Knowledge, Attitude, and Practice of Menstrual Hygiene in Women Aged 13–45 Years Attending Hind Institute of Medical Sciences, Sitapur: A Cross-sectional Study

INTRODUCTION

There is a substantial lack of awareness of young girls, even adult females, about menstruation. Numerous research studies have shown this discrepancy and have shown a low awareness among girls about menstruation.^1–4 Menstruation is a natural, normal female body physiological process that is the main sign of womenfolk’s reproductive condition in the reproductive age group.¹ The word “menstruation” (period/menstruation period-menstruation cycle-MC) was derived from the Latin term “MENSES” meaning moon, and that defines—it as a cyclical discharge of blood and tissue debris from the uterus that repeats in nonpregnant breeding-age women after 28 days per month.^1,5,6

Many erroneous behaviors and misconceptions have been connected with menstruation since ancient times, resulting in adverse health effects (affect the quality of life).^1,2 Several clinical survey studies have shown that most adolescent girls or young women do not have full precise knowledge of the menstrual cycle and its hygiene habits. They get information from a specific source—mothers, television, peers, teachers, and relatives provide valuable information about MC.^1,6–8

The hygiene status of women during MC is not maintained in rural areas, not only in India but also in other developing countries, and it harms women’s health.^6,9,10 Different clinical studies have exposed that females avoid baths during MC, and also, they are restricted consumption to specific diets.^6,11 Numerous clinical health conditions such as cervical cancer, miscarriage, ectopic pregnancy, sexually transmitted infection (STI), and reproductive tract infection (RTI) emerge from unhygienic practices and often affect the social well-being of females of reproductive age.^6,12,13

Shingade and his colleagues reported in 2016 that >70% of women’s RTIs are due to unhygienic practices; it can also lead to fetal abortion.^6,14 Lack of menstrual hygiene awareness affects not only social, health, physical, and educational activities, but also the environment; improper disposal (keeping inside the washroom, indiscriminate throwing in ponds/open areas or drains) creates an environmental hazard and impacts health indirectly (not only female but all living ones).^14,15

Moreover, women are unaware of menstrual hygiene practices (did not get adequate knowledge from primary sources), especially in rural areas of developing countries such as India, and cannot discuss MC because of social prohibition.¹⁶ However, menstrual hygiene activity is a public health issue, but no one takes significant action because of an undesirable circumstance (ignored by politicians, decision-makers).^17,18 Therefore, good menstrual hygiene habits are also necessary during the menstrual period, including good sanitary pads, adequate genital cleaning, regular bathing, and eating a good diet.^6,18 With this background, the current research was conducted to evaluate the habits and knowledge of menstrual hygiene among women of reproductive age group (different age group).

AIMS AND OBJECTIVES

• Evaluation of menstrual awareness, attitudes, and self-care during menstruation in women aged 13–45 years in rural areas of Sitapur, UP.
• To identify the prevalent menstrual hygiene patterns in rural communities.
• To determine the relative contribution of participants and their mothers’ educational status to the use of unhygienic activities during menstruation.

MATERIALS AND METHODS

The present research was performed by the Department of Obstetrics and Gynaecology at Hind Institute of Medical Sciences, Ataria, Sitapur, UP; conducted from July 2019 to September 2019. The study duration consisted of 3 months. All females of the reproductive age group (13–45 years) attending routine gynecology OPD (including the patients’ female relatives accompanying them) in July 2019 were included in the study after taking their consent and selected by systematic random sampling method.

The questioner was used to collect data from subjects on their sociodemographic profile, effects, restrictions imposed, menstrual awareness, and about use of sanitary napkins, feminine health, and hygiene. The confidentiality of the data gathered during the analysis was preserved. Face-to-face discussion (interview method) was done for data collection, and before the start of the study, it was approved by the Institutional Ethics Committee, Hind Institute of Medical Sciences, Sitapur (IEC/IRB NO: HIMS/IRB/2019-20/04 DATED 10-06-2019).

RESULTS

Out of the total 237 subjects, the majority (98.31%) belonged to rural areas, whereas 1.68% urban areas. The mean age of subjects was 29.00 ± 9.67 years. Table 1 demonstrates that women have participated in different age groups (13–45 years old) in the present study. Most of the females were in the age group between 19 years and 26 years (37.13%) mean age was (21.93 ± 2.42) followed by 13–18 years (29.53%); the mean age was (15.46 ± 1.63) (Fig. 1).

