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Household sanitation and menstrual hygiene management among women: Evidence from household survey under Swachh Bharat (Clean India) Mission in rural Odisha, India

Introduction: Discussion on women empowerment without addressing their basic needs would be meaningless. As such, the needs of women and girls have been prioritized in global sanitation efforts including menstrual hygiene. However, there is little research on existing approaches on menstrual management. India’s most ambitious sanitation campaign named Swachh Bharat Mission or “Clean India Mission” aimed to achieve universal sanitation coverage in every single household, targeted to end open defecation by October 02, 2019. This study aimed to assess the women’s perception of household sanitation facilities and menstrual hygiene management experience in Odisha under Swachh Bharat Mission. Methods: The study is a community-based survey having cross-sectional in nature conducted among 700 rural women and girls aged 15–45 years in the Balesore district of Odisha state in India from January to April 2021. A multi-stage sampling method was adopted to select the study participants. Data was collected using a pretested questionnaire based on the Performance Monitoring and Accountability 2020 survey questionnaire and analyzed by SPSS version 25. Descriptive statistics was used to assess the household sanitation and menstrual hygiene management experience among women. Results: More than two-thirds (68.4%) of rural households use improved sanitation facilities. Around 30% of families have inadequate sanitation infrastructure, which means at least one household member defecates in the open space. Nearly 64.6% disposed of their menstrual absorbents in the bush or field, while 29.1% disposed in the river and 24.1% in the waste bin. Still, 40.6% of women were using clothes as menstrual absorbents, and 54.9% of the respondents reported washing their menstrual materials for re-use. Of those who washed and re-used, 99.2% said their re-use material was completely dry before re-use. About 69.7% of the respondents mentioned that they change their menstrual absorbents in sleeping areas at home. About 91% of the respondents reported that the place where they changed their menstrual absorbents was safe, clean, and private. Only 22.5% of women responded to having water and soap at their menstruation management area. Conclusion: The effort for improvements in sanitary techniques during menstruation is partly effective in creating healthy behavior. The current strategy for developing programs to adopt menstrual hygiene measures needs a bottom-up approach with women at the center. Components associated with menstrual hygiene management, such as women’s cleanliness, water supply, and the availability and accessibility of disposable sanitary napkins, should be given specific attention. It is essential to acknowledge the issues like toilet construction and behavior change communication to consolidate the gains in an era of “Clean India Mission.”


