Menstrual hygiene behaviour among the tribal married women aged 15 to 49 years: A cross-sectional study in a community development block of Paschim Bardhaman District, West Bengal

ABSTRACT

Background:

Menstrual hygiene management is integrally associated with reproductive health of women. Menstrual health and hygiene needs, particularly of tribal women still remain unmet for many reasons. Inappropriate menstrual behaviour leads to adverse health consequences.

Objectives:

This study aimed to ascertain the menstrual hygiene behaviour of tribal married women aged 15 to 49 years and its correlates.

Methods:

A descriptive cross-sectional study was conducted from May 2019 to April 2020 in the Barabani block of Paschim Bardhaman district, West Bengal. A calculated sample of 530 women was selected randomly from 10 tribal villages of the study area; they were interviewed through a pre-designed schedule for socio-demographic and menstrual hygiene behaviour characteristics. Menstrual hygiene management score was derived based on five essential components- hygienic absorbents, hygienic disposal of absorbents, frequency of changing of absorbents, cleaning of external genitalia and source of water for cleaning; menstrual hygiene behaviour was categorised as favourable and unfavourable. Bivariate and multivariable logistic regression was performed using SPSS v. 20.

Results:

All 530 women were Hindu and belonged to Santhal ethnicity; 53.4% were illiterate. Sanitary pads were used by 43.8% of women; 63% practised indiscriminate throwing for disposal of absorbents; 86% practised appropriate changing of absorbents. Overall, 63% had favourable menstrual hygiene management behaviour, and the literacy status of women was found to be a significant predictor.

Conclusion:

Unfavourable menstrual practices are still widely prevalent among tribal women, mainly attributable to lack of knowledge. Awareness generation should be focused on improving those practices, which would also result in the improvement of general health conditions.

Introduction

Menstruation is a normal physiological phenomenon in women of reproductive age. But it is still considered by a wider section of the population as an unclean phenomenon in our country’s perspective.[1] Menstruation-related aspects/problems remained a subject of neglect and less priority for a long because of the taboo and discrimination attached to it.[2] However, comprehensive reproductive health is a priority issue; special health needs of women, including menstrual hygiene management, are duly recognised.

Menstrual hygiene deals with the special health care needs and requirements of women during menstruation. Menstrual hygiene management (MHM) focuses on practical strategies for coping with monthly periods and refers to the management of hygiene associated with the menstrual process.[3] WHO and UNICEF have defined MHM as: “women and adolescent girls using a clean menstrual management material to absorb and collect blood, that can be changed in privacy as often as necessary for the duration of the period, using soap and water for washing the body as required and having access to facilities to dispose of used menstrual management materials.”[4]

Inadequate access to these leads to unhygienic menstrual behaviours with a potential threat to various adverse health consequences.[2] The use of unhygienic sanitary absorbents and the practice of unhygienic storage and disposal of used absorbents are often seen in rural and urban areas, which also vary in severity according to caste and ethnicity. Inadequate WASH (water, sanitation and hygiene) facilities in general, and particularly in public places, such as in schools, workplaces or health centres, are major obstacles to women and girls for MHM. In addition, illiteracy, persisting gender inequality, social norms, and cultural taboos are some of the prevailing constraints.[2,5]

However, MHM is currently being emphasised in India.[6] A flagship sanitation operation, the Swachh Bharat Mission has made a remarkable stride in breaking the taboo around menstruation. MHM has also been included in large-scale programmes, including measures on constructing facilities that cater to the needs of menstruating girls/women and raising awareness among the community. The Government of India has provided subsidies on sanitary pads under the scheme of Gandhi Scheme for Empowerment of Adolescent Girls-SABLA programme of the Ministry of Women and Child Development. The SABLA programme has covered adolescent girls, creating awareness of MHM as a very important initiative for improving health, nutrition and empowerment.[6]

Tribal population as a social group is more vulnerable, being socio-culturally deprived and having lack of access to most of the essential amenities. A low level of awareness about menstruation among the tribal women along with beliefs in taboos, spiritual powers and tribal remedies, superimposed with lack of availability and accessibility to sanitary absorbents make their menstrual behaviour unhygienic.[2,5]

Understanding the current status in diverse contexts, the needs, influencing factors and barriers and also the consequences of unhygienic menstrual practice on overall reproductive health is of critical significance. Studies specifically among tribal women on MHM are yet limited in India. Few earlier studies among tribal adolescent girls/women in different states in India[7,8,9,10,11] reflected unsatisfactory MHM practices including lack of knowledge and its relationship with Reproductive Tract Infection. Research evidence is grossly lacking in West Bengal.

