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Knowledge and practice of self‐hygiene during menstruation among female adolescent students in Buraidah city

Background: Menstruation is a physiological phenomenon that begins in females in adolescent age. Poor menstrual hygiene can result in significant reproductive disorders. However, improving the knowledge about menstruation even before menarche can improve menstrual hygiene. Objective: The aim of this study was to determine the knowledge and practice of adolescent girls towards menstrual hygiene, in Buraidah city. Materials and Methods: A cross‐sectional study was conducted among 258 intermediate school girls in Buraidah city. A semi‐structured, self‐administered questionnaire was used to collect information on demographics, menstrual history, knowledge about menstruation, hygiene practices, and school absence during menstruation. The survey was conducted from December 2019 to Februry 2020. Results: Before menarche, 49.6% of the girls knew about menstruation. The mothers were the most common (94%) source of information about menstruation. Regarding menstruation, 68.2% had bleeding for four to six days, and 42.2% had an interval of 21 to 35 days between periods. Approximately 61.7% participants had ‘acceptable’ level of knowledge, 2.0% had a ‘good’ knowledge and 36.3% had ‘poor’ knowledge regarding menstruation. Most (60.5%) students were categorized as having unsatisfactory self‐hygiene practice. During the last three months, 35.8% of the girls were absent for one day due to menstruation. 47.7% of the students omit some foods and drinks from their diet during menstruation; soft drinks were the most omitted. Mother’s occupation (P = 0.022), family monthly income (P = 0.007), and prior knowledge on menstruation (P = 0.006) were significantly associated with knowledge regarding menstruation. Conclusion: Knowledge and practice toward menstrual hygiene is unsatisfactory. Creating awareness on self‐hygiene during menstruation is recommended.

Introduction a few studies are conducted on this topic. To fill the gap, this study was designed to assess knowledge and practice regarding self-hygiene during menstruation among adolescent school girls in Buraidah city, Saudi Arabia. Moreover, the study also determined the age of menarche, and explored the association of socio-demographic characteristics with knowledge and practice of self-hygiene during menstruation among adolescent school girls in Buraidah city.

Subjects and Methods
This cross-sectional study was conducted among intermediate girls' schools in Buraidah city, Saudi Arabia. The survey was conducted from December 2019 to February 2020. All intermediate girls in selected schools who have reached menarche were considered for inclusion and girls who were absent on the day of data collection were excluded.
Two-stage cluster sampling was used. In the first stage, five schools were selected by simple random sampling. In the second stage, two intermediate classes were randomly selected, and all the students meeting eligibility criteria in the selected classes were invited to participate in the study.
After approval from the school authorities, data were collected using a semi-structured, self-administered questionnaire. The contents of the questionnaire were adapted from a validated instrument used in a previous study. [7] Some modifications were done in the questionnaire according to objectives of the current study. The questionnaire was prepared in English language and back-translated into Arabic language. The questionnaire was pre-tested, and modified according to feedback of the participants.
The questionnaire consisted of 6 sections: • First section about sociodemographic data (age, educational level and occupations of a mother, monthly income) • Second section about menstruation history (age of menarche, durations of blood flow, the interval between period) • Third section about knowledge of hygiene during menstruation • Fourth section about practice during menses (the type of absorbent material used during menses, ways to dispose materials, frequency of changing pads, frequency and type of genital cleaning, bathing, hand washing) • Fifth section about school attendance during menstruation (absence from schools, causes of absence) • Sixth section about the activities restricted during menses (including sports, foods, herbal use)

Data management and analysis plan
Statistical package for social sciences (SPSS) software Version 21.0 (Chicago) was used for data entry and statistical analysis. Categorical variables were summarized using frequency and percentage, and continuous variables were described using mean with standard deviation.
Girls' knowledge and practices towards menstruation were evaluated by giving one point to the correct answer and zero for the wrong answer, then calculating the score for each of the knowledge and practice sections. The total score for the knowledge section was ten, while the total score for the practice section was seven. The average score was then compared over different demographic variables for both knowledge and practices using one-way ANOVA and t-tests at a level of significance P < 0.05.
The total score for knowledge was classified as follows: • Good knowledge = Score ≥8 • Acceptable knowledge = Score 4-7 • Poor knowledge = Score <4 The total score for practice was classified as follows: • Good self-hygiene practice = 5-7 • Unsatisfactory self-hygiene practice = 0-4

Ethical considerations
Informed Consent Form was included in the questionnaire and was obtained from all participants. Institutional ethical committee approval was taken from Qassim Regional Ethics Committee on 12/3/2019 reference 1440-1411907 and later permission was taken from school authorities. After explanation of the nature and purpose of the study, verbal permission was taken from each participant. Participation in the study was voluntary, and the participants had the choice to refuse to participate. The questionnaire did not include participants' names. All data were kept confidential and were used for study purpose only. Institutional ethical committee approval was taken from Qassim Regional Ethics Committee (Letter No:1440-1411907)march 11/2019.

