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A community-based study of
menstrual hygiene practices and
willingness to pay for sanitary
napkins among women o...
Vivek Gupta

The National medical journal of India

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A COMMUNIT Y BASED ST UDY ON KNOWLEDGE AND PRACT ICES OF MENST RUAL

Short Report
napkins. Health sector functionaries should play a proactive
role in the delivery of such information.
A community-based study of menstrual
Natl Med J India 2013;26:335–7
hygiene practices and willingness to pay
for sanitary napkins among women of a INTRODUCTION
In Indian society, menstruation is still considered an unhygienic
rural community in northern India process and is linked to several misconceptions and practices.1,2
Hygiene-related practices of women during menstruation are of
PUNEET MISRA, RAVI PRAKASH UPADHYAY, importance as these can predispose women to the risk of
VINITA SHARMA, KRISHNAN ANAND, VIVEK GUPTA reproductive tract infection.3,4 Studies have found high levels of
ignorance about the normal physiological process of
menstruation.3,5,6 Further, there are certain taboos related to it such
as avoiding bathing, consumption of certain foods, etc. along with
ABSTRACT low prevalence of adequate perineal care with soap and water.1,5,7
Background. Hygiene-related practices of women during Hygienic practices such as the use of sanitary napkins are
menstruation are of paramount importance. There is a lack of useful during menstruation. Women of reproductive age require
sizeable literature on menstrual practices from northern India. access to clean and comfortable absorbent sanitary products
We documented the menstrual hygiene practices of rural which apart from ensuring proper hygiene would also protect their
women and assessed their willingness to pay for sanitary napkins. health. However, insufficient attention has been given to this
Methods. A cross-sectional study was done in villages under issue. We aimed to ascertain the knowledge gap, document
the Comprehensive Rural Health Services Project (CRHSP), existing hygiene practices during menstruation and assess
situated in Ballabgarh, Haryana. The study participants were willingness to pay for low-cost sanitary napkins among women in
women in the age group of 15–45 years. Nine villages were the reproductive age group in a rural community of Haryana.
selected randomly while the number of respondents in each METHODS
selected village was decided through the probability propor-
Villages under the intensive field practice area of the Comprehensive
tionate to size sampling method. The households were selected
Rural Health Services Project (CRHSP) situated in rural Haryana
using systematic sampling. One woman was interviewed in
were included. The CRHSP is run by the Centre for Community
each household using a pre-tested questionnaire. Medicine, All India Institute of Medical Sciences (AIIMS), New
Results. A total of 995 women were interviewed. A Delhi. A sample size of 1027 was calculated assuming that 30%
majority of them (62%) were unaware of the reason(s) for women had adequate knowledge about menstruation, with an
menstruation. The role of the health sector in providing absolute precision of 3% and adding for a 10% refusal rate.8 All
information regarding menstruation was low as only a few women 15–45 years of age were eligible to participate in the study.
women (1.5%) had got information from the auxiliary nurse For those around the age of menarche, they should have attained
midwife (ANM)/health worker (HW). For the majority of menarche a year before the start of the study. Pregnant women,
women, besides religious activities, other routine activities did those who had amenorrhoea of 2 months or more, those who had
not suffer during menstruation. Only 28.8% of women were their last childbirth within 6 months of the interview and those on
using sanitary napkins and of those who did not use napkins, treatment for any gynaecological ailment were excluded.
only one-fourth (25.3%) were willing to buy them. The mean Nine of 28 villages were randomly selected. The number of
(SD) price per napkin that these women were ready to pay was respondents in each village was decided through probability
`0.54 (0.43), equivalent to US$ 0.01. proportionate to size (PPS) sampling and households through
Conclusion. Women in the reproductive age group should systematic sampling. One woman was interviewed in each household.
be provided with appropriate information about menstruation, In case of more than one eligible woman in the house, the selection
and they should be told about the advantages of using sanitary was done using a lottery method. Data collection was done by
trained women research workers through a pre-tested questionnaire.
Revisits were made if the eligible person was absent or the houses
All India Institute of Medical Sciences, New Delhi, India were found locked. The interview schedule was administered in
PUNEET MISRA, KRISHNAN ANAND Centre for Community Medicine Hindi. Approval was obtained from the institutional ethics committee
Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, of AIIMS before initiation of the study.
India
RAVI PRAKASH UPADHYAY Department of Community Medicine RESULTS
Science for Equity, Empowerment and Development (SEED) Division, A total of 1217 women were eligible for the study and 995 women
New Delhi, India
VINITA SHARMA Department of Science and Technology were included after obtaining consent for the final interview
The Inclen Trust, New Delhi, India
giving a response rate of 81.8%. The mean (SD) age of the women
VIVEK GUPTA was 28.2 (7.5) years. A large group of women interviewed
Correspondence to PUNEET MISRA; doctormisra@gmail.com (44.4%) were in the age group of 20–29 years. The mean (SD) age
© The National Medical Journal of India 2013
336 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 26, NO. 6, 2013

