INTRODUCTION:

Menstruation is the process of periodic sloughing and erosion of uterine lining along with blood and unfertilised egg through vagina. It lasts for about 3-7 days.^[1,2] Certain menstrual practices result in adolescent girls being unaware of the scientific actualities and sanitary health practices, essential for maintaining positive reproductive health.^[3,4] Taboos associated with menstruation exists in almost all cultures which is manifested in subtle yet complex ways. Even in this 21^st century, some communities continue to banish women during their period because of so-called 'adulteration' during menses, despite the ancient practice being outlawed. Young girls are taught from an early age that they have to manage it privately and discreetly.

Hygienic practices during menstruation are of significant concern as it has a health impact in terms of vulnerability to infection.^[5,6] Social prohibitions and negative attitude of caretakers in discussing the associated issues openly has gridlocked the adolescent girls from gaining the right kind of information especially in rural and tribal communities.^[7,8]Women who are aware of menstrual hygiene and who are practicing safe menstrual sanitation are less vulnerable to reproductive tract infections and its consequences. Therefore, adequate awareness about menstruation right from childhood may result in safe practices and may help in reducing the misery of millions of women. So there is a need for compulsory health education on menstrual hygiene so that they can discuss freely about it without hesitation. With this background, the present study was undertaken to assess the knowledge and beliefs regarding menstruation and hygiene practices among adolescent girls and also to provide them health education.^[9,10,]

MATERIALS AND METHODS:

This prospective interventional study was conducted in higher secondary schools in Palakkad district in Kerala and Nilgiris district in Tamil Nadu from November 2016 to August 2017. Sample size was calculated using G’Power software with α at 0.05 and a minimum required sample size of 220 was obtained. Girls between the age of 10-19 years (Adolescents according to WHO definition) who attained menarche was included into the study and those who have not filled the questionnaire completely were excluded. Data was collected by using self -administered questionnaire. The questionnaire was drafted in English. Readability of the questionnaire was measured using Flesch reading ease formula. Pilot test of questionnaire was conducted among 10% of total students before undertaking the major study to test the interview schedule and to assess any limitations that could arise and would need to be addressed during this study and also sought suggestions from experts to fine tune the questionnaire. After the baseline survey educational sessions was conducted for educating the girls about the normal physiology of menstruation, about menstrual disorders, the importance of maintaining hygiene and safe hygienic practices during menstruation. One hour lecture was conducted in a particular day for every week and the total health education session was completed within 2 months. Furthermore, the approximate time taken for completing the self -administered questionnaire was identified during the pilot study. In order to assess the impact of the program, a post-test was done after the total health education sessions got completed. months of health education session using the same tool (Pre tested Self administered questionnaire). The post test results were compared to the pretest results.

RESULTS:

The prospective study was conducted among Adolescent girls for a period of 6 months in and around Palakkad district (Kerala) and Nilgiris district (Tamil Nadu). The demographic details of the 300 participants completed the study are shown in table -1.

Table 1: Demographic Characteristics of Study Participants

SI. No	Variables	Years	Frequency	Percentage
1	Age	13 14 15 16 17	31 93 118 27 31	10.33% 31% 39.33% 9% 10.33%
		Standard
2.	Level of education	8 9 10 11 12	24 100 118 29 29	8% 33.33% 39.33% 9.6% 9.6%
3.	Study site Palakkad (Kerala) Nilgiris (Tamil Nadu)		200 100	66.66% 33.33%
4.	Mean Age of MENARCHE Mean ± SD (range)		12.55 ± 0.72

There is a significant association between the level of knowledge and age. Among the participants who belong to 13 years age group, an average of only 56.2% had the correct knowledge about menstruation, followed by 59.1% in 14 years age group. A notable increase was seen in 17 years age group i.e. 84% of the participants of the respective group had correct knowledge. Results of the correlation test (r=0.639) showed that there is a positive correlation between increase in the age and level of knowledge

The two study region were compared to analyse the difference in the knowledge level regarding menstruation and the results showed that the number of participants who had the correct knowledge about menstruation was higher in Tamil Nadu when compared to Kerala.

Table 2: Comparison between Pre-Post knowledge about Menstruation

Variables	Pre-test		Post-test		P value
	Number	%	Number	%
What is menstruation?
Correct knowledge	130	43.33%	283	94.33%	P <0.0001
Incorrect knowledge	59	19.66%	14	4.66%
Don’t know	111	37%	3	1%
Is menstruation a disease?
Correct knowledge	279	93%	299	99.66%	P < 0.0001
Incorrect knowledge	21	7%	1	0.33%	P < 0.0001
From which organ does the menstrual blood come?					P < 0.0001
Correct knowledge	106	35.33%	285	95%
Incorrect knowledge	173	57.66%	15	5%
Do pregnant women usually menstruate?					P<0.0001
Correct knowledge	163	54.33%	290	96.66%
Incorrect knowledge	116	38.66%	10	3.33%
What is the normal age at which menstruation starts?
Correct knowledge	207	69%	286	95.33%	P < 0.0001
Incorrect knowledge	44	14.66%	11	3.66%
Don’t know	28	9.3%	3	1%
What is the average duration of a menstrual cycle?					P < 0.0001
Correct knowledge	107	35.66%	285	95%
Incorrect knowledge	114	38%	10	3.33%
Don’t know	58	19.33%	5	1.66%
How long is the normal menstrual bleeding in a single cycle					P < 0.0001
Correct knowledge	206	68.66%	288	96%
Incorrect knowledge	61	20.33%	9	3%
Don’t know	18	6%	3	1%

