the same time, religion, wealth index, perceived socioeconomic class, information before menstruation, perception toward pad use, and social connectivity were not significantly associated with menstrual hygiene management practices. Girls who experienced first menstruation at or after thirteen years of age were more likely to practice good and fair management than those who experienced first menstruation at earlier ages.

Only significant variables (p-value of 0.05 or less) from the bivariate analysis were entered into regression analysis (Table 7 ). The results show that the girls aged up to 15 years were less likely to have bad menstrual hygiene management practices (RRR: 0.50; 95% CI: 0.32–0.80, P  = 0.004) than if they did not have good management practices than the girls aged 16 and above years. Urban girls were less likely (RRR: 0.61; 95% CI: 0.38–0.98, P  = 0.045) to have bad menstrual hygiene management practices if they did not have good management practices compared to those from rural areas. Adolescent girls from small families were significantly less likely to have bad (RRR: 0.52; 95% CI: 0.31–0.86) menstrual hygiene management practices if they did not have good management practices compared to those from large families. Girls whose fathers had no formal (RRR: 2.28; 95% CI: 1.16–9.28, P  = 0.025), primary (RRR: 3.56; 95% CI: 1.84–6.88, P  < 0.001) and secondary education (RRR: 3.11; 95% CI: 1.67–5.82, P  < 0.001) were more likely to have bad menstrual hygiene management practices compared to those whose fathers had HSC or higher levels of education. Girls who experienced their first menstruation at 12 years or earlier were 66% more likely to practice bad menstrual hygiene management than those who experienced their first menstruation at 13 years or older (RRR: 1.66; 95% CI: 1.05–2.63, P  = 0.030).

Discussions

The main objectives of this study were to explore the menstrual hygiene management practices, the urban–rural differences in the practices, and the determinants of such practices. Our findings indicate that the mean age of respondents and the mean age of first menstruation in the study were 15.5 and 12.8 years, respectively. The mean age at first menstruation was slightly higher in rural (12.9) areas than urban areas (12.6). These findings are consistent with similar studies [ 7 , 10 , 19 , 32 , 33 , 34 ]. Proper education and information on menstruation before reaching menarche are the right to information of adolescent girls and are crucial for healthy menstrual management. A cross-sectional study conducted by Alam et al. (2017) shows that 64% of girls did not know about menstruation before reaching menarche [ 10 ]. The Bangladesh National Hygiene Baseline Survey 2014 also described that only 36% were informed about menstruation among the students before reaching menarche [ 7 ]. Compared to these studies, our study indicates that about 75% of the respondents received information about menstruation before reaching menarche, which indicates an increase in getting menstrual information before reaching menarche.

Before reaching menarche, getting information regarding menstruation was positively but not significantly associated with menstrual hygiene management practices. Like other studies, this study also found that mothers and sisters together were the two primary sources of menstruation-related information [ 7 , 10 , 19 , 35 , 36 ]. This finding is important because mothers with a lower level of knowledge can transfer very little regarding menstruation and often transfer misconceptions to their girl child [ 9 ]. On the other hand, high literacy and slight inhibition of mothers sharing their accurate knowledge to their daughters can positively affect adolescent girls’ conception and healthy management of menstruation over generations [ 19 ].

The absorbent used for managing menstrual blood is a primary health concern. The reuse of cloths without maintaining proper hygiene may increase the risk of reproductive tract infections [ 19 ]. The prevalence of using sanitary pads was 37.7%, significantly higher than previous studies conducted in Bangladesh [ 7 , 8 , 10 , 12 , 31 ]. According to our study, among the cloth users, including sometimes sanitary pads and sometimes cloth users, 71.1% reused cloths for absorbing menstrual blood, and 97.7% washed those materials before reusing; among them, 57% used water and soap, and 7.4% used water only. These findings were consistent with similar studies [ 1 , 7 , 10 , 15 , 19 , 25 , 37 ]. Re-using of clothes may even be better when proper sanitization is maintained as cotton cloths are reusable, readily available, and more environment-friendly than commercial sanitary pads [ 38 ]. However, drying sanitary materials in open and sunny places before re-using (51.6%) was significantly higher. Moreover, 74.7% of the respondent stored their dried clothes in hidden places within the room, and 13.8% with other cloths for reuse, and these findings differed from other studies [ 7 , 12 , 15 ].

Regular changing sanitary materials is a prerequisite for maintaining good menstrual hygiene management. Although there is no hard and fast rule of changing sanitary materials during menstruation, it depends mostly on blood flow, varying from person to person. However, it is suggested to change absorbent at least every four to eight hours during the menstrual cycle [ 7 ]. We considered changing sanitary materials at least three times a day to be good practice. This study results suggest that about 48.5% of the respondents changed their sanitary materials three times a day during menstruation, and this finding was also consistent with existing similar studies [ 7 , 10 ]. Rechanging sanitary materials and regular washing of external genitalia maintaining proper hygiene are crucial for healthy menstrual management. One study suggests that those who washed the body and external genitalia with water only were 2.4 times more likely to be asymptomatic of one or more urogenital diseases than those who used both water and soap for washing [ 39 ]. This study shows that 33.7% of respondents washed their genitalia four or more times, and another 44.2% washed it three times per day. In comparison, 38.7% of adolescent girls used water and soap for washing their external genitalia. These findings were identical to two similar studies conducted in India [ 19 , 40 ].

Disposal of sanitary materials properly is as important as other indicators of the menstrual hygiene management. Unhygienic disposal of sanitary materials in rivers, ponds, or even under the soil may increase the risk of infection of Hepatitis and HIV as sanitary materials soaked with the blood of an infected girl/woman may contain these Bacteria and viruses [ 38 ]. This study indicates that more than 55% of the participants disposed of their used sanitary materials under the soil. We found that 20.2% of adolescent girls threw their sanitary materials in ponds/rivers. This unhygienic behavior of disposing of used sanitary materials may put hundreds of people at risk of infection with fatal diseases like Hepatitis and HIV. Many people in Bangladesh use river and/or pond water for bathing and domestic washing purposes [ 41 ]. According to this study, the unmet need for disposable sanitary pads among non-pad users was 71.8%. Despite the high need, they (35.6%) could not use because of the high cost of sanitary pads and the embarrassment of buying pads from male shopkeepers (37.5%). Similar results were found in previous studies [ 1 , 8 , 37 ].

This study found that age, religion, family size, parental education, fathers’ income, perceived socioeconomic class, and age at first menstruation had a significant statistical association with menstrual hygiene management practices at the bivariate level, and these findings are similar to other studies [ 8 , 25 , 37 , 42 ]. Being Muslims, members of a large family and children of less-educated fathers were associated with bad menstrual hygiene management practices. In Bangladesh, Muslim adolescent girls are more conservative, which may result in lower access to modern sanitary materials. On the other hand, girls from well-off families and daughters of educated parents may have more accessibility, affordability to sanitary pads, and more chance of getting information on menstrual hygiene management [ 8 , 25 , 37 , 42 , 43 ]. This study observed significant urban–rural differences in terms of menstrual hygiene management practices. Like all other indicators of demography and health [ 43 , 44 ], the residents of urban areas have better menstrual hygiene management practices than rural areas. As a result, the percentage of respondents who did not participate in social activities, school, or work due to their last menstruation was significantly higher in rural areas than urban [ 43 ].

Limitations of the study

This study used a cross-sectional research design. Thus, causal inferences about relationships observed in the data cannot be established. Another limitation of the study was that it was confined to a single geographic location (Rajshahi) in Bangladesh. Therefore, findings from the study may not represent the experiences of all adolescent girls in the country. Due to the sensitivity of the research topic, during the data collection procedure, we faced some challenges. One of the biggest challenges was the hesitancy of the heads of selected schools and the parents of primarily selected respondents' to allow their girls to participate in the survey. We had to go through a lengthy discussion to convince them in this regard. Even so, we faced complete refusal from at least one identified institution. Although we primarily intended to record responses by a trained interviewer, we had to rely on self-administration of the questionnaire by the respondents as the heads of the selected institutions did not allow male interviewers to conduct face-to-face interviews. Participating respondents were seated in a class environment where at least two or more respondents were seated on a single bench. We suspected that some of them had either been influenced by the fellow respondent or copied responses from others. A face-to-face interview would produce more quality data. We also noticed that some respondents were too shy to ask for help from their overseer even though they could not understand a particular question properly. Finally, the sample size of this study was relatively small; as a result, true population parameters may not be found.

The primary objective of our study was to assess the menstrual hygiene management practices of adolescent girls, the urban–rural differences, if any, of the practices, and the determinants of such practices. Although the research findings show that many adolescent girls have information before reaching menarche about menstrual hygiene management, it should be considered that nearly one-fourth of respondents reach at menarche without any prior information about this. This study suggests that girls reaching menarche without prior information are more likely to practice bad menstrual hygiene management. Thus, measures must be taken to ensure information availability about menstrual management before a girl reaches her menarche through proper channels. As mothers and sister/s are the two significant sources of menstrual information, and as they often translate their misconception and attitude to adolescent girls, steps should be taken to change adult females’ attitudes and knowledge towards menstrual management. This study shows that more than one-fourth of adolescent girls use cloth, and another 35.2% sometimes use pads and sometimes cloths to manage their menses; therefore, measures must be taken to ensure a continuous supply of pads for all. Although nearly three-quarters of non-pad users wish to use sanitary pads, more than one-third cannot use them because of the high cost of sanitary pads. Among cloths users, more than one-fourth do not even want to use pads because it causes unnecessary money expending. Thus, it is essential to make pads available at affordable costs. Shyness to buy pads and unavailability of pads at nearby places also prevent many adolescent girls from pad use; thus, existing social norms regarding menstrual hygiene management must be changed. All those necessary measures must be taken to ensure adolescent girls’ healthy menstrual management to meet the SDG goals of good health and wellbeing, quality education, gender equality, and clean water and sanitation.

Availability of data and materials

This research was conducted as a part of partial fulfillment of the Bachelor of Social Sciences (BSS) honors degree from the Department of Population Sciences, University of Dhaka. The Department of Population Sciences, University of Dhaka has the right to reserve the data. Therefore, data cannot be provided in supplementary file or deposited in a public repository. However, the dataset could be obtained from the Department of Population Sciences, University of Dhaka ( https://www.dpsdu.edu.bd/index.php/en/ ) or the corresponding author on reasonable request.

Abbreviations

Human Papillomavirus

Reproductive tract infections

Sexually transmitted disease

Sustainable Development Goal

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We acknowledge the Department of Population Sciences, the University of Dhaka, to approve this research. We also acknowledge all the unknown respondents who participated in the study.

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MATH and MZA conceptualized the study. Both authors completed the analysis, drafted the manuscript, and reviewed the draft manuscripts. After reading thoroughly and carefully, both authors approved the final manuscript.

