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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 7  |  Issue : 2  |  Page : 252-257

Knowledge and practice regarding menstrual hygiene and alternatives to sanitary pad among Indian undergraduate medical students: A cross-sectional study


1 Department of Physiology, Mahatma Gandhi Medical College, Sri Balaji Vidyapeeth (Deemed to be University), Puducherry, India
2 Department of Physiology, BGS GIMS, Bengaluru, Karnataka, India
3 Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission05-Jan-2022
Date of Decision24-Jan-2022
Date of Acceptance29-Jan-2022
Date of Web Publication09-Sep-2022

Correspondence Address:
Sonal Gaonkar
Department of Physiology, BGS GIMS, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_2_22

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  Abstract 


INTRODUCTION: While the availability and use of disposable sanitary pads have increased considerably in the last two decades, awareness about disposal and menstrual waste management has been neglected. This study was designed to determine the knowledge and practice of sanitary pad usage, disposal, and alternative methods of menstrual hygiene attitude toward menstrual leave among Indian undergraduate medical students.
MATERIALS AND METHODS: The study participants were Indian undergraduate medical students. Self-administered online questionnaires were utilized, using Google Forms that requested personal details, menstrual history, usage and disposal of the sanitary pad, alternatives to the sanitary pad, and opinions about paid menstrual leave or sick leave policy. Quantitative data were summarized using mean and standard deviation, whereas qualitative data were summarized using percentages and frequencies. Data collected were analyzed using SPSS software version 20.
RESULTS: Four hundred sixty-four students participated in the study. The mean age at menarche was 13 years. Menstrual bleeding lasted an average of 5.2 ± 1.6 days. Cycle length was 21–35 days in 92% of cases. Approximately 42.9% of respondents reported dysmenorrhea. 98% reported using the sanitary pad; among them, 48% reported they use a single pad (nonbio-degradable pads) for more than 6 h, and the most common mode of disposal is by wrapping in a newspaper. Menstrual cup followed by tampons is common alternatives to the sanitary pad. 48.7% reported that sometimes menstruation keeps them away from colleges. Eighty-two percent expressed menstrual leave policy of 1–2 days would be a positive and welcome move.
CONCLUSIONS: Knowledge about sanitary pad disposal and alternatives is adequate among Indian undergraduate medical students but what is inadequate is the practice. Emphasis should be made on strategies that can be adopted to prevent the dumping of unsorted disposed of unsafe menstrual waste across the landfills resulting in a global health issue.

Keywords: India, medical students, menstruation, sanitary pad, tampons


How to cite this article:
Nalini Y C, Gaonkar S, Anjusha I B, Basavarajegowda A. Knowledge and practice regarding menstrual hygiene and alternatives to sanitary pad among Indian undergraduate medical students: A cross-sectional study. BLDE Univ J Health Sci 2022;7:252-7

How to cite this URL:
Nalini Y C, Gaonkar S, Anjusha I B, Basavarajegowda A. Knowledge and practice regarding menstrual hygiene and alternatives to sanitary pad among Indian undergraduate medical students: A cross-sectional study. BLDE Univ J Health Sci [serial online] 2022 [cited 2023 Jan 28];7:252-7. Available from: https://www.bldeujournalhs.in/text.asp?2022/7/2/252/355846



India has been striving with magnanimous efforts to make sanitary pads available to the reproductive age group women both in urban and rural populations. Thus, according to the national family health survey 4 (2015–2016), 57.6% of women aged 15–24 years reported the current use of safe, hygienic products available in the market.[1] While the availability and use of disposable sanitary pads have increased considerably in the last two decades, awareness about disposal and menstrual waste management has been neglected. Suppose an estimated 121 million girls and women use an average of eight disposable (noncompostable) sanitary pads per month, the waste load generated in India is estimated to be: an annual disposition of 12.3 billion pads and 113,000 tonnes of menstrual waste.[2]

