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International Journal of Human and Health Sciences Vol. 06 No. 04 October’22
404
Original Article
How Tamil Nadu Is Performing Better in Menstrual Hygiene Management in India: Evidence
from National Family Health Survey (NFHS-4)
Sherin Raj TP1, Bhawna Kathuria2
Abstract
Background:Menstruation is an integral part and natural process among women and it
involved many myths, customs and misconceptions in India.Menstrual Hygiene Management
(MHM) is a problem for young girls in India. Along with basic sanitation facilities, young
girls and women need access to clean and soft, absorbent sanitary products for a long run
and protect their health. In Tamil Nadu, India, menarcheof a girl is celebrated with the
relatives and friends like a festival. Objective:This paper examines the initiatives taken
by the state of Tamil Nadu of Indiaand the various factors associated with the menstrual
hygienepractice among young women. Methods: Data collected from the 4th round of
National Family Health Survey (NFHS-4), conducted in 2015-16 were used for analysis.
The sample consists of 14,949 young women in the age group of 15-24 years who have
ever menstruated. Results: The state government’s initiatives, series of activities, inter-
departmental collaboration and coordination, participation of civil society and community
helped Tamil Nadu state to perform in a better manner.The resultsreveals the odds for
women in the richest quintile, higher education, living in urban areas with higher awareness
and availability of ush toiletsgive higher odds ratio determining the factors associated
with the usage ofhygienic methods. Conclusion: For better menstrual hygiene it requires
a very good knowledge and awareness on menstrual cycle, hygiene essentials, safe and
secure sanitary products and good water, sanitation and hygiene (WASH) facilities.
Keywords: Menstrual hygiene, young women, Tamil Nadu, India
Correspondence to: Dr. Sherin Raj TP, Assistant Research Ocer, Department of Planning &
Evaluation, The National Institute of Health and Family Welfare, New Delhi-110067, India.
Email: sraj@nihfw.org
1. Assistant Research Ocer, Department of Planning & Evaluation, The National Institute
of Healthand Family Welfare, New Delhi-110067, India.
2. Assistant Research Ocer, Department of Epidemiology, The National Institute of Health
and FamilyWelfare, New Delhi-110067, India.
Introduction
Menstrual Hygiene Management (MHM) has been
identied as a major issue for adolescent girls,
aecting their health and well-being, creating
problems to pursue education and employment
opportunities, and has adverse implications for
the environment.1 Menstruation is not just a
personal and biological event in India, it also
assumes asa social phenomenon related to many
myths, misconceptions and misbelieves.2Social
and cultural beliefs, strong bondage by taboos
and traditional customs during menstruation, and
hesitation of parents to discuss the related issues
openly to their daughters has prevent the access
to get the exact knowledge regarding menstrual
hygiene practices.3 Better understanding of
the good menstrual hygiene is crucial for the
education, health and dignity of girls and women.4
According to Census 2011, women in the age
group of 15-24 years constitute about 19 percent
of the total female population of India.5 Hence, the
monthly menstrual need of such a huge population
has to be received proper attention. By recognizing
the importance of promotion of menstrual
hygiene, in June 2011, the Ministry of Health and
Family Welfare (MoHFW) launched a menstrual
International Journal of Human and Health Sciences Vol. 06 No. 04 October’22 Page : 404-411
DOI: http://dx.doi.org/10.31344/ijhhs.v6i4.480
405
International Journal of Human and Health Sciences Vol. 06 No. 04 October’22
hygiene scheme to make sanitary pads available to
adolescent girls in rural areas of selected districts
at a subsidized cost through Accredited Social
Health Activists (ASHAs).6 From 2014 onwards,
the scheme extended to all districts under Rashtriya
Kishore Swasthya Karyakram (RKSK) to enhance
knowledge about menstrual hygiene, improve
hygiene practices, provide sanitary absorbents at
subsidized cost, and raise awareness about MHM
at school.7,8 To enhance the capacity building of
ASHA’s the “Training Module for ASHA on
Menstrual Hygiene” is also used.9
Few states like Bihar, Madhya Pradesh and
Assam performed very poor in terms of menstrual
hygiene practices, with hygienic methods usage
of 31 percent, 37.6 percent and 4.8 percent
respectively according to NFHS-4.10 The other
states such as Mizoram, Tamil Nadu, Kerala,
Goa and Sikkim were performed well with 93
percent, 91 percent, 90 percent, 89 percent and
85 percent respectively in terms of menstrual
hygiene practice. Tamil Nadu is moderately larger
and populous state with 37 districts and more
than half of the population is living in rural area.
