Excerpt
Table of Contents
DEDICATION
ABSTRACT
ACKNOWLEDGEMENT
CHAPTER ONE
INTRODUCTION
1.1 BACKGROUND
1.2 PROBLEM STATEMENT
1.3 RESEARCH OBJECTIVES
1.3.1 MAIN OBJECTIVE
1.3.2 SPECIFIC OBJECTIVES
1.4 JUSTIFICTION OF THE STUDY
1.5 ORGANIZATION OF THE STUDY
CHAPTER TWO
LITERATURE REVIEW
2.1 INTRODUCTION:
2.2 ADOLESCENCE
2.3 MENSTRUATION AND THE MENSTRUAL CYCLE
2.4 MENARCHE
2.5 MENSTRUATION HYGIENE MANAGEMENT (MHM)
2.5.1 The importance of Adequate Menstrual Hygiene Management
2.6 POOR MENSTRUAL HYGIENE
2.7 ROLE OF SOCIAL TABOOS
2.8 WATER, SANITATION AND HYGIENE (WASH) SCHEME
2.9 UTILIZATION OF SANITARY NAPKINS
2.10 EMPIRICAL EVIDENCE OF KNOWLEDGE, ATTITUDES REGARDING MENSTRUATION AND MENSTRUAL HYGIENE PRACTICES
2.11 MENSTRUAL EDUCATION
2.12 INFLUENTIAL FACTORS OR PREDICTORS OF MENSTRUAL HYGIENE MANAGEMENT
2.12.1 Role of Health knowledge
2.12.2 Role of Culture and societal norms
2.12.3 Influence of hand washing
2.12.4 Availability of Sanitary products
2.12.5 Risk of infection in the menstrual cycle
2.12.6 Socio-economic factors
2.13 CONCLUSION
CHAPTER THREE
METHODOLOGY
3.1 INTRODUCTION
3.2 STUDY DESIGN
3.3 STUDY AREA
3.4 STUDY POPULATION
3.5 SAMPLE SIZE DETERMINATION AND SAMPLING METHODS
3.6 INCLUSION AND EXCLUSION CRITERIA
3.6.1 Inclusion Criteria
3.6.2 Exclusion criteria
3.7 DATA COLLECTION TOOLS, TECHNIQUES/ METHODS
3.9 DATA PROCESSING AND ANALYSIS
3.10 ETHICAL CONSIDERATIONS
3.11 LIMITATION OF THE STUDY
CHAPTER FOUR
DATA ANALYSIS
4.0 INTRODUCTION
4.1 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS
4.2 KNOWLEDGE ABOUT MENSTRUATION AND ITS HYGIENE
4.3 RESPONDENTS' SOURCES OF INFORMATION ABOUT MENSTRUATION
4.4 PREDICTORS OF KNOWLEDGE ABOUT MENSTRUATION AND MENSTRUAL HYGIENE
4.5 HYGIENIC PRACTICES DURING MENSTRUATION
4.6 PREDICTORS OF PRACTICE ABOUT MENSTRUATION AND MENSTRUAL HYGIENE
CHAPTER FIVE
DISCUSSION, RECOMMENDATION AND CONCLUSION
5.1 INTRODUCTION
5.2 KNOWLEDGE OF MENSTRUATION
5.3 SOURCES OF INFORMATION ON MENSTRUATION
5.4 PREDICTORS OF KNOWLEDGE ABOUT MENSTRUATION AND MENSTRUAL HYGIENE
5.5 HYGIENIC PRACTICES DURING MENSTRUATION
5.6 PREDICTORS OF PRACTICE ABOUT MENSTRUATION AND MENSTRUAL HYGIENE
5.7 CONCLUSION
5.8 RECOMMENDATION
REFERENCE LIST
APPENDIX A
Structured Questionnaire
DEDICATION
This thesis is dedicated to our family members who through their hard work and support made our tertiary education possible and also to our supervisor (NAME support during the study.
ABSTRACT
Background:
The issue of menstrual hygiene is inadequately acknowledged and has not received proper attention. Use of sanitary pads and washing the genital area are essential practices to keep the menstrual hygiene. Unhygienic menstrual practices can affect the health of the girls and there is an increased vulnerability to reproductive tract infections and pelvic inflammatory diseases and other complications. Therefore, the objective of this study was to assess the knowledge and practice of menstrual hygiene among high school girls at Oforikrom, Kumasi.
Method:
A school based cross-sectional study design was employed in the study. A multi stage sampling technique was used to select 200 female junior high school students from XXX and YYY both at Oforikrom, Kumasi. Data collection was carried out from the students in their schools and homes using a pre- tested structured questionnaire. The data were entered into a computer using Excel and then exported to SPSS for Windows version 22 for analysis. Bivariate and multivariate logistic regression analysis was done at 95 % confidence interval.