at menarche was 14.7 (1.4) years. Nearly all the study participants TABLE III. Reported reasons for using a particular type of material
(97.7%) were Hindu by religion and the majority of them were for soaking menstrual blood
married (84.3%). About one-third (30.8%) of women interviewed Reason n (%)
were illiterate. One-fourth (27%) of the women reported their Old cloth (n=582)
monthly family income to be <`3000 (<56 US$). Easily available 289 (49.7)
A majority of women (62%) were not aware of the reason(s) of Comfortable using it as have been using since long time 138 (23.7)
menstruation (Table I). About 13% of women perceived it as a Nakpins costly and cloth is cheaper 57 (9.8)
mechanism of the body to remove dirty blood and fluids whereas Cannot get napkins from market 46 (7.9)
11% of them associated it with childbirth. Nearly 58% of women Do not like using napkins 17 (2.9)
correctly reported the source of menstrual blood to be the uterus Can be reused 15 (2.6)
(Table I). Only two-fifths (39.1%) of the study participants had Cloth soaks well 9 (1.5)
Don’t know about napkins 11 (1.9)
received any information on menstruation. Most women had
Sanitary napkins (n=287)
received the information from their mother (41.4%), followed by Napkins are safe and easy to use 221 (77.0)
friends (22.4%) and sisters (19.8%). Only 3.1% and 1.5% of Cloth becomes messy and gets stained 39 (13.6)
women reported having received the information from school Cannot get cloth at home 9 (3.1)
teachers and auxiliary nurse midwife (ANM)/health worker (HW), It soaks well 8 (2.8)
respectively. Easily accessible/available 6 (2.1)
For most women, besides religious activities, other routine Been using it since early age 4 (1.4)
activities were not affected during menstruation (Table II). Hygienic
practices were followed during menstruation by the study
participants. Nearly all women (n=986; 99.1%) reported taking a
bath daily during the menstrual period. Around 85% of women was its safety and ease of use (77%). Around 93% of women
reported washing genitals with ordinary soap and water whereas usually discarded the used material in fields or dustbins whereas
another 7.1% said they washed with plain water. Dettol (4.4%) the remaining women reused the material.
and medicated soap (2.6%) were also used to wash the genitals Those who were using sanitary napkins said the mean (SD)
during menstruation. Only 28.8% (n=287) of women were using monthly expenditure on buying sanitary napkins was `26 (14.2)
sanitary napkins, while the majority (58.5%) of women was using or US$ 0.48 (0.26). Most women purchased it from outside the
an ‘old cloth’ as a material for absorbing menstrual blood. Among village (40.8%). Of the 708 women, who did not use sanitary
women who used an old washed cloth, the most preferred reason napkins, only one-fourth (25.3%) were willing to buy sanitary
was its ease of availability (49.7%; Table III). On the other hand, napkins whereas the remaining felt these were expensive. The
among women who used sanitary napkins, the commonest reason mean (SD) price per sanitary napkin that women were ready to pay
was `0.54 (0.43) or US$ 0.01. Although half the women (51.3%)
were willing to participate in making sanitary napkins, over two-
TABLE I. Causes of menstruation and sources of menstrual blood
thirds (70.6%) were willing to devote 3 hours or less for the same
as reported by the study participants (n=995)
on workdays. Further, more than half the women (67.8%) were
Item n (%) willing to work only if they got a minimum monthly wage of
Perceived causes of menstruation `1500 (US $28).
Don’t know 619 (62.2)
To clean body/remove dirty blood or fluids 137 (13.8) DISCUSSION
For reasons of childbirth 115 (11.6) This was a pilot study to assess the knowledge, attitude and
Everyone has it/way of nature 55 (5.5)
practices (KAP) of menstrual hygiene and willingness to pay for
Supernatural causes 32 (3.2)
Reasons of inner heat 19 (1.9)
low-cost sanitary napkins by rural women residing in Haryana.
Biological/hormonal reasons 18 (1.8) We found that the majority of women did not know the cause of
Perceived source of menstrual blood menstruation and of those who received information related to
Uterus 580 (58.3) menstruation, the majority got it from family members and the
Don’t know 216 (21.7) role of healthcare workers was quite low.
Abdomen 146 (14.7) The findings of our study corroborate the findings of previous
No response 53 (5.3) studies done in Rajasthan and Gujarat.3,8 Our study highlights
certain good practices in the context of menstruation-related
taboos and hygiene during menstruation. Most women said that
TABLE II. Effect of menstruation on routine activities (n=995)
apart from religious activities, other routine activities such as
Activity Response n (%) attending school, cooking food and participating in social functions
Sleeping in usual room during menstruation Yes 978 (98.3) was not impacted by menstruation.
Cooked food during the last menstrual period Yes 964 (96.9) Only one-third of women in our study were using sanitary
Going out of home during menstruation Yes 908 (91.3) napkins and most of them procured it from outside their village.
Going to school during menstruation* Yes 112 (85.5) Among those who used an old cloth, the main reason was non-
Participation in religious activities during Yes 23 (2.3) availability of sanitary napkins in the village and their high cost.
menstruation
Further, those using a cloth and willing to use sanitary napkins
Participation in social functions during Yes 941 (94.6)
menstruation
wanted to pay around `0.50. These findings underline the need to
establish mechanisms to ensure easy availability of sanitary napkins
* Of all the women interviewed, 864 of them did not go to school or college. The
denominator for calculating the percentage was therefore 131, i.e. women who were
at a low cost in villages. This could possibly be achieved through a
enrolled in a school/college. number of means such as enabling manufacture by self-help groups
MISRA et al. : MENSTRUAL HYGIENE PRACTICES AMONG WOMEN 337

