Beyond access to sanitary pads: a comprehensive analysis of menstrual health scheme impact among rural girls in Northeast India

Abstract

Menstrual hygiene management (MHM) among girls in rural India poses a substantial challenge for public health, education, and quality of life, exacerbated by limited access to and affordability of menstrual products. In response to these issues, the Government of India initiated the Menstrual Hygiene Scheme (MHS) to enhance access and awareness. This study evaluates the impact of the MHS in Assam and Tripura, designated as “treatment states” with consistent pad supply from 2017 to 2021 compared to neighboring “control states” with negligible pad distribution. Utilizing data from two National Family Health Surveys, NFHS-4 and NFHS-5, and employing the propensity score matching difference-in-differences approach, we isolated the causal effect of the MHS distribution program. The key findings reveal a significant rise in sanitary pad and hygienic method usage in the treatment states, particularly among girls aged 15–19 years who received pads during the survey period. Their sanitary pad usage increased by 10.6 percentage points [95% confidence interval (CI) (0.046, 0.167)], and adoption of hygienic methods overall saw a 13.8 percentage point [95% CI (0.087, 0.188)] jump. Notably, younger girls aged 15–19 years also experienced a 6.1-percentage point [95% CI (0.004, 0.118)] increase in their understanding of ovulation, showcasing the MHS’s potential to go beyond providing products and promoting menstrual health awareness. A rise in reported sexually transmitted infections in both age groups, with a statistically significant 1.8-percentage point [95% CI (0.004, 0.032)] increase for younger girls, warrants further exploration. Disparities in impact were observed, with girls with high media exposure and greater autonomy demonstrating greater improvements in hygienic practices, highlighting the importance of information dissemination and empowering girls. Most socioeconomic groups, except the highest wealth and education levels, witnessed rises in hygienic method usage, indicating the scheme’s potential to reduce inequalities while hinting at the need for tailored interventions for marginalized communities.

Introduction

India is home to 20% of the worlds’ menstruating adolescents (Omidvar et al. 2018). Yet, menstrual hygiene remains compromised to a significant part of this demography who reside in rural areas. Menstrual health is defined as complete physical, mental, and social well-being in relation to the menstrual cycle. It involves access to accurate information, effective menstrual care, timely healthcare, a supportive environment free from stigma, and the ability to participate fully in all life areas without menstrual-related restrictions (Hennegan et al. 2021). A recent study on India by the United Nations International Children’s Emergency Fund (UNICEF, n.d.a:) reveals that half of the adolescent girls cannot afford sanitary napkins or tampons during menstruation, leading to inadequate menstrual hygiene facilities. From lack of access and affordability to many other factors such as scarcity of water, sanitation, and hygiene (WASH), these issues compound the difficulty in coping with menstruation (Kolil and Achuthan, 2024, Achuthan et al. 2021). In both family and school settings, discussions about menstruation are often hushed. Current estimates indicate that more than half of girls are unaware of menstruation when they first experience it (Van Eijk et al. 2016, UNICEF, n.d.b).

The educational journey for female students in the country undergoes a significant decline, plummeting from 51.9% upon completing primary education to merely 10.5% progressing to postsecondary education [World Bank (Genderdata)]. Several studies (Psaki et al. 2022, Mitra et al. 2023) attribute discontinuing of their education to domestic responsibilities, economic factors, and inadequate facilities. Menstruation is one of the key factors contributing to school dropouts (Nielsen and India 2010), as some studies show up to 40% of girls (Vashisht et al. 2018) adopting partial or complete absence in school during the length of their period. The fact that menstruation is seen as shameful further facilitates absenteeism linked to menstruation. Major factors contributing to absenteeism include fear of leakage, embarrassment, lack of privacy, inadequate sanitary facilities, and limited availability of pain relievers at school (Sharma et al. 2020). The shame associated with menstruation leads to anxiety and discomfort, causing many girls to stay at home to avoid stigma. Absenteeism and dropping out of school have an extremely important effect on the quality of life of a woman, making her more likely to marry early and have kids during their adolescence. This can hurt their child’s health and impact their economic freedom (Marphatia et al. 2019). The inappropriate management of menstruation has not only a detrimental effect on girls’ education but also significant implications on their health. Inadequate availability and economic means to purchase hygienic Menstrual Hygiene Management (MHM) materials compel women to choose readily available materials such as cloth that are associated with higher risk for infections due to reuse, improper washing, drying, and storage methods (Torondel et al. 2018, Chandra-Mouli and Patel, 2017). As part of recent survey conducted by International Institute for Population Sciences (IIPS), around 50% of the women aged 15–24 years in rural regions were found resorting to usage of cloth for menstrual needs. Several studies report the strong linkage between inadequate menstrual hygiene and the risk of lower reproductive tract infections such as bacterial vaginosis, Candida, abnormal vaginal discharges and dysmenorrhea (Dasgupta and Sarkar 2008, Anand et al. 2015, Torondel et al. 2018). Suboptimal WASH practices and facilities play a dominant role in causing these infections (Ademas et al. 2020). Regarding modern menstrual hygiene products like menstrual cups that may be cost-effective and tampons, the discomfort with insertions dissuades women from considering them (Britto et al. 2023).

