Sanitation and Menstrual Health Challenges Among Pandharpur Women Pilgrims: An Exploratory Study With Recommendations

Abstract

Background:

In the state of Maharashtra in India, a pilgrimage called “Pandharpur Wari” attracts half a million pilgrims annually. Orthodox Hindu culture is generally resistant to allowing women to participate in religious functions during their menstruation. With a significant female presence, ensuring adequate Water Sanitation and Hygiene (WASH) facilities and Menstrual Health and Hygiene (MHH) is crucial. Due to scant reliable quantitative data, a qualitative study was conducted to investigate first-hand accounts of experiences of WASH facilities and MHH practices of women pilgrims during 2023 pilgrimage.

Methods:

This study employed a qualitative design with convenience sampling, selecting 100 women pilgrims (aged 18-45 years) from the pilgrimage across 3 sites. Data were collected through semi-structured interviews. Descriptive and thematic analyses were conducted to examine experiences, challenges, and suggestions.

Results:

Over half (53%) were aged 32 to 41 years while (18%) were between 22 and 31 years. Most had studied up to secondary level (77%) and were married (95%). Thirty-four percent were farmers and a few had some other day job (7%). A large majority (97%) faced difficulties accessing toilets and bathing facilities, with some resorting to open defecation (36%). About (2%) used oral contraceptive to delay periods and (7%) experienced menstruation during pilgrimage. Lack of facilities for bathing and toilets along the pilgrimage route was one prominent challenge. Other challenges were, needing to bathe in the open, lack of gender-segregated facilities, and scanty sanitary facilities along the route. Women were found to be resilient in managing menstruation amidst systemic gaps. It was also found that cultural beliefs shaped pilgrimage participation while in menses and how it was hard to manage menstruation during pilgrimage without adequate infrastructure.

Conclusion:

The pilgrimage poses logistical, sanitation challenges for the pilgrims. Strategic planning, including mobile toilets, private bathing, menstrual hygiene support can improve the experience.

Introduction

Pilgrimages have been a part of human endeavours for a long time in history. The Camino de Santiago of Spain (Christianity), the Lumbini of Nepal (Buddhism), the Kumbh of India (Hinduism), the Kumano Kodo of Japan (confluence of multiple religions), or the Hajj of Saudi Arabia (Islam) are a few examples of them. ¹ The practices might vary, yet all pilgrims ultimately share a pursuit of meaning, connection, and transcendence, binding together through universal emotions and aspirations.

Pilgrimages bring with them a plethora of public health challenges. For example, “heat stroke” has been a cause of numerous deaths during Mecca pilgrimage in Saudi Arabia. ² Generally, the local governments and public health agencies are responsible to deal with various health related administrative and logistical challenges such as providing WASH facilities, potable water for drinking, toilets, and bathing areas for the pilgrims, the risk being not only harm to health and well-being of individuals but also a potential for epidemics or mass accidents by stampedes.^3,4

The pilgrimage in Maharashtra, India called “Pandharpur Wari” is an illustrious event in western India, attracting pilgrims from across the country. Over 21 days, a congregation of pilgrims cover a distance of more than 300 km while walking along palanquins carrying idols of Hindu Gods and saints. ⁴ Concrete numbers being absent and also there is a large year-to-year variability, it is anecdotally said that about half a million pilgrims partake the event. This generates a huge challenge of providing adequate water and sanitation facilities at various stopover sites. Temporary measures like mobile toilets, water supply stations, and makeshift bathing arrangements often fall short for the demand.

Though there are no exact data available, close to half of the pilgrims are women in the Pandharpur pilgrimage. ⁴ Sustainable Development Goal (SDG) number 6 aims to ensure access to clean water and sanitation for all, promoting safe and sustainable WASH practices. Achieving this goal is vital for public health, dignity, and well-being—especially in mass gatherings and pilgrimages—by preventing disease and improving safety through better WASH facilities. ⁵ Secondly, MHH highlights how social, cultural, and structural factors—like gender norms, taboos, and resource access—shape women’s hygiene practices, especially in public settings. ⁶ Given that in orthodox Hindu culture, women once were not allowed to and even today are generally dissuaded from participating in religious functions or ceremonies,^7,8 integrating this perspective is key to understanding the challenges women face during mass gatherings, emphasizing the need for gender-responsive WASH solutions that support MHM and promote equitable health outcomes. ⁹

To the best of our knowledge data or literature are absent regarding the challenges faced by women regarding the above mentioned issues in the Pandharpur pilgrimage of India. Therefore, the study was designed to explore and or document

1. The WASH-related challenges—particularly access to bathrooms, toilets, and MHH facilities—experienced by women pilgrims during the 2023 Pandharpur pilgrimage in India.

