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Scientific Reports volume 14, Article number: 22062 (2024 ) Cite this article Sap
The predominant use of disposable, non-organic menstrual products has significant environmental impacts due to waste and resource depletion. Concerns over the environmental, economic, and health implications of menstrual hygiene management (MHM) have highlighted the need to explore sustainable options like reusable sanitary pads (RSPs). Despite their benefits, the adoption of RSPs is limited by a lack of awareness, availability, cost, and research. This study emphasizes the need for the development of an instrument that can capture the effectiveness, safety, and user satisfaction of RSPs, addressing a significant gap in the literature. Using a convenient sampling method, data were collected through a structured offline survey and the sample comprised 446 South Asian women of reproductive age. The instrument included 15 items designed to measure factors such as comfort, hygiene, convenience, and environmental consciousness. The instrument’s reliability and validity are thoroughly assessed using reliability and factor analysis to ensure its effectiveness in capturing the multifaceted dimensions of MHM product choices. The study revealed that the overwhelming majority of women would prefer the option of RSPs that are comfortable, accessible, and easy to use and dispose of. The findings aim to provide a validated tool for manufacturers, policymakers, and researchers to evaluate reusable pads, promoting their broader acceptance and adoption of a sustainable and equitable approach to menstrual hygiene.
The choice of products chosen for menstrual hygiene management (MHM) has significant environmental, economic, and health implications1,2. Disposable non-organic products have been the majority choice of menstruators worldwide. With innovations such as quilting of lining, wings, adding of fragrance, reduced thickness coupled with aggressive advertising and streamlined production methods, the multi-billion-dollar feminine hygiene industry focused on enhanced design and comfort to appeal to women3. Unfortunately, the environmental footprint of disposable sanitary products is considerable, encompassing high levels of waste generation and resource consumption4. Landfills around the world are burdened with billions of disposable pads and tampons annually, contributing to environmental pollution and resource depletion5.
At the other end of the spectrum, women living in rural and bottom of (income) pyramid environments, which account for a quarter of the world’s menstruators suffer from the lack of access to adequate menstrual health resources6. Literature also suggests that rural women face challenges due to misinformation, lack of awareness, and inadequate menstrual hygiene practices7,8. Economic barriers significantly influence menstrual hygiene practices, particularly in low-income regions9. The recurring cost of disposable sanitary products poses a financial burden for many, leading to compromised menstrual hygiene and associated health risks such as the use of unhygienic materials or rags10. Government subsidies and free distribution of disposable pads help lessen the financial burden, but their quality and potential health impact and/or environmental impact are questionable. Health and hygiene are paramount in the context of menstrual hygiene products. Concerns have been raised regarding the chemical composition of disposables and their association with health risks such as Toxic Shock Syndrome, allergies, and infections11.
Menstrual hygiene is deeply entwined with social and cultural norms, which can influence the acceptability and usage of menstrual products. In many cultures, menstruation is stigmatized, and discussing or managing it openly is discouraged. This stigma can lead to inadequate access to and use of menstrual hygiene products, exacerbating the challenges faced by women in these communities. While menstrual cups have also been a sustainable alternative, their intrusive nature causes discomfort and is culturally unacceptable (or averse) in rural communities. The shift towards sustainable menstrual products, such as reusable sanitary pads (RSPs), has emerged as a promising solution to address these multifaceted issues12,13.
RSPs, by virtue of their longevity, offer a cost-effective solution. Such products also present a more acceptable alternative, promising to significantly reduce menstrual waste and conserve resources14. Peberdy et al.15 delve into the public’s awareness of the environmental impact of menstrual products and how this awareness influences their choice of products. The research uncovers a spectrum of awareness levels among the public and concludes how a higher degree of environmental awareness tends to lead to a preference for sustainable menstrual options. However, the transition to these eco-friendly alternatives is often hindered by factors like availability, cost, cultural norms, and a general lack of information. Highlighting the urgent environmental concerns associated with conventional menstrual products, the authors call for enhanced educational efforts and policy reforms to promote the use of sustainable menstrual products. They argue that with adequate information and access to sustainable options, individuals can make environmentally conscious choices without compromising on the quality or convenience of MHM. Recent evidence that indicates women are increasingly returning to the traditional practice of using materials that can be laundered and re-used is encouraging.
