Healthy menstruation: Myth or reality? Insights into urban slums of Vishakhapatnam city, India Open Access

Menstrual health is vital for the overall reproductive health and well-being of any woman. Healthy and hygienic menstruation is widely recognized as a foundation for promoting gender equality and universal human rights (Ghalay & Rajendra 2019). Menstruation, a universal physiological progression and a key milestone in adolescent girls' development, prepares them for motherhood but can pose various challenges in cases of inadequate knowledge and lack of awareness (Tegegne & Sisay 2014; Bachloo et al. 2016; Ghalay & Rajendra 2019; Ramya 2020). Menstrual health and hygiene are crucial for the well-being, reproductive and maternal rights, and dignity of all menstruating women. Poor menstrual hygiene can lead to various infections, reproductive health concerns, and other related complications. The World Health Organization (WHO) and UNICEF have jointly introduced the first set of global indicators to monitor progress in menstrual health and hygiene under the Joint Monitoring Program for Water Supply, Sanitation, and Hygiene, aligning with Sustainable Development Goal (SDG) 3. Menstrual hygiene is a critical human rights issue, also emphasized in the Universal Declaration of Human Rights, impacting women's dignity and reproductive rights (Garg et al. 2012; Boosey 2013). Millions of women face challenges related to menstrual hygiene due to poverty, stigma, taboos, myths, and lack of education resulting in inadequate management practices obstructing these rights, especially in low- and middle-income countries (LMICs) (Chakravarthy et al. 2019; Bhusal 2020; Babbar et al. 2021).

Even in the 21st century, healthy and hygienic menstrual health management (MHM) is far from the reality in the majority of the LMICs and countries like India. Menstruation is still considered taboo surrounded by various myths, leading to misinformation, health risks, and social exclusion. Healthy menstruation and MHM become more challenging when it comes to the poverty-stricken urban slums, which are growing and accommodating a larger share of the migrated population with economic instability and awareness. Urban poverty and life in slums limit the women's ability to manage their menstrual cycles hygienically. Unlike rural areas, urban slums represent different sets of challenges such as poor sanitation, hygiene, privacy, access, and affordability for menstrual products. In these areas, the awareness about menstruation and its physical and psychological impacts during puberty is still lacking among young girls. The onset of menstrual cycles significantly affects young women, particularly those of school-going age (Garg et al. 2012; Sommer & Mmari 2015). Proper hygiene management during menstruation is often neglected as periods are still considered taboo in LMICs (Gaudineau 2010; Juyal et al. 2012). Hygiene and menstrual management are crucial for gender equality and empowerment, affecting not only the women's reproductive health (RH) and attainment of education but also participation in the workforce (Abed & Yousef 2011; Rao et al. 2014; Sommer & Mmari 2015; Garikipati & Boudot 2017; Heise et al. 2019). Menstruation needs to be looked beyond the matter of RH by applying a human rights approach to MHM which involves taking swift and effective actions to enhance women's lives (Hennegan 2017).

Menstrual hygiene is often neglected in India, leaving adolescent girls vulnerable to serious health concerns such as reproductive tract infections (RTIs), urinary tract infections (UTIs), pelvic infections, and long-term conditions like cervical cancer, infertility, and ectopic pregnancy (Sarkar et al. 2017). Enhancing menstrual knowledge, attitudes, and practices (KAP) along with the availability of affordability and access to proper sanitary product usage and disposal mechanisms through sensitization can significantly improve women's reproductive health, benefiting a large portion of the population. In India, women of reproductive age constitute approximately one-quarter of the population, totalling around 353 million. Over 60% of unmarried women do not use hygienic menstrual methods (Vishwakarma 2021), and half of those aged 15–24 years still rely on cloth, revealing a grim situation regarding the usage of sanitary napkins and other hygienic options (Garikipati & Boudot 2017).

Studies indicated a notable urban-rural divide in terms of MHM in India which varies widely across rural and urban areas due to awareness gaps, cultural taboos, and myths. The adoption of hygienic products and methods among adolescent women was limited to only 42%, with state-level usage ranging from 23% in Uttar Pradesh to 85% in Tamil Nadu (NFHS-5; Hulme et al. 2001; Singh et al. 2022). Although the access and usage of these products were comparably better penetrated in the urban areas, the situation of urban slums was grim and still a matter of concern. The urban slums often lack in terms of basic amenities, sanitation, and access issues, posing significant challenges to maintaining hygienic menstruation affecting not only reproductive rights but also socio-economic and human rights (Dos et al. 2017; Gutberlet 2021). Knowledge about menstrual hygiene is an essential element in adolescent health education, later shaping the health and human rights of a woman. The unavailability of clean water, sanitation, and hygiene (WASH) facilities in school, inadequate puberty awareness, and unmet needs of MHM may lead toward shame, stigma, and uncomfortable menstruation experiences (Goswami & Manna 2013; Kumari 2023). Even though menstruation is a natural physiological process, it is linked to several misconceptions, customs, myths and taboos, leading to poor hygiene practices and adverse health outcomes (Sumpter & Torondel 2013; Patel 2019; Khan 2022). In spite of being a natural biological process, menstruation is associated with various myths such as the impurity associated with period blood, isolation, and social exclusion. Often, menstruating women are asked to avoid contact with other family members, stay without a bath, and sleep in an unhygienic environment (Patel 2019; Khan 2022).