2. The MHH practices, needs, and experiences of menstruating women during the 2023 pilgrimage and,

3. Women’s suggestions for improving sanitation, hygiene, and MHH facilities during the 2023 pilgrimage.

Methods

The study adopted an exploratory qualitative design and employed convenience sampling to recruit women pilgrims participating in the Pandharpur pilgrimage. Although there was a quantitative section in the tool that collected descriptive information, the study primarily relied on a qualitative design. The descriptive quantitative component was incorporated to generate complementary data that could inform public health agencies and guide future interventions.

Previous years newspapers reported a participation of 1 to 1.5 million pilgrims in the Pandharpur every year, with women comprising 50% of the total. ¹⁰ The number of participants varies annually, and there is no established system to accurately record them. Therefore, it is difficult to plan and implement probability-based sampling methods and calculation of statistically representative sample size. Hence convenience sampling was used as the most practical approach. Data were collected at 2 locations: one near the starting point of the pilgrimage and another in a city located 50 km away, where pilgrims rest for 2 days before continuing their journey.

The first author approached 3 groups known as “Dindi” (detailed in Appendix A) and obtained permission from their leaders to recruit women pilgrims for the study. A total of 100 adult women aged 18 to 45 years, willing to give consent from these 3 Dindi groups participated in the study in the month of July 2023.

The study employed a semi-structured interview schedule. The quantitative section included closed-ended questions focussed on participants’ sociodemographic characteristics, availability of toilet/bathing facilities, types of challenges in accessing them, and questions about MHH practices. The qualitative section used open-ended questions to explore participants’ experiences with WASH facilities in the context of accessing toilets and bathrooms, their perceptions of participating in the pilgrimage while menstruating, and their suggestions for improving WASH and MHH during the event. The tool helped in getting a comprehensive data reflecting widespread issues and individual perspectives among women pilgrims.

It is important to note that as this is a pioneering study on this topic and no validated tool was available, the first author developed the tool based on their understanding of the pilgrimage. The second author provided high level feedback during the development of the tool as currently they have no direct experience of the pilgrimage, although they had exposure to the pilgrimage in the capacity of a physician about half a century ago. The tool was translated into the native language “Marathi” and pilot tested among ten women to ensure content validity. Reliability was also considered by checking the consistency and clarity of responses during the pilot, ensuring the tool would yield dependable results across participants.

Initially, data collection was carried out on paper, but subsequently, it was transferred to Excel and SPSS software for descriptive analysis that involved calculation of frequencies and means. The qualitative data were analysed thematically, using Braun and Clarke’s (2022) reflexive thematic analysis and themes identified across the data. ¹¹ The coding process in thematic analysis involved systematically identifying and labelling meaningful units of data that captured key ideas or patterns. These codes were then reviewed, grouped, and refined to develop broader themes that represented significant concepts across the dataset. Themes emerged by identifying recurring patterns, connections, and underlying meanings within the coded data.

Ethical Consideration

The study was approved by the Independent Ethics Committee of the university. Written informed consent was taken from all the women participants.

Quantitative Findings

Results

Characteristics of the Respondents

A total of (53%) respondents were in the age group of 32 to 41 years, and (18%) were in the age group of 22 to 31 years. Majority (77%) had completed education up to the secondary level, equivalent to grades of 8 to 10. Most of the women (95%) were married except (3%), who were single and (2%) were widows. Regarding occupational status, (34%) were farmers, (7%) were doing salaried jobs, (16%) were working as contract labourers, (1%) (a single person) was a bard (Kitankar), and (1%) (one person) was a Hindu temple priest (Table B1 in Appendix B).

Experiences on the Arrangements for Toilets and Bathing and the Challenges

Out of the total surveyed, (97%) reported facing challenges in accessing toilets and bathing facilities regularly while (36%) reported of defecating in the open (Table B2 in Appendix B). The multiple option findings reported overcrowding as the primary reason for difficulties in accessing toilets in (97.9%) of the cases. Concerns about sanitation, emerged in (96.8%) of cases. Additionally, (94.7%) and (93.7%) of cases identified scarcity of water and lack of access to toilets or gender separation respectively as challenges (Table B2 in Appendix B).