Table 2 shows that most of the majority (98.31%) of subjects belonged to rural areas (most of them close to the hospital’s village), while 17.39% were from urban areas. Around 149 (62.86%) out of 237 women were married, whereas 37.13% were unmarried. The majority of them had an education level underclass 10 that is 88.18%, whereas less in the above class 10, i.e., 11.81%. Most of the mothers were illiterate, 33.33%, whereas primary school (25.73%), middle school education (18.98%), and secondary school (10.54%), respectively. About 83.54% of the females were Hindus, whereas only 16.45% belong to Muslims; 96.62% were from Joint, whereas significantly less 3.37% from nuclear families in the present finding. Most of the participants (55.69%) were from class IV (lower class families), followed by the lower middle class (class III) (38.81%) as per the modified 2018 BG Prasad scale. The majority of the participants (46.41%) go outside the house for the toilet, and 48.94% had water stored in their homes.

According to the menstrual background (including its symptoms), the sample population’s distribution is seen in Table 3. In the present study, most participants had a bleeding time of fewer than 3 days (74.68%), and 21.51% of subjects had less than five bleeding times. The majority of participants (75.10%) registered an abnormal or irregular menstrual cycle, whereas only 24.89% of participates had a regular menstruation period. Around 27.84% of subjects who had excess bleeding complained. Through the menstruation period, most participates (49.72%) had stomach or abdominal pain accompanied by fatigue or weakness (27.84%) and other symptoms like headache (6.32%), vomiting (4.64%), nausea (3.79%), and few participates 4.21% had to feel breast pain and soma were, itching around genital (3.37%).

Concerning various types of restrictions during menstruation cycles; around, 54.43% of women sleep separately, 49.78% of women were restricted to attend some religious event, 41.35% of women did not perform some household tasks, several girls did not even allow to play, 49.52% of girls did not attend any other marriages, and occasions (did not go to school) including different forms of prohibitions during menstrual periods, seen in Table 3.

Table 4 shows awareness of study participants about the menstruation cycle and menstrual hygiene was found, as 41.35% of the participants knew about the type of napkin to be used, and 41.35% of them were aware of cleaning perineum while changing pads or after urination. Around 36.28% of them were aware of the problems likely to arise due to unhygienic practices, whereas awareness about sanitary napkins before menarche was low (23.20%). The majority of participants (98.73%) knew about menstruation as indicating fertility, whereas only 24.89% of women were aware of proper sanitary products. Around 90.71% knew about menstruation’s cause, while 67.93% of participants were aware of the age of normal cessation of menstruation. Similarly, 81.85% of subjects were aware of sanitary pads by other female family members; whether cost constraints are present for using sanitary pads, they knew 83.12% of subjects. Through this study was found as 83.54% of participates aware that menstrual blood being impure. Around 91.13% of subjects knew about normal monthly menstruation duration, whereas 24.89% of participants were aware of hot or cold food affecting the menstrual cycle. Regarding awareness, about 75.52% of participates had reported that menstruation is a natural biological female body process, and around 6.3% knew that it is due to god curse (Table 3).

In the present study, it was also found that 75.00% in an urban area and 4.72% in the rural area used sanitary pad, whereas new cloth 15.87% in the urban area and 25.00% in the rural area and the majority of subjects 79.39%, used old cloths in the rural areas during menstruation. Regarding the menstrual hygiene practices, it was found that 57.08% of subjects wash genitalia daily in rural and urban, the majority of participants cleaned genitalia daily (Table 5).

Regarding cleaning material, about 52.36, 41.02, and 6.43% participate in rural cleaning with water, soap and water, and antiseptic, respectively, whereas 100% in urban areas used antiseptic for cleaning external genitalia. More than 72.10% of rural areas burnt the used cloth/pad of menstruation, and only 27.89% threw it in waste, whereas 100% of subjects threw pads in the waste, regarding the place of drying cloth if they re-used after washing, most subjects (72.96%) of rural area dried in sunlight and 27.03% inside the house.

