Menstrual hygiene practices : Is it practically impractical ?

Background: Menstruation is the physiological process, but its physiology and nature are very poorly understood among the female population due to many sociocultural factors which make them to adapt certain practices unknowingly whether it is correct or false. This study was done with the objectives of exploring the menstrual practices followed among urban and rural female population. Materials and Methods: This study was done as a community based – cross-sectional study at the outskirts of Chennai, among the randomly selected females in the reproductive age (15-44) group from both rural and urban fi eld practice areas using questionnaire and interview method. The results were expressed in percentages, and appropriate test of signifi cance was performed. Results: Approximately, a total of 212 from the rural area and 206 from urban slum were randomly selected for the study of which 9% (19) from rural and 5.3% (11) not aware of sanitary pads that can be used during menstruation. Among the study participants, 42.5% (90) of rural and 40.3% (83) of urban were unaware from which organ menstruation is from. The prevalence of better menstrual hygienic practices using the menstrual hygiene index was found to be 63.6% (131) in urban slum and 35% (75) in a rural area which was found to be statistically signifi cant (P < 0.0001). Conclusion: Our study has revealed that most of the females are still unaware menstrual hygienic practices which suggest that appropriate health promotive measures to be implemented for their reproductive well-being.


INTRODUCTION
Menstruation is the physiological process which starts at menarche at or before sexual maturity, in females and ceases at or near menopause.But its physiology and nature are very poorly understood among the female population due to many sociocultural factors which make them to adapt certain practices unknowingly whether it is correct or false.All women, whether rural or urban, irrespective of their socioeconomic status have their own beliefs and practices concerning menstrual hygiene.It is well-known that cultural factors are deeply involved in all the affairs of man and women.Some of these cultural factors, followed years together without any scientifi c background and for which they have their own explanation in relation to their cultural practices.These sociocultural factors like myths and taboos concerning menstruation and health and disease were explored by many studies like. [1,2]Although many studies were conducted to assess the menstrual practices, the diversity of cultural practices in India, mandates to investigate more and more on menstrual hygiene.This study was done with the objectives of exploring the menstrual practices and addressing the knowledge, cultural beliefs, and experiences regarding menstrual practices among the female population residing in urban slum and rural areas.2000 houses, and rural fi eld practice area has approximately 2500 houses."House to house survey" was done in both the areas.During the survey, the women who were aged (15-44 years) were selected as our study participants after getting informed consent.The study tool which we had used was preformed pretested questionnaire which had two parts, one with general information such as sociodemographic profi le, menstrual history, knowledge, attitude, and practices on menstrual hygiene, sociocultural environment such as role of family and school, food habits, embarrassing moments, and health problems faced by them during menstruation.The second part of the questionnaire was menstrual hygiene index [3] developed by Tamil Selvi and Ramachandran.It was developed using nine questions.Almost all the questions are dichotomous in nature (Yes or No type).While the answers relating to maintaining menstrual hygiene are given the score 1, other alternative answer is given score "0."

Outcome measure
For all the questions considered for this index, a respondent can obtain a score ranging from 0 to 9 which can arbitrarily be classifi ed into three level as poor (1-3) moderate (4-6) and better menstrual hygiene (7-9).

Statistics
The data were analyzed with Epi-info software Version 3.5.1(2008)  and Chi-square test was used as a test of signifi cance.

RESULTS
Our study was done as a community-based cross-sectional study with 212 study participants from the rural area and 206 from urban slum, with the mean age of 29.72 and 28.52, respectively.Mean age at menarche was 13.5 (13.32 and 13.67) among the total study population from both the areas.Among 212 study participants from rural area, 193 (91%) belonged to Hindu by religion, 89 (42%) were in Class IV socioeconomic status, and 154 (73%) were from the nuclear family, similarly among 206 study participants from urban slum 163 (79%), 90 (43.7%), and 145 (70.4%) were belonged to Hindu religion, Class IV socioeconomic status and nuclear family, respectively.Among the total population, 157 (76%) from urban and 158 (74.5%) from rural were married.Majority of them from both urban slum and rural areas belonged to Class III and IV socioeconomic status, and most of them belonged to the nuclear family [Table 1].

