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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 1  |  Issue : 1  |  Page : 22-29

Exploring college student's menstruation-related difficulties during early COVID-19 lockdown period in North India


1 Principal, Shri Gurunanak Girls Degree College, University of Lucknow, Lucknow, Uttar Pradesh, India
2 Department of Applied Economics, University of Lucknow, Lucknow, Uttar Pradesh, India
3 Department of Obstetric and Gynecology, Career Institute of Medical Sciences and Hospital, Lucknow, Uttar Pradesh, India
4 Department of Community Medicine, Career Institute of Medical Sciences and Hospital, Lucknow, Uttar Pradesh, India

Date of Submission19-Nov-2020
Date of Acceptance12-Dec-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Absar Ahmad
Department of Community Medicine, Career Institute of Medical Sciences and Hospital, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jphpc.jphpc_13_20

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  Abstract 


Objective: Sanitary napkins are an essential aspect of the menstrual hygiene management. Despite its critical importance to women and adolescent girls from menarche and menopause, access to menstrual hygiene products has been neglected during the COVID-19 pandemic. At the time of this writing, there was no information on the challenges associated with accessing menstrual hygiene products in Indian settings during this period. This paper investigates the prevalence of socio-demographic correlations of access to sanitary napkins among college students in Lucknow, the largest state located in North India. Methods: Students of undergraduate (UG) and post-graduate (PG) courses currently studying in colleges in Lucknow were eligible to participate in the study. An online cross-sectional survey was conducted in Lucknow in September 2020. In total, 1439 participants took part in the survey. After removing 55 participants who quit the survey by clicking on the disagree button and 13 who did not satisfy inclusion criteria, the final sample comprised 1371 participants. The data collection was anonymous. Responses were analysed using descriptive statistics and bivariate logistic regression. Results: Up to 1371 students completed the survey, resulting in a response rate of 96.2 percent. The analysis revealed that about 12.5 percent of students reported problems in access to sanitary pads during the lockdown. Logistic regression analysis showed that being Muslim, having less-educated fathers, having farmers as fathers, having low income, rural residence, and a history of using cloth, all independently predict challenges in getting access to sanitary pads during the COVID-19 lockdown (P < 0.05). Conclusion: During the COVID-19 lockdown, students were dependent on either locally available resources as absorbents during menstruation or paid more to buy sanitary pads in Lucknow. Low-income families are reluctant to spend on sanitary pads, which is why few college girls resumed their previous practice of managing their periods using cloth pieces or rags. This study's findings may be used to plan and implement interventions during a future pandemic or such crises to maintain the supply chain of sanitary pad.

Keywords: College, COVID-19, Lockdown, Lucknow, Sanitary pad, Students


How to cite this article:
Garg SG, Alvi R, Gupta S, Ahmad A. Exploring college student's menstruation-related difficulties during early COVID-19 lockdown period in North India. J Public Health Prim Care 2020;1:22-9

How to cite this URL:
Garg SG, Alvi R, Gupta S, Ahmad A. Exploring college student's menstruation-related difficulties during early COVID-19 lockdown period in North India. J Public Health Prim Care [serial online] 2020 [cited 2021 Jan 27];1:22-9. Available from: http://www.jphpc.com/text.asp?2020/1/1/22/305984




  Introduction Top


It is a well-established fact that the COVID-19 pandemic and lockdowns are having an adverse impact on all sections of the population, both economically[1] and psychosocially.[2] Vulnerable groups, such as people living below the poverty line, differently-abled people, women, children, elderly and migrant workers[3] are badly affected. Healthcare, a fundamental human right, is also affected[4] as the pandemic has affected routine healthcare services due to shortages of essential medical supplies and health staff.[5]

Across diverse social contexts, the topic of menstruation has often been relegated and it was not on the priority list of policy makers.[6] Global health priorities were aimed only at reducing maternal morbidity and mortality, and the problematic feminization of the HIV epidemic.[7] The reasons for this were “menstrual shame”, the perception that the complexities of menstrual management are an inevitable part of the social order. With resource limitations, other priorities consumed more attention.[6]

