Assessment of menstrual health practices and sociocultural perceptions among women

Introduction

The term "menstruation" refers to the monthly physiological process experienced by individuals assigned female at birth, typically characterized by the shedding of the uterine lining, accompanied by bleeding through the vagina (Jarrah & Kamel, 2012) [5] . This cyclical phenomenon is controlled by hormonal fluctuations and marks the reproductive phase of a person's life, signalling the readiness of the body for potential pregnancy (Santina et al., 2013) [16] . Menstruation usually occurs in the absence of fertilization and lasts for an average of three to seven days, although variations in duration and flow are common among individuals. Despite its physiological significance, menstruation is frequently shrouded in myths, societal taboos, and cultural beliefs, profoundly influencing attitudes and behaviours towards this natural occurrence (Ali & Fadlalmola, 2020) [1] . Furthermore, menstruation is a key indicator of overall health and well-being in individuals with female reproductive systems. Changes in menstrual patterns or irregularities may signal underlying health conditions, such as hormonal imbalances, reproductive disorders, or systemic illnesses (Kaiser, 2008) [8] . In addition to its biological and health-related significance, menstruation carries cultural, social, and psychological meanings. It is often surrounded by societal beliefs, customs, and taboos, which vary widely across different cultures and communities (Chothe et al., 2014) [2] . Understanding menstruation's significance requires consideration of its multifaceted aspects, encompassing biological, cultural, and social dimensions (Kaiser, 2008) [8] . This interconnectedness prompts an exploration into the physiological mechanisms underpinning menstruation. Firstly, we delve into the role of different hormones in the menstrual cycle, shedding light on how these biological processes intersect with cultural perceptions and practices. [9,3,7,10] .

Role of Different Hormones in the

Objectives 1. To survey individuals aged 35-50 years in Ambala, Haryana, to explore prevalent myths, taboos, and hygiene practices related to menstruation. 2. To analyse the collected data using frequency and percentage methods to understand the prevalence and distribution of beliefs and practices. 3. To provide insights into the cultural beliefs and practices surrounding menstruation in this demographic.

Hypothesis

The study hypothesizes that individuals aged 35-50 in Ambala, Haryana, adhere to cultural beliefs and practices regarding menstruation, influencing hygiene behaviours. Disparities in menstrual health infrastructure and education across communities are expected. Through survey analysis, the study aims to uncover prevalent beliefs, practices, and their impact, informing initiatives to promote menstrual health and reduce stigma.

Research Methodology

Study Design: This research adopts a quantitative approach to explore menstruation beliefs and practices among perimenopausal women in Ambala, Haryana. Utilizing structured questionnaires predominantly featuring closedended questions, the study aims to provide insights into the cultural aspects surrounding menstruation.

Sampling Strategy: Convenience sampling was utilized to recruit diverse participants aged 35-50, comprising perimenopausal women in Ambala, Haryana. This approach ensured accessibility within the community while targeting the desired demographic.

Questionnaire Development: A meticulously structured questionnaire, primarily comprising closed-ended questions, was meticulously crafted. This questionnaire, developed through expert consultation, serves as a tool to assess the varied beliefs and practices associated with menstruation among the target population in Ambala, Haryana.

Data Collection Procedure: Questionnaires were distributed offline, ensuring clear instructions, and efforts were made to maximize response rate and sample representativeness.

Data Analysis: Quantitative data were statistically analyzed to determine frequency and percentage of responses, providing insights into prevalent beliefs and practices.

Ethical Approval and Trial Registration

The study was approved by the Ethics Committee of Kurukshetra University, Kurukshetra, Haryana, India, and registered with the Clinical Limitations: It includes potential sampling bias and reliance on self-reported data, which may be subject to social desirability bias.