Despite the growing interest in RSPs, there is a notable gap in the literature regarding their comprehensive validation. The difficulty for stakeholders in the reusable product market who want to popularize reusable products and meet the demand is that there is a paucity of scientific research on the acceptability of these interventions among users16. The study by Van Eijk et al.17 provides a global perspective on reusable menstrual pads through a systematic review and meta-analysis, covering 44 studies across 20 countries that included high-income and low- and middle-income countries. It delved into the effectiveness, safety, and user experiences of these pads, highlighting their potential advantages. However, the authors point out a significant concern regarding the generally poor quality of the studies reviewed, emphasizing the urgent need for more rigorous research in this field. Thus, the lack of validated research instruments to assess reusable products’ overall acceptance limits the ability to conduct high-quality studies and quantify and communicate their benefits effectively. Poor quality studies defer and slow the proliferation of sustainable options.
Angeli et al.18 discuss the integration of poverty alleviation and environmental protection through a socio-ecological perspective on menstrual health management. It highlights the crucial role of menstrual health management for low-income women and its environmental implications. They discuss the need to capture their preferences towards menstrual products, emphasizing the importance of biodegradability and socio-economic and cultural factors in their choices. The findings suggest that environmentally friendly and culturally sensitive business models could synergize poverty alleviation and environmental conservation efforts. This gap highlights the urgent need for a validated instrument capable of assessing these multifaceted dimensions to support the evidence-based promotion of RSPs.
A generic reusable menstrual product survey instrument serves some pivotal purposes. Incorporating aspects such as preferences, usability challenges, feasibility in different environments, resource constraints, and disposal of RSPs into a generalized questionnaire for reusable and/or biodegradable menstrual products is crucial for several reasons. Firstly, capturing user preferences is essential for product design and acceptance. As highlighted by Sommer et al.19, menstrual products must align with the cultural, personal, and socio-economic contexts of users. Preferences can vary widely, influenced by factors like comfort, discreetness, and individual menstrual flow. A questionnaire that assesses these preferences can guide manufacturers in creating products that are more likely to be accepted and used regularly. Secondly, understanding usability challenges is critical for ensuring practicality and adherence. As noted by Hennegan and Montgomery20, challenges such as difficulty in cleaning, drying, or changing products can significantly impact the usability of menstrual products. Exploring these challenges to identify potential areas for improvement and ensuring that products are not only environmentally friendly but also user-friendly is important. Thirdly, assessing the feasibility of use in different environments is vital. Menstrual hygiene practices vary greatly depending on factors like climate, water availability, and living conditions. For instance, in water-scarce regions, washing and maintaining reusable products can be challenging. Capturing the environmental and infrastructural constraints that users face, as emphasized by Phillips-Howard et al.21, is beneficial. Fourthly, resource constraints, particularly regarding the quality and quantity of water, are crucial considerations. The availability and accessibility of clean water are essential for the hygienic use of menstrual products, as discussed by Jadhav et al.22. Finally, the disposal of products is a key component of menstrual product use, especially for biodegradable options. As per the findings of Van Eijk et al.23, the environmental impact of menstrual products is not limited to their production but also their disposal23. A comprehensive instrument should, therefore, include questions about disposal practices and facilities, which are critical for the environmental sustainability of these products.
The proposed study aims to develop and validate an instrument grounded in the theory of planned behavior (TPB) to comprehensively assess the effectiveness, safety, user satisfaction, and overall impact of RSPs. The TPB is a widely used framework for understanding and predicting human behavior24,25,– 26. To guide this assessment, the study will address the following research questions: How does users’ environmental consciousness affect their attitudes toward using RSPs? What is the impact of the perceived cost-effectiveness of RSPs on users’ satisfaction with the product? To what extent does social influence affect users’ willingness to adopt RSPs? The validation of RSPs through a reliable instrument is crucial to ensuring their effectiveness, safety, and feasibility while capturing a comprehensive set of factors that include comfort, hygiene, convenience, environmental consciousness, and economic viability. This research will pave the way for the broader acceptance and adoption of reusable alternatives as a more sustainable and equitable approach to menstrual hygiene. This instrument will also serve as a vital tool for manufacturers, health professionals, policymakers, and researchers, facilitating the systematic evaluation of reusable pads against established standards. By ensuring that RSPs meet the criteria specified by women, the study will contribute significantly to advancing sustainable menstrual hygiene practices, enhancing public health outcomes, and supporting environmental conservation efforts.
