Parental education, embarrassment, and sanitation facilities influence menstrual product choices among female nursing students in Bangladesh Open Access

Menstruation is a physiological process that usually occurs periodically in a cycle between 21 and 35 days and lasts for approximately 2–7 days, resulting in a blood flow of around 25–80 mL (Agampodi & Agampodi 2018). Although menstruation is a natural recurring event in the life of a woman or girl child, occurring between the ages of 12 and 50, more often than not, it is a subject that has been neglected worldwide. However, recent movements have propelled menstrual health to the forefront as an essential public health concern and a fundamental right to achieve the Sustainable Development Goals by 2030 (Sommer et al. 2021; Babbar et al. 2022). Hennegan and colleagues defined menstrual health as the absence of ailments and the overall state of physical, mental, and social well-being concerning the menstrual cycle (Hennegan et al. 2021).

It is of paramount importance that women and girls, particularly those residing in low- and middle-income countries (LMICs) and conflict zones, are empowered to manage their menstrual cycles privately, safely, and with dignity. This not only affects their health, both physically and mentally, but also their contribution to community development (Plesons et al. 2021). Poor menstrual health and hygiene (MHH) may lead to adverse health outcomes and adversely affect many parts of life, including education, social involvement, and psychological health (Balakrishnan et al. 2022). Every individual who is menstruating should be able to experience menstruation in a safe and dignified manner. Furthermore, gender equality, women's health, empowerment, education, and general well-being align with menstruation as factors that bring out the importance of menstrual hygiene management (MHM) in public health (UNICEF 2019). It, therefore, follows that the issue of menstruation has a strong bearing on the academic performance, class attendance, and general participation of the students in functions within the college or particularly in the university set-up (Munro et al. 2021).

MHH is a crucial factor that significantly contributes to the physical, emotional, and empowerment well-being of adolescent girls and women (World Bank Group 2021). The effective MHM comprises the use of hygienic materials to collect or absorb menstrual blood, access to facilities safe for disposing of and changing materials, and information distribution to raise awareness about menstruation and the use of menstrual hygiene (UNICEF 2019). The quality and safety of menstrual products are essential because they come into direct contact with the body repeatedly each month over a woman's lifetime, which, on average, spans about 40 years (Choi et al. 2021). Most of these girls and women lack access to high-quality, appropriate, hygienic, and absorbent materials to manage menstruation (WHO/UNICEF Joint Monitoring Programme (JMP) 2012). Menstrual hygiene products include one-time-use products such as disposable pads and tampons, as well as reusable products such as clothes, menstrual cups, and washable cloth pads (Pednekar et al. 2022). Due to high costs and limited knowledge, many women resort to using old clothes as menstrual products (Meher & Sahoo 2023). However, these reusable materials can be unhygienic because they are often cleaned without soap and with unclean water, and social taboos and restrictions further complicate matters by forcing women to dry these clothes indoors, away from sunlight and fresh air (Das et al. 2015).

In Bangladesh, a densely populated South Asian country, there is commendable development in infrastructure related to water, sanitation, and hygiene (WASH). However, the country has a huge gap in the extensive literature on the practice of menstrual hygiene in the country (Ministry of Health and Family Welfare 2019; Ministry of Local Government 2021). According to the Bangladesh National Hygiene Survey, only 41% of females aged 15–49 practiced hygienic menstrual management, with a mere 39% having access to sanitary pads (Bangladesh Bureau of Statistics 2020). Most studies have focused exclusively on adolescent girls, offering a gendered perspective on menstruation. They largely emphasise societal stigma, including embarrassment, misconceptions about menstruation, inadequate facilities in educational institutions, and familial restrictions that contribute to school absenteeism.(Alam et al. 2017; Hennegan & Sol 2020). Most extant studies have concentrated on needs and practices concerning menstruation (Ha & Alam 2022; Hunter et al. 2022). However, limited studies have been undertaken on MHM among adult women, particularly those in specialised sectors such as nursing. Women in these fields are essential members of the female population and future healthcare professionals who tackle women's health concerns. This implies, therefore, that these MHH practices among women have to be well inculcated into the nursing programmes.

Based on the literature, many factors contribute to MHM, which play a vital role in the health, social involvement, and overall well-being of women. Despite progress in understanding MHH, there is still a notable gap in research that specifically addresses the factors influencing menstrual product choices among nursing students. Their choices and practices are shaped not only by personal preferences but also by the surrounding environment. This study thus sought to identify the parental education, embarrassment, and sanitation facilities that affect nursing students' choices of menstrual hygiene products in Bangladesh.

Therefore, 366 nursing students were included in this study after the sample size was calculated. Following the allocation of students from seven selected nursing colleges using proportional allocation to size (PAS), the participants were chosen through simple random sampling.

