Objectives: The primary objectives were to determine the proportion of modern menstrual method (MMM) users among college going women in Coimbatore district, Tamil Nadu; and to estimate the unmet needs associated with use of MMMs in comparison with other menstrual hygiene methods (MHMs). We also assessed the factors that determine MMM use among college going women. Methods: This was a descriptive cross-sectional study conducted among college going women in Coimbatore district, Tamil Nadu, India between October 2022 and January 2023 using a purpose predesigned, pretested, semi-structured proforma that included validated Menstrual Practice Needs Scale (MPNS-36). Results: Only 1.4% of the study participants used MMMs – menstrual cups (1.3%) and tampons (0.1%). Sanitary pads were the most common MHM of choice (96.3%); of which majority (98.6%) used disposable pads and more than half (50.4%) used non-biodegradable pads. Importantly, one in six (16.5%) were not aware of nature of sanitary pads (biodegradable or nonbiodegradable) used. The unmet needs associated with MMMs (menstrual cups and tampons) were significantly lower than that for other MHMs (including sanitary pads), in particular, the unmet material and home environment needs, unmet material reliability concerns, unmet reuse needs and unmet reuse insecurity. However, we found no significant difference between MMMs, sanitary pads and other MHMs in terms of unmet transport, college environment, change and disposal insecurity needs. The significant predictors of use of MMMs were age (more than 21 years of age), residence (urban), type of stay (off campus including home), socioeconomic status (upper), fathers' and mothers' education (high school and above), and presence of personal income. Discussions with friends (or peers) both before and after menarche regarding menstruation resulted in higher adoption of modern menstrual methods. Conclusion: MMMs provided comparative advantage with lesser unmet needs for material reliability and reuse insecurity concerns, particularly in home environment. However, none of the MHMs fulfilled the user expectations for transport and disposal insecurity concerns, particularly outdoors.
Keywords: Modern hygiene management; Menstrual cups; Tampons; Adolescents; India; Unmet needs
Menstruation is a normal physiological process; a part of reproductive events in primate females [[
The National Family Health Survey – 5 (NFHS-5) defines hygienic methods of protection during the menstrual period as use of locally prepared napkins, sanitary napkins, menstrual cups, or tampons during their menstrual period by women between 15 and 24 years of age. The data highlighted that 78.0% of women in this age group used a hygienic method of menstrual protection [[
Against this background, the primary objectives of the present study were to determine the proportion of modern menstrual method users among college going women in Coimbatore district, Tamil Nadu, and to estimate the unmet needs associated with use of modern menstrual methods in comparison with other menstrual hygiene methods. We also assessed the factors that determine modern menstrual method use among college going women.
This was a descriptive cross-sectional study conducted among college going women in Coimbatore district, Tamil Nadu, India between October 2022 and January 2023. The study enrolled all women studying in colleges of Coimbatore district. However, we excluded participants not willing to provide digital informed consent. A line list of universities and colleges in Coimbatore district was prepared by referring to the Public Utilities directory available at the District Collectorate, Coimbatore district, Government of Tamil Nadu; disaggregated by type of institution (university or college), location (urban or rural), type of ownership (government or private), and courses offered (medicine, allied health sciences, arts and science, and commerce). We randomly (simple random sampling technique) choose six colleges (because of feasibility concerns only six colleges were chosen) – one university and five colleges; two from rural and four from urban; three arts and science colleges, one medical, allied health science and commerce college each. Each college was visited twice. During the first visit, permission was sought from respective heads of the institution, study rationale was explained, and consent/assent forms were circulated to all eligible participants (complete enumeration). In the second visit, a purpose predesigned, pretested, semi-structured proforma in Google Forms platform (https://forms.gle/AwUa3wmhS68DwT177) that included socio-demographic characteristics, choice of menstrual hygiene methods and validated Menstrual Practice Needs Scale (MPNS-36) was administered [[
We defined the choice of menstrual hygiene method as the most preferred method or that method currently used (last menstrual period) [[
The data obtained using Google Forms was exported in Microsoft Excel format and analysed using Statistical Package for the Social Sciences (SPSS) v27. Descriptive analysis was presented using numbers and percentages for categorical variables and mean (standard deviation) for continuous variables with appropriate graphs. To test for association between MPNS-36 domain scores and choice of menstrual hygiene method we used one-way analysis of variance (ANOVA) assuming equal variance with Bonferroni correction to adjust for probability values because of the increased risk of a type I error when making multiple statistical tests. This was adjusted for factors significantly associated with modern menstrual method use among college going women. To test for association between independent study variables and choice of menstrual hygiene methods we used Chi square test (two sided). Statistical significance was considered at p < 0.05.
