Menstrual hygiene management among visually impaired women

Abstract

This descriptive study aimed to determine the menstrual hygiene management among visually impaired women. The study sample included 187 visually impaired women. Data were evaluated using descriptive statistics. Of the visually impaired women, 61.5% had knowledge of menstrual hygiene management. They obtained this information mostly from their mothers (49.5%). Of them, 95.7% used sanitary pads, 52.4% changed their sanitary pads less than four times a day. Only 52.9% of the women managed their menstrual hygiene dependently. Most of the women determined the start date of their menstrual cycle noticing the smell of blood and determined the end date monitoring the duration of their normal cycle. In conclusion, visually impaired women had difficulty in managing their menstrual periods independently, their menstrual hygiene practices were not at a desired level, almost half of them received support in menstrual hygiene management, most of them used some indicators to determine the start/end of their menstrual period.

Keywords

Hygiene menstruation nurses visually impaired individuals women’s health

Introduction

Women in the reproductive age group have a menstrual cycle 11–12 times a year for approximately 30–40 years, each cycle lasting 2–7 days, from menarche to menopause (House et al., 2012), which means that a woman spends approximately 3000 days (Ministry of Drinking Water and Sanitation (MDWS), 2015; United Nations Women, 2014) (8 years) of her life menstruating. Therefore, proper management of this time, which affects women’s daily life, sexual life, and reproductive and sexual health, is highly important for both their reproductive/sexual health and general well-being.

Literature review

Proper management of menstrual hygiene depends on a woman having adequate and appropriate knowledge, appropriate hygienic supplies and environment. However, studies show that a great number of women do not have adequate knowledge about menstrual hygiene (Arumugam et al., 2014; Chandra-Mouli & Patel, 2017; Republic of Turkey Ministry of Health, Directorate General for Health Research, 2014) and perform genital and general hygiene practices incorrectly (Daşıkan et al., 2015; Pokhrel et al., 2014). In addition, inadequate knowledge and supplies required for menstrual hygiene management (MHM), obstacles, and incorrect hygiene practices result in women experiencing health problems (Abd-El Sattar Ali & Abd-El Aal, 2015; Koyun et al., 2013; Ravisankar & Kanmani, 2014).

There are more than 1 billion people living in the world with different forms and degrees of disabilities (World Health Organization [WHO], 2011). The number of visually impaired people who comprise approximately one-fourth of all disabled people was 223 million in 2010 (Stevens et al., 2013) while this number reached 253 million in 2017 (WHO, 2017). Visually impaired women, who are included in the disabled groups, have menstrual cycles similar to non-disabled women (Maxwell et al., 2007). Implementation of MHM is the only point that distinguishes visually impaired women from their non-disabled counterparts. The method of training that should be provided to the visually impaired women (regarding menstruation, use of pads or tampons, and hygiene) or the level of support varies by the degree of the disability the woman has and their symptoms associated with menstruation (Kirkham et al., 2013). For example, women with low vision may have less difficulty in managing menstrual hygiene than someone completely blind. Therefore, a blind woman may need to receive more support from families and friends during MHM (Maxwell et al., 2007).

Protection and promotion of health are significant duties of nurses. Therefore, helping a woman gain the knowledge and autonomy she needs to perform MHM is one of the responsibilities of nurses. Visually impaired women, in particular, are likely to require more nurses’ support for this issue. There are few studies in the literature regarding the way visually impaired women conduct MHM and their needs (Kanmani & Ravisankar, 2016a, 2016b; Yaşar et al., 2017) Understanding the current situation and needs of visually impaired women during MHM is important for the nurses’ caregiving and educational roles, as well as their innovative approaches.

Study aim

This study aims to determine the MHM of visually impaired women.

Method

Design and sample

This study was conducted between 2017 and 2018 using the descriptive research design. The study was conducted with the subscribers of an audio magazine for women issued by the Six Points Association of the Blind in Turkey and made available to the subscribers online or as CDs (WEB_1, 2017). The population of the study included 522 visually impaired women who subscribed to this magazine. The sample size was calculated using a sampling formula for known population (90% confidence interval, p = .5, N = 522). Accordingly, the study was intended to include at least 179 participants. It was completed with 187 women selected out of the visually impaired women who were subscribers of the Kibele magazine, agreed to participate in the study and had not gone through menopause, using the purposive sampling method.

