Background: The extent to which reproductive tract infections (RTIs) are associated with poor menstrual hygiene management (MHM) practices has not been extensively studied. We aimed to determine whether poor menstrual hygiene practices were associated with three common infections of the lower reproductive tract; Bacterial vaginosis (BV), Candida, and Trichomonas vaginalis (TV). Methods: Non-pregnant women of reproductive age (18–45 years) and attending one of two hospitals in Odisha, India, between April 2015 and February 2016 were recruited for the study. A standardized questionnaire was used to collect information on: MHM practices, clinical symptoms for the three infections, and socio-economic and demographic information. Specimens from posterior vaginal fornix were collected using swabs for diagnosis of BV, Candida and TV infection. Results: A total of 558 women were recruited for the study of whom 62.4% were diagnosed with at least one of the three tested infections and 52% presented with one or more RTI symptoms. BV was the most prevalent infection (41%), followed by Candida infection (34%) and TV infection (5.6%). After adjustment for potentially confounding factors, women diagnosed with Candida infection were more likely to use reusable absorbent material (aPRR = 1.54, 95%CI 1.2–2.0) and practice lower frequency of personal washing (aPRR = 1.34, 95%CI 1.07–1.7). Women with BV were more likely to practice personal washing less frequently (aPRR = 1.25, 95%CI 1.0–1.5), change absorbent material outside a toilet facility (aPRR = 1.21, 95%CI 1.0–1.48) whilst a higher frequency of absorbent material changing was protective (aPRR = 0.56, 95%CI 0.4–0.75). No studied factors were found to be associated with TV infection. In addition, among women reusing absorbent material, Candida but not BV or TV - infection was more frequent who dried their pads inside their houses and who stored the cloth hidden in the toilet compartment. Conclusion: The results of our study add to growing number of studies which demonstrate a strong and consistent association between poor menstrual hygiene practices and higher prevalence of lower RTIs.
Keywords: Menstrual hygiene management; Bacterial vaginosis; Candidiasis; Trichomonas vaginalis; Reproductive tract infections
Electronic supplementary material The online version of this article (10.1186/s12879-018-3384-2) contains supplementary material, which is available to authorized users.
Menstrual hygiene management (MHM) practices vary by socio-cultural context, educational background and economic status, and there is wide variation in MHM practices between and within countries [[
Reproductive Tract Infections (RTIs) are a major public health concern worldwide and are particularly common in low-income settings [[
The clinical signs and symptoms of these infections overlap to a large extent, though the etiologies are quite different. Common clinical symptoms include vaginal discharge, dyspareunia, itching and burning sensation. However, the poor sensitivity and specificity of individual clinical symptoms, and the poor performance of standard laboratory tests in many settings, make the accurate clinical diagnosis of these infections difficult [[
Most studies assessing an association between MHM and RTI have used self-reported symptoms to measure outcomes which are likely biased [[
In a recent case-control study in Odisha, India, it was observed that women of menstruating age with urinary tract infections (UTI) and BV were more likely using reusable absorbent pads than using disposable pads [[
This was a cross-sectional study that surveyed women attending the Obstetrics and Gynecology (O&G) Out-Patient Department (OPD) of two public hospitals in Odisha state, India: Capital Hospital, Bhubaneswar; and, Ispat General Hospital (IGH), Rourkela. Capital Hospital is a government hospital with approximately 700 beds specializing in Obstetrics and Gynaecology, and Family Welfare which caters to the urban and peri-urban population of Bhubaneswar city as well as adjoining rural areas. Almost all health care services are provided free of cost and the majority of patients attending Capital hospital are from the financially disadvantaged groups specifically from the urban and peri urban slums and rural areas IGH, Rourkela is managed by the Steel Authority of India Limited and provides free treatment for its employees and their dependents and treatment for the general public at a subsidized cost. The hospital is situated in a District inhabited predominantly by a tribal population, a large proportion of the patients attending the hospital are from tribal populations. The study population in Rourkela is therefore, covers a broad spectrum of socio-demographic status. The patient recruitment was done from April 2015 to February 2016.