Experiences Related to Bathing Arrangements

Majority (98%) reported of bathing daily, out of which (76%) reported of bathing openly and (22%) reported of bathing sometimes openly and sometimes in enclosed baths. Nobody reported of receiving any adverse comment on personal hygiene and 1 reported of experiencing skin irritations.

MHH Management During the Pilgrimage

All women reported that they do not cancel the pilgrimage in anticipation of getting menstrual periods. (2%) reported taking oral contraceptives to delay their periods, which were expected during the pilgrimage days and (7%) shared that they got the menses during the pilgrimage but still continued with the journey. They were prepared and had carried sanitary pads with them.

Qualitative Findings

Theme 1: Lack of Facilities for Bathing and Toilet Along the Pilgrimage Route

Almost all participants reported significant challenges related to the lack of adequate bathing and toilet facilities along the pilgrimage route. The absence of private, segregated spaces for women, along with insufficient sanitation infrastructure, created considerable discomfort and posed hygiene risks.

Subtheme 1.1: Bathing in the Open and Lack of Gender-Segregated Facilities

After a full day of travel and halting at pre-designated stopover points, pilgrim groups typically rise early in search of shelter or covered spaces suitable for bathing. Unfortunately, such facilities are often unavailable or entirely absent. In some instances, local authorities provided water tankers at public locations to meet the pilgrims’ basic hygiene needs. However, these arrangements frequently lack essential privacy measures, with no gender-specific bathing provisions in place.

To address this gap, pilgrims, particularly women, reported that they woke earlier than their male counterparts and took the initiative to construct temporary bathing shelters near the water tankers. These makeshift structures are typically fashioned using available resources—most notably their traditional garment, the “sari,” a large rectangular piece of cloth, and wooden sticks or branches collected from the surrounding area. This simple arrangement provides a measure of privacy and is a widely observed practice across pilgrim groups, especially during the early morning hours before dawn.

In locations where natural water sources such as ponds or springs were available at resting sites, open bathing became the norm. In such cases, men and women tended to seek out separate, secluded spots to maintain gender-based privacy. While water availability was generally not a concern along the journey, the consistent lack of enclosed or secure bathing spaces—particularly for women—remained a significant infrastructural shortcoming along the pilgrimage route.

Men often bathe in the open near the water tankers, even when these makeshift bathing areas are situated in close proximity to those used by women. Despite the spatial limitations, male participants consistently exhibited ethical and culturally sensitive behaviour, contributing to an atmosphere of mutual understanding. Cooperation emerged as a key feature of this shared arrangement, enabling both men and women to navigate the use of communal spaces with respect and dignity.

This informal system allowed pilgrims to maintain personal hygiene while upholding cultural norms around privacy and gender propriety. As 1 pilgrim remarked,

We all know the difficulties, but we manage by understanding each other’s needs. No one crosses the line of decency, I have been participating in the pilgrimage for last five years but did not experience or hear about any untoward incident.

One women stated

In the crowd, privacy vanishes, and gender differences dissolve — all are treated and represented as bhaktas (devotee) of Mauli, (god) with the sole purpose of cleansing themselves to continue the journey forward.

Subtheme 1.2: Sanitary Challenges Along the Pilgrimage Route

In addition to the lack of bathing infrastructure, there was an absence of toilet facilities along the pilgrimage route—particularly for women. Women said they were surprised that despite the massive influx of pilgrims who walked long distances every year, there were no permanent sanitation provisions along the road. Mobile toilet units were provided temporarily, but they were extremely limited and often insufficient to meet the needs of the large number of pilgrims. Women reported experiencing frustration at not being able to use the toilets.

As a result, open defecation became the only viable option for most pilgrims, who were compelled to seek out secluded spots behind trees, rocks, or bushes to relieve themselves. This practice was typically undertaken during the early morning hours, in an attempt to preserve privacy and reduce embarrassment, particularly for female pilgrims. Women participants reported this as one of the most difficult aspects of the journey, citing not only discomfort and lack of privacy but also the physical and emotional toll of managing basic bodily needs under such constrained conditions.