The state have more than 90 percent of the young
women were practicing hygienic methods.Hence,
this paper examines the initiatives taken by the
Tamil Nadu state government regarding menstrual
hygiene management and factors associated with
menstrual hygiene practices.
Methods
Data from the fourth round of National Family
Health Survey (NFHS-4) India, conducted in
2015-16 is used for the analysis of this study.10
The survey presents the data on population, health,
and nutrition at National, State and District level.
As the young women in the age group of 15-24
years are considered in the analysis, the sample
consists of 14,949 young women in the age group
of 15-24 years who have ever menstruated in
Tamil Nadu state of India. Secondary data from
peer-reviewed and review of menstrual hygiene
management (MHM) policies and initiatives by
Tamil Nadu state in the past few years were also
used for this study.In the present paper, hygienic
method includes those women who use locally
prepared napkins, sanitary napkins, or tampons
during their menstrual period. All other methods
used such as cloth, any other method and those
women who used nothing were considered as
unhygienic method. To examine the levels and
dierentials of prevalence of usage of hygienic
methods of menstrual protection among young
women with various background characteristics,
bivariate analysis has been used. To nd out the
determining factors associated with the usage of
hygienic methods, binary logistic regression has
been performed in which the individual eect of
various background characteristics on menstrual
hygiene practices are measured. The data were
analyzed using IBM SPSS Statistics Version 20.0.
Results
Initiatives taken by Tamil Nadu state for
Menstrual Hygiene Management: Tamil Nadu
is the rst state in India introduced the measures
for menstrual health management, long before the
issue came into national importance, to overcome
lack of awareness and access to menstrual hygiene
practices.11The detailed research on Tamil Nadu’s
initiatives through secondary data and reviews
signify that a series of activities and initiatives
by various stakeholders at various periods, that
helped the state to make an environment, in which
various sectors like government departments,
non-governmental organizations (NGOs) and
private companies collaboratively functioning for
eectively manage menstrual hygiene practices.
The main aim of these initiatives was to make
awareness, accessibility, usage and disposal of
menstrual waste to increase the menstrual hygiene
practices in the state.The rst state recognized
menstrual hygiene management as an issue to
be addressed through it sanitation policies and
programmes in 2004.12 But the background
work to solve the poor hygiene practices in the
state started much early, about 1992 through
the socially motivated individual Ms. Kannaghi
Chandrashekharan, “Pioneer in Menstrual
Hygiene” called by UNICEF. The menstrual
hygiene activist started three selfhelp groups
(SHGs) in 1998 with three napkin production units
at Pudukottai and set up an NGO, WOMEN to
make awareness on menstrual hygiene and develop
skill among women to locally making sanitary
pads.13 Following this, Ms.Sheela Nair, IAS ocer
posted in Tamil Nadu Planning Commission,
monitored the interventions by state government
for managing menstrual health condition of
the state. Under the guidance of state planning
commission, Ms. Nair started intervention on the
same strategy of Ms.Kannaghi’s where Self help
groups (SHGs) were produce their own sanitary
napkins in hygienic environment.11 Thus, the
state of Tamil Nadu pioneered the idea of local
International Journal of Human and Health Sciences Vol. 06 No. 04 October’22
406
production of sanitary napkins through SHGs
and thereby widely distributed menstrual hygiene
products in the state (Table 1).