Non-pregnant women of reproductive age (18–45 years) attending the O&G OPD with vaginal symptoms (vaginal discharge, itching, burning, dyspareunia, with lower abdominal pain, and lower back pain), or attending the Family Welfare Department (FWD) for contraceptives, such as intra-uterine devices (IUD) were eligible for enrolment. We excluded all women meeting one or more of the following criteria: menstruating during the clinic visit, had a hysterectomy, taken a course of antibiotics during the previous three weeks, used oral contraceptive pills in the previous three months, had diabetes mellitus, were HIV positive, or had any severe medical disorders requiring immediate referral to a higher level of health care.
After identification by the treating doctor, all potential study participants underwent an informed consent process in the local language (Odia) and those choosing to participate provided written consent. The participants were informed that they would be tested for RTI and that their results would be provided free of cost and confidentially. Trained female interviewers administered a questionnaire collecting information about potential risk factors for the three infections. The examined risk factors were selected using a pre-specified conceptual framework with three groups of risk factors: socio-economic characteristics, MHM practices (related with menstrual absorbent material and body hygiene), and WASH access variables (access to water and sanitation resources for practicing safe MHM) (Fig. 1). This framework was already used by the authors in other related work, as it captures aspects of the working definition of MHM by the Joint Monitoring Program of the WHO and UNICEF in 2012 (defining MHM as: Women and adolescent girls using a clean menstrual management material to absorb blood that can be changed in privacy as often as necessary for the duration of the menstruation period, using soap and water for washing the body as required, and having access to facilities to dispose the used menstrual management materials) and also other important risk factors related to the RTI identified in the literature. We used a questionnaire developed and tested previously by our team [[
Graph: Fig. 1 Conceptual framework of risk factors. A conceptual framework with three groups of risk factors: sociodemographic characteristics, MHM practices and WASH access variables
A speculum examination of the vagina and cervix was done by a trained O&G specialist to assess the presence of cervical erythema, bleeding, inflammation, with or without discharge, and ulcers at cervix. Vaginal specimens from the posterior vaginal fornix were collected using four BD BBL swabs (BD, Maryland, USA). The first swab was used for Gram staining to diagnose BV, the second swab was used to determine the presence of Candida, the third swab was used for DNA extraction for diagnosis of TV by nucleic acid amplification test, and the fourth swab was stored for future studies. After labelling, all materials (slides and swabs) were transported immediately to a local laboratory for preservation and subsequent diagnosis.
BV was diagnosed using Nugent's laboratory diagnostic criteria [[
All data were double-entered into Epi Info 7 software (Epi info, Centers for Disease Control and Prevention (CDC), Atlanta, USA) and analyzed using Stata 11.0 (StataCorp, Stata Statistical Software: Release 11. 2011, StataCorp LP: College Station, Texas, USA). Pearson χ2 tests were used for initial examination of the association between individual exposures and each of the four of outcomes of interest (BV, Candida Infection, TV and having at least one infection). Among the participant-subgroup reporting use of reusable pads, we explored whether different washing, drying and storing practices were associated with the three studied infections. To estimate the prevalence rate ratios (PRR) and adjusted prevalence rate ratios (aPRR), and the associated 95% confidence intervals (CIs) for factors in relation to each of the four outcomes we used Poisson survival regression models.
Potential risk factors for the three infections were examined using a pre-specified conceptual framework with three groups of risk factors: socio-demographic characteristics, MHM practices (related with menstrual absorbent material and body hygiene), and WASH access variables (access to water and sanitation resources for practicing safe MHM) (Fig. 1). Analysis was done using a hierarchical approach. Age and education were retained in all final models as a priori potential confounding factors. Other variables were selected for inclusion based on stepwise elimination of variables associated (P < 0.1) in univariate analysis with the outcomes of interest. Owing to the collinearity of MHM practices, the effect of each practice on the risk of infection was evaluated in separate multivariable models adjusted for age, and education and by the other variables of interest from univariate model. Potential interacting variables were evaluated by including an interaction term in the regression model which was retained if judged statistically significant (P < 0.05) by likelihood-ratio test.
Of 860 reproductive age women who visited the gynaecology OPD of the two hospitals during the study period 558 were enrolled in the study, 106 did not consent to participate and a further 196 were excluded according to our criteria (Fig. 2). Among enrolled women50.5% of women had at least one RTI symptom (data not shown). 29% of infected women reported that the symptoms motivating attendance at the clinic were recurrent, but only 30 out of 101 changed their MHM practices and only 17 changed the type of absorbents (the majority of them using disposable ones when interviewed) as a result of symptoms (Data not shown). Having abnormal vaginal discharge was the most frequently reported symptom (36.6%), followed by the feeling of burning or itching in the genitalia (27.9%) and presence of genital sores (8.9%) (data not shown). 62.4% were diagnosed with at least one of the three tested infections (1.3% had all three infections, 15.8% had two infections and 45.3% had only one infection). BV was the most prevalent infection (41%), followed by Candida (34%) and TV (5.6%) (Table 1).