Introduction
Sanitation and menstrual hygiene among women are an integral part of the primary health care. Without safe sanitation and menstrual hygiene, the overall mortality and morbidity among women would be increased, which ultimately escalate the disease burden in society. Hence, the issue of sanitation is a matter of concern for both primary care providers and family physicians indirectly. The care and cure provided by physicians can only be optimized with a functional sanitation network in any geographical areas. As a basic human right, sanitation services are therefore crucial to primary health care for the delivery of high-quality care for improved population health.
Every month, adolescent girls and premenopausal women are facing menstrual hygienic issues. However, menstruation is a natural phenomenon for them in the course of life. As a result, these women and teenage girls have developed strategies to cope with issues of menstruation, according to their individual choices, educational attainment, socioeconomic status, and cultural beliefs. [1] In 2017, Caruso et al. [2] conducted eight focus group discussions in rural Odisha, India by interviewing 69 women and young girls. They discovered that sanitation is a multifaceted issue for women and adolescents. The study reports that during the process of urinating, defecating, entering or leaving toilets, bathing at menstrual onset, washing, drying, and disposing of menstrual products, the women are concerned about being seen and shamed. [2] As a result, menstruation and menstrual hygiene management (MHM) practices continue to be a significant challenge for girls and women across Odisha. On the other hand, women and adolescent girls faced a slew of challenges regarding safe and healthy menstrual hygiene management. The factors like lack of clean water, soap, sanitation services, private place, and waste disposal act as barriers to maintain hygiene, which otherwise may negatively impact the health. [3] Menstruation management is more difficult in areas with restricted Water, Sanitation, and Hygiene (WASH) access, according to studies conducted in eastern India. [4][5][6] The MHM has been associated with a number of Sustainable Development Goals (SDG), including health (SDG3), education (SDG4), and gender equality (SDG5). The SDG 6 focuses on improving accessibility to safe drinking water, sanitation, and hygiene, while SDG 6.2 emphasizes the importance of paying particular attention to the needs of women and girls. [7] The Government of India initiated an ambitious sanitation campaign, named Swachh Bharat Mission (SBM) or "Clean India Mission" aimed to achieve universal sanitation coverage in every single household leading to end open defecation (OD) by October 02, 2019. This effort is aimed to hasten the target for achievement of sanitation among the people of vulnerable community. Also, according to India`s national menstrual hygiene program, there is a goal to achieve proper household sanitation facilities for the promotion of menstrual hygiene by building latrines for both men and women with proper privacy, water and soap, and adequate space. [8] Many socio-cultural constraints still apply to menstruation and menstrual activities. Many women and girls are unaware of scientific evidence and hygienic practices, leading to adverse health outcomes. Menstrual hygienic practices are essential in reducing reproductive tract infections (RTI). The RTI and its complications affect millions of women now-a-days, and these diseases are often passed on to the offspring of pregnant women. [9] In the context of Indian culture, majority of childbearing occurs within a marital union. Interestingly, women's age at marriage keep rising with falling parity levels, which leads to rising of normal menstrual cycles among women. On the other hand, most women lack the financial and nonfinancial resources needed to maintain adequate sanitation standards. Young women from economically and socially disadvantaged backgrounds are particularly vulnerable. [10] There is still much hesitation in Indian society to talk about menstruation-related problems. Menstrual hygiene has historically served as a springboard for addressing broader topics such as gender equality and women's empowerment, including sex education, female genital mutilation, child marriage, fistula, sexual health, and women's rights. Taking that into consideration, each country should eliminate all types of gender discrimination, which also include issues of menstruation. Menstruation should be addressed indirectly as a sign of excellent health and discussed openly. Thus, every woman to arrive at their maximum capacity of great health and wellbeing, the taboos surrounding menstruation must be broken. [11] Though there is an increasing local and global effort toward MHM practices and their impact on adolescent girls and women, an extensive knowledge gap persists. [12] The majority of existing information is focused on determining the socioeconomic and demographic variables of menstruation and related concerns. Limited studies found how household sanitation facilities play an essential role in menstrual hygiene management among females. Also, many studies have shown that the stress level associated with menstruation and an unmet menstrual need in low and middle-income groups magnifies adolescent girls' problems in the school settings during their menstrual cycle. [13,14] Thus, studying women's and girls' MHM practice and its management outside of the classroom has been mostly ignored in various programs and research. [13,14] Additionally, sanitation insecurity causes major stress among women during their menstrual cycle, but it is highest at home for both women and adolescent girls. [15,16] This is consistent with recent findings from Odisha state that mentioned menstruation to be the most stressful sanitation activity at home for women. [4] Moreover, policymakers and researchers mostly ignored the importance of household sanitation toward MHM. Further, misconceptions, lack of understanding, and negative attitude toward menstruation are all factors that contribute to low self-esteem in Odisha. [4] The diversities concerning socio-demographic (social, economic, and cultural) factors and access to household sanitation facilities for MHM practices vary in different parts of Odisha. Hence, it is crucial to study women's perceptions of household sanitation and MHM in rural Odisha. Therefore, the present study was designed to assess the challenges among the females (15-45 years) in rural areas of Odisha, which is measuring the proportion of rural households using improved sanitation facilities, sharing of household sanitation facilities, management of child feces, types of handwashing station, characteristics of handwashing station, and to assess their menstrual hygiene management practices. The findings of this study will help in understanding the situation of women in the control of their menstrual cycle by using household sanitation and other infrastructure. More importantly, research findings can also be used to establish and assess strategies and programs in the future.

Study type and setting
A community-based, descriptive, cross-sectional survey was conducted in the rural households of two administrative blocks named Bahanaga and Simulia in Odisha state of India.

Study population
The populations in the study were females aged 15-45 years who were asked to participate in this study.

Sampling strategy
The sample size was calculated using the formula Zα 2 P (1-P)/d 2 , taking the proportion of improved sanitation facilities in rural households in Odisha, as 23% (NFHS-4), 95% confidence level, and 5% confidence absolute precision and design effect of 2.
Considering the 10% of nonresponse rate, the total sample size became 598 totaling to 600.
Multi-stage sampling was adopted to obtain the females who participated in the study. At the first stage, Balasore district was chosen purposively. This is because, as per the recent data April 2019, Balasore has achieved 100% individual household latrine coverage (IHHL) and now racing toward achieving open defecation-free (ODF) district under Swachh Bharat Mission (SBM). [17] Therefore, Balasore district is chosen as the study site to examine if hygienic menstrual management practices of women are consistent with the access to a safe household sanitation facility. At the second stage, two blocks were randomly selected out of 12 blocks of Balasore district. Those randomly selected blocks were Bahanaga and Simulia blocks. At the third stage, 15 villages from each block were selected through systematic sampling, making it a total of 30 villages from 2 blocks. At the village level, the female field investigators (FFI) were mapped and all households listed. In the last stage, 20 households from each village were randomly selected and surveyed. Thus, this study included a total 600 households. We assume each household in a village to have at least one woman aged 20-45 years. According to National Family Health Survey (NFHS) and National Sample Survey Organization (NSSO), six households in a village have at least one adolescent girl aged 15-19 years. With this estimation, and the final sample in this study included 700 females aged 15-45 years. Women who are usually members of the household and reported menstruating in the past three months were eligible for interviews. In the case of more than one eligible woman and adolescent girl in the house, the selection was done using a lottery method.