The research instrument was a rigorously structured questionnaire that contained 64 questions from the Menstrual Health Questionnaire (Medina-Perucha et al. 2020; Hassan et al. 2023) and a recent study about confidence in managing menstruation (Munro et al. 2022). The research instrument underwent translation into Bangla and subsequent revision by the research team. The questionnaire gathered data on socio-demographic and menstrual characteristics, menstrual information and education, menstrual hygiene products and supplies, and perceptions of the sanitation facilities. The questionnaire included multiple-choice questions, yes/no questions, and Likert scale items. For example, one question asked, ‘Are you embarrassed to buy menstrual products?’, with response options on a Likert scale ranging from 1 (I do not know) to 5 (Always). The data were gathered through face-to-face interviews held on campus every weekday, except Friday, spanning from June to July 2023. The data collection process was facilitated by the first author and six trained research assistants, all of whom are professional nurses and midwives.

Numbers and percentages were utilised for the analysis of categorical variables. Pearson's chi-square was employed to evaluate the bivariate relationships between types of sanitary products and socio-demographic factors. Multivariable logistic regression analysis was employed to ascertain the potential factors linked to using single-use pads and old clothes. We created dummy variables for Likert scale data (e.g., lacked money to buy menstrual products) to input our regression models. Responses to items with ‘always’, ‘sometimes’, and ‘few times’ response options were recorded as ‘1’ meaning yes and ‘never’, and the ‘I don't know’ response option was recorded as ‘0’ meaning no. We similarly treated responses to each item on the perception of sanitation facilities, with ‘always’, ‘most of the time’, and ‘sometimes’ response options recorded as ‘1’ meaning good and ‘rarely’ and ‘never’ response options recorded as ‘0’ meaning poor conditions. The stepwise regression technique was used to select the best predictive model. In the stepwise regression variable selection, the bivariate odds ratio was calculated between each dependent and independent variable. Only those with an odds ratio less than 0.25 were incorporated into the multilevel model (Sun et al. 1996). For entry and removal into the adjusted odds ratio model, the respective p-value thresholds were set at 0.25 and 0.1. The significance level was established at p < 0.05, maintaining a confidence interval of 95% using JMP version 17 Pro (SAS Institute Inc., Cary, NC, USA).

Ethical approval was obtained from the Directorate General of Nursing and Midwifery, Dhaka (45.03.0000.008.14.097.2021-354), NIANER, Dhaka (NIA-OS-2023-09), and the Ethical Review Committee of the Faculty of Health Sciences, Hokkaido University in Japan (23-52). An information sheet was provided to the participants before the survey, explaining in clear terms the voluntary nature of their participation and their ability to withdraw from participation at any point. We obtained consent by affirming their willingness to participate with a response of ‘yes’.

The mean age of participants was recorded as 23.3 ± 4.3 years (Table 1), and the average age at menarche was 13.2 ± 2.3 years. The majority of participants were first-year (54.1%), and 37.7% were enrolled in the B.Sc. in Nursing (4 years) course. Notably, 35.8% of participants' mothers had received a secondary education, whereas 29.9% of participants' fathers had received a higher secondary education. Additionally, it revealed that most of the participants' religions were Islam (86.1%), they were born in rural areas (75.7%), they lived in hostels (74.6%), and their monthly family income was between 10,000 and 20,000 BDT (36.6%).

The research revealed that 15.8% of the participants had irregular menstrual periods (Table 2). Over half of the participants (51.9%) reported fear of blood leakage, which is a proxy for the severity of bleeding. The participants expressed a combination of favourable and unfavourable emotions while menstruating. The unfavourable emotions reported by participants were tired (54.9%), sensitivity (31.4%), anger (40.2%), sadness (32.5%), dirty (21.6%), and embarrassment (22.4%). Some participants reported feeling happy (1.1%) and relaxed (1.4%) during their periods. The key information source about menstruation for the participants was their family (80.6%), followed by school (24.9%) and friends (25.4%). More than half of the participants (58.7%) did not have any knowledge about menstruation before they experienced their first period. Most participants (83.6%) expressed a need for more information on different topics related to menstruation. The majority (71.5%) of the participants experience feelings of embarrassment while discussing menstruation (always 15.8% and sometimes 54.6%).

Almost all participants (98.9%) reported being unable to get free menstrual hygiene products in hostels (Supplementary material, Table S1). Most of them (85%) reported that menstrual hygiene products were expensive. Most of them (86.6%) stated that they obtain their menstrual products from pharmacies while on campus. The pharmacy was identified as the most preferred location for purchasing menstrual products due to comfort (71.3%). A large majority (86.3%) of those surveyed mentioned using menstrual products for an extended duration beyond recommendations due to inadequate access to suitable washing facilities. Among them, 5.8% answered ‘always’, while 64.8% replied ‘sometimes’, and 15.7% answered ‘few times’. More than two-thirds (76.5%) of the participants also reported experiencing embarrassment when purchasing menstrual products. Among them, 10.1% answered ‘always’, 57.9% replied ‘sometimes’, and 8.5% answered ‘few times’.

