Knowledge, attitude and practice regarding menstrual cup among adolescent girls in Savadatti taluka, Belagavi district, Karnataka

INTRODUCTION

Menstrual hygiene management (MHM) is an important yet often neglected aspect of adolescent and reproductive health. Disposable sanitary pads and tampons are the most widely used menstrual products globally. They generate non-biodegradable waste leading to both environmental and public health challenges. Menstrual cups, with the lowest ecological footprint compared to single-use pads and tampons, are being used by 49 and 19 billion individuals each year in the European Union (EU) and United States of America (USA), respectively.^1,2 Despite these advantages, their adoption worldwide remains limited, due cultural stigma, insertion-related fears, and lack of awareness.²

In India, the burden of menstrual waste is particularly high. Approximately 336 million menstruating women uses more than 12 billion sanitary products annually, most of which are non-biodegradable and may take 500–800 years to decompose.³ Despite the availability of reusable products like menstrual cups, their use is still limited with only 0.3% of Indian women aged 15–24 years are using them.⁴ Cultural taboos, fear of hymen rupture, concerns about leakage, and inadequate awareness are the major barriers for the use of menstrual cups.^5,6

Health implications are equally significant. Inadequate menstrual hygiene practices increase the risk of reproductive tract infections, absenteeism from school, and psychosocial stress among adolescent girls.⁷ However, the use of sustainable products like menstrual cups if introduced at an early age, can be easier to accept and lead to long-term hygiene practices, while also reducing the associated stigma and offering economic and environmental benefits. Yet existing evidence from India shows that awareness of menstrual cups is moderate to high in some populations, but actual adoption remains consistently low.^8-10 Studies from both urban and semi-urban contexts report barriers such as lack of practical guidance, concerns over safety, and socio-cultural resistance.^9-11

The unique socio-cultural setting of Savadatti taluka, Karnataka with a mix of rural and urban communities, presents certain challenges for menstrual hygiene promotion. Several factors such as low awareness, cultural norms, resource constraints, and infrastructural barriers may affect the adolescent girls’ perceptions and practices around menstrual cups. However, there is limited evidence from this region. Therefore, understanding the knowledge, attitude and practices (KAP) of adolescent girls in this setting is essential to: identify gaps and misconceptions, design culturally appropriate education and awareness interventions, and to inform policies to promote sustainable menstrual hygiene. Hence, this study was conducted to assess the KAP regarding menstrual cups among adolescent girls in Savadatti taluka, Belagavi district, Karnataka.

METHODS

This was a community-based cross-sectional study conducted among adolescent girls aged 15–19 years in Savadatti taluka, Belagavi district, Karnataka. Data collection was carried out between January and June 2025.

A total of 10 schools and 5 colleges were selected by random sampling. Within each institution, participants were chosen through simple random sampling. Permission was obtained from the respective headmasters and principals before initiation of the study. The objectives of the study were explained in the local language, and informed consent/assent was obtained from all participants. For minors, parental consent signatures were also collected. Confidentiality and anonymity were maintained throughout the study.

Data were collected using a semi-structured, pre-tested questionnaire administered in classroom settings. The tool collected demographic characteristics, as well as knowledge, attitudes, and practices related to menstrual cups. Students were seated separately during administration, and the process was supervised by both teachers and the investigator. Each questionnaire required approximately 20–25 minutes to complete.

The primary outcomes were levels of KAP regarding menstrual cups. Secondary analyses examined associations between KAP scores and socio-demographic variables.

The study was approved by the Institutional Ethics Committee (IEC) of Manipal Academy of Higher Education (MAHE) and the Block Educational Officer in Savadatti Block, Karnataka.

Statistical analysis

Data were entered in Microsoft Excel and analysed using Jamovi software (version 2.4.6). Categorical variables were summarized as frequencies and percentages. Associations between socio-demographic variables and KAP categories were tested using the Chi-square test or Fisher’s exact test, as appropriate. A two-sided p value of <0.05 was considered as statistically significant.

RESULTS

Sociodemographic characteristics

A total of 426 adolescent girls participated in the study. The majority (89.0%, n=380) were aged 15–17 years, with only 10.8% (n=46) in the 18–19-year group. More than half (56.8%, n=242) were from rural areas, while 43.2% (n=184) resided in urban areas. Most were school-going students (72.1%, n=307), and a smaller proportion were in pre-university education (27.9%, n=119).

