Adolescence is a transitional phase of growth and development between childhood and adulthood, which is not only physical but also emotional and psychological. According to the WHO, adolescent is defined as any person between the ages of 10 and 19 years [1].

Menstruation, a unique phenomenon is a part of the female reproductive cycle starts when girls become sexually mature at the time of puberty. Woman bleeds from her uterus via the vagina during menstrual period. The menstrual rhythm depends on the function of hypothalamus-pituitary-ovarian and amount of blood loss depends upon the uterine contraction. It lasts from three to seven days. Each period commences approximately every 28 days unless women become pregnant during a given cycle. The average age of menarche for most girls is from 10-14 years until 45-55 years varying from race and family. It can also be affected via geographical conditions, racial factors, nutritional standards, environmental influences and indulgence in strenuous physical activity [2].

During adolescence, the onset of menstruation is the most important physical change occurring among girls. In this phase of life, girls have many curiosity and concerns related to menstrual cycle. Menstrual hygiene management is an important issue for adolescent girls due to lack of experience. Even parents lack the required information in managing the related issues of menstrual cycle. Besides, growing adolescent girls often lack appropriate information about their reproductive health and hygiene matter. Menstrual taboos create chaos among adolescent girls which is rooted to socio-cultural values in Nepalese society. Women are forbidden to participate in any religious ceremony and prohibited from participating in normal life activities including cooking and eating together within a family and hence hygiene aspect is always overlooked [1,3].

Result leading to faulty menstrual practices occurs when there is faulty perception or misconception on menstruation and menstrual cycle which either leads to reproductive health problems in the adolescent, such as dysmenorrhoea, gastrointestinal manifestations; depression; and reproductive tract infections which may in turn cause congestive dysmenorrhea [4].

Many studies have revealed that most of the adolescent girls had incomplete and inaccurate information about the menstrual physiology and hygiene. It also revealed that mothers, television, friends, teachers and relatives were the main sources which provided information on menstruation to the adolescent girls. Good hygienic practices of using the sanitary pads and adequate washing of the genital area are essential during menstruation. Women and girls of the reproductive age need access to clean and soft, absorbent sanitary products which can in the long run, protect their health [5].

Adequate level of information, positive attitude and practices of menstrual hygiene by adolescent girls can lead to a healthy reproductive life throughout the womanhood span. For this adolescent girls mother should have adequate information regarding menstruation and its management. They can help their daughter in a very young age to build a positive attitude towards menstruation and dealing all those cultural taboos of the society.

When it comes to Nepal, many people still take menstruation as rituals where the girls/women are forbidden to attain the religious ceremony. They are forced to stay away from the house. They even cannot perform their daily normal activities. Specially, adolescent girls had been a target group of all these menstrual taboos due to which they are even lacking in their academic performance.

The overall aim of the study was to create awareness on menstruation and its management to adolescent girls and build up a positive attitude. The researcher was interested in finding the knowledge, attitude and practices of menstrual hygiene of adolescent girls and their problem in different aspects.

The general objective of the research is to assess knowledge, attitude and practices of menstrual hygiene among rural adolescent school girls of ward no. 5 of Banganga municipality of Kapilvastu district.

Research Design 

A descriptive cross sectional study design was used to assess knowledge, attitude and practices of menstrual hygiene among rural adolescent school girls.

Population and Setting

Population in this study were adolescent school girls studying in 6th, 7th, 8th and 9th grade of three schools, , Annapurna Vidhya Mandir Secondary School Kopawa, Shree Secondary School, Jhanda-Madhauli and Shree Mahendra Secondary School, Kopawa of ward no. 5, Banganga municipality, Kapilvastu district.

Sampling Technique

Probability cluster sampling technique was used to select the sample. As there are all together three schools in the ward, the classes from six to nine were selected randomly through lottery method. A total of 218 sample size was calculated with 85.5% prevalence and 5% non-response rate. Design effect was taken 1.5 as the sampling technique is probability cluster sampling. Out of 218 sample size, 210 samples were taken for the study with response rate of 96.33%.