The study utilized a convenient sampling method and included 446 participants from India and Nepal with an age range of 10-50 years. The participants were randomly identified through an NGO working on the MHM. A pre-condition to be included in the study was a minimum requirement of four months of RSP usage by each participant. In this study, all environmentally friendly sanitary pads are referred to as RSPs. The largest subgroup consists of students, comprising 38.60% of the sample, indicating the inclusion of a substantial number of individuals still pursuing formal education. Furthermore, the presence of homemakers/unemployed individuals (33%) suggests economic diversity within the study population. Notably, a notable proportion of participants are classified as professional workers (19.70%), reflecting the presence of individuals with specialized skills and higher socioeconomic status. In terms of marital status, 211 (47.30%) participants were unmarried, and 235 (52.70%) were married. Participants shared that the average monthly cost of disposable pads they used ranged between $0.60 and $1.80. Previous research suggests that personal characteristics such as age, occupation, and marital status have a direct influence on consumer behavior27. The sample size was determined for this scale validation study on the attitude towards the use of RSPs, taking into account a 95% confidence interval and 5% margin of error28. Given the variability in the prevalence of reusable menstrual materials as indicated by previous studies29,29,31, the sample size of 446 appears adequate to capture this variability and provide reliable insights into the attitude towards the use of RSPs.
Factors influencing women’s attitudes towards the use of RSPs.
In crafting our scale to gauge users’ attitudes toward RSPs, we have carefully selected key factors to delve into their preferences, challenges faced, available resources, and economic considerations (Fig. 1). Each item was chosen to shed light on different aspects influencing attitudes towards RSPs.
Secondly, the challenges delve into the difficulties users face while using RSPs. It also includes challenges in water availability, distance to the water source, the quality of water, issues faced in the early stages (during the first 4 months) of using RSPs, and challenges they experience after 4 months of using RSPs. Challenges in water availability refer to the obstacles users may encounter due to limited access to water, which is essential for washing and maintaining RSPs. The distance to a water source refers to the proximity of the water source. Water scarcity can hinder proper cleaning and hygiene practices, impacting the usability of RSPs32. The quality of water used for washing RSPs is crucial for maintaining hygiene. Poor water quality can lead to ineffective cleaning, potentially causing health issues for users33. Ensuring access to clean and safe water is essential for the proper maintenance of RSPs. Challenges faced in the early stages (during the first 4 months) of using RSPs referees the user’s experience in the initial use of RSPs. Users may experience initial challenges when transitioning to RSPs, such as adapting to a new hygiene routine, learning proper care and maintenance practices, and adjusting to the comfort and fit of the pads. These early-stage challenges are common as users familiarize themselves with using RSPs. Finally, the challenges they experience after 4 months of using RSPs refer to the challenges after using an extended period. After using RSPs for an extended period, users may encounter issues such as wear and tear of the pads, reduced absorbency over time, changes in comfort levels, or concerns related to hygiene and odor control. Addressing these challenges is important to ensure continued user satisfaction and comfort with RSPs. By identifying these challenges, the product manufacturers and researchers can work towards solutions that make the use of RSPs more feasible and comfortable.
Thirdly, resources such as reliable water sources, soap, and bathroom facilities at their workplace, school, or home were included in our survey instrument. These factors are crucial determinants of the feasibility and ease of using RSPs. Assessing their availability provides context for understanding users’ experiences and the potential constraints they face. These factors are also crucial in determining the practicality of using RSPs. Availability of reliable water sources refers to having consistent access to a dependable water supply that is essential for various purposes, such as washing RSPs. It involves ensuring a steady and predictable flow of water. Additionally, the availability of bathroom and soap is necessary for changing and washing RSPs, especially at the workplace or school. This ensures the proper hygiene and usability of RSPs.
Ease of cleaning, washing or drying represents the various aspects of maintenance of RSPs. The easiness of cleaning RSPs can depend on factors such as the material of the pad, the level of absorbency, and the presence of any stains or odors. The easiness of drying refers to the ease with which RSPs can be dried after washing. Proper drying is essential for maintaining the hygiene and usability of RSPs. Just as with cleaning/washing, drying of RSPs also depends on factors such as the material of the pad and the availability of sunlight or other drying facilities.
Disposal of RSPs and user awareness of the menstrual waste impact represents the environmental consciousness of users. Disposal refers to the proper and responsible disposal of RSPs after their useful life has ended. RSPs are reusable and can last for several years, but eventually, they will need to be disposed of. Proper disposal of RSPs and awareness of waste impact can help minimize the environmental impact of menstrual waste.
Lastly, economic factors, including subsidies for RSPs, were also deemed essential for capturing users’ attitudes toward RSPs. Government policies and subsidies can significantly impact the affordability and accessibility of RSPs, influencing user perceptions and adoption rates. Additionally, understanding the cost dynamics of RSPs provides insights into users’ economic considerations and decision-making processes. While the initial cost of RSPs might be higher than disposable pads, they can be used multiple times, spreading the cost over a longer period and offering significant long-term savings. Additionally, RSPs are more environmentally friendly than disposable pads, leading to indirect economic benefits such as reduced waste management costs and environmental damage.
