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Title of the article: Knowledge and practices related to menstruation among Lucknow college students
in North India: results from cross-sectional survey

First author and Corresponding author: Absar Ahmad, PhD

Assistant Professor
Department of Community Medicine,
Current Affiliation: Manipal Tata Medical College, Jamshedpur
Former Affiliation: Career Institute of Medical Sciences and Hospital, Lucknow
Email: r.absar.ahmad@gmail.com
Phone: +91-9920676968
ORCID: https://orcid.org/0000-0001-5843-4571

Second author: Surbhi G. Garg, PhD

Principal, Shri Gurunanak Girls Degree College, Lucknow
Email id: surbhigarglko@gmail.com
Phone: +91-9005195010

Third author: Suman Gupta, MS

Head of Department, Obstetric and Gynecology
Career Institute of Medical Sciences and Hospital, Lucknow
Email id: drsumangupta327@gmail.com
Phone: +91-9452780006

Fourth author: Ruqayya Alvi, MA

Doctoral Student, Department of Applied Economics,
University of Lucknow
Email id: a.ruqayya.alvi@gmail.com
Phone: +91-7887034920
https://orcid.org/0000-0002-6754-1106

NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
 medRxiv preprint doi: https://doi.org/10.1101/2021.02.10.21251460; this version posted February 12, 2021. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
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It is made available under a CC-BY 4.0 International license .
Knowledge and practices related to menstruation among Lucknow college students in
North India: results from cross-sectional survey

Background: Girls in many low and middle-income countries enter puberty with knowledge gaps and
misconceptions about menstruation may lead to unsafe hygienic practices that increase health risk. Despite
such importance, educated girls' knowledge and hygienic practice towards menstruation are not well addressed
in India. Consequently, the present study attempted to assess menstrual hygiene knowledge and practice
among college students in Lucknow city in north India.
Method: An online college-based cross-sectional study design was employed in Lucknow, the capital of Uttar
Pradesh in India. Data collection was carried out from September 11 to September 25, 2020, using a google
form among undergraduate and Postgraduate students. All variables that were significant at bivariate level (at
P-value < 0.05) were entered into multivariate analysis using a logistic regression model to control for
confounding factors. In the final model, P-value of less than 0.05 was used as a base to identify factors having
a statistically significant association with poor knowledge and hygiene practice at corresponding 95%
confidence interval.
Results: More than half of students' ages of menarche were between 12-15 years, and duration of menses flow
was between 3-5 days. The most common premenstrual symptom was abdominal pain (67%) and back pain
(50.5%). Majority of the students had first time discussed menstrual problems with their mothers (69.2%).
Around 94% of students were currently using a sanitary pad as an absorbent. Regarding cleanliness, about
(90.9%) girls clean their genitals after urinating during mensuration. Around 18.9% used medication during
menstruation. Multivariate analyses reveal that students of Science and Technology (vs Commerce and
Management Students) and monthly family income 50-100 thousand (vs < 25 thousands) were associated with
good knowledge about menstruation. In contrast, students' fathers were graduates (vs school educated); the
occupation was 'Other'(vs Farmer) ; living in a nuclear family(vs Joint family) and residing in urban areas(vs
Rural) were less likely to have good menstruation knowledge. Besides, good hygiene practices are less likely
to have with 'Other' Religion(vs Hindu), working mother(vs Housewife), monthly family income between 25
to 50 thousand(vs <25 thousands), and Nuclear family(vs Joint family) (p<0.05).
Conclusions
Most college students had poor knowledge but followed hygienic practices correctly. It demonstrates a need
to design acceptable awareness creation and advocacy programs to improve college students' knowledge
during menstruation. Of all the sociodemographic factors, monthly income and types of family influenced
students' knowledge and practices related to menstruation.