Graph: Fig. 2 Schematic diagram of recruitment of participants. Schematic diagram of recruitment of participants at Capital Hospital, Bhubaneswar and Ispat General Hospital, Rourkela, Odisha, India
Socioeconomic characteristic of women participating in the study according to infection status Data are expressed in no (%) of women
Exposures With BV (N = 229) Without BV (N = 329) P-value With Candidiasis (N = 190) Without Candidiasis (N = 368) P-value With TV (N = 31) Without TV (N = 527) P-value Age 18–25 years 63 (27.51) 100 (30.40) 0.758 59 (31.05) 104 (28.26) 0.069 7 (22.58) 156 (29.60) 0.468 26–35 years 89 (38.86) 124 (37.69) 81 (42.63) 132 (35.87) 15 (48.39) 198 (37.57) 36–45 years 77 (33.62) 105 (31.91) 50 (26.32) 132 (35.87) 9 (29.03) 173 (32.83) Marital status Never married 23 (10.04) 52 (15.81) 0.146 28 (14.74) 47 (12.77) 0.137 1(3.23) 74 (14.04) 0.177 Married 203(88.65) 273 (82.98) 162 (85.26) 314 (85.33) 30 (96.77) 446 (84.63) Divorcee& widow 3 (1.31) 4 (1.22) 0 7 (1.90) 0 7 (1.33) What is your religion Hindu 222(96.94) 316 (96.05) 0.098 183 (96.32) 355 (96.47) 0.524 31 (100.00) 507 (96.20) 0.543 Muslim 7 (3.06) 7 (2.13) 6 (3.16) 8 (2.17) 0 14 (2.66) Christian 0 6 (1.82) 1 (0.53) 5 (1.36) 0 6 (1.14) What is your caste or tribe Scheduled caste (SC) 41 (18.47) 47 (14.87) 0.250 22 (12.02) 66 (18.59) 0.067 5 (16.13) 83 (16.37) 0.667 Scheduled tribe (ST) 6 (2.70) 10 (3.16) 4 (2.19) 12 (3.38) 0 16 (3.16) Other backward caste (OBC) 127 (57.21) 168 (53.16) 114 (62.30) 181 (50.99) 16 (51.61) 279 (55.03) Other Caste 48 (21.62) 91 (28.80) 43 (23.50) 96 (27.04) 10 (32.26) 129 (25.44) Education No formal education 40 (17.47) 46 (13.98) 0.266 40 (21.05) 46 (12.50) 0.006 7 (22.58) 79 (14.99) 0.235 5th – 10th grade 102 (44.54) 137 (41.64) 85 (44.74) 154 (41.85) 9 (29.03) 230 (43.64) 12th grade or higher 87 (37.99) 146 (44.38) 65 (34.21) 168 (45.65) 15 (48.39) 218 (41.37) What is your occupation Employed 30 (13.10) 52 (15.81) 0.351 26 (13.68) 56 (15.22) 0.642 4 (12.90) 78 (14.80) 0.534 Housewife 179 (78.17) 238 (72.34) 141 (74.21) 276 (75.00) 26 (83.87) 391 (74.19) Student 15 (6.55) 33 (10.03) 20 (10.53) 28 (7.61) 1 (3.23) 47 (8.92) Other 5 (2.18) 6 (1.82) 3 (1.58) 8 (2.17) 0 11 (2.09) How many family members in hh 3 or less 47 (20.52) 66 (20.06) 0.712 44 (23.16) 69 (18.75) 0.470 7 (22.58) 106 (20.11) 0.379 4–5 119 (51.97) 162 (49.24) 92 (48.42) 189 (51.36) 12 (38.71) 269 (51.04) More than 5 63 (27.51) 101 (30.70) 54 (28.42) 110 (29.89) 12 (38.71) 152 (28.84) Economic status (monthly income) < 5000.00 30 (13.10) 35 (10.64) 0.427 26 (13.68) 39 (10.60) 0.607 5 (16.13) 60 (11.39) 0.776 5000.00 – 10,000 65 (28.38) 114 (34.64) 59 (31.05) 120 (32.61) 11 (35.48) 168 (31.88) > 10,000.00 103 (44.98) 136 (41.34) 77 (40.53) 162 (44.02) 11 (35.48) 228 (43.26) Don't know 31 (13.54) 44 (13.37) 28 (14.74) 47 (12.77) 4 (12.90) 71 (13.47)
P-value determined by Pearson's chi-square (χ
The median age of participants was 31 (range 18–45), and 85.3% of women were married and most identified as Hindu (96.4%). 15.4% of women had no formal education, 42% had attained 12th grade (12 years of education) or higher education. Table 1 shows the socioeconomic characteristics of study participants by the three infections. A significant difference in the education status (P < 0.006) between those with Candida and those without was observed, while other demographic and socio-economic variables didn't show any significant difference among this group or any of the other infections.