Participants shared that given that the pilgrimage extends over a period of approximately 21 days, the continuous absence of access to safe and dignified toilet facilities imposes a considerable burden on them. This situation signifies the pressing need for gender-sensitive sanitation planning in large-scale religious and cultural mobilizations, where the well-being and dignity of all participants—especially women must be prioritized.

As 1-woman pilgrim expressed, “They woke up before dawn to find a hidden place for defecation, but it was never truly private. For women, that was the hardest part of the journey.”

While the majority of pilgrims travelled and stayed within organized groups (Dindi), a small number of individuals chose to walk alone and could afford, often stayed at the residences of relatives or family friends along the pilgrimage route, or opted for hotel accommodations. This flexibility allowed these pilgrims to access a modicum of comfort that was not available to those traveling in larger groups. However, the vast majority of pilgrims remained with their respective pilgrimage groups, adhering to the collective schedule and communal living arrangements.

In some cases, particular groups would reach out to well-acquainted relatives or known contacts along the route, requesting them to make specific arrangements for their accommodations, including provisions for bathing and sanitation facilities. In these instances, the relatives or acquaintances made the necessary arrangements, sometimes offering makeshift toilet and bathing facilities on private properties or in nearby areas. While these solutions were often seen as a temporary relief, they did not always meet hygiene standards, and in many cases, the facilities provided were subpar.

Challenge to avail a toilet facility a participant’s experience.

Throughout my 21-day pilgrimage, I had the opportunity to use closed toilets only twice.

The pilgrims’ perception towards toilet and bathing facility is reflected in the quotes given below.

We often overlook these aspects and simply continue walking, taking advantage of restroom and bathing opportunities when available, or else continue without interruption.

There is one organized group a Dindi that excludes women due to challenges related to sanitation, hygiene, and menstrual issues.

Theme 2: Women’s Resilience in Managing Menstruation During the Pilgrimage Amidst Systemic Gaps

The theme highlights how women are resourceful in managing menstruation during the pilgrimage, despite the lack of adequate facilities provided by the system. While women pilgrims adapt and develop coping strategies, the absence of proper sanitation and menstrual care infrastructure underscores the system’s failure to meet their specific needs during the journey.

Subtheme 2.1

1: Perceptions About Walking in the Pilgrimage With Menstruation Are Deeply Rooted in Socio Cultural Beliefs.

Women reported their deep-rooted socio-cultural beliefs and embodied experiences of walking in the pilgrimage with menstruation. Many participants described menstruation as a period of impurity, culturally perceived to be incompatible with the sanctity of the pilgrimage. Walking while menstruating was generally regarded as inappropriate, with most women sharing that they intentionally planned their participation to avoid their menstrual cycle coinciding with the pilgrimage dates. However, the participants generally expressed an attitude of acceptance toward the possibility of women pilgrims menstruating during the pilgrimage, acknowledging that the journey could be continued with appropriate arrangements and attention to personal health.

A participant’s perspective on participation of menstruating women in pilgrimage

Ultimately, the decision of walking in the pilgrimage in menses relies with each individual woman, considering her own physical capacity and circumstances.

For those who did menstruate during the journey, considerable efforts were made to adhere to perceived norms of cleanliness and social distance. Women reported taking regular baths and maintaining heightened personal hygiene while walking. One pilgrim noted that menstruating women were expected to maintain physical distance from others and even separate their personal belongings, a practice rooted in longstanding cultural taboos around ritual purity and contamination.

These accounts suggest that while the continuation of the pilgrimage during menstruation is not formally prohibited, it remains heavily stigmatized. Participation during menstruation is tolerated to some extent as an unavoidable biological reality, but it is not fully normalized within the collective spiritual ethos of the pilgrimage. The prevailing sentiment among women was that walking during menstruation should be avoided—not only for cultural reasons but also due to physical and health-related challenges. Many expressed concern that the physical demands of the pilgrimage, including long hours of walking and limited access to sanitary facilities, could exacerbate discomfort and health risks during menstruation.

Moreover, some women feared social exclusion or discrimination from within their own groups if they were known to be menstruating. This potential for ostracization further reinforced the perception that it is preferable for women to refrain from participating in the pilgrimage during their menstrual cycle. As 1 participant put it, “Walking in menses is not only difficult for the body—it isolates you from your group.”