Keywords: Knowledge, Menstruation, Practice, Sanitary pads, Hygiene

Introduction
Menstruation is a universal, normal, unique, and physiological phenomenon (1) that women and adolescent
girls experience every month (2), but this topic has been taboo until a date in India (3). Girls in India hide their
pad from gazing by the male at home. The shopkeeper always gives sanitary pads in the black polyethylene
bag and wrap fully with newspaper. The issue is inadequately acknowledged and not received proper attention
(4), so girls enter puberty with knowledge gaps and misconceptions in many low and middle-income countries.
The adults around them, including parents and teachers, are ill-informed and uncomfortable discussing
 medRxiv preprint doi: https://doi.org/10.1101/2021.02.10.21251460; this version posted February 12, 2021. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY 4.0 International license .
sexuality, reproduction, and menstruation (5). During menstruation, these sociocultural impositions make this
phenomenon burdensome and an event that makes them feel fear, disgust, and shame (6). Among
premenstrual, dysmenorrhea symptoms were the most frequent problems (7), linked to several misconceptions
and practices (8) lead to poor menstrual hygiene (9). Its management is an important aspect of reproductive
health, which, if not handled appropriately, can cause infections of the urinary tract, pelvic inflammatory
diseases and vaginal thrush, as well as bad odor, soiled garments and, ultimately, shame, leading to
infringement on the girls’ dignity (10)(11)(12).
It is advise that good menstrual hygiene practices are essential during menstruation; the practices include: 1)
regular change of clothing and underwear; 2) change of hygienic pads every three to four hours; 3) daily
showering, especially in instances of dysmenorrhea; 4) adequate washing of genitalia after each voiding of
urine and/or feces; 5) continuing normal routine and daily activities (e.g. going to school, doing physical
exercise), and 6) maintaining a balanced diet with plenty of fruits and vegetables rich in iron and calcium(13).
Adolescent girls constitute a vulnerable group, not only concerning their social status but also to their health
(1). They are often reluctant to discuss menstruation with their parents and usually hesitate to seek medical
help regarding menstrual problems (14). This time for these students is crucial to prepare and adjust
themselves to manage their menstrual bleeding safely and cleanly (15). College student’s life is very diverse
than school student’s life. They make them independent, accountable, and robust. They also make decisions
of their own that will transform their future. It is also an ideal time for girls to plan for their careers and prepare
for a job competition. Managing the practical and psychological aspects of menstruation is difficult for these
girls, affecting self-confidence, self-esteem and achieving the wider development goal of women’s
empowerment (16). Menstrual also afflicts girl students absenteeism and academic performance (17). Risk
factors associated with absenteeism include misconceptions about menstruation, insufficient and inadequate
facilities at school or colleges, and family restriction (18).
Every year approximately 10 % of women worldwide are exposed to genital infections, including urinary tract
infections and bacterial vaginosis, and 75 % of women have a history of a genital infection. Specifically, the
common risk factor for vaginal infections include poor hygiene (19). A study in India reported exclusive use
of disposable absorbents was low among young women aged 15-24 (37%) and varied substantially by caste,
education, wealth, and residence (20). However, study of uses of sanitary pads particularly among college
students in India were 80 % (21),but uses were in Pakistan(22) and Ghana (6) were 77.5 % and 100%
respectively. A study in Uttar Pradesh state of India among 10-19-year girls reported about half of the girls
did not have information or knowledge about menstruation. Less than one-quarter of them only followed
proper hygiene practices (23). Another findings from a study in India suggest that rural school going girls who
used old clothes or cloth boiled in water and dried before re-use suffered from genital infection (24). More
than half of the women who did not use any hygienic method during menstruation suffered from vaginitis
(25).
India is the second-largest country in the world, where we find state-wide variation in the use of menstrual
absorbents , ranging from the highest in Mizoram (93.4%) to the lowest in Bihar (31%)(26). Further, these
 medRxiv preprint doi: https://doi.org/10.1101/2021.02.10.21251460; this version posted February 12, 2021. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
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It is made available under a CC-BY 4.0 International license .
studies conducted among adolescents either using secondary data (20)(26) or school students (27)(8) in India
and abroad (28)(6). These studies have shown inadequate knowledge of menstruation and poor menstrual
hygiene practices among these population. Society considers persons with tertiary-educated proficient in
diverse fields, their knowledge related to reproductive systems such as menstruation would be also high (6).
Besides, there is little information about gynecological morbidity associated with menstrual problems in
young populations (such as university students) (29). Considering the above scenario, this study was
conducted among college students in Lucknow, India. This study assessed female undergraduate and post-
graduate college student’s knowledge of various disciplines in Lucknow on menstruation and their menstrual
hygiene practices. This study also evaluated determinants that could influence these students' knowledge of
menstruation. This study again tries to explore the taboo related to mensuration among college students.
Policymakers and stakeholders will use the information obtained from this study to identify the awareness and
practices of menstrual hygiene to provide information about menstruation and menstrual hygiene for college-
going students in the study area.
Data and Methods
Methods section of study were also published in previous study in 2021(30).
Study design and methods
A descriptive cross-sectional online survey was performed in Lucknow using the google form platform.
Study Setting
This study was carried out in Lucknow district of Uttar Pradesh, India.
Participants
Undergraduate and Post Graduate students of any stream were eligible for the study.
Sample size
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.
Ethical consideration
Before the data collection, ethical clearance was obtained from the Institutional Ethical Committee of Career
Institute of Medical Sciences and Hospital, Lucknow, with the reference number (Ref:
PHARMA/SEP/2020/02). This work was done in collaboration with Shri Gurunanak Girls Degree College,
Lucknow, and Career Institute of Medical Sciences and Hospital, Lucknow. The consent form was included
in the online survey tool regarding their participation in the study. The study's purpose was explained in the
google form. The recipients had the full liberty to disagree and submit the survey form after knowing the
purpose of the study. Personal information like mobile number, email id, and Name was not asked in the
survey. Participants have also been informed as there will not any risk due to their participation, and the
confidentiality of the collected information will be kept well. They were also informed that they have the right
 medRxiv preprint doi: https://doi.org/10.1101/2021.02.10.21251460; this version posted February 12, 2021. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
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It is made available under a CC-BY 4.0 International license .
to refuse or withdraw their participation at any time they want, and no harm could be imposed towards them
due to their refusal.
Data collection
Data were collected by using an anonymous, internet based self- administered questionnaire that contained
both open- and close-ended questions. The questionnaire was in English as well as Hindi, to get responses
from Hindi medium students. The online questionnaires were conveniently distributed through emails,
WhatsApp, Telegram, and other social media throughout Lucknow. The respondents’ social media were
identified and recruited through a link and networking of all co-researchers and colleagues.
Study variables
The predictor variable was chosen based on an extensive review of the literature on levels and factors
associated with menstruation: Course of the study(Commerce and Management, Humanities, Medicine and
Allied and Science and Technology),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), and Place of residence(Rural and Urban).
Outcome variables

Two outcome variables of the study are knowledge and practice related to menstruation. To measure girls'
knowledge about menstruation question was asked (i.e., what is the menstrual cycle; what the normal age of
menarche is; organ of menstruation; and the normal duration of the menstrual cycle). Correct responses were
coded as 1 otherwise 0 for analyses (see table 4). Similarly, to measure menstruation management's good
practice, five questions were asked and coded (See Table 5). Questions were the type of menstrual absorbent
currently used, number of sanitary pad used per day during periods, cleaning genitals after urinating during
mensuration, Types of pad wrap used for disposing of it, place at where the pad was disposed and bath during
menstruation. For this study menstrual materials (sanitary pads or homemade cloth) changed four and more
times a day is considered as good hygienic practices(31).

