Menstrual Hygiene Practices, Social Taboo and Attitude towards it- A Community-based Cross-sectional Study among Young Women in a Rural Area of West Bengal, India
Correspondence Address :
Dr. Amrita Samanta,
10/7, Jyangra Ghosh Para Road, Merlin Daffodil, Flat No: 1F, Kolkata-700059, West Bengal, India.
E-mail: amritasmnt@yahoo.co.in
Introduction: In developing countries like India, awareness about menstrual hygiene is limited among women leading to stigma, restriction of social activities and various menstrual and urogenital ill-health among women.
Aim: To find out the menstrual hygiene practices, social taboos and attitude towards it among 15-24 years aged women of a rural area of West Bengal, India.
Materials and Methods: This observational descriptive study with cross-sectional design was conducted during September-December 2019, among 110 young women in the age group of 15-24 year residing in Amdanga community development block. Multistage sampling technique was adopted and data was collected by interviewing study subjects with a predesigned, pretested and semi-structured questionnaire. Data were analysed with the Statistical Package for the Social Sciences (SPSS) software (version 20.0). Proportion and Chi-square test were applied where applicable. The p-value <0.05 was taken as significant.
Results: Nearly 80% of the study subjects used only sanitary napkins. Disposal of used pads under the soil was most common practice. Restrictions to social activities like taking part in religious activity, going outdoor, kitchen and household work were reported by 100%, 85.45%, 58.18% and 74.54% participants, respectively. A 64% of study subjects were unaware of menstruation before menarche. Statistically significant association was observed between socio-economic condition and number of sanitary pad use, (p<0.0001) and school absenteeism, (p=0.011634). Education above primary level was positively associated (p<0.00001) with awareness about menstruation before menarche.
Conclusion: The study conveyed that wide spread social stigma, restrictions and poor attitude still exists in this rural community about menstruation which is affecting safe disposal of used absorbents and overall health of women.
Menarche, Menstruation, School absenteeism, Stigma
Menarche begets the reproductive period in a women’s life. It is the beginning of a multitude of physical, physiological and psychological changes in the lives of girls (1). Menarche and menstruation is special event in every girl’s life which is related to various hygiene, health and social aspects of life. In developing countries like India, awareness about health and hygiene related to menstruation and its social determinants is very limited among women (2). Large number of girls has little knowledge about menstruation until their first experience because menstruation is something that is usually kept secret in the homes and outside (3),(4). Better understanding of the good menstrual hygiene is crucial for the overall and reproductive health of the women, as researches worldwide showed that unhealthy MHM during menstruation have been associated with serious ill-health ranging from genital tract infections, urinary tract infections, and bad odour (5). Unhealthy menstrual practices encompass inadequately washing genitalia regularly, using unclean cloth etc., (6).
Menstrual hygiene is a multisectoral issue that requires an integrated approach from the Department of Education, Health, Women and Child Development and Water Sanitation Hygiene (WASH) (7). Recently Government of India (GOI) has taken different steps addressing this public health issue. In National Rural Health Mission in 2005, menstrual hygiene promotion was formally included as a key responsibility of the community health workers (Accredited Social Health Activist; ASHA) followed by the implementation of menstrual hygiene promotion scheme for girls in rural areas in 2011 (8). The Ministry of Drinking Water and Sanitation published guidelines on MHM 2015 (9). At the same time at national and international level there is a lot of push to address this issue at various social media platforms resulting in wide spread menstrual hygiene campaigns, commencement of trials on eco-friendly menstrual products, implementation of comprehensive sexuality education in schools, etc., (10). Different qualitative research worldwide reported that the factors affecting school absenteeism are multiple like girls’ fear and humiliation from leaking of blood, body odour etc., (10),(11),(12). Variety of cultural taboos increase young women’s difficulties, preventing them from seeking help (12),(13), and impose various restrictions on their diet and social personal activities like taking part in religious activities, cooking, bathing, sex during menstruation (13),(14). Study conducted in South India showed that during rituals on attainment of puberty, young girls are imparted with knowledge about menstruation which mostly consists of restrictions on her movements and behaviour during menstruation along with some superstitions (15).
