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Article
1 Assistant Research Officer, Department of Epidemiology, The National Institute of Health and Family
Welfare, New Delhi-110067, India.
2 Assistant Research Officer, Department of Planning & Evaluation, The National Institute of Health and
Family Welfare, New Delhi-110067, India.
Correspondence may be sent to Sherin Raj T P via email at sraj@nihfw.org
Abstract:
Introduction: Menstrual Hygiene Management (MHM) is a serious issue for young girls
in India.
Objective: The study examines the regional disparities in menstrual hygiene practices
among young women in India.
Methodology: Data collected from the fourth round of National Family Health Survey
(NFHS-4), conducted from 2015 to 2016 has been used for this study.
Results: The study found that, overall 57.6% of young women in India are practicing hy-
gienic methods during their menstrual period. About half of the rural women (48.2%)
used hygienic methods compared with 77.5% of women in urban areas. Women belong-
ing to the richest category were six times more likely to use hygienic methods compared
to women belonging to the poorest category (OR= 6.4). The study also found that women
with higher education, have a flush toilet at home, and access to media every day were
more likely to use menstrual hygiene methods. The range of using hygienic methods var-
ies from 79.8% in the Southern region to 43.8% in the Eastern region.
Conclusion: Young women should be educated about the importance of maintaining hy-
giene during menstruation to prevent the risk of reproductive tract infection. The govern-
ment has to make MHM a priority and commit a budget for free distribution of sanitary
pads.
Keywords: Hygiene practice, Regional disparity, Menstrual Hygiene, Young women,
India
Factors Explaining Regional Variations in Menstrual
Hygiene Practices among Young Women in India:
Evidence from NFHS-4
Bhawna Kathuria1 and Sherin Raj T P2
INTRODUCTION
There are many socio-cultural practices within the country that are not scientifically supported and accepted.
The regional, socio-cultural, sometimes, religious often-superstitious practices pose a significant conundrum to
the overall wellbeing of the society. Menstruation is generally considered as an unclean, dirty or impure phe-
nomena in the Indian society, which is commonly clouded by various myths and misconceptions (Anand et
al., 2015; Dhingra et al., 2009; Kumar and Srivastava, 2011; Paria et al., 2014 ). Women undergoing the
monthly cycle are subjected to restrictions in participating household and non-secular activities like cooking,
touching pickles, entering a kitchen, having a meal together, wearing certain clothes, touching men or having
sexual intercourse (Dasgupta and Sarkar, 2008; Juyal et al., 2013). They are also not permitted to enter a tem-
ple (Juyal et al., 2013; Kumar and Srivastava, 2011; Thakur et al., 2014).
JOURNAL OF SOCIAL HEALTH (FEBRUARY 2022) VOLUME 5 ISSUE 1
36 Factors Explaining Regional Variations in Menstrual Hygiene Practices
© Kathuria & Raj T.P 2022
Menstrual hygiene is defined as maintaining cleanliness of the body during menstrual flow. It requires basic
facilities like suitable clothes, soakage material, water, soap, and toilet facilities with privacy. Poor personal hy-
giene and defective menstrual management practices may lead to problems, such as itching or rashes in the per-
ineal region, bad odor (Kumar et al., 2017); and it give rise to repeated reproductive tract infections, which are
otherwise preventable (Barman et al., 2017). Unaddressed menstrual hygiene is said to hamper the achieve-
ment of a number of sustainable development goals (SDGs) because it is closely related to gender equality and
feminine empowerment through its direct effect on women’s reproductive health, education, and work partici-
pation. A large study by Neilson (2010) concluded that only 12% of India’s 355 million menstruating women
use sanitary pads. Goyal (2016) reported that over 88% of women depend on different alternatives like unsan-
itized cloth or rugs, ashes, and husk sand. The percentage of the usage of cloth and sanitary napkins varies de-
pending on many factors like awareness, finance, availability, and social norms (Farid, 2016). According to Cen-
sus of India (2011), women in the age group of 15 to 24 years constitute about 19% of the overall female popu-
lation of India. Hence, the monthly menstrual need of such an enormous population has to be received with
proper attention. For the promotion of menstrual hygiene, in June 2011 the Government of India launched a
brand new scheme to make sanitary napkins available in rural areas at a subsidized cost. While all initiatives
transpire, by the Government of India, a major section of adolescent girls still do not have a prior awareness
about menstrual cycle and menstrual hygiene practices, which results in poor menstrual hygiene. Some micro
level studies that focused on menstrual practices among school-going adolescent girls have reported the utiliza-
tion of sanitary pads between 20% to 35%in rural India ( Kansal et al., 2016; Patil, 2014; Sarkar et al., 2017).