Results
Three hundred girl students were contacted for participation in the study. Out of these, 258 (86%) students responded to this questionnaire. The characteristics of respondents and analysis of the questionnaire are described below:

General characteristics of respondents
Out of 258 students, 87 students (33.7%) were 13 years old, with a minimum age of 12 and a maximum age of 16. Additionally, 226 students (87.6%) lived with both parents. As for the mothers' educational level, 1.9% had a university degree or higher, while 89.5% had illiterate mothers. Regarding the profession of the mothers, 60.9% of the mothers were housewives, while 4.3% were administrative employees. Also, 24.0% of the students mentioned that their family income was more than 10,000 Saudi Riyal, and 54.3% did not know their family's monthly income [ Table 1].
The students were also asked if they knew about menstruation before it started. 49.6% of the girls mentioned that they 'knew about it very clearly', 41.5% responded that they 'had some idea' while 8.9% stated that they 'did not know at all' about it. Also, the students were asked about their source of information about menstruation. The most common (94.1%) source of information was mother followed by sister and teacher. Around 4.3% of the students used social media to get information about menstruation.

Characteristics of menstruation
The students were asked about their characteristics of menstruation. Regarding the age of menarche, 98 (38.0%) respondents attained menses at the age of 12 years. Duration of bleeding was four to six days for 68.2% of the girls, while 8.9% had bleeding for less than four days. Responding to the question regarding interval between periods, 42.6% reported 21 to 35 days between their periods. A total of 160 (35.2%) students mentioned of having abdominal pain during menstruation [ Table 2].

Knowledge about menstruation
To evaluate the level of knowledge of the students, they were asked a set of ten questions about their knowledge of menstruation. A total of 170 (65.9%) participating students knew that normal menstruation should start at the age between 11 and 14 years. One hundred and eighty two (70.5%) participants knew that normal menstruation lasts for three to seven days, around half of them were aware that regular menstruation is repeated after 20 to 30 days (51.9%), and that the cause of menstruation is physiological (51.2%), and 60.9% knew that menstrual blood comes from the uterus. 82.6% of them answered correctly that absorbent sanitary pads are ideal for menstruation [ Table 3].
The result of the study showed that out of 256 students who responded to all knowledge questions, 61.7% participants had acceptable level of knowledge, while 2.0% had a good knowledge and 36.3% had poor knowledge regarding menstruation [ Table 4].

Practices during menstruation
The practices of students towards menses were also explored. A total of 238 (92.2%) respondents used commercially available sanitary pads, 82.2% of them dispose pads in plastic bags, and 96.9% of them washed their hands regularly after changing pads and toileting [ Table 5]. The results of the study showed that 156 (60.5%) students fall into the category of unsatisfactory self-hygiene practice and 102 (39.5%) were categorized as having good self-hygiene practice towards menstruation.

School absenteeism during menstruation
On enquiring about school absenteeism because of menstruation, 34.5% of the girls were absent for one day due to menstruation  during the last three months [ Figure 1]. Among those absent from school, 68.4% were absent because of pain, and 6.9% of the students were absent because their family prohibited them to go to school.

Restrictions during menstruation
The students were asked about their restriction of activities during menstruation. Around 44.2% of the students omit some foods and drinks from their diet during menstruation, where soft drinks were the most commonly omitted drinks (48.1%) among students. Also, 20.9% of the girls used herbal medicines during menstruation.

Association of demographic characteristics with knowledge and practices towards menstruation
The mother's occupation (P = 0.022), family monthly income (P = 0.007), and prior knowledge on menstruation before menarche (P = 0.006), were significantly associated with the knowledge regarding menstruation, where girls of teachers, family income of more than 10000 Saudi Riyals/ month and girls with previous knowledge on menstruation had higher mean knowledge scores as compared to their peers [ Table 6].
Regarding practices, family monthly income was significantly associated (P = 0.039) with the mean practice scores of girls, where girls with a family income of more than 10000 Saudi Riyals/month had better practices compared to their peers.