The present study included a total of 3144 college going women in Coimbatore district, Tamil Nadu. The mean (SD) age of the study population was 19.34 years (1.83), with a median (IQR) of 19.00 years (18.00 to 20.00) and ranging between 16 and 46 years.
Only 1.4% of the study participants used modern menstrual methods – menstrual cups (1.3%) and tampons (0.1%). Majority (96.3%) of the study participants used sanitary pads during their last menstrual period (current choice) – of which 98.6% used disposable and 1.4% used reusable pads. We also noted that 50.4% participants used non-biodegradable pads, 29.4% used biodegradable pads and 16.5% were not aware of biodegradability (Fig. 1).
Graph: Fig. 1Distribution of choice of menstrual hygiene method
The other menstrual hygiene methods practised by the participants (2.3%) in the present study were cotton wool, natural materials (including use of mud, leaves, grass), normal underwear alone, strips of sari, towel, or other cloth and toilet paper or tissues.
The mean MPNS scores were significantly lower for sanitary pad users (Mean 1.89, SD 0.44) and users of other menstrual hygiene methods (Mean 1.75, SD 0.44) in comparison with MMM users (Mean 2.10, SD 0.52). In other words, the unmet needs associated with MMMs were significantly lower than sanitary pads and other menstrual hygiene methods (p < 0.05). It was found that the unmet material and home environment needs associated with MMMs (Mean 2.32, SD 0.69) was significantly lower in comparison with use of sanitary pads (Mean 2.06, SD 0.66) and other menstrual hygiene methods (Mean 1.68, SD 0.85) (p < 0.05). Similarly, the unmet material reliability concerns were significantly lower among MMM users (Mean 2.10, SD 0.73) in comparison with sanitary pad users (Mean 1.72, SD 0.78). However, we found no significant difference between MMMs, sanitary pads and other menstrual hygiene methods in terms of unmet transport, college environment, change and disposal insecurity needs (p > 0.05) (Table 1a).
Table 1a Unmet needs associated with menstrual hygiene methods
MMM Sanitary pads Others Total Mean (SD) Mean (SD) Mean (SD) Mean (SD) MPNS scores – Total 2.10 (0.52) 1.89 (0.44) 1.75 (0.44) 1.89 (0.44) Ref 0.005* < 0.001* Material and home environment needs 2.32 (0.69) 2.06 (0.66) 1.68 (0.85) 2.05 (0.66) Ref 0.032* < 0.001* Transport and college environment needs 1.78 (0.84) 1.75 (0.72) 1.56 (0.81) 1.74 (0.73) Ref 1.000 0.372 Material reliability concerns 2.10 (0.73) 1.72 (0.78) 1.90 (0.87) 1.73 (0.79) Ref 0.005* 0.571 Change and disposal insecurity 2.16 (0.81) 2.03 (0.74) 1.87 (0.85) 2.03 (0.74) Ref 0.797 0.136 Reuse needs 2.26 (0.67) 1.66 (0.80) 1.68 (0.77) 1.71 (0.81) Ref < 0.001* 0.044* Reuse insecurity 2.16 (0.85) 1.64 (0.82) 1.88 (0.56) 1.69 (0.83) Ref 0.001* 0.777
*Statistically significant at p < 0.05
Table 1b Unmet needs associated with menstrual hygiene methods
MMM Sanitary pads Others Total n (%) n (%) n (%) n (%) Unmet needs (Overall) Present 18 (41.9) 1901 (62.8) 56 (77.8) 1975 (62.8) 0.001* Absent 25 (58.1) 1128 (37.2) 16 (22.2) 1169 (37.2) Unmet material and home environment needs Present 13 (30.2) 1374 (45.4) 50 (69.4) 1437 (45.7) < 0.001* Absent 30 (69.8) 1655 (54.6) 22 (30.6) 1707 (54.3) Unmet transport and college environment needs Present 30 (69.8) 2117 (69.9) 54 (75.0) 2201 (70.0) 0.646 Absent 13 (30.2) 912 (30.1) 18 (25.0) 943 (30.0) Unmet material reliability concerns Present 18 (41.9) 2202 (72.7) 43 (59.7) 2263 (72.0) < 0.001* Absent 25 (58.1) 827 (27.3) 29 (40.3) 881 (28.0) Unmet change and disposal insecurity Present 17 (39.5) 1464 (48.3) 41 (56.9) 1522 (48.4) 0.177 Absent 26 (60.5) 1565 (51.7) 31 (43.1) 1622 (51.6) Unmet reuse needs Present 14 (41.2) 289 (73.2) 12 (70.6) 315 (70.6) < 0.001* Absent 20 (58.8) 106 (26.8) 5 (29.4) 131 (29.4) Unmet reuse insecurity Present 15 (44.1) 308 (78.0) 14 (82.4) 337 (75.6) < 0.001* Absent 19 (55.9) 87 (22.0) 3 (17.6) 109 (24.4)
*Statistically significant at p < 0.05
For participants using reusable methods, it was found that the unmet reuse needs associated with MMMs (Mean 2.26, SD 0.67) was significantly lower in comparison with sanitary pads (Mean 1.66, SD 0.80) and other menstrual hygiene methods (Mean 1.68, SD 0.77). Similarly, the unmet reuse insecurity needs were significantly lower among MMM users in comparison with sanitary pad users (p < 0.05).