As mentioned earlier, India is a country with several disparities, like wealth related disparities, gender related
disparities attributable, to which there exists a significant variation among girls between various regions of the
country. Numerous studies have been conducted across the country to study the prevalence of unsafe menstru-
al hygiene practices and their causes and implications. One such study conducted by Kumar et al. (2013) in
Northern India found that noticing the signs of menstruation before menarche was reported to be 60%, while
awareness was significantly related to age. Studies conducted in other Indian states, including Maharashtra and
Tamil Nadu, have shown that, during menstruation, girls are asked to remain far away from religious spaces,
kept in isolation, not allowed to play outside, or even go to school (Bharatwaj et.al., 2014; Deo & Ghattargi,
2005). Another study conducted by Empowered Action Group (EAG) found that about 44% of the women
used hygienic methods during their menstrual period, whereas the remaining 56% were used clothes or unhy-
gienic method of menstrual protection (Kathuria & Raj, 2018). In this view, this paper makes an attempt to pro-
vide the evidence on the regional variations in the prevalence of menstrual hygiene practices among young
women and its socio-demographic correlates in India from a nationally representative survey.
METHODOLOGY
The study used secondary data from the fourth round of the National Family Health Survey (NFHS-4) in India
conducted from 2015 to16. The survey presents the data on population, health, and nutrition on a national,
state, and district level. A total of 601,509 households and interviews from 699,686 women ages 15 to 49 were
taken from all states and union territories of India. Stratified 2 stage sampling was used as the sampling design
covering 28,586 clusters for NFHS-4 study. In the first stage, primary sampling units were selected, and in the
second stage, the households for the study were chosen. Primary sampling units with at least 300 households
were divided into segments of approximately 100 to 150 households. Two of the segments were selected using
systematic sampling with probability proportional to size. From each selected rural and urban cluster, 22 house-
holds were selected using systematic sampling (IIPS, 2017). As the young women in the age group of 15 to 24
years old were considered in the analysis, the sample consists of 244,500 young women who have ever menstru-
ated. For regional analysis, we followed the NFHS-4 classification where Indian states and Union territories
grouped into six regions: North-East, North, Central, East, West, South. The details of each region’s classifica-
tion are given in Table 1.
JOURNAL OF SOCIAL HEALTH 37
© Kathuria & Raj T.P 2022
Table 1: Regional Classification of states in India
Dependent variable
Using a hygienic method of menstrual protection is important for women’s health and personal hygiene. The
dependent variable of this study is the usage of hygienic methods during menstruation. In NFHS-4, a multiple
response question was asked to young women aged 15 to 24 about what method or methods they use for men-
strual protection. The responses include whether they used cloth, locally prepared napkins, sanitary napkins,
tampons, nothing, and others. In the present paper, all these methods were classified into two categories: hy-
gienic and unhygienic methods. Hygienic methods include those women who use locally-prepared napkins,
sanitary napkins, or tampons during their menstrual period (coded as '1'). All other methods used, such as
cloth, any other methods and those women who used nothing, were considered as unhygienic methods (coded
as '0').
Independent variables
The independent variables used in this study are age of the respondent in the two categories (15 to 19 and 20 to
24), place of residence (rural, urban), educational status of the respondent (no education, primary, secondary
and higher, religion), caste group, wealth quintile, type of toilet, working status in the last 12 months, access to
media, usually going to the cinema/theater at least once in a month, and region.