Figure 1 shows the subjects’ distribution in the different age groups. The majority (37.19%) of participants had reported in the 19–26 years, whereas less percentage (9.70%) in the age group 33–38 years. Figure 2 shows the restrictions during menstruation across rural and urban areas. Avoiding worship (10.23 vs 5.12%), restriction in diet (11.29 vs 3.25%). Avoiding games were more common in rural areas (9.86 vs 5.74%), whereas staying at home (6.6 vs 0.0%) and avoiding social function (9.8 vs 1.2%) were more common in rural areas. Figure 3 shows the source of menstruation across rural and urban areas. Uterus source (68.21 vs 50.00%), urinary bladder (8.15 vs 00%), vagina (6.86 vs 25.00%), abdominal (3.86 vs 00%), kidney (38.19 vs 00%), and some were do not about the source of menstruation, were more common in rural areas. Figure 4 represents the majority (72.10%) of rural participates who had to burn menstruation pads.

DISCUSSION

This study aims to discuss menstrual hygiene practices among women of reproductive age (mainly rural areas). The mean age was 29.0 ± 9.66, most of which were married, similar to those reported by Balamurugan et al., where the majority (33.33%) of the study population was aged 27–45 years while they were aged 21–26 (23.62%) and overall subjects, around 62.86% were married.^21,22 Similar findings were also reported by Mathiyalagen et al.,²² where the subjects’ mean age was 28.2 ± 7.5, and most were married.

Regarding the place of subjects, the majority of participates (98.31%) from the rural area and this high than the performed study by Paul et al.,⁵ where findings had been reported (40.2%) and in the present study resulted indicated that most of the family were joint (96.62%), whereas 83.1% were from nuclear families had been reported by Mathiyalagen et al.²² The females having school education (under class 10th) was about 88.88% in our study, and it was higher than both reports Thakur et al.,⁶ and Misra et al.,¹¹ where it was only about 30 and 15%, respectively.

In Indian different communities, and they follow a different type of restrictions during menstruation. In our study, most Hindus who participated (83.54%) have been reported and supported by Mathiyalagen et al.,²² where 96.3% of participants were Hindus. Around 54.43 and 49.78% of females were sleeping separately, restricted for the religious task, and this result very similar to the finding reported by Mathiyalage et al.²² where females were asked to sleep separately (58.7%) and followed by restricting religious activities (44.6%).

The present study has reported that 74.68% had >3 days (<5 days) of menstrual flow, and this result was similar to the findings by Balasubramanian²¹ and Juyal et al.¹⁷ The finding of the present study regarding the cause of menstruation was unknown to a few participates (21.29%). The result was near-similar to the study finding by Langer et al.¹³ In this study, around 24.89% of them mentioned that hot/cold food affecting the menstrual cycle, and 83.54% of them considered menstruation was as impure blood, but less percentage¹² was had been reported by Paul et al.⁵ Around 36.28% of the participants mentioned that awareness about problems likely to arise due to unhygienic practice, but higher percentages (58%) were reported by Paul et al.⁵

Around 57.38% of the study participants knew about menstruation before menarche, which was similar to Verma et al.,²³ where 58.3% of females had reported having prior knowledge about menstruation²⁴ in this study. More than half of the study people were not aware of menarche menstruation. Presumably, every female child should be aware of menstrual before menarches play an extended role in maintaining and avoiding menstrual hygiene.

Regarding the cause of menstruation, the majority (75.52%) of the study participants supposed that menstruation is natural physiology which was somewhat similar to the finding by Verma et al. where 85.83% of girls believed it to be a natural phenomenon;²³ it was evident that a 12.23% of females in the study were not the aware cause of menstruation and fewer believed 6.3% that it was due to God’s curse which was the complete wrong perception of rural area’s females which was similar to finding by Paul et al., where 6.5% females have a perception the same.