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This manuscript is a part of a research monograph submitted to the Department of Population Sciences, the University of Dhaka, for partial fulfillment of the bachelor (undergraduate) degree. The Academic Committee (AC) of the Department of Population Sciences, University of Dhaka, approved the topic and study protocol. The AC is the responsible body that handles all aspects of the research monograph. The present study was carried out in accordance with the Declaration of Helsinki. Moreover, the research evaluation committee of the Department of Population Sciences, University of Dhaka, approved the study and provided written permission before the field visit. Most of the respondents were below the age of 18 years. As a result, verbal consent was taken from parents. The study’s objectives were clearly stated to each parent (in some cases, the questionnaire was provided) and asked permission whether we can interview their children using the following question ‘do you (parent/guardian) agree that your daughter will participate in this study after reading the information about this research?’ We also took the respondents' informed consent and the headteachers of the selected schools after reading out the research objectives to them. We interviewed the respondents after getting approval from parents, respondents, and the institutional head.

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Ha, M.A.T., Alam, M.Z. Menstrual hygiene management practice among adolescent girls: an urban–rural comparative study in Rajshahi division, Bangladesh. BMC Women's Health 22 , 86 (2022). https://doi.org/10.1186/s12905-022-01665-6

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Menstrual hygiene practices among adolescent women in rural India: a cross-sectional study

• Aditya Singh 1 ,
• Mahashweta Chakrabarty 1 ,
• Shivani Singh 2 ,
• Rakesh Chandra 3 ,
• Sourav Chowdhury 4 &
• Anshika Singh 1  

BMC Public Health volume  22 , Article number:  2126 ( 2022 ) Cite this article

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Exclusive use of hygienic methods (sanitary napkins, locally prepared napkins, tampons, and menstrual cups) to prevent the visibility of bloodstains during menstruation is still considerably low among adolescent women in rural India. However, no prior research has explored the prevalence and determinants of exclusive hygienic methods among rural Indian adolescent women. To address this gap, this study examines the factors affecting adolescent women’s exclusive use of hygienic methods in rural India. Additionally, this study explores state- and district-level geographical disparities in the exclusive use of hygienic methods among adolescent women in rural India.

Information on 95,551 adolescent women from rural India from the latest round of National Family Health Survey (NFHS-5) was analyzed. Bivariate statistics and multilevel logistic regression analysis were used to assess the Individual- and community-level factors associated with exclusive use of hygienic methods among adolescent women in rural India. Choropleth maps were used to discern the geographical disparities in the exclusive use of hygienic methods.

In rural India, only 42% of adolescent women exclusively used hygienic methods, with substantial geographic disparities at the state and district levels. At the state level, the exclusive use of hygienic methods varied from 23% in Uttar Pradesh to 85% in Tamil Nadu. Even greater variation was observed at the district level. There was a clear north-south divide in the exclusive use of hygienic methods among adolescent women in rural India. The results of multilevel logistic regression indicated a considerable amount of variation in the exclusive use of hygienic methods at community level which further reduced when controlled for individual and community-level factors. Rural Indian adolescent women with higher education (AOR:3.20, 95% CI: 2.81–3.64), from general category (AOR: 1.14, 95% CI: 1.07–1.21), with medium mass media exposure (AOR: 1.43, 95% CI: 1.35–1.51), and from richest wealth quintile (AOR: 3.98, 95% CI: 3.69–4.30) were more likely to use hygienic methods exclusively.

Wide differential across biodemographic and socioeconomic groups, and substantial geographic disparities at state- and district-level in the exclusive use of hygienic methods suggests a need to adopt context-specific interventions for adolescent women in rural India. Distribution of subsidized or free menstrual hygiene methods to disadvantaged adolescent women, and in the low-prevalence districts may increase the level of exclusive use of hygienic methods remarkably.

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Introduction

Menstruation is a natural biological process which is often recognized as a period of change from adolescence to womanhood [ 1 , 2 , 3 , 4 ]. Despite this, millions of adolescent women worldwide are denied the right to control their menstrual cycle in a dignified and healthy manner [ 2 ]. To ensure healthy and dignified menstruation, Menstrual Hygiene Management (MHM) has received particular attention from the World Health Organization (WHO) and United Nations International Children’s Emergency Fund (UNICEF) [ 1 , 2 , 5 ].

Adolescent women are often inexperienced in MHM [ 6 , 7 , 8 ]. They lack adequate and correct knowledge about their bodies, especially the reproductive system and its working, given the social prohibitions on discussing these issues [ 6 ]. They also lack the disposable income to buy hygienic menstrual products [ 9 ]. Inability to manage menstrual hygiene can have serious consequences for their physical, mental, and emotional health, as well as their social development and educational attainment [ 2 ]. Therefore, managing menstrual health and hygiene among adolescent women is a major public health concern for policymakers in low- and middle-income countries, including India [ 5 , 10 ].

India hosts about one-fifth of the world’s population of adolescent women. Unfortunately, most of them, especially those living in rural areas, typically face many restrictions that limit their agency and autonomy [ 7 ]. During menstruation, these restrictions become much more severe, preventing them from participating in many aspects of social life, worshipping, bathing, cooking, and sexual activity [ 7 , 9 , 11 , 12 ]. Millions of adolescent girls in India drop out of school every year due to restrictions on mobility, a lack of restrooms and disposal facilities in schools, and fear or shame caused by the odour and stains of menstrual blood [ 13 ]. The situation is further worsened by the widespread ignorance around puberty and menstruation, the lack of access to menstrual hygiene products, and the absence of adequate water, sanitation, and hygiene facilities, leading to poor menstrual hygiene practices [ 14 , 15 ].

Poor menstrual hygiene practices may cause reproductive and urinary tract infections in addition to rashes, itching, foul odour, and many other reproductive health morbidities [ 16 , 17 , 18 ]. Poor menstrual hygiene management can also compromise women’s educational and economic opportunities. In addition, several sustainable development goals (SDGs) such as SDG 3 (healthy lives and well-being for all), SDG 4 (inclusive and equitable education), SDG 5 (gender equality), and SDG 8 (equal economic opportunities) cannot be achieved without ensuring safe and dignified menstruation women of all ages [ 19 , 20 ]. Therefore, it is crucial for the policy makers to understand the access to and use of menstrual hygiene methods among adolescent women, especially in rural areas of India, where a large proportion of the country’s adolescent population resides.

A few studies in recent years have sought to explore the knowledge, attitude, and prevalence of hygienic absorbent use among adolescent girls in India [ 8 , 21 , 22 , 23 , 24 , 25 ]. However, most studies have only been carried out in small geographical areas. Though small-scale studies provide valuable insights into people’s health behaviours, their results are not generalizable to a wider population due to insufficient geographic coverage and a small sample size, which limits their power. An increasing amount of literature in the recent past has examined the factors affecting the use of hygienic methods during menstruation among young women (aged 15–24) in India [ 16 , 26 , 27 , 28 , 29 ]. They have identified that the use of hygienic methods during menstruation is associated with level of education, household wealth, mass media exposure, and place of residence [ 26 , 27 ].

Despite various government schemes to promote menstrual hygiene during menstruation in rural areas by providing subsidized sanitary napkins, data from the most recent round of the National Family Health Survey (NFHS-5) indicate that the use of hygienic methods during menstruation is still lower in rural areas than in urban areas [ 16 , 26 , 27 , 28 ]. Yet, no study in India has examined how the use of hygienic methods varies among adolescent women in rural India using a nationally representative sample. The review of previous literature also reveals that sub-national geographical disparities in the use of hygienic methods among adolescent women in rural India have remained unexplored [ 30 ].

To increase the use of hygienic methods during menstruation among adolescent women in rural India, it is necessary to identify the disadvantaged subsets of this population so that policymakers and programme designers may focus their efforts on them. Therefore, the present study examines the correlates of exclusive use of hygienic methods during menstruation among adolescent women in rural India. In addition, it examines state- and district-level variation in the exclusive use of hygienic methods to provide reliable, research-based evidence on geographic disparity in the use of hygienic methods among rural adolescent women in India.

Data and methods

This study used data from the fifth National Family Health Survey (2019–2021). The NFHS is a nationally representative cross-sectional survey that collects data on various demographic, socioeconomic, maternal and child welfare, reproductive health, and family planning aspects. NFHS-5 interviewed 724,115 women of the reproductive age group (15–49 years) and 101,839 men of age 15–54 years from 636,669 households in 28 states and 8 Union territories (UTs) across 707 districts, with a response rate of 97%. The detailed sampling procedure, sample size, and findings are available in the national report [ 31 ]. For this study, data for 95,551 adolescent women aged 15–19 from 28 states and 8 UTs were included in the analysis (see Fig.  1 ). The NFHS asks women questions on different methods used during menstruation, which is asked to all women, except women aged 25 or above who have had a hysterectomy or have never menstruated. For the current study, methods such as sanitary napkins, tampons, and menstrual cups were considered hygienic [ 29 ].

Flow chart showing the steps to select a representative sample of rural Indian adolescent women aged 15–19 for the current study

Conceptual framework

The analysis for this study is based on the framework adapted from existing literature on hygienic methods during menstruation [ 15 , 19 , 24 , 25 , 26 ]. The framework shows pathways through which various factors might affect the exclusive use of hygienic methods among adolescent women in rural India. It was hypothesized that the exclusive use of hygienic methods was associated with demographic factors, socioeconomic factors, geographic factors, and factors related to exposure to information and services. The list of variables considered for analysis is provided later in this section. The conceptual framework based on which the analysis for this study was conducted is given in Fig.  2 .

Conceptual Framework: Factors affecting exclusive use of hygienic methods

Dependent variable

NFHS-5 asks a multiple-response question to eligible female respondents about methods used during their menstrual period to prevent blood stains from becoming evident. Response options included seven categories, i) locally made napkins, ii) sanitary napkins, iii) tampons, iv) menstrual cups, v) cloth, vi) nothing, and vii) others. The NFHS-5 categorizes these methods into two: hygienic and unhygienic. The first four of these are labelled as hygienic methods, and the remaining as unhygienic [ 16 ].

The outcome variable of this study is “exclusive use of hygienic methods”. It is a binary variable. A woman is considered “an exclusive user of hygienic methods” if she uses hygienic methods only. This category was coded as ‘1’. Any woman who either uses unhygienic methods or a combination of hygienic and unhygienic methods is considered “not an exclusive user of hygienic methods”. This category was coded as ‘0’. This variable has been defined in this way in many previous studies in India [ 16 , 18 , 26 , 30 , 32 ].

Independent variables

Several relevant socioeconomic and demographic predictors (including respondent’s current age, age at menarche, age at marriage, woman’s education, social group, religion, household wealth status, region of residence, types of home, exposure to mass media, discussion on menstrual hygiene with a healthcare worker, respondent’s working status, and ownership of a bank account and mobile phone were included in the analysis. The independent variables were selected based on previous research on menstrual hygiene management and the availability of variables in the NFHS-5 dataset [ 15 , 25 , 26 , 27 , 28 ]. Table  1 describes the independent variables used in this study in detail.