The household wealth index used as a proxy indicator of the standard of living and wealth quintile was calculat-
ed from the ownership of household assets, housing characteristics, and access to necessities. Exposure to mass
media was assessed from the frequency of reading newspapers, watching television, and listening to the radio.
Statistical Analysis
In this study bivariate analysis was carried out to analyze the regional variations in hygiene practices with socio-
economic and demographic factors. To find out the correlates of prevalence of the use of hygienic methods,
multivariate logistic regression has been performed in which the individual effect of assorted background char-
acteristics on menstrual hygiene practices are measured. Logistic regression determines the impact of multiple
independent variables presented simultaneously to predict membership of one or the other of the two depend-
ent variable categories. Odds ratios (OR) are accustomed to interpret the results of the predictor variables for
each of the outcome variable. Odds greater than one indicates an increased probability, while those less than
one indicate a lower probability. The 95% confidence interval (CI) for the odds ratio is also presented to estab-
lish the precision of the estimates. The data has been analyzed using IBM SPSS Statistics V20.
Sl. No. Regions States/ UTs
1. North-East Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Naga-
land, Sikkim, Tripura
2. North Chandigarh, Delhi, Haryana, Himachal Pradesh, J&K, Punjab, Raja-
sthan, Uttarakhand
3. Central Chhattisgarh, Madhya Pradesh, Uttar Pradesh
4. East Bihar, Jharkhand, Odisha, West Bengal
5. West Dadra &Nagar Haveli, Daman & Diu, Goa, Gujarat, Maharashtra
6. South Andaman &Nicobar Islands, Andhra Pradesh, Karnataka, Kerala,
Lakshadweep, Puducherry, Tamil Nadu, Telangana
© Kathuria & Raj T.P 2022
38 Factors Explaining Regional Variations in Menstrual Hygiene Practices
RESULTS
Regional variations in Usage of Hygienic Methods of Menstrual Protection
Figure 1: Menstrual Hygiene Practices among Young Women in India by Region, NFHS-IV,
2015 to 16 (in percent)
In Figure 1, it is clear that about 58% of the young women were using hygienic methods of menstrual protec-
tion in the country, while the regional analysis indicates a wide variation between geographical regions. The
higher proportion of menstrual hygiene practices is found in the Southern region with the highest result of 80%,
followed by the Northern region with 69.6%, and the Western region with 64.4%) and the lowest proportion
was found in the Eastern region with 43.8%. These results also indicate the huge gap between good and poor
performing regions.
Type of Methods Used for Menstrual Hygiene
Table 2: Percentage of young women in India, ages 15-24, using sanitary menstrual hygiene
methods according to region, NFHS-IV, 2015-16
Type of Protec-
tion
North-East North Central East West South India
Cloth 74.4 53.9 80.0 73.5 49.4 36.3 62.1
Locally Prepared
Napkins
13.0 14.9 13.7 13.5 21.1 21.2 16.3
Sanitary Napkins 36.7 56.3 30.8 29.3 45.0 60.4 41.8
Tampons 2.4 1.3 2.1 1.9 3.8 3.3 2.4
© Kathuria & Raj T.P 2022
JOURNAL OF SOCIAL HEALTH 39
Note: Multiple responses, total may not be 100
The proportion of various menstrual hygiene methods used during menstruation according to regions is depict-
ed in Table 2. The use of sanitary napkins, locally-prepared sanitary napkins, and tampons are considered as
hygienic methods whereas clothes and other methods are considered as unhygienic methods in the present
study. Overall, 62% of young women in India were using pieces of cloth during their menstruation: in Central
(80%), North-East (74.4%), and East regions (73.5%). When it comes to the usage of sanitary napkins in India,
about 42% were using it for menstrual protection: South (60%), North (56%), East (30%), and Central (30%)..
Locally prepared napkins were utilized by only 16%, which was reported highest in the South and West region
with 21% each. Finally, only 2.4% were reported using tampons for menstrual protection in India, which was
also reported highest in the West (4%) and South (3%) regions.
