Practices and Predictors of Menstrual Hygiene Management Material Use Among Adolescent and Young Women in Rural Pakistan. A Cross-Sectional Study.


 BackgroundIn low- and middle-income countries, women often use inappropriate materials to manage menstruation, which can pose a hazard to their health. Inappropriate menstrual hygiene management (MHM) can also have important downstream consequences beyond physiologic health, including the restriction of adolescent girls’ access to academic pursuits. This impacts one’s quality of life and has potential economic consequences for society. Methods Among menstruating adolescent and young women 15-23 years of age living in rural Pakistan (n = 25,305), we aimed to describe MHM practices and generate a predictive model of the socioeconomic and demographic factors related to the use of MHM materials. Beliefs and barriers around MHM were also summarized. The outcome variable included: those who practiced appropriate (reported use of a sanitary pad or/and new piece of cloth) and inappropriate MHM (reported use of an old cloth and/or nothing). Logistic regression was used to generate the predictive model, with results presented as odds ratios (OR) and 95% confidence interval (CI). ResultsInappropriate MHM practices were reported by 75% of participants. The majority (61.9%) reported using old cloths, 12.6% used nothing and 0.5% used old cloth with sanitary pad. One fourth of participants reported appropriate MHM material use, including, 16.2% sanitary pads, 8.6% new cloth and a few reported using sanitary pads with new cloth (0.2%). Inappropriate MHM practices were more common in lowest wealth quintile (OR 4.41; 95% CI = 2.77 to 7.01, P<0.0001), followed by those with no education (OR 3.9; 95% CI = 3.36 to 4.52, P<0.0001). Mothers were the primary source of information about menarche (84.5%). Among school-going girls, 22% reported not going to school while menstruating. The affordability of menstrual hygiene products, awareness of appropriate practices, access to clean supplies, and cultural beliefs were identified as factors contributing to MHM practices.ConclusionsFindings indicate the need for multi-sectorial efforts to introduce MHM-specific and MHM-sensitive interventions to improve MHM practices, ranging from availability of low-cost MHM materials to the inclusion of MHM education in school curriculums and within community platforms. Trial RegistrationThe trial was registered on ClinicalTrials.gov (Identifier: NCT03287882).

In resource-limited settings, it is common for menstruating women to use poorly-suited materials to manage menstruation (e.g., pieces of used cloths or rags). This can pose serious health risks. Being unable to access affordable, hygienic sanitary materials can have a negative impact on self-esteem and dignity. Menstruation can also present a barrier to school attendance, which has the potential to affect long-term economic productivity.
We used cross-sectional data from menstruating adolescent girls and women 15-23 years of age (n=25,305) living in rural Pakistan to describe their menstrual hygiene practices and investigate factors associated with the use of different products. Within the analysis, use of a sanitary pad or/and new piece of cloth was considered an appropriate menstrual hygiene material, while the use of an old cloth and/or nothing was an inappropriate material.
Overall, 75% of participants reported using an inappropriate material during menstruation. This was more common among poorer participants and those without formal education. Among those who attended school, 22% did not go to school while menstruating. Barriers to using an appropriate menstrual hygiene product included affordability; limited awareness of appropriate practices; lack of access to clean supplies; and cultural beliefs.
The study ndings suggest that there is a need to increase the awareness of adolescent and young women and their families about the importance of safe menstrual hygiene practices. Engaging multiple stakeholders to ensure the availability, accessibility, and affordability of appropriate hygienic sanitary products in this setting will be important to improving practices.