Furthermore, the women in urban slums often face economic challenges along with infrastructural, WASH, and MHM which hinder investment in their menstrual health compared to other segments of the population. The Vishakhapatnam city is one of the rapidly urbanizing cities in India, experiencing the growing burden of a slum population where menstrual health remains a critical and less explored issue. This underscores the need to explore factors contributing to unmet needs for menstrual hygiene and overall MHM among reproductive age women in the urban slums of Visakhapatnam city in India. The KAP about menstruation significantly impacts women's reproductive health and is crucial for policymaking to address violations of basic rights and dignity associated with menstrual hygiene. This study investigates the determinants of menstrual hygiene practices among girls aged 12–26 years in urban slums of Visakhapatnam city, Andhra Pradesh, India, focusing on factors influencing the adoption of hygienic methods during menstruation. Understanding local perceptions, challenges, and practices will certainly contribute to better MHM and menstrual hygiene.

A cross-sectional survey was conducted among girls aged 12–26 years in the slums of Vishakhapatnam, Andhra Pradesh, India, from March to April 2022. Vishakhapatnam has one of the highest proportions of slum population in Andhra Pradesh (Varma & Sudhakar 2018), with over 16% of the city's population living in slums (Tripathi 2015). To conduct this study, we visited the slum areas of Visakhapatnam district in Andhra Pradesh, India. With the assistance of the local health center, we initially identified and visited households with unmarried girls aged 12–26 years. The study used a combination of snowball and random sampling techniques to select clusters. This was done with the purpose of effectively capturing the clusters which can help offer a balanced and efficient approach for data collection in scenarios where the targeted population is partially reachable with notable diversities. Snowball sampling was adopted for identifying desired clusters and uncovering critical groups of the population to be recruited for data collection. Snowball sampling was chosen as the sampling method due to the challenges in directly identifying households with unmarried girls in the specified age group, given the high population density and limited resources. Using the snowball sampling technique, the households helped us to identify additional families with girls in the same age group. Some families willingly provided information about others after recognizing the significance of our study. Initially, the data were collected from 165 respondents; however, 15 were excluded due to incomplete information, resulting in a final sample size of 150 for analysis. Afterward, random sampling techniques were employed to ensure representativeness and reduce the bias for better generalizability (Van Eijk et al. 2016; Shumie & Mengie 2022). The combination of these methods ensures inclusive data with systematic coverage which is critical in such studies. As the present study dealt with the informal settlements in urban slums, otherwise, it was difficult to identify the groups of menstruating women. After identifying the groups, random sampling was used to select individuals within these groups to avoid the skewness of collected information. Data were collected via structured questionnaires having open-ended questions which were administered to explore menstrual knowledge, attitudes, and practices among unmarried girls aged 12–26 years. Before collecting the primary data, the questionnaire was pre-tested for validity and reliability to avoid redundancy in the statistical analysis and for its validity.

Ethical Consent: Informed consent was obtained from the participants who were of legal age, while consent was sought from legal guardians/representatives for respondents under the age of 18 years. Further, the study protocol was developed and approved by the appropriate Committee for the Protection of Human Participants under the Ethical Research Committee of SRM University Vijayawada Andhra Pradesh, India in January 2022 before administering the questionnaire.

For determining the factors affecting the awareness of menstruation hygiene, a logit regression model was used taking ‘menstruation hygiene awareness’ as the dependent variable. For this purpose, we constructed a dummy variable with the value of 1 for awareness of menstruation hygiene and 0 otherwise (Anand et al. 2015).

Interpreting the estimated coefficients of the logit model is challenging due to its nonlinear nature. Each coefficient (β) in the model represents the log odds ratio of the probability of an alternative occurring relative to the base category. Since R² values are typically low in qualitative response models, model fit is evaluated using correct classification probabilities and two-log-likelihood statistics, which follow a chi-square (χ²) distribution. McFadden (1973) proposes a pseudo R² measure, akin to R², derived from the log-likelihood ratio test, to assess model accuracy (Palli et al. 2001).