Regional Disparities and Differentials in Practicing Menstrual Hygiene Methods
The regional disparities in practices of menstrual hygienic methods by various background characteristics is
shown in Table 3. The use of hygienic methods during menstruation among women in the age group of 15 to
19 years old (57.7%) was almost the same compared to women in the age group of 20 to 24 years (57.4%).
There is not much difference in these two age groups in various regions, except the South. The urban-rural
disparity was perceptible, less than half of the rural young women (48.2%) used hygienic methods compared to
urban areas (77.5%). The same kind of variation was observed in each region, except the South. The Central
and East regions have the highest rural-urban differences with more than 31%. Table 3 also shows that as the
level of education improved, the use of hygienic methods among women had also increased. Only 20% of un-
educated young women used hygienic methods to prevent bloodstains from becoming evident during menstrua-
tion.
Table 3: Percentage of young women in India, aged 15-24, practicing menstrual
hygiene according to region and background characteristics, NFHS-IV, 2015-16
Other 0.1 0.1 0.0 0.1 0.1 0.0 0.1
Nothing 1.0 0.7 0.1 0.6 0.8 0.5 0.5
Background Char-
acteristics
North-
East North Central East West South India
Age-group (in
years)
15-19 53.2 69.4 42.6 45.8 66.0 84.4 57.7
20-24 48.0 69.7 47.2 41.8 62.9 75.8 57.4
Place of residence
Rural 45.1 60.7 36.7 37.3 55.1 73.8 48.2
Urban 74.8 85.1 68.1 68.9 75.1 87.5 77.5
Education
No education 19.9 29.5 17.6 12.3 29.0 35.9 19.9
Primary 24.7 43.5 25.1 22.7 44.0 48.0 31.1
Secondary 53.9 74.0 46.1 50.0 63.7 80.2 60.1
High school &
above
82.7
91.1
77.4
80.9
85.0
91.2
85.5
© Kathuria & Raj T.P 2022
40 Factors Explaining Regional Variations in Menstrual Hygiene Practices
Religion
Hindu 53.4 69.0 44.4 44.2 63.2 78.8 57.3
Muslim 33.1 61.5 45.6 41.9 67.6 84.5 53.9
Christian 68.0 86.1 67.0 48.5 86.5 83.1 74.9
Others 69.3 83.9 77.6 46.7 70.4 71.4 72.8
Caste
Scheduled Caste 46.7 68.6 39.2 38.4 64.7 77.0 54.5
Scheduled Tribe 62.0 36.7 23.2 35.0 46.9 63.0 40.3
Other Backward
Class
51.6 66.8 44.3 39.3 64.4 82.2 57.3
Others 49.7 82.8 63.9 58.1 71.1 81.7 68.9
Wealth Quintile
Poorest 22.5 18.0 17.8 20.6 30.6 50.9 21.1
Poorer 39.1 41.4 32.4 39.5 46.7 63.7 41.3
Middle 63.5 60.3 47.7 60.0 59.3 73.0 60.4
Richer 81.1 77.3 65.3 77.5 70.8 85.8 76.2
Richest 89.0 91.6 84.1 90.9 83.5 93.5 88.8
Type of Toilet
flush 66.3 80.8 64.0 64.2 72.4 85.9 73.6
pit/dry 40.3 71.4 47.3 49.6 71.0 81.0 56.7
no facility/ open
space
32.7 39.7 28.3 27.5 46.3 68.9 37.2
others 53.7 62.9 49.9 45.7 63.4 72.9 56.8
Access to Media
Not at all 20.4 25.6 18.5 17.4 33.8 52.1 20.9
Less than once a
week
36.2 45.9 31.8 32.8 52.4 64.7 37.2
At least once a
week
53.5 59.8 38.7 40.0 58.8 70.9 47.4
Almost everyday 66.3 78.8 60.3 61.5 69.3 81.3 70.7
Usually go to cine-
ma/ theatre at
least once in a
month
No 49.0 68.0 43.3 42.2 60.2 77.6 54.7
Yes 68.0 90.8 76.9 67.1 89.2 87.1 83.2
Total 50.6 69.6 44.8 43.8 64.4 79.8 57.6
© Kathuria & Raj T.P 2022
JOURNAL OF SOCIAL HEALTH 41
The practice of hygienic methods was higher among young women with educational attainment above second-
ary education. A similar kind of trend has been evident in each region. The usage of hygienic methods was not
much different among Hindu (57.3 %) and Muslim women (53.9 %) whereas it had been the highest among
Christian women (74.9 %) in India. Regional disparities were also clearly visible as far as the religion is con-
cerned, except in the Southern region. In Central and Eastern regions, the use of hygienic methods was almost
equal among young women belonging to Hindu (44.4% & 44.2%) and Muslim (45.6% & 41.9%) religions. The
lowest use of hygienic methods was reported among Muslim women from the North-Eastern region with
33.1%. The use of hygienic methods was high among Christian women in Western (86.5%) and Northern
(86.1%) regions.