The finding regarding the source of blood in menstruation, 50.20% of the study participants did not know about the source of menstrual blood, which was lower than a finding by Pundkar et al. where reported 70.71% (females did not know the source).²⁴ The present study showed that most participants (83.54%) believed menstruation blood as impure blood, which was high to findings by Paul et al., where 12% mentioned it as dirty blood. Around 30% of the participants mentioned that the uterus was the source of blood, but higher percentages (58%) had been reported by Misra et al.¹¹

The present study finding indicated that most participants acquired knowledge about menstruation from their primary source—mother and our findings have been supported by Paul et al.⁵ and Johnson et al.²⁵ In contrast, most mothers were illiterate, and similar findings have been reported by Paul et al.⁵ Around 52.36% of participates were water used for cleaning genitalia in the present study in the rural area, and the finding supported by Mathiyalagen et al.,²² whereas the most common agent was only water (53.7%). In the present study, the commonly practiced method of disposing of the absorbent was burning, similar to the findings by another Pundkar et al.²⁴ Numerous studies have been reported improper disposal of sanitary pads/cloths is a threat to the environment and affect people’s health. In the present study, it was observed that improper disposal of sanitary pads or cloths by about 72.10% of study participants (due to lack of proper knowledge about menstrual hygiene practice and they belong to the rural area). Various studies have already defined the disposal of used sanitary pads or cloths thrown in waste by the proper packing.²² Also, lack of knowledge about personal hygiene care and unsafe sanitary products, improper perineal washing, and other practices have led to various gynecological problems (cervical cancer and ovarian cancer, infertility) among women in many studies. Therefore, they should be encouraged to use safe, sanitary pads with health education by health workers and follow the regular cleaning with soap, water, and antiseptic should be advised to every rural woman of all age groups.

CONCLUSION

Menstruation is a milestone or natural event in a females’ life, a vital sign of the reproductive age group, and the beginning of a females’ reproductive life. Menstrual hygiene practices are an essential phenomenon of reproductive female health. The present study tries to defined awareness about menstrual hygiene practice, and it is good habits for good health even also for the environment or all living one, though knowledge before menarche of females was not satisfactory. Still, many females follow restrictions in rural areas and enforced various activities during menstruation cycles of women. Menstrual hygiene practice, especially disposal, needs unique reconsideration. Sanitary napkin use and perineal washing were satisfactory among the participants. This study is limited by its single setting as well as self-reported responses. Moreover, in-depth exploration of menstrual behavior was beyond the scope of this study. Further studies with more qualitative nature are recommended to explore the in-depth factors responsible for poor menstrual hygiene practices.

RECOMMENDATION

For the country’s development, women should be healthy; teachers, parents, and healthcare workers can successfully run education, healthcare, and awareness programs and focus on menstrual hygiene practices. The government should include health education programs in every school curriculum and even colleges and universities. Between time duration, different educational and awareness programs and campus should be implemented in rural and urban areas, and safe, sanitary pads, the origin of mensuration, and hygiene practices should be encouraged. Primary care physicians should run the education class for rural people about menstruation, menstrual hygiene management, the importance of toilets at homes, diseases related to reproductive tract due to poor hygiene, and so forth, and comprehensive policy menstrual hygiene should be promoted at every level.

LIMITATION OF STUDY

For the present study, only Gynaecology OPD women were taken. Therefore, they are not indicative of both the community in general.

REFERENCES

1. Gupta M, Tiwari S, Wavare RR. Awareness and practices regarding menstrual hygiene among women of reproductive age group attending a tertiary care hospital of Indore, India. Nat J Commu Med 2015;6(2):247–277.

2. Ahuja A, Tiwari S. Awareness about pubertal changes among adolescent girls. J Family Welfare 1995;41(1):46–50.

3. Chaudhari RH, Socio-economic demographic and reproductive health profile of adolescents in the SAARC countries. Paper presented in south Asia Conference on Adolescents; 21–23 July 1998; New Delhi, India.

4. Khanna A, Goyal RS, Bhawsar R. Menstrual practices and reproductive problems: a study of adolescent girls in Rajasthan. J Health Manage 2005;7(1):91–97. DOI: 10.1177/097206340400700103.

5. Paul KK, Chaudhuri S, Maiti A. Menstrual hygiene practices among women aged 15-49 years attending a medical college hospital in Kolkata: a cross-sectional study. J Family Med Prim Care 2020;9(9):4699–4704. DOI: 10.4103/jfmpc.jfmpc_718_20.

6. Thakur H, Aronsson A, Bansode S, et al. Knowledge, practices, and restrictions related to menstruation among young women from low socio-economic community in Mumbai, India. Front Public Health 2014;2:72. DOI: 10.3389/fpubh.2014.00072.