Table 1 represents the socio-demographic profile of 150 young girl respondents aged 10–26 years (mean age: 16.6 years). The majority were aged between 15 and 20 years (65.33%), with 36% between 10 and 15 years and around 3% over 25 years. Although the majority of the respondent's mothers were lacking formal education (around 60%), the girls themselves had educational attainment up to secondary and above (97%). More than 73% of the respondents have attended government schools, and over 64% came from nuclear families. Around 95% of sampled respondents identified themselves as Hindus, 3% as Muslims, and the remaining 2% as Christians.

Table 2 presents hygiene practices followed during menstruation among the sampled population. About 72% have used disposable sanitary napkins, 17% used cloths, and 11% have used both during their last menstrual cycle. Girls from more educated and financially stable families prefer using disposable sanitary pads. Those using cloths during periods often did not consider the quality, citing reasons such as cost, availability, and lack of knowledge about sanitary pads. Some girls have mentioned that they felt embarrassed to purchase pads from stores. The majority of the girls reported changing their menstrual pads on a regular and daily basis. About 58% of surveyed respondents have used only water for cleaning their genitals during menstruation, while 9% mentioned that they do not wash properly. It was found that only 23% of respondents used a piece of soap and water for cleaning during the periods.

Table 3 illustrates the correlation between Open Defecation Free (ODF) status and UTIs. The table shows a 30.7% association between UTIs and ODF, with a p-value of (0.000), indicating a significant relationship. This suggests that using toilets significantly reduces the likelihood of UTIs and related infections. Also, ODF exposes individuals to microorganisms, increasing the risk of UTIs and other diseases due to unsanitary conditions (Supplementary material, Table S1).

A logit regression model was used to assess covariates influencing KAP related to menstrual hygiene in slum areas. Explanatory variables were selected from the literature and survey data, encompassing socio-demographic and menstrual factors which present the outcomes of the logit regression model, as shown in Table 3. Smaller household size correlates negatively and significantly with better KAP regarding menstrual hygiene among respondents. Younger girls show higher awareness compared to older siblings within families. The availability of smartphones and internet access positively influences menstrual hygiene awareness. Private school attendance, compared to government schools, also correlates positively and significantly with menstrual hygiene awareness, indicating a greater emphasis on menstrual education and hygiene in private institutions. Interestingly, in the slum area studied, predictors like distance to healthcare centres, head of household's education, mother's education, living with joint families, menstrual information sources from mothers, and caste affiliation were not significant factors affecting KAP among respondents. However, the respondent's schooling level, number of living rooms, teacher-provided information, and monthly household income were statistically significant and positively associated with KAP among girls.

Menstruation not only affects the overall reproductive health of women but also a woman's human rights regarding their dignity, privacy, safety, and overall harmonious existence. Due to various socio-economic and demographic barriers such as lack of privacy, autonomy, and basic sanitation facilities in educational and working institutions, there is continuous violation of the rights of women to bleed. As per the SDGs, adequate hygiene and MHM will contribute toward achieving environmental sustainability and in return improve the reproductive rights of a woman. Due to issues such as gender disparity, lack of financial autonomy, poor sanitation and WASH, and poor MHM, there is an indirect effect on school absenteeism hampering the realization of universal education, gender equality, and women's empowerment (Tegegne & Sisay 2014; Rani et al. 2022).

The present study attempted to explore the predictors of KAP regarding the MHM among the girls from the urban slums of Visakhapatnam city, India. Being one of the fastest growing cities accommodating a notable share of the slum population possesses various underlying challenges, especially for the reproductive rights of women. These urban slums are turning into breeding grounds for poor menstrual hygiene practices and myths. The results of the present study would be crucial as more than half of the global population comprising of women have been menstruating since the beginning of time. Still, it is dealt with as a topic of taboo surrounded by various myths across cultures and places. The finding of the present study indicates that in an Indian context, the major source of primary information related to menstrual hygiene is mothers. Earlier studies (Kumar & Srivastava 2011; Juyal et al. 2012; Oche et al. 2012; Tegegne & Sisay 2014; Rani et al. 2022) support our findings that the mother is the major source of menstruation awareness among young girls informally. As girls are more comfortable and open with their parents, especially their mothers, they act as a major source of early knowledge sharing and awareness regarding menstrual hygiene to a large extent along with emotional support and fostering a safe environment (Mary et al. 2022; Rani et al. 2022). It is only at the level of secondary education that the students are educated about sexual reproduction and menstrual health. Access to hygiene products at the initial puberty also depends on the awareness, education, and economic status of the parents. Undoubtedly, maternal education or awareness may contribute significantly at the early stage; it is not a standalone factor in determining a girl's MHM outcomes. Other factors such as access to social media, peer influence, community outreach, and curriculum-based MHM may need to be considered.

