In India, most adolescent girls experience their first menstrual period with limited/incomplete knowledge of the process, compounded by various myths and misconceptions associated with menstrual hygiene. Around 60 percent of women suffer from common RTIs due to the usage of unhygienic sanitary items and access to inadequate sanitation facilities [3]. Also, India is home to the highest number of adolescents in the world [1]. One-third of the new-borns are from adolescent pregnancies [27]. Therefore, it is crucial to understand how many women use hygienic sanitary items and what they know about the ovulatory cycle. Our results show that the average age of first menstrual period in India is 13.96 years, starting as early as eight years old. In contrast, only 11% of women know about ovulatory cycle knowledge.
Through Swachh Bharat Abhiyan (Clean Indian Mission), the emphasis has been laid on the construction of toilets in schools as well as at homes to provide better sanitation facilities. However, merely ensuring the availability of toilets is not sufficient for better MHM. Regular use of these toilets and its proper maintenance, including cleanliness and supply of water, along with the availability and adequate knowledge on usage of hygienic sanitary items, are other factors contributing to proper MHM. NFHS-4 data shows that approximately 56 percent of the women in the age group of 15-24 use hygienic sanitary items, including locally prepared sanitary napkins, sanitary napkins, and tampons. Our analysis depicts that the proportion of women using hygienic sanitary pads has increased over time, with 56% recorded as per NFHS-4 data (2015-16), approximately one and a half to four times more as compared to the 33% [33] based on District Level Household and Facility Survey-3 data (2007-08) dataset, 27% from [37] based on data collected in 2005, and 13% from [38] based on data of 190 adolescent girls.
One of the potential reasons for this increased usage of hygienic sanitary items reported from NFHS-4 (2015-16) is the awareness campaigns started by the Indian Government, like Swachh Bharat, Swachh Vidyalaya in 2014 (Clean India, Clean School), MHM Scheme under National Health Mission [39]. But such campaigns are limited to schools, and hence, one may see a difference in the hygienic sanitary item usage between the schooled and non-schooled women. Our analysis speaks directly to this gap, where women who have completed high school education were found five times more likely to use hygienic sanitary items as compared to the women who have not.
Educational background of the partners
In addition to women’s educational levels, their partner’s educational background also plays a critical role in the adoption of hygienic menstrual practices by these women. According to NFHS-4 data, around 27 percent of the women in India get married before the age of 18, and 7 percent get married before the age of 15. Our analysis suggests that women whose husbands/ partners have completed high school education are likely to choose a hygienic product for menstruation. Going to school gives them a preliminary knowledge about the biological process of both men and women, and the potential infections that may happen using old clothes or rags. However, [4] reported that when men felt like they were not given enough information to understand menstruation completely.
Men with formal schooling lead to better-paying jobs and maintain a decent standard of living [40]. They are also more sensitized about female anatomy due to primary school education with improved access to menstruation and other biological processes through media platforms. Thus, they are expected to make informed decisions in purchasing hygienic sanitary products for the women in their families. Having girls and their potential partners with minimum high school education has contributed to preventing early marriages [41] and in bringing hygiene as an essential factor in their menstrual product choices and practices.
Thus, emphasizing girls' education is observed to have a positive impact on multiple fronts. The Indian Government started the Beti Bachao Beti Padao Abhiyaan [save the girl child, educate girl child program] in 2014-15 in an attempt to focus on girl’s education from early on. One of the significant advocacies of this program was to prevent early girl child marriage and emphasize the importance of completing school education and further pursuing higher education [42]. Even after the implementation of such schemes, around 30 percent of the girls drop out by class IX and 57 percent drop out by class XI [43]. Similar trends can be seen across the country. The number of girls dropping out has increased three-fold from 2016-17 to 2018-19 in Madhya Pradesh [44]. With the onset of the menstruation, girls coming from poorer family backgrounds drop out since they do not have enough resources to buy sanitary pads, making affordability of sanitary pads as one of the critical concerns for policymakers.
Affordability and income levels
Affordability is another factor contributing to limited usage, compounded by availability, lack of awareness, and safe disposal facilities [45]. As quoted by Garg and his colleagues, the average expenditure for rural women during the one menstrual period is Rs 48 for sanitary pads, which is considered expensive as per the Indian Standards. This makes sanitary pads affordable only for women from middle-to-high income households (See figure 1). Efforts need to be put in easing out the affordability pressure on women, mainly from rural and low-income backgrounds. With the support of Self-Help Group (SHGs), the Government can engage in local production and sanitary pads at a much lower cost. The Government has already tied up with multiple SHGs, but the model doesn’t work quite well. They need to identify the loopholes and come up with a solid plan to make these plan work.