This quantitative research methodology aims to provide insights into menstruation beliefs and practices among perimenopausal women in Ambala, contributing to menstrual health knowledge and informing future interventions. Table 1 presents the demographic profile of the 150 participants varied across age groups, with the majority falling between 41-45 years, accounting for 54 percent, followed by 46-50 years at 27 percent, and 36-40 years at 19 percent. The sample predominantly consisted of Hindus at 61 percent and Sikhs at 29 percent. In terms of education, 48 percent held graduate degrees, 29 percent were postgraduates, and 23 percent completed higher secondary education. Occupation-wise, 30 percent were working women, while 70 percent were housewives. These diverse demographics form the foundation for exploring menstruation myths, taboos, and hygiene practices in Ambala, Haryana (Fig. 1). [12,17] . Table 2 highlights the prevalence of enduring myths surrounding menstruation, which continue to influence societal perceptions and behaviours. A substantial 74 percent of respondents believe that women shed impure blood during their periods, while 46 percent subscribe to the notion that missing a period always indicates pregnancy. Surprisingly, 97 percent hold the misconception that one cannot get pregnant while menstruating. Additionally, 57 percent equate using a tampon with losing virginity, and 55 percent believe menstruation reduces a woman's ability to think clearly. Other prevalent myths include the idea that exercising during menstruation is harmful (37%), refraining from washing hair is necessary (25%), and menstruation makes women physically weaker (69%). Notably, all respondents unanimously view sex during menstruation as harmful or unhygienic. These findings underscore the persistence of misinformation surrounding menstruation and its impacts on individuals' beliefs and behaviours. [11,14] . Table 3 illustrates that menstruation continues to be surrounded by taboos and restrictions in many communities. A significant 79 percent of respondents acknowledged a taboo against openly discussing menstruation, while 65 percent reported being restricted from participating in religious ceremonies during their periods. Additionally, 48 percent noted that menstruating individuals experience differential treatment in social settings. Additionally, 27 percent believe menstruation to be shameful or embarrassing, and 31 percent reported restrictions on what menstruating individuals can touch or handle. Disposing of menstrual hygiene products is deemed taboo by 63 percent of respondents. Moreover, a large majority (88%) consider menstruation a private matter not to be openly discussed, with 82 percent feeling pressured to keep their period status hidden. Nearly 40 percent perceive menstruation as a punishment or curse. Furthermore, food-related taboos during menstruation are prevalent, with 85 percent avoiding cold beverages, 33% refraining from raw vegetables or fruits considered "cold," and 27 percent avoiding dairy products. Similarly, pickles, ice cream, and foods with high water content are avoided by significant portions of respondents. These findings highlight the enduring cultural norms and beliefs surrounding menstruation that impact individuals' experiences and behaviours (Fig. 2).

Results and Discussions

Menstruation Myths

Menstruation Taboos

Sadiq & Salih, (2013) [15] found that 66 percent of respondents believed consuming pickles could impact menstruation, while 89.6 percent felt that drinking cold beverages had a negative effect. Additionally, 35.4 percent reported that exercise adversely affects menstruation. These findings align with the results of the current study.

Puri & Kapoor, (2006) [12] revealed in their study that numerous girls and women face limitations in their daily routines solely due to menstruation. Urban girls predominantly encounter restrictions such as abstaining from entering the "puja" room, while rural girls are primarily prohibited from entering the kitchen during their menstrual cycles. Srivastava et al. (2016) [19] demonstrated in their study that menstruating individuals are often barred from offering prayers and handling holy books. These constraints stem from cultural perceptions of impurity linked to menstruation. There is a prevailing notion that menstruating women are unhygienic and dirty, thereby potentially contaminating the food they prepare or handle.

During Ramadan, the holiest month in Islam marked by fasting as a core observance, not all individuals are obligated to fast. This includes children, pregnant or nursing women, and menstruating women and girls. According to Islamic beliefs, menstruating women and girls are deemed impure during their periods and are therefore exempt from participating in fasting and prayer rituals. Instead, they are expected to compensate for missed fasting days once their menstruation ends and they undergo ritual purification. (Selby, 2018) [18] . Munro et al. (2021) [10] highlighted those cultural norms and religious taboos often associate menstruation with negativity, linking it to shame, embarrassment, and evil spirits. In some cultures, women bury menstrual clothes to prevent their misuse by evil spirits (UNICEF, 2008) [20] . In Suriname, menstrual blood is believed to be harmful, with concerns that it can be used for black magic, known as "wisi," to harm menstruating women or girls (El-Hameed et al., 2011) [4] . There is also a belief that women can manipulate men using menstrual blood. Interestingly, such practices continue in parts of Asia, including India, despite lacking any scientific or logical basis (Wateraid, 2012) [21] .