The findings indicate that the majority of the respondents have reported low levels of Hb concentration. It is indicative that they were not consuming nutritious and healthy food enriched with iron leading toward a lower concentration of Hb and higher incidence of anemia. In cases of iron deficiency and anemia, the girls may suffer in future with undesirable complications during pregnancy, with prolonged menstrual problems (Goonewardene et al. 2012). Anemia significantly impacts women's menstrual cycles, overall well-being, and reproductive health. It is characterized by a deficiency of red blood cells or hemoglobin (Hb), often due to iron deficiency, which is common among women. This leads to fatigue, weakness, and lowered immunity as red blood cells carrying oxygen to organs decrease. Iron levels drop during menstruation, potentially causing depletion and fatigue. Low Hb levels can even lead to absent or irregular periods. Women ideally need at least 12 g of Hb per deciliter; levels below this indicate anemia as per the scientific literature. Studies also indicate that due to a lack of awareness regarding the food and dietary supplement, women may neglect their food pattern, resulting in severe iron deficiency causing various health complications (Agarwal & Raj 2020). In terms of the problems faced by the respondents, it was found that the majority have experienced abdominal pain and discomfort in the stomach which is similar to the study conducted by Nagar & Aimol (2010). Studies also indicate that the majority of the respondents have reported the problem of itchiness, sensation in intimate areas during periods, UTI, foul smell, prolonged and heavy bleeding, and severe abdominal and body pain (Nagar & Aimol 2010; Goonewardene et al. 2012; Nabwera et al. 2021). UTI and odor in the genitals are due to not washing private parts correctly or not changing menstrual products frequently. Abdominal pain and heavy bleeding should be treated under the guidance of a gynecologist (Adinma & Adinma 2008; Tegegne & Sisay 2014).

The majority of respondents were attending the schools/office which was a positive sign of women-friendly facilities in schools and workspaces. These facilities can be critical factors in empowering women and promoting a dignified living. Studies have indicated that open-mindedness and awareness among households often encourage women to work or go to school even during periods (Crawford et al. 2014). Certain studies conducted in a similar context have highlighted that if the basic minimum facilities are not available in schools and workplaces, women try to avoid going to school or their workplaces during menstruation (Ghimire 2020). As per a study in India, about 25% of the schools have no toilets, and menstruation is the second major reason after household work for girls missing school (Lahiri-Dutt 2015).

The study highlighted toward the concern that in spite of various programs and policies, implemented at the school level, the majority of the girls have found it difficult to manage their periods in school due to a lack of privacy and adequate sanitation arrangements. This was preventing the mode of disposal of the sanitary napkins by the girls. The majority were not practicing the correct disposal methods and there were also instances where some girls reused the same pads after washing them. Various other studies have also reported instances where due to a lack of waste disposal facilities, girls were required to wear soiled absorbents at home (Bono et al. 2022), skip school and preferred to stay at home during their menstruation period (McMahon et al. 2011; Lahiri-Dutt 2015).

The literature also indicates a positive association between menstrual knowledge management practices and the nature of schools. The results indicate that the private schools were positively and significantly associated with MHM. The present study indicates that various factors such as privacy and personal spaces, availability of water, and proper disposal facilities at schools were major predictors of KAP status. Other studies also portrayed the significant differences in the school setups based on the urban versus rural schools and/or private versus public schools (El-Gilany et al. 2005; Baumann et al. 2019; Gimmer 2020). Better awareness in the private and urban schools is devoted to better knowledge and exposure to the girls through media and awareness camps and discussions among themselves. Certain observational studies also found that private and urban schools assign higher priority to menstruation and adult education than government and rural schools (Mahon & Fernandes 2010).

The study reports that hygiene practices were positively correlated with the education and economic status of the parents. The study highlights that the girls with more educated and economically better-off families were better accustomed to the usage of sanitary pads and following hygienic methods. The girls from poor families whose parents were illiterate were using other means such as cloths and other methods compared to the use of sanitary pads to soak the menstrual blood, without concerns regarding its quality in terms of cleanliness (Kaur et al. 2018). The findings from the present study stress the association of menstrual hygiene practices with financial empowerment, access, and skill gaps on how to use sanitary pads and social stigma/taboos and shame. Although menstrual hygiene is not explicitly mentioned in any of the 17 SDGs, it is directly linked with several of them concerning health, overall well-being, quality education, gender equality across age groups, access to water and sanitation, and the right to decent work and economic growth (Loughnan et al. 2020; Bono et al. 2022; Yadav & Singh 2022). Poor hygiene during menstruation has been associated with serious ill health, including reproductive tract and UTIs (Dasgupta & Sarkar 2008; Garg et al. 2012; Raina & Balodi 2014).