Various studies have been done on the effectiveness of menstrual cups, vaginal tampons in comparison to sanitary pads. They have found that menstrual cups are a satisfactory alternative to tampons and sanitary pads and have the potential to be a sustainable solution to menstrual management, with moderate cost savings and much-reduced effects on the environment compared with tampons.[3]

First, the two main concerns concerning menstrual waste management are that women tend to resort to unhygienic practices like using a single pad for 12 h due to a lack of proper disposal options.[2] Second, dumping unsorted disposed of unsafe menstrual waste across the landfills results in a global health issue. As there is limited literature available on awareness about alternatives to the sanitary pad, this study was undertaken to identify the awareness and usage of alternatives to the sanitary pad.[4]

Although the menstrual leave concept is new in India, menstrual leaves are recognized in a few other countries such as Japan, Taiwan, Indonesia, South Korea, and Zambia. In Japan, from 1947, a law was passed on menstrual leave policies, which allows any woman to take a day off with painful periods or whose job might exacerbate period pain.[5]

Objectives

The objectives of the study were to determine the knowledge and practice of sanitary pad usage, disposal, and alternative methods of menstrual hygiene and attitude toward menstrual leave among Indian undergraduate medical students.


  Materials and Methods Top


Study design, setting, and duration

A cross-sectional study to determine knowledge and practice of sanitary pad usage, disposal, and alternative methods of menstrual hygiene and attitude toward menstrual leave among Indian undergraduate medical students was designed. It was an online study done among undergraduate medical students among all phases of the course from two medical colleges of the authors in Southern India, one in Karnataka and the other in Puducherry, with an annual intake of 150 and 250, respectively. The students include people from all the states of India, predominantly from Karnataka, Andhra Pradesh, Kerala, Tamil Nadu, and Puducherry. The duration of the study from the day the questionnaire link was disseminated to the closure of the survey was 1 month, i.e., from August 1 to 31, 2020.

Study tool

A well-structured questionnaire containing personal details, menstrual history usage and sanitary pad disposal, alternatives to the sanitary pad, and opinions about paid menstrual leave or sick leave policy with closed and open-ended questions was prepared. Construct and content validity of the questionnaire was done with inputs from physiology, gynecology, and community medicine experts by disseminating it to them by mail and modifying as per their comments/suggestions. A pilot study was conducted on student volunteers (n-20) among medical students willing to participate in the study by administering a questionnaire. Based on the feedback obtained from the students, the questionnaire was modified.

The questionnaire consisted of 18 questions, excluding personal history. It had both open and closed questions with a combination of both for a few questions. Questions 2 and 3 were open-ended, about the age of onset of menarche and frequency of the cycle, whereas others were semi-open questions. Question 15 was a conditional question on using alternatives to the sanitary pad. Mandatory questions were only mail id and attainment of menarche. The order of the questions was the same for the participants, and they were provided with the option of obtaining a copy of the responses after submitting the responses.

Ethical clearance and informed consent

The ethical clearance for the study was obtained from the Institutional Human Ethics Committee. Subjects expressing voluntary participation were recruited after obtaining informed consent, which was also online. The participants were briefed about the purpose and duration of the survey by the investigator. Privacy and confidentiality of the data collected were maintained.

Sample size

Convenient sampling was adopted; the questionnaire was sent to all the female students in the two participating institutes. There were a total of 652 female students in the colleges, of which 464 responded. According to the NFHS study-based prevalence of sanitary pad usage in the age group (15–24) as 57.6, the minimum sample size required was calculated to be 376 using Daniel's formula.

Data collection and analysis

A link was shared to female medical students above 18 years and having an active menstrual cycle from Phase I to Phase III Part 2 MBBS from August 1 to 31 2020 by E-mail Ids individually and in WhatsApp groups with the help of student council members. Google Forms-based online questionnaire consisted of five pages that included informed consent and an option to terminate the participation in the study. No incentive was given to the participants for participating in the study. The investigator anonymized the collected data before analysis. Incomplete responses were excluded from the analysis. Duplicates were eliminated as participants could fill the survey only once based on their mail ID. The option of “only allow one response per person” was activated in the Google Forms. Quantitative data were summarized using mean and standard deviation, whereas qualitative data were summarized using percentages and frequencies. Data collected were analyzed using SPSS software version 20.