However, menstrual hygiene management (MHM) is currently a globally recognized public health issue.[6] The COVID-19 lockdown made menstruating females a part of the vulnerable groups, because menstruation is a biological process and does not cease during a lockdown. With the sudden closure of campuses worldwide, many female students who were confined at home faced challenges in managing menstrual hygiene practices.[8] The pandemic-led lockdown increased the difficulties of accessing menstrual hygiene products[9] in India because it is not a socially discoursed area. During the lockdown, There was a shortage of sanitary pads,[10] which facilitate personal hygiene and disposal of waste with adequate privacy.[11] During the lockdown, around 58 per cent of the small and medium scale manufacturers of sanitary pads were not able to operate fully, whereas 37 per cent were not operational at all.[12]

Hygiene practices such as the use of sanitary napkins during menstruation protect women's health.[13] The closure of shops and shutdown of transport meant less availability of and access to menstrual hygiene provisions.[14] Further, with male family members present at home, the lockdown made it challenging for female members to access toilets for menstruation management.[15]

India went into one of the world's strictest lockdowns from March 25[16] to May 31,[17] and it was extended four times. From June 1, there were gradual relaxations. However, schools and colleges are still not open. During the initial phase of the lockdown, sanitary napkins were not included in the essential items list (this was later rectified following massive public outrage). That led to a shortage in the supply of sanitary pads, leaving many girls and women with no choice but to resort to the unhygienic practice of using old clothes/rags to manage their periods.[18]

Various State governments have a provision for school-based distribution of sanitary pads under a central government programme, Kishori Shakti Yojna. Due to schools closing down, many girls have no access to sanitary pads and have been forced to shift from disposable sanitary pads to cloth pads.[18]

A common problem linked to cloth pads is that those who use it do not have adequate information on how to maintain them so that they do not pose risk of infection on reuse. Using cloth pads without knowing how to maintain them poses a danger to the woman's health, including risks of infections of a grave nature.[19]

Unhygienic menstruation practices can predispose women to the risk of reproductive tract infection.[20] For menstruating girls and women, anxiety over menstrual hygiene is a key concern. The interplay of socio-economic status, menstrual hygiene practices, and RTI are noticeable.[21] Women's autonomy, residential status, occupation of father, caste, exposure to mass media, and wealth status are found to be the most significant factors in hygienic menstrual practices.[20],[22]

The National Family Health Survey (NFHS) 4 (2015 -16) of Uttar Pradesh reported that only 47.1% of women (Urban 68.6, Rural 39.9) in the age group of 15 to 24 years use hygienic methods of protection during their menstrual period.[23] Girls with higher levels of education are more likely to use safe menstruation methods compared to less educated girls.[24] College students have more hygienic menstruation practices than the general female population. A study in Telangana reported about 87% of college students use sanitary pads,[25] while a study from Ghana found that 100% were using sanitary pads.[26]

However, during the lockdown, the rapid assessment survey carried out in May 2020 reported 56% of young women had an unmet need for sanitary napkins. The problem was most acute in Rajasthan (73%) and Bihar (55%), and in Uttar Pradesh, less than 20% of female respondents expressed this concern.[27]

The lack of sanitary products can create a sense of isolation and fear[28] among menstruating women. In Lebanon, 69% of adolescent girls walk long distances to buy menstrual pads. Likewise, parents of 63% of young girls could not afford menstrual pads. In Uganda, 100% of respondents said they were struggling to get access to menstrual pads.[29]

Menstrual hygiene is an important need. Adolescent girls constitute a vulnerable group, particularly in India, where a girl child is neglected and discriminated against.[30] Many Indians still consider menstruation as something unclean or dirty.[21] Women and adolescent girls face many challenges during emergencies, related to various cultural and logistical issues in their menstrual hygiene were studied during the flood[31] and earthquakes.[32],[33] But there is no study on menstrual management materials in India during the COVID-19 lockdown. Therefore, we conducted this study to understand the socio-demographic correlations of access to sanitary napkins among college students in Lucknow.