Tamil Nadu was also able to manage the menstrual
hygiene initiatives with the funding and aid for
sanitation and menstrual hygiene management,
from charitable organizations and international
organizations like UNICEF.14Along with these
activities, various NGOs entered in the state and
started running their own awareness programmes
and production of their own sanitary napkins in
the state. Several non-governmental stakeholders
who work on MHM together formed a Menstrual
Hygiene Management Consortium (MHMC) in
2010 at Tiruchi with the support from UNICEF.15
In 2011, under the leadership of Chief Minister
Ms. Jayalalitha, introduced the Menstrual Hygiene
Programme (MHP) to provide free sanitary
pads to girls in schools, women prisoners and
lactating mothers.16 During the same time,central
government also started a national level scheme
to distribute sanitary napkins at low price to
adolescent girls in certain districts of 17 states in
the country. Subsequently the scheme was brought
under the umbrella of National Health Mission in
2014 as RKSK.17 At the same time, Tamil Nadu
state focused on strengthening the accessibility
and infrastructure facility for menstrual hygiene
such as separate toilets for girls and installing
incinerators and sanitary napkin vending machines
in schools. All these initiatives, interventions and
programmes were helped the state of Tamil Nadu
became the leading state in menstrual hygiene
management among Indian states.
Mass media also played a crucial role in addressing
the existing taboos and misconceptions on
menstrual hygiene. Advertisements on MHM by
the vernacular media help to reaching the message
to the farthest possible audience. The distribution
of free Television by the state government in 2006
again improved the spread of awareness through
the advertisements in the media, led to increase the
awareness. The success of MHP in Tamil Nadu,
compare to national programme, is through its
holistic coverage and consistent budget allocations
for MHP in the state. During 2011-12, 2012-13
and 2013-14, the budget allocation was Rs.46
crores, 55 crores and 54.6 crores respectively for
menstrual health programme (MHP). In 2014-15
also the same amount of 54.6 crores were allocated
for MHP. While in 2015-16, the sate allocated
60.58 crores, 61 crores for 2016-17 and the same
Table 1: Achievements of Tamil Nadu in MHM
Year Major Achievements
1989
First SHG in Tamil Nadu Formed in Dharmapuri District
with the support of International Fund for Agricultural
Development (IFAD)
1998 Women SHGs formed for making Sanitary napkins
under the leadership of Ms.Kannaghi
2002 Lack of Menstrual Hygiene among rural women were
indentied and SHGs started making Sanitary Napkins.
2004 NGOs started working on Menstrual Hygiene
2006-08 Organized large number of conferences under WASH on
Menstrual Hygiene
2010 Menstrual Hygiene Management Consortium (MHMC)
formed at Tiruchi
2011 Tamil Nadu CM Ms. Jayalalitha launches the rst
sanitary napkin scheme in India.
2014 Govt. of India started the RKSK scheme to provide
sanitary napkins for adolescent girls.
2015
Menstrual Hygiene Management National Guidelines
has been published by Ministry of Drinking Water and
Sanitation with the support of UNICEF.
2017 NFHS-4 (2015-16) report published and carries all state
level data on menstrual hygiene practices.
Source: NFSSM, 201911
amount of Rs.61 crores were allocated during
2017-18 in the budget for MHP.18
In short, the MHM movement in Tamil Nadu can
be said as government driven one, as much as one
championed by individuals in the community.
The state government’s initiatives, series of
activities, inter-departmental collaboration and
coordination, participation of civil society and
coupled with community, helped Tamil Nadu to
make a sustainable MHM model.
District-wise prevalence of usage of hygienic
methods of menstrual protection: Table 2
depicts the district level prevalence of practicing
menstrual hygiene among young women in Tamil
Nadu according to NFHS-4 data. The analysis
reveals that out of 37 districts, 18 districts have
the prevalence of above 90% in using hygienic
methods of menstrual protection. In rests of the
districts, more than 80% of the young women
were practicing menstrual hygiene except
Virudhunagar district (79.8%). It indicates the
penetration of menstrual hygiene activities to the
whole state through various governmental and
non-governmental initiatives and programmes.