Unmet needs associated with MMMs was significantly lower (41.9%) than sanitary pads (62.8%) and other MHMs (77.8%) (Table 1b). The estimated overall unmet material and home environment needs were 45.7%, unmet transport and college environment needs were 70.0%, unmet material reliability concerns were 72.0%, unmet change and disposal insecurity needs were 48.4%, unmet reuse needs were 70.6%, and unmet reuse insecurity needs were 75.6%. A significantly lower proportion of MMM users (30.2%) had unmet material and home environment needs in comparison with sanitary pads (45.4%) and others menstrual hygiene methods users (69.4%). Similarly, MMM users had a significantly lower unmet material reliability concerns, unmet reuse needs, and unmet reuse insecurity (p < 0.05). No method performed better in terms of transport, college environment needs, change and disposal insecurity (p > 0.05) – unmet transport and college environment needs ranged between 69.8% for MMM users, 69.9% for sanitary pad users and 75.0% for users of other menstrual hygiene methods; unmet change and disposal insecurity needs ranged between 39.5% for MMM users, 48.3% for sanitary pad users and 56.9% for users of other menstrual hygiene methods.
The results of the present study showed that a significantly (p < 0.05) higher proportion of MMM users were more than 21 years of age (23.3%), from urban areas (current residence, 76.7%), with off campus type of stay (including home, stay with relatives, hostels, as paying guests, and similar, 86.1%), upper socioeconomic status (69.8%), with fathers' and mothers education high school and above (83.7% and 88.4% respectively), and presence of personal income source (14.0%). However, marital status, hometown, and freedom to manage day-to-day expenses were not statistically associated with use of modern menstrual methods in the present study (p > 0.05) (Table 2a).
Table 2a Factors associated with choice of menstrual hygiene methods
MMM Sanitary pads Others Total n (%) n (%) n (%) n (%) Age (in years) 33 (76.7) 2738 (90.4) 67 (93.1) 2838 (90.3) 0.008* > 21 10 (23.3) 291 (9.6) 5 (6.9) 306 (9.7) Marital status Unmarried 41 (95.3) 2979 (98.3) 70 (97.2) 3090 (98.3) 0.253 Married/ Separated/ Divorced 2 (4.7) 50 (1.7) 2 (2.8) 54 (1.7) Current residence Rural 10 (23.3) 921 (30.4) 32 (44.4) 963 (30.6) 0.022* Urban 33 (76.7) 2108 (69.4) 40 (55.6) 2181 (69.4) Hometown Rural 17 (39.5) 1341 (44.3) 39 (54.2) 1397 (44.4) 0.201 Urban 26 (60.5) 1688 (55.7) 33 (45.8) 1747 (55.7) Type of current stay Home 23 (53.5) 1997 (65.9) 53 (73.6) 2073 (65.9) 0.001* In campus hostel 6 (14.0) 628 (20.7) 7 (9.7) 641 (20.4) Off campus@ 14 (32.6) 404 (13.3) 12 (16.7) 430 (13.7) Socioeconomic status Lower and middle 13 (30.2) 1858 (61.3) 50 (69.4) 1921 (61.1) < 0.001* Upper 30 (69.8) 1171 (38.7) 22 (30.6) 1223 (38.9) Fathers' education Illiterate and/or up to middle school 7 (16.3) 748 (24.7) 27 (37.5) 782 (24.9) 0.019* High school and above 36 (83.7) 2281 (75.3) 45 (62.5) 2362 (75.1) Mothers' education Illiterate and/or up to middle school 5 (11.6) 694 (22.9) 24 (33.3) 723 (23.0) 0.024* High school and above 38 (88.4) 2335 (77.1) 48 (66.7) 2421 (77.0) Freedom to manage day-to-day expenses Absent 11 (25.6) 1167 (38.5) 31 (43.1) 1209 (38.5) 0.160 Present 32 (74.4) 1862 (61.5) 41 (56.9) 1935 (61.5) Personal source of income Absent 37 (86.0) 2883 (95.2) 67 (93.1) 2987 (95.0) 0.018* Present 6 (14.0) 146 (4.8) 5 (6.9) 157 (5.0)