Adequate and comprehensive evidence on MHM among socially vulnerable groups of tribal women would identify targeted needs and approaches, help in the practice of family care physicians and strengthen the existing programmes.

In this overall perspective, the present study was conducted to assess the menstrual hygiene behaviour and socio-demographic correlates among tribal married women of reproductive age in a community development block of Paschim Bardhaman district, West Bengal.

Materials and Methods

Study type/design, study area and subjects

A descriptive cross-sectional study was conducted from May 2019 to April 2020 in Barabani Block of Paschim Bardhaman District, West Bengal. Barabani block had been selected as the study area for this research work as it is one of the eight community development blocks of the district, with 14% of total population belonging to scheduled tribe.[12] The block has 52 census villages, of which ten villages with more than 90% of the population are tribal.[13] These were considered tribal villages, and study subjects from these villages were included.

Tribal married women within the reproductive age group (15 to 49 years), residing for at least one year in the identified ten tribal villages of the block, were considered the study population. Seriously ill and those who attained menopause were excluded.

Sample size and sampling

The present study was part of a research work assessing multiple reproductive behaviours (contraceptive prevalence, unmet need, menstrual hygiene, etc.), the primary aspect of which has already been published elsewhere[14] with the details of sample size calculation to satisfy the requirements of various outcome variables. The sample size was calculated using the formula, n = (Z_1-α/2)²*P*(1-P)/d², considering 45% prevalence (p) of contraceptive methods among the currently married tribal women,[15] with 95% confidence interval and a relative precision (d) of 10%. An anticipated non-response of 10% was added, and the final sample size was 523. An equal number of study subjects (523/10 = 52.3 ≈ 53) were selected from each of the 10 tribal villages of the study area. With the help of peripheral health workers, a sampling frame of eligible study subjects was prepared for each of the ten villages, and the required number of subjects (53) was selected by simple random sampling. Thus, finally, a total of 530 study subjects were included in the study.

Tools and techniques/data collection

Data was collected at the household level by interviewing the selected eligible study subjects with a pre-designed, pre-tested schedule. Before interview, purpose and procedure of the study were briefed to the selected women and written informed consent or assent was taken as per the age of the participant. Necessary permission was also obtained from the district health authorities before the conduction of the study.

Study variables and operational definitions/descriptions

Background and socio-demographic variables included age, age at marriage, age at first pregnancy, number of children, religion, ethnicity, occupation, literacy status, type of family, family income, number of family members, and socioeconomic status.

Variables related to menstrual hygiene behaviour included age of menarche, types of absorbent used in the last menstrual cycle, reuse of absorbents and method of washing of the reused absorbents, appropriate use of absorbents in the last menstrual cycle, frequency of changing of absorbents, disposal of absorbents used in the last menstrual cycle, cleaning of external genitalia-frequency of cleaning, source of water used for cleaning and place with privacy (in-house toilets) for cleaning.

MHM score: MHM was a derived variable calculated based on five essential components, as also conducted by other researchers[8,16] (a) hygienic absorbents[17] (considered as sanitary napkins or single-use clean cloth or cloths if re-used-washed with soap and water and dried in the sun); (b) hygienic disposal of absorbents[17] (considered as dedicated waste bins with lids); (c) adequate frequency of changing absorbents (at least twice daily for average flow and minimum thrice daily for heavy flow); (d) adequate cleaning of external genitalia (as often required, minimum twice a day) and (e) appropriate source of water for local cleaning (piped/tap water) [Table 1].

Table 1.

Menstrual hygiene management (MHM) components - correct practice for each of the components, scoring system and categories

MHM components	Correct/hygienic practice[8,16,17]	Scoring system/categories
Types of absorbent use	Sanitary pad/single-use clean cloth/cloth reused and washed with soap and water, dried in the sun	For each component: Correct practice=1 Incorrect practice=0
Frequency of changing absorbents	Frequency of change at least twice daily and thrice or more in case of heavy flow	Range of score=0–5
Frequency of local (external genitalia) cleaning	At least twice a day	Categories of MHM:
Disposal of absorbents	Waste bin with lids	Favourable: Score ≥3
Source of water for local (external genitalia) cleaning	Piped (tap) water	Unfavourable: Score <3