Operational Definition

Total knowledge score varies from 0 to 4 and practice scores varies from 0 to 6. Median is considered as the
cut-off point. A score below-median was considered as low or lacking knowledge and practices. Similarly, a
score above median was considered as good or adequate knowledge and practices related to menstruation.

Data Analysis
 medRxiv preprint doi: https://doi.org/10.1101/2021.02.10.21251460; this version posted February 12, 2021. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
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It is made available under a CC-BY 4.0 International license .
The data recorded in the spreadsheet were exported to SPSS Version 25. Initially, bivariate analysis was
performed between dependent variable (Knowledge and practice of menstrual hygiene) and each of the
independent variables (Socio- demographic variables). All variables that were significant at bivariate level (at
P-value < 0.05) were entered into multivariate analysis using a logistic regression model to control for
confounding factors. Their odds ratios (OR) at 95 % confidence intervals (CI) and P-values were obtained to
identify important candidate variables for multivariate analysis.
Results
From a total of 1439 students who participated in the online survey, 1371 completed the interview with a
response rate of 95.2%. Table 1 shows the socio-economic and demographic profile of study participants.
More than half (56.5%) were from the Commerce and Management course, followed by Humanities (33.6%).
About 88% were undergraduate students, and the rest were postgraduate students. The mean (±SD) age of
respondents was 20.06 (±1.78) years with a minimum and maximum age range of 16 and 30. Fifty-six percent
of the sample students belonged to the general castes, 34% to other backward classes, and 10.3% to scheduled
castes/ scheduled tribes. Most students surveyed were Hindu (86%), and 12% were Muslims. Forty-nine
percent of students' fathers were only up to school educated, one-third of fathers were graduate, and 17%
postgraduate and above. Almost 60% of students' mothers were up to school educated, 28% were graduate,
and 12 % postgraduate and above. Most student's fathers were self-employed (28%), followed by private
organization employees (26%) and government employee (21%). However, 87% of student's mothers were
housewives, and 13 percent employed. Fifty-nine percent of students' monthly family income was less than
25 thousand, two-third were living with Nuclear families, and three-fourths belonged to urban Lucknow.
Table 2 depicts the Obstetric and gynecological related characteristics of College girls in Lucknow. More than
half, (57.8%) have experienced their menarche (onset of first menses) within the age range of 12–15 years,
and 54.8 % had duration of menstrual flows of 3-5 days. Majority of college girls have experienced abdominal
pain (67 %) during menstruation followed by backpain(50.5%), weakness(47.2%), irritability(41%),
anorexia(24.3%), headache (17%), acne(17.1%), vomiting(10.3%), bloating(9.6%), insomnia(9.1%),
constipation(7.9%) and breast pain(7.1%).
Table 3 present the awareness among college girls of Menstruation at menarche and their reaction to first
menstrual blood. Less than half (45.7%) of the students were aware of Menstruation before the onset of
menarche. Mother is the first source of information for most of them, 69.2%). Friends (19.8%), teachers
(18.4%), and sister (16.4%) were also the first source of information. Most of the respondents (30.6%) felt
discomfort on seeing blood flowing from their genitals for the first time at menarche. However, mothers were
the first persons the majority (70.8%) discussed menarche with rather than the least consulted father (0.2%).
The majority (82.9%) expressed satisfaction with the level of education on Menstruation they got from the
first persons they discussed their first menstrual episode.
Table 4 present the knowledge among college girls on menstruation in Lucknow. Solely 31 percent of college
girls reported the definition of menstruation appropriately. Little lower than two-third (63.2%) of college girls
correctly informed the typical age of menarche. While 65% of girls accurately reported organ of menstruation.
 medRxiv preprint doi: https://doi.org/10.1101/2021.02.10.21251460; this version posted February 12, 2021. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
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It is made available under a CC-BY 4.0 International license .
Means Only 65 % of the girls knew that menstrual bleeding comes from the uterus. Only 64 % of girls correctly
reported the usual duration of the menstruation cycle.
Table 5 shows the menstrual hygiene practices of college students in Lucknow. Around 85% of students used
the sanitary pad to absorb their menstrual blood during the first year after menarche, while 15% of students
used reusable cloth. However, almost 94% of students are currently using the sanitary pad to manage their
menstrual flow. The average sanitary pad used per day was thrice a day, and 91% clean their genitals after
urinating during menstruation. Around 70% of students used paper to dispose of sanitary pads after wrapping
it, while 29% used plastic bags. Approximately 9 % of students absent from at least one day during
menstruation, and 19 % also used medication during menstruation. Around 15% skipped bathing on the first
day of menses.
Tables 6 exhibits the bivariate and multivariable relationship between the student's knowledge and background
characteristics. The multivariable analysis reveals the study's course, father's education, father's occupation,
monthly family income, type of family, and residence place. Students from Science and Technology course
were five times more knowledgeable about menstruation than Commerce and Management students (AOR
5.17,95%CI: 2.274-11.752).