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International Journal of Human and Health Sciences Vol. 06 No. 04 October’22
Table 2: Districtwise percentage of women
aged 15-24 using a hygienic methods during
menstruation in Tamil Nadu, India, NFHS-IV,
2015-16
Districts Percentage of women
using a hygienic method
Number of
women
Thiruvallur 88.4 865
Chennai 97.3 976
Kancheepuram 93.0 820
Vellore 94.9 782
Tiruvannamalai 87.9 464
Viluppuram 87.8 694
Salem 93.8 836
Namakkal 91.4 371
Erode 94.1 657
The Nilgiris 90.7 172
Dindigul 91.5 484
Karur 95.3 236
Tiruchirappalli 94.1 510
Perambalur 90.9 121
Ariyalur 86.1 122
Cuddalore 91.5 577
Nagapattinam 86.0 344
Thiruvarur 88.0 217
Thanjavur 88.5 470
Pudukkottai 88.2 287
Sivaganga 90.7 258
Madurai 88.7 505
Theni 81.2 250
Virudhunagar 79.8 357
Ramanathapuram 85.4 246
Thoothukkudi 86.9 298
Tirunelveli 89.9 493
Kanniyakumari 92.7 354
Dharmapuri 91.9 358
Krishnagiri 95.4 474
Coimbatore 96.3 821
Tiruppur 94.5 530
Tamil Nadu 91.4 14949
Levels and Dierentials of usage of menstrual
hygienic methods: The percentage distribution
of use of hygienic method by various background
characteristics has been shown in Table 3.
Overall, more than 91 percent of the women
were used hygienic method during menstruation
whereas remaining 9 percent using cloths or other
unhygienic method of menstrual protection. The
usage of hygienic methods during menstruation
was higher among the women in the age group 15-
19 with 94 percent, compared to women in 20-24
age group (89.3%).
Table 3: Percentage of young women aged 15-
24 practicing menstrual hygiene by background
characteristics in Tamil Nadu
Background
Characteristics
Percentage
using a
hygienic
method
Number of
women p-value
Age-group (in years)
15-19 93.9 6980 0.000
20-24 89.3 7969
Place of residence
Rural 89.5 7724 0.000
Urban 93.5 7223
Education
No education 71.3 202
0.000
Primary 75.8 297
Secondary 91.2 9516
High school & above 93.6 4934
Religion
Hindu 91.1 13677
0.000Muslim 95.8 670
Christian 93.1 595
Caste
Scheduled Caste 89.0 4667
0.000
Scheduled Tribe 85.9 249
Other Backward Class 92.8 9812
Others 87.2 172
Wealth Quintile
Poorest 80.8 411
0.000
Poorer 85.8 2219
Middle 90.0 4386
Richer 94.1 4599
Richest 94.7 3333
Type of Toilet
ush 94.0 8323
0.000
pit/dry 91.0 310
no facility/ open space 87.9 5943
others 89.8 372
Access to Media
Not at all 88.9 153
0.577
Less than once a week 91.2 137
At least once a week
92.8 305
Almost everyday 91.4 14353
Usually go to cinema/theatre
at least once in a month
International Journal of Human and Health Sciences Vol. 06 No. 04 October’22
408
Background
Characteristics
Percentage
using a
hygienic
method
Number of
women p-value
No 90.8 11564 0.000
Yes 93.7 3384
Total 91.4 14948
Note: Total includes women belonging to “other”
religions and women who don’t know their caste/tribe,
are not shown separately.
The urban-rural disparity is very less, as rural
women (89.5%) used hygienic method as compare
with 93.5 percent of women in urban areas. As the
educational level improved, the usage of hygienic
methods among women had also increased. But
in Tamil Nadu, 71 percent of the women having
no education used hygienic methods to prevent
their bloodstains during menstruation and among
primary educated women it is 75.8%. On the other
hand, more than 90% of women with education
high school and above used hygienic methods. The
usage of hygienic method of menstrual protection
was almost same among Hindu women (91.1%),
Muslim women (95.8% %) and Christian women
(93.1%). The usage of hygienic method among
women from other backward classes (OBC) was
higher (92.8%) in comparison to women belong
to Scheduled Caste (89%), Scheduled Tribe
women (85.9%) and women with no caste/tribe
(87.2%). The economic status of women seems to
be a dominant factor in the prevalence of usage
of menstrual hygienic method. Usage of hygienic
methods were higher among the young women in
the richest wealth quintile (94.7%) compared to
the young women belong to the poorest wealth
quintile (80.8 %). Toilet facility at home is very
essential for women to ensure privacy in changing
sanitary pads. It has been observed from the table
that 87.9 percent of women use hygiene methods
who do not have toilet facility at their home as
compared to 94 percent of women who have
ush toilets at their home. The usage of menstrual
hygienic methods were high among young
women those who have access to media atleast
once a week (92.8%) compared to those who have
never access to these medium of communication
(88.9%). Similarly, use of hygienic methods were
comparatively higher among those women who
are usually go to cinema/ theatre at least once in a
month compared to those who don’t go. All these
background variables were signicantly associated
with menstrual hygiene except access to media.
