The WHO defines “Adolescents” as individuals in the age group of 10–19 years. Adolescence in girls has been recognized as a special period in their life cycle that requires specific and special attention. This period is marked with onset of menarche. The first menstruation is often distressing and traumatic to an adolescent girl because it usually occurs without her knowing about it. Although menstruation is a natural process, it is linked with several perceptions and practices, which sometimes result in adverse health outcomes.
There are several reasons for a focus on adolescent girls in public health. Adolescent reproductive and sexual health (ARSH) continues to elude many and many are denied the right to make safe and informed decisions that affect their health and well-being. At the same time, girls’ ARSH situation has huge implications both for their later health as well as the health of the next generation. Women having a better knowledge regarding menstrual hygiene and safe menstrual practices are less vulnerable to reproductive tract infections and its consequences.
A timely and accurate intervention regarding reproductive and sexual health, to this vulnerable age group is expected to enhance their knowledge, change their attitudes and strengthen their decision-making skills regarding their own reproductive health. A well-informed girl is expected to manage her personal hygiene properly, influence her family size and differences in consecutive pregnancy, thus affecting the overall family health and well-being, and prevent episodes of reproductive tract infections as well as contracting sexually transmitted infections and HIV.
This study was undertaken in late adolescent girls residing at an urban slum, with an aim to assess the impact of felt need-based ARSH education module, on knowledge, attitude and practices of their menstrual hygiene. It was achieved through objectives of assessing the baseline knowledge of menstrual hygiene practices, studying its association with sociodemographic factors and finally testing the impact of health education on the existing knowledge on menstrual hygiene practices of late adolescent girls in an urban slum.
MATERIALS AND METHODS
Study is an interventional study, intervention being health education quantitative study done in an urban slum of a metropolitan city of Western India. Study population includes adolescent girls in the age group of 15–19 years residing in that slum. Inclusion criteria into the study were all adolescent girls in the age group of 15–19 years residing in the study area and exclusion criteria were girls not willing to participate in the study and/or whose parents had objections to their participating in the study and adolescent girls who were married. Institutional Ethics Committee clearance for the study was taken vide letter no. IEC/2020/342 dated December 31, 2020.
Sampling technique used was systematic random sampling. Sample size of 177 was calculated using the formula 4 pq/L2. Considering loss to follow-up, a sample of 200 adolescent girls in the age group of 15–19 were selected. The study area was divided into 50 plots, 8 girls were selected from each alternate plot. A total number of 206 adolescent girls participated in the study, out of which 190 were evaluated at the end of 3 months, as 7 girls did not attend all the sessions and 9 did not attend the revision session and thus were lost to follow-up.
After taking an informed consent, Focus Group Discussion (FDG) was held in group of 8–12 girls to assess felt needs regarding puberty and menstrual knowledge. The content of the education sessions was based to optimize their felt needs. Baseline knowledge, attitude, and practices regarding menstrual hygiene were assessed through a semi-structured self-administered questionnaire comprising a combination of open-ended and close-ended questions before conducting the sessions.
The 206 girls were divided into five batches. FDGs were conducted for each batch separately and at a time convenient to the study subjects. Content of these sessions included introduction and rapport building, changes felt by girls while growing-up, menstrual hygiene practices and life skill education. Analysis of menstrual hygiene practices was done after 3 months of health education intervention.
A one-way repeated measures ANOVA was conducted to compare the effect of health education on knowledge score about puberty and menstruation in pretest, first post-test, and second post-test. Three paired sample t-tests were used to make post hoc comparisons.
Age distribution pattern showed that majority of the girls, 45.63% were 16 years of age and their mean age was 16.10 years. Nearly 71.85% of girls in the present study were Hindu, 22.33% Muslim, and 1.94% were Christian. A considerable majority, 77.18% girls were staying in nuclear family 14.07% belonged to a three-generation family, and only 8.74% lived in a joint family. High proportion of girls, 84.46% lived in a pukka house, 10.68% in kutcha house, and 4.86% stayed in a mixed type of house. This study brought out 48.54% girls had a facility of sanitary latrine within the house, whereas 51.46% of girls did not have it within the house premises. Around 44.66% of study subject’s mothers had attended middle school, followed by primary school by 25.73%, 18.93% attended high school or higher secondary school and 3.88% were illiterate. None of the mothers had attended college [Figure 1].
Sanitary pad was used by 91.26% girls, while 5.83% (12) used cloth. Six of the 12 who used cloth, used a new cloth every time, while six reused the old one. Those who reused old cloth were assessed for proper washing and drying of the cloth. It was found that 0.97% of total, i.e., 2 of the 6, who reused previously used cloth, washed it with soap and water and dried it in sun, while 1.94% of total, 4 of the 6 either did not wash it with soap and water or dried the cloth in shade. Nearly 36.41% (75) changed the absorbent material more than two times in a day, while 60.19% (124) changed it two or fewer times a day. Nearly 3.40% (7) did not respond. Around 87.38% (180) girls wrapped the sanitary pad in paper before discarding, while 7.77% (16) did not. Around 4.85% (10) did not respond.