Discussion
Menarche represents a significant change in females' development, which can be fearsome to some young girls due to a lack of knowledge. [8,9] The behaviour towards menstruation largely depends on the level of knowledge about it and girls' practices during menses. [10,11] A good knowledge can reduce the incidence of future reproductive disorders. [12,13] Hence, it is essential to understand the knowledge and practices of girls during menstruation.  According to socio-demographic data in our study, the mean age of menarche is 12.29 ± 1.04 years. The same mean age was observed in the study conducted in Saudi Arabia, which illustrated the mean age of menarche as 12.7 ± 1.3 years. [14] Another study conducted in India reported the mean age of 12.84 ± 1.4 years for menarche. [15] Also in Kuwait, Egypt and Canada, similar mean ages for menarche are reported (12.41 years, 12.44 years, and 12.72 years, respectively). [16][17][18] The present study aimed at examining the knowledge and practice of self-hygiene during menstruation among female adolescent students in Buraidah, Saudi Arabia. The study demonstrated that 49.6% of the girls knew about menstruation before it started, where 94.1% of the students had their mothers as their source of information. In our study, the teachers had a little role as a source of information on this topic. A similar result in a study conducted in Riyadh, Saudi Arabia revealed that 61.5% of girls went to their mothers to get information related to menstruation and teachers were the last source of information. [19] In our study, 68.2% of the girls reported bleeding for four to six days, and 42.2% had 21 to 35 days between their periods. As for absence from school, 34.5% of the girls were absent for one day due to menstruation during the last three months, among these 68.4% of them were absent because of pain. Furthermore, 44.2% of the students omit some foods and drinks from their diet during menstruation, where cold drinks were the most omitted drinks. A similar result in the study from Saudi Arabia was found in which 64.4% of participants avoided certain food and drink and especially cold drinks and spicy food. [2] In the present study, 49.2% of students believed that physical activity should be performed during menstruation. Whereas, 57% of the participants in another similar study avoided physical activity during menstruation. [2] In the current study, the mother's occupation (P = 0.022), family monthly income (P = 0.007), and prior knowledge on menstruation before menarche (P = 0.006), were significantly associated with the knowledge of girls towards menstruation.
Family monthly income (P = 0.047) was significantly associated with the practices of girls towards menstruation.
The knowledge and practices of menstr uation have been evaluated in different settings and countries. In the present study, mothers represented the primary source of information for their girls. A review article on the knowledge and practice towards menstrual hygiene among adolescent girls in low-and middle-income countries, illustrated that adolescent girls in low-and middle-income countries usually do not receive sufficient and trusted information about menstrual health and hygiene before menarche and that the source of information is mainly the mothers who might not have all the information required by their daughters in a reliable form. [20] These findings support the results of the present study, where mothers represented the primary source of information for their girls.
Another study was carried out by Alam et al. in Bangladesh to examine the knowledge and practices of adolescent girls towards menstrual health and absence from school due to menstruation, through surveying 700 girls in the age between 11 and 17 years old. [21] Alam et al. found that the girls had a reduced level of knowledge towards menstrual health, which has led to misconception and increased absence from school due to menstruation. [21]    Additionally, the most significant factors that affected their knowledge were the mother's occupation (P = 0.022), family monthly income (P = 0.007), and prior knowledge on menstruation before starting (P = 0.006). Similar findings were also reported in other countries such as Tanzania, Ghana, Cambodia, and Ethiopia, as documented by Sommer et al. [22] This research project had some limitations; it was performed in only one city in Saudi Arabia, leading to limited generalizability of the results. A self-administered questionnaire was used which might have resulted in misunderstanding of some of the questions. Also, the responses to the questionnaire included in this survey depend mainly on the honesty and subjective view of the respondents, which could influence the reliability of the outcomes.
To the best of our knowledge, this is the first study in Buraidah, Saudi Arabia, to examine the knowledge and practices of Saudi girls towards self-hygiene during menstruation. To get the broader picture of the knowledge and practice towards hygienic measures during menstruation among adolescent females on a national level, further similar studies with larger sample sizes and in different areas in Saudi Arabia is recommended.
To conclude, the level of knowledge and practices towards menstruation among adolescent girls in Buraidah, Saudi Arabia, requires significant improvements. This improvement of knowledge could reduce the risk of future reproductive disorders. We recommend that the decision-makers in the education sector include in educational courses for adolescent girls lessons about their reproductive health and healthy hygienic measures during menstruation. This needs to be the primary source of information for girls about their menstruation rather than relying on their mothers' knowledge or obtaining information from untrusted resources, which might affect their health and wellbeing.
To summarize, most of students fall into the category of unsatisfactory self-hygiene practice and had acceptable level of knowledge. The most significant factors affected knowledge about menstruation is mother's occupation, family monthly income, and prior knowledge on menstruation before starting. Regarding practices, family monthly income was significant affected factor.
One of the main goals in primary health care is prevention. After exploring the knowledge and practice we have the clear picture size of problem and establish a plan to prevent it by made health program in schools supervised by primary health care physicians.