With growing concern for adolescents’ and women’s health, the Government of India has undertaken several initiatives to address the lack of access and economic barriers to menstrual hygiene. The largest national initiative is the Menstrual Hygiene Scheme (MHS) that began in 2011 [MHS (National Health Mission)]. Targeting rural girls aged 10–19 years, the MHS implements a multifaceted approach encompassing three key objectives: enhancing menstrual hygiene awareness, increasing access to affordable sanitary napkins, and promoting environmentally sound disposal practices. A comprehensive description of the MHS and its implementation can be found in Garg et al. (2012). Despite the emphasis on menstrual hygiene at both the national and state levels, access to pads continues to be a challenge stemming from irregular distribution of pads. This was also flagged as a concern recently in India’s parliament [Sansad data (Government of India, Ministry of Health and Family Welfare, Lok Sabha, Unstarred Question No. 2986)] as a response to a question raised on the effectiveness of the MHS scheme in rural India. Given this backdrop of troubling disparity between some states receiving support and others not (Singh et al. 2022b), its influence on menstrual hygiene practices could be gleaned through data collected from National Family Health Surveys (NFHS) periodically conducted by the Government of India. This paper delves into the uneven distribution of sanitary pads and the consequential impact within the context of North Eastern states, a region with poorer menstrual hygiene practices (Karjee and Biswas 2023), and additionally lacks comprehensive and in-depth research studies on adolescents and women (Krishnakumari and Arun 2012).

Given the profound impact of MHM on the lives of adolescent girls, this study focuses on evaluating the effects of the MHS in rural Assam and Tripura. We hypothesize that MHS significantly increases sanitary pad usage. However, understanding the interplay between various aspects of the MHS, such as the hygienic methods used, media exposure, autonomy, and ovulatory knowledge, alongside socioeconomic status and education, is crucial. The primary research questions addressed in this work are as follows: how did the intervention influence sanitary choices, of adolescents and young women in rural Assam and Tripura? Additionally, to what extent did media exposure, women’s autonomy, socioeconomic status, and educational level impact the efficacy of the intervention?

Materials and Methods

Data

According to the Lok Sabha Unstarred Question No. 2986 (March 17, 2023) from the Ministry of Health and Family Welfare, two North Eastern states maintained substantial sanitary pad distribution during 2017–2021: Assam achieved high distribution volumes ranging from 413,481 pads (2018–19) to 20,465 pads (2020–21), while Tripura’s distribution increased significantly from 16,029 pads to a peak of 287,131 pads (2021–22). In stark contrast, the remaining North Eastern states recorded markedly lower distributions: even at their highest points, Mizoram peaked at just 14,532 pads (2017–18), Manipur at 1,772 pads (2021–22), Nagaland at 600 pads (2021–22), Meghalaya at 20 pads (2021–22), Sikkim at 2 pads (2021–22), and Arunachal Pradesh at 24 pads (2018–19), with several years showing zero distribution across these states. (Fig. 1). To analyze the impact of this distribution under the MHS in the Northeast states, we utilize data from two rounds of the NFHS. The NFHS, conducted by the International Institute of Population Science in Mumbai, is a comprehensive, nationally representative household survey covering all states, union territories, and districts across India (IIPS 2022).

Our analysis primarily draws from NFHS-4 (2015–16) and NFHS-5 (2019–21), surveys that have also been utilized to study other public health issues in India (Kodali et al. 2023). The NFHS collects a wide range of health and demographic data, including information on menstrual hygiene practices, and employs multistage sampling procedures at national, state/union territory, and district levels to ensure representativeness. The survey covers women aged 15–49 years, but the data providing insights into menstrual health practices are only available for girls aged 15–24 years. NFHS-4 (2015–16) serves as our baseline, offering predistribution data on menstrual hygiene practices across the Northeast region. This includes detailed information on practices, state-level variations, and socioeconomic disparities. NFHS-5 (2019–21) provides crucial postdistribution data, allowing us to compare findings and isolate the effects of the structured distribution efforts implemented from 2017 onward under the MHS.

Study population

The study population comprises girls aged 15–24 years from a representative sample of households across Northeast India. This includes individuals with varying levels of education: primary, secondary, higher, and no education. The sample size includes 23 688 individuals from the NFHS-4 data set and 26 176 individuals from the NFHS-5 data set.

