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\title{Study on Knowledge Attitudes and Practices Regarding menstrual Hygiene among Rural Women in Kerala}
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             \author[1]{Sagar  Borker}

             \affil[1]{  Kannur Medical College}

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\date{\small \em Received: 6 December 2013 Accepted: 3 January 2014 Published: 15 January 2014}

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\begin{abstract}
        


Background: Menstruation is a phenomenon unique to females. It carries with it the joy of being a mother and also the sorrow of guilt due to unclean feeling. Orthodox Indian culture does not allow open discussion about it and the associated problems. Aims: To measure the knowledge, attitude, & practice regarding menstrual hygiene among the adolescent girls & women in rural area aged between 15-50 years, in Anjarakandy Panchayat of Kannur district of Kerala. Settings and design: It is a cross sectional study. The data was collected by interview method by MBBS students under the supervision of investigators. There were 217 women who could be contacted during our visit to 3 clusters (in 3 wards) of households of Anjarakandy Panchayat. The first house was randomly chosen & subsequently each adjacent house was taken. All the eligible women who could be contacted during the allotted time were included. Material and Methods: The questionnaire consisted of both open ended & closed ended questions. Statistical analysis: The collected data was tabulated in Microsoft excel and it was analyzed in SPSS version 11.0. Chisquare test, proportions and percentage was used for the data analysis. Results: Most (76%) ladies have a positive attitude towards menstrual hygiene.Main reason (35%) for not using sanitary napkins was economic reasons. However 29% of the women opined that they were not aware of it & another 29% opined that they did not like it. Conclusion: 75.6% of women of the study population knew that menstrual hygiene is very important. Another 21.7% opined not important that it was. The attitude needs to be reinforced with the help of the stake holders in the community.