Background
Menarche is a key event in a woman's life, representing a social and physical transition from childhood.
(1) If quanti ed cumulatively, a woman will spend around 6-7 years of her life menstruating. (2) Being able to manage one's menstrual period appropriately is therefore of great importance. The World Health Organization (WHO) and United Nations International Children's Emergency Fund (UNICEF) de ne appropriate menstrual hygiene management (MHM) as the use of a clean material to absorb or collect menstrual blood. This also includes being able to change and dispose of the material at will, in private, and without discrimination. Furthermore, one must have reliable access to appropriate facilities to be able to keep themselves desirably clean. (3) However, low-and middle-income countries (LMICs) globally can lack the necessary materials and facilities for the appropriate management of menstruation. (4) UNICEF (2019) has emphasized that multiple Sustainable Development Goals (SDGs) related to health, education, gender equality and water sanitation and hygiene (WASH) cannot be fully realized without paying due attention to and investing in menstrual health and hygiene. (3) There are several possible consequences to inappropriate MHM. Physiologically, it can increase one's susceptibility to urinary tract infections. (5-7) Some studies also report an association between secondary infertility and unhygienic MHM practices. (8,9) There are additionally non-physiological consequences. If a girl has not been adequately informed about menstruation, experiencing menarche for the rst time can be traumatic and cause a feeling of distress. (10) Whether a woman is menstruating can also in uence her ability to participate social and religious practices due to cultural norms. (2,6,11) For adolescent girls, school absenteeism during menstruation is broadly reported in various LMIC settings, including Pakistan. (10)(11)(12)(13)(14)(15) Such schools typically lack gender-sensitive sanitation facilities to manage menstruation, which can have consequences for the safety, dignity and privacy of adolescent girls. (4,10,(14)(15)(16)(17) On personal level, this can affect an adolescent girl's sense of self-esteem and agency. (2,6) From an economic perspective, there can be reduced per capita earning potential, as monthly absenteeism can lead to poor performance and negatively impacts education success. (3) Multiple factors contribute to the way menstrual hygiene is managed. Within LMICs, menstrual hygiene products are frequently reported to not be easily available or accessible. (12,18) Lacking knowledge around how to adequately manage menstruation, such as misinformation based on cultural beliefs, can substantially add to unhygienic MHM practices. (19) Leading causes of inappropriate MHM practices in LMICs include lack of appropriate sanitation facilities, cost and access to MHM products. (4,11,20,21) The use of old cloths to manage menstruation is a practice widely reported across African and South Asian countries. (2,11,14,20) The re-use of old cloth for many months has been reported in South Asia.
(2) This poses an increased risk of infections and other illness (2, 6, 7) A systematic review and metaanalysis of 138 studies of menstruation practices in India found that use of commercial sanitary pads was uncommon among women living in rural locations (Pooled Prevalence (PP): 32%, 95% CI: 25-38%, I 2 : 98.6%, n = 56, p < 0.0001) compared to urban (PP: 67%, 95% CI: 57-76%, I 2 : 99.3%, n = 38). (11) Of the few studies that have been conducted in Pakistan, they have found very limited use of appropriate MHM practices during menstruation. (10,20) Among the limited number of published and unpublished research studies assessing MHM, most focus on knowledge and practices. Addressing MHM-related issues has been largely ignored by health managers and policy makers. (20) Collectively, this has led to a call for global action to address the MHM in schools, gaps in understanding, and the development of evidence-based advocacy. (4) Given the limited data and understanding around MHM practices and beliefs in Pakistan, we aimed to gain a better understanding among adolescent and young women enrolled in an ongoing trial. We aimed to describe MHM practices, barriers towards the use of sanitary napkins and generate a predictive model of factors related to the use of MHM materials. Ideally, ndings around MHM practices and determining factors could be utilized by research entities and policy makers to design evidence-based interventions to improve the MHM practices among adolescent and young reproductive age women living in similar settings.

Methods
Data was collected from June 2017 to July 2018 as a part of a baseline assessment of a communitybased research trial conducted in a rural district, Matiari. This study was a collaboration between the Aga Khan University, Pakistan and The Hospital for Sick Children, Canada.
Per district health department data as of June 2020, Matiari is constituted of around 0.8 million population living in around 1800 villages. Nearly half of the population is covered by lady health workers (LHWs), the public sector's primary outreach health care work force.
The ongoing Matiari emPowerment and Preconception Supplementation (MaPPS) Trial primarily aims to determine the impact of life skills building education (LSBE) and multiple micronutrient supplementation on anemia prevalence and low birth weight (LBW) among adolescent and young women. (22,23) Assessing MHM practices was a secondary outcome of the trial and embedded within the evaluation framework of larger LSBE intervention. LSBE community sessions are used to inform adolescent girls what to expect during menstruation, what is happening, and aim to dissipate stigma. This includes discussion of appropriate ways to manage menstrual hygiene, consequences of inappropriate cleanliness during menstruation and general good personal hygiene management practices. The discussion is delivered in the community using trained lady health workers (LHWs) once a month.
However, for this assessment, we have used cross-sectional data on MHM collected upon enrolment in the study (i.e., prior to exposure to the intervention).
The sample was based on the main MaPPS trial sample size requirement, which was powered to observe 25% relative reduction in LBW. (22) In total, 25,447 adolescent and young women consented to participate. However, 142 participants had reportedly not experienced menarche, thus they were excluded from this analysis. Trained female data collectors administrated a structured questionnaire to participants at their homes. This questionnaire included questions consistent with Pakistan demographics and health survey (PDHS) (24) such as demographic data and individual characteristic (e.g. age, marital status and education), as well as additional questions regarding MHM (age at menarche, MHM practices, source of information on menarche and perceived barriers towards use of sanitary napkins). The study was approved by institutional ethics boards at both the Aga Khan University and The Hospital for Sick Children, and the National Bioethics Committee in Pakistan. The trial was registered on ClinicalTrials.gov (Identi er: NCT03287882).