*Statistically significant at p < 0.05
Table 2b Factors associated with choice of menstrual hygiene methods
Discussion about menstruation MMM Sanitary pads Others Total n (%) n (%) n (%) n (%) Before menarche, mother/sister/any family member No 11 (25.6) 1221 (40.3) 26 (36.1) 1258 (40.0) 0.117 Yes 32 (74.4) 1808 (59.7) 46 (63.9) 1886 (60.0) Before menarche, friend(s) No 12 (27.9) 1408 (46.5) 42 (58.3) 1462 (46.5) 0.007* Yes 31 (72.1) 1621 (53.5) 30 (41.7) 1682 (53.5) After menarche, mother/sister/any family member No 2 (4.7) 188 (6.2) 7 (9.7) 197 (6.3) 0.433 Yes 41 (95.3) 2841 (93.8) 65 (90.3) 2947 (93.7) After menarche, friend(s) No 4 (9.3) 260 (8.6) 15 (20.8) 279 (8.9) 0.001* Yes 39 (90.7) 2769 (91.4) 57 (79.2) 2865 (91.1)
*Statistically significant at p < 0.05
We also assessed whether discussions with family members (mother and/or sister) and friends about menstruation would predict the choice the modern menstrual methods. It was found that discussions with friends both before (72.1%) and after (90.7%) menarche regarding menstruation resulted in higher adoption of modern menstrual methods (p < 0.05). However, such an association was not found to be statistically significant for discussion with family members (mothers and/or sisters) (Table 2b).
This descriptive cross-sectional study found that only 1.4% college going women in Coimbatore district, Tamil Nadu used modern menstrual methods (menstrual cups and tampons). Sanitary pads were the most common menstrual hygiene method of choice (96.3%); of which majority (98.6%) used disposable pads and more than half (50.4%) used non-biodegradable pads. Importantly, one in six (16.5%) were not aware of nature of sanitary pads (biodegradable or nonbiodegradable) used. Nearly two third (62.8%) college women had unmet needs with current choice of menstrual hygiene methods. The unmet needs associated with modern menstrual methods were significantly lower than that for other menstrual hygiene methods (including sanitary pads), in particular, the unmet material and home environment needs, unmet material reliability concerns, unmet reuse needs and unmet reuse insecurity. However, we found no significant difference between MMMs, sanitary pads and other menstrual hygiene methods in terms of unmet transport, college environment, change and disposal insecurity needs. The significant predictors of use of modern menstrual methods were age (more than 21 years of age), residence (urban), type of stay (off campus including home, stay with relatives, hostels, as paying guests, and similar), socioeconomic status (upper), fathers' and mothers' education (high school and above), and source of personal income. Our results also showed that discussions with friends (or peers) both before and after menarche regarding menstruation resulted in higher adoption of modern menstrual methods. However, such an association was not found to be statistically significant for discussion with family members (mothers and/or sisters).
