Abstract
Menstruation, as a natural physiological process, intersects with health, human rights, and environmental concerns, making its management a critical issue influenced by cultural, social, and systemic factors. This study aims to determine the hygiene product preferences of university graduate women, the individual factors (such as personal habits and preferences) and systemic factors (such as availability, marketing, and cultural norms) influencing their product choices, as well as their level of product knowledge. This study was conducted between April and May 2021 and included 3301 menstruating individuals aged 18-49 years using menstrual hygiene products. Data analysis was performed using Spearman’s correlation test and the Chi-square test. The mean age of participants was 26.7 ± 6.4 years. Of the menstrual hygiene products used, 93.8% of participants reported using single-use pads, 21.8% reported using tampons, and 2.5% reported using menstrual cloth. Among the participants, 88.1% reported using single-use products, 4.1% reported using reusable products, and 7.8% reported using both types of products. A positive correlation was identified between the usage of and knowledge about each type of menstrual hygiene product. Among the users of reusable products, the answer of ‘environmental effect’ as the most effective factor influencing the preferences was found to be more frequent when compared to the single-use product users and those using the products in both groups (p < 0.001). It was observed that women’s age and employment status were factors that created a difference in menstrual hygiene product choices.
Introduction
Menstruation is a natural process where the lining of the uterus is periodically shed. Each day, millions of people who menstruate face serious challenges to manage their periods in a healthy way with dignity (1). This is a health and human rights issue with physical, psychological, and social dimensions, and a broad life course perspective (2). Poorly managed periods can lead to various health problems, such as genitourinary infections (3). Although menstruation is not typically seen as a personal hygiene issue, proper menstrual management is closely tied to access to menstrual products and knowledge of how to use them, both of which are influenced by systemic and political factors. Despite the significant health and environmental impacts of menstruation, there is still a taboo and silence surrounding the topic (4).
Menstrual hygiene management strategies can vary greatly depending on factors such as country, culture, employment status, educational level, and knowledge of menstrual hygiene. These strategies can start even before the onset of menarche, with the development and implementation of policies focused on menstrual health and equity that take into account these various factors (5). During bleeding periods, properties, perceptions, and choices of menstrual hygiene products, as well as social norms, can also affect menstrual hygiene management (6–8). Proper usage recommendations and cautions for menstrual products can vary depending on the type of product; for example, reusable products must be washed, dried, and stored properly. Women should be able to access clean and reliable menstrual hygiene products during their periods, and have access to an environment that provides privacy and proper disposal or washing of used products (9,10). The beliefs and values of social circles can also influence which menstrual hygiene products are used and what information is communicated about their usage (11). Therefore, knowledge associated with menstrual hygiene products and their usage is essential to good menstrual management practices (12).
There are many single use (commercial hygienic pads, tampons, hygienic pads produced using local materials, newspapers, toilet paper, etc.) or reusable (menstrual cup, washable tampon, washable hygienic pad, old cloths, etc.) menstrual hygiene products at different levels of costs (13). The performance, reliability, and cost of these products are all important factors in product choice (5). However, disposable hygienic pads can be unaffordable for many due to their relatively high prices. Tampons and menstrual cups may be less commonly used in many cultures due to inaccurate associations with hymen tearing and loss of virginity (14). Single-use products are more commonly used than reusable products by individuals (6) and reusable alternatives such as menstrual cups and reusable menstrual pads or panties are less well known (15). These alternatives are less harmful to the environment and have been on the market for a long time, but have only recently become more widely available.
Effective menstrual hygiene management necessitates evaluating the types, accessibility, and usage of menstrual hygiene products. Therefore, this study aimed to evaluate the knowledge about menstrual products, menstrual product choices and menstrual hygiene behaviors of university-graduate women aged 18-49 years.
Materials and methods
This cross-sectional study was conducted online between April and May 2021 on menstruating women aged 18-49 years who used menstrual products. Approval was obtained from the Eskişehir Osmangazi University’s Medical Faculty Non-Interventional Clinical Research Ethics Committee prior to the study; electronic informed consent was obtained from all participants prior to completing the survey (Approved 28 April 2021; approval number E-25403353-050.99-174639).
