Menstrual health and hygiene management among female college students and their mothers in Thoothukudi district, Tamil Nadu, India

INTRODUCTION

Menstruation is a normal discharge of blood and tissue from the uterine lining, through the vagina as a part of a woman’s monthly menstrual cycle. Menstruation occurs from menarche, a girl’s first period, till menopause when a menstrual cycle ends. The average menstruation time in normally menstruating women is about five days. Adequate menstrual hygiene management is defined as women and adolescent girls, using clean menstrual management material to absorb or collect blood.¹

Every day 800 million people between the age group of 15 to 49 years are menstruating. But for so many a natural biological process spells more monthly inconvenience. Girls may miss school because they do not have access to sanitary supplies, they are in pain or the schools lack adequate toilet facilities. It is estimated that more than 26 million women and girls are likely to be displaced because of conflict or climate disaster, robbing them from dignity when they have difficulty managing their menstruation and exacerbating their vulnerability. Menstruation should not mean the end of rights to health and gender equality.²

Period poverty describes the struggle many low-income women and girls face while trying to afford menstrual products. The term also refers to the increased economic vulnerability women and girls face during menstruation due to the financial burden posed by menstrual supplies. Period poverty is a continuing issue in India due to the cultural stigma surrounding menstruation. The origin of myths related to menstruation in India dates back to the Vedic times. Further in orthodox families’ women are prohibited and not allowed from participating in normal life while menstruating.³ It is believed that menstruating women are unhygienic and unclean, hence the food they prepare or handle can get contaminated. They consider during menstruation the body emits some specific smell, which turns preserved food spoiled, therefore they are not allowed to touch pickles.⁴ Girls are asked to stay away from religious places, the kitchen, kept in isolation, and not allowed to play outside or even go to school. The myths and beliefs are passed from one generation to the other. Adult women may themselves not be aware of good hygiene practices and pass on cultural taboos and restrictions to be observed.⁵

A two-generation study on menstrual health and hygiene practices among daughters and their mothers is limited. In my study, the main focus is to compare the practices of menstrual health and hygiene practices between mothers and daughters.

METHODS

Study design and population

A community-based cross-sectional study was conducted over seven months from January to July 2023. The data collection period was March – April 2023.

Ethical consideration

The study protocol was approved and reviewed by the dissertation review committee and Institutional Ethics Committee of the Amrita School of Medicine. Permission was also obtained from the principals and deans of the selected colleges. Written informed consent was obtained from the study participants.

Selection process

Thoothukudi district is located in the southern part of Tamil Nadu, a state in South India. There are 20 colleges currently functioning in the Thoothukudi district. Out of 20 colleges, five colleges were chosen by simple random sampling- lottery method. College names were written according to the stream of education and it was divided into separate bowls which were chosen randomly. Informed and written consent was taken from the mothers and students. The study was conducted among female students from the selected colleges and their mothers. Female college students and their mothers who are permanent residents living for more than one year in Thoothukudi district, Tamil Nadu were included in our study. Mothers of female college students who are bedridden, and attained menopause were excluded from the study. From the obtained list, female college students were selected by computer-generated simple random sampling method. From each selected college 100 female college students were chosen based on the inclusion and exclusion criteria.

Sample size

The sample was calculated based on a study done by Parikh et al, in which 79% reported having proper knowledge of menstrual hygiene.⁶ Considering this proportion and 4% absolute precision (d), using the formula given below, the calculated sample size for the study was 415. Therefore, 415 female college students and their mothers were included.

Study instrument and process of administration

A semi-structured questionnaire was used for collecting data for socio-demographic details. A structured questionnaire consisting of 14 questions was used for collecting data related to menstrual health and a set of 10 questions was used to collect information related to period poverty.⁷ For collecting data regarding menstrual hygiene which consisted of 17 questions developed by Global Health Action were used.⁸ The questionnaire was converted into the local language (Tamil) and was validated by two Tamil teachers. The questionnaire was distributed in the local language (Tamil) to mothers and in English to female college students.

Statistical analysis

Data collection was done by the distribution of printed forms to the study participants. Data entry was made in google forms and imported into Excel. Statistical analysis was performed using IBM statistical package for social sciences (SPSS) version 21.0 software. The categorical variables' responses to each question in the questionnaire were expressed in frequency and percentage. The continuous variable age was summarized using mean (SD). Responses to each question were summarized as frequency and percentage. The Chi-square test was used to test the differences in menstrual health, period poverty and menstrual hygiene responses to each question in the questionnaire between mothers and daughters. A p value lesser than 0.05 was considered statistically significant.

RESULTS

Among 500 daughters thirteen are currently married so the other sociodemographic characters have differences. Table 1 shows the distribution of study participants based on the socio-demographic factors of female college students and their mothers.

A comparison of menstrual health between daughters and mothers in the study population was shown in Table 2. The questions like menstrual pain, missing plans with friends, feeling less capable and being scared of staining clothes were responded favourably for mothers. Treating menstrual pain, speaking about menstrual pain, stopping exercising during menstruation, having information about menstruation before menarche and having no symptoms during menstruation for the past 6 months were the questions that are favourable for daughters.