Univariate analysis showed that certain MHM practices were associated with certain infections (Table 2). Women with BV or Candida infections were more likely to use reusable cloths more frequently than those without these infections (P < 0.014 and < 0.001, respectively). However, there was no observed difference by type of reusable material (Table 2). Similarly, women with BV or Candida infections were more likely to use reusable cloths versus disposable pads, to change their absorbents somewhere other than in a toilet facility, and to wash less frequently during menstruation. Women changing absorbents less frequently were more likely to have a BV infection but not a Candida infection. TV infection was not associated with any of the tested variables, and access to sanitation facilities or water at the household level was not associated with any of the three infections.
Different menstrual hygiene management practices and WASH access variables of women participating in the study according to infection status
Exposures With BV (N = 229) Without BV (N = 329) P-value With Candidiasis(N = 190) Without Candidiasis (N = 368) P-value With TV (N = 31) Without TV (N = 527) P-value MHM practices Absorbent material Disposable sanitary pads 99 (43.23) 177 (53.80) 0.014 70 (36.84) 206 (55.98) 0.001 12 (38.71) 264 (50.09) 0.218 Reusable cloths 130 (56.77) 152 (46.20) 120 (63.16) 162 (44.02) 19 (61.29) 263 (49.91) Type of reusable material use Old cotton fabric 61 (46.92) 84 (55.26) 0.162 62 (51.67) 83 (51.23) 0.943 9 (47.37) 136 (51.71) 0.715 Old silk/nylon fabric 69 (53.08) 68 (44.74) 58 (48.33) 79 (48.77) 10 (52.63) 127 (48.29) Frequency of change of absorbent Once a day 69 (30.13) 60 (18.24) 44 (23.16) 85 (23.10) 0.869 7 (22.58) 122 (23.15) 0.653 Twice a day 110 (48.03) 156 (47.42) 0.001 88 (46.32) 178 (48.37) 17 (54.84) 249 (47.25) Three times a day or more 50 (21.83) 113 (34.35) 58 (30.53) 105 (28.53) 7 (22.58) 156 (29.60) Place of change of absorbent In a toilet facility 130 (56.77) 218 (66.26) 0.023 112 (58.95) 236 (64.13) 0.231 20 (64.52) 328 (62.24) 0.799 Outside a toilet facility 99 (43.23) 111 (33.74) 78 (41.05) 132 (35.87) 11 (35.48) 199 (37.76) What type of washing do you practice during menstruation Only vaginal wash 45 (19.65) 58 (17.63) 0.545 43 (22.63) 60 (16.30) 0.068 5 (16.13) 98 (18.60) 0.731 Bath of full body 184 (80.35) 271 (82.37) 147 (77.37) 308 (83.70) 26 (83.87) 429 (81.40) Frequency of washing during menstruation Twice or more per day 96 (41.92) 166 (50.46) 0.047 77 (40.53) 185 (50.27) 0.029 15 (48.39) 247 (46.87) 0.869 Once a day 133 (58.08) 163 (49.54) 113 (59.47) 183 (49.73) 16 (51.61) 280 (53.13) WASH Access variables Do you have a latrine at home? Yes 186 (81.2) 265(80.6) 0.84 162 (85.3) 289 (78.5) 0.056 25 (80.7) 426 (80.8%) 0.97 No 43 (18.8) 64 (19.4) 28 (14.7) 79 (21.5) 6 (19.3) 101 (19.2%) Where is the water source located? In the house 155 (67.7) 211 (64.1) 0.14 122 (64.2) 244 (66.3) 0.74 20 (64.5) 346 (65.7) 0.64 In the yard 34 (14.9) 42 (12.8) 24 (12.6) 52 (14.1) 6 (19.4) 70 (13.3) At relatives/neighbor house or yard 2 (3.65) 2 (0.87) 6 (3.2) 8 (2.2) 0 (0) 14 (2.7) At a public location 38 (16.6) 64 (19.4) 38 (20) 64 (17.4) 5 (16.1) 97 (18.4)