Study instrument and data collection

The study data were collected through a telephone interview method using a questionnaire form. The questionnaire form consisted of two sections and 42 questions. The first section included nine questions on personal information such as age, education level, the time when the vision impairment began and the degree of vision impairment. The second section focused on MHM and included 32 questions (27 closed- and 5 open-ended questions) on visually impaired women’s practices with MHM, the effect of menstrual period on their social lives, and their needs regarding the menstrual period. Following the interview, the participants were asked whether they had anything to ask or say regarding women’s health.

The questionnaire form created was tested for understandability and applicability through telephone interviews with five visually impaired women who were members of the Six Points Association of the Blind, but not subscribers to the Kibele magazine. The pilot study was carried out to determine whether the questions were correctly understood, as the data would be collected by telephone calls. Since it is difficult to reach visually impaired women in Turkey, the number of participants in the pilot study was limited to five. The questionnaire form was not changed after the pretest. The data were collected through telephone interviews between April 2016 and December 2017. The telephone interviews lasted approximately 20–25 min (minimum 10, maximum 58 min).

The participants’ voices were not recorded during data collection. During the telephone calls, the researcher read the questions, the participants answered them, and then the responses were marked on the questionnaires. Some of the questions were open-ended (How do you recognize the onset and end of menstruation? What kind of difficulties do you have with changing panty liners or in social life? etc.). The responses to these questions were categorized afterward.

Data analysis

The data were analyzed using the SPSS 18 (Statistical Package for the Social Sciences) software package. The sociodemographic characteristics of the visually impaired women and their practices for MHM were evaluated using descriptive statistics (mean, frequency, and percentage). Since the questionnaire was prepared to collect quantitative data, and the data were not collected by telephone calls in the qualitative study, the responses to the open-ended questions were not subjected to qualitative data analysis. However, some of the participants explained their difficulties with MHM very well in their own words, so some of their responses were included in this study.

Ethical consideration

Adnan Menderes University, Faculty of Medicine, Non-Invasive Clinical Research Ethics Committee gave approval for the study (approval number: 2016/948). Written permission was obtained from the Six Points Association of the Blind (permission date: 23 September 2016 and number: 38690). Because data were collected by telephone, verbal consent was obtained from the participants informing them about the aim of the study and the use of data for scientific purposes.

Results

Participants’ characteristics

The mean age of the visually impaired women included in the study was 32.89 ± 8.27 (min. 16, max. 53). Of the participants, 49.7% were high school graduates and 38.5 % had a professional life. Of them, 79.1% were blind and 20.9% had low vision. The women were asked when their disability began, and approximately three out of four women (71.7%) reported that they were born blind. The study found that the menarche age of the visually impaired women varied from 9 to 17, the mean menarche age was 12.93 ± 1.23, and their mean duration of menstrual bleeding was 5.36 ± 1.52 days (min. 3, max. 10) (Table 1)

Table 1.

Visually impaired women’s sociodemographic and menstrual cycle characteristics (N = 187).

Sociodemographic characteristics
Age	$\bar{X}$ = 32.89 ± 8.27 (min. 16, max. 53)
	N	%
Education level
Illiterate	7	3.7
Literate	6	3.2
Primary school graduate	13	7.0
Middle school graduate	22	11.8
High school graduate	93	49.7
University graduate	46	24.6
Wage-earning employment status
No	115	61.5
Yes	72	38.5
Degree of visual impairment
Blind	148	79.1
With low vision	39	20.9
The time when vision impairment began
Born blind	134	71.7
Went blind	53	28.3
Menstrual cycle characteristics
Age of menarche	$\bar{X}$ = 12.93 ± 1.23 (min. 9, max. 17)
Duration of menstruation	$\bar{X}$ = 5.36 ± 1.52 (min. 3, max. 10)
	N	%
Duration of menstruation (days)
3–4	53	28.3
5	58	31.0
6–10	76	40.7
Obtained information about menstruation
Obtained	115	61.5
Did not obtain	72	38.5
Information sources of menstruation^a (n = 115)
Mother	57	49.5
School	47	40.1
Health care professional	20	17.4
Friend	12	10.4
Relative	12	10.4
Internet	6	5.2
Experiencing a health problem during menstruation
No	98	52.4
Yes	89	47.6
Heath problems experienced during menstruation^a (n = 89)
Abdominal pain	71	79.8
Low back pain	32	36.0
	N	%
Nausea-vomiting	13	14.6
Inguinal pain	7	7.9
Irritability	4	4.5
Other^b	4	3.1
Practices performed for health problems^a (n = 89)
I do not do anything	44	49.4
I take medicine	30	33.7
I use hot water bottle	15	16.9
I take a rest	9	10.1
I drink herbal tea	4	4.5
Other^c	4	4.5