A minimal proportion (15.3%) always noted the presence of disposal bins for menstrual products in their regular bathrooms (Supplementary material, Table S2). Slightly more (15.6%) confirmed the consistent availability of clean running water and soap always for handwashing. Participants reported ‘always’ when asked if they had consistent privacy (22.1%), functional toilets (13.9%), cleanliness (13.4%), functional door locks (30.1%), and toilet paper availability (9.3%) in the bathrooms.

Table 3 shows the association between different menstrual hygiene products and socio-demographic backgrounds. Statistically noteworthy variations existed in the selection of menstrual hygiene products among the categories of studentship (p ≤ 0.0001), fathers’ education level (p = 0.0307), mothers’ education level (p = 0.0050), and monthly family income (p ≤ 0.0001). Interestingly, there were no statistically significant differences in types of menstrual hygiene products between the year of college (p = 0.5687), religion (p = 0.3419), birthplace status (p = 0.9615), and resident status (p = 0.9562).

Table 4 presents the multivariable logistic regression analysis for assessing the factors affecting single-use pads and old clothes. These were significantly predicted by menstrual characteristics, access to menstrual hygiene products, and perceptions of sanitation facilities. However, the utilisation of single-use pads and old clothes did not show significant prediction by menstrual information and education. The significant independent predictors that increased odds for single-use pads were fear of staining clothes with blood (AOR: 2.95; 95% CI: 1.53–5.68), having a clean and sanitary bathroom (AOR: 3.17; 95% CI: 1.20–8.39), and the bathroom having functional locks on doors (AOR: 4.45; 95% CI: 1.67–11.85). The odds of having single use pads were less for those who lacked the money to buy menstrual products (AOR: 0.26, 95% CI: 0.09–0.68), were embarrassed to buy menstrual products (AOR: 0.37, 95% CI: 0.16–0.86), and had privacy in their bathroom (AOR: 0.33, 95% CI: 0.14–0.77). Therefore, the significant independent predictors that increased odds for old clothes were being embarrassed to buy menstrual products (AOR: 2.86, 95% CI: 1.16–7.07) and having privacy in their bathroom (AOR: 2.92, 95% CI: 1.12–7.63). The significant independent predictors that had reduced odds for old clothes were the bathroom being clean and sanitary (AOR: 0.20, 95% CI: 0.07–0.58), the bathroom having functional door locks (AOR: 0.21; 95% CI: 0.07–0.67), and the bathroom having a supply of water and soap (AOR: 0.23; 95% CI: 0.07–0.77).

Family is the primary source of menstrual information (Table 2), and choices of menstrual hygiene products are significantly influenced by parental education, as given by Pearson's chi-square test (Table 3). In other related studies carried out in different nations, the family was the primary source of information on menstruation: Egypt (53–92.2%) (Chandra-Mouli & Patel 2017), Saudi Arabia (66.8%) (Alharbi et al. 2018), India (50.3%) (Tshomo et al. 2021), and Indonesia (almost half) (Assa et al. 2024). This suggested the importance of family as an educational resource for girls who are menstruating and the need for proper menstrual hygiene practices. The resulting lack of information about menstruation can lead to the use of unhygienic materials, which have significant implications for women's health, including an increased risk of infections and other health issues. The unique educational and professional context of the participants as nursing students does not directly affect their product choices, as these decisions are often influenced more by their surrounding environment than by personal preference. This indicated that not only are menstrual information and education important, but parental education is also significant for the participants.

Most participants experienced embarrassment both in discussing menstruation (Table 2) and purchasing menstrual products (Supplementary material, Table S1). This embarrassment significantly increased the likelihood of using old clothes rather than single-use pads in multivariable logistic regression (Table 4). Similar levels of embarrassment were observed in studies from Bangladesh, India, and Australia (Hennegan & Sol 2020; Munro et al. 2022; Kumar et al. 2024), in contrast to Palestine, which had lesser embarrassment (Hassan et al. 2023). This indicates that the issue of embarrassment during menstruation is not dependent on the country's affluence but is a relatively sensitive topic. The embarrassment nursing students feel about menstruation is particularly troubling, as they are future healthcare providers who will need to educate and support patients. It could hinder their ability to properly educate and care for patients, leading to missed opportunities for effective menstrual education and potentially perpetuating misinformation. Researchers recommend further investigations, including qualitative research to see the reasons behind this embarrassment.