Present study found contrast result from many studies. Students whose fathers graduated were significantly
lower knowledge of menstruation than students whose fathers were school educated (AOR 0.634, 95%CI:
0.426-0.944). Likewise, students whose fathers' occupations were 'Other' had lower knowledge of
menstruation than students whose fathers were farmers (AOR 0.671, 95%CI:0.466-0.967). Students whose
monthly family income was between 50 to 100 thousand were more knowledgeable about menstruation than
those whose monthly income was less than 25 thousand (AOR 1.804, 95% CI:1.067-3.049). Students living
in a Nuclear family were less knowledgeable than those living in a joint family (AOR 0.765 95% CI:0.600-
0.975). Furthermore, rural students were more knowledgeable than urban (AOR 0.701, 95% CI: 0.527-
0.933).This finding were also contrast of many Indian studies.
Table 7 presents the bivariate and multivariable relationship between sociodemographic characteristics and
menstrual hygiene practices. The multivariable analysis reveals the factors associated with good hygiene
practice of menstruation among students were religion, mother occupation, and family type. Other religion
(Sikh and Christian) students were 88% less likely to had good menstrual hygiene practices than Hindu
students [AOR = 0.11, 95 % CI: 0.048–0.273]. However, Students whose mothers were working women were
37% less likely to have good menstrual hygiene practices than students whose mothers were housewives [AOR
= 0.63, 95 % CI: 0.42–0.953]. Nuclear family's students were 34% less likely to have good menstrual hygiene
practices than students from the joint family [AOR = 0.659, 95 % CI: 0.508–0.855].
Discussion
Menstruation and its management have become a globally recognized public health topic. Around the world,
people and various stakeholders are mobilizing to bring attention and resources to address the menstrual-
related shame, embarrassment, and taboos experienced by many girls in low and middle-income countries(32).
 medRxiv preprint doi: https://doi.org/10.1101/2021.02.10.21251460; this version posted February 12, 2021. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
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It is made available under a CC-BY 4.0 International license .
Menstruation is the process through which every woman must come across throughout the reproductive years.
Educated women manage menstrual hygiene in a better way, which positively impacts the personal welfare
and health of a girl. Furthermore, these women are more likely to be healthier than uneducated women, which
possibly ensures better health status and education for their children (33). Despite that, there is a limited study
on university students' menstrual knowledge and practices in India, and this study attempted to examine the
menstruation knowledge and practices among them. The analysis introduced several significant insights.
More than 50% of students reported their age of menarche in the present study were in between 12-15 years.
This was similar to the studies where the age of onset of menstruation or menarche were between 11-15 years
(34)(35)(36)(37). The age of menarche varies by geographical region, race, ethnicity and other characteristics
but ‘normally’ occurs in low income settings between the ages of 8 and 16 with a median of around aged
13(38)(39).
In present study every student experienced one or more symptom, respectively, in the premenstrual phase.
Abdominal pain (menstrual cramps or dysmenorrhea) and back pain were most common symptoms related to
menstruation in students, and these findings were concordant with other studies (40,41)(42)(36). Students
reported that premenstrual symptoms made them excruciate and exhausted physically, mentally, and
emotionally and counting days to end. Due to the high prevalence of these symptoms among students which
increases long resting hours, negatively affected students daily living activities , disturbed social life and
absenteeism from institutions (43)(44). Early diagnosis and knowledge about menstrual disturbances are
essential because they help choose appropriate treatments, minimizing the disruptions or adverse effects on
students' lives (43).
In present study unfortunately, 54.3 % students were unaware of menstruation before menarche. The
researchers observed that these percentages varied in various studies. The finding differs from 17% to 90 %
(8)(34)(6) (45). Most of them were frightened, embarrassed, and disturbed due to ignorance about such a
natural process (45).
The mother gave the first and primary source of information on menstruation to daughter. It was similar to the
study done in Gujarat (46) and also revealed through meta-analysis (47) were the primary source of
information was a mother. It has been also observed that the imperfect knowledge regarding menstruation
among mothers and other adult family members is transferred to their young girls (48). Students reported
knowledge like don't bathe, don't drink cold water, don't eat curd, don't play, and don't exercise during
mensuration passed this knowledge to children by mothers and other family members.
Most students' reactions to seeing blood flow from their genitals the first time made them discomfort and
created fear and panic. This study found results are congruent with other study in Ghana(6) and Pakistan(22)
were the most students experienced fear and panic. Lack of information results in undue fear, anxiety, and
wrong ideas in adolescents' minds (49). It is also reported in India that women told nothing about menstruation
until their first personal experience of it(50). It was also seen in some places that mothers do not teach their
daughters about menstruation and hygiene maintenance during periods(8). Present study also found about 85%
of students were used sanitary pads in the first year of menstruation, and currently, 94% were using sanitary
 medRxiv preprint doi: https://doi.org/10.1101/2021.02.10.21251460; this version posted February 12, 2021. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY 4.0 International license .
pads which is higher than sanitary pad(37%) used by women aged 15-24 in India(20). The researchers
observed the prevalence of currently using menstrual pad varied in various studies. The findings were ranges
from 56% to 100 among college or university students (6)(22)(51)(21). In the present study, around 18.9%
used medication during menstruation. However, in a study done in Malaysia among school girls, about 11.1
percent seek medical consultation for their menstrual disorders(35). Some women have had bad premenstrual
symptoms on the days before their period that they can’t go about their usual activities. To cope with and
manage common symptoms such as abdominal pain, women used medications.
In this study, multivariable analysis showed students from Science and Technology field were five times more
knowledgeable about menstruation than Commerce and Management students. However, this association was
not significant in the status of menstrual hygiene practice. Likewise, a study in Ghana found a significant
association between the study's course with menstrual knowledge (6). It might be because, in science, students
have more exposure to this topic than commerce and management students.
Although knowledge of menstrual hygiene with religion was not significantly associated, the menstrual
practice was significantly associated. The study found 'Other' religion students were less likely to follow good
hygienic practices than Hindu religion students. In this study, the 'Other' religion consists of Sikh and
Christian. Religion was a significant predictor of menstrual practice in studies in Ghana (6) and India(14). The
present finding was the contrast of a study based on a large sample of women aged 15-24 where Christian
women and those belonging to "other" religions were more likely than Hindu women to report exclusive uses
of sanitary pads (20). In another study based on a large sample, the hygienic method was low among women
aged 15-49 following Hindu and Muslim religion compared to women following Christianity, Sikhism, and
other religion (52). As the sample size of the present study is very low among the reference group, this relation
to be further explored with larger samples to develop any firm conclusion.
In this study, multivariable analysis showed that students whose fathers’ educational status was graduate were
36% less likely to had good knowledge about menstruation. However, the relationship was not significant for
menstrual hygiene practices. Our finding is different from a study that stated good menstrual hygiene practice
was high among schoolgirls whose fathers were educated (53). It may be because college students' menstrual