As far as the caste system is concerned, women belonging to the general category were highly using menstrual
hygienic methods (68.9%) followed by women from other backward classes (57.3%) and the scheduled caste
(54.5%). The proportion of women practicing hygienic methods among scheduled tribes (ST) were lower com-
pared to women from other categories in all regions, except the North-East. The economic status of women
seems to be a dominant factor in the usage of hygienic methods. It was highest among women belonging to the
richest wealth quintile (88.8%) overall and shows similar pattern in all regions. Funding could be a big factor to
purchase good quality menstrual hygiene protection products. The analysis indicates that those who have a
flush-type toilet, garnered the highest percentage in practicing menstrual hygiene in all of India (73.6%). . Wom-
en who have access to media almost every day were the highest users (70.7%) of menstrual hygiene methods
compared to women with no access to media (20.9%). When it comes to women who practice hygienic meth-
ods and have access to media almost every day, the Southern region has the highest percentage (81.3%), fol-
lowed by the Northern (78.8%) and Western (69.3%) regions. The study also recognized that a prime percent-
age of women (83%) who usually go to the cinema or theater were practicing menstrual hygiene methods com-
pared to those who do not (55%). In the Northern region, more than 90% of women who go to the cinema or
theater were practicing hygienic methods, followed by women from the Western region (89.2%), and the South-
ern region (87.1%).
Factors Responsible for Practicing Menstrual Hygienic Methods
Table 4 presents the multivariate logistic regression analysis to find out the socio-demographic correlates of
menstrual hygiene practices among young women.
Table 4: Odds Ratio for practicing menstrual hygienic methods according to background
characteristics of young women in India
Background Characteristics Odds Ratio CI (95%)
Age-group (in years)
15-19® 1.00
20-24 0.786*** 0.770 – 0.802
Place of residence
Rural® 1.00
Urban 1.416*** 1.380 – 1.452
Education
No education® 1.00
Primary 1.381*** 1.318 – 1.448
Secondary 2.780*** 2.677 – 2.887
High school & above 6.334*** 6.037 – 6.646
© Kathuria & Raj T.P 2022
42 Factors Explaining Regional Variations in Menstrual Hygiene Practices
Note: *** p<0.001
The results of the logistic regression shows that most of the predictor variables fitted in the model were statisti-
cally significant. Women who are in the 20 to24-year-old age group were less likely (OR: 0.79, p<0.001) to use
menstrual hygiene methods compared to the15 to 19-year-old age group. Women staying in urban areas were
42% more likely to practice hygiene during menstruation compared to those living in rural areas. The educa-
tional status is also a major determining factor in practicing hygienic methods. Women who are educated up to
Caste
Scheduled Caste® 1.00
Scheduled Tribe 0.879*** 0.847 – 0.913
Other Backward Class 0.941*** 0.917 – 0.966
Others 1.163*** 1.127 – 1.200
Wealth Quintile
Poorest® 1.00
Poorer 1.630*** 1.577 – 1.683
Middle 2.350*** 2.266 – 2.437
Richer 3.585*** 3.434 – 3.743
Richest 6.419*** 6.094 – 6.762
Type of Toilet
Flush® 1.00
Pit/Dry 0.983 0.944 – 1.025
No facility/Open space 0.832*** 0.810 – 0.855
Others 1.041 0.997 – 1.087
Access to Media
Not at all® 1.00
Less than once a week 1.402*** 1.343 – 1.462
At least once a week 1.667*** 1.604 – 1.732
Almost everyday 2.003*** 1.937 – 2.071
Usually go to Cinema/Theater at
least once in a month
No® 1.00
Yes 1.506*** 1.446 – 1.568
Regions
North-East® 1.00
North 1.273*** 1.193 – 1.358
Central 0.714*** 0.671 – 0.760
East 0.908 0.854 – 0.965
West 0.887*** 0.832 – 0.946
South 1.872*** 1.756 – 1.996
Religion
Hindu® 1.00
Muslim 0.889*** 0.863 – 0.917