Subtheme 2.2: Experiences of Managing the Menstruation in Resource Constraint Situations

Despite these beliefs, a number of women chose to continue with the pilgrimage even while menstruating, demonstrating a form of bodily negotiation and resilience. Anticipating the onset of their menstrual cycle, many came prepared with sanitary pads and basic medications. In some instances, women procured sanitary products from medical stores in larger towns and cities along the route. A few even received them free of charge from non-governmental organizations that had set up stalls to assist pilgrims. In more proactive cases, some participants reported resorting to oral contraceptives to delay menstruation altogether, thus allowing them to complete the journey without interruption.

These accounts illustrate the persistent stigma surrounding menstruation within the context of religious practice. While continuing the pilgrimage during menstruation is increasingly seen as a practical necessity, it remains a culturally sensitive issue. The prevailing sentiment among many women was that menstruating during the pilgrimage should be avoided—not only due to socio-cultural taboos, but also because of physical discomfort, logistical challenges, and concerns over social acceptance. The arduous nature of the journey—combined with limited access to sanitation and privacy—was cited as making menstruation particularly difficult to manage.

An additional and often underreported challenge faced by menstruating women during the pilgrimage was the lack of appropriate facilities for changing and disposing of sanitary pads. In the context of an already inadequate infrastructure—marked by the near-total absence of toilets and bathing areas—this aspect of menstrual hygiene management posed significant logistical and emotional strain. They were not able to access private clean spaces for changing menstrual products which created physical discomfort. Women reported having to wait for long stretches of time or seek secluded areas, often under unsanitary conditions, to manage their menstrual hygiene. The absence of designated disposal systems further complicated the issue, as used sanitary products were sometimes buried, burned, or carried until a proper waste bin could be located—usually only in major towns or designated halts. This made maintaining menstrual hygiene difficult and, for many, distressing.

As 1 woman aptly described, “There is no place to change, no place to throw the sanitary pad. You have to carry it with you, and that feels shameful.”

Another shared that

While walking, we constantly had to search for a place to change our sanitary pads. In doing so, our group would move ahead and leave us behind. There was absolutely no proper place to dispose of the used pads—we had no option but to throw them in open garbage. Once, I walked nearly 20 kilometres (12 miles) without finding a single place to urinate or change my pad.

Theme 3: Strategic Measures for Improving Sanitation, Hygiene, and Facilities as Suggested by Participants

All participants were asked to provide suggestions for improving the pilgrimage experience, particularly in relation to sanitation and hygiene, with a specific focus on the challenges faced by women. The women unanimously emphasized the need for greater institutional coordination and accountability. They proposed that pilgrimage organizers, group leaders, senior members of pilgrimage boards, and government representatives including officials from public health systems convene a joint meeting prior to the commencement of the journey. The purpose of this meeting would be to develop a clear understanding of the on-ground challenges and collaboratively explore practical solutions to address the sanitation and hygiene issues encountered by the growing number of women participants.

Furthermore, the participants expressed the hope that women pilgrims would be adequately represented in such forums and that representatives would possess the authority to make decisions on their behalf. Some participants went further to suggest that the government should establish an official statutory body dedicated to representing women’s interests in the context of the pilgrimage. This body would be tasked with overseeing the operations of organized groups and ensuring that the specific needs of women are integrated into planning and implementation processes. Participants noted that, for many years, there is a lack of formal oversight or support from governmental agencies. They suggested to have a designated authority or institution to take the lead in addressing these long-standing issues through structured, sustainable interventions.

The participants recommended the allocation of an adequate number of mobile toilets specifically designated for women, emphasizing the need for facilities that ensure privacy, safety, and hygiene.

Additionally, the participants suggested that a substantial number of makeshift, enclosed temporary bathing arrangements be established at each stopover site along the pilgrimage route. These facilities would allow women to maintain personal hygiene while preserving privacy, an essential consideration given the cultural and social sensitivities surrounding menstruation and bodily care. The establishment of these facilities at regular intervals would also help mitigate health risks and promote well-being among female participants during the long and physically demanding journey.

These suggestions were specifically put forward by a few women who were highly educated—participants proposed several measures to manage menstruation more effectively during the pilgrimage, with an emphasis on ensuring easy access to and availability of sanitary pads. They suggested that each pilgrimage group be responsible for carrying a sufficient stock of sanitary pads, along with essential medicines and other necessary supplies. This provision would ensure that women pilgrims are adequately prepared for menstrual hygiene management throughout the journey.

