Note: The Tables of the article can be accessed and seen in the PDF file.
Menstruation is a natural phenomenon among matured
females who experience shedding of blood for 1-7 days
every month from the age of maturity until menopause.
Various aspects such as physiology, pathology and
psychology of menstruation have been found to associate
with health and wellbeing of women; hence it is an
important issue concerning morbidity and mortality of
female population. On the other hand, hygiene-related
practices during menstruation are of considerable
importance for reproductive health, poor practices
increase vulnerability to reproductive tract
Good hygiene, such as use of sanitary pads and adequate
washing of the genital area, is essential during
menstruation. Women and girls of reproductive age need
access to clean and soft absorbent sanitary products,
which in the long run protect their health[3-4].
Menstrual hygiene and management is an issue that is
insufficiently acknowledged and has not received
Adolescent girls constitute a vulnerable group not only
with respect to their social status but also in relation
to health. Menstruation is regarded as unclean or dirty
in Indian society. Although it is a natural process, is
linked with several misconceptions and practices which
sometimes results into adverse health outcomes. Never
the less, reaction to menstruation depends upon
awareness and knowledge about the subject. The manner in
which a girl learns about menstruation and its
associated changes may have an impact on her attitude to
the event of menarche .
Primarily poor personal hygiene and unsafe sanitary
conditions result in gynecological problems .
Infections due to lack of hygiene during menstruation
are often reported [6-7]. Repeated use of unclean
napkins or the improperly dried cloth napkins before its
reuse results in harboring of micro-organisms causing
vaginal infections . Very few studies have included
the detailed aspects of menstrual practices prevalent
among young girls. It was therefore considered relevant
to investigate menstrual related practices among females
aged 15-22 years from South India.
Methods and materials
The study was conducted during the academic years 2009 –
2010. A cross-sectional study was carried out on 350
students recruited from educational institutions
offering higher secondary education, pre-university and
under graduate courses in the urban areas from a major
city in South India. A purposeful sampling was done to
select girls who were unmarried and in the age group of
15-22 years. Also those who volunteered to give complete
and correct information were included for the study. The
selected women were explained about the protocol and
purpose of the study and were requested to complete the
questionnaires to elicit information relating to
demographic features, menarche age and menstrual hygiene
The demographic information included family details
relating to family size, type, parent's education,
occupation, house type, and possession of costly goods
like vehicles, computer, TV, DVD, refrigerator, phones
etc., and the information was used to derive the socio
economic status. The chronological age and age at
menarche was also elicited.
Menstrual hygiene questionnaire included quarries about
type of napkins used, storage place, usage of napkins
such as clean and unclean napkins, frequency of change
and cleaning. Information about personal hygiene
included, washing and bathing during menses, practice of
wearing stained clothes etc. The research protocol was
approved by the Ethical Committee, University of Mysore.
The data was analyzed using SPSS for Windows version 16.
Descriptive statistics was used to determine mean and
percentages. The categorical data were analyzed using
Chi-sq or Fisher’s exact test and regression analysis.
Table 1 presents the demographic details of the selected
girls. It is evident that the mean age of the subjects
studied was 18.6±1.7 years, while the age range was 15 -
22 years. Among these 42.6 % girls were in the age group
of 15-19 years, and others were aged 19-22 years
(57.4%). Age at menarche in the selected group ranged
from 10-17 years, with a mean of 13.4±1.2 years.
Majority of the participants (90.9%) belonged to
families practicing Hinduism, 85.4% girls were from
nuclear family. The girls belonged to low (20.8%),
middle (49.1%) and high (11. 7%) SES.
Table 2 presents data regarding the awareness about
menstruation before encompassing menarche. It is evident
that 64.2% of the participants were aware and the most
important source of information was mothers, while
friends and television also contributed to their
Table 3 highlights the pattern of use of sanitary
napkins by girls according to age. It can be perused
that two-thirds of the selected girls (68.9%) regardless
of age used disposable pads and a small proportion (7.4%
and 19.1%) used cotton or cloth material, respectively.
However use of both the disposable and non disposable
materials by girls was also common. With respect to
storage of the sanitary napkins and the pattern of use,
it was found that 56.6% girls stored the clean (unused)
pads in the cupboards or drawers, and 15. 1 and 21.1%
girls used dress cabinet and bathroom respectively. The
practice of changing pads during night was mentioned by
79.1% while changing in school or college was less
common (20.6%). Majority (78.3%) of the girls changed
napkins 2-3 times a day and 16.6% mentioned to change
once a day.
The hygienic practices were different in girls aged 19
years and above as compared to younger ages. We found
significant association between type of napkin/pads used
and the age (P=0.001) of the participants, higher
proportion of older girls used disposable pads than the
young girls. Since significant associations were also
found between age and practice of storage (P= 0.002),
change of pads during nights (P=0.018); number of pads
used per day (P= 0.045) and reuse of pads (P= 0.014).
Table 4 presents information regarding personal hygiene.
Practice of bathing (P=0.049) during menstruation, using
washed napkins (P=0.009) and wearing stained dress
(P=0.001) were significantly associated to age.
Significantly higher percent of older girls (87.2%)
practiced bathing as compared to younger age (79.3%).
Nearly 83% of the girls studied regardless of age
mentioned to practice washing of genital tract. Other
practices such as using washed napkins and wearing
stained dress were noted among younger girls in higher
percentage. Majority of the participants opined the need
for more information regarding menstruation and hygienic
practices to be followed during these days.