As discussed above, household income levels do play a critical role in allowing women to purchase and use hygienic sanitary items. Still, there can be challenges other than just affordability that prevents poor women from using them. We found that women from high-income households are six times more likely to use hygienic sanitary items than poorer women. This finding is quite intuitive and also consistent with the previous studies [46]. Factors like cultural barriers, shame, and social stigma associated with the purchase of menstrual products have been cited in the literature, contributing to low usage amongst women from rural and impoverished backgrounds [3]. For instance, women may not be able to step out to purchase the sanitary pads from a male shopkeeper, or might hesitate to ask their husbands/male members in the house to purchase it for them, due to shame and social stigma attached to sanitary pads. Males, on the other hand, might not feel comfortable in buying sanitary pads, again due to shame and feelings of embarrassment [47]. In most of the cases, there is no discussion of MHM between husband and wife [48].
Traditionally, females in rural areas have been known to use clothes and old rags (considered unhygienic) during menstruation to prevent bloodstains [46]. These women have been found to insist other women and girls in their families from a young age to follow the same practice [49]. Using an old cloth piece, rag, or other unhygienic methods for blood absorption can be unsafe and risky, potentially leading to RTIs [33]. Thus, efforts need to be made on multiple fronts simultaneously, ranging from affordability and easy accessibility to breaking the cultural barriers, for ensuring effective MHM practices for women living in poor and remote communities.
Access to Media
Media has been found to become a critical factor in uplifting the hygienic sanitary item usage for women [57,58]. Traditional media platforms (like newspapers, magazines, television, radio) help understand which products are hygienic and why there is a need to use hygienic sanitary items. NFHS-4 data shows that approximately 60 percent of women (educated as well as uneducated) watch television every day. Our study suggests that women who listen to the radio or watch television every day are one and a half times and two times more likely to use hygienic sanitary items, respectively. Our results build on the evidence pointed out by Nemade, Anjenaya & Gujar R [57] and Arora et al [58] on the impact of access to traditional media in improving the usage of hygienic sanitary items.
The knowledge gained through media is not limited to improving awareness of hygienic menstrual practices, but it also helps disseminate knowledge of the ovulatory cycle among people. We found that women who watch television every day are one and a half times (OR=1.345) more likely to know about the ovulatory cycle as compared to women who do not watch television at all. We need more research to understand how and in what ways does access to media contributes to enhanced knowledge of the population on ovulatory cycles so that the awareness messages and ad campaigns can be strategically designed to address this need. This will help reduce the social stigma associated with these issues and bring conversations on such critical aspects to the forefront. This will also potentially help students engage in more meaningful and informative conversations within schools and at home.
Taking about media, Movies also play a critical role in shaping the community's perspectives and, in some way, also addressing the social issues of a country. Movies and documentaries like Padman and The Period, have helped in reducing the stigma around menstruation and bring the discussions on menstruation to the mainstream. Such films prove remarkably empowering for women, as it helps them gain confidence in talking about such issues and feel comfortable with their bodies [56].
In this digital age, traditional media is now overloaded with so many additional online platforms for news, connecting with people, doing fun activities together, like Facebook, Instagram, and recently Tiktok, which are also being used by many women. Such platforms can be used as the engaging spaces for targeting specific messages and advertisements for a wide variety of population groups. Messages can be designed, bringing together various concerns raised above and help promote effective MHM.
Developing strong MHM programs
Previous studies have shown that mothers were the most frequent source of information for awareness about menarche and building girls' knowledge and perception about menstruation [46]. In many families, mothers themselves have limited knowledge and experience in explaining menstruation and how to deal with the problems linked with it, in their daily life, in the school and the local community. In some communities, it is seen as taboo, where mothers do not consider it appropriate to discuss menstruation with their daughters who have not yet experienced menarche [50]. Mothers tend to pass on minimal information to their daughters (perhaps not always at the right time) and compound them with several preconceived notions, myths, and other taboos associated with menstruation [51]. Educating these women has to be the first step before moving on to seeking men’s support. Further, involving men and various civil society organizations working towards improving male engagement in MHM activities can potentially help in addressing these myths and taboos. However, male attitudes are one of the significant factors contributing to these myths around menstruation [4,52,53]. The inclusion of both the parents in MHM programs has been found helpful in improving parenting skills as well as enhancing communication around sexual and reproductive health issues within the family [54].
Phillips-Howard and his colleagues [55] stressed the need and importance of engaging all the family members in understanding the physiological processes and changes that women in their family experience. They need to be sensitized on the challenges women face physically and socially to start contributing their bit in busting the myths and taboos associated with menstruation. Previous studies have also suggested that boys in the school understand menstruation superficially in their biology lessons; however, they lack knowledge of the biological processes and social issues surrounding menstruation [4]. The course curriculum needs to be more detailed and comprehensive and include various physiological processes of human bodies. Equal focus should also be laid on sensitizing these boys on the social and cultural barriers these girls and women face while undergoing these processes, so that they can provide support and break societal norms. Young boys and men can eventually become advocates of the MHM agenda, supporting women not only in their families but also in their communities. Overall, there is a strong need to build comprehensive adolescent programs that include menstruation, MHM, pregnancy, and mechanisms through which each individual (boy or girl) can contribute to this.