Data management and statistical analysis

Collected data were checked for completeness and consistency and entered in Excel data sheets. SPSS Statistics Version 20 was used for analysis. The results of categorical variables were expressed in frequency and percentage. Data pertaining to MHM were organised into correct and incorrect practice in relation to five component domains (as mentioned above and in Table 1). Hygienic/appropriate/adequate practice for each of the components was given a score of 1, and for incorrect practice, a score of 0. Thus, the total composite score ranged from 0 to 5 and finally were categorised into two outcome categories[8]: favourable (score ≥3) and unfavourable (<3). The favourable menstrual hygienic behaviour was considered the outcome variable for analysis; bivariate and multivariable logistic regression analysis was performed to identify the correlates. P value ≤0.05 was considered to be statistically significant for all inferential statistics.

Ethical considerations

Ethics approval was obtained from the Institutional Ethics Committee of Burdwan Medical College and Hospital, Purba Bardhaman, West Bengal (No. 83. dated January 08, 2019). Before data collection informed consent/assent (for respondents below 18 years) was obtained from each study subject. Confidentiality and anonymity of information was maintained.

Results

Background characteristics

Out of 530 study subjects, all were Hindus and belonged to the Santal ethnic group. Majority of them (55.3%, 293/530) belonged to the age group of 20 to 29 years; they were illiterate (53.4%, 283/530), homemakers (91.1%, 483/530) and from lower socioeconomic classes (67.6%, 358/530). Around half of the women belonged to a joint family (50,9%, 270/530), were married before the age of 18 years (51.7%, 274/530), and among the women who had ever been pregnant, 52.4% (267/510) had their pregnancy before 19 years of age. Among all the study subjects, 308 (58.1%) experienced menarche between 9 and 11 years of age, and the rest (41.9%) experienced menarche between the ages of 12 and 14.

Menstrual hygiene behaviour and management

Details of the menstrual hygiene behaviour characteristics are presented in Table 2. Only 43.8% were using sanitary pads, and 55.3% were using reused cloths as absorbents, of which only 44% were correctly washing with soap and water and drying in the sun. Indiscriminate throwing was the most prevalent method (63%) for the disposal of absorbents. For cleaning the external genitalia, only 20.9% had an in-house toilet facility and 83.8% used pond water for cleaning purpose.

Table 2.

Menstrual hygiene behaviour characteristics among the study subjects (n=530)

Menstrual hygiene behaviour characteristics	Frequency (%)
Age at menarche (years)
9–11	308 (58.1)
12–14	222 (41.9)
Mean (SD)	11.30±0.04
Median (IQR)	11 (11-12)
Types of absorbents used
Sanitary pad	232 (43.8)
Single-use clean cloth	5 (0.9)
Cloth reused	293 (55.3)
Washing practices of reused cloths (n=293)
Wash with soap and water, dry in the sun	129 (44.0)
Wash with only water and dry in the sun	96 (32.8)
Wash with soap, water and dry in the shade	68 (23.2)
Disposal of absorbents
Indiscriminate throwing	334 (63.0)
Hiding in the mud or bushes	166 (31.3)
Drains	30 (5.7)
Waste bins with lid	0
Change of absorbents/day
Once	38 (7.2)
Twice	311 (58.7)
≥Thrice	181 (34.1)
Local cleaning of external genitalia/day
Once	23 (4.3)
Twice	309 (58.3)
≥Thrice	198 (37.4)
Place used for local cleaning
In-house toilet	111 (20.9)
Other places	419 (79.1)
Source of water for cleaning
Piped (tap) water	55 (10.4)
Pond water	444 (83.8)
Other sources	31 (5.8)

Overall, 69.1% of women were found to use hygienic absorbents, but none were found to dispose of the absorbents following appropriate methods. However, 86% were reported to be practising appropriate changing of absorbents. Only 55 (10.4%) women had access to piped water for cleaning and bathing during menstruation. Based on the calculated composite score, overall, 63% of tribal women had favourable MHM behaviour [Table 3]. On multivariable logistic regression, among the various socio-demographic characteristics, the literacy status of the women was found to be the only significant predictor of favourable MHM behaviour and, though the model is fit (Hosmer Lemeshow test P value = 0.972), only 3.6% variation in the outcome variable can be explained by this model [Table 4].

Table 3.