Statistical analysis

To begin with, the study used bivariate analysis techniques to underscore the differences in the exclusive use of hygienic methods by adolescent women (aged 15–19 years) of rural India during menstruation by their socioeconomic predictors recorded in the study. To assess the association between outcome and each predictor variable, Chi-square test was employed.

Due to the clustering of individuals within primary sampling units (PSUs), a multilevel statistical model was required for our study [ 33 ]. Multilevel modelling controls potential clustering effects and corrects any bias arising out of that in the standard errors [ 34 ]. As the nature of our outcome variable was binary, we used a multilevel logistic regression model with two-level to investigate the effect of measurable individual and community level factors (fixed effects) on the exclusive use of hygienic methods [ 35 ]. The ‘runmlwin’ command in Stata 16 was used to estimate the random effects at the community level [ 36 ].

Two models for the dependent variable were estimated. In the first model, no explanatory variables were included (null/empty model). The final model expanded on the previous model by adding the individual- and community-level variables found statistically significant in the Chi-square test. The fixed-effect (association measures) results are shown as odds ratio (OR) with 95% confidential intervals (CIs). The results of random effects (variation measures) are presented as the variance partition coefficient (VPC) [ 37 ].

As the study included various variables that might be correlated, variance inflation factors (VIF) were calculated to assess the multicollinearity. The results of the multilevel logistic regression were presented in the form of adjusted odds ratios and 95% confidence intervals. For statistical analysis and modelling, Stata 16 software was used [ 38 ]. The 'Svyset ' command was used in Stata to adjust for the complex survey design (sampling weights, clustering, and stratification) of the NFHS-5 [ 39 ]. ArcMap 10.5 software was used for preparing maps to show the spatial distribution of the outcome variable [ 40 ].

Respondent characteristics

Table  2 shows the distribution of adolescent women in rural India covered by the study sample by their socio-demographic characteristics. Out of the 95,551 adolescent women in rural India aged 15–19, about 87% of women were unmarried, and most women had their menarche between 13 and 15 years of age. About two-thirds of women were Hindu, and about two-fifths belonged to Other Backward Classes (OBCs). Only about a quarter of sampled women reported having high mass media exposure. About half of the respondents lived in the central and east regions of the country.

Exclusive use of hygienic methods by background characteristics

About 42% of adolescent women in rural India reported exclusive use of hygienic methods during menstruation. Table 3 shows the proportion of adolescent women using only hygienic methods by background characteristics in rural India. The use of hygienic methods was slightly higher in adolescents who had menarche after age 16 than in women who had menarche before age 16. The exclusive use of hygienic methods was relatively higher among those married after the legal age of 18 years (47%). The exclusive use among those with higher education was four times higher (62%) than those without education (15%). Further, the exclusive use of hygienic methods was considerably higher among Christians (56%) than Hindus (43%) and Muslims (35%). Only 37% of Scheduled Tribe women reported exclusive use of hygienic methods compared with 51% of General (Others) category women.

Only 24% of women in the lowest wealth quintile reported exclusive use of hygienic methods. In comparison, 65% of women in the highest wealth quintile did so. Furthermore, the percentage of women who reported exclusive use of hygienic methods was 57% among those who were fully exposed to mass media compared to 26% among those who were not. The exclusive use was higher among those women who met and discussed menstrual hygiene issues with healthcare workers in the three months prior to the survey than those who did not (52% vs 42%).

The exclusive use of hygienic methods was higher among those women who owned a bank account and mobile phone than those who did not. In addition, the exclusive use of hygienic methods was higher in the rural areas of southern (68%), northern (58%), and western regions (56%) of India as compared to the rural areas of central and north-eastern regions (25 and 30% respectively).

The findings also show significant diversity in the exclusive use of hygienic methods at the regional, state-, and district-levels (described below).

Spatial patterns of exclusive use of hygienic methods among adolescent women across 28 states, 8 UTs, and 707 districts of India

Analysis at the regional level provides only a broad idea regarding spatial variation in the exclusive use of hygienic methods. It marks spatial heterogeneity at the macro level. Therefore, we mapped the exclusive use of hygienic methods at the state and district level of India.

Figure  3 indicates a substantial state-wise variation in the exclusive use of hygienic methods among adolescent women in rural India. Among the 28 states, Uttar Pradesh (24%) had the lowest prevalence of exclusive use of hygienic methods, followed by Madhya Pradesh (26%), Bihar (29%), Chhattisgarh (29%), and the north-eastern state of Assam (29%). On the other hand, exclusive use of hygienic methods was highest in Tamil Nadu (85%), followed by Telangana (82%) among states and Andaman and Nicobar (92%), followed by Puducherry (91%) among Union Territories. On the other hand, the prevalence of exclusive use of hygienic methods was modest in Gujarat (41%) and Kerala (56%).

State-wise distribution of exclusive use of hygienic methods during menstruation among women aged 15–19 in rural India, NFHS-5, 2019–21

Figure  4 depicts the district-level spatial pattern of exclusive use of hygienic methods among adolescent women. The geographical pattern of adolescent women’s exclusive use of hygienic methods at the district-level is considerably more varied than the state-level geographical pattern. The exclusive use of hygienic methods ranged from 6 to 8% in the West Jaintia Hills and West Khasi Hills districts of Meghalaya to 100% in the Thoothukuddi and Kanyakumari districts of Tamil Nadu. The state average obscures any differences between individual districts within a state. Therefore, we analysed the patterns at the district level. The analysis of within-state district-level patterns revealed considerable between-district variation in the exclusive use of hygienic methods in many states. In Uttar Pradesh, for instance, the exclusive use of hygienic methods ranged from 7% in Banda to 45% in Goutam Buddha Nagar. In Madhya Pradesh, the exclusive use of hygienic methods ranged from 8% in Umaria and Sidhi to 63% in Balaghat. Similarly, the exclusive use of sanitary methods in Tamil Nadu ranged from 47% in Erode to 100% in Thoothukuddi and Kanyakumari. In Karnataka, it ranged from 25% in Gadag and Bagalkot to 75% in Udupi and Kolar districts.

District-wise distribution of exclusive use of hygienic methods during menstruation among women aged 15–19 years in rural India, NFHS-5, 2019–21

In almost a quarter of all districts (179 out of 707), the exclusive use of hygienic methods was less than 30%. Three distinct pockets of low exclusive use of hygienic methods can be identified. The first pocket is spread over large swathes of central Indian states of Uttar Pradesh, Madhya Pradesh, Bihar, and Chhattisgarh. The second pocket is located in northeast India, comprising the districts of Assam, Nagaland, Manipur, and Meghalaya. The third pocket comprises the districts from western Gujarat, northern Karnataka, and Jammu & Kashmir. There were multiple pockets of ultra-low exclusive use of hygienic procedures among these pockets of low exclusive use of hygienic methods, with fewer than 15% of women reporting exclusive use of hygienic methods. For example, in Madhya Pradesh (MP), there were two such pockets – one in the eastern MP comprising Barwani, Jhabua and Alirajpur districts, and the other in the western MP comprising Sidhi, Umaria, Damoh, and Dindori districts.

About 17% of all districts in the country (111 out of 707) had a prevalence of over 75%. Thus, there were three main pockets of high exclusive use of hygienic methods in the country – a) the southern pocket included districts from Tamil Nadu, Andhra Pradesh, Telangana, and Maharashtra b) the northern pocket included districts of Haryana, Punjab and Himachal Pradesh, c) the north-eastern pocket included districts from Arunachal Pradesh and Mizoram.

Determinants of exclusive use of hygienic methods

The determinants of the exclusive use of hygienic methods were examined using a multilevel logistic regression model. Before fitting the multilevel model, we assessed the association between the exclusive use of hygienic methods and potential individual- and community-level independent variables using the Chi-squared test. It was done to eliminate any variables not associated with the dependent variable. Only those variables which were found statistically significant ( p  ≤ 0.05) were included in the final logistic regression model. In addition, we also calculated variance inflation factors (VIFs) to check the degree of multicollinearity between the independent variables included in the regression model. Since all the variables had a VIF within the acceptable range of 5 [ 41 ], we did not have to modify or remove from the final regression model any of the variables that we began our analysis with (for detailed VIF values, see supplementary Table 1, Additional file  1 ).

The first step of applying any multilevel model is determining whether the data supports the decision to assess random effects at higher levels. In this study, we set up a two-level random intercept-only model (a model with no covariates, also known as the null model). The variance partition coefficient (VPC) revealed that about 39% of the total variance in the exclusive use of hygienic methods was attributable to the differences across communities (see Table  4 ).

Table  5 presents the odds ratios obtained from the two-level logistic regression fitted to examine the factors affecting the exclusive use of hygienic methods among adolescent women in rural India. The random parameters revealed that the exclusive use of hygienic methods varied considerably at the community level, however, after controlling for the community-level factors, the variation in the use of hygienic methods attributed to the differences across communities reduced from 35 to 30%.

Results of the multilevel model show that the odds of exclusive use of hygienic methods in women who were married off before the legal age of 18 years were 14% lower (AOR: 0.86, 95% CI: 0.78–0.95) than the unmarried women (see Table 5 ). Women with secondary education were about two and a half times (AOR: 2.48, 95% CI: 2.23–2.75), and women with higher education were about three times (AOR:3.20, 95% CI: 2.81–3.64) more likely to use hygienic methods. Muslim women were almost 40% less likely (AOR: 0.62, 95% CI: 0.58–0.67) to exclusively use hygienic methods than their Hindu counterparts. The odds of exclusive use of hygienic methods were higher among the general category (AOR: 1.14, 95% CI: 1.07–1.21) than among SCs.

Wealth status was positively associated with the exclusive use of hygienic methods among adolescent women in rural India. Women from the wealthiest quintile were nearly four times (AOR: 3.98, 95% CI: 3.69–4.30) more likely to use hygienic methods exclusively than women from the poorest quintile. In addition, women with medium exposure to mass media were 43% more likely to use hygienic methods (AOR: 1.43, 95% CI: 1.35–1.51) than women without mass media exposure.

The odds of exclusive use of hygienic methods varied significantly across regions of India. Adolescent women of the southern region (AOR: 6.45, 95% CI: 5.90–7.06) were more likely to use hygienic methods exclusively than those of the central region.

At the community level, the proportion of women with secondary education in a village was positively associated with the exclusive use of hygienic methods during menstruation. On the other hand, an increase in the proportion of poor women in PSUs was associated with decreased odds of exclusive use of hygienic methods.