Data are expressed in no (%) of women. P-value determined by Pearson's chi-square (χ
We used multivariable analysis to assess the association between MHM variables and the three outcomes of interest whilst controlling for potential confounding factors. Reusable cloths were found to strongly associated with Candida infection (aPRR = 1.54, 95%CI 1.2–2.0), weakly associated with BV infection (aPRR =1.23, 95%CI 1.0–1.54) and not associated with TV infection (Table 3). Changing the absorbent in a location other than in a toilet facility was associated with a higher risk of BV (aPRR =1.21, 95%CI 1.0–1.48). Women who washed themselves less often during menstruation had a higher risk of BV and Candida infection (aPRR =1.25, 95%CI 1.0–1.55, aPRR =1.34, 95%CI 1.07–1.7, respectively) but not for TV. In the BV confirmed group, women who changed their absorbent material more frequently (twice or more) presented with reduced rates of infections compared with women who changed only once per day (aPRR = 0.75, 95%CI 0.6–0.93, aPRR =0.56, 95%CI 0.4–0.75, respectively).
Multivariable table with crude and adjusted PRR for each disease model
Risk Factors BV Unadjusted BV Adjusted Candidiasis Unadjusted Candididasis Adjusted TV Unadjusted TV Adjusted Infected Unadjusted Infected Adjusted PRR (95%CI) PRR(95%CI) PRR (95%CI) PRR (95%CI) PRR(95%CI) PRR (95%CI) PRR(95%CI) PRR(95%CI) Absorbent material Disposable 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 Reusable 1.28 (1.1–1.6) 1.23(1.0–1.54) 1.67(1.3–2.1) 1.54(1.21–2.0) 1.55(0.8–3.1) 1.78(0.81–3.9) 1.38(1.2–1.6) 1.35 (1.17–1.56) Frequency of change of absorbent Once a day 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 Twice a day 0.77 (0.6–0.9) 0.75(0.6–0.93) 0.96(0.7–1.3) 0.97(0.7–1.27) 1.17(0.5–2.8) 1.12(0.47–2.7) 0.81 (0.7–0.9) 0.79 (0.60–0.9) More than twice a day 0.57 (0.4–0.8) 0.56(0.4–0.75) 1.04(0.8–1.4) 1.08(0.78–1.5) 0.79(0.3–2.2) 0.74(0.26–2.1) 0.74 (0.6–0.9) 0.72 (0.61–0.86) Place of change absorbent In a toilet facility 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 Outside a toilet facility 1.26 (1.03–1.53) 1.21(1.0–1.48) 1.15 (0.91–1.45) 1.09(0.8–1.3) 0.91(0.4–1.8) 0.81(0.4–1.64) 1.24(1.19–1.4) 1.16 (1.02–1.31) Frequency of washing during menstruation Twice or more per day 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 Once a day 1.22 (1.0–1.5) 1.25(1.0–1.55) 1.29(1.0–1.6) 1.34(1.07–1.7) 0.94(0.5–1.9) 1.09(0.53–2.3) 1.18(1.0–1.4) 1.21(1.06–1.38)
PRR Prevalence rate ratio, CI confidence interval
In order to explore if these MHM practices and other exposure factors were also associated with at least one infection, we performed univariate and multivariate analysis between the same exposure variables and the new infected outcome group (Table 3). Analysis of the aggregated infection outcome (one or more of any infection) showed a similar pattern in the adjusted multivariate analysis with significant association between at least one infection and reusable absorbents (aPRR = 1.35, 95%CI 1.17–1.56), non-access to a toilet facility for changing the pads (aPRR = 1.16, 95%CI 1.02–1.31) and lower frequency of self-washing and cleaning during menstrual cycle (aPRR = 1.21, 95%CI 1.06–1.38). Higher frequency of change of absorbents was protective of infections (aPRR = 0.72, 95%CI 0.61–0.86).