Note: Bold value shows the highest value in the data.

More than one answer was given. The percentages were calculated based on “n.”

Migraine attack (n = 1), headache (n = 1,) fatigue (n = 1), and dizziness (n = 1) problems were included in this group.

The answers I see a doctor (n = 1), I take a bath (n = 1), and I eat chocolate (n = 1) were included in this group.

Participants’ MHM

Of the visually impaired women, 61.5% received information on menstruation, and they obtained this information mostly from their mothers (49.5%). The women were asked whether they experienced health problems during menstruation. Approximately one out of every two visually impaired women (47.6%) was found to experience problems, and the most widely observed problem (79.8%) was abdominal pain. Of the participants, 41.5% did not do anything to solve the health problems experienced during menstruation. The women who made attempts to address the health problems primarily took a painkiller (33.7%) and used a hot water bottle (16.9%) (Table 1).

Of the visually impaired women, 95.7% used sanitary pads during menstruation and 52.4% changed menstruation supplies such as pads/pieces of cloth/tampons less than four times a day. Wrapping the pad up in a piece of paper and/or its package (99.5%) was the method the women preferred most to dispose of the supplies they used during their menstrual period. Of the visually impaired women, 25.1% washed their hands both before and after going to the toilet. Approximately one out of two participants cleaned their genitals front-to-back (56.1%), most of the participants (93.6%) used toilet paper and water together for daily genital cleaning, and 33.2% of the participants did not take a bath during menstruation. The women did not take a bath primarily because they believed that the bleeding would stop (48.3%), were worried that the bathroom would be covered in blood (22.6%), and thought that taking a bath would cause pain (12.9%) (Table 2).

Table 2.

Visually impaired women’s practices for menstrual hygiene (N = 187).

Practices	N	%
Supplies used during menstruation^a
Sanitary pad	179	95.7
Diaper	19	10.2
Tampons	5	2.7
Cloth	3	1.6
Under pad	2	1.1
Period panties	1	0.5
Frequency of changing the supply used (on the day when bleeding is most intense)
Less than four times a day	98	52.4
Four to six times a day	62	33.2
Seven to 12 times a day	27	14.4
Way of disposing of the used supply^b (n = 185)
Throwing the pad in the trash after wrapping it up in a piece of paper and/or its package	184	99.5
Throwing the pad in the trash without wrapping it up	1	0.5
Washing hands before going to the toilet
No	140	74.9
Yes	47	25.1
Washing hands after going to the toilet
Yes	187	100.0
Way of cleaning the genitals
Front-to-back	105	56.1
Back-to-front	59	31.6
Randomly	23	12.3
Supplies used in daily genital cleaning
Toilet paper and water	175	93.6
Only toilet paper	10	5.3
Only water	2	1.1
Taking a bath during menstruation
No	62	33.2
Yes	125	66.8
Reason for not taking a bath^a (n = 62)
Bleeding stops	30	48.3
The bathroom is covered in blood	14	22.6
Pain occurs	8	12.9
Infection is caught	7	11.3
The menstrual cycle lasts longer	7	11.3
A cyst is formed	2	3.2
It is a sin	2	3.2
The bathrobe is stained with blood	1	1.6

More than one answer was given. The percentages were calculated based on “n.”