\end{abstract}


\keywords{menstruation, Kerala, sanitary pads.}

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\let\tabcellsep& 	 	 		 
\section[{M}]{M}\par
infections are common in rural women thus affecting their health \& productivity. \hyperref[b1]{2} In most societies the basis of conduct norms \& communication about menstruation is the belief that menstruation must remain hidden. Menstruation must be concealed verbally. Different religions have different beliefs about menstruation. Some religion describes a menstruating woman as ritually unclean. The taboo is so great that not only the woman. women are prohibited inparticipating in routinue life activities. during periods. She must be purified before she is allowed to return to her family. South Indian women who are menstruating are not allowed in the household for a period of 3 nights. Hygienic practices during menstruation remains poor in rural India. Government of India, under NRHM made arrangements to provide 322 lakh sanitary napkins but only 34\% of these have been utilized in the country. When the data of State wise uptake was analyzed an astonishing fact was found out; >80\% of these low cost sanitary pads were distributed in the state of Kerala. \hyperref[b2]{3} Thus the present study was conducted among rural women in the Anjarakandy Panchayat, Kannur district of Kerala. It is a descriptive type of cross section study done at the field practice area of Kannur Medical College Anjarakandy. 
\section[{II.}]{II.} 
\section[{Objectives}]{Objectives}\par
To measure the knowledge, attitude, \& practice regarding menstrual hygiene among the adolescent girls \& women in rural area aged between 15-50 years, in Anjarakandy Panchayat of Kannur district of Kerala. 
\section[{III.}]{III.} 
\section[{Materials \& Methods}]{Materials \& Methods}\par
The data collection lasted for 2 months (April-May 2009). Women in the age group of 15-50 years of age were interviewed by 12 MBBS students. There were 217 women who could be contacted during our visit to 3 clusters (in 3 wards) of households of Anjarakandy Panchayat. We obtained the ethical consent from the institutional ethics committee of Kannur Medical College Anjarakandy. The first house was randomly chosen \& subsequently each adjacent house was taken. All the Volume XIV Issue III Version I Year ( ) Pie chart 1 clearly states that most (76\%) ladies have a positive attitude towards menstrual hygiene. 1\% said that it was not important to know about menstrual hygiene.\par
Table \hyperref[tab_1]{2} describes the Knowledge, attitudes and practices about the ideal absorbent used by the girls.Main reason (35\%) for not using sanitary napkins was economic reasons. However 29\% of the women opined that they were not aware about it \& another 29\% opined that they did not like it. Further probing questions indicated that they were not aware regarding the method of its disposal. These points need to be addressed before suggesting the use of sanitary napkins.68\% of the women of the study population reuse their cloth during their periods.43.67\% of the women of the study population use soap to clean the reused cloth during their period. Also 31\% of women were using dettol for cleaning the cloth before re-use. 76.5\% of the women of the study population took bath twice per day during their periods. 99\% of women were taking bath atleast once a day during the periods.100\% of the women clean their genitalia as well as wash their hands after changing pad/cloth. eligible women of these houses who could be contacted during the allotted time were included. Pre-tested questionnaire consisting of both open ended \& closed ended questions was used for the study. Data was collected by questionnaire filled by participant under the supervision of investigators. The collected data was tabulated in Microsoft excel and it was analyzed in SPSS version 11.0 Table \hyperref[tab_0]{1} shows the baseline demographic characteristics of the study population. 33.64\% of the population belonged to 25-34 years age group. 76.1\% were educated till high school and above. 42.8\% were very poor. 74\% were housewives. 76.5\% were married.  V. 
\section[{Discussion}]{Discussion}\par
Menstruation is an extremely complex process involving different hormones, sexual organs, and nervous system. The present study has been compared in the light of literature available on the subject. Dasgupta A et al conducted a community based cross sectional study in 2008 among 160 women in West Bengal and found that 108(67.5\%) girls were aware about menstruation prior to attainment of menarche. Mother was the 1 st informant regarding menstruation in case of 60(37.5\%)girls.138(86.25\%)girls believed that it is a physiological process.78 (48.75\%) girls knew the use of sanitary pads during menstruation. Regarding practices only 18(11.25\%) girls used sanitary pads during menstruation. For cleaning purpose, 156(97.5\%) girls used both soap\& water. Regarding restrictions practiced 136(85\%) girls practiced different restrictions during menstruation. \hyperref[b0]{1} In the current study we did not study the different restrictions, but 76\% had a positive attitude towards menstrual bleeding. 30\% of women in the current study who reused the cloth, cleaned it with dettol and/or soap. Using dettol is not an advisable practice nor is it necessary. Use of chemicals like dettol may be harmful if traces are left behind as it may cause rash/inflammation. So also if the soap is not thoroughly rinsed out by washing, it may cause irritation. There is a need to educate the women on these points.   
\section[{Global}]{Global} 