knowledge might be different from school student's knowledge. This contradictory finding could be explained
by the fact that the menstrual knowledge of students in college may independent of father education while in
other studies the results were not significant (37)(54). So, the father's education role might be changed from a
previously established relation, which needs to be explored further using a different sample.
Furthermore, students whose fathers' occupations were 'Other' had lower knowledge of menstruation than
students whose fathers were farmers. However, the association between father occupation and menstruation
were not significant in the present study. Other professions mostly include labour class or daily wagers. A
study in Pakistan revealed that fathers' occupation status is associated with students' knowledge (54).
However, a study in India shows girls living in households where the main occupation was labour had lower
knowledge of menstruation than other works (23).
 medRxiv preprint doi: https://doi.org/10.1101/2021.02.10.21251460; this version posted February 12, 2021. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY 4.0 International license .
In multivariable analysis the knowledge level of menstrual hygiene doesn’t find significant association with
mother occupation. However, the results were significant in case menstrual hygiene practices. Students whose
mother is working less likely to follow good hygienic practices compare to those whose mother were
housewife. Mothers’ employed status benefits children by improving family income, better disciplined work
behaviour and better structure of family routines(55) . Studies have shown that inadequate preparation for
menarche creates a poor attitude toward menstruation and poor menstrual practices(56). Some students said
that mothers do not teach kids because they think it makes children impudent, others expressed embarrassment
of discussing it with their mothers, and some students believed that their families should not be involved in
their sexual education(57). Those mothers who go to work and total time spent with the child has decreases
(58). It was found that incidence of health issues was found to increase with increases in maternal employment
as the number of hours spent with the child decrease(59).
In present study found that knowledge and practices related to menstruation were significantly associated with
monthly income. In this study, we found that students whose monthly family income was 50 to 100 thousand
were more knowledgeable about menstruation than those whose monthly income was less than 25 thousand.
A study in India reported that girls living in households with poor economic status had lower knowledge of
menstruation than better-off families(23). Students those family incomes were in between 25 to 50 thousand
were less likely to follow good hygienic practices compare to students those family incomes were less than
25 thousand. due to low family income, men hesitate to give money for such costly products. So, in both
cases, women have to compromise with their menstrual needs and personal hygiene(60).
In the present study found that knowledge and practices related to menstruation among college students were
significantly associated with type of family. In the present study students living in a Nuclear family were less
knowledgeable than those living in a joint family. However other study in India on knowledge level among
students were not statistically significant with family type(61). During the discussions some of the girls stated
that they were not aware about phenomenon of menstruation, but they observed that the females in their family
keep themselves away from certain activities for two to three days every month(45). Students were belonging
to nuclear family were less like to practice good hygienic practices compare to students belong to joint family.
In Asian countries, and in many joint family systems, grandparents, and other nonworking family members
fulfil the need for childcare–they take over the job of childcare when the mother is at work. This very important
benefit (of readily available child support from the family members themselves) in joint families not only
recognizes that the working mother is an important member of the family, but also provides her the necessary
support to be able to perform her dual role efficiently(55).
Rural students were more knowledgeable than their counterparts (AOR 0.701, 95% CI: 0.527-0.933). The
rural area of Lucknow has almost a rural-urban fringe, and students daily travel to the city for college. It shows
twelve years of education have filled the knowledge gap related to menstruation. However, this relationship
might be different when a study is done in another small city. Many students from rural backgrounds come to
the city for under graduations and post-graduation and stay at a hostel or as paying guests in the city. Another
 medRxiv preprint doi: https://doi.org/10.1101/2021.02.10.21251460; this version posted February 12, 2021. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY 4.0 International license .
situation was many colleges in Lucknow coming up in rural areas. These two situations might have altered
the result of this study.
This study's main strength is the inclusion of many students from different colleges in Lucknow. With such a
large number and extensive participation, this study's findings are difficult to be ignored. Despite that, there
is a limitation in the study. The cross-sectional nature of the data could obscure the causal effect relationships
of different factors, lacking qualitative data. Furthermore, we selected study subjects using a convenience
sampling method to have shortcomings such as non-generalizability and selection bias. However, our study
provided an insight into menstrual knowledge and practices in Indian college students and need further
research for an in-depth understanding of the issue.
Conclusion
Most college students had poor knowledge but followed hygienic practices correctly. It exhibits a need to
design acceptable awareness creation and advocacy programs to improve college students' learning regarding
menstruation. Of all the sociodemographic factors, monthly income and family type influenced students'
knowledge and practices related to menstruation. Discussing the challenges faced by the girls during
menstruation with family and friends and colleges can relieve anxiety and stress. Availability of adequate
water, sanitary products, essential medicines, and privacy at home and the educational institutions can address
the challenges. This paper reemphasizes the critical, urgent, and neglected need of providing correct
knowledge to the community, including college students.
Recommendation through students
It is recommended that students from 5th standard should make aware regarding menstruation. It should be
cheap and accessible to all sections of girls. There should visit a yearly check-up for the students and
medication should be prescribed for premenstrual symptoms. Male should also be informed about
menstruation-related knowledge. The pad should be made more comfortable. Another option of menstrual
hygiene management should also be introduced which should be environment friendly. Disposing bags should
also be provided with sanitary pads. College should give off for at least one days when the pain was severe.
A girl needs lots of love and care during her periods. It’s a natural process that every woman faces in this
world to stop making them feel like a curse or insult. Every school, college, hospital, and institution should
separate and individual small departments for girls where all related things about the menstrual cycle should
be stored.
Acknowledgments
Our deepest gratitude also goes study participants, and faculties working at colleges in Lucknow for their
dedicated cooperation.
Authors contributions
AA, SG1, SG2 and RA conceived the topic, developed the proposal, and developing the study tool,
manuscript preparation. AA took major roles in analysis. All authors gave final approval for this version of
the manuscript to be considered for publication.
Funding The author(s) received no financial support for the research and/or authorship of this article.
 medRxiv preprint doi: https://doi.org/10.1101/2021.02.10.21251460; this version posted February 12, 2021. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY 4.0 International license .
Availability of data and materials All data has presented
Competing interests
The authors declare that they have no competing interests
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Table 1: Socio-economic and demographic characteristics of college girls in Lucknow(n=1371)