Use of reusable pads was correlated with other practices that plausibly influence the risk of RTI which required further investigation to assess what aspects of reusable pad use might explain the higher observed risk among users. In a sub-group of women who reported using reusable cloths (n = 282), we analyzed the independent association of the method of washing, the place of washing, the place of drying, the method of packing for storage, and the place of storage of the reusable pads on different infections (Table 4). Almost all women washed the reusable menstrual cloths in soap and water (data not shown) and there was no difference in risk of at least one infection by place of washing nor method of packing for storage of pads. However, significant differences in Candida infection were associated with the place of drying and the place of storage of the cloths. Women who dried their reusable menstrual absorbent inside their house and women who kept the stored cloth hidden in the toilet compartment were more likely to have Candida infections compared with women who dried them in the sun or open space (aPRR = 1.78, 95%CI 1.34–2.38) or who kept stored within cupboard in the changing room (aPRR = 1.96, 95%CI 1.49–2.57).
Multivariable table among women who use reusable cloth comparing the PRR of different MHM practices
Risk Factors BV Unadjusted BV Adjusted Candidiasis Unadjusted Candidiasis Adjusted TV Unadjusted TV Adjusted PRR (95% CI) PRR (95% CI) PRR (95% CI) PRR (95% CI) PRR (95% CI) PRR (95% CI) Place to wash absorbent Inside the toilet stall 1.0 1.0 1.0 1.0 1.0 1.0 At the tube well or yard 1.04(0.81–1.34) 1.01 (0.76–1.34) 0.80 (0.61–1.07) 0.86 (0.64–1.16) 1.39 (0.58–3.33) 2.30 (0.80–6.56) After washing, how did you dry the cloth Dry it in the Sun/open space 1.0 1.0 1.0 1.0 1.0 1.0 Dry it inside the house 1.15(0.89–1.48) 1.07(0.82–1.39) 1.89(1.41–2.55) 1.78(1.34–2.38) 2.13(0.83–5.47) 1.91(0.68–5.32) How do you store the cloth for use next time Wrapped in polythene 1.0 1.0 1.0 1.0 1.0 1.0 Wrapped in another material 1.01(0.76–1.35) 1.04(0.76–1.42) 0.83(0.59–1.16) 0.86(0.62–1.20) 0.33(0.79–1.42) 0.28(0.07–1.10) Where did you store the cloth for use next time Within the cupboard in the changing room 1.0 1.0 1.0 1.0 1.0 1.0 In the toilet 1.10(0.85–1.42) 1.11(0.85–1.43) 1.98(1.50–2.61) 1.96(1.49–2.57) 0.63(0.24–1.61) 0.54(0.21–1.38)
PRR Prevalence rate ratio, CI confidence interval
Among the women studied, the RTI prevalence was 62.4% with BV the most common infection (41%) and abnormal vaginal discharge the most commonly reported RTI symptom. These results are slightly higher than those observed in the District Level Household Survey - Reproductive & Child Health (DLHS-RCH) (2002–4) survey which reported a 35.2% prevalence of RTI/STIs in Odisha or the ones reported in another district of Odisha (39.2%) [[
The current study supports the hypothesis that certain MHM practices are associated with a higher risk of lower reproductive tract infections. Women using reusable absorbent pads were more likely to have Candida infection and BV than women using disposable pads. This effect remains statistically significant for Candida infection, but not for BV, after adjustment for potential confounding factors. A similar lack of association with BV was observed in a previous study by our team [[
The place where women normally change their absorbent material was also associated with BV after adjusting for confounders (changing inside a toilet facility was found to be protective for these infections). Similar findings with BV were observed in our previously hospital based study [[
Interestingly, higher education was found to be protective only for Candida infection after adjustment for confounding (data not shown). Many different studies have showed that with education, people are better prepared to prevent disease and use health services effectively [[
More frequent changing of absorbents and regular body washing during menstruation was associated with a lower risk of BV which was not observed in our previous study in the same setting [[
Unhygienic MHM practices may create abnormally moist conditions in the vulvo-vaginal area, which may promote opportunistic infections such as Candida. Once infected, removal of Candida from the clothes may be difficult in absence of adequate cleaning and drying. In this study, whilst both BV and Candida infection were associated with several unhygienic MHM practices, TV infection was not. This could be due to the generally low prevalence of this infection among this population [[
There are several limitations to our study. Firstly, this was a hospital-based study and socio-economic, education, and WASH characteristics risk factors may differ from the wider population. Only women attending the Obstetrics and Gynecology departments consented to participate in the study, and to provide vaginal swabs, such that our findings may not be representative of either the wider population attending other sections of the hospital and, again, limiting the generalizability of our findings to the wider population. Secondly, this is a cross-sectional observational study and so we cannot infer causality based on the observed associations between MHM practices and health outcomes. Although we adjusted for a range of potential confounders, it is likely that there is residual confounding in our results. Furthermore, we did not collect data on, nor therefore adjust for, other possibly important factors, such as sexual practices or other infections. The Candida culture was able to detect only Candida albicans but no non-albican species. There is a possibility that other forms of Candida were not detected.