According to National Family Health Survey-4 (NFHS-4) (16), in West Bengal, the proportion of women aged between 15-24 years using hygienic methods during menstruation was 72.9% in urban area and 47.6% in rural population. Same findings have been found in similar studies (3),(17). Poverty, poor access to sanitary pads are common factors that lead to poor menstrual hygiene and these are more profound in rural areas compared to urban areas (18). Although many studies have been conducted (2),(19),(20),(21),(22),(23),(24) on menstrual hygiene in rural West Bengal, very few threw light on social stigma and taboo related to the issue (25). With this background, the current study was conducted to find out the practices and social taboo related to menstrual hygiene and attitude towards it among 15-24 years aged women of a rural area of West Bengal, India.
This observational descriptive study with cross-sectional design was conducted during September-December 2019 among 110 young women in the age group of 15-24 year residing in the Amdanga community development block which is field service area of Department of Community Medicine, RG Kar Medical College and Hospital, Kolkata, West Bengal, India.
Study protocol was sent to the Institutional Ethics Committee (IEC) and after their approval data collection was started. (Letter No. RKC/Ethics/25, dated 19.5.18). Informed written consent was taken from every study participant prior interview. Measures were taken to ensure the confidentiality and privacy of the all study participants, while intervening and examination.
Inclusion criteria: Those women, who were residing in the area atleast for last one year, aged 15-24 years and attained menarche, were included into the study.
Exclusion criteria: Young women who were severely sick and unable to understand the questionnaire and who did not gave informed written consent were excluded from the study.
Sample size calculation: According to NFHS-4 (16), the proportion of women aged between 15-24 years using hygienic methods during menstruation in rural area was 47.6%. Using this proportion in the formula N=(z?)2pq/l2, the sample size comes to be 100 (z?=standard normal deviate, p=proportion, q=1-p, l=absolute precision=10%), taking the 10% extra for non response, the final sample size calculated was 110.
Study Procedure
The Amdanga community development block consists of 25 sub-centres and 81 villages. For the feasibility purpose from 81 villages, 10% i.e., 8 villages were randomly selected. From this eight villages, list of households were collected from the local administration with the help of ASHA workers. From eight villages, 110 households were selected randomly from all the households according to probability proportion of population size (ppps). From each household one woman of 15-24 age group was asked to participate in the study. In case where in one household more than one woman aged 15-24 years were found, there one was selected randomly from them and in such households where no such woman was found, the next household was visited for eligible participant.
Data were collected by house to house visit during November and December, 2019 by interviewing the selected study subjects with a predesigned, pretested questionnaire. The questionnaire was prepared by the authors after thorough literature review (2),(3),(9),(10),(12) and translated into local language (Bengali). Back translation exercise was done by two language experts. It was pretested among 20 young women and modified accordingly and those 20 women were excluded from the final study. The validity and internal reliability (Cronbach’s alpha=0.84) of the questionnaire were found to be high. The questionnaire had three parts and total 36 questions (Annexure I). The first part contains 10 questions about background information, the second part had 10 questions related to menstrual history and menstrual problems and the third part had 16 questions on knowledge, attitude and hygiene and social practices related to menstruation. For attitude section, there are 10 statements about menstruation seeking the opinion of study participants on three point Likert scale. Socio-economic status of the study participants was analysed on the basis of modified BG Prasad’s scale, August 2020) (26).
Statistical Analysis
Data were entered into Microsoft Office Excel and then transferred into the SPSS software version 20.0 (Chicago, Illinosis, USA). Categorical data was expressed by frequency and percentage. Appropriate bivariate analysis was performed using Chi-square test to find out the association between various socio-demographic factors and knowledge attitude and practice of study subjects. The p-value <0.05 was taken as significant.