Knowledge aspect
Majority 384 (92%) of the study participants from both areas were aware that menstruation is a normal process, but surprisingly most of them not aware about the cause and the exact anatomical organ involved.Among the women, 9% (19) from rural and 5.3% (11)  not aware about sanitary pads that can be used during menstruation and also 42.5% (90) of rural and 40.3% (83) of urban were unaware from which organ menstruation is from [Table 2].

Attitude aspect
Most of them (202) 48.3% were scared when they attained menarche, 147 (35%) of them were worried or disgusted about the forthcoming menstruation, 232 (56%) felt that the girls should know about the menstruation before they attain menarche.309 (74%) realized that education about menarche is mandatory in the school and also in the family [Table 3].

Practice aspect
Totally 303 (72.5%) of the study participants use sanitary pads during menstruation, regarding the disposal of the absorbent the methods

Sociocultural practices
The sociocultural practices or restrictions faced by the study participants during menstruation were varied and still predominantly seen in rural areas and urban slum.The restrictions were not to go to the temple, not to see the god images, not to go to school, not to touch fl owers, not to touch males, not to enter kitchen or pooja room and to sleep separately during menstruation.But the trend in urban areas is decreasing when compared to the rural population in this study.The overall extent of religious and social restrictions was high in both areas during menstruation which was found to be 85% and 80% in rural and urban, respectively [Figure 1].Many of the study participants felt embarrassing moments in school, work places, in the public during menstruation [Figure 2].Most of them felt embarrassing to purchase napkins from the shops, to carry the napkins to schools or workplaces, worried about men or even other woman seeing napkins, fear of wearing light colors, and fear of staining.

Dietary habits and beliefs
Some of the study participants 86 (21%) and 81 (19%) from both areas consumed less food and not eating at all during menstruation, instead 141 (34%) participants replied that they craved for food.243 woman (58%) and 74 (17.8%) believed that certain food items can hasten or delay the menstruation of which 158 (37.8%) of them tried some food items to hasten or delay it [Table 5].

Menstrual hygiene index
The prevalence of better menstrual hygienic practices using the menstrual hygiene index was found to be 63.6% (131) in urban slum and 36.8%(78) in a rural area which was found to be statistically signifi cant (P < 0.0001) [Figure 3].

DISCUSSION
Our study refl ected that the menstrual hygiene awareness and its practices are still an issue among the various age group women either from urban slum or rural area.Dr. Varina Tjon A Ten [4] has stated that menstrual hygiene, a neglected condition for the achievement of several millennium development goals in developing countries.This study was done with the aims of exploring the neglected areas and sociocultural factors related to menstrual hygiene practices.In this study, the mean age at menarche was 13.5 which is comparable to several studies 13.2 [5] and 12.8. [6]

Knowledge and attitude
Unfortunately 14% and 42% of the study participants in this study were not aware of sanitary pads, the anatomical organ from which the menstruation process occurs and most of them were scared or worried on fi rst menstruation.In a study conducted in Nepal among school girls, 92% had heard about menstruation before menarche, 81% recognized menstruation as normal physiological process, only little more than half (55%) recognized the cause of menstruation to be hormones.Very few respondents (2%) mentioned disease or curse/sin as the cause of menstruation.In the survey, majority of the respondents (73%) identifi ed vagina, and only 13% identifi ed uterus, as where the menstrual blood comes from.Similarly to our study, the girls in this study also replied the onset of menarche as a shocking and fearful event.
Information about the use of cloth, the practice of rituals in the form of restrictions on their movements and behavior were given as soon as they got menarche. [7]In our study, the women felt that the knowledge about the menstruation should be instilled to them before the menarche, and it should be done both in the school and the family.The study conducted by Deo and Ghattargi [8] reported that 40 (42.5%)urban and 41 (55.4%) were aware of menstruation prior to attainment of menarche.However, a study conducted by Khanna et al. [5] in Rajastan, nearly 92% of the girls were not aware of the natural phenomenon of menstruation.