In addition to the availability of sanitary pads, the previously mentioned toilet facilities would also play a crucial role in facilitating the safe and hygienic changing of sanitary pads. To address the disposal of used sanitary pads, participants recommended the establishment of designated biodegradable sanitary napkin disposal bins at each stopover site. These bins would offer a sanitary and environmentally responsible means of disposal, aligning with both hygiene and sustainability objectives.

Furthermore, the participants proposed that the management of waste generated from sanitary napkins be coordinated with relevant agencies. These agencies would be tasked with regularly collecting and responsibly removing the waste from all stopover sites, ensuring that the disposal process adheres to environmental and public health standards. This coordinated approach would not only address the immediate needs of menstruating women but also contribute to maintaining cleanliness and minimizing the environmental impact of the pilgrimage.

Additionally, they highlighted the necessity for readily available clean drinking water along the pilgrimage route, as current arrangements required pilgrims to find their own sources such as purchasing water or refill bottles along the way. A women’s quote regarding government’s role speaks thousand words.

While people may have adapted to and endured the circumstances and challenges over many years, this should not mean that the government should refrain from implementing technology-driven solutions to address WASH issues during such pilgrimages.

Discussion

This study uncovers the ground realities of WASH and MHH challenges faced by women pilgrims in Pandharpur pilgrimage. It highlights the severe lack of sanitation and bathing facilities for both men and women, with particular focus on open defecation, open bathing practices, and the significant discomfort experienced in accessing toilets by women. The qualitative findings further reveal that perceptions surrounding participation in the pilgrimage are deeply shaped by entrenched socio-cultural beliefs. During menstruation, women often struggle to find private spaces to change and hygienic ways to dispose of used sanitary materials.

Pilgrimages often lead to mass gatherings, which are defined as the convergence of a large number of individuals at a specific location for a common religious or cultural purpose. ¹² Ensuring the well-being and hygiene of pilgrims in such contexts is a critical public health concern. Sustainable Development Goal 6 (SDG 6) mandates universal access to WASH services, highlighting their importance even in temporary but large-scale gatherings such as religious pilgrimages. ⁵ Our study on the Pandharpur pilgrimage of India strongly reinforces the urgent need to improve women-specific WASH facilities, including provisions for MHH as an essential component of upholding basic human rights.

In practice, however, the existing system often fails to meet these basic standards. Inadequate access to sanitation facilities not only leads to widespread open defecation and outdoor bathing but also imposes serious health risks, particularly for women. Similar findings have been documented in previous studies on the Kumbh Mela and the Hajj pilgrimage, which consistently report issues such as insufficient toilet infrastructure and overall hygiene deficiencies.^{13 -16} Despite these persistent challenges, there are promising examples of effective, localized interventions. For instance, the successful collaboration between GIWA-India and UNICEF during the 2016 Ganga Sagar Mela resulted in the installation of thousands of toilets and the promotion of cleanliness across the pilgrimage site. Such in-house, technology-supported strategies serve as exemplary models that can be replicated and scaled to meet the growing demands of large pilgrimage events in India and elsewhere. ¹⁷

A particularly under-researched issue within this domain is the lack of proper bathing facilities. The absence of enclosed and gender-sensitive bathing arrangements compels many pilgrims—especially women—to bathe outdoors, often using makeshift shelters that offer little privacy. While communal cooperation sometimes mitigates this challenge temporarily, it remains an unsustainable solution. The critical need for structured, private bathing spaces is evident, yet there is a notable gap in academic literature addressing this aspect of pilgrimage experiences. Few studies, if any, have examined the specific bathing practices and related needs of pilgrims, particularly women. Addressing this gap is essential for developing inclusive infrastructure planning that reflects lived realities.