Outcome variables

In the NFHS survey, girls were presented with a multiple-choice question: “What do you use for preventing menstrual blood stains?” The options included locally prepared napkins (LPNs), sanitary napkins, tampons, menstrual cups, cloth, nothing, and others. To assess the impact of sanitary pad distribution, we analyzed responses to this question, focusing on three critical menstrual hygiene practices: sanitary pad usage, LPN usage, and cloth usage. Furthermore, we examined overall hygienic method usage, which encompassed LPN, sanitary pads, menstrual cups, and tampons. For our analysis, we categorized menstrual hygiene methods into two groups: hygienic and nonhygienic. Hygienic methods were defined as those reported by girls who responded affirmatively to using sanitary napkins, LPNs, menstrual cups, or tampons. Conversely, the use of cloth, nothing, or other unspecified materials was classified as nonhygienic methods.

Previous research, such as the study by Austrian et al. (2021), has shown that menstrual hygiene management interventions can positively impact adolescent girls’ knowledge and attitudes toward menstruation. This study aimed to build on these findings by investigating the impact of sanitary pad distribution on women’s understanding of ovulation in rural Northeast India. This was achieved by creating a binary variable based on participant responses to a survey question inquiring about the period of peak fertility within the menstrual cycle. The correct response (“middle of the cycle”) was coded as 1, while all other responses were coded as 0.

While the potential link between menstrual hygiene and sexually transmitted infection (STI) prevalence has been explored in developing countries (Phillips-Howard et al. 2016), this study investigates this relationship specifically in rural Northeast India using self-reported STI data. This was achieved using a binary variable, “STI” coded as one if the participants reported having any STI in the previous 12 months.

Covariates

Based on existing research on sanitary pad usage in India, including studies by Goli et al. (2020), Ram et al. (2020), Roy et al. (2021), and Singh et al. (2022a), we identified several independent variables that are likely to influence menstrual hygiene practices. These included demographic factors like age, wealth index, caste, marital status, and menarche age. We also adapted existing variables to suit our context better. For instance, the toilet facility variable was transformed into a binary (1 = toilet available, 0 = no toilet/open defecation) to account for diverse sanitation settings in rural India.

Building on existing research, we crafted three additional variables crucial in the Indian context of hygienic method use. “Media exposure,” coded as 1 for regular radio, TV, or newspaper use, reflects the potential influence of mass media on women’s understanding of health benefits and menstrual hygiene practices. “Marital home,” coded as 1 for wives, daughters-in-law, or sisters-in-law of the household head, acts as a proxy for potential power dynamics within the family unit and their influence on women’s hygienic choices. Finally, “women’s autonomy,” coded as 1 for affirmative responses to any of the following: independent market access, healthcare facility access, participation in major household purchases, or healthcare decision-making, captures the potential impact of agency on hygienic method choice. These carefully chosen variables offer a deeper understanding of the complex factors shaping the use of hygienic methods in the Indian context (Singh et al. 2023).

Conceptual framework

Our conceptual framework, illustrated in Fig. 2, elucidates the complex inter-relationships between the sanitary pad distribution intervention, outcomes, and covariates. At its core, the framework posits that the intervention directly influences usage methods, ovulatory knowledge, and potentially STI prevalence. The outcomes are also interconnected, with ovulatory knowledge influencing usage methods, such as sanitary pad usage, cloth usage, LPN usage, and hygienic method usage, and both potentially affecting STI prevalence. Furthermore, demographic and social-environmental covariates, such as age, wealth index, media exposure, and women’s autonomy, influence the likelihood of receiving the intervention and also have direct effects on the outcomes.

Intervention and covariate association

To assess the association between covariates and the intervention, we employed a probit regression model followed by the calculation of marginal effects. This approach allowed us to quantify the relationship between various socioeconomic and demographic factors and the likelihood of being in a treatment state (i.e. receiving the sanitary pad distribution under MHS). The outcome variable, Treatment, is a binary indicator for treatment states.