Inclusion criteria were menstruating women aged 18–49 years, university graduates, and voluntary participation in the online survey. Exclusion criteria were incomplete surveys, non-graduate participants, and users reporting ambiguous product categories (menstrual cloth). A sample size of 3049 was calculated based on an assumed frequency of 50% for using reusable products, a type-I error of 5%, a test power of 80%, and an effect size of 0.08. A total of 3365 individuals were accessed. Given the 2019 data of the Turkish Statistical Institute, the rate of women having a university degree or higher was found to be 18.5% (16). Since 90% of the study group had a university degree or higher, the accessed sample did not represent the Turkish society and was influenced by internet access. Consequently, the analyses were conducted on 3031 individuals with a university degree or higher.
The survey was developed through a literature review and expert consultation. It was pilot tested with 20 women and revised for clarity before distribution. Data were collected using a survey form consisting of 24 questions about sociodemographic characteristics, menstrual hygiene product choices, and knowledge about these products. Participants were asked to indicate their menstrual product preferences, which menstrual hygiene products they had knowledge about (including single-use pads, tampons, menstrual cloths, reusable pads, and menstrual cups), and where they obtained information about these products. Knowledge was operationalized as correct responses to seven structured questions on product safety, replacement intervals, and hygiene behaviors (see Table 3). Participants’ knowledge of menstrual hygiene was assessed through questions regarding their handwashing practices, frequency of changing underwear, and genital hygiene during menstruation. The survey was conducted on online platforms such as WhatsApp, Instagram, and Twitter. Data collection was stopped once the calculated sample size was reached.
The menstrual hygiene products used by participants were classified into three categories based on UNICEF’s menstrual hygiene product guideline: single-use products (single-use hygienic pad, tampon), reusable products (reusable pad, menstrual cup), and those using products from both categories (14). The responses of individuals using single-use menstrual cloth (n = 75) were not included to avoid misclassification bias, as these participants variably described the product as both single-use and reusable in any category as they were reported to be used as both single-use and reusable products.
The dependent variable of the study was the choice of menstrual product, while the independent variables included sociodemographic information (age, education, working status, and average monthly income), menstruation information source, factors influencing menstrual product preference, menstrual product information, and menstrual hygiene information. The question about factors influencing the choice of menstrual product was a multiple-choice question with options including affordability, ease of access, ease of use, comfort, social circle effects, suitability for amount of bleeding, and environmental impact.
Individuals’ income status was classified as very high, high, middle, and low based on their perception of their income compared to the minimum wage (2825₺~343USD).
In this study, the term ‘woman/women’ was used to refer to all menstruating individuals, regardless of their gender identity.
The collected data were analyzed using the SPSS Statistical Package Software (version 15.0, Chicago). Descriptive statistics were calculated and results stratified by sociodemographic variables on a computer. Statistical significance was set at p < 0.05. As the data did not follow a normal distribution, quantitative data were presented as median (minimum–maximum) values. The data were analyzed using Spearman’s correlation test and the Chi-square test.
Results
The mean age of the participants was 26.7 ± 6.4 years, and they were between 18 and 49 years old. Out of the participants, 1422 (46.9%) were employed, and 531 (17.5%) had a low monthly income, while 1537 (50.7%) had a middle income, 879 (29%) had a high income, and 84 (2.2%) had a very high income. The menstrual product usage was as follows: 93.8% used single-use (hygienic) pads, 21.8% used tampons, 9.3% used menstrual cups, 3% used reusable pads, and 2.5% used menstrual cloth. The distribution of menstrual product usage is presented in Figure 1.
Distribution of menstrual product usage.
Of the participants, 2604 (88.1%) reported using single-use products, 120 (4.1%) reported using reusable products, and 232 (7.8%) reported using both types of products. Analysis of menstrual product preferences based on sociodemographic characteristics showed that single-use products (55.8%) were more common among the 18–25 age group compared to reusable products (36.7%) and both combined (38.4%) (p < 0.001). While single-use products were the most commonly used overall, participants in the younger age group had a higher usage of reusable products. Women who were employed (54.8%) reported higher use of single-use products compared to reusable products (37.5%) and both groups combined (40.1%) (p < 0.001). There was no statistically significant relationship between average monthly income level and menstrual product usage preferences (p > 0.05) (Table 1).