The state government has promised allocation of over 100 crore rupees, that is, 1.2 million USD to upgrade sanitation infrastructure along the pilgrimage route in the study area. This funding aims to establish strategically located facilities designed to alleviate the burdens associated with inadequate sanitation. If properly implemented, these measures hold the potential to significantly enhance the pilgrimage experience by providing greater comfort, dignity, and hygiene for all participants. ¹⁸

The study further explored various aspects of MHH during the pilgrimage. Women’s perceptions of menstruation as linked to impurity and exclusion from pilgrimages reflect deep-rooted socio-cultural beliefs in India.^7,8 Studies have shown that menstruating women are often considered unclean and barred from religious activities. This includes restrictions on temple entry and participation in worship, reinforcing gendered exclusions and social exclusion similar to this study’s finding.^7,8 Many women reported using oral contraceptives to delay menstruation and proactively carrying sanitary napkins in anticipation of their menstrual cycles. These findings are consistent with other research conducted during the Hajj pilgrimage, as well as studies involving South African and Malaysian women pilgrims, which similarly highlight proactive strategies for managing menstruation in religious travel contexts.^{19 -21}

A recurring concern across these studies—including our own—is the challenge of changing and disposing of sanitary pads in overcrowded and unsanitary conditions. Hygiene-related anxieties around menstruation were commonly expressed, often exacerbated by the lack of clean, private spaces. ¹⁹ Additionally, the findings reveal a complex interplay between traditional customs and contemporary understandings of women’s rights. While some women affirmed their right to continue the pilgrimage while menstruating, others voiced concerns about prevailing norms that still emphasize segregation of menstruating women. ²² This duality reflects a broader scepticism around recognizing and normalizing women’s full participation in religious practices during menstruation. Further research is needed to unpack these socio-cultural tensions and to inform the development of culturally sensitive, yet rights-based, WASH interventions.

The findings from this study highlight the multifaceted challenges women face in accessing adequate WASH facilities during pilgrimage. Reports of open defecation, lack of safe bathing spaces, and the difficulties of managing menstruation underscore the urgent need for gender-sensitive interventions. Participants articulated clear and practical recommendations, including the provision of gender-specific mobile toilets, accessible sanitary pads, biodegradable menstrual waste disposal systems, reliable potable water sources, improved overall hygiene, and enclosed bathing facilities. Additionally, the women suggested a multi-stakeholder dialogue to address existing challenges and drive sustainable change. Equal representation of women pilgrims ensuring diverse perspectives and inclusive solutions. Together, they can identify innovative, lasting improvements for pilgrim well-being. Most of the above recommendations are in alignment with WHO strategies for effective management of WASH challenges during mass gatherings. It also states a comprehensive strategy is essential. Apart from the components mentioned above, the interventions must be scalable, context-specific, and supported by public education, stakeholder collaboration, community engagement and continuous evaluation to safeguard attendee health and ensure effective, adaptable responses. Forming volunteer teams in each group to oversee sanitation at stopovers, along with educating pilgrims on hygiene, environmental care, and its spiritual importance, would enhance safety and dignity, ensuring a smoother, more inclusive pilgrimage. ²³

These insights not only reflect the lived realities of women pilgrims but also provide a roadmap for policymakers, organizers, and public health authorities to implement more inclusive and effective WASH solutions in the context of religious mass gatherings.

Limitations of the Study

The study’s limitations include a sample size of 100 participants. This may not fully represent the diverse population of pilgrims. Additionally, convenience sampling introduces potential bias, limiting the generalizability of the findings and potentially skewing the results toward the experiences and perspectives of individuals who are more accessible or willing to participate. Lastly, participants sharing socially desirable responses and subjective experiences may not translate well for general application in public health.

Conclusion

The Pandharpur Pilgrimage stands as a revered tradition in Maharashtra, India, spanning over 800 years’. However, managing logistics and ensuring sanitation and hygiene for the vast numbers of pilgrims, who walk and stop at specific sites en-route destination, presents a considerable challenge. Coping with such a large influx of pilgrims over 21 consecutive days is a monumental task.

Nonetheless, given India’s diverse population and the socio-cultural and historical context of pilgrimages, strategic planning—backed by strong political will, fair resource allocation, and effective government execution—is essential to significantly improve the pilgrimage experience.

The limited research in this area presents significant opportunities for future studies. Large-scale surveys with representative samples from stopover sites are needed to document pilgrims’ perspectives on health, hygiene practices, and the availability of comprehensive WASH facilities. Additionally, robust qualitative research should explore behavioural patterns, coping strategies, and the spiritual motivations behind repeated pilgrimage participation. Integrating public health, socio-behavioural, and policy research can offer valuable insights to inform culturally sensitive interventions and improve health outcomes for pilgrims. Such multidisciplinary efforts are essential for addressing the complex challenges faced during large-scale religious gatherings.