Introduction
“Every month, more than 350 million women and girls in India are ashamed, uncomfortable, and often unsafe.[1
Adolescent girls constitute a vulnerable group, particularly in India. Despite the prominence of the ceremonial attention to “coming of age,” very little is told about the actual facts of menstruation. Much of the information is imparted in the form of restrictions.[2
An adolescent girl should be made aware of the phenomenon of menstruation before menarche, so as to enable her to accept it as a normal developmental process and manage it appropriately.[3
Need of study
This study was taken up to study the social factors and social pathology of menstruation depending on the knowledge, attitude, and practices (KAP) related to menstrual management among adolescent school girls.
Materials and Methods
Study design
The study was a cross-sectional study.
Study area
This study was conducted in Maralur and Maralur Dinne, the urban field practice area of Sri Siddhartha Medical College, Tumkur, which has 6 schools and 1 preuniversity college and with an urban health center located in it.
Study population
All school going adolescent girls were of age 10–19 years.
Inclusion criteria
All adolescent school going girls of schools under the urban field practice area of SSMC, Tumkur and whose parents had given the consent for interviewing them on menstrual health were included in the study. A verbal consent was taken from the girls too.
Exclusion criteria
None.
Study period
Data were collected from April 2013 to April 2014.
Sampling method
Purposive sampling.
Sample size
Of 507 girls of the age group 10–19 years enrolled in 6 schools and 1 PUC college, 452 gave the consent for the interview based on the questionnaire.
Method of collection of data
There are 6 schools and 1 PUC college in the urban field practice area of Sri Siddhartha Medical College, Tumkur. There were 3 private institutions, 3 government schools, and 1 government-aided school included in the study. All school going adolescent girls studying in these schools, of the age group 10–19 years irrespective of their place of residence were included in the study. Data collection was started after obtaining clearance from the ethical committee and verbal consent from the principals of each school. An informed written consent in Kannada was given to each student. Those whose parents gave the consent were interviewed using a pretested semistructured questionnaire.
List of schools
Vidya Niketan High School (Private)
Vidya Niketan Preuniversity college (Private)
Ankitha Primary and High school (Private)
Sheshadri School (Govt. school)
Banjaara Vidya Vardhaka High School (Govt. aided)
Urdu medium Govt. Model school
Hindi medium Govt. Model School.
Methodology for data analysis
Data were entered onto a computerized Excel (Microsoft Excel 2009) spread sheet, subsequently it was analyzed using Epi info version 3.5.3 (Centre for Disease Control, Atlanta, Georgia, USA) and presented in the form of tables and bar diagrams.
Statistical methods used
Descriptive statistics (means, proportions, percentages), Chi-square test was applied. P < 0.05 was considered statistically significant.
Definitions
A KAP survey means KAP. To properly carry out this type of survey, it is important to establish a basic premise and provide definitions for each word[4
K: Knowledge is a set of understandings, knowledge, and “science.” It is also one's capacity for imagining, one's way of perceiving. Knowledge of a health behavior considered to be beneficial, however, does not automatically mean that this behavior will be followed. The degree of knowledge assessed by the survey helps locate areas where information and education efforts remain to be exerted[4
A: Attitude is a way of being, a position. These are leanings or “tendencies to….” This is an intermediate variable between the situation and the response to it. It helps explain that among the possible practices for a subject submitted to a stimulus, that subject adopts one practice and not another. Attitudes are not directly observable as are practices; thus, it is a good idea to assess them. It is interesting to note that numerous studies have often shown a low and sometimes no connection between attitude and practices[4
P: Practices or behaviors are the observable actions of an individual in response to a stimulus. This is something that deals with the concrete, with actions[4
Menstrual hygiene: It includes sanitary napkins, toilets in schools, availability of water, privacy, and safe disposal.[5
Results
Most of the adolescent girls were in the age group of 10–13 years (44.24%) followed by 13–16 years (42.04%) and 16–19 years (13.72%). The youngest age in the study was 10 and oldest age was 18. The mean age and standard deviation of girls included in the study were 13.05 years ± 0.09472.
Two hundred and fifty-eight (57.08%) girls were Hindus, 193 (42.69%) were Muslims, and 1 (0.22%) was a Christian.