Period poverty among female college students and their mothers’ is shown in Table 3.

The questions like embarrassed about buying menstrual products, using menstrual products longer than recommended due to lack of money and lack of facilities, thinking period products are expensive, lack of money for buying menstrual products and difficulty in accessing menstrual products were responded by the majority of mothers among our study population. Made up an excuse not to say menstruating, trouble concentrating at work and the necessity for menstrual leave were responded to by a majority of daughters.

A comparison of menstrual hygiene between daughters and mothers in the study population was shown in Table 4. The questions like using clothes, menstrual cups, and cotton as menstruating materials at home during menstruation were found to be favourable for mothers among the study population. Changing menstrual materials away from home and disposing of menstrual materials during menstruation away from home were responded to satisfactorily among mothers. Using disposable sanitary pads at home, clothes menstrual cups and disposable sanitary pads as a menstrual material away from home were favourable for daughters among the study participants. Changing menstrual materials at home and disposing of menstrual materials during menstruation at home were responded to satisfactorily among daughters.

Others* in the marital status of mothers include divorced, separated and widow, APL*- above poverty line, BPL*- below poverty line

DISCUSSION

In our study, 42.2% of daughters had symptoms during menstruation whereas in a study done in Pondicherry among adolescent girls, 8.4% of adolescent girls had symptoms during menstruation.¹⁰ In our study, during menstruation among female college students, 71.8% feel tired, 3.6% feel happy, 29.9% feel sad, 59.8% feel angry and 14.6% feel irritated. In a study done in a Palestinian female college,78% feel tired, 12.8% feel happy, 45.3% feel sad, 55.3% feel angry and 64% feel sensitive during the time of menstruation.¹¹ Among female college students in our study, 83.8% are scared of staining clothes during menstruation, and in a study done among the Kalinga Institute of medical sciences 80% of female college students fear leakage or staining and this was one of the reasons for college absenteeism.¹²

In this study, 72.2% of the daughters think that period products are expensive while 63% of daughters are embarrassed about buying menstrual products. In a study done in Pondicherry among adolescent girls, 57.9% of adolescent girls think period products are expensive and 14% of adolescent girls are embarrassed about buying menstrual products.¹⁰

In our study, 66.8% of female college students experience period poverty whereas, in a study done in the United States by Cardoso et al, among first generation college girls 20.6% experience period poverty.¹³ In our study, 70.6% of mothers of female college students think that menstrual leave is not a necessity, whereas, in a study done by Bhattacharya et al, 23% of female respondents think that menstrual leave is unfair.¹⁴

Among the study participants in this study, 99.8% of female college students have unsatisfactory methods of changing menstrual products when they are away from home most probably in college and disposing of used menstrual material at college was found to be 82.8% satisfactory. The major reason for unsatisfactory methods of changing menstrual products may be due to unsanitary facilities or hesitation to uncleaned restrooms during menstruation. In a study done in Bhuvaneswar in Kalinga Institute of Medical Science, the major reason for college absenteeism during menstruation was mainly due to lack of privacy in the bathroom for girls 12.73%, lack of disposal system for menstrual material 8.46%, lack of continuous water supply in college toilets was 8.46% and no private place to manage periods at college was 75.91%.¹² In a study done by Munro et al, among university students in Australia, the reason for not changing menstrual products at university was no requirement in changing menstrual materials 63.6%, fear of being heard or seen 14.3%, no disposal bin was 2.6%, no replacement to use 18.2%, unsanitary facility 31.2% and others like not enough time between classes or toilet is too far 26%.¹⁵

In our study, 46.2% of daughters and 19.8% of mothers have information about menstruation whereas, in a study done among mothers and daughters in Rangpur Bangladesh, 36.11% of daughters and 37.04% of mothers have good knowledge of sexual and reproductive health.¹⁶ In a study done at Kalinga Institute of Medical Sciences, Bhuvaneswar 80% of the female college students inculcated their menstrual habits from their mothers.¹²

The limitation of this study was self-administrated, so there may be an overestimation or underestimation. Menstruation-related topics may have social desirability bias while reporting.

CONCLUSION

This study provided the baseline for understanding menstrual health, period poverty and menstrual hygiene among female college students and their mothers in Thoothukudi district, Tamil Nadu. Mothers hesitate to talk about menstrual-related topics and menstrual practices were influenced by various factors while daughters’ menstrual practices were found to constrain those factors. There is a need to expand the Menstrual Hygiene Scheme program to provide safe and sanitary menstrual products to college girls and mothers who are menstruating especially in rural areas where they are out-stocked with menstrual products.

ACKNOWLEDGEMENTS

The authors acknowledge Dr. K. R. Thankappan, Professor and Head, Department of Public Health, Amrita School of Medicine, Kochi, who supported with the constructive feedback, generous advice, and kind support.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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