Research Instruments

In order to measure the research variables self-administered structure and semi-structured questionnaire were developed by the researcher in simple understandable English language. The instruments were divided into five parts:

• Part I – Socio-demographic information 

• Part II Questionnaire related to menstrual experiences of respondents

• Part III Questionnaire related to knowledge regarding menstruation

• Part IV Questionnaire related to attitude regarding menstruation 

• Part V Questionnaire related to practices and hygiene during menstruation

Validity and Reliability

Content validity of the instrument was ensured by reviewing of the literature, seeking the opinion of the research teacher, subject matter specialist, advisor, consulting expertise of related field and peer review. Valuable suggestion and comments were incorporated at the final modification of the questionnaire.

The reliability of the instrument was established using 10% of sample size. Researcher herself has collected the data. Researcher had explained the purpose of the study and advantages of the study to the respondents.

Data Collection Procedure

The data was collected from three schools of ward no.5 of Banganga municipality, Kapilvastu by probability cluster sampling. The selection of classes of the schools was done under simple random sampling by lottery method. The researcher’s respondents were from the selected classes as per the required sample size.

Data Analysis Procedure

The gathered data were checked for accuracy, utility and completeness. Any errors, incompleteness and inconsistencies in the data that could affect the result were removed. The data was analyzed through the SPSS 16.0 for window software and findings were presented in the tables by using descriptive statistical tools such as mean, frequency, percentage and standard deviation. The data were presented in different Tables.

Ethical Consideration

The ethical approval from the Sanjeevani College of Medical Sciences and the respective schools of the study (Annapurna Vidhya Mandir Secondary School, Shree Secondary School, Jhanda-Madhauli and Shree Mahendra Secondary School) were taken. Respondents were explained about the purpose of the study. The subjects were assured for the confidentiality of information. Confidentiality and privacy was ensured for subjects to safeguard the interest. Informed verbal and written consent were taken from the respondents. The right to refuse to participate in the study had been respected. 

Table 1 represents the socio-demographic status of the respondents showing age, religion and ethnicity. A sample size of 210 students was taken covering three schools with the age group of 11-17 years. Among the sample taken, more than half of the respondents (55.7%) were of age 13-14 years and only 5.7% were of age 11-12 years. The mean age of the respondents was 14.17±1.25 years. Almost all the respondents were Hindu with 99% with total of 208 and only 1% of them were Buddhist. More than half of the respondents (58.1%) were Janajati followed by Brahmin/Chhetri (31.9%), Dalit (7.1%) and others (2.9%).

The educational status of the parents of respondents was found to be of different level. Out of 210 samples, around half of the respondents father were literate (41.4%) followed by secondary level (26.7%). Similarly, educational status of the respondent’s mothers who were literate was 35.7% followed by secondary level (23.3%) (Table 2).

Around half of the respondent’s father’s occupational status was agriculture (41.9%) followed by foreign worker (24.3%), business (16.2%), daily labour (8.6%), government employee (8.1%) and private organization employee (1%). More than half of the respondent’s mothers were found to be engaged in agriculture (53.3%), 26.2% were housewife and 8.6% of them were engaged in business, government employee were 5.7%, daily labor were 5.7% and private organization employee were 0.5%.

Table 1: Socio-Demographic Status of Respondents 

n=210

Table 2: Educational and Occupational Status of Parents of Respondents 

n=210

Out of 210 respondents, more than half of them (51%) had menarche at the age group of 10-12 years and 43.3% were at 13-15 years. However, 5.7% were unknown about their menarche age. The mean age at menarche was 12.47±1.02 years. Among 210 respondents, half of them (57.6%) had shown the scared reaction at menarche while 28.6%, 9% and 4.8% were discomfort, emotional disturbance and happy respectively. More than two third of the respondent (67.1%) had faced physical symptoms of abdominal and back pain at menarche.18.6% and 8.6% had faced heavy bleeding and sleeplessness respectively. There were no physical symptoms on 5.7% of the respondents at menarche.

Mean days of interval for occurrence of menstruation in respondents was 32.14±7.47 days. Nearly about half of the girls (46.2%) had their menstruation at the interval of 30 days. 32.9% did not knew about their interval of menstruation occurrence. Majority of the girls (28.6%) had their menstruation flow for 5 days whereas 12.4% did not know about the duration of menstruation flow. The average duration of menstruation flow was 5.49±1.59 days. Abdominal pain was the commonest problem associated with menstruation in respondents with 69%. 15.7% of them had weakness followed by back pain with 8.1% and headache with 7.1% (Table 3).