Data collection tools and techniques
This study used the pretested Performance Monitoring and Accountability 2020 (PMA 2020) questionnaire to measure sanitation at household level and hygienic practices during menstruation. This questionnaire had two sections, i.e., questionnaires for household as a unit and female participants, which is widely available on URL of the PMA2020 website (https://www.pma2020.org/questionnaires).
Household questionnaire: It comprises questions related to portable water, hygienic practice facilities, and handwashing place generally used by the family.
Female questionnaire: It comprises questions related to the socio-demographic profile of the respondents and menstrual hygiene management.
This questionnaire was made in English language, which was translated to the local language of Odia by a native language professional. Further, following the questionnaire preparation convention, it was back-translated to English by two professionals having no prior idea of English version of the PMA 2020 questionnaire.
Three experts checked the content validity of each domain and the face validity of each item from Kalinga Institute of Industrial Technology (KIIT) University, Bhubaneswar. Maximum efforts were made to keep the questions unambiguous and simple so that respondents can easily understand.
Household sanitation facilities were defined as "improved" and "not improved" based on definitions used by the World Health Organization (WHO). Improved sanitation facilities include if the excreta separated hygienically from human contact like flush to a septic tank, flush to a piped water system, flush/pour flush to pit, ventilation improved pit latrine and pit latrine with a slab. [18] Unimproved sanitation facilities include the pit latrine without a slab, toilet without a bucket, and lack of amenities like a brush. In the present study, the "not improved" sanitation facilities are referred to as "open defecation." This is because no household under SBM in the study site was given to unimproved sanitation. However, some household members, despite having SBM toilets defecate in the bush/filed/open space. Hence, the classification of unimproved sanitation is referred to as open defecation in this study.
The block development officer of Bahanaga and Simulia block were informed about the study. The three female field investigators and one Research Assistant were trained on data collection. Quality of data collection was assured by frequent visits to field areas from the day of data collection that can ensure the completeness and correctness of the questionnaire.

Results
A total of 700 women and girls aged 15-45 were contacted to participate in the study from surveyed families. The aggregated sample for this study was 694, yielding a response rate of 99%. The participant's mean age was 31.86 years (SD = 8.3), with 45.5% (n = 316) of them being between the age of 30-39 years. Around 21.9% (n = 152) of the participants were over the age of 40, 99.7% (n = 692) of interviewed participants were Hindu, 42.7% had a secondary education, 38.2% (n = 265) belonged to the scheduled caste (SC), and 33.6% (n = 233) belonged to the other backward caste (OBC). Around 83.7% of the respondents were married, and 46.8% had a family income of more than Rs 8000 per month. The socio-demographic characteristics of the study group are mentioned in Table 1.

Main household sanitation facility
This study showed 68.4%of the households used improved toilets, of which 63.7% had pit latrine with slab, 3.7% had pit latrine ventilated improved pit, and rest had flush/pour toilet facilities. Nearly 30% of the households continued to use unimproved sanitation facilities, which means members of these households defecate in open fields, and 1.6% used shared toilets, including the improved latrines category [ Figure 1].
Households with single toilet facilities are the most common, with 98.4% of participants reported that they do not share sanitation facilities with other families. About 1.4% of households share toilets with other families, while only 0.1% of households used public toilets [ Figure 2]. Figure 3 shows that the feces of the child is mainly disposed at the household garbage site (58.6%) while 28.4% household reported that their child uses latrine. Whereas 26.3% of participants disposed their children`s feces in a latrine, 15.1% in wastewater, and nearly 1.3% of households used their children's feces as manure.
Households were also asked about handwashing activities and the location of the handwashing station. About 88.9% of the household population did not have a specific place where they washed their hands, which means they washed their hands anywhere they find convenient. Only 10.1% of households reported that they had a fixed handwashing station [ Figure 4]. Figure 5 indicates that 56.8% of the households washed their hands with water from a tap or a stored source, while 35.3% of households use only soap. Just 4.6% had both soap and water at their handwashing station.