The present study examined individual and community-level factors associated with the exclusive use of hygienic methods among adolescent women in rural India. A little over two-fifths of adolescent women in rural India reported exclusive use of hygienic methods, considerably lower than their urban counterparts. The multilevel model identified important individual- and community-level predictors of the exclusive use of hygienic methods among adolescent women in rural India. The multilevel model also demonstrated significant community-level variation in the exclusive use of hygienic methods. Community-level variables used in this study were able to explain some of this variation. It suggests the need to look beyond individual-level factors when examining the exclusive use of hygienic methods during menstruation among adolescent women in rural India. Statistically significant individual-level predictors of exclusive use of hygienic methods among adolescent women in rural India included age at marriage, education, religion, wealth, region of residence, mass media exposure, working status, and mobile ownership.

Similar to many previous studies, this study also found a positive association between the exclusive use of hygienic methods and the age at marriage [ 16 , 26 , 27 , 42 , 43 ]. It may be because older adolescents have more knowledge about hygiene methods, more flexibility to make their own decisions, and more disposable income to spend on the hygiene products they want [ 16 ].

One of the most critical predictors for the exclusive use of hygienic methods among adolescent women of rural areas was their level of education. Compared to uneducated women, adolescent women with higher education were more inclined to adopt hygienic methods [ 17 , 42 ]. Education confers decision-making autonomy, financial independence, increased knowledge of the benefits of using hygienic methods, and awareness of the risks associated with unclean menstruation practices on women [ 5 , 26 , 27 ]. This finding is in line with previous research on this issue [ 5 , 16 , 18 , 26 , 27 ].

Religion also turned out to be a predictor of the exclusive use of hygienic methods among adolescent women in rural India. The exclusive use among Muslim adolescent women was lower than among Hindu adolescent women. Many previous studies on this issue have concluded the same [ 5 , 16 , 18 , 26 , 28 , 44 ]. Low decision-making and mobility autonomy, as well as a lack of awareness regarding the availability of hygienic methods, may be at the root of this behaviour among Muslim adolescent girls in rural India [ 26 , 45 ]. Another possible explanation for the relatively low rate of exclusive use of hygienic methods among Muslim women is that a disproportionate number of them belong to lower socioeconomic strata and have low social status and limited decision-making autonomy within their own households [ 46 ].

Household wealth, a proxy for the family’s income, also determined whether or not adolescent women in rural India used hygienic methods exclusively. As household wealth increased, so did women’s exclusive use of hygienic methods. This finding is consistent with other studies that have shown that affluent women are more likely than their less privileged counterparts to use hygienic methods exclusively [ 5 , 26 , 27 ]. Poverty has also been identified as a factor behind unsanitary menstrual behaviours in many previous studies [ 25 , 27 , 47 , 48 ]. A pack of 10 sanitary napkins in India currently costs around 30–40 INR (0.39–0.52 USD), which is extremely expensive and unaffordable for most rural households in India [ 49 ]. The inability to afford sanitary methods may be one of the reasons why poor women resort to using rags/clothes or other unhygienic methods.

The findings of this study indicate that the exclusive use of hygienic methods rose in tandem with the respondents’ exposure to the media. This finding is in line with many previous studies in India. Mass media helps disseminate appropriate information about innovations to the masses and helps it diffuse and spread to rural areas [ 5 , 26 ]. It appears to be true with regard to menstrual hygiene practices as well. Mothers aside, mass media are often the primary sources of information about menstrual hygiene among adolescent girls. It broadens their knowledge of the variety of low-cost, subsidized, or free menstrual hygiene methods available and the health advantages of using them [ 5 , 27 , 50 ].

Our study revealed that mobile phone ownership was positively associated with the exclusive use of hygienic methods during menstruation. Adolescent women today benefit from increased mobile phone ownership in various ways, including easy access to information. It is critical to have access to accurate and sufficient information to raise awareness about menstrual hygiene management. In addition, mobile phone availability enables peers to offer each other advice on menstrual hygiene and share their experiences. Many public health interventions in India (Kilkari, Mobile Vani, and Mobile Academy) and elsewhere have used mobile phone messaging services to disseminate health information and improve health behaviour and service delivery [ 51 , 52 ]. The success of such interventions suggests that the recent rapid and high penetration of mobile phones in rural areas can be leveraged to relay accurate information on menstrual hygiene practices to enhance awareness among adolescent girls in rural India [ 16 ].

The prevalence of exclusive use of hygienic methods during menstruation varied greatly across India’s regions, states and districts. Adolescent women of southern and western regions were more likely to use hygienic methods exclusively than the country’s eastern and central regions. These results are consistent with prior research on the subject [ 16 , 26 , 27 ]. One probable explanation for the higher rates of hygienic practises in the southern region is the availability of toilet facilities and separate enclosed spaces for disposing of sanitary napkins in the schoolyard, as found in previous studies [ 23 , 26 , 53 ]. Furthermore, most southern states have a highly functional public healthcare system that has adopted numerous measures, including subsidized sanitary napkin distribution projects, to enhance women’s menstrual health [ 54 ].

Tamil Nadu, Kerala, Karnataka, Andhra Pradesh, and Telangana state governments have implemented various free or subsidized sanitary napkin distribution initiatives. In 2011, the Government of Tamil Nadu began providing 20 free sanitary napkins to adolescent women in rural areas of the state through a programme called Pudhu Yugam (New Era) [ 55 ]. In addition, schools in some areas of these states have placed sanitary napkin vending machines in collaboration with local non-governmental organizations (NGOs), which dispense locally-produced napkins at a reduced price [ 19 , 56 ]. To ensure that girls between the ages of 10 and 19 always have access to sanitary products, the state government of Karnataka has recently launched the Shuchi scheme [ 57 ]. Similarly, the state government of Andhra Pradesh has decided to distribute for free ten sanitary napkins per month to all girls in classes seven through 12 as part of its Swechha programme [ 58 ].

Our study revealed that exclusive use of hygienic methods was particularly low in the central and eastern regions of the country. These regions are characterized by low socioeconomic development, high levels of poverty, and an inefficient healthcare system. These reasons, coupled with the strong presence of social taboos, could be behind the lower exclusive use of hygienic methods among adolescent women in these regions [ 26 , 27 ]. About 25% of districts reported less than 30% exclusive use of hygienic methods among adolescent women in rural India. These districts were home to almost one-third of the sampled adolescent women. Therefore, it is crucial to focus on these districts if the overall level of exclusive use of hygienic methods among adolescent women in rural India is to be increased. Within the states with low exclusive use of hygienic methods, there were also pockets of districts with ultra-low exclusive use (less than 15%). However, more research is required to discern why these districts lag behind their neighbouring districts despite being in the same state and governed by the same policies.

The state governments of Uttar Pradesh ( Kishori Suraksha Yojna ), Madhya Pradesh ( Udita Yojana ), Bihar ( Kishori Shakti Yojana ), Maharashtra ( Asmita ), Rajasthan ( Udaan ), and Tripura ( Kishori Suchita Abhiyaan ) have implemented several schemes to distribute free or subsidised sanitary napkins in schools [ 58 , 59 , 60 , 61 , 62 , 63 ]. However, to date, many of these initiatives are in pilot phases and are yet to be scaled up. Moreover, existing schemes in most states are plagued by a plethora of issues, including procurement and supply issues, poor quality of pads, lack of awareness and knowledge about the schemes, and unaffordable prices [ 64 , 65 , 66 ]. This might explain why the exclusive use of hygienic methods is so low and unequal in these states.

Under the National Health Mission (NHM), the Central Government of India has made several efforts to educate young women on the importance of menstrual hygiene and promote the use of hygienic methods during menstruation [ 67 ]. To reduce access and cost barriers to sanitary napkin use in rural areas, accredited social health activists (ASHAs) are mandated to sell NHM’s subsidized sanitary napkin brand, ‘Free Days’ at Rs.1 per napkin, to adolescent women [ 68 ]. However, this initiative has been hampered by procurement and supply issues, high costs, and a lack of enthusiasm among ASHAs. This may explain why the exclusive use of hygienic methods remains low in many districts across the country [ 69 ]. More research is needed to unearth why ASHAs have had less success in promoting hygienic methods. In 2020, the Central Government launched 100% biodegradable sanitary napkins under the brand ‘ Suvidha ’. It was made available at Jan Aushadhi Kendras (government-run pharmacies) at a subsidized price. However, as of December 2021, there are only 8640 pharmacies in 707 districts, i.e., about 12 pharmacies per district. Moreover, they are primarily concentrated in metropolitan areas, leaving large swaths of the country’s rural areas unserved [ 70 ]. Consequently, the availability and affordability of hygienic methods in rural areas remain persistent problems even today [ 2 , 71 ].

The major strength of this study is that this is the first national-level study to assess adolescent women’s exclusive use of hygienic methods in rural India, using the latest NFHS-5 data. In addition, it has used a multilevel approach that is appropriate to model hierarchical data, such as that of NFHS-5. Finally, this study also examined in detail the geographical patterns of exclusive use of hygienic methods among adolescent women in rural India, which could help formulate location-specific interventions to enhance the level of exclusive use of hygienic methods.

The study has some limitations despite providing detailed information on the factors influencing adolescent women’s exclusive use of hygienic methods during menstruation in rural areas. First, this study could not establish the causal relationship between predictors and outcome variable, as it needs experimental data to do that. NFHS-5 provides cross-sectional data which can only establish the association between regressed and regressor variables. Second, due to data constraints, we were unable to include certain supply-side variables in our study that, according to the demand-supply framework of healthcare use, are important in explaining the degree of utilization of a service or product. The variables related to the supply of subsidized methods to rural health workers, availability and price of hygienic methods at rural pharmacies and provision stores, and supply situation of sanitary napkins at schools have not been included in the analysis due to the lack of these variables in the NFHS dataset. Among other variables we could not include due to the lack of such variables in the NFHS dataset were social taboos/cultural norms, the sanitary situation at schools and disability issues.

The exclusive use of hygienic methods is still quite low among adolescent women in rural India. This study highlighted significant differences in adolescent women’s exclusive use of hygienic methods throughout rural India’s regions, states, and districts. We found substantial north-south disparities in the exclusive use of hygienic methods, where the hygienic methods use is considerably low in the central districts of rural India. Improved menstrual hygiene and health has been a part of policy discussions in India for long but the discussion has largely been blind to existing geographical variations in the patterns of the same. This suggests that the future interventions and programmes to enhance menstruation hygiene among adolescent women would focus on reducing geographical differences in rural India. Results of multilevel model revealed that household wealth, education, and mass media exposure were the most important factors associated with the exclusive use of hygienic methods, therefore empowering adolescent women and promoting their education would yield greater results in increasing the level of exclusive use of hygienic methods in rural India. Policymakers and stakeholders could target disadvantaged groups of adolescent women to improve the level of hygienic methods’ exclusive use among them and make the overall progress more equitable. Several government programs have begun in recent years, and these could be supported, expanded and broadened to cover the entire adolescent women population. Furthermore, this study suggests state- and district-specific menstrual hygiene policies to improve the universal access to hygienic methods among adolescent women in rural India.