Above Table 4 includes the knowledge of respondents regarding menstruation. Majority of the respondents i.e. 89% correctly defined menstruation as physiological where 5.7% did not know the meaning of menstruation. 85.7% of the respondents had correctly answered hormones as a cause of menstruation while 10.5% did not know the cause of menstruation. 38.1% of the respondents had correctly answered uterus as the organ form where menstrual blood comes out. 12.4% did not know about it.

Around two third of the respondents i.e. 61.9% had knowledge of the normal age of menarche in age group 12-13 years followed by 16.7% in age group 10-11 yearsand 11% in age group 14-15 years. 10.5% did not have knowledge about the normal age of menarche. More than half of the respondents (53.3%) had reported the duration of menstruation as 3-5 days followed by 39.5% as 5-7 days. Only 7.1% of the respondents did not have knowledge about the duration of menstruation.71% out of total 210 knew about menstruation before menarche whereas 29% did not know about it.

Table 3: Menstruation Experiences of Respondents

n=210

Table 4: Knowledge of Respondents Regarding Menstruation

N = 210

Table 5 represents the information related to the source of information regarding menstruation to the respondents, where high percentage of information was gained by mother i.e. 78.6% followed by teacher, friends, books and media (T.V, Radio) with 28.6%, 19.5%, 9.5% and 2.9% respectively.

Table 6 includes the attitude of respondents regarding menstruation. Out of 210 respondents, 41.9% answered there should be any restriction while 58.1 % answered there should not be any restriction during menstruation. Almost all of the respondents(90.5%) followed restriction in house remaining 9.5% didn’t follow the restriction.36.2% of the respondents answered menstrual problem interfere while 63.8% answered menstrual problem didn’t interfere with school performance.

Table 7 explains the restriction followed by the respondents during menstruation. It was found that most of the restrictions were related to participation of the respondents in the religious activities (80%) followed by kitchen work (58.9%), take bath after 4 days and enter the kitchen by 46.8%, touch/sit/talk with male members of family (27.4%), use older cloths by 15.8%, stay/go in others house by 15.8% and sleep in usual bed/sleep in floor by 5.8%.

Table 5: Source of Information Regarding Menstruation 

Note: Result of the table has frequency and percentage more than 210 and 100 due to multiple responses, n=210

Table 6: Attitude of Respondents Regarding Menstruation 

N = 210

Table 7: Restriction Followed by Respondents during Menstruation 

Result of the table has frequency and percentage more than 190 and 100 due to multiple responses, n=190

Table 8: Respondents School Absenteeism during Menstruation 

N = 210

Nearly three fourth of the respondent attend school during menstruation i.e.74.8% with total of 157 out of 210 whereas 25.2% answered not attending school. Out of 53 respondents, 71.7% reported fear of unexpected bleeding as a reason for not attending the school followed by lack of material or pad, presence of menstrual symptoms and lack of water facilities with 13.2%, 9.4% and 5.7% respectively. It was reported that 11.4% of respondents missed their school for 1 day, 7.1% missed for 2 days and 6.7% missed for ≥3 days in a month due to menstruation. Nearly three fourth of the respondents (74.8%) did not miss the school due to menstruation (Table 8).

Table 9: Practices of Respondents during Menstruation 

N = 210

Table 9 includes practices of respondents during menstruation. Around three fourth of the respondent (71.4%) with 150 out of 210 answered sleeping in house while 28.6% answered not sleeping in house during menarche. 

Almost all (92.4%) of the respondents had the practice of taking rest whereas 7.6% of the respondents did not take rest during menstruation. 

Sanitary pad gained the highest percentage i.e. 46.7% out of 210 respondents as the type of absorbent material used during menstruation. 19% of the respondents used cloths as absorbent materials and 34.3% used both. It was found that respondents changing pad/cloths 2-3 times per day was 49% followed by 1 time and ≥4 times with 44.3% and 6.7% respectively. 100% of the respondents reused the cloths for the next menstruation. Out of 112 respondents, almost all (99.1%) used soap and water and only 0.9% used water for cleaning the cloths pad.

Respondents pad disposal practices are shown in Table 10. Out of 170 respondents, disposal of pad in dustbin after its use was reported by 42.4% followed by burn and burry underground with 29.4% and 28.2% respectively. 