Menstrual hygiene management (MHM) practices and categories among the study subjects (n-530)

MHM Practices and Categories	Frequency (%)
MHM Practice—Components#
Use of hygienic absorbents	366 (69.1)
Appropriate disposal of absorbents#	0 (0)
Adequate frequency of change of absorbents	456 (86)
Adequate local cleaning of external genitalia	507 (95.7)
Hygienic source of water for local cleaning	55 (10.4)
MHM Categories (Score)#
Favourable (≥3)	334 (63)
Unfavourable (<3)	196 (37)

^#Defined/described in Table 1

Table 4.

Multivariable logistic regression for predicting overall menstrual hygiene management (MHM) of the study subjects (n=530)

Sociodemographic characteristics	n	Favourable MHM n (%)	OR (95% CI)	AOR (95% CI)	P
Age (years)
15-19	81	49 (60.5)	Ref.	Ref.
20-29	293	196 (66.9)	0.758 (0.46-1.26)	0.959 (0.52-0.17)	0.894
30-39	117	68 (58.1)	1.103 (0.62-1.97)	1.138 (0.53-2.43)	0.738
40-49	39	21 (53.8)	1.312 (0.61-2.83)	1.281 (0.50-3.28)	0.606
Age at marriage (years)
<18	274	168 (61.3)	Ref.	Ref.
≥18	256	166 (64.8)	0.859 (0.60-1.22)	0.974 (0.63-1.50)	0.974
Age at first pregnancy (years) (n=510)
<19	221	137 (62.0)	Ref.	Ref.
≥19	291	189 (64.9)	0.880 (0.61-1.27)	0.918 (0.59-1.41)	0.700
Number of children
≤2	364	236 (64.8)	Ref.	Ref.
>2	166	98 (59.0)	1.28 (0.88-1.28)	1.080 (0.67-1.75)	0.755
Occupation
Homemaker	483	307 (63.6)	Ref.	Ref.
Working outside	47	27 (57.4)	1.292 (0.70-2.37)	0.821 (0.43-1.57)	0.552
Literacy status
Literate	247	175 (70.9)	Ref.	Ref.	0.004
Illiterate	283	159 (56.2)	0.528 (0.37-0.76)	0.570 (0.39-0.84)
SE status*
Lower	358	219 (61.2)	Ref.	Ref.
Middle#	172	139 (38.8)	0.781 (0.53-1.44)	0.950 (0.61-1.49)	0.822
Family type
Joint	270	166 (61.5)	Ref.	Ref.
Nuclear	260	168 (64.6)	0.874 (0.61-1.24)	0.844 (0.57-1.23)	0.406

*Based on the updated B G Prasad scale (January 2020); ^#Middle category includes middle and lower middle classes. Hosmer Lemeshow test P=0.972; Nagelkerke’s R²=0.036

Discussion

The present study revealed variable menstrual hygiene behaviours among rural tribal women in an area of West Bengal.

The mean (SD) age of menarche in this study was 11.30 ± 0.04 years, which is similar to the studies in Tamilnadu,[18] Nagpur district of Maharastra[8] and Rajasthan[19] but slightly lower compared to the findings in Dhur Ghond tribe in Chhatisgarh.[7]

In our study, 43.8% of married tribal women were found to use sanitary pads. Similar reports regarding the use of sanitary pads have been observed in other studies.[8,20] A study among a specific tribe group in Madhya Pradesh reported that 40.9% of women were using hygienic menstrual absorbents (22.7% only sanitary pads and 18.2% both sanitary pads with new cloth).[20] A school-based study in a rural area of West Bengal reported that 47.9% used both sanitary napkins and clothes, and 20.8% of girls used only sanitary napkins.[21]

On the contrary, according to a study among reproductive age group women, majority of the women preferred cloth pieces rather than sanitary pads as menstrual absorbent. Only 35% of women used sanitary pads during menstruation.[18] However, in another study among the Dongria Kondh tribe in Maharashtra, none were found to use sanitary pads among women of reproductive age.[9]

Besides sanitary pads, considering single-used cloth and reused cloth, which is washed with soap and water and dried in the sun as appropriate absorbents, 69.1% of women in the present study were found to be using appropriate absorbents, which was favourably higher compared to other studies in different states.[1,8,9,10,11,22]

We found that 86% of the tribal women in the present study were practising appropriate changing of absorbents, contrary to only 33.9% in a similar study.[8] A study in Tamilnadu reported that 32% of women changed two to three sanitary pads, and only 2.5% changed four to five sanitary pads per day.[18]

Appropriate disposal of used absorbents was practiced by no one in our study. Though 95.7% had hygienic practices for cleaning their external genitalia, only 10.4% were using the recommended piped water for this purpose. Inappropriate disposal of absorbents was also reported by other studies.[18,20,23]

Considering the different individual components of menstrual hygiene together, overall menstrual hygiene behaviour was favourable for majority of the tribal women in the present study and among the various factors analysed as predictors, only the literacy status of women was found to be a significant predictor of favourable menstrual hygiene practice. Few other studies[10,18,22] also reported literacy as a significantly associated factor.