Identification and estimation strategy

We selected Assam and Tripura as treatment states and Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, and Sikkim as control states for our study. The treatment states received sanitary pad distribution under the MHS between 2017 and 2021, while the control states did not receive or received it to a lesser extent. The inclusion of both control and treatment states from the Northeast region of India ensures that the analysis is contextually relevant, accounting for the unique geographical, cultural, and economic conditions of this area. Table 1 provides a comparison of key indicators between the treatment and control states. This selection process was guided by the need to ensure comparability between the treatment and control states, in terms of socioeconomic and demographic characteristics. By choosing states from the same region, we minimize potential biases and ensure that the analysis is sensitive to the local context. Furthermore, this selection process is essential for our propensity score matching combined with difference-in-differences (PSM-DID) analysis, as it enables us to establish a credible counterfactual and accurately estimate the impact of the MHS intervention. By selecting treatment states based on governmental decisions, rather than state-specific characteristics, we ensure that the assignment of the intervention is unrelated to the outcomes we are trying to measure, which is a critical assumption in PSM-DID analysis. Additionally, the similarity between treatment and control states helps to identify the specific impact of the MHS intervention, reducing the likelihood of confounding factors that could influence the results. Finally, by selecting control states with limited or no exposure to MHS, we minimize potential spillover effects that could contaminate our control group. This approach, combined with the use of PSM to match treatment and control units based on observable characteristics, strengthens our analysis by creating a more comparable set of states. As a result, we can more confidently attribute any differences in outcomes to the MHS intervention rather than pre-existing differences between states.

To explore the impact of the sanitary pad distribution program, we leverage PSM-DID. While the DID approach stands out as a robust tool for our study, it relies on the assumption of parallel trends. This means that outcomes in both the treatment and control groups would have followed similar trajectories even without the intervention. The lack of pre-2015 data on sanitary pad usage prevents us from directly assessing the parallel trend assumption.

To overcome this limitation, we employ a two-step approach:

• PSM: We calculate propensity scores for girls in the treatment states by assessing their likelihood of receiving the intervention based on observed characteristics. These factors encompass age, caste, education, wealth level, menarche age, marital home, meeting with an Accredited Social Health Activist (ASHA) worker, media exposure, menstrual knowledge, toilet type, and autonomy. Subsequently, we employ kernel PSM to pair individuals in the treatment states with their similar counterparts in the control states. Through this process, we create comparable groups, enhancing the plausibility of parallel trends and facilitating a more robust application of DID in the second phase of our analysis.

• DID: We apply DID to the matched groups generated by PSM, incorporating the same set of covariates used for matching. This involves estimating the average difference in sanitary pad usage between the treatment and control groups after the pad distribution program. This difference, captured by the PSM-DID equation (1) adapted from the study by (Michalek et al. 2012), represents the program’s average treatment effect on the treated—the impact of the pad distribution program on girls’ sanitary pad usage in the treatment states compared to their counterparts in the control states,

where Y_i is an outcome variable (sanitary pad usage), T = 1 is the treatment state, T = 0 is the control state, |$({Y_{it}}\left| {\left( {T = 1} \right) - {\ }{Y_{it}}} \right|\left( {T = 0} \right)$| is the difference in mean outcomes between the i individuals and the i-matched comparison units after the pad distribution program, and |$({Y_{it^{\prime}}}\left| {\left( {T = 1} \right) - {\ }{Y_{it^{\prime}}}} \right|\left( {T = 0} \right){\ }$| is the difference in mean outcomes between the i individuals and the i-matched comparison units before the pad distribution program.

To further strengthen the robustness of our analysis, we incorporate district-fixed effects to control for unobserved district-level factors that might influence sanitary pad usage, such as variations in infrastructure, cultural norms, or access to health services.

We rigorously assessed matching quality using multiple strategies to ensure the validity of our comparisons. These included examining standardized bias (targeting a reduction to below 10% postmatching), pseudo-R-squared to evaluate group membership prediction, Rubin’s B (<25%) and R (0.5–2) tests, and visual assessment using kernel density plots to check for common support between control and treatment groups (Harder et al. 2010, Austin 2011, Morgan 2018). After establishing matching quality, we examined the impact of distributing sanitary pads on two distinct age groups: girls aged 15–19 years, who received sanitary pads during the survey, and girls aged 20–24 years, who did not receive sanitary pads at the time but may have in previous years. Furthermore, a primary objective of the MHM scheme was to enhance awareness about menstrual health. We examined the scheme’s impact on knowledge about ovulation. We also examined the impact of distributing sanitary pads on the sexual health of women, focusing on STIs. This variable is binary, with women reporting a “yes” if they had an STI in the past 12 months. The analysis included the same covariates, with the addition of hygienic methods used as an additional covariate. We conducted subgroup analyses to examine differential impacts based on media exposure, women’s autonomy, wealth index, and education level.

Sensitivity analysis

To ensure the robustness of our findings, we conducted a validation process using the methods of PSM-local linear regression (PSM-LLR) and PSM-radius (PSM-R). These methods were employed to mitigate potential biases and enhance confidence in the observed effects of the intervention in the distribution of sanitary pads.