Christian 1.532*** 1.412 – 1.662
Others 1.403*** 1.318 – 1.493
JOURNAL OF SOCIAL HEALTH 43
© Kathuria & Raj T.P 2022
high school or above were six times more likely (OR: 6.3, p<0.001) to use hygienic methods during menstrua-
tion compared to uneducated women, and it is statistically significant (see table 4). Compared to women belong-
ing to the Hindu religion, the usage of hygienic methods were 53% higher among Christian women (OR:1.53,
p<0.001) and 40% higher among women belonging to other religions (OR:1.40, p<0.001).The wealth index has
a very strong positive association with menstrual hygiene practices. Women from the richest wealth quintile
were more than six times likely to practice hygienic methods compared to those from the poorest wealth quin-
tile (OR: 6.4, p<0.001). Highest odds were observed among women from other caste categories compared to
women from the scheduled caste. The likelihood of using menstrual hygiene methods were also two times high-
er (OR:2.00, p<0.001) among those who were accessing media almost every day compared to those who did
not access media at all. The prevalence of hygienic methods among women who usually go to the cinema or
theater, at least once a month, were comparatively higher (OR: 1.51, p<0.001); and it is statistically significant.
As far as the region is concerned, the likelihood of practicing menstrual hygiene methods among young women
was higher in the Southern region (OR: 1.87, p<0.001) and the Northern region (OR: 1.27, p<0.001), while it
was lesser in the Eastern, Western and Central regions compared to the reference category (i.e., North-Eastern
region).
DISCUSSION
A hygienic menstrual absorbent helps young women to manage menstruation effectively, safely, and comforta-
bly. The present study found that the use of hygienic methods of menstrual protection among young women
(15 to 24 years old) was low. Previous studies conducted in India also reported low levels of menstrual hygiene
practices (Anand et.al, 2015; Kathuria & Raj, 2018; Mudey et. al., 2010). About 57% of the women were using
hygienic methods during menstruation in India: only 44% in Central and Eastern regions, while 80% in the
Southern region. The high percentage of practicing hygiene methods may be due to high educational status,
awareness level, and availability of good sanitation facilities in the Southern region.
The study observed that the line of division between rural and urban becomes stark. The use of hygienic meth-
ods during menstruation among young women was 41% more likely in urban areas compared to rural areas.
Another study by Anand et al. (2015) reported that the use of hygienic methods among unmarried women in
urban areas was 52%, while rural areas was 25%. Paria et al. (2014) revealed in their study that the use of sani-
tary pads was higher among girls in urban areas (64%) in comparison to rural areas (45%). A similar kind of
result was also observed in another study by Thakre et al. (2011). The possible reasons may be due to lack of
knowledge and poverty compared to urban women. Other contributing factors include, rural women do not
have a toilet facility and are accustomed to defecating in the open; they do not use undergarments and sanitary
napkins cannot be used without an underwear. There are also cultural barriers involved like women who avoid
buying sanitary napkins from shops with male shopkeepers due to shame. Since, traditionally, women are using
pieces of cloth and unhygienic rags as alternatives because these are inexpensive, they convince their daughters
and daughters-in-law to do the same. Rural women also find it comfortable to stick to using washable pieces of
cloth because disposing of the pads needs to be handled sensitively to avoid further complicated unhygienic
conditions (Chakravarty, 2016).