The finding from the logit model indicates that the size of the household and the age of the respondents was negatively and significantly associated with the level of awareness. The negative relationship with age could be because as the older respondents attained puberty, the outlook of society and family has changed toward the menstrual practices resulting in better awareness and access to hygiene products for the younger ones. Also, other factors could be better access to the sources of information for the younger girls of the family than the older ones. Also, the study has established the fact that the deeper penetration of social media especially through the reach of Android phones and cheaper internet access has improved awareness and knowledge about mensuration. The use of smartphones has significantly improved the access to information that they gain, they can research anything they need (Boulos et al. 2011). The role of social media also cannot be ignored along with the better access to information available in the schools.

The size of the family was another important predictor of menstrual awareness among the girls. In extended or joint families, family members are reluctant to speak much with the females/girls on the issue of periods and menstrual hygiene (McMichael 2019). As more girls in the same family are attaining puberty, the associated stigma with menstruation may also reduce with the span of time, making the periods more convenient for the younger girls in the family. Also, as peer group significantly affects the behavior associated with hygiene practices as they can discuss freely with their friends, the associated concerns may be reported to be significantly lower for younger girls (Boulos et al. 2011).

The other important variables like distance of health center, education level of household head, education level of mother, living with joint family, sources of information about menstruation from the mother, and the cast are not statistically significant. This implies that these variables are not associated with the menstruation hygiene awareness of respondents living in urban slums in Visakhapatnam. However, the coefficient of the level of schooling of the respondent, the number of living rooms, the information concerning the teacher's rules, and the monthly household income are significantly and positively associated with better MHM. The level of education of the respondent strongly influences the level of awareness. A girl with a higher educational level has good knowledge of problems and menstrual factors. Furthermore, the information disseminated by the teacher positively influences the awareness among young women (Coast et al. 2019; Bulto 2021). The larger number of living rooms indicates privacy (Mohammed & Reindorf 2020). The level of household income positively relates to menstrual hygiene awareness among respondents indicates that as income increases the availability and accessibility of resources will be easily available that help with hygiene (Thakur et al. 2014; Hennegan 2017; Ahmad et al. 2021).

Menstrual hygiene remains a critical but neglected aspect of women's human rights. This study investigates menstrual awareness, practices, and hygiene among girls in the slums of Vishakhapatnam district, Andhra Pradesh, India. The present study underscores the multifaceted challenges and predictors of MHM among girls in the urban slums of Visakhapatnam. Although menstruation is a natural physiological process, it notably affects the reproductive health, dignity, and rights of women. The findings reveal that approximately one-third of girls receive menstrual information from their mothers, with a majority using only water for hygiene during menstruation. A significant proportion reported school absenteeism due to barriers such as inadequate sanitation facilities, socioeconomic disparities, cultural taboos, and lack of awareness regarding proper MHM. Common menstrual issues included abdominal pain, itching, heavy bleeding, and foul smell. Although mothers are the first source of information, the study highlights the pivotal role played by factors such as social media, peer influence, and curriculum-based education to improve awareness among younger girls. The findings highlight the pivotal role of financial autonomy and access to education in shaping menstrual hygiene practices.

The study identified several factors significantly associated with menstrual hygiene awareness, including age, family size, type of schooling, education level, teacher-provided information, income, and living conditions. Poor hygiene practices, low Hb levels, and the associated health risks such as anemia and RTIs underscore the need for targeted interventions. The study also emphasizes the need for women-friendly school and workplace facilities which will positively help in reducing absenteeism and promoting dignity. To address these challenges, a holistic approach encompassing education, infrastructural improvements, and community awareness is essential. Also, there should be a focus on sensitizing the women and family members that MHM is more than a myth and they should not force the women to follow unhygienic practices as myths and taboos. Policy implications underscore the importance of pre-menstrual education in schools to promote dignity and respect. The study recommends the inclusion of disposable sanitary pads and suitable facilities in schools, alongside general awareness and health education programs to empower women. The only limitation of the study was the small sample size from one district, suggesting the need for broader exploration across various slums/districts to fully understand menstrual hygiene's human rights implications.

The authors received no financial support for the research, authorship, and/or publication of this article.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.