One person who used a piece of cloth, but threw it in the trash instead of washing was included (n = 185).

In addition to the findings on the table, the visually impaired women had problems with providing hygiene and disposing of used pads when they were away from home. Following are statements for the problems the women experienced regarding this issue:

If I am out, I cannot find anywhere to put the clean pad when I go to the toilet. Sometimes I have difficulty in finding a trash bin. (Aged 43, born blind)

. . . A directive label can be hung on the back of the toilet door such as “There is a hanger above the door. There is . . . on the right of the siphon, and . . . on the left of it.” (Aged 21, born blind)

The indicators that the visually impaired women used to identify the start of their menstruation based on the degree of the disability were examined. The blind determined the start of menstruation mostly by noticing the smell of blood (54.1%), and those with low vision determined it by putting the napkin closer to the eye and seeing blood (87.2%). The women with low vision determined the end of menstruation mostly (77%) by not seeing the blood, whereas the blind women determined it often (22.3%) by the dryness of the pad and not feeling the wetness (19.6%) (Table 3). Here are some of the statements of the visually impaired women during the interviews to understand the start and end of menstruation:

Table 3.

Methods for the visually impaired women to understand the start and end of their menstruation (N = 187).

Methods to determine whether menstruation started or ended	Blind^a		With low vision^a (n = 39)		Total^a
Methods to determine whether menstruation started or ended	(n = 148)		With low vision^a (n = 39)		(n = 187)
	n	%	n	%	n	%
Methods to determine whether menstruation started
Noticing the bloody smell (smelling the pad/discharge)	80	54.1	2	5.1	82	43.9
Abdominal pain	67	45.3	9	23.1	76	40.6
Tracking the menstrual cycle	36	24.3	7	17.9	43	23.0
Distinguishing the density of blood from the discharge	37	25.0	2	5.1	39	20.9
Formation of wetness	25	16.9	2	5.1	34	18.2
Seeing the blood (by putting the napkin closer to the eye)	0	0	34	87.2	34	18.2
Showing their mother the pad/toilet paper	33	22.3	0	0	33	17.6
Stickiness of blood	6	4.1	1	2.6	7	3.7
Breast pain	6	4.1	1	2.6	7	3.7
Inguinal pain	4	2.7	0	0	4	2.1
Low back pain	3	2.0	0	0	3	1.6
Leg pain	2	1.4	0	0	2	1.1
Distinguishing blood from discharge by its higher amount	1	0.7	1	2.6	2	1.1
Using a color diagnostic device	2	1.4	0	0	2	1.1
Showing their daughter/sibling the pad/toilet paper	2	1.4	0	0	2	1.1
Methods to determine whether menstruation ended
Being unable to understand/extending using pads to 1 or 2 days longer	41	27.7	6	15.4	47	25.1
Tracking the duration of menstruation	42	28.4	4	10.3	46	24.6
Showing their mother the pad/toilet paper	33	22.3	0	0	33	17.6
Dryness of the pad	33	22.3	0	0	33	17.6
Not feeling wetness	29	19.6	2	4.7	31	16.6
Not seeing blood any more (by putting the napkin closer to the eye)	0	0	30	77.0	30	16.0
The hand’s not getting contaminated during cleansing oneself	9	6.2	1	2.6	10	5.3
Disappearance of the smell of blood	4	2.7	0	0	4	2.1
Feeling a mild pain	3	2.0	0	0	3	1.6
The changing viscosity	3	2.0	0	0	3	1.6
Using a color diagnostic device	1	0.7	0	0	1	0.5
Showing their daughter the pad/toilet paper	1	0.7	0	0	1	0.5

Note: Bold value shows the highest value in the data.

More than one answer was given. The percentages were calculated based on “n.”

The biggest problem is failing to understand the end of the period. I cannot feel. The blood is coming only in drops. If there is someone, you show the pad; otherwise, you wait one more day. (Aged 34, born blind, housewife)

In general, we understand whether bleeding is going on just in the way a usual woman understands it. I think the main problem is to distinguish between the blood and the discharge. (Aged 33, born blind)

You cannot see the color. You hardly distinguish the discharge. There is also a prayer aspect of it . . . I wash the toilet more frequently in those days to avoid it to be covered in blood. (Aged 20, born blind, housewife)

More than half of the visually impaired women (52.9%) received support during menstruation, and they obtained this support mostly from their mothers (70.8%). The women mostly received support for the provision of supplies to be used during menstruation, checking whether the clothes were stained with blood and whether the toilet was left clean (Table 4). Here are some statements of the women during the interviews regarding support received during MHM:

Table 4.