However, for a substantially high proportion of women, the frequency of changing absorbents, frequency of cleaning private parts, behaviour related to disposal of absorbents and using clean water for cleaning private parts were not appropriate to attain good menstrual hygiene. Not only in our study, as revealed by many of the other studies[8,10,18,20,22,23] in different geographical areas, such undesirable menstrual hygiene behaviour still persists among tribal married women of reproductive age.

It is not only the extent of women adopting a particular favourable or unfavourable practice, the existing other eco-social features may make the situation more complex with far-reaching consequences. The practice of inadequate washing of reused clothes might attract infection in the private parts, and the context of women with no clean place to wash their clothes, households with a pond as a source of water for domestic use, and the absence of adequate toilets aggravates the likely adverse effects of unfavourable menstrual practice. Often, the washed clothes are dried inside the room, over the bamboo supporting the roofs. Even wet clothes are hidden in the dark, damp corners and often reused before they are completely dry. The frequency of changing absorbents also varied according to their belief and awareness. All these behaviours are related to the belief that menstruation is a dirty, shameful and cursed part of women’s lives.

Despite the Total Sanitation Campaign of the Government of India, there are insufficient toilets and fewer clean private bathrooms for cleaning private parts during menstruation.[3] In the present study, 20.9% of the tribal women reported the availability of in-house toilets. This further reveals that awareness generation regarding MHM among married tribal women is not sufficient to ensure menstrual hygiene. Accessibility to safe water and appropriate sanitation facilities, affordability and availability of hygienic sanitary absorbents are equally essential to acquiring menstrual hygiene and health.

The serious concerns regarding the implementation of government programmes also deserve special focus. Village-level health functionaries should utilise every contact with the women regarding different aspects of menstrual hygiene—use of sanitary pads, changing of pads and appropriate disposal, cleaning of local private parts, use of clean water, etc., Sanitary pads, free of cost, are being supplied to adolescent girls up to 19 years of age from Anwesha clinic under the ARSH programme. Besides monitoring to ensure the provision of sanitary pads to every eligible adolescent, relaxation of the age limit may also be considered for tribal women of reproductive age. At the same time, ensuring the availability of low-cost sanitary pads at local shops may improve the menstrual hygiene status of the tribal women.

Menstrual hygiene issues should also be comprehensively addressed through school health programme as envisaged in the national strategy. Besides ensuring the supply of sanitary pads through schools and creating necessary infrastructural provisions for MHM, the teachers can also be trained. The teachers, trained with the necessary skills to impart reproductive health education, may help to minimise the misbelieves and taboos among the school-going tribal girls.

Though comparable studies are lacking in regards to all these behavioural components of menstrual hygiene, the findings of the present study itself indicated certain specific areas of unfavourable practice, which need special emphasis while targeting interventions.

The study has the inherent strengths of being community-based and among tribal women. However, it has few limitations. Recall bias like age at menarche and response bias, especially with the information provided by the women about their age, and sanitary material use behaviour cannot be ruled out.

Conclusions

Besides favourable menstrual hygienic practices like using appropriate absorbents, practising appropriate change of absorbents, and hygienic cleaning of private parts; unhygienic practices are still prevalent. As components like disposal of absorbents, washing of reused clothes and water used for cleaning private parts during menstruation are unhygienic in the studied area, it may be assumed that not only IEC/BCC activities are lacking in the area, but lack of access to safe water, inadequate sanitation and sewerage facilities may be considered to have a significant role in this aspect. General vulnerability issues of the tribal married women of the study area are an alarming indicator of unfavourable menstrual hygiene which needs to be addressed too.

Financial support and sponsorship

This paper, being a part of the larger study, was financially supported by the Indian Council of Medical Research financial grant for Post Graduate Thesis vide Memo no. 3/2/July2019/PGThesisHRD (33) dated 30/07/2019.

Conflicts of interest

There are no conflicts of interest.