One of the imperative determinants of using hygienic methods is the socio-economic status (Garg, Goyal, &
Gupta, 2012; Thakre et. al., 2011; Umar, Yusuf, & Musa, 2010). There was also a huge gap in practicing hy-
gienic methods among literate and illiterate women and women who belong to the poorest and richest wealth
quintile. This study shows that highly educated women were six times more likely to use hygienic methods com-
pared to uneducated women. This finding corroborates with many earlier studies (Anand, Unisa, & Singh,
2015; Anand, Singh, & Unisa, 2015). Several studies revealed that the rationale for not using sanitary napkins
was affordability. The authors found that the use of hygienic methods is more than six times among women in
the richest wealth quintile compared to women in the lowest wealth quintile. Women from the poor wealth
quintile cannot afford these commercial menstrual hygiene products (Sharma, 2018; Ghatak, 2016). Our study
findings also support the studies done by Anand et al (2015) and Kamath et al (2013). The cost of sanitary nap-
kins are an important barrier in India. On an average, total expenditure of Rs.48 for sanitary napkins is re-
quired during menstruation and it is expensive for Indian standards (Garg, Goyal & Gupta, 2012). Therefore,
purchasing sanitary pads is a big financial challenge for women from poor families.
44 Factors Explaining Regional Variations in Menstrual Hygiene Practices
© Kathuria & Raj T.P 2022
Concerning religion, our study says, Muslim women were less likely to use hygienic methods during menstrua-
tion compared to Hindu women, while women from Christian and other religious groups were more likely to
practice hygienic methods compared to Hindu women. Previous studies conducted in India corroborates this
findings ( Anand, Singh & Unisa, 2015; Anand, Unisa & Singh, 2015; Kathuria & Raj, 2018).
Across the nation, women and girls face three types of toilet insecurities: (1) the material reality that they do not
have the access to toilets; (2) even if they have access to public toilets, the toilet is unusable or unsafe to use; and
(3) they accept the risk of open defecation (O'Reilly, 2016). Therefore, a well-functioning toilet facility is very
essential for women to ensure privacy in changing sanitary pads during their menstrual period. It has been re-
vealed from this study that young women who had flush toilets in their homes were using hygienic methods
more than women who do not own a toilet facility or those who opts to defecate in open spaces. This study
also corroborates the studies conducted by Singh and Anand (2018), Anand et al. (2015), and Kamal and Ra-
shid (2004).
The effect of exposure to media and its significant association with menstrual hygiene was visible in our study.
This study observed that the usage of hygienic methods during menstruation was more than two times higher
among those women who have exposure to any mass media almost every day compared to those who do not
have access at all. Patil (2014) showed in her study that the level of menstrual hygiene increases with an increase
in time spent on watching television or listening to the radio. Another study conducted by Afiaz and Biswas
(2021) found that women who had mobile phones and regular access to the media were 43% more likely to use
menstrual hygienic methods. It indicates that the media can play a significant role in making awareness and in
improving menstrual hygiene practices.
In short, the major factors that affect the usage of hygienic methods of menstrual protection are: place of resi-
dence, educational status, wealth status, type of toilet, and exposure to mass media. Apparently, accessibility,
affordability, and lack of awareness were the primary reasons for the use of unhygienic menstrual absorbents,
especially among rural women. Thakre et al. (2011) observed that the reasons for not using sanitary pads were
lack of knowledge (30.3 %), high costs (30.9 %), unavailability and shyness. Mahajan et al. (2017) also found
some barriers in using sanitary napkins which were: lack of awareness, limited availability of the product at eco-
nomical prices, non-availability in the rural and interior areas, no space for cleaning/changing, absence of toilets,
shyness to buy napkins from shops, lack of disposal facilities, and financial constraints.