Two hundred and thirty-three girls of 452 attained their menarche before interview, whereas 219 girls did not. Only one girl in the age group of 16–19 years had not attained menarche and only 10.7% girls of 10–13 years attained menarche.
The mean age at menarche was 12.39 years and standard deviation was 1.12. Youngest age of attaining menarche was 10 years, median and mode was 12 years.
Knowledge
[Table 1 ] notes that 62.39% of girls knew that menstruation occurs only in females. 57.08% were aware that the best sanitary products are pads and only 31.42% girls knew about menstruation before menarche. It was observed that only 37.39% girls knew that infection would occur if they do not clean their vagina regularly during menstruation.
Table 1: Distribution of adolescent school girls according to knowledge and attitude toward menstruation and its management
Maximum, i.e., 82.9% of girls who did not attain menarche responded as “don't know” for their perception regarding menstruation. 89.7% girls who attained menarche reported that it is a physiological process.
78.8% of Hindu girls considered menstruation as a physiological process. Maximum, i.e., 57.1%, Muslims answered “don't know” as their perception regarding menstruation. There was one Christian girl who considered menstruation as God's curse. This observation is because majority of Muslim girls did not attain menarche and therefore must have responded as “don't know”.
In this study, only 25 girls said that there was health education regarding menstruation in school. Other factors include lower socioeconomic status and education of the mother.
It was observed in this study that 52.11% of girls, who were aware about menstruation before menarche, were informed by their mother. Friends as informants were 33.09% followed by sister.
Practices
According to [Table 2 ], majority of the girls (84.12%) used sanitary pads during menstruation. 10.3% used cloth pieces and 5.58% used both. Out of the girls who used cloth pieces, 70.83% reused them, and of those, 82.35% washed the cloth pieces and dried it in the sun.
Table 2: Distribution of girls according to practices of menstruation and its hygienic management (n =233)
Maximum, i.e., 76.0%, of school girls changed their material of protection 2–3 times daily. 7.7% of girls changed pads or cloth pieces <2 times/day. Best practice is to change the pad more than or equal to 4 times a day, which was observed in 16.3% girls. 83.26% girls took bath daily during menstruation. Cleaning of external genitalia <2 times/day was found in 43.78% girls.
In this study, 42.92% girls recorded the date of menstruation which is important so that the adolescent school girls take the responsibility of their periods and manage them hygienically and be prepared for them. Thirty-four girls had reported being absent from school during menstruation, which was associated with heavy flow and severe pain in the abdomen.
Majority of the girls (54.89%) discarded the pad or cloth pieces by throwing it into the dustbin. Two girls reported that they throw it in a bush. 13.62% flush the pads in the toilet, which can lead to blocking of the sewerage system. Burning of the material for protection is the best option which was practiced by 36.64% girls. Fifteen girls of lower socioeconomic status used cloth pieces for protection. One hundred and twenty-nine girls of upper and upper middle status used sanitary pads.
It was observed that 35.2% of girls with their mother's level of education at least up to middle school used pads. As the education level of mothers went on increasing, more number of girls used sanitary pads for protection. Where the mother's education was up to primary school or illiterate, only 19% used pads.
Of 37 cloth piece users, 12 (32.4%) used cloth pieces as protection corresponding with mothers' education till primary school.
Of 42.9% girls who recorded their date of menstruation were informed by their mother regarding menstruation. However, this association was not found to be significant.
Attitude
It was noted that 49.36% girls had celebrations at home when they first attained menarche.
[Table 1 ] shows that majority of the girls (35.32%) reported that they were scared when they first attained menarche. 28.09% girls responded that they were casual when they attained menarche.
Only 11.08% girls said that they had no restrictions during menstruation. Maximum responses, i.e., 53.98%, indicated that they were not allowed to do pooja or read Quran. One girl was segregated from home during periods. 54.51% girls reported that they were forced by their family members to follow restrictions.
37.7% of school girls had restriction of food during menstruation. The foods avoided were curds, buttermilk, milk products, spicy and salty food, nonvegetarian, cucumber, papaya, sweets, orange, pickles, and eggs.
It was observed that 76.4% of Hindus were not allowed to do pooja. There was one Christian girl who was also not allowed to perform religious rituals; however, no significant association was found between religion and permission to do pooja during menstruation.