Out of total 110 participants, majority of the study population (42.73%, n=47) belonged to adolescent age group (i.e., 15-18 years), Muslim religion (n=73, 66.36%) and of general caste (n=84, 76.36%). About half (n=58, 52.73%) of the study subjects were married and majority was from nuclear family (n=74, 67.27%). Nearly half of the study subjects were school drop-out (n=53, 47.27%, not in table). Thirty one subjects (28.18%) completed graduation during time of data collection. By occupation, 51 (46.36%) of the study subjects were students and 49 (44.55%) were house wives. Socio-economic status showed 39 (35.45%) in class IV (Table/Fig 1).
Mean age of menarche of the study population was 13.04±1.3 years. Currently, most of the study subjects had regular cycle (n=95, 86.36%), moderate flow (n=42, 38.18%) and 3-5 days of duration (n=66, 60%) (Table/Fig 2). It was found that out of total 75 women who reported dysmenorrhoea, only 11 (14.67%) used medicine and 6 (8.0%) used hot water bag compress for pain relief (Table/Fig 3).
Regarding personal hygiene practice during period, it was seen that 88 (80%) of study subjects used only safe sanitary napkins, 16 (14.55%) used only cloths and 6 (5.45%) used both. Among 16 girls who used cloth, 13 girls (81.25%) reported washing the cloth with detergent and water and 10 (62.5%) reported repeated use of cloth after washing and drying. Six girls who reported to use both cloth and sanitary pads, told that they never reused the clothes so, never wash them but dispose them after single use. Majority (N=87, 92.55%) of study subjects who used sanitary napkins, needed 1-3 napkins per day (Table/Fig 4). Majority (90.80%, N=79) who used 1-3 napkins per day told that the number of napkins depends on the flow of menstruation while rest told they could not afford more sanitary pad (not in table).
The most common disposal practice was disposal of used absorbents under the soil after digging the soil (N=42, 44.68%).Throwing to bathroom chamber, in dustbin or pond, in or nearby bushy area after wrapping with plastic were the other reported mode of disposal. Only 11 subjects (11.7%) reported that they disposed used sanitary napkins after wrapping with newspaper (Table/Fig 4).
Other personal hygiene practices during menstruation was found to be adequate as all study participants reported to take bath, wash garments and wash hands with soap and water after using toilet and cleaning during menstruation. However restriction in daily activities during menstruation was revealed by many study subjects. All reported that they abstain from any religious activities during period and 94 (85.45%), 82 (74.54%) and 64 study subjects (58.18%) told that they were not allowed to do outdoor activities like playing, walking with friend, going to market etc., ‘household work’ and kitchen work respectively during menstruation (Table/Fig 5).
Seventy study subjects (63.64%) were not aware about menstruation before menarche. Although 93 participants (84.55%) reported at least one female person shared about experience of menstruation during their lifetime, only 27 (24.55%) reported that at least one female person had shared that with them before menarche. Sixty percent of study subjects told that they never discussed with or revealed menstrual status to any of the male family members whereas 71 (64.54%) subjects told that they could discuss with their mothers only. Twenty participants (18.18%) reported that they did not even discuss about monthly bleeding with any female members of the family. Sixty six study subjects (60.0%) reported school absenteeism at least for one or two days during menstruation (Table/Fig 5).
When they were asked about the cause of menstruation, majority (N=93, 84.55%) could not say anything whereas only 11 (10%) could rightly point out as monthly ovulation is the cause. Misbeliefs like ‘releasing of bad blood’ or ‘excess blood’ coming through menstruation also found to be existed among 6 study subjects (5.45%).