Statistical Analysis
All continuous variables were reported as a mean ± standard deviation (SD), and categorical variables were reported in the form of frequencies and percentages. Between those who practiced appropriate and inappropriate MHM the mean differences were compared using a student's t-test and categorical variables were compared using a Chi-square test.
Univariate analyses between the outcome and predictor variables were rst assessed, with results presented as odds ratios (OR), 95% con dence interval (CI) and P-values. From the univariate analyses, all variables for which P < 0.25 were considered for inclusion in a multivariate analysis. A step-wise backward elimination method was applied and variables that retained signi cance (P < 0.05) were maintained in the nal multivariate model. Data was analyzed using STATA version 15.0 (Stata Corporation, College Station, TX, USA).
A bivariate categorical variable for MHM practice was generated based on the method participants reported using to manage their period while menstruating. Women who reported the use of sanitary pads (an absorbent item worn by a woman while menstruating to absorb the blood ow from her vagina that is usually disposable and thrown into the garbage after use) and/or new cloth (strips of new fabric, often cotton or annel, used to absorb the blood ow from a woman's vagina) during menstruation were categorized as practicing "appropriate MHM". Women who used other materials (old cloth (strips of rags), other material and/or nothing) during menstruation were categorized as practicing "inappropriate MHM".
To generate a predictive model of MHM practices, we considered predictors identi ed as important within the literature and that appeared within the MaPPS Trial dataset. Associations between demographic, household, and individual factors and MHM practices were evaluated using logistic regression. These included living location (rural (village)/urban (township)), socioeconomic status (SES), participant age, education level, occupation, marital status, religion, Decision maker about what to use during menstruation and hand-washing index. Based on SES, wealth quintiles (poorest, poorer, middle, richer and richest) were generated using standard household indicators.(25) A cumulative score was calculated for handwashing from the number of times a participant washed her hands at set times, including before preparing food, before eating and after toilet use. Scored ranged from 0-3: "0" meant no handwashing was observed in the three situations, whereas "3" re ected handwashing in all scenarios."

Participants' Characteristics
Participants' reported mean age was 18.2 ± 2.3 years, and on average they experienced menarche at 13.0 ± 0.9 years. Twenty-three percent of participants were married, with a mean age at marriage of 16.9 ± 1.8 years. Around half of study participants (52.5%) were from rural villages. The majority of participants were Muslim (90.6%), and 44.7% reported no formal education ( Table 2).

Menstrual Hygiene Management Material Use
Overall, 25% of participants reported the use of an appropriate MHM material, although materials use was variable, including sanitary pads (16.2%), new cloths (8.6%) and sanitary pad with new cloth (0.2%). Majority participants reported an inappropriate use of MHM material, largely, 61.9% participants reported the use of old cloth, some (12.6%) reported using no material to manage their most recent menstrual period and a few reported used old (0.5%) or new cloth (0.2%). There was no reported tampon use. There were differences in demographic characteristics between those who practiced appropriate or inappropriate MHM (Table 02), except for age. However, there was no difference in MHM material use between adolescent and young women (P = 0.369).

Consequences of menstruation
Slightly less than half of participants (45.4%) indicated that their routine activities were restricted due to menstruation. Among the 2147 participants who reported attending school regularly, 22.2% mentioned not going school while menstruating.