  Methods Top


Study design and settings

A quantitative approach was utilised to achieve the objectives of this study. An online cross-sectional survey was employed as it was the most appropriate for gathering information on access to sanitary napkins among college students between 11th September 2020 to 25th September 2020.

Ethical approval

This work was done in collaboration with Shri Gurunanak Girls Degree College, Lucknow and Career Institute of Medical Sciences and Hospital, Lucknow. Ethical approval for this research was obtained from the Institutional Review Committee of Career Institute of Medical Sciences and Hospital (Ref: PHARMA/SEP/2020/02), Lucknow, India. Participants who gave consent to participate in the survey would click the 'Agree' button and then be directed to complete the self-administered questionnaire.

Recruitment procedure

Study was done among college students studying in Lucknow city, the largest state's capital, Uttar Pradesh, located in north India. A total of 1439 participants took part in the survey. After removing participants 'data with 55 participants', the questionnaires quit the survey by clicking on the disagree button and 13 not satisfying inclusion criteria. So, the final sample consisted of 1371 participants whose responses were included in the analysis. As colleges were closed, it was not feasible to conduct a systematic sampling procedure; the researchers opted for the Google Forms platform to create an online survey. Students of UG and PG courses studying in colleges in Lucknow were eligible to participate. We utilised several strategies to reach as many respondents as possible all over Lucknow within the two-week data collection period. This included relying on the researchers' professional and personal networks to share the survey. WhatsApp was selected as the most popular social platform for communication during online teaching in colleges in Lucknow. Every college set up a Student's group for communication-related to course instruction and notice. A description about the survey was provided in the WhatsApp message postings before the link was provided to both English and Hindi language versions of the questionnaire.

Measures

Outcome variables

Students were asked the following question: Did you face difficulties to access sanitary pads during the lockdown? Response were recorded as No=0 and Yes=1. Further, additional open questions were also asked about alternative method used during that time.

Independent variable

We examined the distribution of this variable with a range of independent variables that have been suggested in the literature to predict the use of menstrual absorbents precisely: Grade (Graduation and Post-graduation), Age(<19,20-22,23+) caste (General, OBC, and SC/ST), Religion (Hindu, Muslim and Other), Father's education (Illiterate or up to 12th, Graduate, and Postgraduate and higher), Mother's education (Illiterate or up to 12th, Graduate and Postgraduate and higher), father's Occupation( Farmer, Government employee, Self-employed/Businessman, Private employed, and Other), Mother's occupation (Homemaker and working), Monthly salary in Indian Rupees (<25 thousand, 25 thousand to 50 thousand, 50 thousand to 1 lakh and 1 lakh above), Type of family (Joint and Nuclear), Place of residence (Rural and Urban) and history of reusable cloth use( No and Yes).

Statistical analysis

For this study, the data collected were analysed using the Statistical Package for the Social Sciences (SPSS), version 25. To identify factors associated with difficulties to access sanitary pad during COVID19, we first performed bivariate analysis using Pearson's Chi-square test (χ2). All factors found significant at P value <0.05 were incorporated into the bivariate logistic regression model. The statistical significance level was set at P < 0.05.


  Results Top


[Table 1] shows the college students' characteristics. The mean age of students was 20.06 years (SD = 1.78). There were more Undergraduate students (87.7%) participants, and the majority of students were Hindu (85.5%) followed by Muslims (11.7%). About 55.9% of the students were from the General caste category, followed by Other Backward Class (33.8%). The fathers of about 48.8 percent of the students had school education, and 34.3 percent were graduates, and (16.9%) had postgraduate and higher education. Up to 60.2% of the students' mothers were had school education, and 28% and 11.8% had graduate and postgraduate and higher education, respectively. The majority of the students' fathers were self-employed/businessman (27.9%) followed by private organization employees (26%), Government employees (20.7%), and farmers (10%). Besides, 86.9% of student mothers were homemakers. The monthly family's income of the majority (59.1%) of the students' was less than Rs. 25,000 and 66.5% lived in a nuclear family set up. The place of residence of more than three-fourth of the students was urban Lucknow. Nearly 15.1% of students reported they had previously used reusable cloth.
Table 1: Descriptive statistics of college student's in Lucknow (n=1371)