Nearly 96.12% (198) girls had bath every day during menses. Around 79.13% (163) used soap and water to wash genitals while bathing, whereas 18.93% (39) used only water. Using clean and dry panty after every bath was practiced by 81.55% (168) of adolescent girls, while 23 (11.17%) did not use a clean and dry panty every time [Table 1 and Figure 2]. Almost all, 96.12% of girls observed restriction in attending religious functions/ceremonies during menses [Figure 3]. Majority 84.47% attended school/college/work during menses [Figure 4].
ANOVA conducted to compare the effect of health education on knowledge score about puberty and menstruation in pretest, first post-test, and second post-test showed a significant effect, with Wilks Lambda = 0.171, F (2,188) = 456.271, and P < 0.001. Maulchy’s test for sphericity was insignificant [Table 2 and Figure 5]. Between pretest and first and second posttest, both the posttests showed a significant increase in mean knowledge score, whereas there was a significant decrease in the mean knowledge score in second posttest as compared to the first posttest [Table 3]. In the pretest, menstrual perceptions among them were found to be poor and practices incorrect, while in the posttest, there was a significant difference in the level of knowledge, with McNemar test P = 0.039 [Table 4].
Association of various sociodemographic factors with baseline menstrual hygiene practices brought out that two factors, mother’s education, and facility of sanitary latrine in house were significantly associated with menstrual hygiene practices (P < 0.05). 85.47% of girls who had inadequate menstrual hygiene, had mothers who attended only middle school or lower. The above results indicate that an educated mother is in a better position to inculcate good menstrual hygiene practices in her daughter and emphasize on them by pointing out their advantages. Similar results were also echoed by Sudeshna and Dasgupta in their study that good menstrual hygiene was more among those whose mothers were literate (adjusted odds ratios 2.3 [1.06–5.01]).
In this study, large majority, 91.26%, of girls used sanitary pad and among girls using cloth, almost 33% did not followed recommended hygiene norms of proper washing and drying it in sun. In a study done by Yasmeen et al. in an urban community in West Bengal, sanitary pad was used by 82.2%, 1.4% used new cloth, and 15.0% used old cloth. Around 15.7% (23) of the respondents uses old washed cloth, and out of them, 16 had problem while washing and drying of the cloth which mostly consisted of lack of privacy (93.7%). Both the studies concluded that keeping the cloth in places away from prying eyes was the reason for not drying it in the sun and storing it at unhygienic places.
Regarding hygienic practices during menstruation, in this study, 96.12% of girls had bath every day during menses and 79.13% used soap and water. Almost similar results of have been brought out by Yasmeen et al. and a study done by Shanbhag et al. in Bangalore city. Others felt, bathing should be restricted in the first 2 days of menstruation as bathing increases the menstrual flow. In Shanbhag et al. study, 56.8% of the study population used soap and water to clean their private parts, while the rest, 43.2% used only water. Nearly 94.2% of girls observed restrictions to go to the place of worship. While in another study done by Sudeshna and Dasgupta, not visiting temple (75.6%) was one of the most common restrictions observed by the girls. Again these results are very close to 96.12% of girls observed restriction in attending religious that has been brought out in this study.
Absenteeism from school during menses was seen in 15.53% in this study, whereas the figure was 33.8% in a study done by Datta et al. in West Bengal. The reasons were also different in two studies. Absenteeism was mainly due inadequate disposal facility or water, pain or weakness in the former, in that later study, pain in abdomen, and excessive bleeding were the main reasons. In schools, due to a lack of sanitary facilities, girls throw their pads in toilets. In some cases, girls threw away their used menstrual clothes without washing them. Furthermore, many were reported being absent from school due to a lack of disposal system, broken lock/doors of toilets, lack of water tap, bucket, and poor water supply.
Baseline knowledge about puberty and menstruation was poor in 17.16% (35) of girls, average in 39.22% (80), and good in 43.62% (89) of the girls. As compared to this, the number of girls who had good knowledge score increased to 92.6% (185) and those who had average and poor knowledge dropped to 7.04% (14) and 0%, respectively, in the first post-test. In second post-test that was conducted after 3 months, number of girls having good knowledge score dropped to 73.16% (139), while number of girls with average knowledge increase to 26.94% (51). Poor knowledge remained at 0% [Table 3].
Number of girls having good knowledge about puberty and menstruation increased significantly after health education intervention. The present study concludes that, although the knowledge increased drastically after the education sessions, even after conducting revision session, the girls could not retain all of it by the end of 3 months, indicating reinforcement of knowledge is a must. The findings in this study are similar to those of Nemade et al. and Arora et al.
Sanitary pad is being used by large majority of adolescent girls, in urban slum setting now. Menstrual hygiene practices were better in daughters of more educated mothers and those who had sanitary latrine in house. During menstruation, not visiting place of worship was the most common restriction and absenteeism from place of the study was mainly due inadequate pad disposal facility or water and pain or weakness. Number of girls having good knowledge about puberty and menstruation increased significantly after health education intervention. Although the knowledge increased drastically after the education sessions, the girls could not retain all of it, indicating reinforcement of knowledge is a must.
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Conflicts of interest
There are no conflicts of interest.
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