Variables Subgroups n Percentage(95%CI)

Course of the study Commerce and Management 774 56.5[53.8-59.1]
Humanities 460 33.6[31.1-36.1]
Medicine and Allied 97 7.1[5.8-8.6]
Science and Technology 40 2.9[2.1-4.0]
Grade Graduation 1203 87.7[85.9-89.4]
Post-Graduation 168 12.3[10.6-14.1]
Age (in years) <19 562 41.0[38.4-43.6]
20-22 681 49.7[47.0-52.4]
23+ 128 9.3[7.8-11.0]
Mean(±SD) 1371 20.06(±1.78)
Caste General 767 55.9[53.3-58.6]
OBC 463 33.8[31.3-36.3]
SC/ST 141 10.3[8.7-12.0]
Religion Hindu 1172 85.5[83.5-87.3]
Muslim 161 11.7[10.1-13.6]
Other 38 2.8[2.0-3.8]
Father education School 669 48.8[46.1-51.5]
Graduate 470 34.3[31.8-36.9]
PG and above 232 16.9[15.0-19.0]
Mother education School 825 60.2[57.5-62.8]
Graduate 384 28.0[25.6-30.5]
PG and above 162 11.8[10.2-13.6]
Father occupation Farmer 137 10.0[8.5-11.7]
Government employee 284 20.7[18.6-23.0]
Self-Employed/Businessman 383 27.9[25.6-30.4]
Private Org. employee 357 26.0[23.7-28.4]
Other 210 15.3[13.5-17.3]
Mother occupation Housewife 1191 86.9[85.0-88.6]
Working 180 13.1[11.4-15.0]
Monthly salary (INR) <25,000 809 59.0[56.4-61.6]
25 to 50,000 311 22.7[20.5-25.0]
50 to 100,000 163 11.9[10.2-13.7]
Above 100,000 88 6.4[5.2-7.8]
Type of family Joint 459 33.5[31.0-36.0]
Nuclear 912 66.5[64.0-69.0]
Place of Residence Rural 319 23.3[21.1-25.6]
Urban 1052 76.7[74.4-78.9]
Total 1371 100.0
Source: Online primary survey
 medRxiv preprint doi: https://doi.org/10.1101/2021.02.10.21251460; this version posted February 12, 2021. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY 4.0 International license .

Table 2: Obstetric and gynecological related characteristics of College girls in Lucknow, Uttar Pradesh,
India 2020 (n = 1371)

Variables Subgroup n Percentage(95%CI)

Age of Menarche <12 Years 197 14.4[12.6-16.3]
12-15 Years 792 57.8[55.1-60.4]
>15 Years 266 19.4[17.3-21.6]
Don’t Know 116 8.5[7.0-10.1]
Duration of menses flow <3 days 249 18.2[16.2-20.3]
3-5 days 751 54.8[52.1-57.4]
>5 days 371 27.1[24.7-29.5]
Symptom during menstruation Acne 234 17.1[15.1-19.2]
Vomiting 141 10.3[8.70-12.0]
Diarrhoea 73 5.3[4.20-6.60]
Insomnia 125 9.1[7.60-10.80]
Breast pain 97 7.1[5.80-8.60]
Bloating 132 9.6[8.10-11.30]
Anorexia 333 24.3[22.0-26.60]
Irritability 563 41.1[38.40-43.70]
Backpain 692 50.5[47.8-53.2]
Constipation 108 7.9[6.50-9.40]
Headache 233 17.0[1.50-19.1]
Weakness 647 47.2[44.5-49.9]
Abdominal pain 918 67.0[64.4-69.4]
At least one 1371 100.0
Source: Online primary survey
 medRxiv preprint doi: https://doi.org/10.1101/2021.02.10.21251460; this version posted February 12, 2021. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY 4.0 International license .
Table 3: Awareness of menstruation of College girls in Lucknow, Uttar Pradesh, India 2020 (n = 1371)

Variable Subgroups n Percentage

Awareness about menstruation before it started No 745 54.3
Yes 626 45.7
First source of information on menstruation Teacher 252 18.4
Sister 225 16.4
Mother 949 69.2
Media 104 7.6
Health
personal 31 2.3
Friend 271 19.8
Father 7 0.5
Reaction on seeing blood flow from your genitals the first
time Confusion 184 13.4
Discomfort 420 30.6
fear and panic 410 29.9
Happiness 50 3.6
Shyness 91 6.6
Surprise 216 15.8
First person you discussed your menstruation with Father 3 0.2
Friends 104 7.6
Mothers 970 70.8
Nobody 49 3.6
Other
Relatives 24 1.8
Sister 167 12.2
Teacher 54 3.9
First discussed your menarche was able to educate you
enough on menstruation No 235 17.1
Yes 1136 82.9
Source: Online primary survey
 medRxiv preprint doi: https://doi.org/10.1101/2021.02.10.21251460; this version posted February 12, 2021. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY 4.0 International license .

