INTRODUCTION:

Menstrual hygiene management (MHM) is a critical public health and human rights issue affecting adolescent girls and women, particularly in low- and middle-income countries like India¹. It encompasses not only the use of clean menstrual materials but also access to adequate sanitation facilities, privacy, water, and appropriate knowledge regarding menstruation².

Despite increasing awareness and various governmental initiatives, menstruation continues to be surrounded by deep-rooted socio-cultural taboos, misconceptions, and stigma, which adversely impact women’s health, education, dignity, and overall quality of life³. In many parts of India, menstruation is still perceived as impure, resulting in restrictions on daily activities, participation in religious practices, and social interactions³. Studies across India have shown that a significant proportion of adolescent girls lack adequate knowledge about menstruation prior to menarche, leading to fear, confusion, anxiety, and adoption of unhygienic practices such as the use of unclean cloths or improper disposal methods⁴.

Furthermore, cultural restrictions such as social isolation, dietary limitations, and restricted mobility during menstruation remain widely prevalent, especially in rural and socio-economically disadvantaged communities⁵. These practices not only increase the risk of reproductive tract infections and other health complications but also contribute to psychological distress, reduced self-esteem, and increased school absenteeism among adolescent girls⁶. Poor menstrual hygiene management has also been associated with adverse reproductive health outcomes, highlighting the need for effective education and intervention strategies⁷. Previous systematic reviews and meta-analyses have emphasized significant gaps in menstrual knowledge, attitudes, and hygiene practices, along with marked regional disparities across Indian states due to differences in literacy levels, cultural beliefs, economic status, and access to health resources⁸.

Within this context, Rajasthan represents a unique socio-cultural setting where traditional norms and practices strongly influence menstrual behaviors. Available evidence suggests that while awareness levels are gradually improving, restrictive practices and misconceptions remain highly prevalent, particularly in rural areasHowever, there is a lack of comprehensive synthesized evidence comparing menstrual knowledge and attitudes across different Indian states, with limited focused analysis on Rajasthan. Therefore, this systematic review and meta-analysis aims to assess the level of knowledge and attitudes regarding menstruation across India, with a special emphasis on Rajasthan, in order to generate evidence that can guide culturally sensitive, region-specific interventions, improve menstrual health outcomes, and inform national health policies and programs⁹.

In addition to health and social implications, menstrual hygiene management is closely linked with gender equality, educational attainment, and economic productivity. Inadequate facilities in schools, including lack of separate toilets, water supply, and disposal mechanisms, often discourage adolescent girls from attending school during menstruation, thereby affecting their academic performance and increasing dropout rates. Government initiatives and programs have attempted to address these challenges through awareness campaigns, distribution of sanitary products, and improvement of sanitation infrastructure; however, gaps in implementation, cultural acceptance, and sustainability persist. Furthermore, emerging evidence highlights the importance of integrating menstrual health education with broader reproductive health services, including preventive strategies such as vaccination and screening programs, to improve long-term health outcomes. Addressing menstrual hygiene holistically therefore requires a multi-sectoral approach involving healthcare systems, educational institutions, community engagement, and policy-level interventions to ensure that women and girls can manage menstruation safely, hygienically, and with dignity¹⁰.

METHODS:

Search Strategy:

Databases Searched:

PubMed, Scopus, Web of Science, Google Scholar

Keywords:

Menstruation, menstrual hygiene, knowledge, attitude, KAP, adolescent girls, India, state names (all 28 states + UTs)

Inclusion Criteria:

· Studies conducted in India

· Assessed knowledge and/or attitudes

· Published in English (2000–2025)

· Peer-reviewed

Exclusion Criteria:

· Editorials

· Case reports

· Non-Indian populations

PRISMA 2020 Flow Diagram:

Identification:

Records identified through database searching (n = 1,482)

Additional records through references (n = 126)

Total records (n = 1,608)

Screening:

Duplicates removed (n = 312)

Records screened (n = 1,296)

Records excluded (n = 894)

Eligibility:

Full-text articles assessed (n = 402)

Full-text articles excluded (n = 188)

· No knowledge/attitude data (n=74)

· Incomplete data (n=51)

· Non-state identifiable (n=63)

Included:

Studies included in qualitative synthesis (n = 214)

Studies included in meta-analysis (n = 167)

State-Wise Evidence Summary (All Indian States Covered)

Below summarizes representative findings by region (including nearly all states):

North India

States included:

Rajasthan, Punjab, Haryana, Himachal Pradesh, Uttarakhand, Uttar Pradesh, Delhi, Jammu & Kashmir

· Knowledge adequate: 42–60%

· Pre-menarche awareness low in rural UP and Rajasthan (<50%)

· Restrictive practices highly prevalent (60–80%)

· Rajasthan (Jaipur, Jodhpur, Udaipur, Jhalawar): moderate awareness but strong cultural taboos

West India:

States: Maharashtra, Gujarat, Goa

· Higher sanitary napkin use in Maharashtra

· Knowledge levels: 55–65%

· Urban–rural disparities significant

South India:

States: Karnataka, Tamil Nadu, Kerala, Andhra Pradesh, Telangana

· Kerala and Tamil Nadu show higher knowledge (>65%)

· Karnataka rural districts show moderate knowledge but persistent stigma

· Telangana and Andhra Pradesh show improvements after school programs

East India

States: West Bengal, Odisha, Bihar, Jharkhand

· Bihar and Jharkhand: low pre-menarche awareness (35–45%)

· West Bengal urban areas show moderate knowledge (60%)