Odds Ratios for Practicing Hygienic Methods:
The results of the binary logistic regression have
been presented in Table 4, which shows that
most of the predictor variables tted in the model
were statistically signicant. Women in the age
group of 20-24 years were 50 percent less likely
to use menstrual hygiene methods compared to
women in the 15-19 age group. Similarly, women
living in urban areas were more likely to practice
hygienic methods of menstrual protection.
However, the value of odds ratio for educational
status and wealth status is high, which indicates
that these two factors are the most important and
associated with the usage of hygienic menstrual
absorbents. Women who are educated up to high
school or above are three times more likely to
use hygienic method during menstruation as
compared to uneducated women (OR= 3.6).
Compared to women belong to Hindu religion,
the usage of hygienic methodswasfound higher
among Muslim women (OR=1.5) and Christian
women (OR=1.1). The prevalence of menstrual
protection was signicantly higher among women
belong to OBC category compared to women
from scheduled caste. The usage of hygienic
menstrual absorbents increases sharply with the
wealth status. Women belong to richer category
of wealth index were more than two times higher
the use sanitary methods as compared to women
belongs to poorest category (OR=2.5). The usage
of hygiene methods was higher among women
those who have ush toilet facility at their home
as compared to women who do not have toilets at
their home.
Discussion
Management of menstruation hygiene involves
not only access to basic sanitation facilities,
soap and water but also to so-called menstrual
absorbents. The initiatives for managing menstrual
hygiene were started long time back in the state
of Tamil Nadu and self help groups formed to
make sanitary napkin during 1998. That is one
of the mainreasonsfor the state to be continuing
in the top among the Indian states as far as the
menstrual hygiene is concerned. Tamil Nadu state
had increased the accessibility and infrastructure
facility for menstrual hygiene such as separate
toilets for girls and installing incinerators and
sanitary napkin vending machines in schools.
A study conducted in Karnataka found that
46 percent of the girls prefer to use cloths due
tohigh cost of sanitary pads, shyness to buy and
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International Journal of Human and Health Sciences Vol. 06 No. 04 October’22
Table 4: Odds Ratios for practicing menstrual
hygienic methods among young women in Tamil
Nadu
Background Characteristics Odds Ratio CI (95%)
Age-group (in years)
15-19® 1.00
20-24 0.500*** 0.440-0.570
Place of residence
Rural® 1.00
Urban 1.120 0.976-1.285
Education
No education® 1.00
Primary 1.229 0.811-1.860
Secondary 2.563*** 1.850-3.549
High school & above 3.567*** 2.536-5.016
Religion
Hindu® 1.00
Muslim 1.592** 1.074-2.361
Christian 1.063 0.761-1.485
Caste
Scheduled Caste® 1.00
Scheduled Tribe 0.926 0.627-1.367
Other Backward Class 1.190** 1.045-1.354
Others 0.532** 0.331-0.854
Wealth Quintile
Poorest® 1.00
Poorer 1.317** 0.993-1.745
Middle 1.755*** 1.328-2.317
Richer 2.532*** 1.851-3.464
Richest 2.365*** 1.669-3.349
Type of Toilet
Flush® 1.00
Pit/Dry 0.937 0.617-1.425
No facility/Open space 0.841* 0.707-1.001
Others 0.765 0.534-1.097
Usually go to Cinema/
Theatre at least once in a
month
No® 1.00
Yes 1.238** 1.057-1.451
Note: *** Signicant at p<0.001, ** Signicant at
p<0.05, * Signicant at p<0.01
disposal issues.19These issues were not much high
in Tamil Nadu state due to the sanitary napkin
vending machines and incinerators installed in
schools.The state government’s initiatives, series
of activities, inter-departmental collaboration and
coordination, participation of civil society and
coupled with community, helped Tamil Nadu to
make a sustainable MHM model.