Table 4: Knowledge among college girls on menstruation in Lucknow, Uttar Pradesh, India 2020 (n = 1371)

Variable Knowledge n % Scores

What is the menstrual cycle
Impure blood flows out Wrong 871 63.5 0
Physiological and natural process Correct 431 31.4 1
Some disease Wrong 8 0.6 0
Curse of god Wrong 9 0.7 0
Don’t know Wrong 52 3.8 0
What is the normal age of menarche
<10 Wrong 48 3.5 0
10-13 Correct 867 63.2 1
>13 Wrong 456 33.3 0
Organ of menstruation
Bladder Wrong 315 23 0
Don’t know Wrong 109 8 0
Other Wrong 19 1.4 0
Stomach Wrong 37 2.7 0
Uterus Correct 891 65 1
What is the normal duration of the menstrual cycle
25-30 Correct 885 64.6 1
Else Wrong 486 35.4 0
 medRxiv preprint doi: https://doi.org/10.1101/2021.02.10.21251460; this version posted February 12, 2021. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY 4.0 International license .
Table 5: Menstrual hygiene practices of College girls in Lucknow, Uttar Pradesh, India 2020 (n = 1371)

Variable Subgroups N Percentage Scores

Sanitary material used in first year of Menstruation Sanitary pads 1168 85.2 NA
Reusable cloth 207 15.1
Toilet tissue 33 2.4
Other 43 3.1
Current sanitary material Sanitary Pad 1292 94.2 1
Other 79 5.8 0
Number of Sanitary pads used per day Mean(±SD) 1371 2.91(±1.10) 1 if ≥4
Cleaning genitals after urinating during mensuration No 125 9.1 0
Yes 1246 90.9 1
Types of pads wrap used for disposing of it Papers 957 69.8 2
Plastic bag 398 29.0 1
Not wrap 16 1.2 0
Place at where pad was disposed Drain 13 0.9 0
Toilet 35 2.6 0
Open field 19 1.4 0
Dumped 91 6.6 1
Dustbin 1260 91.9 1
Absent at least one day to college during menstruation Yes 123 9.0 NA
No 1248 91.0
Used any medication for menstrual problems No 1112 81.1 NA
Yes 259 18.9
Bath during menstruation Daily 1161 84.7 1
First day 16 1.2 0
Second day 149 10.9 0
Not take any time 45 3.3 0
Total 1371 100
Source: Online primary survey
Table 6: Predictors of good knowledge related to menstruation of College girls in Lucknow, Uttar Pradesh, India 2020 (n = 1371)

Variable Subgroup Poor Good n Test, p value COR (95%CI) AOR (95% CI)
Course of the Commerce and χ =57.58, <0.01**
2

study Management 462(59.7) 312(40.3) 774 Reference category Reference category

Humanities 280(60.9) 180(39.1) 460 0.825(0.436-1.564) 1.086(0.554-2.13)
Medicine and Allied 20(20.6) 77(79.4) 97 0.786(0.410-1.506) 1.049(0.529-2.078)
Science and Technology 22(55.0) 18(45.0) 40 4.706(2.128-10.407) ** 5.17(2.274-11.752) **
Grade Graduation 686(57.0) 517(43.0) 1203 χ2=0.103,0.74 NA NA
Post-Graduation 98(58.3) 70(41.7) 168
Age <19 345(61.4) 217(38.6) 562 χ2=6.96,0.03* Reference category Reference category
20-22 368(54.0) 313(46.0) 681 0.783(0.532-1.155) 1.14(0.749-1.735)
23+ 71(55.5) 57(44.5) 128 1.059(0.725-1.549) 1.265(0.843-1.897)
Caste General 451(58.8) 316(41.2) 767 χ2=2.25, 0.32 NA NA
OBC 252(54.4) 211(45.6) 463
SC/ST 81(57.4) 60(42.6) 141
Religion Hindu 671(57.3) 501(42.7) 1172 χ2=2.61,0.27 NA NA
Muslim 87(54.0) 74(46.0) 161
Other 26(68.4) 12(31.6) 38
Father education School 418(62.5) 251(37.5) 669 χ2=23.45,<0.01** Reference category Reference category
Graduate 263(56.0) 207(44.0) 470 0.479(0.354-0.649) ** 0.634(0.426-0.944) *
PG and above 103(44.4) 129(55.6) 232 0.628(0.458-0.863) ** 0.695(0.482-1.002)
Mother education School 504(61.1) 321(38.9) 825 χ2=13.50,<0.01** Reference category Reference category
Graduate 201(52.3) 183(47.7) 384 0.606(0.432-0.850) ** 1.141(0.729-1.786)
PG and above 79(48.8) 83(51.2) 162 0.867(0.600-1.251) 1.24(0.804-1.913)
Father occupation Farmer 77(56.2) 60(43.8) 137 χ2=12.85,0.01* Reference category Reference category
Government employee 143(50.4) 141(49.6) 284 0.962(0.623-1.483) 1.227(0.772-1.95)
Self-Employed /
Businessman 219(57.2) 164(42.8) 383 1.217(0.851-1.740) 0.945(0.634-1.409)
Private Org. employee 229(64.1) 128(35.9) 357 0.924(0.658-1.297) 0.878(0.611-1.261)
Other 116(55.2) 94(44.8) 210 0.690(0.487-0.976) * 0.671(0.466-0.967) *
Mother occupation Housewife 702(58.9) 489(41.1) 1191 χ2=11.44,0.01* Reference category Reference category
Working 82(45.6) 98(54.4) 180 0.583(0.425-0.799) ** 0.777(0.54-1.117)
 Monthly Income χ2=26.21, <0.01**
<25,000
(INR) 506(62.5) 303(37.5) 809 Reference category Reference category
25 to 50,000 154(49.5) 157(50.5) 311 0.788(0.505-1.230) 1.342(0.800-2.251)
50 to 100,000 74(45.4) 89(54.6) 163 1.341(0.833-2.161) 1.804(1.067-3.049) *
Above 100,000 50(56.8) 38(43.2) 88 1.583(0.938-2.668) 1.688(0.957-2.978)
Type of family Joint 287(62.5) 172(37.5) 459 χ2=8.04,0.01* Reference category Reference category
Nuclear 497(54.5) 415(45.5) 912 0.718(0.570-0.903) ** 0.765(0.600-0.975) *
Place of Residence Rural 209(65.5) 110(34.5) 319 χ =11.79,0.01*
2
Reference category Reference category
Urban 575(54.7) 477(45.3) 1052 0.634(0.489-0.824) ** 0.701(0.527-0.933) *
Total 784(57.20) 587(42.80) 1371
COR Crude Odds Ratio, AOR Adjusted Odds Ratio, *P-value < 0.05, **P < 0.01; Source: Online primary survey
Table 7: Predictors of good menstrual hygiene practices among College girls in Lucknow, Uttar Pradesh, India 2020 (n = 1371)