  Results Top


Personal details of the students [Table 1]
Table 1: Sociodemographic profile of the study participants

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Four hundred sixty-four students participated in the study (n = 464). Most of the students belong to Phase 1 (35.6%) and Phase II (24.8%) of MBBS. The students who responded were mainly from Karnataka (61%), followed by Tamil Nadu (9.3%). Monthly family income was more than 1 00,000 in 38.4% of the respondents. The mean number of females in their family was 2.76 (standard deviation [SD] 0.94). About 44.2% of students reported more than two females in the family, while 40.3% reported more than three females.

Menstrual history of students [Table 2]
Table 2: Prevalent features of menstruation in the study population

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The mean age at menarche was 13 years (SD 2.14). Menstrual bleeding lasted an average of 5.2 ± 1.6 days. Cycle length (duration of the menstrual cycle) varied from 21 to 35 days, while 30.2% reported that cycle length of 30 days. About 42.9% reported the occurrence of dysmenorrhea.

Sanitary pad usage and disposal [Table 3]
Table 3: Prevalent practices on sanitary pad usage

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Almost 98.3% reported using the sanitary pad; 48.1% reported they use a single pad (Non-bio-degradable pads) for more than 6 h, and the most common mode of disposal is by wrapping in a newspaper (78.1%). About 47.8% reported that they “did not know how long it takes for a single nonbiodegradable (noncompostable) sanitary pad to decompose?,” while 47.6% of students were aware of sanitary pad incinerators to dispose of sanitary pads.

Respondents' knowledge and practice of alternatives to sanitary pad [Table 4]
Table 4: Knowledge and practices regarding sanitary pad usage and disposal attitude toward menstrual leave among the respondents

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Only 18.8% are aware of alternatives to the sanitary pad, and most common among the alternatives are menstrual cups followed by tampons, while 11.9% of the students reported using alternatives to the sanitary pad. Almost 86.9% of the medical students are aware of the availability of these alternatives on the online portal.

Respondents' opinion on menstrual leave policy [Table 4]

About 48.7% reported that sometimes menstruation keeps them away from colleges, and 82% expressed that the menstrual leave policy of 1–2 days would be a positive and welcome move.


  Discussion Top


Menstrual waste management is a burning issue of the century. We opted to do this study among undergraduate medical students for two reasons: first, because they are a convenient sample and second, if medical students are made aware of better choices, they can modify their attitude and practice and educate the family, friends, and the community at large to make better choices.

Most of the students attained menarche between the ages of 10–15 years. Their mean age of menarche was 13 years, consistent with the study done by Lawan in Kano, Nigeria, which examined the knowledge and practices of adolescent school girls around menstruation and menstrual hygiene.[6] A study done by Dhambare et al. found the mean age of menarche in urban and rural India to be 13 years.[7]

Most of the students used the sanitary pad for menstruation, and family members were the first source of information regarding sanitary pads to the respondents.[8],[9] The higher proportion of female undergraduate students using a sanitary pad could be attributed to better socioeconomic status and education. As most of the menstrual hygiene studies conducted in India are among schoolchildren, they show variable data about usage of the sanitary pad.[10],[11],[12] The most common sanitary pad disposal mode is by wrapping in a newspaper similar to study findings in Nigeria[6] and Quetta, Pakistan.[9]

Our study found that dysmenorrhea is a common symptom associated with menstruation among medical students; similar findings have been reported by Sharma et al. in their study on the problem related to menstruation among adolescent girls.[12]

Regarding the usage of a single sanitary pad for more than 5 h, in our study, 48.1% reported “sometimes,” and 27.4% reported “yes.” We hypothesize that this practice could be due to a lack of knowledge and unavailability of proper disposal facilities everywhere. Dewi et al. has reported a similar observation in a study on personal hygiene during menstruation in female teenagers at high school in Indonesia, where 77.1% reported using a single pad for more than 6 h.[13]