Distribution of participants’ menstrual hygiene product choices by their sociodemographic characteristics.
Column percentage.
Row percentage.
A total of 99.3% of the women had knowledge about single-use (hygienic) pads, 78.9% about tampons, 67.7% about menstrual cups, 45.7% about reusable pads, and 28% about menstrual cloth. There was a very weak positive correlation between product usage and knowledge of each menstrual hygiene product. The sources of information about menstruation for the participants are shown in Figure 2.
Distribution of participants’ source of information about menstruation.
The study found that the most influential factors in menstrual hygiene product choices among the participants were ‘ease of use’ (64.9%) and ‘comfort and ease’ (61.6%), while ‘environmental effect’ had the least impact (10.4%). Reusable product users were more likely to consider affordability (42.5%) compared to single-use product users (32.6%) (p = 0.006). Those who preferred reusable products were less likely to consider ‘ease of access’ (10%) compared to single-use product users (60%) and those using products from both groups (38.4%) (p < 0.001). Among those who did not prefer single-use hygienic products, reusable product usage was more frequent (99.2%) compared to the other groups (p < 0.001). Reusable product users were more likely to consider the ‘environmental effect’ (91.7%) compared to single-use product users (0.9%) and those using products from both groups (75.4%) (p < 0.001) (Table 2).
Distribution of participants by the factors influencing their menstrual hygiene product preferences by menstrual product types.
Column percentage.
Row percentage.
The difference between groups not having the same letter is significant.
On examining the menstrual hygiene habits of the study group, it was discovered that a vast majority of the participants, specifically 96.1%, were taking showers during their menstruation period. For those who opted not to take a shower, the reasons were mostly due to feelings of fatigue and weakness (31.9%) and the belief that it would increase menstrual pain. With regards to washing hands during menstrual hygiene product changes, the responses were distributed as follows: 55.9% wash their hands after replacing, 40.2% wash before and after replacing, 3.1% do not wash their hands before and after replacing, and 0.8% wash their hands only before replacing. In terms of the frequency of changing underwear during the menstrual period, the responses were as follows: 46.6% change once a day, 45.3% change once every 2–3 days, and 8.1% change less frequently. Women expressed that they cleaned their genital area using water and toilet paper as the most frequent method at 71.4%, and only 2.2% reported not cleaning their genital area. Finally, it was found that perineal cleaning was done correctly, specifically from front to back, by 63.8% of participants.
The correct answer frequency for the question ‘Which one of the menstrual hygiene products poses the least health risk?’ was lower among those who used disposable products (48.8%) compared to those who used reusable products (10.0%) and both types of products (17.7%) together (p < 0.001). For those who use reusable products, they answered questions such as ‘Menstrual cloth and reusable pads require less maintenance than other menstrual hygiene products’, ‘The time to change tampons is at least 8 hours’, ‘The replacement time of menstrual cups is about 10–12 hours’, ‘Reusable pads can be used for more than 10–12 hours’, and ‘Menstrual cups can only be used by sexually active individuals’ more accurately than those who used disposable products (p < 0.001). Table 3 presents the distribution of answers to questions about the participants’ level of knowledge about menstrual products by type of menstrual hygiene product (p < 0.001).
Distribution of answers to the questions about the participants’ level of knowledge about menstrual products by the type of menstrual hygiene product.
Column percentage.
Row percentage.
The difference between groups not having the same letter is significant.
Discussion
Menstruation, a natural physiological process, was recognized as a fundamental human right by the Human Rights Council in 2018. Despite this, cultural stigmatization and societal restrictions persist, particularly in developing countries, impacting women’s health and dignity (17,18).
Women develop their own strategies for managing menstruation based on various factors, including cultural beliefs, economic status, education, and access to products. These factors also influence their choice of menstrual hygiene products (19,20). In our study, the most used menstrual hygiene products among university-educated women were single-use (hygienic) pads (93.8%) and tampons (21.8%). A meta-analysis of studies in high-income countries found that 77% of women used single-use pads, and 65% used tampons (15). In a study of medical students in India, the most commonly used product was also a hygienic pad (86.36%) (21), while in another study conducted in Türkiye, the majority of women (96.7%) reported using hygienic pads (22).