Variable Subgroup Poor Good n Test, p value COR (95%CI) AOR (95%CI)
Course of the study Commerce and Management 152(19.6) 622(80.4) 774 χ =14.23,0.003*
2
Reference category Reference category
Humanities 126(27.4) 334(72.6) 460 1.18(0.554-2.548) 0.996(0.426-2.332)
Medicine and Allied 31(32.0) 66(68.0) 97 0.77(0.356-1.662) 0.705(0.299-1.661)
Science and Technology 9(22.5) 31(77.5) 40 0.618(0.263-1.45) 0.661(0.258-1.698)
Grade Graduation 288(23.9) 915(76.1) 1203 χ2=3.06,0.08 NA NA
Post-Graduation 30(17.9) 138(82.1) 168
Age <19 138(24.6) 424(75.4) 562 χ2=1.11,0.57 NA NA
20-22 150(22.0) 531(78.0) 681
23+ 30(23.4) 98(76.6) 128
Caste General 182(23.7) 585(76.3) 767 χ2=3.39,0.18 NA NA
OBC 112(24.2) 351(75.8) 463
SC/ST 24(17.0) 117(83.0) 141
Religion Hindu 233(19.9) 939(80.1) 1172 χ2=72.81, <0.01** Reference category Reference category
Muslim 80(49.7) 81(50.3) 161 0.611(0.236-1.581) 0.637(0.243-1.67)
Other 5(13.2) 33(86.8) 38 0.153(0.057-0.413) 0.144(0.052-0.399) **
Father education School 173(25.9) 496(74.1) 669 χ2=5.76,0.05 NA NA
Graduate 101(21.5) 369(78.5) 470
PG and above 44(19.0) 188(81.0) 232
Mother education School 208(25.2) 617(74.8) 825 χ2=5.07,0.07 NA NA
 Graduate 80(20.8) 304(79.2) 384
PG and above 30(18.5) 132(81.5) 162
Father occupation Farmer 35(25.5) 102(74.5) 137 χ2=4.15,0.38 NA NA
Government employee 60(21.1) 224(78.9) 284
Self-Employed/Businessman 100(26.1) 283(73.9) 383
Private Org. employee 74(20.7) 283(79.3) 357
Other 49(23.3) 161(76.7) 210
Mother occupation Housewife 294(24.7) 897(75.3) 1191 χ2=11.31,0.001* Reference category Reference category
Working 24(13.3) 156(86.7) 180 0.47(0.299-0.736) ** 0.49(0.304-0.791)**
Monthly Income (INR) <25,000 209(25.8) 600(74.2) 809 χ2=8.52,0.03* Reference category Reference category
25 to 50,000 61(19.6) 250(80.4) 311 0.543(0.300-0.982) * 0.415(0.216-0.795)**
50 to 100,000 34(20.9) 129(79.1) 163 0.775(0.410-1.465) 0.534(0.269-1.058)
Above 100,000 14(15.9) 74(84.1) 88 0.718(0.362-1.424) 0.537(0.258-1.114)
Type of family Joint 127(27.7) 332(72.3) 459 χ2=7.75,0.005* Reference category Reference category
Nuclear 191(20.9) 721(79.1) 912 0.69(0.534-0.898) ** 0.675(0.513-0.889)**
Place of Residence Rural 92(28.8) 227(71.2) 319 χ2=7.43,0.006* Reference category Reference category
Urban 226(21.5) 826(78.5) 1052 0.67(0.508-0.896) ** 0.757(0.557-1.027)
Total 318(23.2) 1053(76.8) 1371
COR Crude Odds Ratio, AOR Adjusted Odds Ratio, *P-value < 0.05, **P < 0.01; Source: Online primary survey