In several regions of India, dietary restrictions during menstruation are strictly followed. Sour foods such as curd, tamarind, and pickles are often avoided due to the belief that they may interfere with or stop menstrual flow, as reported by Kumar & Srivastava, (2011) [8] , Sadiq & Salih, (2013) [15] , and Raina & Balodi, (2014) [14] .

Menstruation Hygiene

 Menstruation hygiene refers to the practices and behaviours adopted by individuals to manage menstruation hygienically and safely.  This includes the use of menstrual hygiene products such as pads, tampons, menstrual cups and proper sanitation facilities for disposal.  Maintaining good menstruation hygiene is essential for preventing infections, promoting menstrual health, and enhancing individuals' dignity and well-being (Raina & Balodi, (2014) [14] ; Putri & Setianingsih, 2016) [13] . Table 4 highlights key findings on menstrual hygiene practices and perceptions. Notably, 91 percent of respondents emphasized the importance of using menstrual hygiene products during menstruation. Among them, 68 percent relied on pads, 23 percent used cloth, and 9 percent reported using both (Fig. 3). Additionally, 100 percent of participants emphasized the importance of access to clean water for maintaining menstruation hygiene. However, only 75 percent believed that menstrual hygiene products are readily available and accessible. Almost all respondents (98%) acknowledged the impact of menstrual hygiene practices on a woman's fertility and overall health, with 93 percent recognizing that improper hygiene could increase infection risks. Furthermore, 77 percent believed that the lack of access to menstrual hygiene products could disrupt women's daily activities. Education about menstruation hygiene was deemed important by 96 percent of participants for promoting overall menstrual health, with 98 percent agreeing that hygiene practices vary depending on socioeconomic status. Moreover, 59 percent noted taboos against openly discussing menstruation hygiene in certain cultures. Finally, 70 percent viewed reusable menstrual hygiene products as viable sustainable alternatives. [11] reported that around 65 percent of women relied solely on sanitary pads, 3 percent used only cloth pieces, and 5 percent utilized a combination of both. The use of sanitary pads was notably higher among specific age groups, aligning with the findings of the current study. Similarly, Putri & Setianingsih. (2016) [13] highlighted poor personal hygiene practices among females during menstruation. Consistent with this, a study conducted in West Bengal also revealed inadequate menstrual hygiene practices (Sarkar et al., 2017) [17] .

Kirk & Sommer, (2006) [7] emphasized that inadequate menstrual protection and limited access to proper washing facilities can increase the risk of infections. Additionally, the odour associated with menstrual blood may subject girls and women to social stigma, potentially impacting their psychological well-being.

Conclusion

Our study illuminates the menstrual experiences of individuals aged 35-50 in Ambala, Haryana. Analysis of data from 150 participants reveals a nuanced array of cultural beliefs and practices surrounding menstruation. Highlighting pervasive myths and taboos, it underscores the urgent need for adequate menstrual hygiene resources and access to clean water. Disparities in menstrual health infrastructure call for targeted interventions to bridge these gaps. Our research offers valuable insights for implementing informed initiatives to enhance menstrual health outcomes and destigmatize menstruation within the community. Moving forward, prioritizing culturally sensitive approaches will be crucial in addressing challenges and promoting holistic menstrual well-being.

Implications and suggestions for future work

The findings stress the need to address cultural beliefs and practices in promoting menstrual health in Ambala, Haryana. Initiatives should prioritize providing menstrual hygiene resources, improving water access and rectifying infrastructural disparities. Culturally sensitive approaches are crucial for effective intervention. Future research should explore culturally tailored interventions' effectiveness in promoting menstrual health and destigmatizing menstruation.

Additionally, studies could assess community-based education programs' impact on changing cultural perceptions and behaviours. Longitudinal research is essential to evaluate sustained intervention effects on menstrual health outcomes and community attitudes.

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