Nearly three fourth of the respondents (72.4%) out of 170 answered the use of plastic bag for wrapping the pad for after its use disposal while 24.7% of the respondents answered paper and only 2.9% of the respondents answered the disposal of pad without wrapping.

Table 11 shows the hygiene practices of respondents during menstruation. Less than two third of the respondents (63.8%) out of 210 answered bathing daily during menstruation followed by third day and first day with 22.4% and 13.8% respectively. All of the respondents (100%) answered cleaning of genital during menstruation. Almost all i.e. 98.6% of the respondents used soap and water and only 1.4% of the respondents used water for washing their hands after cleaning genitalia.

Table 12 shows the knowledge, attitude and practice scores of the respondents, more than two third of the respondents (68.3%) had good knowledge and attitude (66.7%) regarding menstruation while only around half (51.9%) had good practices regarding menstruation.

Table 10: Respondents Practices of Pad Disposal 

N = 170

Table 11: Hygiene Practices of Respondents during Menstruation 

N = 210

Table 12: Knowledge, Attitude and Practice Scores of the Respondents

The purpose of the study on menstrual hygiene among rural adolescent school girls was to access the knowledge, attitude and practices of menstrual hygiene among rural adolescent school girls in ward no. 5 of Banganga municipality of Kapilvastu district. This study provides a brief scenario of the knowledge, attitude and hygiene practices of rural adolescent school girls. It provides information on their experiences of menstruation, knowledge, sources of the information, attitude and different practices and hygiene during menstruation.

Socio-Demographic Aspect

In this study, the mean age of respondents was found to be 14.17±1.24 which was similar to other studies [1,6-8]. In the study that was conducted in Siraha and Sunsari had highest percentage of respondent following Hindu region i.e. 71.4% and 73.8% respectively followed by Buddhist, Muslim and Kirant which was similar to this study as 99% of respondents following Hindu with only 2% being Buddhist [3,9]. 

In this study the educational status of father with illiterate, literate, primary level, secondary level and graduate was found to be 7.1%, 41.4%, 23.3%, 26.7% and 1.4% respectively which was similar in other studies (8, 14) as literacy level was high as compared to illiteracy. It was also found that educational status of mother had literacy level higher than illiteracy in many studies [5-6,8,10-12] and in this study too. 

Around half of the respondents father occupation in this study was agriculture with 41.9% which was slightly higher than the study conducted in Ethiopia with 37.8% [11]. This could be because this study was carried out in rural settings. It was found that more than half of the respondent’s mothers were engaged in agriculture with 53.3% for the earning while the percentage of housewife in other studies was higher than working mothers [10-11]. 

Menstruation and Its Experiences 

The mean age of menarche in this study was 12.47±1.02 years which was similar to other studies [1,6-7,13]. In this study, scared reaction was showed by the more than half of the respondents i.e. 57.6% followed by discomfort, emotional disturbance and happy with 28.6%, 9% and 4.8% respectively which was supported by the study of Funmito Omolola Fehintola et al. [8]. The mean days of interval of menstruation occurrence and duration of menstrual flow of respondents was found to be 32.14±7.47 days and 5.49±1.59 days respectively which was favored by the study of Gandhinagar by Prajapati, J., and Patel, R. [5]. In this study, abdominal pain followed by weakness, back pain and headache with 69%, 15.7%, 8.1% and 7.1% respectively was found as the problem of respondents at menstruation. In various studies, abdominal pain remained to be the common problem of the respondents at menstruation [4,13]. 

Knowledge Regarding Menstruation 

In this study, majority of the respondents (89%) correctly defined menstruation as physiological and 85.7% of the respondents had answered hormones as a cause of menstruation, 38.1% of the respondents had correctly answered uterus as the organ from where menstrual blood comes out. This study had high percentage of correct answer as compared to other studies [2] Prajapati, J., and Patel, R. [5,8,11-12,14]. This study revealed high level of awareness of respondents before menarche and the main source of information was the mother which was similar to the other studies [3,6,8]. The reason for this might be due to the fact that most of the respondent’s mothers are educated in this study.