Results

Summary statistics

In Table 2, we report the summary statistics on the demographic characteristics and menstrual hygiene practices of young women aged 15–24 years from two survey rounds, NFHS-4 (2015–16) and NFHS-5 (2019–21). The table presents the mean, standard deviation, and number of observations for each variable, divided into control and treatment groups for both survey rounds. The sample sizes are as follows: in NFHS-4, the control group consisted of 14 060 observations, while the treatment group included 9628 observations. In NFHS-5, the control group had 14 310 observations and the treatment group had 11 866 observations. Sanitary pad usage in the control group was 63% in NFHS-4 and 74% in NFHS-5, while in the treatment group, it was 28% in NFHS-4 and 52% in NFHS-5. Cloth usage was 61% and 52% for the control group and 82% and 70% for the treatment group in NFHS-4 and NFHS-5, respectively. The age distribution is even between 15–19 and 20–24 years age groups across all samples. The average menarche age was about 13.1 years for the control group and 12.4 years for the treatment group in both surveys. Regarding socioeconomic factors, the proportion of the treatment group in the poorest wealth category was 24% in NFHS-4 and 43% in NFHS-5, while in the control group, it was 12% in NFHS-4 and 28% in NFHS-5. Educational attainment was similar across groups and surveys, with about 75%–78% having secondary education. The treatment group showed marriage rates of 47% in NFHS-4 and 46% in NFHS-5, compared to 32% in NFHS-4 and 26% in NFHS-5 for the control group. Contact with health workers in the treatment group was 27% in NFHS-4 and 32% in NFHS-5, compared to 9% in NFHS-4 and 12% in NFHS-5 for the control group. Ovulatory knowledge in the treatment group was 20% in NFHS-4 and 30% in NFHS-5, compared to 9% in NFHS-4 and 13% in NFHS-5 for the control group.

Intervention and covariate association analysis revealed significant associations across multiple dimensions (Table 3). Age plays a role, with the 20–24 years age group being 11.7 percentage points less likely to be in the treatment group compared to the 15–19 years age group cohort. Wealth shows a strong negative correlation, with individuals in higher wealth quintiles progressively less likely to be in treatment states, reaching a 90.2-percentage point difference for the richest quintile compared to the poorest. Caste also exhibits notable disparities, with Scheduled Tribes 153.8 percentage points less likely to be in the treatment group than Scheduled Castes. Education level demonstrates a positive association, with higher education linked to a 48.2-percentage point increase in the likelihood of being in a treatment state. Other factors such as media exposure, marital status, autonomy, menstrual knowledge, and interaction with health workers also show significant associations. For instance, those who met with a health worker are 54.6 percentage points more likely to be in the treatment group.

Matching quality

Our matching quality assessment yielded excellent results. The standardized bias demonstrated a substantial reduction to below 3% following matching (Fig. 3), comfortably meeting the 10% benchmark. The pseudo-R-squared dropped dramatically from 0.178 to 0.003, further solidifying the balance achieved. Rubin’s B and R tests confirmed excellent balance, with B at 12.6% (well below 25%) and R at 1.01 (within the ideal range of 0.5–2). Visually, kernel density plots a showcased remarkable overlap between the control and treatment groups after matching (Fig. 4), fulfilling the crucial common support condition.

Impact on usage methods

The PSM-DID estimates of the impact of the sanitary pad distribution on usage methods based on equation (1) are presented in Table 4. The estimates suggest that a sanitary pad distribution intervention impact on girls’ sanitary pad usage increased by 10.6 percentage points for girls aged 15–19 years (Column 1) and 5.9 percentage points for girls aged 20–24 years (Column 2). We also examined how this intervention impacted the LPN usage, and the estimates in Columns 3 and 4 suggest that there is around a 6-percentage point increase in LPN usage for both age groups after the intervention. The coefficient for cloth usage is negative (Columns 5 and 6), which might imply that there is a decrease in the usage of cloth, but we do not have significant results (P > .05). Furthermore, we investigated the impact of the intervention on the adoption of hygienic methods. The results, presented in Columns 7 and 8 in Table 4, demonstrate that the intervention led to a 13.8-percentage point increase in the usage of hygienic methods among girls aged 15–19 years and a 10.3-percentage point increase among girls aged 20–24 years.