The majority of families had an annual income <50,000 Indian Rupees (INR) (92.0%, n=392). Nearly half of mothers (50.5%, n=215) had completed secondary school leaving certificate/pre-university course (SSLC/PUC), while 46.0% (n=196) were below SSLC. Fathers showed slightly higher education levels, with 23.0% (n=98) being graduates. Homemaking (28.9%) and garment/tailoring (34.3%) were the most common occupations among mothers, whereas farming (23.2%) and business (20.2%) predominated among fathers (Table 1).

Awareness and sources of information

Among the 426 participants, only 43.9% (n=187) were aware of menstrual cups, while 56.1% (n=239) had no prior knowledge (Figure 1). Among those who were aware, the internet and social media were the primary source of information (39.6%, n=74), followed by family and friends (24.1%, n=45), healthcare professionals (18.7%, n=35), schools/teachers (10.2%, n=19), and advertisements (7.5%, n=14) (Figure 2).

Knowledge, attitudes, and practices

Only 21.1% (n=90) of participants had adequate knowledge about menstrual cups, while the majority (78.9%, n=336) had inadequate knowledge. Attitudes were similarly limited, with 43.7% (n=186) showing a positive attitude and 56.3% (n=240) expressing poor attitudes. Practices were least encouraging, as only 9.2% (n=39) reported good practices, while 90.8% (n=387) had poor practices (Table 2).

INR: Indian rupees; KAP: knowledge attitude and practice; PUC: pre-university course; SSLC: secondary school leaving certificate

Detailed analysis of knowledge items showed that while about half of participants correctly identified silicone as the cup material, many believed it was plastic or leather. Misconceptions regarding duration of use were common, with several respondents believing the cup could only be used once or for a few months. Internet and social media were the major information sources (Table 3).

Item-wise responses on attitude found that most girls agreed that menstrual cups are hygienic, modern, and cost-effective, and nearly 80% would recommend them to peers. However, concerns about safety, ease of use, and the possibility of infection were present (Table 4).

Practice-related findings showed very low adoption. Among the few current users, most had been using the cup for less than one year. While many participants acknowledged the menstrual cup’s safety and cost-effectiveness, several expressed concerns regarding its comfort, possible interference with daily activities, and a lack of confidence in using it correctly. Among non-users, a considerable number were still uncertain about whether they would be willing to try it in the future (Table 5).

Determinants of knowledge

Logistic regression analysis found that age, residence, and family income were significantly associated with knowledge levels. Participants aged 18–19 years were less likely to have adequate knowledge compared to those aged 15–17 years (adjusted odds ratio [AOR]=0.34; 95% confidence interval [CI]: 0.14–0.83; p=0.069). Rural participants were more likely to have adequate knowledge than their urban ones (AOR=1.71; 95% CI: 0.86–3.41; p<0.001). Family income also influenced knowledge with participants from families earning >50,000 INR annually were less likely to have adequate knowledge (AOR=0.23; 95% CI: 0.04–0.88; p=0.032) (Table 6).

Determinants of attitude

Educational status and family income were the significant predictors of attitudes toward menstrual cups. Pre-university students were less likely to show a positive attitude compared to high school students (AOR=0.44; 95% CI: 0.28–0.68; p<0.001). Similarly, participants from families with an annual income >50,000 INR were significantly less likely to have a positive attitude (AOR=0.11; 95% CI: 0.04–0.32; p<0.001). No significant association was observed with age, residence, or parental education (Table 7).

AOR: Adjusted odds ratio; CI: confidence interval; COR: crude odds ratio; INR: Indian rupees

AOR: Adjusted odds ratio; CI: confidence interval; COR: crude odds ratio; INR: Indian rupees

DISCUSSION

This study evaluated the KAP related to menstrual cup use among adolescent girls aged 15–19 years. The findings show that while menstrual cups are increasingly recognized as a sustainable menstrual hygiene option, awareness and actual usage among young girls is limited. Only 43.9% of participants had heard of menstrual cups, and only 9.2% had ever used them. Although many participants expressed willingness to recommend menstrual cups to others, persistent gaps in knowledge, cultural hesitations, and misconceptions continue to hinder their wider acceptance.