\section[{Conclusions and Recommendations}]{Conclusions and Recommendations}\par
75.6\% of women of the study population know that menstrual hygiene is very important. Another 21.7\% opined that it was important. The attitude towards menstrual hygiene is favorable in the study population. This may be due to universality of education even in the remote rural area of Kerala state. The study also shows that there is a statistically significant difference in the use of sanitary napkins as compared to cloth in educated and uneducated group of ladies but not according to the occupation or marital status. The attitude needs to be reinforced through health awareness programmes to have sustained behavioral impact. These can be carried out at Primary health centres, subcentres, Maternal and Child Health clinics and also through medical auxiliaries like ASHAs and Anganwadi workers. Women from different neighbourhoods/ towns/ cities from the same state should be studied to come to a more authentic conclusion. Due to feasibility and time constraints we could not do this as a part of our exercise. Such mulitcentric studies can be done which will prove to be of great interest for the scientific community as a whole. 
\section[{VII.}]{VII.} 
\section[{Limitations}]{Limitations}\par
We did not use qualitative methods of data collection due to paucity of time and money. We also did not use random sampling but since the population of Anjarakandy area was homogeneous there is no reason for bias in results.\par
The study thus clearly states the utilization of these services by the women even among rural women of Kerala. 60\% of those women who did not use sanitary pads cited the reason as either they did not know or because they did not like it. The main reason that we later found was that they were unaware of the disposal of these pads. They can thus be educated on these issues of pad disposal.\par
Although the current study was quantitative study and not a focus group discussion still the findings can be of wide scientific interest.\par
Adhikari P et al conducted a study in 2007 among 150 female students in Nepal \&found that 94 \% of them were not properly maintaining menstrual hygiene. Only 6\% of them knew that menstruation is a physiological process.36.7\% knew that it was caused by hormones.94\% of them used pads during periods but only 11.3\% disposed it appropriately. Overall knowledge \& practice were 40.6\% \&12.9\% respectively. They also recommended that most of the girls spray water by touching onto gold; thus in turn following the age-old ancestral rules. \hyperref[b3]{4} We found that such practices were not so common in our study setting in rural Kerala. The ladies in the current study setting disposed their pads appropriately.\par
Rao R et al conducted an interventional studyin 2003-2004 among a stratified cluster of 791 students belonging to 29 colleges in Karnataka \& it was found that awareness regarding menstrual hygiene was about 77.2\% before started \& it increased to 95.6\% after the awareness program. \hyperref[b5]{5} This study clearly showed that an educational intervention program can bring about a desirable change in knowledge. \hyperref[b5]{5} In the current study due to resource constraints, in terms of funding we could not manage to take up any sort of interventions.\par
Fernandes M has authored a report titled Menstrual Hygiene in South Asia a neglected issue for wash programmes (water, sanitation, and hygiene) in 2008. The study was conducted on 2579 women in north India \& was found that 89\% used cloth, 2\% used cotton wool, 7\% sanitary pads, \& 2\% ash as an absorbent. Majority of participants quoted high cost \& unavailability for not using sanitary pads.14\%of women suffered from menstrual infection.41\%of women were unaware of menstrual hygiene.  {\ref 7} The current study states that there was a statistically significant difference in the use of sanitary napkins as an absorbent as compared to cloth in educated and uneducated group of ladies but not according to the occupation or marital status. We 75.6\% of women of the study population know that menstrual hygiene is very important. Another 21.7\% \begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_0}E}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.47339544513457554\textwidth}P{0.1108695652173913\textwidth}P{0.26573498964803316\textwidth}}
\tabcellsep Number of ladies\tabcellsep Percentage\\
Religion\tabcellsep \tabcellsep \\
Christian\tabcellsep 39\tabcellsep 18\%\\
Hindu\tabcellsep 173\tabcellsep 79.7\%\\
Muslim\tabcellsep 5\tabcellsep 2.3\%\\
Age in years\tabcellsep \tabcellsep \\
15-24\tabcellsep 62\tabcellsep 28.57\%\\
25-34\tabcellsep 73\tabcellsep 33.64\%\\
35-44\tabcellsep 61\tabcellsep 28.12\%\\
>45\tabcellsep 21\tabcellsep 9.67\%\\
Educational status\tabcellsep \tabcellsep \\
Primary \&middle school\tabcellsep 52\tabcellsep 23.96\%\\
High(Higher)secondary school\tabcellsep 127\tabcellsep 58.52\%\\
Degree\tabcellsep 33\tabcellsep 15.4\%\\
Professional course\tabcellsep 1\tabcellsep 0.46\%\\
No response\tabcellsep 4\tabcellsep 1.84\%\\
Income\tabcellsep \tabcellsep \\
SES 1\tabcellsep 93\tabcellsep 42.85\%\\
SES 2\tabcellsep 48\tabcellsep 22.11\%\\
SES 3\tabcellsep 25\tabcellsep 11.52\%\\
SES 4\tabcellsep 10\tabcellsep 4.60\%\\
SES 5\tabcellsep 28\tabcellsep 12.89\%\\
No response\tabcellsep 13\tabcellsep 5.99\%\\
Occupation\tabcellsep \tabcellsep \\
Student\tabcellsep 43\tabcellsep 19.8\%\\
House wife\tabcellsep 161\tabcellsep 74.2\%\\
Working\tabcellsep 13\tabcellsep 6\%\\
Marital status\tabcellsep \tabcellsep \\
Married\tabcellsep 166\tabcellsep 76.5\%\\
Unmarried\tabcellsep 51\tabcellsep 23.5\%\end{longtable} \par
 