Discussion
The current literature suggests that various socio-cultural and structural reasons are important to why many girls and women living in LMICs often do not practice appropriate MHM. (4,11) Notably, within South Asia, MHM is widely excluded from public infrastructure design and public health promotion campaigns, and there is limited guidance to health workers. (2) We aimed to further understand MHM practices, and the predictors and barriers to practicing appropriate MHM, among a cohort of adolescent and young women in rural Pakistan.
We found that 25% of participants practiced appropriate MHM, which is lower than gures reported in other regions of Pakistan, although none were conducted rurally, as was the case in our study. Michael  Affordability is known to be a barrier to the use of appropriate MHM materials across LMICs. (11,(27)(28)(29).
Various studies carried out in parts of Africa and Asia have suggested the suboptimal use MHM materials is because of the high cost of hygienic absorbents. Most qualitative and quantitative ndings are from school-based settings. (11,13,20,(27)(28)(29) In our community-based study, household wealth had the strongest association to the use of either material during menstruation. Participants who belonged to poorest wealth quintile were > 4 times as likely to practice inappropriate MHM during menstruation compared to those in the richest quintile. Study results revealed that almost half (48.7%) of participants reported cost as barrier to the use of sanitary napkins. This suggests that the production of and access to affordable hygienic sanitary material will be critical to improving MHM in the study setting.
Our study ndings revealed a robust relationship between having formal education and the appropriate use of menstrual hygiene material, as schooling was signi cantly associated with higher use of sanitary pads (OR 3.9; 95% CI = 3.36 to 4.52, P < 0.0001). Because education level increased correspondingly with wealth quintile, it is possible that access to appropriate MHM materials is limited by poverty. A review of studies from Indian settings showed less common use of old cloths to manage menstruation (inappropriate MHM) in the studies carried out in school settings compared to those situated in the community. (11) Ali et al (2010) reported greater than two-fold use of sanitary pads among adolescent girls who were studying in private school, in contrast to out-of-school participants Karachi, and emphasized the need to initiate MHM awareness programs beyond school platforms. (20) Together with our current ndings, this suggests the importance of community-based platforms to reach out-of-school girls and women, given that the practice of inappropriate MHM among these groups was high.
We found that two-thirds of study participants reported inappropriate MHM. The majority lived in more remote villages within the study catchment area. Consistent with the trends reported in several studies, univariate analysis suggested that participants who belonged to comparatively urban areas were more likely to practice appropriate MHM OR 2.56 (CI 59% = 1.69, 3.88, P < 0.0001). (5,11) The impact of living rurally on the use of sanitary products may not be well understood in isolation, as educational attainment and access to sanitary product is higher in urban areas.
Our current ndings revealed that about one fth of study participants (17.4%) lacked access to hygienic MHM material. This is further complicated by study participants' reported unease in buying sanitary pads from the shops, which are usually run by male vendors, on top of that they did not feel comfortable asking their parents to buy MHM materials. The lack of suitable facilities at which to dispose of sanitary napkins was also identi ed to restrict the uptake of the use of sanitary pads. Interestingly, a tenth of participants were not familiar with sanitary pads, the majority of whom were from rural and semi-urban areas, belonged to poorer wealth quintiles and lacked formal education. Overall, we believe there is a role of improved knowledge and awareness around the appropriate use of MHM materials, as highlighted by various researchers across settings in order to dissipate stigma, spatial restrictions, gender inequalities and enhance school attendance. (15,18,28,30) Limitations While we aimed to understand what materials participants within the MaPPS trial used to manage menstruation, we did not investigate the diverse factors that contributed to their decision-making. Study data was limited to self-reported, structured questionnaire information, which does not allow for more nuanced and qualitative data capture that could be informative to why appropriate menstrual hygiene management practices were low. The inclusion of health manager and market suppliers' perspective around MHM materials could have enriched the data and allowed for more robust recommendations to address the issue. Given the observed effect of menstruation on girls' school attendance, an assessment of facilities for private and appropriate hygiene and disposal in schools could offer greater insight.

Strengths
This study included data from > 25,000 adolescent and young women aged 15-23 years. While the majority of studies on MHM have only focused adolescent girls enrolled in schools, the current study provides us with an opportunity to expand to understanding community-based MHM practices. Furthermore, the study lls the gap in information on MHM in rural settings within Pakistan. We hope this might serve as a platform for researchers to further explore and enable appropriate MHM practices. The presented evidence may help health managers to design a programmatic set of action to address the MHM issues of girls and women living in similar settings.

Conclusions
Within our assessment, the majority of participants were not found to practice what is considered appropriate MHM. The factors that predicted the use of appropriate MHM and the barriers reported to inhibit the use of sanitary pads are not unique to this setting and re ect the ndings within several other LMICs. To adequately tackle the identi ed barriers to MHM in this setting, there is a need for a synergistic initiative from different sectors. The introduction of MHM-speci c and MHM-sensitive interventions ranging from availability of low cost MHM materials to the inclusion of MHM awareness in school curriculums and educational materials for use in community platforms can potentially improve MHM.
Given the existing culture of silence around menstruation, the educational material should also aim to sensitize the male segments of communities. Moreover, local low-cost production of MHM materials, possibly accompanied by the engagement of local girls and women, could not only serve to address the MHM-speci c barriers but also contribute to overall women's economic empowerment. procedures, potential risks, bene ts and volunteer nature of participation. Right to refusal and withdrawn without any sort of consequence communicated in local language.

Yes
Availability of data and materials The datasets used for the article and the study is available from the corresponding author on request.

Competing interests
The authors declare that they have no nancial or non-nancial competing interests.