In addition to examining the direct impact of sanitary pad distribution, our analysis also reveals significant associations between various socioeconomic factors and menstrual hygiene practices. Secondary education significantly increases sanitary pad usage, with a rise of 15.8 percentage points for the 15–19 years age group and 15.5 percentage points for the 20–24 years age group. Additionally, it boosts LPN usage by 3.7 and 3.9 percentage points for these age groups, respectively. Socioeconomic status plays a crucial role, with girls from the richest category more likely to use sanitary pads and hygienic methods, showing increases of 27.7 and 26.2 percentage points for the younger group and 28.6 and 29.0 percentage points for the older group. Conversely, higher socioeconomic status corresponds to a significant decrease in cloth usage, with reductions of 31.6 and 35.6 percentage points for the respective age groups. Media exposure positively impacts sanitary pad and hygienic method usage, increasing the likelihood by 9.6 and 13.4 percentage points for the 15–19 years age group and 8.9 and 12.1 percentage points for the 20–24 years age group, while also reducing cloth usage around 4.7 percentage points across both age groups. Knowledge about ovulation, potentially amplified by the intervention, increases sanitary pad usage by 5.4 percentage points and hygienic method adoption by 5.5 percentage points for the 15–19 years age group and by 3.9 and 3.6 percentage points for the 20–24 years age group, respectively. Caste dynamics reveal that Scheduled Tribe girls exhibit a notable decrease in cloth usage compared to Scheduled Caste girls, particularly in the 15–19 years age group, with a reduction of 4.5 percentage points. Other factors such as age, marital status, autonomy, menarche age, interactions with health workers, and toilet type show varied impacts on menstrual hygiene practices. Notably, age shows a minimal impact, while living in a marital home slightly decreases sanitary pad use and increases LPN use. Autonomy positively influences the use of hygienic methods, with a more significant effect observed in the younger group. Being married is associated with decreased use of sanitary pads and hygienic methods. Later menarche age increases sanitary pad use and decreases LPN use, with significant effects across both age groups. Meeting health workers exhibits mixed effects, and toilet type influences outcomes differently across age groups.

Impact on knowledge about ovulation

We examined the scheme’s impact on knowledge about ovulation and found a 6.1-percentage point increase among girls aged 15–19 years, as indicated in Table 5. However, no significant impact on ovulatory knowledge was observed among girls aged 20–24 years. Furthermore, Table 5 shows how socioeconomic factors are significantly associated with ovulatory knowledge. Age plays a positive role, with each year increase associated with a 1.6-percentage point increase in knowledge for the 15–19 years age group and a 0.8-percentage point increase for the 20–24 years age group. Socioeconomic status shows a clear gradient effect on ovulatory knowledge, particularly for the younger group. Compared to the poorest category, girls from the richer category in the 15–19 years age group demonstrate a 5.9-percentage point higher likelihood of ovulatory knowledge. This effect is similar (5.9 percentage points) for the 20–24 years age group. Interestingly, education level shows mixed effects. For the 15–19 years age group, primary education is associated with a 7.9-percentage point decrease in ovulatory knowledge compared to no education. However, for the 20–24 years age group, higher education is associated with a substantial 12.2-percentage point increase in knowledge. Media exposure positively influences ovulatory knowledge, with a 2.7-percentage point increase for the younger group and a 4.7-percentage point increase for the older group. Notably, being currently married is associated with increased ovulatory knowledge, with an increase of 10.3 percentage points for the 15–19 years age group and 14.9 percentage points for the 20–24 years age group. This unexpected finding may warrant further investigation. Lastly, interaction with health workers (met worker) shows a positive association with ovulatory knowledge, increasing it by 5.0 percentage points for the younger group and 4.4 percentage points for the older group.

Impact on STI

Table 5 also displays the estimated impact of the intervention on sexual health outcomes for each age group. In Columns 3 (age 15–19 years) and 4 (age 20–24 years), it is observed that there is a rise in STIs for both age groups. However, the increase is statistically significant only for girls aged 15–19 years, with a 1.8-percentage point rise (P < .05), while it is not statistically significant for girls aged 20–24 years (P = .088). Further analysis of the covariates reveals several significant associations with the reporting of STIs. For girls aged 15–19 years, those from Other Backward Class (OBC) backgrounds are 1.2 percentage points more likely to report STIs compared to Scheduled Castes (P < .05). Additionally, girls in this age group living in their marital homes show a 1.5-percentage point increase in STI reporting (P < .05). Among women aged 20–24 years, those with higher education are 4.2 percentage points more likely to report STIs compared to those with no education (P < .05), and currently married women in this age group show a 5.5-percentage point increase in STI reporting (P < .05). Interestingly, direct sanitary pad usage shows no significant impact on STI reporting for either age group. Other factors such as wealth quintiles, media exposure, and autonomy exhibit varying trends across age groups, although these trends are not statistically significant.

Disparities in impact based on media exposure and autonomy

The intervention’s impact based on media exposure varied between usage methods (Table 6). For women with high media exposure, sanitary pad usage increased by 9.9 percentage points, while for women without any media exposure, there was no significant increase in sanitary pad usage. LPN usage increased for both groups. At the same time, cloth usage increased by 11.2 percentage points for women without media exposure even after the intervention. For hygienic method usage, women with media exposure had a 12.7-percentage point increase. Columns 3 and 4 in Table 6 show the estimated impact of the intervention based on women’s autonomy. Notably, the analysis revealed that the usage of sanitary pads, LPNs, and hygienic methods increased for both women with and without autonomy. However, the percentage point increase in these methods’ usage was consistently higher for women with autonomy compared to those without. For instance, the use of sanitary pads increased by 18 percentage points for women with autonomy and 7.4 percentage points for women without autonomy.