Results:
In this study, 122 (61%) and 80 (40%) respondents had good knowledge and practice of menstrual hygiene respectively. The findings of the study showed a significant positive association between good knowledge of menstruation and educational status of mothers (AOR=1.51, 95 % CI=1.02 - 2.22), having radio/TV (AOR=2.42, 95 % CI: 1.64 - 3.56). Educational Status of the mother (AOR=2.03, 95 % CI=1.38 - 2.97) and earning permanent pocket money from parents (AOR=2.73, 95 % CI=1.76 - 4.26) revealed significant positive association with good practice of menstrual hygiene.
Conclusions:
The findings showed that the knowledge and practice of menstrual hygiene is low. Awareness regarding the need for information about good menstrual practices is very important. So, health education program should be setup to create awareness and practice of good menstrual hygiene.
ACKNOWLEDGEMENT
We wish to thank the Almighty God for granting us the desired strength and guidance to finish this study successfully. Writing this thesis was a very big academic undertaking which we might not have been able to undertake, let alone complete it without the supervision, guidance and advise from a number of people who deserve particular mention.
We take this opportunity to express our sincerest gratitude to the entire SDA Nursing and Midwifery Training College and our Supervisor (NAME ) for their guidance, support and constructive criticisms during the course of the study. We are also grateful to the entire students, teachers and parents of Jubilee Preparatory JHS and Oforikrom M. A. JHS for their time and willingness of participation.
Finally, our special gratitude goes to our parents, siblings and other family relatives for their constant support and encouragement and all others who contributed to the success of this work.
CHAPTER ONE
INTRODUCTION
1.1 BACKGROUND
According to the World Health Organization (2014), Adolescence is a transitional stage of physical, psychological, social and biological human development that generally occurs during the period from puberty to legal adulthood. The World Health Organization (2014) defines adolescents as young people between the ages of 10 and 19 years. Adolescent population constitutes about 16% of world's total population (World Health Organization, 2002). Adolescence is a transition period from childhood to adult life which is an important and sensitive phase of life. Many physical, mental and social developments take place during this phase (Ghongdemath, Sidhmalswamy, Mallapur, & Shindholimath, 2016).
Menstruation is a universal and normal phenomenon during the reproductive age of females (Matsumoto, 1962; MacGregor, Chia, Vohrah, & Wilkinson, 1990). The onset of menses takes place during adolescent period in which dominant physiological and emotional changes take place (Ayele & Berhan, 2013). Adolescent is an essential period where females are preparing and adjusting themselves to manage their menstrual bleeding in safe and clean way (Lee, 2002). This is also the ideal time that girls often join different environments including high schools and tried to plan for their next adulthood life (Ayele & Berhan, 2013).
For a girl, adolescence is a period of rapid transition to womanhood. The onset of menstruation is one of the most important changes that occur for girls during the adolescent years (Haque, Rahman, & Itsuko, 2014). Menstruation occurs periodically throughout the child bearing years, except during pregnancy and lactation. It commences with menarche and ends with menopause. Throughout this period it is important for women to understand the changes that happen with menstruation. Even though menstruation is a physiological process, it is linked with several misconceptions and malpractices which may result in adverse health outcomes. Menstruation and menstrual hygiene related practices are still clouded by taboos and socio-cultural restrictions (Ghongdemath et al., 2016).
Poor hygiene during menstruation has been associated with serious ill-health, including reproductive tract and urinary tract infections. There is a substantial lacuna in the knowledge towards menstruation and menstrual hygiene among adolescent girls. However, most adolescent girls enter their puberty stage without preparing themselves due to the shortage of adequate information (Dasgupta & Sarkar, 2008). Most women are uncomfortable to discuss “menses” as it is has a social taboo and adolescent girls could not have access to gain adequate information (Wall, Belay, Bayray, Salih, & Gabrehiwot, 2016). Even the little information they receive most commonly from religious institutions, peers and family member is often selective and surrounded by misperceptions (Sommer, Ackatia-Armah, Connolly, & Smiles, 2015).
For example, people in developing countries like Ghana and Nigeria often perceive menstruation as something happened as a result of being cursed, a sign of diseases, punishment from God, a lifelong process and others (Adinma & Adinma, 2008). As a result, adolescent girls perceive menstruation as something embarrassing that should be kept hidden (Kumar & Srivastava, 2011). This can increase the vulnerability of adolescent girls to have mental, emotional and physical problems (Kumar & Srivastava, 2011). These conditions further impair the daily activities, academic performance, school attendance, and social relationships of adolescent girls (Omu, Al- Marzouk, Delles, Oranye, & Omu, 2011).