Practices
In this study, 72.5% of the women use sanitary pads during menstruation and 37% clean the genitalia with soap and water, 26 (6%) clean water, and antiseptics.In the West Bengal, study conducted by Dasgupta and Sarkar, [6] only 11.25% of the girls use sanitary pads during menstruation and the Khanna et al. [5] study stated that only one-fi fth of the girls use sanitary pads.A study done by Singh et al. [9] among married women in Dehradun reported that only 13% of the women use sanitary pads, 13.5% used homemade pads, whereas the remaining the 73.5% used cloth during menstruation.Analogous study by Roy et al. [10] at rural Wardha observe that 83.6% women used "reused cloth" during menstruation, followed by 15.6% using "fresh cloth," and a mere 0.7% using "homemade pads" and "sanitary pads".These fi gures are comparable with other studies in Nepal [11] and India [6,12] where large majority of the participants used re-usable cloth during menstruation.When compared to these studies, our study had shown majority use the sanitary pads, which could be due to more awareness, better socioeconomic status and the higher age study participants and sociocultural groups.The menstrual hygiene index score was favorable to urban slum women rather than the rural women which was statistically signifi cant in this study.

Role of family
Majority of constrains faced by an individual either gets aggravated or diminishes only based upon the role of the family.During menstruation, the female undergoes both physical and emotional changes due to hormones, where she needs additional support to keep her balanced.Thus, we enriched our study with a new aspect practices and restrictions were concerned both the places showed a similar picture as well as with the other studies.These scenarios suggest that we have to go a long way in educating and creating awareness among the rural women in relation to improve the knowledge, behavior change, and practices.
of "family's role" in which we elicited the factors which support her and also the factors, which suppress her -this is a unique feature of our study when compared with other studies.We found that need of emotional support during menstruation provided by the family was 95 (46.1%) in the urban area and 129 (60.8%) in a rural area.Surprisingly, in the modern world though women have achieved wonders in various fi elds, they are being isolated during menstruation from the family members 52 (25.2%) in urban and 66 (31.1%) in rural areas [Table 6].

Sociocultural factors
The sociocultural practices or restrictions during menstruation were varied and still predominantly seen in rural areas and urban slum.However certain practices were common like to sleep alone during menstruation, religious practices like restriction to go to temple and pooja room irrespective of religion, residence, socioeconomic status, various cultural backgrounds from different states.This was elicited by various studies like Dasgupta and Sarkar [6] Narayan et al. [12] In our study, many dietary habits and beliefs were noted among the women, like eating less food is good during menstruation, certain foods will hasten or delay periods, and most of them tried those food items during menstruation.These observations indicate that our sociocultural, dietary practices are still more prevalent in spite of improvement in literacy status in our country.

CONCLUSION
An attempt was made to study and compare the menstrual hygiene practices between the women from urban slum and rural area, and the results showed that their hygienic practices were far better in urban slum women than the rural women.As far as the sociocultural Journal of Medicine and Public Health | Oct-Dec 2014 | Vol 4 | Issue 4

Figure 1 :Figure 2 :
Figure 1: Sociocultural practices (restrictions faced by the women during menstruation)

Figure 3 :
Figure 3: Menstrual hygiene index urban slum versus rural

Table 2 : Knowledge aspect (urban slum versus rural)
followed were burial, burning, fl ushing it in the toilet, just outside the house indiscriminately.As far as the cleaning and washing the genitalia, 238 (57%) wash with only with water, 154 (37%) clean with soap and water, 26 (6%) clean water and antiseptics [Table4].
International Journal of Medicine and Public Health | Oct-Dec 2014 | Vol 4 | Issue 4