Visually impaired women’s status of receiving support for the menstrual hygiene management (N = 187).

Data on receiving support	n	%
Receiving support
No	88	47.1
Yes	99	52.9
Support was taken from^a (n = 99)
My mother	68	70.8
My friend	20	20.2
My husband	17	17.2
My sibling	15	15.2
Other^b	8	8.1
Support was taken for^a (n = 99)
Providing menstrual supplies	77	77.8
Checking whether clothes were stained with blood	38	38.4
Checking whether the toilet was clean or not	26	26.3
Understanding both the start and the end of the menstrual cycle	16	16.2
Understanding the start of the menstrual cycle	10	10.1
Understanding the end of the menstrual cycle	7	7.1
Checking whether the bed was stained with blood	2	2.1
Putting the cloth in the washing machine	2	2.1

More than one answer was given. The percentages were calculated based on “n.”

The options daughter (n = 3), mother-in-law (n = 3), relative (n = 1), and neighbor were collected under this group.

Now I have my mother by me. What will I do alone when she is not by me in the future? I want to succeed in performing this task on my own. (Aged 22, born blind)

If I were able to see, I would track my period more easily and realize whether my clothes were stained with blood or not. (Aged 33, born blind)

I live alone. Therefore, I cannot notice whether my clothes are stained with blood and I experience problems. (Aged 20, born blind)

Discussion

This study sought an answer to the question “How do visually impaired women manage their menstrual hygiene?” and found that the menstrual hygiene practices of the women were not at a desired level (more than half of the women changed pads less than four times a day, only one-fourth of the women washed their hands both before and after going to the toilet, approximately half of them did not clean their genitals properly, and approximately one-third of them did not take a bath during menstruation). The women had the most difficulty in determining the start and end of menstruation. They received support for this issue and used some indicators of their own to determine the start or end of menstruation. One out two visually impaired women received support for MHM. Approximately one-fifth of them had difficulty during pad changing and nearly half of them could not manage their menstrual period independently.

The mean menarche age of the women included in the study was 12.93 ± 1.23, which is similar to the results found in studies conducted with visually impaired women (Kanmani & Ravisankar, 2016a; Umlawska, 2007) and women with no sight impairment (Kusuma & Mansoor, 2016; Republic of Turkey Ministry of Health, Directorate General for Health Research, 2014; Tegegne & Sisay, 2014). This shows that visually impaired women have their menarche at a usual age range similar to sighted women.

The mean duration of menstruation of the women was 5.36 ± 1.52 days. Similarly, studies conducted with sighted women showed that the duration of menstruation of these women also ranged from 3 and 7 days (Pokhrel et al., 2014; Republic of Turkey Ministry of Health, Directorate General for Health Research, 2014). Furthermore, 40.7% of the participants reported that the duration of their menstruation ranged from 6 and 10 days. This result may be influenced by the duration stated as longer because they did not know that their menstrual period had ended, which means the actual duration of their menstruation might have been shorter. Yet, most of the visually impaired women have a normal menstrual period. This finding of this study complies with the duration of menstruation of sighted women.

More than half of the women who participated in this study (61.5%) were found to receive information regarding menstruation. This rate was found lower (33.4%) in a study conducted by Yaşar et al. (2017) with visually impaired women who lived in Ankara, Turkey. The difference from the previous study could be attributed to the higher number of educated women in this study. Being educated indicates a higher level of questioning and being informed.