Availability of data and materials

The study utilizes secondary sources of data that are freely available in the public domain through https://dhsprogram.com/methodology/survey/survey-display-541.cfm . Those who wish to access the data may register at the above link and thereafter can download the required data free of cost.

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Acknowledgements

The authors are grateful to Measure DHS, ICF International, Rockville, Marylands, USA for providing the data for the analysis. The authors acknowledge the editor and the reviewers of this paper with huge appreciation.

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Aditya Singh: Conceptualization; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Writing – original draft; Writing – review & editing. Mahashweta Chakrabarty: Data curation; Formal analysis; Investigation; Methodology; Project administration; Validation; Visualisation; Writing – original draft; Writing – review & editing. Shivani Singh: Supervision; Writing – original draft. Rakesh Chandra: Supervision; Writing – review & editing. Sourav Chowdhury: Writing – review & editing. Anshika Singh: Writing – original draft. All authors read and approved the final manuscript.

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Singh, A., Chakrabarty, M., Singh, S. et al. Menstrual hygiene practices among adolescent women in rural India: a cross-sectional study. BMC Public Health 22 , 2126 (2022). https://doi.org/10.1186/s12889-022-14622-7

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• Menstrual hygiene
• Hygienic methods
• Sanitary napkins Adolescent women
• Rural India

BMC Public Health

ISSN: 1471-2458

• General enquiries: [email protected]

• DOI: 10.9734/jpri/2021/v33i60b34881
• Corpus ID: 246425641

Menstrual Hygiene Management: A Literature Review

• Prasad A Pagore , S. Chaudhari
• Published in Journal of Pharmaceutical… 25 December 2021

34 References

Menstrual hygiene management in india: the concerns, menstrual knowledge and practices of female adolescents in urban karachi, pakistan., menstrual hygiene, management, and waste disposal: practices and challenges faced by girls/women of developing countries, perceptions regarding menstruation and practices during menstrual cycles among high school going adolescent girls in resource limited settings around bangalore city, karnataka, india, puberty rituals, reproductive knowledge and health of adolescent schoolgirls in south india, menstrual hygiene among adolescent schoolgirls in mansoura, egypt, mapping the knowledge and understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low- and middle-income countries.

• Highly Influential

Cultural and Social Practices Regarding Menstruation among Adolescent Girls

Menstrual hygiene management and waste disposal in low and middle income countries—a review of the literature, a rare case of unusual urogenital tract foreign body (plastic pen) immigrated from vagina due to masturbation / autoerotism, related papers.

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Journal of Pharmaceutical Research International

Published: 2021-12-25

DOI: 10.9734/jpri/2021/v33i60B34881

Page: 2332-2339

Issue: 2021 - Volume 33 [Issue 60B]

Review Article

Menstrual Hygiene Management: A Literature Review

Prasad Pagore

Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha-442001, Maharashtra, India.

Sonali Chaudhari *

Department of Community Medicine, Datta Meghe Institute of Medical Sciences (Deemed To Be University), Sawangi (Meghe), Wardha-442001, Maharashtra India.

*Author to whom correspondence should be addressed.

Background: Menstruation is seldom regarded as an act of immense kindness put forward by a woman to ensure the human race doesn’t cease but ironically, it is now too in this so called modernized world is considered a dirty, unclean, shameful, taboo linking it with the so called term of women’s weakness in which she is at times even considered untouchable. A considerable lot of ridiculous and unhuman superstitious acts, often due to ancestry taboos carried forward, have made menstruation more intensely shamed in today’s so-called advanced world. In many parts of the world, there are still restrictions enforced upon women and girls undergoing menstruation to carry out their normal routine involvement in society, whether it be their home kitchen, religious places, communal gathering, outdoor group activities, etc. In this article, we primarily focus on the management of hygiene during menstruation. Menstruation is subjected to many superstitions that may lead to unhygienic practices. Menstruation, often considered a shame or taboo in various poor undedicated and undeveloped classes of society, need awareness for hygiene, sanitation, and management across the globe. The writer searched web sites like PubMed and Google Scholar for works the usage of the keywords "Menstruation" or "Menstrual Hygiene" and "Menstrual Management.” The writer reviewed case reviews and series, retrospective and potential studies, systematic opinions and meta-analyses, and different narrative critiques. The hints and helping quotation of papers covered withinside the observation have been additionally tested via way of means of the creator. Systemic critiques and meta-analyses have been favored after they have been available. When change facts became no longer available randomized management trials, potential studies, retrospective studies, case reviews, and different narrative critiques have been carried out in order.

Conclusion: Hygiene is the most crucial aspect of living a healthy life, and it is essential during menstruation. On the other hand, the situation is stuck in India's rural areas, where women still confront hygienic issues, particularly when it comes to menstruation.

Keywords: Menstrual health, menstrual hygiene management, menstruation, menstrual products, waste disposal management

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Menarche and menstruation: a review of the literature

• PMID: 3320280
• DOI: 10.1207/s15327655jchn0404_3

PIP: Puberty initiation rites heralding menarche are common across cultures. Paige (1973) reflected that societies with the highest levels of social rigidity and male solidarity also have the strongest codification of menstrual taboos. This may reflect a need to maintain clear sex roles, often by controlling women and their fertility. Social and cultural factors impact on adjustment to menses and have an effect on the early menarcheal experience. Certain common features, however, were observed in that most girls reported their mothers as a principal source of information and received some limited education about menses in school with frequent emphasis on hygienic aspects of menstruation. A more positive attitude toward menses can be achieved if girls are physically and emotionally prepared. The most current evaluation of educational materials on menses dates back to 1975 and reveals a preponderance of emphasis on hygiene to the exclusion of issues of emotional and psychological development. Women perceive themselves as being very knowledgeable but cannot accurately answer physiological questions. A content analysis of advertisements for sanitary products and medications for the relief of menstrual symptoms in a popular teen magazine indicated that advertisements conveyed the image that hygienic aspects of migration could be dealt with effectively. There were no significant relationships between reported incidence of menstrual symptoms and adequacy of preparation for menarche. Nurses involved in the planning or implementing of educational programs for girls regarding the menarche should be sensitive to the adolescent's desire for control of the learning environment and a need for selective sharing of the event. Strategies for coping with the "inconvenience" may be usefully developed with the girls as a part of the learning situation.

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MENSTRUAL HYGIENE MANAGEMENT IN INDIA: A REVIEW AND META-ANALYSIS

2019, Trans-stellar Publications

The objective of this research paper is to find out the current scenario of menstrual hygiene management in our country and what role is media playing in putting it on the forefront. Also to find out the possible government schemes related to menstrual health and their implementation and effect. The methodology adopted is qualitative in nature along with content analysis and focus group survey. According to a landscape analysis report published in May 2016 and sponsored by the Bill and Melinda Gates foundation, there are more than 355 million menstruating girls and women in India. The same report states that more than 75 % of the girls were not aware about periods when they first had it. Not only in the rural areas but in the urban areas also Menstrual Hygiene Management is neglected majorly. The researchers found out that menstrual hygiene management has made an impact. Not only women are more aware than ever but also male population is better informed than before. But this is restricted to a certain %age of the urban areas and educated population only. This research aims to have a social implication through making the women more aware of the menstrual hygiene management and understanding how media aids in propagating the necessary information.

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Menstruation is a natural process, but it is still an unmentionable in Indian society as it is considered unclean and dirty. The wastes that are produced during menstruation are commonly known as menses, periods, or monthly bleeding cycle. Government of India has included MHM into national policies and programs as it is a part of initiatives for improving health, well-being, and nutritional status of adolescent girls and women. This paper highlights the incomplete knowledge about the menstruation which is a great barrier in the pathway of menstrual hygiene management.

Antrocom, Online Journal of Anthropology

Oinam Hemlata Devi

Menstruation is an important life event for every female member of society. The major population overlooks its significance for reproductive health. Simultaneously, there is a wide variation in the knowledge, awareness and practice signalling various social factors responsible for it. Many studies addressed the question of hygiene management in the light of cultural understanding, scientific knowledge and environmental factors. This paper is an attempt to investigate the knowledge, awareness and practices of menstruation among the school-going adolescent girls in Kerala and the assessment of the use of menstrual cups as part of the hygiene management. Methodologically, it deals with an ethnographic approach using face-to-face interviews, questionnaire surveys, and telephonic interviews. There are two phases of data collection. The sample population for the first phase was drawn using a snowballing method of age groups ranging from 11-15 years among the school going girls, and 2nd phase study population was selected using convenient sampling for questionnaire survey-I and voluntary participation for Questionnaire survey-II. The areas of study chosen for the first phase were Meppadi village in Wayanad. For the second phase, different districts of Kerala and medical colleges and health care centres were selected. The study shows a significant amount of menstrual hygiene management in using the absorbents, disposal of sanitary pads and cleaning practices. The awareness level is still yet to be improved through education at school and at home. The socio-cultural practices are still respectfully observed by them. The study also shows successful implementation of awareness campaigns and workshops towards the use of menstrual cups inspiring people to adopt the new methods of menstrual hygiene management. The intervention process of the government initiatives in Kerala is appreciated and responsible for the quick change in the use of menstrual cups. This study concludes that the use of menstrual cups with proper education about the usage of it will help in resolving the hygiene-related issues from the use of sanitary napkins. It also emphasizes the use of sustainable menstrual cups which are good for health and the environment.

Journal of Indian Anthropological Society

KAUSHIK BOSE , Pritam Ghosh

The study aimed to portray menstrual hygiene management among young women of India from various demographic, socio-cultural, economic backgrounds. The study also identified the effect of different background characteristics on the menstrual hygiene management (MHM). We used NFHS-4 (2015-16) data and applied inferential statistics such as chi-square, multinomial logistic regression for the analysis. The results of the study showed partial-hygienic and unhygienic menstrual management were significantly higher in Central or Northeastern India, among the women of Muslims and socially marginalized groups, who belonged to a higher age group, had lower level of education, low media exposure, were economically poor and lived in rural areas as members of an extended family. Unhygienic menstrual management was less common among the teenage girls and unmarried women. Clearly, level of education, media exposure, and economic background largely determine the level of menstrual hygiene management level rather than any specific social, demographic, and religious determinant. The Government of India should take more initiative through implementing different projects or schemes, especially meant for young girls and women belonging to socially, culturally, and economically marginalized communities, so that they can be made aware of MHM and get access to and afford disposable hygienic sanitary products.