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[Table 2] exhibits the relationship between students' characteristics and difficulties in getting access to sanitary pads during the COVID-19 lockdown. The present study found that nearly 12.5% of students encountered problems regarding access to sanitary pad during the lockdown. Caste, religion, father's educational level, mother's educational level, father's occupation, mother's occupation, salary, type of family, place of residence, and history of reusable cloth use were statistically associated with difficulties in getting access to sanitary pads during the COVID-19 lockdown.
Table 2: Study variables and bivariate analysis examining factors associated with difficulties to access sanitary pad during COVID-19 lockdown among college students in Lucknow (n=1371)

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Difficulties encountered in accessing sanitary pad during the COVID-19 lockdown were influenced significantly by religion, father's educational level, father's occupation, salary, place of residence, and history of reusable cloth use. Among the religious groups, Muslim students were more likely (AOR 2.182 95%CI: 1.354-3.517) to encounter difficulties in getting access to sanitary pads compared to Hindu students. Furthermore, students whose fathers were graduates were less likely (AOR 0.559 95% CI: 0.349-0.897) to encounter difficulties in getting access to sanitary pads than those whose fathers were school educated. Students whose father were farmers were more likely (AOR 1.998 95% CI: 1.013-3.937) to face difficulties in getting access to sanitary pads than those whose fathers were government employees. Students whose monthly family income was between Rs 25,000 to 50,000 were less likely (AOR 0.560 95% CI: 0.334-0.937) to encounter difficulties in getting access to sanitary pads compared to those whose monthly income was less than Rs. 25,000. Students who lived in rural areas were more likely (AOR 1.736 95%CI: 1.194-2.525) to experience difficulties in getting access to sanitary pads compared to their counterparts. Students with a history of reusable cloth were more likely to face problems (AOR 2.858 CI: 1.942-4.205) with regard to access to sanitary pads compared to those who had not previously used reusable cloth [Table 3].
Table 3: Binary logistic regression analysis of predictors of difficulties to access sanitary pads during COVID-19 lockdown by background characteristics of college students in Lucknow

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  Discussion Top


The primary impacts of COVID19 are immediate consequences of the epidemic on human health. On the contrary, secondary impacts were those caused indirectly, either through the effect of fear or the measures taken to contain and control it. However, the COVID-19 pandemic has a secondary impact on girls' and women's, leading to their menstruation and health. These impacts vary country wise as well as individual wise. Depend on the country's ability to respond through social protection and health systems, and among individuals, the most affected were economic and socially vulnerable.[34] This is the first study to evaluate difficulties in getting access to sanitary pads during COVID-19 lockdown in any country. Our study is only focused on college students, especially undergraduate and postgraduate students in Lucknow, the capital of Uttar Pradesh state in India. Data also shows that Lucknow is the worst COVID-19 affected district in UP, the fifth-worst COVID-19 affected state in India.[35] Since the COVID-19 outbreak, there were reports in the media about the difficulties faced by menstruating women in getting access to menstrual hygiene products[36] in India as well as abroad.[37],[38] However, there has been no scientific evidence available on the difficulties faced by the menstruating women to access sanitary pads during the lockdown. This study is also a small step to add new evidence about the prevalence of difficulties as well as predictors of access to sanitary pads.

The present study found the 12.5% of college students faced difficulties in getting to access sanitary pads during the lockdown. The commonly used alternative for pads during lockdown were homemade reusable cloth pads. Similar type of pads were also used in Rwanda, though women and girls also used rags, leaves, newspapers or other makeshift items to absorb or collect menstrual blood.[39] Most girls in India are not comfortable asking men in the family to procure pads for them since periods is a taboo subject and not openly talked about in Indian families. In addition, during the lockdown, when all the men were at home because of the lockdown, girls and women may have found it difficult to use toilet facilities as frequently as they needed to and getting additional water to wash pads and putting them out in the sun to dry.[10] Students stated they managed menstruation during lockdown by using branded sanitary pads, which they had never used and size, or by paid more price, bought from another place, used old cloth, home-made pad, and sponge.