Numerous studies, particularly from low-income countries, show that a very high number of girls start menstruating without having any idea what is happening to them or why (Jothy & Kalaiselv, 2012). Since parents can find it difficult to speak of sensitive and sexual issues with their children, even while admitting it is also their responsibility (Jothy & Kalaiselv, 2012). Menstrual hygiene is also likely to be affected by contextual factors, such as access to places where girls can manage menstruation-related washing in privacy and comfort. These factors are influenced by having access to water, hygiene and sanitation facilities at school or household (Adinma & Adinma, 2008).
Women and girls of reproductive age need access to clean and soft absorbent sanitary products which in the long run protect their health from various infections (Narayan, Srinivasa, Pelto, & Veerammal, 2001). To this effect, the practice of good menstrual hygiene reduces the incidence of reproductive tract infection (RTI). Thus, the consequences of RTIs are severe and may result in significant negative impact to a woman's health including chronic pelvic pain, dysmenorrhea (painful periods) and in severe cases infertility. Reproductive tract infections, which have become a silent epidemic that devastates women's lives is closely related to poor menstrual hygiene (Narayan et al., 2001). Every year approximately 10% of women worldwide are exposed to genital infections including urinary tract infections and bacterial vaginosis and 75% of women have a history of a genital infection (Baisley et al., 2009). Specifically, the common risk factors for vaginal infections include pregnancy and poor hygiene (both perineal and menstrual hygiene) (Baisley et al., 2009).
Studies in Africa have found out the use of sanitary pads as low as 18% amongst Tanzanian women with the remainder using cloth or toilet paper (Baisley et al., 2009). A study on Nigerian school girls found between 31% and 56 % using toilet tissue and cloth respectively to absorb their menstrual blood as opposed to menstrual pads (Adinma & Adinma, 2008). A study conducted in Ethiopia showed that, though, most (92%) students were aware of menstruation before menarche, their utilization of sanitary napkins was low at 37.6 % and a significant proportion, 62.4% were using rags and pieces of cloth (Desalegn, Berihun, & Abay, 2009).
Eleven percent of girls in Ethiopia change their menstrual cloths once a day (Sarah & Thérèse, 2012). Most girls in Ghana are at risk of getting genitourinary tract infections due to their unhygienic practices during their menstruation period which may lead to further complication if left untreated (Emmanuel & Yawson, 2019). Therefore, this study was aimed to assess the knowledge and practice of menstrual hygiene among high school girls in Oforikrom, Ghana. The information obtained from this study will be used by policy makers and stakeholders to identify the awareness and practice of menstrual hygiene so as to provide information about menstruation and menstrual hygiene for high school girls in the study area.
1.2 PROBLEM STATEMENT
The adolescent stage for the girl child is a demanding time in a woman's developmental life. The girl child is at a stage where she is bombarded by a surplus of hormones and societal norms which affects and influences her physical, mental and emotional development. This period is critical as all aspects of life are fully involved in this development, and as such it is important the family and society pay attention to this stage as it shapes the life of the girl. It is at this period that the girl child commences menstruation.
It is realized that although, about 35% of world population constitutes young people between ages 10 and 24; adolescents health needs are either not reached or barely addressed satisfactorily (Abajobir & Seme, 2014). Poor Menstrual Hygiene Management (MHM) may be as a result of inadequate sanitary facilities and poor hygiene practices. Menstruation impacts on the girl child in diverse ways: it could be physical, emotional and physiological. As a result of this there is need for structures and support to be put in place to help the girl child cope with this stage of life. This is what the concept of Menstrual Hygiene Management (MHM) seeks to achieve: aid the girl child in dealing with the associated misconceptions, humiliation, agitation, discomfort and nervousness (Tegegne & Sisay, 2014).
The necessity of Menstrual Hygiene Management (MHM) is mainly because hygiene knowledge among these basic school (JHS) girls of ages 8 to 15 is limited thereby giving rise to their inability to adequately manage their menstruation (UNESCO, 2014). The effect of menstruation on school girls is diverse; amongst these is the impact on their education. It has been realized that girls are faced with challenges associated with menstruation making them unable to attend school sessions during this period.
The primary reason for this is that majority of the school girls have difficulty managing menstruation in the public. The importance of adequate sanitary facilities for good hygiene practices during menstrual flow is underscored by the fact that there is the risk of urinary and/or reproductive tract infection if good hygiene practices are not put to use (Omidvar & Begum, 2010; UNESCO, 2014).