56.4% adolescent school girls who practiced restrictions by the force of family were 13–16 years of age and 52.5% girls were in the age group of 16–19 years. It was found that older girls followed restrictions by force as compared to younger age group.
Menstrual problems
Maximum, i.e., 67.9%, girls responded for dysmenorrhea in the present study. Majority of these responses were in the age group of 13–15 years. 7 (2.8%) girls suffered from irregular cycles, with 4 of them in the age group of 10–12 years.
Premenstrual syndrome was found in 12 responses aged 16–18 years.
Menorrhagia was reported by 13.7% responses, maximum in the age group of 13–15 years. Twenty girls reported passage of clots during menstruation, indicating heavy flow.
Spotting which indicates PCOS or infection was a menstrual problem in 13–15 years of age girls.
63.1% of girls suffered from premenstrual syndrome. It was observed that pain abdomen was the most common response of school girls as complaint during menstruation (40%), followed by backache (26.1%) and irritability (17.3%). Two girls reported leg pain. About 3.6% girls responded as no complaints. [Table 3 ] depicts that the association between menstrual morbidities and age-wise distribution is found to be highly significant.
Table 3: Distribution of girls according to menstrual morbidities and age
Health seeking behavior
According to Table 4 , most of the girls responded that they take mother's help for problems during menstruation, followed by sister and friends.
Table 4: Distribution of girls according to health-seeking behavior
52.8% responded that they do not take any treatment because of no need and fear of side effects. 18.7% responded for home remedies such as drinking lime juice and hot water fomentation, applying castor oil on stomach, drinking coconut water, avoiding spicy food, eating sesame seeds, applying turmeric water on body, and drinking hot water and milk.
19.1% took doctor prescribed medicines, and of them, majority opted for homeopathic or ayurvedic treatment (57.8%) and preferred females as their doctors (82.2%).
9.4% took over the counter drugs such as paracetamol, she care tonic, domperidone, and volini gel, and some girls (7 girls, i.e., 31.8%) were not aware what they take for treatment.
Discussion
Dambhare et al .[6
The religion-wise distribution result was comparable to another study conducted at Uttarakhand by Juyal et al .[7
According to Dambhare et al .,[6 et al .[8 et al .[9
Knowledge
Shanbag et al .[9
It was observed by Shanbag et al .[9 et al .[10
Practices
In the study conducted by Shanbag et al .,[9
According to Shanbag et al .,[9
According to Shanbag et al .,[9
In a similar study conducted by Abhay et al .,[10
Attitude
Abhay et al .[10 et al .,[9
Similarly, in the study conducted by Shanbhag[9 et al ., food taboos were common during menstruation and 42.6% avoided certain food items, common ones being sweets (21.6%), spicy food (3.9%), curd and milk products (9.1%).
Menstrual problems
In a study conducted by Sharma et al .,[11
The observations in the present study were in accordance to the findings of Abhay et al .[10
Health-seeking behavior
Sharma et al .[11
Conclusion
The knowledge about menstruation and menstrual hygiene of school girls was found to be unsatisfactory although the practices were noted to be good. Majority of Hindu girls had attained menarche in this study and they belonged to a better socioeconomic status as compared to Muslim girls.
The knowledge of menstruation was mainly dependent on the education of the mother and socioeconomic status.
Most restrictions were laid down by the force of the family showing a poor attitude in management of menstruation. Schools were not involved in imparting health education regarding periods to adolescent school girls, also depicting a poor attitude of society toward preparing the adolescent school girls for menstrual management.
Healthcare-seeking behavior was satisfactory. Most girls felt no need for seeking help, some followed home remedies and others preferred homeopathic and ayurvedic treatment.
Limitations
This was not a comparative study between rural and urban areas to actually analyze the status of menstrual health among school girls
Not all the school girls resided in the urban field practice area of our medical college, so the results cannot be extrapolated to the total population of the field practice area.
Recommendations
There is a need of health education in the schools regarding menstrual hygiene
Health education can be conducted by health workers, medical college teachers, and nongovernmental organizations
As mothers are the first informant to majority of the adolescent girls, the health education activities can be extended to the mothers
Provision of water supply and sanitary toilets in schools is must to prevent absenteeism and dropouts of school, and increase the age of enrolment.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