\caption{\label{tab_0}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.4026315789473684\textwidth}P{0.4473684210526315\textwidth}}
FREQUENCY\tabcellsep PERCENTAGE\end{longtable} \par
 
\caption{\label{tab_1}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{P{0.37674961119751166\textwidth}P{0.1031104199066874\textwidth}P{0.05287713841368585\textwidth}P{0.1202954898911353\textwidth}P{0.056842923794712286\textwidth}P{0.1401244167962675\textwidth}}
\multicolumn{3}{l}{shows that there is a statistically}\tabcellsep \multicolumn{3}{l}{of ladies but not according to the occupation or marital}\\
\multicolumn{3}{l}{significant difference in the use of sanitary napkins as}\tabcellsep status.\tabcellsep \tabcellsep \\
\multicolumn{3}{l}{compared to cloth in educated and uneducated group}\tabcellsep \tabcellsep \tabcellsep \\
\tabcellsep \multicolumn{5}{l}{Relation b/w variables and absorbent used}\\
\tabcellsep \multicolumn{2}{l}{SANITARY}\tabcellsep \multicolumn{2}{l}{CLOTH}\tabcellsep Statistics\\
\tabcellsep \multicolumn{2}{l}{NAPKIN}\tabcellsep \tabcellsep \tabcellsep \\
\tabcellsep No\tabcellsep \%\tabcellsep No\tabcellsep \%\tabcellsep \\
EDUCATION\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep Chi-square=5.93,\\
Professional\tabcellsep 18\tabcellsep 53\tabcellsep 16\tabcellsep 47\tabcellsep d.f.=2, p= 0.049\\
Higher secondary/High school\tabcellsep 66\tabcellsep 52\tabcellsep 61\tabcellsep 48\tabcellsep \\
Primary\tabcellsep 17\tabcellsep 32.7\tabcellsep 35\tabcellsep 67.3\tabcellsep \\
No response\tabcellsep 2\tabcellsep 50\tabcellsep 2\tabcellsep 50\tabcellsep \\
OCCUPATION\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep Chi-square=0.501,\\
Student\tabcellsep 20\tabcellsep 46.6\tabcellsep 23\tabcellsep 53.4\tabcellsep d.f.=2, p= 0.77\\
House wife\tabcellsep 78\tabcellsep 48.2\tabcellsep 83\tabcellsep 51.8\tabcellsep \\
Working women\tabcellsep 5\tabcellsep 38.5\tabcellsep 8\tabcellsep 61.5\tabcellsep \\
MARITAL STATUS\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep Chi-square=0.33,\\
Married\tabcellsep 77\tabcellsep 46.4\tabcellsep 89\tabcellsep 53.6\tabcellsep d.f.=1, p= 0.565\\
Unmarried\tabcellsep 26\tabcellsep 50.9\tabcellsep 25\tabcellsep 49.1\tabcellsep \\
0\tabcellsep O\tabcellsep \tabcellsep 3\tabcellsep 100\tabcellsep \\
? 1\tabcellsep 29\tabcellsep 74.3\tabcellsep 10\tabcellsep 25.7\tabcellsep \\
? 2\tabcellsep 41\tabcellsep 36.2\tabcellsep 72\tabcellsep 63.8\tabcellsep \end{longtable} \par
 
\caption{\label{tab_2}Table 3}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{P{0.85\textwidth}}
Year\end{longtable} \par
 
\caption{\label{tab_3}Table 3 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.08052631578947368\textwidth}P{0.7694736842105263\textwidth}}
Available\tabcellsep from:\\
\tabcellsep Year 2014\\
\tabcellsep Volume XIV Issue III Version I\\
\tabcellsep D D D D )\\
\tabcellsep (\\
\tabcellsep © 2014 Global Journals Inc. (US)\end{longtable} \par
  {\small\itshape [Note: http]} 
\caption{\label{tab_4}}\end{figure}
 			\footnote{© 2014 Global Journals Inc. (US) Study on Knowledge Attitudes and Practices Regarding menstrual Hygiene among Rural Women in Kerala} 		 		\backmatter  			  				\begin{bibitemlist}{1}
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\bibitem[Kumar ()]{b2}\label{b2} 	 		\textit{Adolescent Health Ministry of Health and Family Welfare Government of India Document},  		 			R Kumar 		.  		 \url{http://mohfw.nic.in/NRHM/Review\%20Meeting\%20with\%20State\%20MD\%20NRHM/AH.pdf}  		2012 31st Oct; 1-20.  	 
\bibitem[Rao et al. ()]{b5}\label{b5} 	 		\textit{Effectiveness of reproductive health education among rural adolescent girls: A school based intervention study in UdupiTaluk},  		 			R Rao 		,  		 			A Lena 		,  		 			N S Nair 		,  		 			V Kamath 		,  		 			A Kamath 		.  		2008. Karnataka. 62 p. .  	 
\bibitem[Adhikar et al.]{b3}\label{b3} 	 		\textit{Knowledge and practices regarding menstrual hygiene in rural adolescent girls of Nepal},  		 			P Adhikar 		,  		 			B Kadel 		,  		 			S Dhungel 		,  		 			A Mandal 		.  		 	 
\bibitem[Dasgupta and Sarkar ()]{b0}\label{b0} 	 		‘Menstrual Hygiene: how hygienic is the adolescent girl?’.  		 			A Dasgupta 		,  		 			M Sarkar 		.  	 	 		\textit{Ind J Comm Med}  		2008. 33  (2)  p. .  	 
\bibitem[Singh ()]{b1}\label{b1} 	 		\textit{Place of menstruation in the reproductive life of women in rural north India},  		 			A Singh 		.  		2006. 31 p. .  	 
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\end{document}