1.3 RESEARCH OBJECTIVES
1.3.1 MAIN OBJECTIVE
The main aim of the study is to assess the knowledge and practices of menstrual hygiene among adolescent female Junior High School students in Oforikrom, Kumasi.
1.3.2 SPECIFIC OBJECTIVES
1. To assess the knowledge of menstruation and menstrual hygiene among adolescent female Junior High School students in Oforikrom, Kumasi.
2. To determine the predictors of knowledge about menstruation and menstrual hygiene among adolescent female Junior High School students in Oforikrom, Kumasi.
3. To determine the menstrual hygienic practices during menstruation among adolescent female Junior High School students in Oforikrom, Kumasi.
4. To find out the predictors of practice about menstruation and menstrual hygiene among adolescent female Junior High School students in Oforikrom, Kumasi.
1.4 JUSTIFICTION OF THE STUDY
The research finds justification in the relationship between menstrual health issues, girl child education and development of the society. Where there is poor Menstrual hygiene management , the girl child can be adversely affected; she could be stigmatized and this could further lead to absenteeism in school. Where absenteeism is prolonged, the education of the girl child is adversely affected and so is her development as well as that of the society. Results from the study will hence provide data for planning and policy formulation for the Ministries of Health and Education in that regard.
1.5 ORGANIZATION OF THE STUDY
The research is grouped into five chapters. Chapter one has the background of the research study, statement of the problem, research questions, also the objectives of the research as well as the justification for conducting the research. Chapter two reviews important literatures associated with the research studied, also the conceptual framework for research. Chapter three outlines the study area, study design, target population, the sampling procedures, sample size, all research instrument used during the study, data as well as its sources, data processing, its analysis and the ethical issues arising from the research. Chapter four states data analysis, and presentations, while Chapter five explains the results of the study, with conclusions and recommendations of the study.
CHAPTER TWO
LITERATURE REVIEW
2.1 INTRODUCTION:
This chapter will review literature in the following areas: challenges faced by women and girls in regard to menstruation; communication in health, especially as it concerns menstruation, and menstrual practices; theoretical frameworks in related conceptual areas; review of literature of menstruation as a taboo topic and a stigma; a review of Knowledge, Attitude and Practice studies in menstruation, a review of cognitive and behavioral involvement factors or predictors of menstruation and health communication campaigns.
2.2 ADOLESCENCE
The World Health Organization defines adolescents as young people between the ages of 10 and 19 years World Health Organization (2002). Adolescence is a transition period from childhood to adult life. Adolescents are a major and most developing building block of the world's population World Health Organization (2002). Some 1.2 billion adolescents aged 10-19 years today make up 16% of the world's population (Ghongdemath et al., 2016). Almost half of all adolescents globally live in Africa (Ghongdemath et al., 2016). In absolute numbers, Africa is home to adolescents around 302 million. It is followed by East Asia and the Pacific with around 277 million (Haque et al., 2014).
2.3 MENSTRUATION AND THE MENSTRUAL CYCLE
Menstruation is unique to females and is part of the female reproductive cycle that starts at puberty (Tegegne & Sisay, 2014). Menstruation is the normal and physiological process of the discharge of blood from the uterus which is unique to females that begins in adolescence. The first menses is called “Menarche”. The first menstruation (menarche) occurs between the ages of 11 and 15 (McPherson & Korfine, 2004). During menarche, girls experience different feelings including fear, shame and guilt because of lack of prior information about menstruation (Oche, Umar, Gana, & Ango, 2012). With onset of menstruation a girl becomes aware of her emerging identity as a female capable to reproduce. Her understanding and acceptance of her new identity will be greatly influenced by the feedback she receives from peers, educators and most importantly her parents (El-Mowafy, Mohamed-Moussa, & El-Ezaby, 2014). Menstruation occurs periodically throughout the child bearing years, except during pregnancy and lactation. The ages of onset of menstruation differ from person to person but seem to be affected by heredity, racial background and nutritional status (Dambhare, Wagh, & Dudhe, 2014).
Menstruation is the cyclical shedding of the inner lining of the uterus, the endometrium, under the control of hormones of the hypothalamopituitary axis. It is monthly bleeding for 3-5 days occurring regularly every 28 days from puberty till menopause in the woman's reproductive life. Menstrual cycle has various phases such as Menstrual, Pre-ovulatory (follicular), ovulation and luteal phase. Menstrual cycle starts at the age of 13-15 years which marks the onset of puberty. Menstrual cycle ceases at the age of 45-50 years. A woman spends approximately 2100 days in menstruating phase of the menstrual cycle, that is almost 6 years of her life (Pokhrel, Mahantashetti, Angolka, & Devkota, 2014).