Attitude Regarding Menstruation 

This study had shown the negative attitude of more than half of the adolescent girls i.e. 58.1% in following restriction during menstruation. Besides their negative attitude, 90.5% of them were still following the restriction at house during menstruation which corresponds with the findings of different studies [6,9,12-13]. Most of the restrictions were related to participation of the respondents in the religious activities (80%) followed by kitchen work (58.9%), take bath after 4 days and enter the kitchen by 46.8%, touch/sit/talk with male members of family (27.4%), use older cloths by 15.8%, stay/go in others house by 15.8% and sleep in usual bed/sleep in floor by 5.8%. Our society is still bounded by social, cultural taboos leading to the negative attitude of adolescents towards menstruation. So, there is a need of effective interventions to address the restrictions which are imposed or practiced by adolescent girls.

In this study, 63.8% of the respondents reported negative attitude on menstrual problem interferes with school performance. Nearly three fourth of the respondent attend school during menstruation i.e.74.8% which was slightly less than the study of Oyo state, Nigeria by Funmito Omolola Fehintola et al. which was 82.10% [8]. Among those who did not attend school 71.7% reported fear of unexpected bleeding as a reason followed by lack of material or pad, presence of menstrual symptoms and lack of water facilities. 74.8% of the respondents did not miss the school but 11.4% missed their school for 1 day, 7.1% missed for 2 days and 6.7% missed for ≥3 days in a month due to menstruation. Although the school going percentage of respondents are high but schools should impart right information and encourage girls to attend school regularly in order to minimize absenteeism.

Practices and Hygiene during Menstruation

The hygiene related practices of women are considered importance during menstruation, to prevent vulnerable infection that can affect health. In this study, around three fourth of the respondent (71.4%) answered sleeping in house at menarche and 92.4% reported of taking rest during menstruation which was significantly high as compared to the study in Chitwan district by Adhikari P et al. [2]. This might be due to the good knowledge and practice of menstruation over the huge interval of time. The findings of this study revealed the use of sanitary pad by majority of respondents (46.7%) which are similar to the other studies [3,15,12]. 

In this study, nearly half of the respondents (49%) reported changing of pad /cloths 2-3 times per day which was similar to the study in Sunsari by Sapkota D et al. [9] Among the respondents who had used cloths as a absorbent material it was found that 100% of them reused the cloths with the hygiene practice of cleaning the cloths with soap and water by 99.1% which is higher than the findings of the various studies [3,11,15]. Among the respondents using sanitary pad, disposal of pad in dustbin after its use was reported by 42.4% which was similar with the study in Oyo state, Nigeria by Funmito Omolola Fehintola et al. [8] nearly three fourth of the respondents (72.4%) answered the use of plastic bag for wrapping the pad which was higher than the study in Oyo state, Nigeria by Funmito Omolola Fehintola et al. which was 31.09% whereas paper as a wrapping was found in various studies [1,11].

In this study 63.8% of the respondents practiced daily bathing during menstruation followed by third day and first day with 22.4% and 13.8% respectively. All of the respondents (100%) answered cleaning of genital during menstruation. 98.6% of the respondents used soap and water for washing their hands after cleaning genitalia.In the study of South India by Pooja Chauhan et al. 100% of girls take bath daily with 74.8% washing hands with soap and water after changing of absorbent [1].

The study was conducted to access the knowledge, attitude and practices of menstrual hygiene among 210 rural adolescent school girls of three secondary schools of Banganga municipality of Kapilvastu district. The respondents were of age ranging from 11 to 17 years. Almost all of the respondents were Hindu and more than half were of Janajati ethnicity. More than half of the respondents experiences menarche at the age group 10-12 years. More than half of them had shown scared reaction where two third the physical symptoms of abdominal and back pain at menarche. Majority of the respondents had correctly answered the meaning and cause of menstruation. Nearly three fourth were aware about menstruation before menarche as mother being the major source of information. 

More than half of the respondent had the thinking that there should not be any restriction during menstruation but they were compelled to follow the restriction at house. Almost all of the respondents had practice of taking rest during menstruation. Nearly half of the respondents had used sanitary pad as absorbent material. The hygiene and disposal practices of the respondents were found to be satisfactory.

Limitation

The test instrument for data collection may not be sufficient to measure the knowledge, attitude and practices of menstrual hygiene of the adolescent girls. The time period for data collection was only for two weeks. Due to limitation of the time schools of only one ward was taken for the study. So, the results may not be representative for the whole population. Besides, it was cross-sectional study. Therefore, it may not be appropriate to generalize the findings.

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