Despite these limitations, this is the first study, to our knowledge, to collect detailed information on individual MHM practices linked to individual laboratory confirmed lower RTI. The strengths of our work include: a large sample size with power to test associations between MHM practices and individual RTIs; the use of validated laboratory methods with external quality controls to diagnose RTI; and, lastly, the use of exclusively female doctors and interviewers in the study to facilitate participation in the study.
In India, and globally, there has been significant interest in recent years around the issue of safe MHM, and much discussion around the inclusion of MHM in the post-2015 sustainable development goals [[
Reusable materials are still used widely and, for them to be hygienic, safe accompanying hygienic practices are required. This can be a great challenge in some settings such as high density urban settlements where private space for such practices is limited and in low income rural areas where the water supply is limited.
Whilst this study aimed to assess the risk presented by certain MHM practices for the health of women, it is important to recognize that access to safe, affordable and appropriate MHM is as much an issue of social justice as it one of public health [[
In conclusion, the results of our study demonstrate a strong association between poor MHM practices and two lower RTIs: BV and Candida albicans infection. Our findings support global calls for a dual focus on the provision of appropriate absorbent materials as well as ensuring that environmental conditions that enable associated hygiene including washing and drying of pads can be practiced with safety and dignity by women. Future research efforts in this area should seek to measure whether and, to what extent, such interventions reduce the risk of RTI through well-conceived and well-designed intervention studies.
PD, BT and PP were involved in conceptualizing the manuscript. BT and PD designed the study and data collection instruments. PD managed and coordinated the study. PD, SS, JRM, PS and TS did the data collection and laboratory work. BP and AN are the gynecologists responsible for recruitment of cases and collection of vaginal samples at Capital Hospital, and MB and BB at IGH, Rourkela. BT and PD conducted data analysis. BT and PD wrote the manuscript. OC reviewed the manuscript critically for important intellectual content. All authors had intellectual input during the study period and contributed to redrafting the manuscript.
The study was approved by the Institutional Review Board of Asian Institute of Public health (AIPH) [ERC/No: 2013–03], Ispat General Hospital, Rourkela [Regd No: ECR/369/Inst/OR/2013], and the Ethical Committee of Government of Odisha [No: 237/SHRMU]. The study was also approved by the Ethics Committee of the London School of Hygiene and Tropical Medicine [LSHTM ethics ref.: 6520]. Only those women who provided written informed consent to participate in the study were included.
Not applicable.
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Graph: Variable table with Definitions (Table that present all the variables measured in the study and their definitions). (DOC 62 kb)
Graph: Diagnosis of BV, TV, and Candida infection. Detail explanation about laboratory methods used to diagnosed the studied infections [ 45 , 46 ]. (DOCX 12 kb)
Graph: Strobe checklist for Cross-sectional studies (Strobe checklist requested from reviewers. It is not referred in the text, but it is added as Additional file). (DOC 97 kb)
We would like to thank Prof Jane Carlton for providing TV positive isolates. We would like to express our appreciation for the support from study participants, and hospital nurses for assisting in this project.
This work was made possible with UK aid from the Department for International Development (DFID), as part of the SHARE research programme, and support from the Water Supply and Sanitation Council (WSSCC). However, the views expressed do not necessarily reflect DFID's official policies or the policies of WSSCC. The funding agencies had no involvement in study design, data collection, data analysis, and data interpretation.
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
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