Awareness levels observed in this study were modest compared to some urban studies in India. A study from urban Kerala reported that over 90% of women were aware of menstrual cups, yet only 15% had used them.⁶ Similarly, another study noted that even among healthcare professionals, misconceptions about safety and insertion were common.¹³ In the present study, less than one-fourth of participants showed adequate knowledge, and many had incorrect beliefs regarding the material, cost, and lifespan of menstrual cups. However, previous studies show that medical-grade silicone cups are durable and can safely be reused for up to 10 years when properly maintained.¹⁴

In the present study, social media and the internet are the most common sources of information about menstrual cups, followed by family and peers. This suggests that adolescents tend to rely more on informal digital sources rather than structured health education. Similar observations have been reported in studies from Kerala and Gujarat, where online platforms often replaced formal channels of menstrual health communication.^15,16 However, certain unregulated sources can also circulate misinformation, reinforcing myths about virginity, pain, and hygiene that strongly influence adolescent perceptions.¹⁷ The limited involvement of teachers and healthcare providers observed in this study highlights an important opportunity to strengthen school-based and community-level menstrual health education through accurate, evidence-based guidance.

Despite these knowledge gaps, nearly half of the participants in the present study expressed positive attitudes toward menstrual cup use, and a few said they would recommend the product to others. This finding indicates that adolescents are open to adopting sustainable menstrual hygiene options when they receive proper information and reassurance. Similar findings were reported in other studies, where young women showed willingness to try menstrual cups but were held back by fears related to insertion, pain, and infection.^17,18

In the current study, attitudes were also influenced by age, education, residence, and family income. Participants from urban areas and better-educated families tended to express more favourable views, consistent with earlier findings that socioeconomic and educational differences play an important role in shaping menstrual health literacy.^12,16

Although awareness and attitudes showed encouraging trends, actual menstrual cup use remained extremely low. Less than one in ten participants reported ever using a menstrual cup, reflecting both national and global patterns. According to the National Family Health Survey-5 (NFHS-5) data, less than 0.3% of Indian women aged 15–24 years use menstrual cups.¹⁶ The major barriers identified in this study are fear of insertion, lack of guidance, and cultural discomfort which are similar to those documented in previous studies.^13,14 While a few users reported positive experiences, several described initial difficulties, emphasizing the need for practical demonstrations, peer support, and continued guidance to improve confidence and comfort during early use.

The present study also demonstrated a strong association between knowledge and attitude, suggesting that better understanding of menstrual cups can lead to more favourable perceptions and greater acceptance. However, translating awareness into actual behaviour requires ongoing engagement, open conversations, and normalization of menstrual cup use within peer and family circles. Evidence from intervention-based studies supports that hands-on demonstrations, peer mentorship, and guided counselling can significantly improve comfort levels and uptake among new users of menstrual cups.¹⁸

These findings highlight the urgent need for structured menstrual health education programs within schools, particularly in rural and semi-urban settings. Integrating menstrual cup awareness and training into existing adolescent health initiatives, such as the Rashtriya Kishor Swasthya Karyakram (RKSK), could help bridge the gap between knowledge and practice. Healthcare providers, teachers, and community educators should be equipped to educate regrading myths, address safety concerns, and offer practical guidance on the use, hygiene, and maintenance of menstrual cups. Strengthening digital and social media campaigns with credible, evidence-based content can also play a vital role in reshaping perceptions and encouraging informed choices among adolescents.

A major strength of this study lies in its focus on adolescents from both rural and urban areas, which provided a balanced perspective on menstrual hygiene awareness in a semi-urban Indian context. The large sample size added robustness to the observed associations between knowledge, attitudes, and sociodemographic factors. Furthermore, the use of validated KAP tools enhanced the reliability and comparability of results with existing literature.

However, certain limitations should be acknowledged. The cross-sectional design limits the ability to infer causality between variables. Self-reported responses may have been influenced by recall bias or social desirability, particularly given the sensitive nature of menstruation. In addition, as the study was conducted in a single taluka, the findings may not be generalizable to all regions. Future research using mixed-method approaches, including qualitative insights, could provide deeper insights into the cultural beliefs, emotional factors, and social barriers that influence menstrual cup adoption among adolescents.

CONCLUSION

The present study highlights that although awareness and attitudes toward menstrual cups among adolescent girls in Savadatti Taluka are gradually improving, actual adoption remains very limited. There are misconceptions, fear of insertion, and inadequate menstrual health education which continue to act as major barriers. Strengthening school-based menstrual health programs, ensuring access to accurate information through healthcare providers and digital media, and promoting open discussions can help bridge the knowledge–practice gap. These efforts are essential to enhance menstrual hygiene, empower the adolescent girls, and support sustainable health practices.

ACKNOWLEDGEMENTS

Authors would like to thank all the adolescent girls who participated in the study, and the school authorities for their cooperation.

Funding: No funding sources

Conflict of interest: None declared

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

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