(SHGs), sourcing through sanitary napkin manufacturers through a is a need to inform women about their use. It is important that a
competitive bidding process, microfinancing and social marketing sustained public health programme through involvement of key
besides government initiatives to provide sanitary napkins at stakeholders such as family members, school teachers, civil
subsidized rates in rural areas. society and healthcare providers is developed for women.
We looked at the option of setting up a mechanism for local
production and distribution of low-cost sanitary napkins through ACKNOWLEDGEMENT
involvement of village level SHGs and women volunteers from Funding for this study was provided by the Department of Science
the community. However, we found that such an initiative could and Technology, New Delhi
be difficult to implement because of financial reasons. Women
who were willing to participate had higher expectations of earning Contributions: PM, VS, VG and KA were involved in the planning,
and were willing to invest comparatively less time. execution and overall supervision of the study. RPU, PM and VG
The disposal of materials used to soak menstrual blood is performed the literature search, analysis and prepared the
another issue that needed to be addressed. In our study, 93% of manuscript; All the authors read and approved the final manuscript.
women usually discarded the used material in fields or dustbins.
Such a practice is harmful to the environment and there is a need Conflict of interest: None
of better methods for disposal of the used materials. The materials
can either be buried in a pit that can be dug near the household or REFERENCES
at the community level, or incinerators can be installed in schools 1 Dasgupta A, Sarkar M. Menstrual hygiene: How hygienic is the adolescent girl?
and in the community. Indian J Community Med 2008;33:77–80.
2 Kumar A, Srivastava K. Cultural and social practices regarding menstruation among
The findings of our study could be generalized to rural areas in adolescent girls. Soc Work Public Health 2011;26:594–604.
northern India with similar socioeconomic and cultural 3 Khanna A, Goyal RS, Bhawsar R. Menstrual practices and reproductive problems: A
environments. Our study has limitations. Our findings were based study of adolescent girls in Rajasthan. J Health Manag 2005;7:91–107.
4 Zhang XJ, Shen Q, Wang GY, Yu YL, Sun YH, Yu GB, et al. Risk factors for
on information reported by the study participants. There is a
reproductive tract infections among married women in rural areas of Anhui Province,
possibility that the study participants would have under-reported China. Eur J Obstet Gynecol Reprod Biol 2009;147:187–91.
certain practices due to their reluctance to acknowledge these 5 Thakre SB, Thakre SS, Reddy M, Rathi N, Pathak K, Ughade S. Menstrual hygiene:
practices to the interviewer. Knowledge and practice among adolescent school girls of Saoner, Nagpur district.
J Clin Diagn Res 2011;5:1027–33.
6 Mudey AB, Kesharwani N, Mudey GA, Goyal RC. A cross-sectional study on
Conclusion awareness regarding safe and hygienic practices amongst school going adolescent
Our study highlights the need to provide women in the reproductive girls in rural area of Wardha District, India. Glob J Health Sci 2010;2:225–31.
7 Deo DS, Ghattargi CH. Perceptions and practices regarding menstruation: A
age with accurate and adequate information about menstruation comparative study in urban and rural adolescent girls. Indian J Commun Med 2005;
and its appropriate management. Healthcare workers should play 5:33–4.
a proactive role in the delivery of such information. It is also 8 Tiwari H, Oza UN, Tiwari R. Knowledge, attitudes and beliefs about menarche of
adolescent girls in Anand district, Gujarat. East Mediterr Health J 2006;12:428–33.
essential for teachers to impart reproductive health education to
their students. Considering the low use of sanitary napkins, there