Journal of Emerging Technologies and Innovative Research (JETIR)

Sunita Ramchandani

Hygiene refers to keeping oneself and surrounding clean in order to avoid poor health and disease. During the menstrual cycle, it is crucial to practice good hygiene habits including washing your genitals thoroughly and using sanitary pads. In order to safeguard their health over time against numerous illnesses, women and girls of reproductive age require access to sanitary products that are clean, supple, and absorbent. This study is focused on hygiene practices followed by females during menstruation, the beliefs and conception they have also restrictions practiced by them. A cross sectional study was conducted among 362 females of Bhopal city. A structured questionnaire including 25 close ended question was designed to collect the data and data analysis was done using MS Excel and SPSS. Entire data was coded and compiled for descriptive and inferential statistics. Out of 358 respondents, 84% girls of 18-25 years have participated in the survey. 77% girls said that mother was the first source of information about menstruation. As a hygiene practice, 78.2% females take shower every day and 41% females are using 1-2 sanitary napkins per day during menstruation. Regarding restrictions practiced, 85%girls practiced different restrictions during menstruation.57.5% females believe that during menstruation there is no need to stay away from pickles, Kitchen, Holy Books.96.6% Females feels that periods are important. Due to the physical and psychological changes brought on by the menstrual cycle, women's bodies produce certain hormones each month to maintain their health and prepare them for pregnancy.

IOSR Journals

This paper has endeavored to find out the role of media to create awareness regarding female hygiene practices during menstruation cycle from the perspectives of females residing in both rural and urban areas of Bangladesh. Based on a review of the previous relevant literature, a 5-point Likert scale questionnaire was developed and used to conduct the survey among 200 respondents from four rural and urban areas of Bangladesh to collect primary data for realizing the objectives of this research. The research is descriptive in the manner that attempted to realize its key objective by conducting a comparative analysis of the data collected from the rural and urban respondents. By undertaking descriptive (mean) and enter-method regression analysis using SPSS 24.0, the findings from rural and urban respondents have been analyzed separately to identify the key modes of media playing crucial roles for creating awareness on female hygiene practices. However, after analyzing the secondary and primary data, this study has suggested some ways to effectively utilize the significant modes of media – highlighted by both previous relevant literature and the respondents of this research – to enhance greater awareness on the topic of the study. Along with suggestions to take extensive actions to educate Bangladeshi females and eradicate social stigmas regarding menstruation cycle, this research has also suggested some other methods to encourage female hygiene practices. Some of the suggestions are, emphasizing more on the conventional media platforms to promote female hygiene practices, focusing on improving the brand image of female hygiene products to ensure their trustworthiness to the consumers, enhancing the marketing and distribution channels and reducing prices of female hygiene products, arranging events like " Uthan Baithak " (focus group discussions in the open space of houses) in rural areas and increasing promotional activities in social and digital media platforms across Bangladesh.

Annals of Tropical Medicine and Public Health

himani pandya

Global Journal of Human-Social Science Research

abhisek bera

Menstruation, also called the menstrual cycle, prepares the sexually mature, female body for pregnancy each month. Menstruation is monthly bleeding that begins in girls around 12 years of age. Because bleeding associated with the menstrual cycle happens regularly or periodically, it also is referred to as a menstrual period or, more simply, as a &quot;period.&quot; Some girls get their first menstrual period as young as 9 years of age, and others do not begin menstruating until 15 years of age. In developing country Menstruation has always been surrounded by different perceptions throughout the world. Nowadays, there is some openness toward menstruation, but differences in attitude still continue between different populations. There are differences between countries, cultures, religions, and ethnics groups. In many low-income countries, women and girls are restricted in mobility and behavior during menstruation due to their “impurity” during menstruation.

International Journal of Engineering Technology Research & Management (ijetrm)

Ijetrm Journal

Adolescence has been considered as a special period that requires specific care as it marks the beginning of menarche, an important turning point hence good hygienic practices during menstruation are crucial to maintain a healthy life. Menstruation and menstrual practices are still darken by socio-cultural conditions resulting in girls remaining ignorant of the scientific facts and hygiene health practices which results into severe health problems. The present study analyse the practices regarding menstrual health and hygiene among rural women respondents in Coimbatore district.The primary data were collected through a structured questionnaire from various villages in Coimbatore district. The study reveals that lack of privacy is a major concern both in household and in schools. Also, ignorance, misconceptions, unsafe practices, and illiteracy of the mother and child regarding menstruation are the root causes of many problems. So, there is a big need to encourage adolescents at school levels to practice safe and hygienic behaviours.

Journal of Global Public Health

Dr. J Balamurugan PhD

Menstruation is still subjected to a slew of societal, cultural, and religious constraints, which pose a significant impediment to proper menstrual hygiene management. Girls particularly in rural areas, are unprepared and unaware of menstruation, leading to several problems at home, in schools, and in an office. Adolescent girls are a particularly vulnerable population, especially in India, where the needs of female children have a history of ignorance. Women's voices are ignored in households, communities, and development programmes due to discriminating rights towards women of our country.

Journal Of Centre for politics and Governance

Anjali Yadav

Menstrual health, hygiene, and management are still not given the required attention in the majority of India. In our society, menstruations as well as females during menstruation are considered as tainted and impure, resulting in unhygienic menstrual practices and consequential varied infections and diseases. Although this is the problem of every society in our country, the condition of adolescent girls and women in rural areas are more grave and miserable. This study is based on a community-based survey conducted in the year 2019-20 in the rural Kaushambi district of Uttar Pradesh. The main objective of the study is to access knowledge, attitude, and practices regarding menstrual health and hygiene management in rural society. The study found that about 72% of girls in a rural area doesn't have any awareness regarding menstruation before their menarche and more than three-fourth of the respondents don't have any knowledge regarding the cause of menstruation even after menarche. The study came to know that less than one-third of respondents don't have access to hygienic sanitary absorbents to manage their menstruation and the majority of participants don't adopt sustainable ways to dispose of their used sanitary absorbents. Respondents were also informed about various kinds of socio-cultural restrictions during menstruation, which makes their life wretched during their periods.

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Systematic review of menstrual hygiene management requirements, its barriers and strategies for disabled people

Jane wilbur.

1 International Centre for Evidence in Disability, Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom

Belen Torondel

2 Environmental Health Group, Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom

Shaffa Hameed

Thérèse mahon.

3 Wateraid, London, United Kingdom

Hannah Kuper

Associated data.

All relevant data are within the manuscript and its Supporting Information files.

One quarter of the global population is of menstruating age, yet menstruation is shrouded in discrimination and taboos. Disability also carries stigma, so disabled people may face layers of discrimination when they are menstruating. The objective of the review is to assess the menstrual hygiene requirements of disabled people, the barriers they face, and the available interventions to help them manage their menstruation hygienically and with dignity.

Eligible studies, gathered across all countries, were identified by conducting searches across four databases (MEDLINE, PubMed, EMBASE, Global Health) in May 2017, with alerts set on each database to highlight new titles added until April 2018. Eligible studies incorporated analyses relevant to menstruating disabled people and/or how their carers provide support during their menstrual cycle.

The 22 studies included were published since 1976; the majority after 2010 (n = 12; 55%). One study was a quasi-experiment; all others were observational. Most studies (n = 15; 68%) were from high income countries and most (n = 17; 77%) focused on people with intellectual impairments, so the review findings focus on this group and their carers. Outcomes investigated include choice and preference of menstrual product, ability to manage menstrual hygiene and coping strategies applied. Barriers faced included a lack of standardised guidance for professional carers; a lack of menstruation training, information and support provided to people with intellectual impairments and their carers; a lack of understanding of severity of symptoms experienced by people with intellectual impairments, the high cost of menstrual products and lack of appropriate options for people with physical impairments. Few interventions were found, and strategies for menstrual hygiene management applied by carers of persons with intellectual impairments include limiting the disabled person’s movements when menstruating and suppressing their menstruation.

Conclusions

Little evidence was identified on the requirements of disabled people and their carers in managing their menstruation, and only one intervention, but a range of barriers were identified. This gap in evidence is important, as the consequences of failing to meet menstrual hygiene needs of disabled people includes shame, social isolation, and even sterilisation.

Systematic review registration

PROSPERO CRD42018095497 .

Introduction

Globally, 663 million people lack access to safe water and 2.4 billion people lack access to adequate sanitation [ 1 ]. There is extensive literature showing that disabled people face barriers in accessing appropriate water, sanitation and hygiene (WASH) services in low and middle income countries (LMICs) [ 2 – 4 ]. WASH services are vital for effective menstrual hygiene management (MHM).

UNICEF and the WHO define menstrual hygiene management as “Women and adolescent girls using a clean menstrual management material to absorb or collect blood that can be changed in privacy as often as necessary for the duration of the menstruation period , using soap and water for washing the body as required , and having access to facilities to dispose of used menstrual management materials . They understand the basic facts linked to the menstrual cycle and how to manage it with dignity and without discomfort or fear ” [ 5 ]. Menstrual hygiene management also involves addressing harmful societal beliefs and taboos surrounding the issue [ 6 ].

Approximately 75% of people experience premenstrual syndrome (PMS), which includes emotional and physical symptoms that occur between one and two weeks before menstruation [ 7 ]. Regular menstruation is a sign of health and fertility; it is inherently female. However, drawing on feminist theory, femininity is linked to beauty, freshness and cleanliness [ 8 ]; these are opposed to the qualities associated with menstruation: dirty, bloody and smelly. This means menstruation does not conform to the gender stereotypes, is linked to inferiority and contributes to the devaluation of females [ 9 ]. This dichotomy may begin to explain menstrual taboos [ 9 ]. These points are demonstrated through the ‘Tampon Experiment’, which aimed to understand how a menstruating woman is perceived by others [ 8 ]. When an informed research participant dropped a tampon (a visible reminder than women menstruate) on the floor, she was viewed more negatively by men and women than when she dropped the hair clip (considered a feminine item that is not linked to bodily functions) [ 8 ].

Menstrual taboos are rooted in, and drive gender inequality. In some settings menstruating people are viewed as impure, so they are separated from men and banned from using the same water sources in order not to contaminate them [ 10 , 11 ]. These taboos and social beliefs have led some people to internalise this stigma, reporting that they feel dirty when menstruating and are ashamed of it [ 12 , 13 ].

Menstruation is not widely spoken about [ 14 , 15 ]. Many pre-pubescent girls do not receive information about menstruation, so their first menstrual cycle can be a frightening experience. In India, a cross sectional study of 387 school going girls reported that only 37% of them were aware of menstruation before menarche [ 16 ].

Affordability of menstrual products is an issue in many countries, especially for people from lower socio-economic groups. In many LMICs, people use bark, paper, sand, mud or cloth to absorb menstrual blood [ 9 ]. Evidence exists that some adolescent girls in western Kenya engage in transactional sex to obtain sanitary pads [ 17 – 20 ], contributing to exposure to sexually transmitted diseases [ 21 ], pregnancy and school dropout [ 22 ].

Attention on MHM has increased over the last decade. Examples include the socio-ecological framework for MHM (developed for school girls and their families) to guide research and interventions in LMICs [ 23 ] and the inclusion of MHM in the Sustainable Development Goal 6 [ 24 ].

This shift is encouraging, but MHM efforts must be inclusive of disabled people.

This review applies the UN Convention on the Rights of Persons with Disabilities’ (CRPD) definition of disability: ‘Persons with disabilities include those who have long-term physical , mental , intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others’ [ 25 ].