The adoption of modern menstrual methods, such as menstrual cups and tampons, was quite low, with only 1.4% of participants reporting their usage. This finding corroborates with existing literature evidence. The dominance of sanitary pads as the primary menstrual hygiene product is consistent with previous studies that have highlighted the popularity of pads among Indian women due to their ease of use, availability, and affordability [[
Menstrual cups minimises the economic burden (given that one cup can last up to 10 years) and menstrual waste compared to the use of sanitary pads; [[
The magnitude of unmet needs signify the gap in meeting menstrual health requirements of young women in the region warranting attention. Comparatively, MMMs were associated with lesser unmet needs. Literature refers to MMMs as better menstrual hygiene solutions [[
It is important to note that modern menstrual methods may not completely eliminate all unmet needs. For example, we observed no significant difference between MMMs, sanitary pads, and other menstrual hygiene methods in terms of unmet transport, college environment, change, and disposal insecurity needs. These aspects can be influenced by factors such as access to clean and private restroom facilities (proper sanitation facilities) at colleges (or other educational institutions and public places), availability of menstrual products at educational institutions, availability of disposal options, and cultural perceptions of menstruation [[
The high prevalence of unmet needs with traditional menstrual hygiene methods, especially sanitary pads, could be attributed to various factors. Firstly, the adverse effects (including rashes, reproductive tract infection, vaginal infections, cervical cancer, urinary tract infection, hepatitis B, and different types of yeast infections) associated with use of sanitary pads may impact the quality of life of women [[
Similar to the findings of this study, in many societies, the menstrual practices may evolve with age, influenced by factors such as cultural norms, peer influence, education, access to information, and financial independence. Increased awareness through educational institutions (including environmental awareness), internet access, and peer discussions (including positive testimonials) may positively influence the adoption of menstrual cups and tampons among older college-going women [[
Urban residence typically offers greater access to information, products (attributable to distribution networks (including online shopping) and market availability), healthcare services (facilities and specialists), and a supportive home environment, all of which can influence the uptake of modern menstrual methods. Similar to the type of residence, socioeconomic status and parents' education can influence various factors, such as awareness, affordability, cultural beliefs, and access to information, all of which may shape individual preferences for menstrual hygiene products. Individuals from higher SES backgrounds or with educated parents may have better exposure to health-related knowledge, including information on menstrual hygiene products [[
The present study highlights the importance of peer influence and social networks in shaping menstrual hygiene practices, particularly when it comes to adopting modern menstrual methods like menstrual cups and tampons. The influence of friends and peers on adolescent behaviours and decisions is well-documented [[
The present study is not without limitations. Firstly, the present study quantified the unmet needs associated with menstrual hygiene methods. Though a validated questionnaire that assessed multiple dimensions (MPNS-36) was used to capture unmet needs, an additional qualitative method (either in-depth interviews or focus group discussions) would have been useful. Secondly, we could establish association and not causation between menstrual hygiene method and unmet needs. However, we adjusted the results for possible predictors of choice of menstrual hygiene methods, so that the unmet needs could be attributed to the method itself.
To conclude, the adoption of modern menstrual methods, such as menstrual cups and tampons, was quite low in the present study. The study also highlights an alarming lack of awareness regarding the biodegradability of sanitary pads, potentially contributing to environmental concerns associated with menstrual waste management. Unmet needs related to menstrual hygiene were prevalent among a substantial proportion of college girls and women, particularly in terms of current menstrual hygiene choices. MMMs provided comparative advantage with lesser unmet needs for material reliability and reuse insecurity concerns, particularly in home environment. However, none of the menstrual hygiene methods fulfilled the user expectations for transport and disposal insecurity concerns, particularly outdoors. The uptake of MMMs is much higher with peer discussions. Policymakers, educators, and healthcare providers should collaborate to create a supportive environment that encourages open discussions about menstruation and menstrual hygiene. Empowering women with accurate information and access to a variety of menstrual products can play a crucial role in improving overall menstrual health and well-being in the Coimbatore district and beyond.
Nil.
TD, SN and MK conceived the idea for the study. AP, JS, SM, SD, RM, and MK were involved in data collection, cleaning, and analysis, writing the first draft, review and editing. MK had full access to the study datasets and act as guarantor. MK and AP were involved in data cleaning, statistical analysis, review, editing and overall study coordination. All authors provided technical inputs to the manuscript and approved the final version of the paper.
Nil.
The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.
The study was approved by Institute Human Ethics Committee (IHEC), KMCH Institute of Health Sciences and Research, Coimbatore (KMCHIHSR/44/IHEC/2022). The content of Participant Information Sheet (PIS) in local language was provided digitally to the study participants and contents were read to them in their own language to their satisfaction. The study subjects were enrolled in the study after obtaining digital informed consent.
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The authors have no conflicts of interest relevant to this article to disclose.
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By Thavansree Durairaj; Periasamy Aparnavi; Seetharaman Narayanan; Sushmitha Mahantshetti; Srihari Dhandapani; Jeevithan Shanmugam; Ramesh Rathinamoorthy and Mohan Kumar
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