7. Mudey AB, Keshwani N, Mudey GA, et al. A cross-sectional study on the awareness regarding safe and hygienic practices amongst school going adolescent girls in the rural areas of Wardha district. Global J Health Sci 2010;2(2):225–231. DOI: 10.5539/gjhs.v2n2p225.

8. Ghattargi CH, Deo DS. Preparation and practices regarding menstruation: a comparative study in rural and urban adolescent girls. Indian J Commu Med 2005;30(1):10–14.

9. Dasgupta A, Sarkar M. Menstrual hygiene: how hygienic is the adolescent girl? Indian J Commu Med 2008;33(2):77–80. DOI: 10.4103/0970-0218.40872.

10. Yasmin S, Manna N, Mallik S, et al. Menstrual hygiene among adolescent school students: an in- depth cross-sectional study in an urban community of West Bengal, India. IOSR J Dent Med Sci 2013;5(6):22–26. DOI: 10.9790/0853-0562226.

11. Misra P, Upadhyay RP, Sharma V, et al. A community-based study of menstrual hygiene practices and willingness to pay for sanitary napkins among women of a rural community in northern India. Natl Med J India 2013;26(6):335–337.

12. Parashar A, Gupta B, Bhardwaj A, et al. Prevalence of RTIs among women of reproductive age group in Shimla city. Indian J Commu Med 2006;31(1):15. DOI: 10.4103/0970-0218.54924.

13. Langer B, Mahajan R, Gupta RK, et al. Impact of menstrual awareness and knowledge among adolescents in a rural area. Indian J Commu Heal 2015;27:456–461.

14. Parashar A, Gupta B, Bhardwaj A, et al. Menstrual hygiene among married women: a hospital based cross-sectional study in an urban slum of Mumbai, India. Int J Commu Med Public Heal 2016;3:57–61. DOI: 10.4103/0970-0218.54924.

15. Shanbhag D, Shilpa R, D’Souza N, et al. Perceptions regarding menstruation and practices during menstrual cycles among high school going adolescent girls in resource limited settings around Bangalore city, Karnataka, India. Int J Collab Res Intern Med Public Heal 2012;4:1353–1362.

16. Khan S, Jha D, Ansari N. Menstrual hygiene knowledge, practices and acne problems among adolescent and young adult females: a cross sectional study. Int J Emerg Technol Innov Res 2020;7:221–228.

17. Juyal R, Kandpal SD, Semwal J. Menstrual hygiene and reproductive morbidity in adolescent girls in Dehradun, India. Bangladesh J Med Sci 2014;13:8–12.

18. Drakshayani Devi K, Venkata Ramaiah P. A study on menstrual hygiene among rural adolescent girls. Indian J Med Sci 1994;48(6):139–143.

19. Kamath R, Ghosh D, Lena A, et al. A study on knowledge and practices regarding menstrual hygiene among rural and urban adolescent girls in Udupi Taluk, Manipal, India. Glob J Med Public Health 2013;2:1–9.

20. Balamurugan SS, Shilpa S, Shaji S. A community based study on menstrual hygiene among reproductive age group women in a rural area, Tamil Nadu. J Basic Clin Reprod Sci 2014(2):3. DOI: 10.4103/2278-960X.140040.

21. Thakre SB, Thakre SS, Reddy M, et al. Menstrual hygiene: knowledge and practice among adolescent school girls of Saoner, Nagpur District. J Clin Diagnostic Res 2011;5:1027–1033.

22. Mathiyalagen P, Peramasamy B, Vasudevan K, et al. A descriptive cross-sectional study on menstrual hygiene and perceived reproductive morbidity among adolescent girls in a union territory, India. J Family Med Prim Care 2017;6(2):360–365. DOI: 10.4103/2249-4863.220031.

23. Verma P, Ahmad S, Srivastava RK. Knowledge and practices about menstrual hygiene among higher secondary school girls. Indian J Community Health 2013;25:265–271.

24. Pundkar RD, Zambare MB, Baride JP. The knowledge and practice of menstrual hygiene among adolescent girls in one of the municipal corporation school of Ahmednagar. VIMS Health Sci J 2014;1:118–124.

25. Johnson LR, Ravichandran M, Thomas MR, et al. Adolescent reproductive and sexual health (ARSH): what do tribal schoolgirls know and do? Acad Med J India 2014;2:14–17.