While exploring attitude of study population towards menstruation only 36 subjects (32.73%) agreed that it is a natural phenomenon. Forty-two women (38.18%) felt that ‘revealing menstrual status to male person except doctor is shameful’. Majority of study population (n=93, 84.55%) opined that women should not take part in religious activity during menstruation. Only 31 (28.18%) women thought that regular daily activities should be continued during menstruation. Most of the study women (n=95, 86.36%) were of opinion of using sanitary napkins if cost permits. When opinion sought on ‘menstrual irregularities is a disease and not due to sin of women’ majority (n=78, 70.91%) did not say anything and only 15 women (13.64%) agreed. Fifty one subjects (46.36%) opined that women should go to doctors if she has any menstrual problem while 54 (49.1%) did not have any opinion (Table/Fig 6).
Statistically significant association was observed between S-E condition and number of pad use (p<0.0001), school absenteeism during menstruation (p=0.011634) and higher socio-economic condition being more favourable. Education above primary level was positively associated with awareness about menstruation before menarche (p<0.00001). At the same time education above primary level had statistically significantly associated with lesser stigma regarding revealation of menstrual status to men (p=0.000602). However, education above primary level was not associated with knowledge about scientific basis of menstruation. Religion was found to be unassociated with school absenteeism, restriction in household or kitchen activity and outdoor activity during menstruation and awareness about menstruation before menarche (Table/Fig 7).
This cross-sectional descriptive study, conducted in a rural community of West Bengal revealed that use of sanitary pad and other hygienic measure during period among young women was good but there is persistence of stigma, misconception, lack of knowledge related to menstruation and restriction of daily activity during monthly bleeding. Inspite of good MHM of study participants, lack of awareness and poor attitude towards menstrual hygiene and reproductive tract infection was noted to be existed among study population. The present study found that number of pad use depended on S-E condition of the study population. The attitude and some practices of study population showed that the stigma towards menstruation is deeply rooted among them. Majority of them (70.91%) thought menstrual irregularities as ‘sin not merely disease and less than half (46.36%) opined for going to doctors for any menstrual problem. In current study, majority (77.33%) of women who experienced dysmenorrhoea and did nothing to relieve pain which was also an indication of the stigma and secrecy associated with period. In current study, it was seen that the taboo and stigma about menstruation can lead to multiple outcomes namely secrecy, shame, decreased mobility, social and religious restrictions, which corroborate different study findings (4),(19),(20),(21),(27),(28),(29).
Regarding disposal of used pad, indiscriminate throwing into open field, pond, behind bush etc. was reported by study participants. The reasons behind such finding might be lack of proper safe place for disposal. Frequent use of plastic for wrapping before disposal is another finding in current study that needs special mention as it may be seen from perspective of environmental pollution.
The present study findings were compared with few similar studies are mentioned in (Table/Fig 8) (1),(2),(3),(4),(16),(18),(19),(30),(32),(33),(34),(35),(36).
Limitation(s)
The current study was conducted by house to house visit and the incorporation of out-of school girls has helped the researchers to ascertain the actual behaviour and practices related to menstruation among young women of the community. However, better understanding about social issues and barriers related to menstruation, could have been ensured by qualitative assessment which was not done in current study.
The study conveyed that inspite of overall better MHM inappropriate disposal of used pads, inadequate knowledge, wide spread stigma, secrecy, taboos and restriction in activities during menstruation still exists in the rural community across all religions. Inclusion of menstruation in school syllabus, free supply of safe sanitary napkins through school and general rationing system, widespread awareness campaign through existing national program about menstrual hygiene and safe disposal may help to reduce stigma and restrictions faced by women and will improve menstrual health as well.
The authors thank all ASHA workers, Public Health Nursing (PHN) staffs and all the study participants of Amdanga block for their whole hearted cooperation.
DOI: 10.7860/JCDR/2022/52939.16012
Date of Submission: Oct 19, 2021
Date of Peer Review: Nov 18, 2021
Date of Acceptance: Jan 15, 2022
Date of Publishing: Feb 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
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• iThenticate Software: Jan 08, 2022 (10%)
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