2.4 MENARCHE
Menarche is the signal that sexual maturation of the young female has occurred and that the body is capable of supporting pregnancy (El-Mowafy et al., 2014). Menarche is the first menstrual period occurs during the period of adolescence and it is a physiological and developmental phenomenon significant in the life of a female. It occurs between the ages of 10 to 16 years with the average age in Ghana being about 12 years (Emmanuel & Yawson, 2019). It occurs earlier than it once did in many parts of the world. The age at menarche shows many socio-economic, environmental, nutritional and geographical differences in the societies. During this phase of growth, the girls first experience menstruation and related problems which is marked by feeling of anxiety and eagerness to know about this natural phenomenon.
2.5 MENSTRUATION HYGIENE MANAGEMENT (MHM)
Menstrual hygiene deals with the special health care needs and requirements of women during monthly menstruation or menstrual cycle. Menstruation Hygiene Management (MHM) focuses on practical strategies for coping with monthly periods. MHM refers to ways women themselves keep clean and healthy during menstruation and how they acquire, use and dispose of blood-absorbing materials (Barathalakshmi, Govindarajan, & Ethirajan, 2014). Menstrual hygiene management (MHM) is a problem for adolescent girls in low and middle income countries (LMICs), when attending school (Barathalakshmi et al., 2014).
United Nations defines adequate menstrual hygiene management as “women and adolescent girls using a clean menstrual management material to absorb or collect blood that can be changed in privacy as often as necessary for the duration of the menstruation period, using soap and water for washing the body as required, and having access to facilities to dispose of used menstrual management materials.” Particularly in poor countries, girls and women face substantial barriers to achieving adequate menstrual management (Barathalakshmi et al., 2014).
2.5.1 The importance of Adequate Menstrual Hygiene Management
Disease outbreaks in a geographical location could be influenced by human attitudes resulting from hygiene practices which can cause various health problems or may even lead to death (Assefa & Kumie, 2014). Absence or poor menstrual hygiene management especially among adolescent girls have significant consequences, with proven association between it and reproductive, urinary tract infections and diseases which can be assessed in terms of way of sanitary protection (Aniebue, Aniebue, & Nwankwo, 2009). This is because for example the use of unclean sanitary cloth to absorb blood flowing from the cervix during menstruation expose the individual to infection (Chin, 2014). The impact of this practice on the society at large is the fact that poor MHM negated efforts targeted at achieving goals 2 and 5 of the erstwhile Millennium Development Goals (MDGs) which were the achievement of universal primary or basic education and the improvement of maternal health respectively before the end of year 2015 (Chin, 2014).
On the strength of the foregoing, it is obvious that if MHM is not put in the front burner of discourse, efforts at achieving goal 3 (ensure healthy lives and promote well-being for all at all ages), goal 4 (ensure inclusive and equitable quality education and promote lifelong learning opportunities for all) and goal 6 (ensure availability and sustainable management of water and sanitation for all) of the newly adopted Sustainable Development Goals (otherwise known as the Global Goals which builds on the MDGs) (UNDP, 2015), would also be frustrated. Thus research into Menstrual Hygiene Management among Junior High School girls in Oforikrom was very important so as to know and tackle various health issues associated with it. This is because a girl child has a right to education which is an intelligent asset that will yield long term gains for her immediate family, nation and enhance sustainable development for future generation (Boosey, Prestwich, & Deave, 2014).
2.6 POOR MENSTRUAL HYGIENE
Even today's modern world, physiology and nature of menstruation are very poorly understood among the female population due to many socio-cultural factors which make them to adapt certain practices unknowingly whether it is true or false. All women, whether rural or urban, irrespective of their socioeconomic status have their own beliefs and practices concerning menstrual hygiene (Zaidi, Sivakami, Jegadeesh, & Ramasamy, 2015). In many areas of developing countries, a culture of silence surrounds the topic of menstruation and related issues. As a result, many young girls lack appropriate information on menstrual hygiene. Infections due to lack of hygiene during menstruation have been reported in many studies. They also revealed that most adolescent girls had incomplete and inaccurate information about menstrual physiology and hygiene.
The menstrual information they did have was acquired primarily through mothers, television, friends, teachers and relatives (Haque et al., 2014). The mothers also lack sufficient knowledge and the skill to communicate to their daughters regarding menstruation and its hygiene. This has openly blocked the access of information to the adolescence. In addition, many myths regarding menstrual hygiene prevails in our society which adds to the lack of proper knowledge, attitude and practice about menstruation. Faulty perceptions or misconceptions on menstruation and menstrual cycle will lead to faulty menstrual practices. Either of these may engender reproductive health problems in the adolescent (Zaidi et al., 2015).