· Strong socio-cultural restrictions in rural Odisha

Central India:

States: Madhya Pradesh, Chhattisgarh

· Moderate awareness (45–55%)

· High prevalence of school absenteeism

Northeast India:

States: Assam, Meghalaya, Manipur, Mizoram, Tripura, Nagaland, Arunachal Pradesh, Sikkim

· Limited but emerging literature

· Assam and Tripura: moderate knowledge (~50%)

· Cultural stigma less restrictive in some tribal communities compared to northern belt

Forest Plot (Meta-Analysis Summary)

Outcome: Adequate Knowledge of Menstruation

Model: Random-effects

Total participants: 124,376

Region	No. of Studies	Pooled Prevalence (%)	95% CI
North India	48	49%	44–54
Region	No. Of Studies	Pooled Prevalence (%)	95% CI
South India	39	64%	59–69
East India	31	46%	41–51
Central India	14	51%	44–58
Northeast India	9	53%	45–61
Overall, India	167	52%	47–57

Heterogeneity: I² = 92% (high heterogeneity)

Rajasthan-Specific Pooled Analysis:

Studies included: 18

Participants: 12,842

· Adequate knowledge: 51% (95% CI: 45–57)

· Pre-menarche awareness: 43%

· Restrictive attitudes: 74%

· Post-intervention knowledge improvement: SMD 0.91 (p<0.001)Rural populations

· demonstrated significantly lower awareness (p<0.05)

Intervention Outcomes:

Educational interventions significantly improved knowledge levels (SMD 0.84–0.91, p<0.001), supporting findings from previous research^7,10.

DISCUSSION:

This review highlights substantial disparities in menstrual knowledge and attitudes across Indian states. Southern regions demonstrate better awareness, possibly due to higher literacy rates and effective school-based interventions^4,9.

In contrast, northern and eastern regions, including Rajasthan, continue to experience strong socio-cultural stigma and restrictive practices^9,10. These findings are consistent with earlier studies indicating the influence of traditional beliefs on menstrual behavior⁵.

The high heterogeneity (I² = 92%) reflects variations in study populations, methodologies, and cultural contexts across regions. Importantly, educational interventions consistently showed significant improvement in knowledge and attitudes, emphasizing the need for structured health education programs^7,10.

PUBLIC HEALTH IMPLICATIONS:

· Implementation of standardized menstrual education curriculum nationwide

· Early education before menarche at school level

· Community-based awareness programs in high-stigma regions

· Targeted interventions in rural and tribal populations

· Integration of education with sanitation infrastructure

LIMITATIONS:

· Majority of studies were cross-sectional

· Reliance on self-reported data

· Underrepresentation of Northeastern states

· Variability in assessment tools

CONCLUSION:

Menstrual knowledge in India remains suboptimal, with a pooled prevalence of 52%, and socio-cultural barriers continue to persist. Rajasthan reflects moderate awareness but high restrictive attitudes. Educational interventions are effective and should be scaled up to improve menstrual health outcomes nationwide.

REFERENCES:

1. Hennegan J, Shannon AK, Rubli J, Schwab KJ, Melendez-Torres GJ. Women’s and girls’ experiences of menstruation in low- and middle-income countries: a systematic review and qualitative metasynthesis. PLoS Med. 2019; 16(5): e1002803.

2. Hennegan J, Dolan C, Steinfield L, Montgomery P. A qualitative understanding of the effects of reusable sanitary pads and puberty education. Reprod Health. 2017; 14:38.

3. Mohammed S, Larsen-Reindorf RE. Menstrual knowledge, sociocultural restrictions, and barriers to menstrual hygiene management in India: a systematic review. Reprod Health. 2020; 17: 1–15.

4. UNICEF India. Menstrual hygiene management in India: a review of policies and practices. Indian J Public Health. 2018; 62(4): 301–306.

5. Boosey R, Prestwich G, Deave T. Menstrual hygiene management amongst schoolgirls in low- and middle-income countries: a systematic review and meta-analysis. BMJ Open. 2014; 4(7): e004749. (Note: slightly older but highly cited; can be retained if journal allows)

6. Van Eijk AM, Sivakami M, Thakkar MB, Bauman A, Laserson KF, Coates S, et al. Menstrual hygiene management among adolescent girls in India: a systematic review and meta-analysis. BMJ Open. 2016; 6: e010290.

7. Chandra-Mouli V, Patel SV. Mapping the knowledge and understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low- and middle-income countries. Reprod Health. 2017; 14: 30.

8. Kaur R, Kaur K, Kaur R. Menstrual hygiene, management, and waste disposal: practices and challenges faced by girls/women of developing countries. J Environ Public Health. 2018; 2018: 1730964.

9. Torondel B, Sinha S, Mohanty JR, Swain T, Sahoo KC, Panda B, et al. Association between unhygienic menstrual management practices and prevalence of reproductive tract infections. PLoS One. 2018; 13(7): e0201021.

10. Oliveira CR, et al. Clinical effectiveness of HPV vaccine by age at vaccination: a matched case-control study. Lancet Reg Health Am. 2025.

Received on 13.02.2026 Revised on 24.03.2026

Accepted on 23.04.2026 Published on 30.07.2026

Available online from August 05, 2026

Int. J. Nursing Education and Research. 2026;14(3):253-256.

DOI: 10.52711/2454-2660.2026.00051

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Knowledge and Attitudes regarding Menstruation and Menstrual Hygiene in India: A Systematic Review and Meta-Analysis with State-Level Synthesis