The fear of blood stains on clothes was significantly associated with menstrual product choices. A high proportion of the participants (51.9%) feared staining clothes with blood (Table 2), and this fear was associated with increased odds of using single-use pads rather than old clothes in multivariable logistic regression (Table 4). These findings differ from another study where 85.3% found fear of staining clothes with blood, but no association was measured (Hassan et al. 2023). The fear of this blood is mental, not physical, as the participants are aware that they menstruate every month. The concern, therefore, is to avoid washing the menstrual products. From the preferences for single-use pads, it follows that the fear of staining clothing with blood from menstruation would guide the choice of menstrual products and the demand for proper sanitation facilities.

The participants had a poor perception of sanitation facilities for practicing menstrual hygiene. These findings indicated that privacy (22.1%), cleanliness (13.4%), and functional door locks (30.1%) were always reported as poor in the bathrooms (Supplementary material, Table S2). These findings align with previous research demonstrating inadequate menstrual hygiene facilities on college campuses, schools, and communities (Hennegan & Sol 2020; Munro et al. 2021, 2022; Bhakta et al. 2024). A possible cause is the lack of prioritisation of sanitation facilities within both these institutions and the community. A good perception of the need for privacy, cleanliness, and functionality of sanitation facilities points to a significant need for prioritizing infrastructure development for sanitation to improve menstrual hygiene and sanitation conditions.

Decisions were based on the sanitation facilities, either single-use pads or old clothes. The multivariable logistic regression of the above-indicated user showed that privacy was a predictor for reduced odds of using single-use pads and an increased likelihood of using old clothes, while the functionality of door locks was one of the predictors for increasing the odds of using single-use pads but decreasing the use of old clothes (Table 4). Similar findings include students using menstrual products longer than advised without water, privacy, and sanitary waste bins (Munro et al. 2021), as well as latrine types (Mudi et al. 2023) and sanitation facilities influencing menstruation management (Shannon et al. 2021; Sato et al. 2023; Sambo et al. 2024). The preference for using old clothes in private bathrooms, despite less sanitary conditions, likely stems from a strong cultural emphasis on privacy and avoiding stigma, which outweighs concerns about the bathroom's cleanliness or functionality. Thus, the physical environment is critical in MHM. It becomes clear that menstrual hygiene product choices are not only a matter of individual choice but are deeply connected with parental education, embarrassment, and sanitation facilities. Addressing these factors can lead to better health outcomes and empower women to manage their menstruation with hygienic products.

This study was confined to government nursing colleges and focused solely on nursing students, which may limit the generalizability of the findings to a broader population of women. The use of proportional sampling might help reduce biases that could affect the representation of the entire student population. Secondly, the study relied on self-reported data, which could be subject to response bias. Participants' answers might have been influenced by recall bias or the desire to present themselves in a socially desirable manner. The use of self-reporting also allows for the collection of nuanced personal experiences and perceptions, which are invaluable for understanding subjective phenomena like menstruation. Thirdly, this study's use of multivariate logistic regression allowed for the identification of statistically significant factors associated with product choices. Due to the complex and multifaceted nature of MHM, some factors that were not statistically significant in our model may still have important social and personal influences that were not fully captured. Future research should consider qualitative approaches to explore these nuanced contributions further. Lastly, the sanitation facilities considered in this study were limited to perceptions of bathrooms and access to menstrual hygiene products. Other potential WASH influences, such as exposure to menstrual health education outside of formal schooling, broader community support systems, and household conditions, were not explored. Concentrating on these specific aspects of WASH facilities allowed for a detailed exploration of core environmental and resource-based factors, directly impacting menstrual hygiene practices.

This study provides important insights into MHH among nursing students, as well as crucial future healthcare professionals. The participants had minimal knowledge of menstruation before menarche and that family was a main source of menstrual information. Single-use pads and old clothes were major menstrual products used among the participants. The inhibition of the menstrual product choices was influenced by parental education, not participant knowledge level. The use of single-use pads and old clothes is influenced by embarrassment about purchasing products, fear of blood-staining clothes, availability of water and soap, privacy of bathrooms, and functional door locks for bathrooms. Better practice of MHH requires improved parental education, reduced embarrassment, and better sanitation facilities.

The authors are thankful to SmileLab (Laboratory of Human Ecology) members, Faculty of Health Sciences, Hokkaido University, Japan. The authors are also grateful to the respondents who participated in this study, the research assistants, the Japan International Corporation Agency (JICA), the Directorate General of Nursing and Midwifery, Bangladesh, and Principals of these seven nursing colleges for their support and cooperation in the field.

This research was supported by a JICA scholarship (Scholarship Number: D2202659).

Data cannot be made publicly available; readers should contact the corresponding author for details.

The authors declare there is no conflict.