Like menstruation, disability often carries stigma [ 26 ]. Research in Uganda and Zambia demonstrate that disabled people are considered ‘dirty’ and contagious, so can be banned from using public latrines and water points [ 27 ]. It is likely that disabled people face layers of discrimination when they are menstruating, which will vary for people with different impairment types. Inaccessible latrines means disabled people who cannot stand or see often have to crawl, or sit on dirty latrine seats to change their pads or cloths [ 10 ]. People with visual impairments may be unable to identify when their period started and finished [ 3 ]. People with hearing, communication or intellectual impairments may be less able to communicate when they are in pain or need support [ 10 ]. There is a widespread misconception that disabled people are asexual, so do not receive information on sexual and reproductive health, or menstrual hygiene [ 10 , 26 , 28 ].

The objective of the review is to assess the menstrual hygiene requirements of disabled people, the barriers they face, and the available interventions to help them manage their menstruation hygienically and with dignity. A review protocol is registered online with PROSPERO; registration number: CRD42018095497.

This review recognises that gender is a social construct, non-binary and fluid. People who menstruate may identify themselves as male, female, or neither. Therefore, this review uses the terms ‘person’, or ‘people’ who menstruate rather than ‘female’, ‘women’ or ‘girl’, unless these terms are pertinent to the study or theory referenced. The authors also chose to use the terminology ‘disabled people’ rather than ‘people with disabilities’.

Materials and methods

Search strategy.

The search strategy was designed to identify peer reviewed published studies researching disability and MHM. The review covered all countries; no date limit was set to ensure the widest range of articles could be identified. The searches were conducted in May 2017, with alerts set on each database to highlight new titles added since then. Four online databases were used: MEDLINE, PubMed, EMBASE and Global Health through Ovid SP. Additional relevant studies were identified by reviewing references of included studies and scanning the internet for relevant studies after the database searches were completed. Search terms were generated to encapsulate three main concepts: disability, menstruation and hygiene management. Disability included both specific impairments and broad assessments (e.g. self-reported functional or activity limitations) ( S1 Table ).

Inclusion / Exclusion criteria

To be eligible, papers had to in English, published in a peer reviewed journal; be original primary research including experimental, observational and qualitative studies, but excluding economic analyses, systematic reviews, project reports, and policy analysis. No exclusion criteria were set on world region or date of publication. Studies were excluded if they reported no empirical qualitative or quantitative data on MHM and if they analysed disability without the inclusion of MHM and vice versa.

Eligible participants were menstruating disabled persons and/or the carers of disabled persons who provide support during their menstrual cycle. Carers were professionals or family members working in institutions or at home. Disabled persons had specific impairments, activity limitations or self-identified as disabled.

Papers were required to investigate the extent to which disabled people and their carers are able to understand and manage their menstrual cycle hygienically and with dignity. The relevant outcomes explored were purposefully broad as there were anticipated to be limited published studies on the issue. Example outcomes include choice of menstrual management material and preference, ability to manage menstrual hygiene and the menstrual cycle; challenges experienced during menstruation and coping strategies applied; changes in behaviour through the menstrual cycle and its management.

Study selection

All studies identified through the search process were exported to EndNote version X7. Duplicates were removed. Two authors independently double screened the titles, abstracts and key words against the eligibility criteria. Results were compared and contrasted and full-text records of potentially relevant publications were obtained and screened using the inclusion criteria for final selection of studies for the systematic review.

Data extraction

Data was extracted from the final selection of studies using pre-designed tables and the socio-ecological framework for menstrual hygiene management [ 23 ]. Through the data abstraction process for this review, a number of gaps in the socio-ecological framework in relation to the MHM requirements of disabled people and their carers were identified and additions were made to fill these gaps ( Table 1 , with changes marked in italic).

Data was extracted into Microsoft Excel against the following study and framework components:

• Publication details: author/s, year, title
• Study location: low, middle or high-income country, country name
• Methods: study design
• Participants: source of participants (household, institution), disability type (e.g. intellectual impairments, physical impairments), means of assessing disability, carer type (family member, professional), sample size
• Aspect of MHM considered

Quality assessment

A meta-analysis was not conducted due to the lack of consistency in study designs, population types and outcomes included. The review was conducted to meet the requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) [ 29 ].

Studies were assessed for their potential risk of various types of bias, by applying an approach used by Banks et al. [ 30 ]. This quality scoring used modified versions of the assessment tools STROBE and RATS for quantitative and qualitative studies [ 31 , 32 ]. Assessment focused on the risk of potential biases stemming from study design, sampling methods, data collection, data analysis and interpretation. As study methodologies varied widely, papers were evaluated to assess their overall risk of bias instead of applying a rigid cut off criteria. Studies were graded as having a low risk of bias when all or almost of the criteria were fulfilled, and those that were not fulfilled were thought unlikely to alter the conclusions of the study; medium risk of bias when some of the criteria were fulfilled, and those not fulfilled were thought unlikely to alter the conclusions of the study; and high risk of bias when few or no criteria were fulfilled, and the conclusions of the study were thought likely or very likely to alter the conclusions of the study [ 30 ] ( S2 Table ).

8026 records were identified through database searches. An additional 3 records were sourced through the authors’ knowledge of the available literature. 2999 duplicates were found and removed. An additional 4902 studies were excluded in the title screening process and a further 87 records were excluded through screening the abstracts. 41 full text articles were assessed and 19 were excluded. The remaining 22 studies were included. No additional studies were sourced through database alerts ( Fig 1 ).

Study characteristics

A summary of the characteristics of included studies are presented in Table 2 . Data extracted from all studies against study framework components is captured in Table 3 . Studies were published between 1976 and 2017, with the majority published after 2010 (n = 12; 55%). Most of the studies were conducted in high income settings (n = 15, 68%), including Northern Europe (UK, Netherlands and Denmark) (n = 6; 27 Eastern Asia (Taiwan, n = 4, 18%) Northern America (USA and Canada, n = 4, 18%) and Australia and New Zealand (n = 1, 5%). Only seven were conducted in LMICs (32%), including in Southern Asia (India, n = 3, 14%); Eastern Europe (Turkey, Bosnia and Herzegovina, n = 2, 9%); Eastern Africa (Malawi, n = 1, 5%); and South Africa (n = 1, 5%). The majority of studies were quantitative (n = 14; 64%); one study was a quasi-experiment; all others were qualitative.

*Knowledge, attitudes and practices

Description of studies

Of the 22 studies, disabled persons were the primary research participant in the majority (n = 13; 59%), followed by the carer (n = 6; 27%), or the carer and the disabled person (n = 3; 14%) ( Table 4 ). These participants were sourced through institutions (n = 13; 59%), such as hospitals and residential homes; households (n = 6; 27%) and households and institutions (n = 3; 14%). The means of assessing disability ranged from clinical (n = 8; 36%), self-reported (n = 4; 18%) to government lists (n = 2; 9%). Seventeen (77%) studies focused on people with intellectual impairments, followed by multiple impairments (n = 3; 14%) and physical impairments (n = 2; 9%).

The quality assessment identified 13 (59%) studies as having low, seven (32%) as medium and two (9%) as high risk of bias. The main reasons for potential bias was the limitations in generalisability of results due to a small sample and response rate being lower than 70%.

Impacts of menstruation

Pre-menstrual symptoms and communication difficulties experienced by people with intellectual impairments.

Nine papers (41%) covered pre-menstrual symptoms (PMS) [ 33 – 41 ]. Eight reported PMS symptoms and related behaviour, including menstrual cramps, mood swings, fatigue, irritability, anger, social withdrawal, decreased concentration, increased hyperactivity, self-injury and inappropriate handling of menstrual blood or hygiene products experienced by people with intellectual impairments [ 34 – 41 ]. Six papers assessed the frequency and severity of pain [ 36 – 41 ], three of which compared these between disabled and non-disabled people [ 37 , 38 , 41 ].

Obaydi and Puri stated that PMS was experienced by 92% of the group of people with autism, compared to 11% in the control group of non-disabled people [ 38 ]. This study had the lowest risk of bias. Kyrkou also concluded that people with Down syndrome or autism experienced higher rates of pain than the general population [ 37 ]. Due to the challenges in communicating the extent and location of pain, Kyrkou deduced this through changes in behavior [ 37 ]. However, Ibralic et al. [ 41 ] and Ranganath and Ranganath [ 39 ] contradicted this finding. Ibralic et al. reported that PMS symptoms were almost equally distributed between non-disabled people and people with an intellectual impairment [ 41 ]. Ranganath and Ranganath reported that no one with Down syndrome experienced menstrual pain or premenstrual tension, but the authors did not include an assessment of the participant’s communication abilities or factor this into the results [ 39 ]. Ranganath and Ranganath’s study was marked as having a high risk of bias [ 39 ].

Three studies investigated the severity of PMS symptoms by disability type [ 34 , 37 , 40 ]. All studies concluded that there is divergence within groups. Kyrkou [ 37 ] and Hamilton et al. [ 40 ] recognised that the ability to report and locate pain was a determining factor. For instance, within the intellectual impairment group, Kyrkou found that 67% (n = 8) of the research participants with Down syndrome were able to say that they were in pain or point to where they had pain, even those with limited communication abilities [ 37 ]. Only one of the nine participants on the autistic spectrum was able to point to, or state when she was in pain, even though all participants had good communication skills.

Three studies stated that the inability of some people with an intellectual impairment to understand the source of pain and communicate affected their behaviour [ 34 , 35 , 37 ].

"She gets short tempered . But it’s not her fault . She can’t speak very well , so I think that’s how she expresses herself” (carer from India) [ 35 ].

Concerns of carers of people with intellectual impairments

Six (27%) studies investigated the key concerns of carers who support people with intellectual impairments [ 34 – 37 , 42 , 43 ].

Carers (mothers) of people with an intellectual impairment in Thapa and Sivakami’s study in India reported that difficulties with communicating to daughters, and vice versa, were a major challenge [ 35 ]. Challenges with communication lead mothers to rely on observing changes in their daughter’s behaviour to anticipate menstruation [ 34 ]. Predictors include irritability, restlessness, crying, self-harm, decreased appetite and disruptions in sleeping patterns [ 34 ].

Other challenges reported by carers included an aversion to wearing a menstrual product, a lack of adherence to social and cultural norms, such as inappropriate handling of menstrual blood and product, talking to others about their menstruation and changing the used menstrual product in front of others [ 35 – 37 , 43 ].

"She will leave the door open while changing her pad , and doesn’t understand that her elder brother is at home . So I tell her , ‘Always bolt this door from inside . ’ Sometimes she understands , but sometimes she starts changing in front of them" (carer from India) [ 35 ] " .

One of these six studies investigated professional carers’ levels of satisfaction of intimate care tasks, finding that menstrual care was the second most disliked aspect for residential staff (after giving enemas), and the most disliked aspect for day unit staff (who do not give enemas) [ 42 ].