The global population of menstruating women is approximately 100 million, and many of them face challenges in managing their menstrual health due to lack of hygiene, limited access to products, and insufficient knowledge (20,23). In this study, it was found that the most common source of information about menstruation was family (75.5%), followed by the internet and other media (56.2%), school (56.0%), and friends (47.7%). In a study carried out on elementary school students, the first rank among information sources was found to be mother by 35.22%, followed by friends at 23.29% (22). In another study carried out on high school students, it was determined that 68.9% of them received information from family and 43.7% from books (24). In studies carried out in Egypt (75.5%) and Iran (37.4%), similarly, ‘mother’ was the most frequent information source (25,26). This is consistent with previous studies that have found mothers to be the most reliable source of information about menstruation. To ensure proper management of menstruation and menstrual hygiene, it is essential to provide education and training for all age groups and to consider their sociodemographic characteristics (27). Mothers should be equipped with sufficient knowledge to manage their daughters’ menstrual cycles accurately and transfer accurate information.
It is important to note that healthcare professionals are considered reliable sources of information about menstruation (28). However, in our study, healthcare personnel were ranked last as a source of information (14.8%). Similarly, a previous study conducted in Nepal on adolescents (1.6%) and another study carried out in India on young mothers (3.25%) also found that information on menstruation was not primarily provided by experts (29,30). Previous studies have shown that training provided by healthcare professionals effectively promotes healthy behaviors (28).
Accessing accurate information about menstruation can be challenging due to the lack of knowledge in society. This can be particularly damaging because online algorithms often prioritize sensational, stigmatizing, or manipulative information. Despite this, the Internet remains the most frequently used source of information due to its accessibility and ease of use. The fact that 56% of participants in this study obtained information about menstruation from the Internet and other media sources highlights the importance of using the Internet consciously and critically to ensure the accuracy of the information obtained.
The findings of the present study suggest that the frequency of taking a shower during the menstruation period is higher among university graduates (96.1%) compared to previous studies conducted on women living in community clinic regions (37.8%) and high school students (83.1%) (24,31). The most common reason for not taking a shower during menstruation was feeling uncomfortable, weak, and tired, followed by the fear of increasing menstrual pain. In previous studies, the reasons for not taking a shower during menstruation were anxiety about catching an infection, beliefs that it is harmful, and concerns about increasing bleeding or pain. In a study examining the genital hygiene behaviors in a university’s girls’ dormitory, the reasons for not taking a shower during menstruation were found to be ‘anxiety of catching infection’ by 73.5% and ‘it is harmful’ by 21.9% (32). In a study on high school students, 35.4% of participants stated that they did not shower during menstruation because it increased the bleeding, 31.6% said it caused pain, and 24.2% stated it caused infection (24). In a study carried out by Ege and Eryılmaz on hygiene behaviors, it was observed that hygiene behaviors were better among individuals having high educational levels, and the education given improved these behaviors (33). In a study of the frequency of taking showers during menstruation period, 37% of participants were elementary school graduates, and it was thought that the difference in the present study was because the participants were university graduates. It has been suggested that education on hygiene behaviors can improve these attitudes and behaviors, and individuals with higher educational levels tend to have better hygiene behaviors. Therefore, it is important to provide accurate information and education about menstrual hygiene to promote healthy behaviors and dispel common misconceptions.
It is important to note that proper hand hygiene during the menstrual period is crucial in preventing the spread of infections. The World Health Organization (WHO) recommends washing hands with soap and water before and after handling menstrual hygiene products. It was found that 40.2% of participants washed their hands before and after replacement, and 55.9% washed their hands after replacing the product. In a study carried out by Tartaç and Özkan (24) on knowledge/attitude about menstrual hygiene, similar to the present study, students’ frequency of washing their hands while replacing the pad was found to be ‘I wash my hands before and after replacing’ by 39.4% and ‘I wash my hands after replacing’ by 57.8%. The findings of the present study and previous studies highlight the need for education and awareness-raising about the importance of hand hygiene during menstruation.