Poor menstrual hygiene and inadequate self-care are major determinants of morbidity and other complications among this age group. Some of these problems include urinary tract infections (UTI), scabies in the vaginal area, abnormal abdominal pain, absence from school, and complications during pregnancy (Zaidi et al., 2015).
2.7 ROLE OF SOCIAL TABOOS
A culture of silence surrounds the topic of menstruation and related issues; as a result many young girls lack appropriate and sufficient information regarding menstrual hygiene (Shah, Nair, & Shah, 2013). It is well-known that cultural factors are deeply involved in all the affairs of men and women. Some of these cultural factors, followed years together without any scientific background and for which they have their own explanation in relation to their cultural practices. These socio- cultural factors like myths and taboos concerning menstruation and health and disease were explored by many studies (Puri & Kapoor, 2006).
When a girl attains puberty, significance is attached to the day of the coming of age. It is the custom to consult a book of omens. The month, the day and the time are noted. If it happens to be a Monday, the girl will be eminently chaste. Tuesday is not favorable, as she is likely to be a widow early in her days of wedlock. If it is Wednesday, she will be wealthy. Thursday is good, too, for she bids fair to be virtuous. Friday is not considered auspicious. Saturday and Sundays are also bad days as she runs the risk of being poor. The time, too, has its meaning. Morning is best. After mid-day, it is not so good. If she happens to wear a white cloth it is lucky and if it is red cloth, it is considered as unlucky. If the girl herself first sees the marks, it is considered to be unlucky. These customs seem to be a reflection of the South Indian tradition (Tamil & Ramachandran, 2012).
The importance of this phenomenon is not only the physiological but also social and religious significant is attached to it. Restrictions such as prohibition from religious activities, attending functions, cooking etc. limits the daily activities and routines of women which is widely practiced in India. Most girls are ignorant about the physiology of menstruation and therefore the first experience of menstruation is of fear, shame and disgust. A fear is deep-rooted in adolescent girls that they will sin if they break these taboos. Due to these reasons girl's attitude and expectations about menstruation has become negative which in turn results in poor menstrual hygiene which is associated with high prevalence of Reproductive Tract Infections (RTIs) (Pokhrel et al., 2014).
2.8 WATER, SANITATION AND HYGIENE (WASH) SCHEME
The Global Goals have set an ambitious new agenda for sustainable development. The new goal for the water sector, Goal 6, aims to achieve universal, sustainable and equitable access to safe drinking water, sanitation and hygiene by 2030. In response to the global goals, UNICEF has developed a new Strategy for Water, Sanitation and Hygiene (WASH) 2016-2030 that provides a framework to guide our work related to water, sanitation and hygiene over the next 15 years (UNICEF). WASH facility in schools are important considerations for school-going girls, both for their educational attainment and their health (Govt. of India, 2017). Qualitative studies report that school absenteeism is associated with poor MHM interventions, but so far only WASH studies have shown an association between toilet improvement and absenteeism, and improved enrolment of adolescent girls when girls-only toilets were constructed (Van-Eijk, Sivakami, & Thakkar,2015).
2.9 UTILIZATION OF SANITARY NAPKINS
Absorbent pads used to manage menstrual blood loss are an important need of adolescent girls. Though sanitary pads are used universally in high income countries, large study in India showed that only 12% of menstruating women used sanitary pads where 70% of women cited cost as major barrier in using them (Shah et al., 2013)
A study conducted in Ethiopia showed most (92%) students were aware of menstruation before menarche, their utilization of sanitary napkins was low at 37.6% and a significant proportion, 62.4% were using rags whereas Urban-rural disparity in access to sanitary napkins was 37.1% of urban girls and only 1.6% of rural girls used this product due to access and financial constraints (Tegegne & Sisay, 2014).
2.10 EMPIRICAL EVIDENCE OF KNOWLEDGE, ATTITUDES REGARDING MENSTRUATION AND MENSTRUAL HYGIENE PRACTICES
A study conducted in Taiwan (Cheng, Yang & Liou, 2007) attempted to understand the differences in knowledge and attitude about menstruation between Taiwanese male and female adolescents. This study utilized secondary data from a cross-sectional comparison study conducted earlier in Taiwan. Cheng, Yang and Liou's (2007) sample consisted of 287 female and 269 male students at a junior high school. It was found in the study that the knowledge levels among young females were significantly higher than among young males. It was also stressed in the study that males were uninterested in knowing about menstruation and were, in general, indifferent towards it.