Table 2 shows the comparison between pre-post knowledge about menstruation among students. Present study showed 43.33% had correct knowledge (i.e. normal physiological process) before the intervention which increased to 94.33% after the health education intervention. Regarding the organ of menstrual blood flow, 35.33% had given correct answer (i.e. uterus) at baseline which increased to 95% post-test. At pre-test 7% believed that menstruation was a disease which was decreased to 0.3% after the health education. At pre-test 38.66% responded that pregnant women will menstruate, this was decreased to 10% after the education. Regarding the query on the normal age of menarche 69% had correct knowledge and increased to 95.33% at post-test. Concerning the knowledge on duration of normal menstrual bleeding 68.66% had correct knowledge (i.e.3-7 days) in pre-test which increased to 96% at post-test. Only 35.66% of the students had correct knowledge on interval between 2 menstrual cycles during pre-test and this also increased to 95%.

The total number of participants who had correct knowledge about menstruation at pre-test was compared with those in post-test i.e. after the educational intervention. Chi-square test was done to assess the impact of health education. Results showed p value <0.0001 for every questions, i.e. p< 0.05 shows that the health education had a relatively high impact on the improvement of knowledge about menstruation.

Comparison between Pre-Post Knowledge about Menstrual hygiene practices:

At pre-test 45.66% of the study population responded that cloth as the most hygienic menstrual absorbent material, 34% responded as sanitary pad, 13.33% reusable sanitary pad. After the class the participants who answered sanitary pad was increased to 95.66%. At pre-test majority of the girls (83.33%) knew that poor hygiene practices can lead to infections which has increased to 98.66% post-test. When asked what should be the frequency of changing pad during the time of menstruation at pre-test, 61.66% answered correctly (i.e. every 3-4hr) and after the health education it increased to 98.3%. At pre-test 49.33% had incorrect knowledge about the disposal of menstrual absorbent materials and at the post-test it was decreased to 1.66%. Regarding the drying of cloths which are used as menstrual blood absorbent, only 31% responded that it should be dried outside the sun and after the health education it increased to 95.66%. 80.66% of the girls responded at the pre-test that it is necessary to take bath during the time of menstruation. It increased to 97.66% after the educational intervention. The total number of participants who had correct knowledge about menstrual hygiene practices at pre-test was compared with those in post-test i.e. after the education. Chi-square test was done to assess the impact of health education. Results showed p value <0.0001, i. e p.0.05 which shows that the health education had a relatively high impact on the improvement of knowledge about menstrual hygiene practices.

Mean age of menarche was 12.55 with SD of 0.72, range between 11-14 years. 39% of the participants were having regular pattern of menstruation whereas 48% had irregular pattern of menstruation. Majority (87.6%) of the participants were having normal duration (i.e.3-7days) of menstruation in their cycle. 88.33% of girls responded that they are having medium blood flow during their menstruation, only 2.33% have heavy blood flow. Dysmenorrhea was reported by 89.66%. In that 80.6% said that menstrual pain is interfering their normal activities. Present study gave the results that only 11% are taking medication to relieve pain. 62% girls skip school because of difficulties during menstruation. 27.4% girls had the problems associated with menstruation. Among them 6.3% reported headache, 9% reported nausea, followed by breast tenderness 10.3% and 1.6% experience increased appetite/ or had cravings for specific foods.

DISCUSSION:

This study has tried to assess the knowledge about menstruation and hygiene practices among school girls. The age range of girls in this study group (13-17 years) falls within the range in Madhusudhan M et.al^[11]study. In this study it is found that knowledge on cause of menstruation was poor among participants i.e. only 43.33% of them knew the actual process of menstruation but later the knowledge was significantly increased to 94.3% after intervention. Similar findings were reported in a study conducted in Zagazig City.^[12]In our study 80.6% girls had an opinion that it is necessary to take bath during menstruation. In the study conducted by Omidvar S et.al^[13] it was shown that 83.9% practiced taking bath during menstruation and this behaviour was found to be associated to age.

Here in the present study dysmenorrhea was reported by 89.66%, out of which 80.6% said that menstrual pain is interfering their normal activities. In a study conducted by Godbole G et.al^[14]68% girls reported dysmenorrhea. In our study 62% girls responded that they skip school because of difficulties during menstruation. Another menstruation related problem faced by girls are premenstrual syndrome (PMS). In a study conducted by Karout N et.al^[15], 54.0% reported having 3 of the signs of PMS. Another study conducted in Chandigarh in India reported that 64.1% of adolescent girls are facing anyone of the symptoms of PMS. Surprisingly in our study 72.66% participants had none of the symptoms of PMS. Only 27.32% had anyone of the symptoms. Diet and lifestyle modification plays an important role in PMS and menstrual pain. Frackiewicz EJ et.al^[16,17] observed in their study that women with proper exercise or jogging experienced a reduction in PMS compared to the women who don't exercise. So doing regular exercise, getting enough sleep, eating balanced diet and reducing intake of sugar, salt, caffeine, and alcohol can reduce symptoms of PMS^[18,19].

CONCLUSION:

The present study concluded that the knowledge regarding menstruation among school girls is not satisfactory which needs to be addressed and their knowledge have improved after the conduct of educational sessions. The results of this study is promising and encouraging to impart more knowledge through large menstrual hygiene education campaigns and focus on this topic.

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Received on 06.05.2019 Modified on 10.06.2019

Research J. Pharm. and Tech. 2019; 12(12): 5673-5676.

DOI: 10.5958/0974-360X.2019.00981.8