This study found that the visually impaired women obtained information regarding menstruation mostly from their mothers (49.5%). A study conducted in Turkey with visually impaired women (Yaşar et al., 2017) and several studies conducted with sighted women also showed that women obtained information regarding menstruation mostly from their mothers (Gupta et al., 2015; Misra et al., 2013; Santra, 2017; Sowmya et al., 2014). The findings of this study support the relevant literature showing that mothers have very important roles in their daughters’ management of menstrual hygiene. Moreover, restricting visually impaired women to social isolation due to family and social reasons causes them to go out of the home less frequently, make less friends and have a limited social environment. As a result, the person whom they are together with and spend more time with are their mothers. Consequently, their primary information source regarding menstruation is their mothers.

School was the second information source for the visually impaired women with a close rate (40.1%) to that of the mothers. This finding is similar to those of the studies conducted by Sowmya et al. (2014) and Gölbaşı et al. (2012). The schooling rate of the visually impaired women included in this study was higher than those of the disabled and non-disabled women in Turkey (Turkish Statistical Institute [TÜİK], 2015; Turkish Statistical Institute & Republic of Turkey Ministry of Family and Social Policies, 2010), which may have led school to rank second in providing education during menarche. Therefore, mothers and teachers should also have an understanding of reproductive health issues including MHM since it is important for the improvement of reproductive health of visually impaired women.

Approximately only two out of 10 women who participated in this study obtained information from health care professionals. Visually impaired women prefer obtaining information regarding reproductive health mostly from health care professionals (Yaşar et al., 2017). However, the number of the women who obtained information from health care professionals is very low. Visually impaired women have the right to have access to health care and be informed like all other individuals. Visually impaired women included in this study had a low rate of obtaining information from health care professionals. The low rate could be related to the limited access to health care services.

Approximately one out of every two visually impaired women experienced problems during menstruation, primarily abdominal pain and low back pain. This result of this study is similar to those of the studies conducted with sighted women (Daşıkan & Saruhan, 2014; Pokhrel et al., 2014). This result suggests that vision does not affect the problems experienced during menstruation and reveals that the visually impaired women have similar problems to those reported in the literature during menstruation although the ranking of the problems experienced may differ.

Almost half of the visually impaired women did not take any treatment for health problems experienced during menstruation, and almost one-third of the women who took steps for health problems took medicine. This rate was found higher in a study conducted with sighted women (Daşıkan et al., 2015). This suggests that visually impaired women have limited support accessing medicine. Few drug packages in Turkey include embossed letters (the Braille alphabet) for use by visually impaired individuals. Therefore, visually impaired women may choose not to take medicine because they cannot be sure they are using the correct medicine. Furthermore, TÜİK and Republic of Turkey Ministry of Family and Social Policies (2010) reported that visually impaired women experience problems accessing health services; consequently, they receive less than adequate service resulting in unresolved health problems during menstruation.

Almost all (95.7%) of the women who participated in this study were found to use sanitary pads during menstruation. The rate of using pads was also found similar in another study conducted with visually impaired women (Yaşar et al., 2017). This shows that visually impaired women used appropriate and similar supplies during menstruation.

Sanitary supplies used during menstruation such as pads, pieces of cloth, or tampons should be changed every 3 or 4 hr, six to eight times a day (Taylor et al., 2010; UNICEF, 2010). This study examined the pad changing frequency of the visually impaired women and found that more than half of the women changed their pads less than four times a day. This finding of this study is similar to the findings of the studies in the literature conducted with sighted women (Geethu et al., 2016; Pokhrel et al., 2014; Republic of Turkey Ministry of Health, Directorate General for Health Research, 2014) and adolescents (Alam et al., 2017; Yadav et al., 2017). These results suggest that visually impaired women have inadequate frequency of changing their pads. Visually impaired women referred to mothers and schools the most for sources of information during the MHM. The participants had a lower frequency of changing pads than expected, which indicates that mothers and school staff did not have adequate qualifications regarding MHM. Therefore, community health, women’s health and school health nurses should primarily focus on these individuals and institutions.