Haque et al. (2014) conducted an Intervention study in Arihazar area, Bangladesh. It was a school- based health education study. Total participants were 416 adolescent female students aged 11-16 years, in grade 6-8, and living with their parents. After health education, participants reported a significant improvement (p<0.001) in ‘'high knowledge and beliefs'' scores compared to baseline (51% vs 82.4%). Significant improvement was also observed in overall good menstrual practices (28.8% vs 88.9%), including improvements in using sanitary pads (22.4% change after the intervention), frequency of changing pads or cloths per day (68.8%), drying the used absorbent (77.6%), methods of disposing of the used absorbent (25.5%), and cleaning of genitalia (19.2%). During the follow-up, the participants reported significant improvements in the regularity of their menstrual cycle (94.5% vs 99.5%) and fewer complications during menstruation (78.6% vs 59.6%) (Haque et al., 2014).
Tegegne and Sisay (2014) conducted a mixed-method research combining quantitative and qualitative methods in Northeast Ethiopia. The quantitative study was conducted among 595 randomly selected adolescent school girls. Nine in-depth interviews; five school-dropout girls and four female teachers, and four focus group discussions among school girls were conducted. The mean age at menarche was 13.98 (±1.17) years. About 51% of girls had knowledge about menstruation and its management. Only a third of the girls used sanitary napkins as menstrual absorbent during their last menstruation. Girls from urban areas, had mothers of secondary and above education and, families of higher monthly expenditure had more chance of using sanitary napkins than their counterparts. More than half of the girls reported to have been absent from school during their menstruation period. Those who did not use sanitary napkins were more likely to be absent from school [AOR-95% C.I: 5.37 (3.02 - 9.55)]. Fifty eight percent of girls reported that their school-performance had declined after they had menarche. In addition, the qualitative study indicated that school-dropout was common among girls who experienced teasing and humiliation by classmates when their clothes were stained with blood as they do not use sanitary napkins (Tegegne & Sisay, 2014).
In Boosey, Prestwich and Deave's (2014) study, self-administered questionnaire was completed by schoolgirls in six government-run primary schools in the Rukungiri district, Uganda. Focus groups were held with girls from each school and semi-structured interviews were conducted with head teachers and female teachers from the participating schools. A toilet assessment was also conducted in each school. One hundred and forty schoolgirls completed the questionnaire. The girls reported a lack of access to adequate resources, facilities and accurate information to manage their menstrual hygiene effectively at school. They reported that, as a result, during menstruation they often struggle at school or miss school. Eighty-six girls (61.7%) reported missing school each month for menstrual-related reasons (mean 1.64, range 0-10, SD. 1.84) (Boosey, Prestwich, & Deave, 2014).
Gultie, Hailu and Workineh (2014) conducted a school based cross sectional study at Amhara Province, Ethiopia. Multistage stage sampling technique was used. The school was first clustered in to grades and sections and then participants were selected by lottery method. A pretested and structured questionnaire was used. In this study, 492 students were included, making a response rate of 100%. Mean age at menarche was 14.16years. The main sources of information about menstrual hygiene management were teachers for 212 (43.1%). Four hundred forty six (90.7%) respondents had high level knowledge about menstrual hygiene management. Most of the respondents 457 (92.9%) and 475 (96.5%) had access for water and toilet facility respectively. Place of residence (AOR = 1.8, 95%CI: [1.42-1.52]) and educational status of their mothers' (AOR = 95%CI: [1.15-13.95]) were independent predictors of knowledge about menstrual hygiene management (Gultie, Hailu, & Workineh, 2014).
A school-based educational interventional study on adolescent health education was conducted by Ghongdemath et al. (2016) in Karnataka district, India. The participants were girls of 11 to 19 years of age. A pretest and post-test were done along with the health education, concerning adolescent health. There were 1249 girl students enrolled into the study. The knowledge on menstruation and menstrual hygiene improved significantly after health education. By this study, it is seen that their knowledge was poor during pretest and remarkable improvement took place after the educational intervention (Ghongdemath et al., 2016).
Zaidi et al. (2015) carried out a descriptive cross sectional study among 150 adolescent school going girls in Thiruporur, India. It was observed that only 18.67% of adolescent girls had knowledge about menstruation before menarche. As high as 67% of them did not know the cause of menstruation where as 23.33% of the girls believed that menstrual bleed comes from the same pathway from which urine comes. Nearly all girls (96.67%) reported sanitary pad usage during the duration of menstruation. Two-third (66%) of the girls were secluded during menstruation and majority (81.3%) were restricted to attend school (Zaidi et al., 2015).