Data for this study were collected through a structured survey form, which included demographic details and a questionnaire specifically developed for this research. The survey was distributed and completed in collaboration with an NGO that works on MHM. The data collection took place from January to March 2024. The NGO facilitated the in-person administration of the survey to ensure reliable data collection and engagement with participants. The study utilized IBM SPSS Statistics (Version 29) and AMOS 29 Graphics for comprehensive data analysis, employing various statistical techniques to explore and validate a theoretical model. Key analyses included descriptive statistics, reliability analysis, correlation analysis with a 99% confidence interval (CI), exploratory factor analysis (EFA), regression analysis, and confirmatory factor analysis (CFA). A 95% CI was used for analyses other than correlation.
The reliability analysis of the scale reveals insightful trends regarding the internal consistency of the measurement instrument. The Cronbach’s alpha (\(\alpha\) ) coefficient was used to assess the internal consistency of the scale in this study. According to the literature, the items that were deleted in the reliability analysis of the scale were those that, when removed, led to an increase in the \(\alpha\) coefficient, indicating an improvement in the internal consistency of the scale34. As shown in Table 1, the scale initially consisted of 20 items. However, as the analysis progressed through different steps (steps 1 to 6), certain items were found to compromise the overall reliability of the scale. Table 1 presents the \(\alpha\) coefficient for each item if it were deleted from the scale at different stages of the analysis. The higher the coefficient, the more reliable the item is in measuring the construct of interest. The analysis shows that the reliability of the scale improved as items were deleted. At step 1, the \(\alpha\) coefficient for the total scale was 0.681, indicating low internal consistency35. However, as items were deleted, the coefficient increased to 0.695 in step 2, 0.705 in step 3, 0.715 in step 4, 0.723 in step 5, and 0.730 in step 6. At step 6, the scale consisted of only 15 items (all items having above 0.2 item-score correlation) but having the highest reliability (\(\alpha\) = 0.730).
Items such as “Type of material usually used”, “Usage pattern”, “Distance to the water source”, “Social influence on migration to RSPs”, and “Awareness of menstrual waste impact” were eliminated at deletion steps, indicating lower reliability and potentially weaker associations (item-score correlation < 0.2) with the underlying construct being measured. These items may have lacked clarity, failed to capture relevant nuances, or overlapped with other measures in the scale, leading to their exclusion. The items on the final scale were labeled in ascending order from Q1 to Q15 for ease of administration and interpretation. The English version of the final 15-item scale is tabulated in Table 2.
Descriptive statistics play a pivotal role in survey data analysis by facilitating the organization, simplification, and summarizing of information. The Table 3 provides an overview of the descriptive statistics derived from a survey. It includes several components, items, and measures such as mean (M), standard deviation (SD), skewness, and kurtosis, as well as correlations with the overall score and subscale. The statistical analysis provides insights into the distribution and interconnections among the survey items within each component. The findings suggest that most items have a normal distribution, but their correlations with the attitude and subscale differ between factors. Factor 1 comprises five items (or questions), specifically Q1, Q2, Q3, Q4, and Q5, each with a mean value that falls between the range of 2.619 to 4.444 and the SD ranges from 0.496 to 1.078. Skewness values are close to zero, which suggests that the distribution of scores is symmetrical around the mean. Kurtosis values range from \(-1.958\) to 1.057, suggesting that the distributions have varying degrees of peakedness or flatness compared to a normal distribution. Overall, this factor seems to represent positive attitudes towards something. Factor 2 has five other items, from Q6 to Q10, each with a mean value of 1.883 and 4.426. SDs vary widely, ranging from 0.397 to 1.319, indicating significant variability in responses. Skewness values suggest asymmetrical distributions, while kurtosis values range from \(-1.918\) to 0.387, indicating that the distributions differ significantly from a normal distribution. Factor 3 has two items, Q11 and Q12, with both items having very similar mean scores (4.058 and 4.083, respectively), indicating strong agreement with their respective statements. The SD range spans from 0.235 to 0.276, showing little variance in responses. Skewness values are quite large, suggesting highly non-normal distributions. Kurtosis values are also extremely high, further supporting the idea of extreme peaks or valleys in the distributions. Similar to Factor 3, both items in Factor 4 have very similar mean scores (4.202 and 4.224), indicating strong agreement with their respective statements. SDs are again low (0.402 and 0.418), showing little variance in responses. Skewness values are moderately large, suggesting somewhat non-normal distributions. Kurtosis values are slightly lower than those in Factor 3, indicating less pronounced peaks or valleys in the distributions.