This study revealed that Muslims students faced difficulties in getting access to sanitary pads during the COVID-19 lockdown. The reason for this could be that Muslims in India have the lowest work participation rate.[40] Further, Muslims mostly rely on the informal economy[41] and during the COVID-19 lockdown, informal workers suffered more[42] in India as well as abroad.[43] Low family income and poor income during the lockdown could be the reason why Muslim girls had to compromise on their menstrual needs and personal hygiene.

Additionally, the study also found students whose fathers were graduates were less likely to encounter difficulties in getting access to sanitary pads than those whose fathers were school educated. A previous study in Nepal also reported good menstrual hygiene practice with father's education.[44] Educated fathers were likely to have more awareness and concern about their daughter's hygiene habits.

Students whose fathers were farmers and students residing in rural areas were more likely to face difficulties in getting access to sanitary pads than those whose fathers were government employees. In previous studies in India[20] and Ghana,[45] it was found that adolescents whose fathers were farmers had poor menstrual hygiene management practices. During the COVID-19 lockdown, Indian farmers were faced with new challenges, although they are already under threat. Additionally, lockdown created a shortage of labour, equipment, access to seeds, fertilizers, and pesticides, which hit farmers a lot.[46] This made farmers financially vulnerable to the present crisis. Besides, in rural areas, women do not have access to sanitary products or available on the high cost of branded napkins and cultural barriers.[47] As a result, they usually rely on cloth pads which they wash and use again.[48] Before the pandemic, college students from the rural area had the advantage of buying sanitary pads when they come to college; during the lockdown, they could not go outside to do so.

Students whose monthly family income was between 25,000 -50,000 INR were less likely to encounter difficulties in getting access to sanitary pads than those whose monthly income was less than Rs. 25,000. Due to limited household income during the lockdown, people prioritized other household needs and, with their fixed income, did not want to spend money on sanitary pads. On the other hand, those who are well-off could afford to buy as much of the product as needed. Indian society is patriarchal, and during the lockdown, women could not tell their family members about their need for sanitary napkins. Men do not support women in menstruation hygiene management and do not give them money to buy menstrual hygiene products. So, women have to rely on cheap cloth pads to wash, dry and use again.

The present study also found that students with a history of reusable clothes were more likely to face problems regarding access to sanitary pads than those who have not previously used reusable cloth. Likely, students from low-income families or rural areas who cannot afford sanitary pads due to their high price once would not be able to buy them during the lockdown too. These students mostly relied on cloth pads, which they wash and use again.[48]

Practices of rag as adsorbents during menstruation, resulting in psychosocial consequences including shame, insecurity, anxiety, and fear of stigma,[49] and during the lockdown, it was also seen among menstruating women;[50] such adverse psychosocial outcomes may arise from inadequate absorbent use.[51] A study highlights the importance of recognizing adolescents' psychological needs during an emergency and ensuring that their needs are integrated into program design and implementation.[52] One such program can be counselling and education for these girls by primary care providers when such students visit them, by Interviewing, counselling, and interpersonal skills in their day-to-day work to promote overall health outcomes.

Strength and limitations of the study

The study tried to evaluate students' difficulties getting access to sanitary pads during the lockdown through an online survey. The authors tried to cover all socio-demographic variables on the students. However, this study had some limitations. First, as the study's design is cross-sectional, it could not show the cause and effect relationships between study variables. Second, this study follows only quantitative data collection, and mixed approaches do not triangulate it. Third, the study lacks random sampling, which leads the statistical confidence and margin of error.


  Conclusion Top


About 12.5% of college students faced difficulties getting access to sanitary pads during the lockdown. Through multivariable analysis, we found that being Muslim, having a less-educated father, having a farmer father, being from a low-income family, living in a rural area, and having a history of reusable cloth all independently posed difficulties in getting access to sanitary pads during the COVID-19 lockdown. Our study demonstrates a need to design acceptable advocacy programs to get access to materials to manage their menstruation during a crisis because menstruation does not cease during any emergency.

Acknowledgment

The authors would like to thank all the participants for take part in this study. The authors are also grateful to faculties of colleges in Lucknow to reassure their students to participate in the studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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