Table 7 presents the results of the intervention’s impact across different wealth groups. The estimates indicate a 10.6-percentage point increase in the usage of sanitary pads among the poorer group and a 12-percentage point increase among the richer group. However, no significant results were found for other wealthy groups in relation to sanitary pad usage. The estimates for LPN usage based on the wealth level indicate an increase in LPN usage for the poorer and poorest wealth groups. Although the coefficient for cloth usage based on wealth level is negative, the results are insignificant (P > .05).

Furthermore, we examined the impact of using hygienic methods and found significant increases for all wealth groups except the richest. Specifically, there was a 12.8-percentage point increase for the poorest group, a 15.3-percentage point increase for the poorer group, an 8.1-percentage point increase for the middle group, and a 10.4-percentage point increase for the richer group. Analyzing the impact on sanitary pad usage and hygienic method usage based on the education level (Table 8), we found an increase of 9.6 percentage points and 13.2 percentage points for sanitary pads and hygienic methods, respectively, for the women with secondary school education. In contrast, there was a significant increase in LPN usage for women with no education and those with primary and secondary education.

Table 9 presents the findings from the robustness checks. PSM-LLR and PSM-R consistently exhibited a positive effect of the intervention on the use of sanitary pads, LPN, and hygienic methods. These findings closely correspond to those derived from kernel matching in the research, thereby strengthening the empirical substantiation for the efficacy of the intervention.

Discussion

In this study, we investigated the impact of sanitary pad distribution programs on the menstrual hygiene practices of adolescent girls and young women in rural Assam and Tripura. Our findings reveal a significant increase in sanitary pad usage among young women in the intervention states, suggesting effectiveness in addressing barriers like affordability and lack of information. This positive shift is particularly pronounced among younger girls (age 15–19 years), highlighting their heightened receptiveness to such interventions (Montgomery et al. 2012, Chauhan et al. 2021). Interestingly, alongside increased access to menstrual products, there has been a notable rise in ovulation knowledge among them. However, a concerning trend emerges through the statistically significant increase in STIs within this demographic. These findings underscore the complex interplay of socioeconomic, demographic, and behavioral factors influencing STI prevalence among young women, suggesting the need for age-specific approaches in sexual health interventions. Our analysis also exposes interesting patterns related to socioeconomic factors, education, and media exposure. Notably, our findings reveal a significant trend favoring lower socioeconomic groups, with the poorer and poorest categories demonstrating the most substantial increases in the adoption of sanitary pads and LPNs. The analysis also suggests that individuals with a secondary school education stood out as the group with the highest adoption of both pads and hygienic methods. This highlights the crucial role that education plays in promoting improved menstrual hygiene practices. Additionally, high media exposure emerged as a potent influencing factor, playing a pivotal role in raising awareness and knowledge about menstrual hygiene. It is also crucial to highlight the intervention’s effectiveness in addressing barriers across different levels of women’s autonomy.

The distribution of sanitary pads appears to positively impact the adoption of more hygienic menstrual health practices among young women, consistent with findings from other studies (Austrian et al., 2021, Hennegan and Montgomery 2016, Borkar et al. 2022). This direct intervention may have increased curiosity and willingness to try sanitary pads, especially among younger girls who are more open to changing their habits. Although the decrease in cloth usage has not yet reached statistical significance, it underscores a shift in preferences toward pads driven by their availability and affordability (Singh et al. 2022b). Women’s knowledge of ovulation and the menstrual cycle, including the various reproductive changes associated with these processes, is crucial for their reproductive health (Ayoola et al. 2016). The results showing an increase in ovulatory knowledge among younger girls likely reflects their higher level of engagement in educational awareness programs. However, it is imperative to conduct a more in-depth examination of the factors contributing to high occurrence of STIs, such as the possible influence of phthalates and Volaile organic compounds found in certain sanitary products (Lin et al. 2020). Deka et al. (2015) conducted a study among adolescent girls aged 10–19 years in Guwahati’s urban slums, focusing on menstrual health, hygiene practices, and health-seeking behavior. They found a high incidence of dysmenorrhea, yet only a few girls sought treatment. The prevalence of reproductive tract infections was notably higher in the 15–19 years age group compared to the 10–14 years age group. A majority of girls used old cloth pieces for menstrual hygiene, often reusing them after washing, rather than disposable sanitary napkins. Additionally, other factors, such as inadequate WASH practices, can also lead to adverse health outcomes (Torondel et al. 2018). Mass media campaigns, utilizing platforms like television, radio, and newspapers, passively expose large populations to health-related messages, often competing with pervasive product marketing and entrenched social norms and behaviors (Wakefield et al. 2010). The results here are in agreement with previous studies where campaigns have been shown to effectively induce positive changes in health-related behaviors on a large scale, especially when supported by available services, community programs, and policies that facilitate behavior change (Desai et al. ). Additionally, even women with limited personal autonomy experienced positive outcomes, underscoring the intervention’s ability to empower and benefit women across various societal strata.