Menstrual hygiene management
Women and girls were asked about the site used for safe menstrual hygienic practices management shown in Figure 6. A total of 69.7% of women and girls mentioned changing their regular menstrual absorbents in their respective sleeping places  or bedroom, 10.1% of women choose to change their menstrual absorbents in their backyards, and only 9.8% used the main household sanitation facility. Meanwhile, 9.5% of the women said that they change their menstrual absorbents in other areas of the house, such as the bathroom etc., while only 0.6% of women reported using a public, work, or school facility.
While investigating the characteristics of the place where women changed their menstrual absorbents and maintained menstrual hygiene, 92.2% reported that menstrual management location was safe, 91.9% mentioned it was private, and 91.9% reported that the place was clean. It was also observed that 67. 4% of women's menstrual management locations were lockable, while 22.5% reported having water and soap accessibility in their menstrual location [ Figure 7]. Figure 8 shows that only sanitary pads were used by 39.8% of women and girls, 40.6% using only cloth, and 19.6% using sanitary pads and clothes. Also, 54.9% (n = 381) of women reported that they wash and re-use their menstrual materials. Of those who wash and re-use, 99.2% (n = 378) said their re-use material (cloth/pad) was completely dry before re-use. Figure 9 shows the percentage of respondent's detail about their discarding of menstrual remains. Respondents were inquired about the practices for disposal of materials. The result showed that 64.6% of the participants simply dispose of their menstrual waste material in bush or fields followed by 29.1% in the pond, 24.1% in the waste bin, and19.9% of women buried it. Only 9.2% of women disposed of their menstrual waste in the toilet.