Table 5 provides information about relationship between
menarche age and various menstrual practices. A partial
correlation that was performed by adjusting
chronological age to identify the effect of menarche
age, however, no significant relationship was observed
for any of the practices studied.
Table 6 exhibits statistically significant association
between SES and practices such as use of disposable pads
(P=0.004), storage behavior (P=0.049), wearing stained
dresses (P=0.004) and expressing the need for
information about menstruation (P=0.027).
Table 7 the linear regression analysis revealed a
significant negative effect of SES on Menarche age,
Awareness about menstruation and use of non disposable
Hygiene related practices of women during menstruation
are of considerable importance as it affects health by
increasing vulnerability to infection especially the
infections of urinary tract and perineum. Studies
reported from India and other developing countries have
highlighted the common practices prevailing among the
young females [2, 9]. The type of absorbent material
used is of primary concern since reusable material could
be a cause for infection if improperly cleaned and
poorly stored  . Studies from India and Pakistan
indicate use of old cloth material as a frequently used
absorbent (98.5%) among both rural and urban
A study from India, reported that majority of rural
school girls who used old cloth, sanitize the materials
by boiling and drying them before reuse. It is evident
that such practices offer protection against possible
infections. In our study 19.1% girls used cloth material
as menstrual absorbents never the less practice of
cleaning or sanitizing was not appraised. Place of
storage of pads/ napkins is equally important for their
cleanliness, especially practice of storing in bath
rooms is disturbing since it could give rise to
harboring of dust and insects. The proportion of
participants having bathroom as storage place was 21.
1%, this practice was significantly prevalent among
younger age. In other studies practice of storing in
bath room was as high as 49.8%. Literature information
regarding the adverse health effect due to bath room
storage is meager .
According to healthy practices changing pads during
night and at school or college is important. Change of
napkins/ pads at an interval of 3–4 hours is considered
as a healthy behavior for comfort and to prevent odor,
regardless of the extent of staining .Higher
percentage of girls(80%) practiced to changing pads at
night while a small proportion changed pads at school /
college hours (20.6%).. Age profoundly influenced the
practice of changing at night, significantly higher
percentage of older girls practiced to change at night
(Table 3). On the other hand, the practice of continued
use of pads during school hours was a common behavior
across all the age groups. It is obvious to expect
health risk due to such practices .The probable reason
for not changing the pads could be ignorance and lack of
facility. Our findings are in accordance to other
studies reported from India and Arabia Saudi .
Further, the practice of reuse of soiled napkins was
found common among girls in the present group; although
the percentage was less, significantly higher proportion
of younger girls used the soiled napkins. It could be
because of lack of knowledge about healthy practices in
young girls. Narayana et al. suggested based on his
study that urban girls have better awareness about
menstrual hygienic practices than their rural
Studies from India indicate that, ritualistically girls
take special bath at the time of menstruation, hence
83.9% practiced taking bath and this behavior was found
to be associated to age. Also a higher percentage of
girls were aware of washing genital tracts and perineum
which is essential for health. Attitudes such as
refraining from bath and poor perineum care were found
common among a small percentage of the participants.
Bathing was significantly associated to age. Lack of
awareness regarding the menstrual hygiene could be an
important influencing factor for poor practices [12-14].
Similar observations have been reported by other studies
from India. On the other hand none of these behaviors
were associated to age of menarche.
Socio economic status was the most influencing factor on
the behavior of girls, it is established fact that
affordability help to acquire healthful behaviors .
It is evident from our observations that, use of
unsanitary and sub-standard menstrual absorbents was
common among girls from low socio economic status.
Therefore undoubtedly poverty and low social class play
a major role on the choices of absorbents leading to the
use of unsanitary materials. It is likely that poor
financial resources has contributed to the use of
‘multiple material’ as menstrual absorbents; Gilany et
al. working with Egyptian girls were also of similar
opinion  .We found significant association between
SES and factors such as kind of pads used, storage place
and wearing stained dress. However, there was an inverse
relation between SES and need for more information about
menstrual practices. Other studies have shown lower
socio-economic status, lack of access to information
about menstruation and money to buy sanitary products
for menstrual hygiene are all related factors affecting
menstrual behaviors[9, 16] . Evidently poverty is more
than just the lack of income as it includes lack of
access to services, resources and skills, vulnerability,
insecurity and powerlessness.
Prior awareness regarding menarche and menstruation
among girls is generally low in most cultures. Never the
less in our study 64.5% of the participants were aware
[17-19]. Mothers, teachers, friends, relatives,
television and books are reported as the major source of
information. Considerable percentage (54 and 35.3% )of
the participants revealed mothers followed by friends to
be the source of information. Prior information about
menstruation has been reported to prepare the girl child
mentally to accept the change in a constructive way and
help her to develop better attitude[19-20].
Healthy practices are important for health and well
being of individuals. Menstrual period is one such time
when females are expected to adopt hygienic practices. A
variety of factors are known to affect the behaviors.
Age, culture, awareness and SES are often found to exert
profound influence on the behaviors and practices. Age
and SES were the most influencing factors, as they
influenced the choices for menstrual absorbents and
other practices such as personal hygiene, bathing and
washing of genital tract was common, changing of pads at
night and school hours was followed by higher percentage
of girls. Further, girls are becoming conscious about
the importance of adopting healthy practices during
menstrual period since majority of girls opined the need
for menstrual health education. It is important
therefore that a sustained public health awareness
program is developed to operate in population to create
better awareness among women. Such initiative would make
women population self sufficient to manage their health
Acknowledgement: Authors are grateful to the all
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