Strategies for menstrual hygiene management

Menstrual product acceptability for people with physical impairments.

Four studies (18%) investigated the menstrual product used and preference [ 34 , 35 , 44 , 45 ]. Two of these studies considered the product used [ 44 , 45 ]. One [ 44 ] explored the product acceptability from the perspective of people with spinal cord injuries, and the remaining two [ 34 , 35 ] investigated the carers’ product preference. 19% of the sample in the study focusing on people with spinal cord injuries (conducted in the USA), reported discomfort and difficulty in positioning the menstrual product to ensure its maximum absorbency, as well as increasing difficulties with catheters and urinary management during menstruation [ 44 ].

Menstrual product acceptability for people with intellectual impairments

Three of the 22 studies explored the disabled person’s preference through the carer [ 34 , 35 , 43 ]. The studies reported that the people with an intellectual impairment often refused to wear the menstrual product, leading to stress felt by the carer and constant negotiation with the disabled person.

"My biggest problem was that she didn’t want to wear a pad . The understanding isn’t there (carer from England) [ 43 ]. ”

In a study, undertaken in India, mothers limited their daughter’s physical movements during menstruation so that she would not go outside with blood stained clothes [ 35 ]. Another coping mechanism applied by carers in Taiwan, was sewing the pad into the underwear or buying adult sized nappies for their daughters [ 34 ].

In two of the four studies, mothers were caring for daughters with incontinence [ 34 , 35 ]. These carers felt that menstruation added another layer of complication [ 35 ], and that the cost of nappies and pads were a major concern [ 34 ]

MHM training and support for people with intellectual impairments

Five studies (23%) investigated MHM training given to people with intellectual impairments [ 35 , 37 , 43 , 46 , 47 ]. One study highlighted a lack of training and support provided to this group because carers did not believe that the individual would understand MHM information [ 35 ]. The authors hypothesised that some people with intellectual impairments refused to wear a menstrual product because they were not given any MHM information, including being shown a menstrual product, or practice wearing it prior to their first menstrual cycle. Consequently, they did not understand the purpose of a menstrual product, did not feel comfortable wearing it and associated it with menstrual cramps [ 35 ].

One of these fives studies explored the teaching on MHM provided to people with intellectual impairments in institutions [ 47 ]. It highlighted a lack of correlation between training provided and the person’s level of understanding [ 47 ]. Three studies showed positive correlations between providing MHM training to people with intellectual impairments and an increased ability to manage menstruation independently [ 35 , 37 , 46 ]. In Kyrkou’s study, conducted in Australia and New Zealand, people with Down syndrome who had been given MHM information prior to puberty were better able to cope with their menstrual cycle than those who were not [ 37 ]. Altundağ and Calbayram showed in their study in Turkey, that using a doll to practice changing and disposing of a used menstrual product, was an effective way to increase the MHM skills of people with intellectual impairments [ 46 ].

MHM training and support for carers

Five studies investigated the level of training and support provided to carers (professionals and mothers) on how to manage menstruation of a person with an intellectual impairment [ 34 , 35 , 42 , 48 , 49 ]. Three of these studies [ 42 , 48 , 49 ] focused on professional carers working in institutions and two studies on mothers at home [ 34 , 35 ]. The three studies conducted in institutions highlighted limited MHM training and standards for intimate and personal care tasks; that the task’s importance was under-recognised by management; understanding of the menstruation of people with intellectual impairments was low, and support provided on menstrual issues was lower than sex education, but higher than menopause [ 42 , 48 , 49 ].

The mothers in the two studies focusing on care provided within the family were given no guidance, information or support on how to manage their daughter’s menstruation, leaving them feeling overwhelmed and unsupported [ 34 ]. In the Indian and Taiwanese settings, mothers believe that menstruation is a private issue so did not discuss their daughter’s menstrual cycle with anyone else, including professionals [ 34 , 35 ].

Menstrual suppression

Six papers included an analysis of menstrual suppression of people with intellectual impairments [ 34 – 36 , 50 – 52 ]. Menstrual suppression includes long-term contraception (i.e. oral contraceptive pill and the patch) and sterilisation (i.e. hysterectomy, tubal ligation). Two of these six studies were from the LMIC and the remaining four studies were from HICs [ 35 , 50 ]. Two studies [ 50 , 52 ] were published before 2000 and four after 2010 [ 34 – 36 , 51 ].

Of these six papers, five reported that people with intellectual impairments were sterilised or on long-term contraception. Reasons for sterilisation cited by carers including a perception that menstruation care is a “burden”, a fear of unwanted pregnancies [ 35 , 36 , 50 – 52 ], difficulties related to the menstrual care tasks; the perceived lack of benefit for the person with an intellectual impairment, as well as mothers’ desire not to “burden” an older daughter with the menstrual care tasks when she is no longer able to undertake these tasks [ 35 , 50 , 52 ].

"I used to do everything–changing the pads every three–four hours , taking her to the toilet . But she was not aware at all; there were no feelings in her . Then when she was 16 years old , I realised that I could not do it anymore , and it was not benefitting her in anyway . Then we got her operated upon . We got her surgery done , and got her uterus removed” (carer from India) [ 35 ].

Three studies included satisfaction levels of carers post sterilisation [ 35 , 50 , 52 ]. All of these reported high levels of carer satisfaction. One study from Taiwan challenged this trend of menstrual suppression [ 34 ]. In this study, regular menstruation was seen as an indication of good bodily health and daughters with an intellectual impairment were given medicine to help regulate their cycles. However, almost all mothers in this study were advised by relatives and medical professionals to sterilise their daughters in order to eliminate the ‘tedious’ menstrual care, for better hygiene and to prevent unwanted pregnancies [ 34 ].

Our search sought to identify studies exploring the MHM requirements of disabled persons, but only found 22 studies that met the inclusion criteria. The majority of studies focused on people with intellectual impairments and their carers.

Fig 2 summarises the key findings in this review that relate to people with intellectual impairments and their carers. It shows that societal beliefs and taboos around menstruation and disability means the issue is shrouded in silence, and that it lacks attention and resources. The silence surrounding disabled people’s menstrual hygiene requirements is demonstrated by the limited number of peer reviewed studies gathered for this review. Without rigorous evidence from different contexts, it is difficult to advocate for greater attention and resourcing to meet the MHM requirements of disabled people and their carers. The subsequent dearth of MHM training, information and support tailored to meet disabled people and their carers requirements means some people struggle to manage. Strategies for MHM applied by carers include limiting the disabled person’s movements when menstruating and suppressing their menstruation.

The top box in Fig 2 focuses on people with intellectual impairments. This review has shown that some people with intellectual impairments do not always understand or follow social and cultural norms [ 35 – 37 , 43 ], or wear a menstrual product [ 34 , 35 ]. This group face challenges in understanding PMS and communicating when in discomfort [ 33 – 41 ]. Carers reported subsequent ‘menstrual behaviours’ make them feel stressed, embarrassed and they coped by not letting their daughters leave the home or sought ways to supress their menstruation [ 35 ]. The authors propose that if repetitive, accessible MHM information and training is provided regularly to the persons with intellectual impairments, they may get a deeper understanding of cultural and social norms and be better able to manage their menstruation more independently.

The bottom box in Fig 2 focuses on findings related to carers, which highlights an absence of standards and training on providing menstrual care in the institutions covered in the studies [ 42 , 48 , 49 ]. Findings show that professional carers dislike providing menstrual care [ 42 ]. If combined, these two factors might mean that a disabled person’s dignity and personal hygiene is compromised in these institutional settings.

The review found that MHM training and support is not provided to family members who care for daughters with intellectual impairments [ 34 ], and that mothers also dislike providing menstrual care [ 35 , 50 , 52 ]. Mothers reported an inability to see how menstruation benefit their daughters [ 35 ], which is intertwined with the societal belief that disabled people should not be parents or sexual beings [ 53 ]. Disability and menstruation related taboos discourages open dialogue, meaning mothers do not seek advice or support, because they view the provision of menstrual care as a private issue [ 34 , 35 ].

In addition to the findings captured in Fig 2 , included studies also investigated the disabled person’s preference of menstrual product [ 34 , 35 , 44 , 45 ]. Research participants, with a physical disability, reported low levels of satisfaction with the menstrual product used (sanitary pads with and without tampons), stating that they find the products uncomfortable, difficult to place and use with catheters [ 44 ].

Implications for future research

There is limited evidence about the MHM requirements of disabled people, interventions to meet these and an assessment of their impact. This is particularly stark in LMICs, so research to investigate these topics must be carried out in these settings. Another key research gap is around the development of standardised measurements of MHM related outcomes for disabled people and their carers [ 54 ], and here the socioecological framework for MHM, adapted to include disabled persons and their carers ( Table 1 ), could be a start. It is useful as the framework recognises MHM outcomes have individual, social and environmental influences that affect menstrual experiences and MHM among the target population.

More research is required to explore the severity of PMS experienced by disabled people compared to non-disabled people, and compared within disability groups with the view of developing mechanisms that enable disabled people to better locate and communicate pain. Finally, research on menstrual product preference and effectiveness for people with different impairments, to understand if the current products on the market are suitable and acceptable, should also be conducted.

Review strengths and limitations

To the authors’ knowledge, this is the first systematic review of the MHM requirements of disabled people and their carers. This review restricted the search to studies in the English language and the number of datasets (such as excluding the CINAHL database), so some relevant studies may have been missed. Few studies met the inclusion criteria and across those, there was no standardised measurement of outcomes, meaning an outcome assessment across the studies was difficult. For instance, only seven (32%) studies defined symptoms and practices associated with menstruation, and only 12 (55%) studies identified the means for assessing disability.

There were not enough studies with consistent methods for a meta-analysis. The authors mitigated this by using Banks et al.’s [ 30 ] quality assessment that combines the STROBE and RATS assessment tools for quantitative and qualitative studies [ 31 , 32 ]. The main reasons for risk of bias are due to a sample size being smaller than 100 and the response rate being less than 70%, or not reported. This could lead to an over estimation of impacts. However, there are no great divergences between the findings in papers that have a high risk of bias and those with a medium or high risk of bias, which alleviates concerns.

In conclusion, limited evidence was identified on the MHM requirements of disabled people and their carers, though a number of barriers were identified. This evidence gap is important and must be filled with future research. MHM interventions that address these barriers must be developed, tested and scaled up in partnership with disabled people. If the inaction continues, disabled people’s rights will continue to be violated; they will continue to face social exclusion and potentially sterilisation.

Supporting information

S1 checklist, acknowledgments.

The authors would like to thank WaterAid for seconding the lead author to the LSHTM to carry out this research.

Funding Statement

Funding for this review was gratefully received from the Bill and Melinda Gates Foundation ( https://www.gatesfoundation.org ), Development Grant number OPP1159651, Global and Country-Level WSH Advocacy. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data Availability