The Pearson correlation (r) method was employed to do a correlation study and investigate the association between each item on the scale, the attitude to use, and its subscales (Table 3). The correlation coefficients range from 0.105 to 0.451, indicating that some items are more strongly related to the attitude to use than others. The correlation coefficients among the items with their subscales also show statistically significant values for all the subscales (Factor 1, 2, 3, and 4). The r value varies from 0.789-0.943 in Factor 1, 0.807–0.927 in Factor 2, 0.948–0.963 in Factor 3, and 0.906–0.913 in Factor 4. All the correlation values are positive and statistically significant at \(p<0.01\) .
The reliability of the scale can be assessed using various coefficients, such as Cronbach’s Alpha (\(\alpha\) ), item-total correlation, Spearman-Brown coefficient, and Guttman Split-half coefficient. Table 3 shows that the \(\alpha\) for each subscale ranges from 0.790 to 0.899 (F1: 0.879, F2: 0.866, F3: 0.899, F3: 0.790), which is generally considered a good value for reliability. The Spearman-Brown coefficient (0.733) and Guttman Split-half coefficient (0.732) also indicate good reliability for the scale36. In the item-total correlation, item Q8 has a correlation of 0.504 with the total score, indicating a stronger relationship between Q8 (reliable water source) with the total score. Each item measured on the scale showed a correlation exceeding 0.2, suggesting good discrimination. Overall, the reliability analysis shows that the scale has a good internal consistency reliability, suggesting that the scale is consistent and reliable in measuring the construct of interest.
An exploratory factor analysis (EFA) was performed on the whole dataset of 446 participants to investigate the data’s structure and identify any underlying patterns or links among the variables. The Kaiser–Meyer–Olkin (KMO) sample adequacy test was utilized to assess the scale’s appropriateness for factor analysis. The KMO value obtained was 0.740, indicating that the scale is suitable for factor analysis37. The scree plot (Fig. 2), displaying the eigenvalues of each factor, verified that four factors had eigenvalues \(> 1\) , signifying their importance. All items under each of the four variables had factor loadings over 0.50 (\(p<\) 0.01), indicating a strong association. The four factors collectively accounted for 81.351% of the variance. Convergent validity is an important aspect of scale development, as it assesses how well the scale measures the intended construct by comparing it to other measures or indicators of the same construct38. In this analysis, the Average Variance Extracted (AVE) represents the proportion of variance in the observed scores that is due to the latent variable being measured. The Composite Reliability (CR), on the other hand, is a measure of the consistency of the scale, taking into account the correlations between the latent variables and the observed scores. Table 4 shows that the AVE values calculated using the factor loading values identified in EFA are relatively high (\(> 0.50\) ) for all factors (Factor 1: 0.757; Factor 2: 0.711; Factor 3: 0.864; Factor 4: 0.802), indicating that a significant proportion of the variance in the observed scores is due to the latent variable being measured. The CR values also indicate high consistency (\(> 0.70\) ) for the scale and its items (Factor 1: 0.939; Factor 2: 0.924; Factor 3: 0.927; Factor 4: 0.890), suggesting that the scale measures the intended construct consistently and reliably36,39. Overall, the convergent validity analysis results demonstrate that the scale has a good ability to measure the intended construct by comparing it to other measures or indicators of the same construct. The high AVE and CR values indicate that the scale is consistent and reliable in measuring the construct of interest.
Four-factor model. Latent variables are represented by ellipses; measured variables are represented by rectangles; and error is represented by circles.
The construct validity of the four-factor model was confirmed using confirmatory factor analysis (CFA). The analysis results suggest that the four-factor model provides a good fit to the data based on the \(\chi ^2\) value (\(\chi ^2\) = 162.124; Degrees of freedom, df = 58) and probability level (\(p<0.05\) ). Table 5 presents the model fit indices for the given model, and these fit indices help assess the quality of the model. The fit indices are used to assess how well the proposed theoretical model fits the observed data. The CFI (Comparative Fit Index) and NFI (Normed Fit Index) are relative fit indices that compare the \(\chi ^2\) for the model tested to one from a null model. Both indices have values that range between approximately 0 and 1.0, with higher values indicating a better fit36,39. The RMSEA (Root Mean Square Error of Approximation) is another fit index that measures the average difference between the observed and model-implied values. It is generally considered acceptable if it is less than 0.0836,39.