Eight out of 10 women included in this study were determined to wrap up the used pad in its own package. However, practices for disposal of a used pad differ by communities. Used pads are found to be disposed of by being thrown in the trash in Turkey (Arıkan et al., 2004; Koyun et al., 2013), while they are thrown into the toilet in Ethiopia (Ketema Gultie, 2014), and they are burnt in India (Arumugam et al., 2014; Reshmi et al., 2015). These results show that the disposal method of used menstrual supplies is mostly affected by social norms instead of vision loss. Disposal in accordance with the waste management of municipalities or burning pads in the health care institutions is the most appropriate method of disposal of the menstrual supplies such as used pads or tampons to protect community health and prevent the spread of blood-borne infections (MDWS, 2015). When visually impaired women have to use toilets in public areas particularly in their menstrual periods, they experience problems with maintaining their hygiene and disposing of the used pads in the trash since they do not know the layout of those toilets. Disabled toilets in public areas are mostly customized for physically disabled people who use wheelchairs. Amenities should be customized in all public areas to include individuals with visual disabilities. Therefore, visually impaired individuals can maintain their MHM outside of their home.

Washing hands before and after going to the toilet is important for both personal hygiene and environmental health in the MHM. A large number of visually impaired women who participated in this study reported that they washed their hands after going to the toilet while only one-fourth of them washed their hands both before and after going to the toilet. This finding of this study is similar to the study conducted by Yaşar et al. (2017) with visually impaired women and the studies conducted with sighted women (Daşıkan et al., 2015; Yadav et al., 2017). Hand washing gains more importance during the menstrual period to avoid urogenital system infections. Teaching the importance of washing hands at an early age is vital to establish good practices. It is important to educate mothers and teachers who are the leading sources of information for visually impaired women about general and menstrual hygiene for the health of the next generation. Emphasis should be placed on the importance of washing hands during menstrual health education.

Cleaning their genitals from mons pubis to anus (front-to-back) is important for women to prevent urogenital infections. Almost half of the visually impaired women were found not to perform genital cleaning appropriately. This finding is similar to conducted with visually impaired women (Yaşar et al., 2017) and sighted women (Daşıkan et al., 2015). It is recommended that genitals be cleaned once with high-quality white toilet paper front-to-back, and colored toileted paper should not be used due to its pigmentary structure (Karatay & Özvarış, 2006; Ministry of General Education, 2016). In this study, four out of five women reported toilet paper and water to be the supplies used for genital cleaning. A similar result was found in a study conducted by Yaşar et al. (2017). Although this result seems positive, it indicated that one out of every five women still do not use the right supplies in perineal cleansing. This situation suggests that the women included in this study are at high risk of having genitourinary tract infection like all other women.

Taking a bath is an important and recommended behavior to maintain hygiene, reduce urinary and vaginal infections which are acquired more easily in this period, and eliminate complaints such as pain experienced during the menstrual period (Taylor et al., 2010). This study found that approximately one-third of the visually impaired women did not take a bath during menstruation. This rate was found higher (61.9%) in another study conducted with visually impaired women (Yaşar et al., 2017). The visually impaired women included in this study had higher rates of obtaining information about menstruation, education level and working, which may account for the difference. Studies conducted with sighted women show that the rate of women who do not take a bath during menstruation varies from 10% to 69% (Misra et al., 2013; Pokhrel et al., 2014), and this study had similar findings. Taking a bath more frequently in this period with confidence and without hesitation may allow visually impaired women to be at lower risk of genitourinary tract infections.

Nearly half of the participants who did not take a bath during menstruation reported the reason for this situation was their concern for stopping the blood flow. Another study conducted by Tartaç and Özkan (2011) with high school students found that the reason for not taking a bath was the concern of an increase in blood flow. Visually impaired women can have problems understanding the end of their menstruation, so they may be hesitant to take a bath. They worry that their menstruation will last longer if their blood flow decreases, and perhaps they will have difficulty in understanding the indicators of the end of menstruation if they bathe. Furthermore, the visually impaired women reported they did not take a bath during menstruation because they were concerned about the bathroom and the towels becoming soiled with menstrual blood. Visually impaired women may feel uneasy that their environment and supplies soiled with menstrual blood may be seen by relatives, and this environment and supplies may have to be cleaned by relatives leading to a sense of burden on these people. However, taking a bath is part of good hygiene particularly during menstruation and this should be explained to visually impaired women.