The socio-economic factors associated with
menstrual hygiene practices reveals that the
use of hygienic method of menstrual protection
among young women (15-19 years) was higher
compared to 20-24 year age group. The study
observed that the line of division between rural
and urban becomes very feeble. This outcome is
contradictory to the ndings reported by Anand
et al (2015) that the use of hygienic method was
higher among unmarried women in urban area
(52 %) as compared to rural area (25 %).20 Few
other studies by Paria et al (2014) and Thakre et
al (2011), were also found similar contradictions
with our study in rural and urban dierence.21,22
The possible reason may be that the availability
and accessibility of sanitary napkins in rural and
urban areas were almost similar due to the various
government initiatives in the state.
Our study reveals that highly educated women were
more likely to use hygienic methods compared to
illiterate women. Hence, education level of an
individual is a signicant contributory factor in
deciding the menstrual hygiene practice. A study
done among rural women in Tamil Nadu reported
that among the illiterate women 95 percent were
used cloths during menstruation, while women
who had completed high school and graduation
more than 70 percent and 94 percent used sanitary
pads during menstruation, respectively.23 Another
study by Ray and Dasgupta found that menstrual
hygiene practices was more among girls with
literate mothers.24 Women belong to richer category
of wealth index were more than two times likely
to use hygienic methods as compared to poorest
category. The result were corroborates with the
study by Nath et.al., reported that menstrual
hygiene practices were associated with education,
religion, economic status and availability of toilet
facilities.25 Our study also found that those who
have ush toilet facility at home, were more likely
to practice menstrual hygienic methods.
This study observed that the usage of hygienic
methods during menstruation was higher among
those women who have exposure to any mass
media and going to cinema or theatre once in a
month. The distribution of free Television by
the state government also helped to improvethe
spread of awareness through the advertisements
in the media. There was lm named “Pad Man”
International Journal of Human and Health Sciences Vol. 06 No. 04 October’22
410
released in 2018, based on the life of a Social
activist, Arunachalam Muruganantham from
Tamil Nadu and also known as ‘Menstrual
Man’. He brought the revolution in the concept
of menstrual hygiene in rural India by creating
a low-cost sanitary napkin machine.26 A study
conducted by Tarhane reveals that 79 percent of
the girls used sanitary pads and the reason was
reported as the high availability and inuence to
television.27Watching cinema from theatre is a
part of their life among common peoples in Tamil
Nadu. Patil (2014) shows in her study that level
of menstrual hygiene increases with an increase
in time spent on watching television or listening
to radio.28
Conclusion
More than 50 percent of the districts have
prevalence of hygienic practice above 90 percent
and rests have above 80 percent in the state. The
state government’s initiatives, inter-departmental
collaboration and coordination, participation of
civil society and coupled with community, helped
Tamil Nadu to stand top among the other states
in India.The paper concludes that women in the
richest quintile, with higher education, living in
urban areas with higher awareness and attitude
were more likely to use hygiene methods. The
usage of hygiene methods were higher among
women those who have ush toilet facility at
their home as compared to women who do not
have toilets at their home. The usage of menstrual
hygienic methods were three times higher
among young women those who have access to
media almost every day (watching television or
reading newspaper or listening radio) compared
to those who have never access to these medium
of communication. In short, for much better
management of Menstrual Hygiene, requires very
good knowledge and awareness on menstrual
hygiene, safe and secure sanitary products, good
water, sanitation and hygiene (WASH) facilities
and menstrual management facilities, too.
Ethical Approval:The study was done based
on the secondary data source; hence, no ethical
approval was required.
Conict of interest: None declared.
Funding statement:The study received no
specic funding.
Authors’ contribution: Both equally involved in
concept, design, literature search and drafting the
manuscript. BK did the data analysis and statistical
analysis. SR edited, nalized and submitted the
article for publication.
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