The CFA supports the EFA results that each question has a positive coefficient estimate, indicating a positive relationship with Factor 1 (Q1 to Q5), Factor 2 (Q6 to Q10), Factor 3 (Q11 and Q12), and Factor 4 (Q13 and Q14) (Fig. 3). All coefficient estimates are statistically significant at the 0.05 significance level. The analysis also suggests that apart from their individual influences on specific questions, Factors 1 (comfort & practicality), 2 (hygiene & acceptability), 3 (convenience & usage), and 4 (sanitation facilities) also collectively contribute to shaping overall attitudes. The CFA analysis results demonstrate significant positive relationships between each factor and Attitude, with standardized regression weights ranging from 0.091 to 0.595. Q1 is significantly positively correlated with Factor 1 (Estimate: 0.981, \(p<0.05\) ), whereas Q5 also shows a positive correlation with Factor 1 but with a lower coefficient (Estimate: 0.610, \(p<0.05\) ). For Factor 2, Q7 shows a strong connection (Estimate: 1.066, \(p<0.05\) ), whereas Q10 shows a comparatively lower correlation (Estimate: 0.712, \(p<0.05\) ). Factor 3 and Factor 4 show greater correlations with Q11 (Estimate: 1.019, \(p<0.05\) ) and Q14 (Estimate: 0.927, \(p<0.05\) ), respectively.
The mediating role of age, occupation, and the marital status of the participants was analyzed using linear regression analysis (Table 6). The variables included in the model are the attitude to the use of RSPs and the interaction of age, occupation, and marital status of participants with their attitude to use. The constant term in the regression model indicates the predicted value of the dependent variable (usage of RSPs) when all independent variables are zero. In this case, it is 1.250, with a standard error of 0.153, indicating that this estimate is statistically significant (t = 8.183, \(p<\) 0.001). The main focus of the analysis is on the attitude toward the actual use of RSPs. The coefficient (B) for attitude to use is 0.484, with a standard error of 0.040. The beta coefficient (\(\beta\) ) of 0.515 suggests a positive relationship between attitude to use and the usage of RSPs. This relationship is statistically significant (t = 11.966, \(p<\) 0.001), indicating that individuals with a more positive attitude towards using RSPs are more likely to use them. The interaction terms between attitude to use and demographic variables (age, occupation, and marital status) are also examined to determine if these factors moderate the relationship between attitude to use and usage of RSPs. The interaction term “Attitude to use X Age” has a \(\beta\) coefficient of -0.038. However, this coefficient is not statistically significant (t = -1.019, p = 0.309), suggesting that age does not significantly moderate the relationship between attitude to use and usage of RSPs. Similarly, the interaction term “Attitude to use X Occupation” has a coefficient of -0.007 with a standard error of 0.003. The negative \(\beta\) coefficient of -0.104 suggests that certain occupations moderate the relationship between attitude to use and the usage of RSPs. This relationship is statistically significant (t = -2.814, \(p<\) 0.005), indicating that the effect of attitude on the usage of RSPs varies depending on the individual’s occupation. Finally, the interaction term between attitude and marital status (“Attitude to use X Marital status”) is significant (\(p<\) 0.001), suggesting that the association between attitude and usage differs depending on marital status. The impact of attitude on usage varies significantly based on occupation, and marital status, suggesting the importance of considering these demographic factors in promoting the adoption of RSPs.
Developing a new instrument scale for measuring users’ attitudes towards RSPs is important for several reasons: (1) understanding user attitudes: it can help understand the attitudes of users towards RSPs, which can provide insights into their acceptance and potential use40,41. (2) Guiding interventions: the findings can guide interventions aimed at promoting the use of RSPs by addressing the concerns and misconceptions of users40. (3) Improving products: it can help manufacturers improve their products based on user feedback and preferences40. (4) Environmental impact: understanding attitudes towards RSPs can also have implications for environmental sustainability, as these products are often more eco-friendly than disposable alternatives41. Literature indicates that TPB is instrumental in examining the behavioral tendencies of women regarding the adoption of feminine hygiene products, particularly from the perspective of gynecologists25. By integrating consumer behavior theories with advanced technology, researchers can gain deeper insights into women’s habits and attitudes, which are essential for effective product development42. Notably, a study utilizing TPB found that attitude significantly influences consumer intentions highlighting how attitudes can mediate the effects of perceived health and sustainability benefits43. This underscores the importance of TPB in guiding the development and marketing of menstrual hygiene products that resonate with women’s values and preferences.
The study analysis provides insights into the distribution and interconnections among the survey items within each component. The findings suggest that most items have a nonnormal distribution, and their correlations with the overall score and subscale differ between factors. The strong Pearson correlation coefficients suggest the strength and direction of the linear relationship between the variables. In the item-attitude correlation, items Q1 and Q2 show a strong relationship with the total score with a correlation of 0.45 (\(p<0.01\) ). This suggests that the items (participants preferred choice of material and the challenges they experienced in the early stages (< 4 months) of using RSP) are significant predictors of the overall attitude toward the usage of RSPs. On the other hand, items Q6, Q13, and Q14 have the lowest correlation with the total score, indicating that users’ answers to the type of duration of use (Q6: 0.111; \(p<0.01\) ) and availability of bathrooms (Q13: 0.105; \(p<0.01\) ) and soaps (Q14: 0.113; \(p<0.01\) ) in workplace or schools have less effect on their overall attitude compared to other variables. This could suggest that other factors, such as comfort, cost, or environmental impact, may be more influential in shaping attitudes towards RSPs.