Visually impaired women may need to receive support in some cases to perform their activities of daily lives. In this study, visually impaired women’s status of receiving support for the MHM was examined, and approximately every other woman had to receive support during MHM. The situation for which the women received support most was the supply provision used during menstruation (77.8%), and the person from whom they received support most was their mother (70.8%). This finding of this study is similar to those conducted with disabled people (Abd-El Sattar Ali & Abd-El Aal, 2015; Joshi & Joshi, 2015). To enable visually impaired women to become more independent during menstruation, their needs from start to the end of menstruation should be determined for other studies as well. Subsequently, modifications/regulations should be made in line with the results. For example, pad aisles in markets can be arranged for visually impaired women. In addition, virtual market applications can be supported with audio commands, so visually impaired women can buy pads without going to the market.

Eyesight is important in understanding the start and end of menstruation. The study found that all of the blind women used more than one method to understand the start and end time of menstruation. Some of the women with low vision decided that using only the perception of light (acknowledging the color of blood), without requiring any other method to indicate start time. The study examined which indicators were used to identify the start of menstruation based on the degree of impairment, and two out of every five visually impaired women decided on the start of menstruation noticing the smell of blood or feeling abdominal pain, while one out of 10 women decided by showing their mother the pad/toilet paper. Dryness of the pad and not feeling wetness were the most commonly observed indicators of the end of menstruation. Moreover, one out of every four visually impaired women reported that they could not identify the end of their menstruation, and therefore, they extended the duration of pad use for one or two more days or they tracked the days. Eyesight has an important role in MHM, and the results show that women pay more attention to their senses and the symptoms in case of blindness or vision impairment. A large number of women were not able to fully understand the end of menstruation despite the indicators, which was a recognizable situation. Women who are not able to fully understand the end of menstruation may become inclined to genitourinary infections due to extending the use of pads and the low frequency of changing pads. The frequency of genitourinary infections among visually impaired women is a separate area of research.

As a result, proper management of menstruation, which is a part of a woman’s life for 30–40 years, is also important for the reproductive health of visually impaired women. Proper hygiene management can be maintained by considering sociodemographic characteristics, supply/material means, and social environment as a whole. One of the most important findings of this study is that visually impaired women experienced problems determining the start and end of menstruation, an important practice for their MHM, and deciding on the time of changing pads. Another important finding is that visually impaired women used some indicators for the time the pads needed to be changed and to know the start and end of menstruation. In addition, the menstrual hygiene practices of the visually impaired women with low education and economic levels are thought to be different as the education level and work status of the visually impaired women included in the study were higher than those of the disabled people throughout the country. The results of this study are important for nurses, health care personnel, and decision makers who will provide visually impaired women with training and counseling regarding menstrual hygiene. Knowing the current situation and planning for the relevant initiatives (training, counseling, care etc.) is an issue that should be considered by nurses.

Limitations

This study has some limitations. First, data were collected through the telephone interview method, and the findings are based on the notifications from the participants. Second, the study results represent only the data of the visually impaired women who were subscribers of the Kibele magazine and were included in the study. Therefore, the results cannot be generalized for all visually impaired women.

Conclusion

The main result of this study that was conducted to determine the MHM practices of the visually impaired women is that the visually impaired women experienced difficulties in managing their menstrual periods independently, and therefore their menstrual hygiene practices were not at an optimal level. Furthermore, they used various indicators to realize the start and end time of menstruation. One-quarter of these women could not understand that their menstrual cycle had ended. One out of every two visually impaired women needed support for many issues during menstruation and received this support mostly from their mothers.

In line with these results and to enable visually impaired women to manage their menstrual hygiene better, training regarding menstruation should be provided before menarche using appropriate training materials. The training should mainly include audio-tactile materials, and it should help them to notice the physiological symptoms that indicate menstruation is about to start, has started, or has ended (Dündar & Özsoy, 2018). The menstrual hygiene of visually impaired women is an under-researched field. Therefore, more studies of this subject need to be carried out. Developing new products to reduce their difficulties with menstruation is also recommended.

Footnotes

Author Contributions

T.D. and S.Ö. contributed to study design and manuscript writing, and T.D. performed data collection and analysis.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Tuğba Dündar

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