About 47.8% of the medical students reported that they “did not know how long it takes for a single nonbiodegradable (noncompostable) sanitary pad to decompose?” It takes around 500–700 years for a single sanitary pad to decompose, and on average, a woman generates up to 125 kg of nonbio-degradable waste through menstruation years.[14],[15] The material used for making commercially available disposable sanitary pads is cellulose fiber and thermoplastic resin, which require specially designed machines to convert it to combustible form.[16]

About 47.6% of the medical students were aware that sanitary pad incinerators could be used to dispose of sanitary pads. As reported by various studies, in our country, the availability of incinerators is a big challenge, and if it is available, most of the incinerators are not in working condition. The concerned authorities should enforce strict guidelines and rules for installing functional incinerators in all educational establishments across the country.

Majority (86.9%) of the study population were aware that alternatives to the sanitary pad are available on online shopping portals like the menstrual cup and vaginal tampons, while only a few (11.5%) reported using them. Flexible, reusable cups made of rubber or silicone and worn intravaginally are called menstrual cups.[3] Many women worldwide and in India opt for it because of the drive toward eco-friendly menstrual products.[17],[18] In a study done in India among 111 and 186 rural and urban women, respectively, the feasibility and acceptability of a novel product banana fiber pad assessed user and environmental perspectives were found to 82.4%, 80.3% and 80.2%, 77.5%.[19] Studies have compared the practice of menstrual cups versus vaginal tampons. A randomized control study done on 110 participants in South Africa comparing menstrual cups versus pad/tampons reported that menstrual cups were comfortable and preferred.[3]

About 81.9% wished for paid leave policy to be implemented as in other countries such as Japan, Italy, Taiwan, and Zambia. Few of the private organizations in our country have already implemented this policy. In various studies worldwide, study respondents missed their school during menstruation. Although absenteeism is multifactorial, one of the prime reasons is the lack of facilities at school.[7],[9]

In-depth interviews conducted in japan among 30 knowledgeable Japanese informants reported that social factors such as working conditions, attitudes, and labor union strength were primary determinants for the use of menstruation leave.[20]


  Conclusion Top


Knowledge about sanitary pad disposal and alternatives is adequate among Indian undergraduate medical students, but what is inadequate is the practice. Emphasis should be made on strategies that can be adopted to prevent the dumping of unsorted disposed of unsafe menstrual waste across the landfills resulting in a global health issue. It is necessary to promote the proper disposal of sanitary pads by installing functional incinerators across the country in all work and educational establishments. More awareness should be created regarding the availability of alternatives to the sanitary pad in medical colleges and communities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Percent of Indian Women don't Have Access to Sanitary Pads: Survey. Deccan Chronicle; 2018. Available from: https://www.deccanchronicle.com/lifestyle/health-and-wellbeing/120218/43-percent-of-indian-women-dont-have-access-to-sanitary-pads-survey.html. [Last accessed on 2022 Jan 24].  Back to cited text no. 1
    
2.
van Eijk AM, Sivakami M, Thakkar MB, Bauman A, Laserson KF, Coates S, et al. Menstrual hygiene management among adolescent girls in India: A systematic review and meta-analysis. BMJ Open 2016;6:e010290.  Back to cited text no. 2
    
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Howard C, Rose CL, Trouton K, Stamm H, Marentette D, Kirkpatrick N, et al. FLOW (finding lasting options for women): Multicentre randomized controlled trial comparing tampons with menstrual cups. Can Fam Physician 2011;57:e208-15.  Back to cited text no. 3
    
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Juma J, Nyothach E, Laserson KF, Oduor C, Arita L, Ouma C, et al. Examining the safety of menstrual cups among rural primary school girls in western Kenya: Observational studies nested in a randomised controlled feasibility study. BMJ Open 2017;7:e015429.  Back to cited text no. 4
    