Discussion
The present study highlighted women's perception of household sanitation facilities and menstrual hygiene management experience in Odisha, India. First, we assessed the women's perception of household sanitation facilities in their homes.  Second, we assessed the women's experience with menstrual hygiene management.
The study highlighted that nearly 68.4% of respondents use improved toilets, while 30% of households use unimproved toilet facilities, which means they practiced open defecation. Under SBM, the improved pit latrine with a slab or standard twin pit latrine was promoted. During SBM, a significant effort has made to improve toilet use through behavior change communication, mass training programs, and local creativity. [19] Despite the fact that every household has accessibility to a toilet under SBM, one or more members of the household engaged in open defecation activities in this study. This emphasizes the need for sanitation initiatives that include both toilets and behavior change methods that enhance toilet use. [20][21][22][23][24][25][26] Yogananth and Bhatnagar [27] mentioned that the reasons for the low usage of toilets were low-quality building, lack of access, scarcity of water, preference for open defecation, and socio-cultural factors.
After the provision of sufficient resources by the government, even during sanitation initiatives, family toilet usage rates have remained stable. For example, in Odisha, 37% of members of the household with latrines reported that they were never defecating in the toilet as part of the India Total Sanitation Campaign. [28] Therefore, in the post-SBM period, it is critical to comprehend why open defecation persists with availability of toilet facilities, [29] in various public places.
New insight is provided from this study that a majority of household residents did not share toilet facilities with other households. This could be due to SBM's efforts to assist behavior change among individuals and to use household latrines constructed under SBM. About a quarter of the women responded that their children use latrine for defecating, and child feces was managed by latrine disposal method. It is not yet clear why most women dispose of children's feces in the garbage, which may expose harmful fecal pathogens and increase the potential for negative health effects. [30] Spears, [31] in his study, suggested lack of sanitation facilities can affect children's health. Furthermore, families with better sanitary conditions do not always flush their children's feces down the toilets. [32][33][34][35][36][37] Although some progress has been made in disposing of children`s feces during total sanitation campaign (TSC), most feces still end up in the environment. It is worth noting that TSC interventions only use limited behavioral change messages to encourage people to utilize toilets, including children, or dispose of their feces safely. Therefore, there is an urgent need to improve the practice of proper disposal of children's feces. [32] According to the findings of this study, many households do not have a designated hand washing area, meaning they wash their hands wherever they feel convenient. Overall, these results indicate that teaching simple hand washing techniques and reinforcing in them the importance of hygiene will contribute to essential hygienic management and motivate women to maintain menstrual hygiene. However, many women and girls (69.7%) mentioned that they change their menstrual material in their bedroom or sleeping areas, though more than half of households using improved sanitation facilities. Girls and women with improved sanitation facilities were significantly more likely to utilize the main household sanitation facilities for changing menstruation materials than those with unimproved sanitation facilities. This could mean that increasing household sanitation facilities will enhance women's possibilities of using them to manage their menstruation. Thus, it can be argued that the level of household hygiene and presence of sanitation facility do not necessarily reflect the location of women's menstrual management or the absence of absorbent replacement sites.
Further, the study results highlighted women significantly given their MHM locations high ratings for being safe, clean, private, and lockable. This means that women's experience while managing their MHM location tends to be positive irrespective of the household sanitation facilities. Some women in this study who said they did not have a place/no provision to change their menstrual materials also rate that the environment was clean, safe, and private. As a result, these findings appear to contradict significant levels of stress related to menstruation management reported in studies of Sub-Saharan Africa's school-going girls [14,16,38,39] and Indian women. [2,4,15] Given the menstruation`s stigmatized nature and the expected social likeability of positively reporting on MHM locations, it may be necessary to carefully interpret the recognition of the environment's cleanliness, safety, and privacy.
According to our study, more than half of the women (55%) reported using reusable clothes during their last menstrual cycle. However, the percentage of women who used disposable sanitary napkins is still poor (39.8%). The study result is consistent with other studies [1][2][3][4] as it showed the impact of rural women using sanitary napkins at a lower rate than those who use reusable cloths. Our study results also suggest many women and girls recycle their menstrual materials, indicating more likely to be infected with infections. Even if the clothes are cleaned and dried before use, this does not guarantee that they are free of infections.
The study reported that women and adolescent girls often dispose of their menstrual absorbents in the bush or field, with some dumping them in ponds and others in waste bins. It is unclear whether the discarded material is wrapped in paper or packed in polythene. As a result, it means that women and adolescent girls are either unaware of proper menstrual hygiene management or are unconcerned about the health consequences of the unsanitary menstrual hygiene management. Several reports have shown similar results in these aspects. [39][40][41] The family physicians not just treat the individual patients but also people in their natural settings. The issues of health promotion and disease prevention are key areas for the family physicians and primary healthcare providers to improve the sanitation facilities in the community. For instance, the counseling part for improvement of diet, hygiene, and preventive healthcare create the need for good health and wellbeing. The major findings of the study show that the families having inadequate sanitation facilities are vulnerable to the menstrual hygiene of the adolescent girls and women. Components associated with menstrual hygiene management, such as women's cleanliness, water supply, and the availability and accessibility of disposable sanitary napkins, should be given specific attention. The survey also conveys a strong message that the government led SBM programs have to be effective to promote overall environmental and behavioral issues of health promotion. The uniqueness of the study demonstrated very systematic and objective observations by the research team that provided meaningful insights into household sanitation facilities and MHM among women in India.

Conclusion
The menstrual cycle is the crucial indicator of women's conceptual wellbeing; thus, feminine cleanliness during menstruation is a significant concern that ought to be more investigated. Despite improvements in the usage of sanitary techniques during menstruation, the situation remains unsatisfactory. The current strategy for developing programs for the adoption of menstrual hygiene measures, which provides protection from infectious diseases, is to take a bottom-up approach with women at the center. This strategy should emphasize women's right to make decisions about their own lives and health.
Additional research is needed to look into all hygienic procedures associated with washing, drying, and storing menstrual absorbents. More research is needed in India to look into aspects that could assist women in adopting more sanitary menstrual habits while maintaining comfort and privacy. Components associated with MHM, such as women's cleanliness, water supply, and the availability and accessibility of disposable sanitary napkins, should be given specific attention. Analyzing existing policies on sanitation insecurity and MHM could provide additional insights and lead to developing women-centered practices. More research on measuring household sanitation facilities could aid in reporting sanitation interventions for infrastructure development and behavior change communication. Therefore, this study provides an essential step in developing adequate indicators to measure how women's experiences toward menstruation and household WASH facilities would contribute to overcoming the adverse health outcomes in women.
It is recognizing that toilet building, and behavior change communication must attain open defecation free India in the post-SBM era. It is necessary to address the cause of less utilization of the latrine. Further, an independent, credible, and robust measuring tool must be put in place to correctly measure the sanitation progress of the country under the post-SBM era.
This study conveys for promotion of "Swachh Bharat Mission" with letter and spirit for a healthy society, especially for vulnerable women and adolescent girls, for leading a healthy life. Further, the behavioral issues have to be aligned with the evidence-based sanitary practices with the help of government and agents of social change in the community.