Regional Variations
Our study documented the regional variations in menstrual hygiene practices in India. A recent study by Goli
(2020) reported that a striking geographical disparity exists in the use of menstrual hygiene absorbents. As far as
the region is concerned, the Southern region is performing better in menstrual hygiene management, followed
by the Northern and Western regions.. Toilet facilities, accessibility and availability are also higher in Southern
states like Kerala and Tamil Nadu. These states have their own programmes for the management of menstrual
hygiene apart from the Central government scheme of Rashtriya Kishore Swasthya Karyakram (RKSK). How-
ever, the implementation and execution in various levels need more attention in certain regions, especially in
Eastern and Central regions.
In Southern and Northern regions, more than 80% of young women who have flush toilets in their homes were
using hygienic methods, while only 64% in Central and Eastern regions (see Table 3). Another interesting find-
ing was that, about 70% of the women without a toilet facility were practicing hygienic methods in the Southern
region, while it was only 28% in Central and Eastern regions.. The state of Tamil Nadu, was the first state in
India to take lead in promoting menstrual health and hygiene. Tamil Nadu state launched the first sanitary nap-
kin scheme in India for women, including girls (NFFSM, 2019). In Kerala, the government has launched a
“She pad” scheme in the state to ensure menstrual hygiene among girls studying in classes 6 to 12 (Nair, 2018).
These factors also contributed to better management of menstrual hygiene in the state. In the Southern region,
more than 80% practiced menstrual hygiene and those who have exposure to mass media every day; followed
by the Northern region with 78.8%; the Western region with 69.3%; and the lowest was reported in the Central
© Kathuria & Raj T.P
JOURNAL OF SOCIAL HEALTH 45
region with 60.3%. In the Southern region, the media have a very strong influence on young women’s hygiene;
and doing a lot of IEC activities was also found to have the highest percentage of hygiene practice.
CONCLUSION
Among reproductive health issues, menstruation and its hygiene are neglected areas; hence, young women
must have adequate and accurate information about menstruation and its management. The study concludes
that women in the richest quintile, with higher education, living in urban areas, with higher awareness and atti-
tude, have flush toilets at home, and have access to media every day were more likely to use menstrual hygiene
methods. Among the regions, the Southern region was performing better, followed by the Northern and West-
ern regions. More attention is required for the Eastern and Central regions.
Economical constraints is the main reason for avoiding hygiene practices during menstruation. Hence, locally
made sanitary napkins may be provided at cheaper rates. The government has to commit a budget for free dis-
tribution of sanitary pads and promote reusable methods and distribute it for free or at least retail it in nominal
rates through rural health care providers, such as ANMs or Anganwadi workers at a village level. The use of
menstrual cups is also ideal because it can be reused for five to ten years and is environmentally friendly. It of-
fers sustainable, practical and cost-effective alternatives where sanitary conditions are not good. Without ad-
dressing the toilet facility at a household level with a running water facility, it is not likely to get the desired out-
come. For the last few years under Swach Bharat Mission, many new toilets have been constructed in the coun-
try. However, the mission needs to assure the availability of water supply at the toilets, so that the purpose may
be solved. Media awareness is also another key player to improve menstrual hygiene practice. Both women
and men need to be made aware about the importance of maintaining hygiene practices during menstruation.
Targeted intervention is required to be introduced for socio-economically vulnerable women to address this
issue. Ensuring menstrual hygiene should be the top priority of developmental agenda, which calls for urgent
and intensive action from all relevant stakeholders to change the scenario of menstrual hygiene in India.
LIMITATIONS
Our study has certain limitations. The National Family Health Survey (NFHS-4) provides the data of menstrual
hygiene practices among women who are 15 to 24 years old only. The data are self-reported, and therefore,
subject to recall bias. In the Indian society, socio-cultural norms play a crucial role in deciding the behavioral
practice of young women. Therefore, menstrual hygiene practices might be controlled by many socio-cultural
factors and existing customs. The researchers could not include these factors in the analysis due to lack of infor-
mation in the dataset. Detailed qualitative research is required to study the socio-cultural norms pertaining to
the access and use of hygienic methods among young women.
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