The reliability analysis of the scale indicates good internal consistency reliability (\(>0.70\) ), which suggests that the scale is consistent and reliable in measuring the construct of interest. The convergent validity analysis results demonstrate that the scale has a good ability to measure the intended construct by comparing it to other measures or indicators of the same construct. The high AVE (\(>0.50\) ) and Composite Reliability (\(>0.70\) ) values indicate that the scale is consistent and reliable in measuring the construct of interest. These results provide strong evidence for the validity of your instrument, suggesting that it is effectively capturing the attitudes of users towards the usage of RSPs. This is a crucial aspect of scale development, as it ensures that the instrument is accurately measuring the construct it is intended to measure.
The confirmatory analysis results of women using RSPs suggest several significant findings related to hygiene & acceptability, comfort & practicality, convenience & usage, and sanitation facility of these products. The regression weights indicate the influence of various factors on hygiene & acceptability, comfort & practicality, convenience & usage, and sanitation facility of RSPs. The user’s preferences, such as their preferred choice material44, the challenges in the early stages of using RSPs, the Quality of water, the economic and social factors like the cost of the pads, and subsidies significantly impact the comfort & practicality of RSPs. These findings align with TPB’s notion that attitudes towards RSPs are shaped by a combination of perceived benefits, social influences, and control factors. The results also suggest that challenges for water availability, reliable water sources, challenges in cleaning/washing17,45, duration of use, and disposal significantly affect the hygiene & acceptability of RSPs. Similarly, challenges in drying17 and challenges while using RSPs significantly impact the convenience & usage of RSPs. Additionally, the study also identified that the proper sanitation facility positively impacts the users’ attitudes to using the RSPs. The literature supports the acceptability, feasibility, and performance of RSPs46. Studies have shown that RSPs are acceptable, effective, and can have a positive impact on MHM, especially in resource-poor settings17,47. The findings of this study provide valuable insights for policymakers and organizations working on menstrual health and hygiene.
According to the literature, it is important to consider the broader context of menstrual hygiene practices and the potential implications for women’s health. While the specific analysis provided does not directly address the health implications, it is essential to consider findings from existing studies. For example, research has shown that the use of reusable absorbents for managing menstruation may have a stronger potential to negatively impact women’s health, as it has been associated with an increased risk of urogenital infections48. Additionally, women’s access to accurate information and the type of absorbent used have been identified as important factors associated with infection and symptoms49. The material used in RSPs can greatly influence the comfort level of the user. Some materials may cause irritation or discomfort, which could discourage usage. According to the literature, the type of material used in RSPs can greatly influence the comfort level of the user12. Pads made from natural fibers like organic cotton are typically softer and more flexible compared to disposable pads, which can feel bulky and uncomfortable. Natural fibers used in reusable cloth pads also allow for better airflow, reducing the chances of odor and creating a more comfortable experience overall. Additionally, the duration of use is also a key factor. If a pad can be comfortably used for a longer duration, it increases the likelihood of acceptance and continued use46. The performance of the pad in terms of leakage can affect the comfort of the user. General satisfaction with the performance of reusable pads, including aspects like leakage, can lead to users recommending them to others. Another crucial aspect when using RSPs is maintaining hygiene. Challenges in cleaning or washing the pads can affect their hygiene, potentially leading to health issues such as sexually transmitted infections (STIs)50.
The results of the mediating effect study provide valuable insights into the factors that influence the usage of RSPs. The attitude to use is a key determinant, showing a significant positive effect on the dependent variable. The analysis indicates that the impact of attitudes toward the use of RSPs varies significantly across participants’ occupations and marital status. Previous studies noted that married women and those with work experience tended to have specific preferences and concerns regarding menstrual hygiene products compared to unmarried individuals51,52. This variation in attitudes reflects TPB’s assertion that personal, social, and control factors influence behavioral intentions and outcomes. Literature also supports that social norms can impact MHM practices53. Furthermore, the financial dependence of some women on their families led to challenges in obtaining permission to use certain sanitary products, highlighting how marital status can indirectly influence attitudes and behavior. The findings suggest that there is a need to consider and address variations in attitudes toward RSPs when designing interventions or policies related to MHM.