Dasgupta and Sarkar (2008) conducted a descriptive, cross-sectional study was conducted among 160 adolescent girls of a secondary school situated in the field practice area of Rural Health Unit and Training Center, Singur, West Bengal, with the help of a predesigned and pre-tested questionnaire. Data were analyzed statistically by simple proportions. Out of 160 respondents, 108 (67.5%) girls were aware about menstruation prior to attainment of menarche. Mother was the first informant regarding menstruation in case of 60 (37.5%) girls. One hundred and thirty-eight (86.25%) girls believed it as a physiological process. Seventy-eight (48.75%) girls knew the use of sanitary pad during, menstruation. Regarding practices, only 18 (11.25%) girls used sanitary pads during menstruation. For cleaning purpose, 156 (97.5%) girls used both soap and water. Regarding restrictions practiced, 136 (85%) girls practiced different restrictions during menstruation (Dasgupta & Sarkar, 2008).
Ramachandra, Gilyaru, Eregowda and Yathiraja (2016)., conducted a study to explore the knowledge, practices and sources of information regarding menstruation and hygiene among adolescent girls in Bangalore, India. An epidemiologic cross-sectional study method was carried out among 550 school- going adolescent girls aged 13-16 years. Around 34% participants were aware about menstruation prior to menarche, and mothers were the main source of information among both groups. Overall, 69% of adolescent girls were using sanitary napkins as menstrual absorbent, while 6% were using both cloth and sanitary napkins. Almost half of the rural participants dried the absorbent inside their homes (Ramachandra, Gilyaru, Eregowda, & Yathiraja, 2016).
2.11 MENSTRUAL EDUCATION
Young and growing children have poor knowledge and lack of awareness about physical and physiological changes associated with the onset and presence of adolescence. They learn about sexuality and secondary sex characteristics primarily from their peer groups or other inappropriate sources (Ganguli, 2003). Most of the girls are not informed about menarche and how to manage menstrual bleeding, and adolescents also lack knowledge about reproductive health issues. Therefore the need for creating awareness and increasing access to the requisite sanitary infrastructure related to menstrual hygiene is very important (Ganguli, 2003).
Adolescent girls often are reluctant to seek help regarding their menstrual problems. Understanding how to manage hygiene during menstruation is definitely one of the most essential ones for girls because poor maintenance of hygiene during menstruation results in several types of diseases such as Reproductive tract infections (RTI), pelvic inflammatory diseases, urinary tract infections etc. which may result in infertility of the girls (Pokhrel et al., 2014).
Adolescent girls should be educated about facts of menstruation, physiological implications, and proper hygienic practices with selection of disposable sanitary menstrual absorbent. This can be achieved through schools and colleges by providing health education to them (Pokhrel et al., 2014).
2.12 INFLUENTIAL FACTORS OR PREDICTORS OF MENSTRUAL HYGIENE MANAGEMENT
Several factors influence the achievement of menstrual hygiene management among adolescent girls. Some of these factors include:
2.12.1 Role of Health knowledge
Reviews have shown that reproductive health which includes school health has been of interest recently to the Ministry of Health and Education in most developed and developing countries. For example, in Iran, health education and hygiene practices during menstruation was incorporated into the routine education which was already in progress and subsequent studies acknowledged the fact that health education conducted by teachers and school health, reduces misconceptions and practice about menstruation by the girl child (Fakhri, Hamzehgardeshi, Hajikhani, Golchin, & Komili, 2012). This has been seen to be very important as it is surprising to realize that about 60% of students surveyed in a study had no knowhow of the fact that there is possibility of the transmission of illnesses from human waste including menstrual blood (Vivas et al., 2010).
A study conducted in Nepal had 67.5% of adolescents being aware of menstruation before menarche but majority did not know where the menstrual bleeding is coming from (Mahon & Fernandes, 2010). This means that lack of or inappropriate sexual health information could lead to different health risks and social difficulties (AlQuaiz et al., 2013). Therefore, knowledge of how general body maturation processes takes place, knowledge on the risk of unwanted pregnancy and sexually transmitted disease gained from MHM could improve the wellbeing of the girl child and society (Kirk & Sommer, 2006). To combat the health and associated challenges menstruation poses to the girl child, there is need for health education focusing on menstrual hygiene management from home and especially at school (Vivas et al., 2010).
Health education and knowledge of MHM is needed to make adolescent girls see the need to wash their hands. This means that the education on hand washing and factors that could motivate the practice of hand washing should be considered. This is important as there is a connection between the girl child with her clean hands, knowledge of MHM, good grades in school and the development of the society (Vivas et al., 2010).
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