This work underscores the importance of targeted interventions to promote sustained attitudinal and behavioral changes in menstrual hygiene practices. The findings also suggest several implications and recommendations. First, expanding sanitary pad distribution programs and the use of mass media can significantly improve MHM. Educational initiatives should be integrated into school curricula and community workshops to enhance health and hygiene awareness, including ovulatory knowledge. Addressing the rise in STIs requires incorporating STI screening and ensuring the safety of sanitary products. One of the key intermediaries that make a substantial effort in implementing MHS is frontline workers such as ASHAs (Garg et al. 2021). Capacity-building activities (Vayeda et al. 2022), monitoring, and enhanced incentivization are crucial in aiding behavioral changes in the women they interact with. Policies should focus on lower socioeconomic groups and support secondary education to maximize the adoption of hygienic methods. Finally, interventions must be inclusive, benefiting women across different levels of autonomy, and ensure community engagement and supportive structures for their empowerment. These strategies can collectively enhance the effectiveness of menstrual health programs, leading to better health outcomes for young women in rural areas.

Limitations

This study is not without its limitations. Firstly, the unavailability of comprehensive data on sanitary pad distribution prior to 2017 in the Northeast states constrains our analysis. Although we utilize NFHS-4 and NFHS-5 as baseline and postintervention data, respectively, the lack of precise distribution data before 2017 may limit our ability to fully account for pre-existing trends or differences in pad accessibility across states. However, our application of the PSM-DID approach mitigates some of these concerns. Additionally, our focus on girls aged 15–24 years restricts the generalizability of our findings to a broader age range, and the geographic scope confines the study to rural areas with distinct socioeconomic and cultural contexts. Furthermore, we acknowledge the potential for unmeasured confounding due to factors not captured in our dataset, such as local cultural norms or individual attitudes toward menstrual hygiene. Our reliance on secondary data from NFHS datasets also presents limitations, including the fixed set of variables available and the lack of data on environmentally safe disposal of sanitary pads. Finally, self-reported data introduce potential biases, and we cannot completely rule out the possibility of time-varying confounders or differential trends between treatment and control states.

Conclusion

This study examined the impact of sanitary pad distribution programs as part of MHS in rural Northeastern states of Assam and Tripura, providing valuable insights into menstrual hygiene practices among adolescent girls. The results indicate a significant increase in sanitary pad usage among young women in the intervention areas, effectively addressing barriers such as cost and lack of information. This beneficial change is significant among younger girls (aged 15–19 years), underscoring strong acceptance of such interventions. Additionally, an increase in STIs among this group necessitates further investigation despite a notable rise in ovulation knowledge in them. The data also uncover significant trends linked to socioeconomic status, education, and media exposure. Remarkably, the most substantial increases in the adoption of sanitary pads and hygienic methods were observed among lower socioeconomic groups, particularly the poorest categories. The analysis also suggests that individuals with secondary school education stood out as the group with the highest embrace of both pads and hygienic methods, underscoring the crucial role education plays in promoting better menstrual hygiene practices. High media exposure has proven to be a crucial factor in enhancing awareness and knowledge about menstrual hygiene. The intervention’s success across different levels of women’s autonomy highlights the need for inclusive and empowering health programs

Acknowledgements

This study derives direction and ideas from the Chancellor of Amrita Vishwa Vidyapeetham, Sri Mata Amritanandamayi Devi.

Author contributions

Krishnashree Achuthan (Conceptualization, Supervision, Review and editing of the manuscript, Approval of the final manuscript), Sugandh Khobragade (Methodology, Formal analysis, Writing—original draft, Approval of the final manuscript), and Vysakh Kani Kolil (Methodology, Writing—original draft, Approval of the final manuscript).

Reflexivity statement

The inclusivity within the authors’ group is manifested in various aspects, including gender (one female and two males) and diverse areas of expertise such as engineering, science, statistics, and policy. The group comprises one experienced researcher and two early-career researchers working in academia. The experienced researcher specializes in menstrual health with an emphasis on sustainable development. All the authors are locally based and have extensive experience in conducting health economics, policy, and health system research in India.

Ethical approval

Ethical approval for this type of study is not required by our institution.

Conflict of interest

None declared.

Funding

This work was funded by Amrita Vishwa Vidyapeetham.

Data availability

The data underlying this article will be shared on reasonable request to the corresponding author.

References