‘What’s the bleeding problem?’ Menstrual health policy and consequential attitudes in India

There were three study conditions: (1) Disposable arm provided with disposable pads and complete information on the full range of menstrual alternatives, their hygienic use and correct disposal; (2) Reusable arm was given cloth-pads and information on menstrual products; and (3) Inform-only arm, continued with usual practice and received same information. The current study analyses the time points directly before for all conditions (baseline), and after the women completed six months of product use (follow-up). Follow-up is used for comparisons between disposable pads to reusable cloth-pads to inform-only.

All study participants received complete information on the entire range of menstrual alternatives along with their hygienic use and correct disposal. For the two product conditions, participants also received sufficient menstrual products for six months. To achieve community acceptance, the products used in the trial had to be selected carefully and with the involvement of the NGOs. A careful selection exercise was undertaken which assessed two products as viable for the community trial: a pad that required burial to compost (‘Disposable’ condition) and a reusable cloth-pad with an anti-microbial top layer (‘Reusable’ condition). The selection process and additional information about the products are detailed in in Appendix A, Box A2.
This gave us the three study arms: information + disposable pad (Disposable condition); information + reusable cloth-pad (Reusable condition); and information only + usual practice (Inform-only condition). After allocation to study conditions, baseline was completed, and menstrual materials distributed to Disposable and Reusable arms. All interactions were administered by pairs of women, one of whom was an employee of the partner NGOs. Most individual interviews were carried out in respondent’s home, but where women preferred it, these were done in partner NGOs’ office.

2017-09-18

2017-10-27

The primary outcome is a measure of women’s preference for reusable menstrual products. This outcome measure was chosen as the main aim of the study to understand the effect of exposing women to alternatives to disposable pads on their preference for menstrual products.

Preference for sustainable menstrual absorbents: We developed this outcome using women’s response to the following question: “Can you please tell us what menstrual material you prefer most? In answering this question, please think only of your preference and not of other factors like price and availability. You can choose a single menstrual material or if you like, you can choose a combination of materials you prefer”. Women who chose a reusable or compostable material (like, homemade cloth-pad; commercial cloth-pad; menstrual cup; compostable pad) received two points, those who chose sustainable products in combination with disposables (like, pad; tampons) received one point and those who chose only disposable pads were given no points. The preference for sustainable score ranged from 0-2, with higher score indicating greater preference for sustainable materials.

We also included three secondary outcomes: women’s willingness to adapt menstrual practices in terms of use and disposal; a measure of women’s awareness of products beyond traditional cloth and disposable pads; and a measure of women’s beliefs about menstruation and menstrual products, including their beliefs about the need for drying cloth in direct sunlight. These outcomes were chosen because in combination they encompassed women’s attitudes towards menstrual materials and practices that are more sustainable than using disposable pads.

1. Willing to adapt menstrual practices: This measures women’s willingness to adopt sustainable practices in two areas: use and waste management. Responses were noted on three questions:
- “Would you be willing to try a new sustainable menstrual product?”
- “Would you be willing to pay for the safe waste disposal of your menstrual absorbent?”
- “Would you be willing to dig a pit for burial of compostable menstrual product?”
A woman received one point if she answered “yes” to the use question and one point for answering “yes” to either of the disposal questions. Thus, the willingness to adapt score ranges from 0-2, with higher score indicating greater willingness to adapt practices.
2. Aware of alternatives to cloth and pad: This measures women’s awareness of the range of menstrual materials beyond traditional cloth and disposable pad. Women were asked to name or describe all the menstrual material they were aware of. For each menstrual material they named or described other than traditional cloth or disposable pad they were given one point. The knowledge of menstrual products scores ranges from 0 to 4, with higher scores indicating greater knowledge of menstrual materials beyond cloth and pad.
3. Beliefs about periods & products: Beliefs about menstruation and menstrual products is measured using the responses women gave to three questions:
- “Should girls and women continue with their normal activities during their menses?”
- “Does menstrual cloth need direct sunlight drying after wash?”
- “If correctly used, can cloth provide equally good menstrual protection as a disposable pad?”
A woman received one point for each question she answered “yes”. Thus, the possible range of scores are 0-3, with higher score indicating more accurate beliefs about menstrual materials.

The study design included repeat cross-sectional surveys over six months to quantify the effects of providing women with complete information about period products compared with combining knowledge provision with reusable cloth pad or disposable pads on women’s preferences for menstrual materials and practices.

In consultation with partner NGOs, ten areas were identified to achieve a mix of geographical spread, access to amenities and other considerations like safety of enumerators, accessibility etc. From each of the study sites, a random sample of 50 households was created. From this list, we removed households that were known to reside in the area only intermittently and households that had no women in the age group 18-45 years of age. Using stratified random sampling, the remaining women were allocated to one of the three study conditions using the ratio of 4 women to product plus information condition for every 1 woman to the information only condition.

Public lottery in presence of study partners (done in office)

Individual

No

10 sites across the city of Hyderabad, Telangana

500

Stratified random sampling was used in this pilot to allocate women to one of the three study conditions: Disposable (n = 200), Reusable (n = 200) and control Inform-only (n = 100). As the main aim of the study was to quantify the effects of exposure to reusable alternatives to disposable pads, the control inform-only condition was kept smaller than the two arms providing menstrual products. Information on the range of menstrual materials was provided to women across all three conditions.

Sample size calculations assumed a 30% increase in preference for reusable menstrual materials after exposure to these alternatives, requiring a total population of 386 (193 per arm), providing 85% power with 0.05 alpha.