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King S. Menstrual Leave; good intention, poor solution. In: Hazzard JT, editor. Aligning Perspectives on Health, Safety and Well-Being. London: Springer Nature; 2021. p. 151-76.  Back to cited text no. 5
    
6.
Lawan UM, Yusuf NW, Musa AB. Menstruation and menstrual hygiene amongst adolescent school girls in Kano, Northwestern Nigeria. Afr J Reprod Health 2010;14:201-7.  Back to cited text no. 6
    
7.
Dambhare DG, Wagh SV, Dudhe JY. Age at menarche and menstrual cycle pattern among school adolescent girls in Central India. Glob J Health Sci 2012;4:105-11.  Back to cited text no. 7
    
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Hennegan J, Dolan C, Steinfield L, Montgomery P. A qualitative understanding of the effects of reusable sanitary pads and puberty education: Implications for future research and practice. Reprod Health 2017;14:78.  Back to cited text no. 8
    
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Michael J, Iqbal Q, Haider S, Khalid A, Haque N, Ishaq R, et al. Knowledge and practice of adolescent females about menstruation and menstruation hygiene visiting a public healthcare institute of Quetta, Pakistan. BMC Womens Health 2020;20:4.  Back to cited text no. 9
    
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Shah SP, Nair R, Shah PP, Modi DK, Desai SA, Desai L. Improving quality of life with new menstrual hygiene practices among adolescent tribal girls in rural Gujarat, India. Reprod Health Matters 2013;21:205-13.  Back to cited text no. 10
    
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Kaur R, Kaur K, Kaur R. Menstrual hygiene, management, and waste disposal: Practices and challenges faced by girls/women of developing countries. J Environ Public Health 2018;2018:1730964.  Back to cited text no. 11
    
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Sharma S, Mehra D, Brusselaers N, Mehra S. Menstrual hygiene preparedness among schools in India: A systematic review and meta-analysis of system-and policy-level actions. Int J Environ Res Public Health 2020;17:647.  Back to cited text no. 12
    
13.
Dewi S, Sumarni T, Yusra A. Personal hygeine during menstruation in female teenegers at junior high schools 34 Padang west of Sumatera Indonesia. Chall Strateg Heal Treat Approach Nutr Mol Epidemiol 2015;2015:48-51.  Back to cited text no. 13
    
14.
Shoor P. A study of knowledge, attitude, and practices of menstrual health among adolescent school girls in urban field practice area of medical college, Tumkur. Indian J Heal Sci Biomed Res 2017;10:249-55.  Back to cited text no. 14
    
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Bhatia A. An Urgent Challenge: Why India Needs To Tackle Its Menstrual Waste | Waste Management. NDTV; 2017. Available from: https://swachhindia.ndtv.com/urgent-challenge-india-needs-tackle-menstrual-waste-6665/. [Last accessed on 2022 Jan 24].  Back to cited text no. 15
    
16.
Woeller KE, Hochwalt AE. Safety assessment of sanitary pads with a polymeric foam absorbent core. Regul Toxicol Pharmacol 2015;73:419-24.  Back to cited text no. 16
    
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Beksinska ME, Smit J, Greener R, Todd CS, Lee ML, Maphumulo V, et al. Acceptability and performance of the menstrual cup in South Africa: A randomized crossover trial comparing the menstrual cup to tampons or sanitary pads. J Womens Health (Larchmt) 2015;24:151-8.  Back to cited text no. 17
    
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Stewart K, Powell M, Greer R. An alternative to conventional sanitary protection: Would women use a menstrual cup? J Obstet Gynaecol 2009;29:49-52.  Back to cited text no. 18
    
19.
Achuthan K, Muthupalani S, Kolil VK, Bist A, Sreesuthan K, Sreedevi A. novel banana fiber pad for menstrual hygiene in India: A feasibility and acceptability study. BMC Womens Health 2021;21:129.  Back to cited text no. 19
    
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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