Grounded in the TPB the study aimed to develop and validate a survey instrument that measures the critical aspects of menstrual hygiene needs with regard to the usage of reusable products. The study revealed that the majority of women would prefer the option of reusable sanitary products that are comfortable and convenient to procure, use, and dispose of. The findings suggest that the instrument is consistent and reliable in measuring the construct of interest, and it effectively captures the attitudes of users towards the usage of RSPs. The study also provides valuable insights into the distribution and interconnections among the survey items within each component. The results of the confirmatory analysis suggest that challenges associated with water availability, cleaning/washing, drying, challenges in the early stages of using RSPs, challenges after 4 months of using RSPs, duration of use, preferred choice of material, disposal of RSPs, subsidies available, cost of the pads, and attitude to use significantly impact the actual use of RSPs. This study’s findings offer useful information for policymakers and organizations involved in menstrual health and hygiene. Additionally, the study revealed that attitudes toward RSPs vary notably among different socioeconomic strata, including occupation and marital status. These insights emphasize the necessity of considering and addressing such variations when formulating interventions or policies for MHM.
The implications of this study are significant for advancing MHM and promoting the adoption of RSPs. By developing a reliable and valid instrument to measure user attitudes toward RSPs, the research provides essential insights that can inform targeted interventions aimed at increasing awareness and acceptance of these eco-friendly alternatives. Understanding user attitudes, preferences, and the challenges faced in the early stages of RSP usage can guide manufacturers in product development, ensuring that RSPs meet the needs of diverse user groups. Furthermore, the findings highlight the importance of addressing factors such as comfort, cost, and hygiene, which are crucial for enhancing user satisfaction and promoting sustained use. Policymakers and organizations involved in MHM can leverage these insights to create supportive environments that facilitate access to RSPs, particularly in resource-poor settings. Additionally, the study underscores the need for tailored educational campaigns that consider the socio-economic and cultural contexts of users, ultimately fostering a more inclusive approach to menstrual health. By addressing the identified barriers and promoting the benefits of RSPs, this research contributes to the broader goal of enhancing women’s health and environmental sustainability in menstrual hygiene practices.
While this study offers valuable insights, it has a few limitations. The participant demography could be expanded to enhance the generability of the study. The requirement for a minimum of four months of RSP usage might exclude users of other menstrual hygiene products. Additionally, the focus on students and professional workers may somewhat restrict the study’s ability to capture perspectives from a broader range of socioeconomic and educational backgrounds.
Future research on RSPs should focus on broadening the demographic scope to include diverse populations, particularly in rural and lower socioeconomic contexts, to capture varying perceptions and barriers to adoption. Longitudinal studies could assess the long-term impacts of RSP use on menstrual health and environmental sustainability, while comparative studies with other menstrual hygiene products would provide insights into user experiences and cost-effectiveness. Investigating the effectiveness of educational campaigns aimed at increasing awareness of RSPs, as well as exploring specific barriers such as cultural perceptions and stigma, will be crucial for developing targeted interventions. Additionally, research into technological innovations for RSPs could enhance comfort and hygiene, and policy recommendations based on findings could support their integration into public health initiatives. Comprehensive life cycle assessments of RSPs compared to disposable products would further quantify their environmental benefits, and user-centric design research could ensure that products meet the needs and preferences of users. Finally, examining global perspectives on MHM will enrich the understanding of cultural practices and trends related to RSP adoption.
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
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This work derives direction and ideas from the Chancellor of Amrita Vishwa Vidyapeetham, Sri Mata Amritanandamayi Devi. The authors thank Ms. Anju Bist for her support and Saukhyam banana fiber based pads. The authors also thank Ms. Sharanya Muthupalani for her contributions to the study.
This study was supported by Amrita Vishwa Vidyapeetham, India.
Center for Cybersecurity Systems and Networks, Amrita Vishwa Vidyapeetham, Amritapuri, Kollam, Kerala, 690525, India
Vysakh Kani Kolil & Krishnashree Achuthan
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V.K.K. and K.A. Conceptualization, resources, writing—original draft, visualization, investigation. V.K.K. Methodology, formal analysis. K.A. Supervision, project administration, funding acquisition, writing—review & editing. All authors reviewed the manuscript.
The authors declare no competing interests.
The research received approval from the Institutional Ethics Review Board of Amrita Vishwa Vidyapeetham. All participants provided informed consent and agreed to publication. For participants under 18, consent was obtained from their legal guardians or parents. The study followed the ethical standards outlined in the Declaration of Helsinki, adhering to all guidelines and regulations.
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Kolil, V.K., Achuthan, K. Development and validation of a survey instrument for reusable sanitary products toward sustainable menstrual hygiene. Sci Rep 14, 22062 (2024). https://doi.org/10.1038/s41598-024-72122-7
DOI: https://doi.org/10.1038/s41598-024-72122-7
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