It is important to note that the frequency of changing underwear and perineal cleaning practices during menstruation can have a significant impact on women’s health (32). Studies have shown that poor menstrual hygiene can increase the risk of urinary tract infections in women (3,34). In the present study, 46.6% of participants reported changing their underwear daily, while 45.3% reported changing it once every 2–3 days. These results are consistent with findings from previous studies. In another study, the frequency of changing underwear was found to be ‘every day’ by 31.4% and ‘once every 2–3 days’ by 64.8%. In a study examining the perineal cleaning practices of women having urinary tract infections, it was determined that the frequency of the answer ‘once every day or more frequently’ was 45.1%, and it was reported that a low frequency of the changing underwear increased the infection risk (35). Similar results achieved in studies might be because of the similar educational levels of study groups.
Proper education and awareness about perineal cleaning practices should be promoted among women of all ages. The perineal region should be cleaned from the front to back to prevent contamination of the vagina and urethra from the anal region (36). It was determined that participants cleaned their perineal region ‘from front backward’ most frequently (63.8%). In a previous study, the direction of cleaning the perineal region during the menstruation period was found to be ‘from front backward’ by 54.5% among high school students (24). In a study carried out on female students in a health sciences faculty, the perineal cleaning habit was found to be ‘backward’ by 76.42% (37). This result might be because health science faculty participants have more information about menstrual hygiene.
Drying while cleaning the genital area decreases the infection risk by preventing the formation of a moist environment and, consequently, the reproduction of microorganisms. In the present study, most of the participants perform genital area cleaning during the menstruation period by using water and toilet paper. Another study determined that 53% of genital area cleaning during the pad replacement was performed using water and toilet paper. It can be concluded that, among university graduate women, genital area cleaning was performed accurately to a large extent.
Policy and advocacy implications should also be emphasized. Access to affordable and sustainable menstrual products remains a challenge. Government programmes, non-governmental organizations (NGOs), and healthcare systems should prioritize subsidies, social marketing campaigns, and distribution strategies that promote reusable products, reduce environmental burden, and ensure equitable access.
Menstruation is a cyclic process starting with puberty. Healthcare providers have a responsibility to offer women access to necessary products, reliable information, and education to increase awareness and improve their overall health.
Limitations and strengths of the present study
One of the primary strengths of this study is its large sample size, which enhances the statistical power and reliability of the findings. Furthermore, the subject matter—menstrual hygiene and product preferences—addresses an underexplored and socially sensitive issue. Given that menstruation remains a taboo in many societies, the study contributes meaningfully to the limited literature on the subject. Nonetheless, the study has certain limitations. Its cross-sectional design restricts the ability to establish causal relationships. Additionally, data were collected through online platforms, which inherently limits participation to individuals with internet access and digital proficiency.
Conclusion and suggestions
The importance of managing menstrual hygiene is highlighted in the study, and it is shown that women’s choice of menstrual hygiene products is significantly influenced by factors such as age, employment in an income-generating job, and monthly average income level. Based on the findings, it appears that women require further education to enhance their understanding and attitudes towards reusable menstrual hygiene products and their environmental impact. The majority of participants reported using single-use products, and the percentage of those who were aware of reusable pads was lower compared to other products. Furthermore, women’s age and employment status impacted their preferences for menstrual hygiene products. It is essential for healthcare providers to offer women accurate and trustworthy information about menstrual health and hygiene, particularly in communities with limited access to resources and information. Education and training programmes for women are necessary to promote healthy menstrual hygiene practices and product choices.
To eliminate stigma and misconceptions surrounding menstruation and encourage healthy practices, future studies should investigate the effectiveness of menstrual hygiene education and knowledge-raising programmes. Additionally, further research is required to inform policies and practices concerning the environmental impact of menstrual hygiene products and the potential advantages of reusable products.
Footnotes
Acknowledgements
The authors would like to thank Rayka Kumru, MSx, MA for comments and support that greatly improved the manuscript.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
