Assessment of menstrual hygiene management and its determinants among adolescent girls: A cross-sectional study in school adolescent girls in Addis Ababa, Ethiopia

Introduction Managing menstruation is essentially dealing with menstrual flow and also in continuing regular activities like going to school, working etc. However, menstruation can place significant obstacles in girls’ access to health, education and future prospects if they are not equipped for effective menstrual hygiene management. Objective To assess the menstrual hygiene management and its determinant among school girls in Addis Ababa, Ethiopia. Methods Cross-sectional study design with quantitative method was carried out among 770 systematically selected adolescent school girls of Addis Ababa from April 1 to May 5, 2017. A self-administered pre-test close ended Amharic questionnaire at school setting was used for data collection. The coding was done using the original English version and entered to EPI-7 software. The quantitative file exported to statistical package for social science (SPSS) version 25.0 software for analysis. Total mean score was used to categorize individuals as good and poor while AOR; 95% CI with p < 0.05 was used to determine factors of menstrual hygiene management practice. Result This study had 98% response rate. 530 (70.1%) and 388(51.3%) respondents had good knowledge and practice of menstrual hygiene respectively. The findings also showed a significant positive association between good knowledge of menstruation and girls from mother’s whose education were secondary (AOR = 10.012, 95 % CI = 3.628-27.629). Wealth index quantile five (AOR = 9.038, 95 % CI = 3.728-21.909) revealed significant positive association with good practice of menstrual hygiene. Conclusion and recommendation Majority of participants had good knowledge and practice of menstrual hygiene and majority of them were from private school. Although knowledge was better than practice, girls should be educated about the process, use of proper pads or absorbents and its proper disposal.


Introduction 28
Background 29 Menarche is an important milestone in a girl's transition to womanhood (1). Around the world 30 women have developed their own personal strategies to cope with menstruation, which vary from 31 country to country and depend on economic status, the individual's personal preferences, local 32 traditions and cultural beliefs and education status. The onset of menstruation presents multiple challenges for school girls. Many girls lack the knowledge, support and resources to manage 1 menstruation in school (2). 2 Managing menstruation is essentially dealing with menstrual flow and also in continuing regular 3 activities like going to school, working etc (3). However, menstruation can place significant 4 obstacles in the way of girls' access to health, education and future prospects if they are not 5 equipped for effective menstrual hygiene management (MHM). Good MHM requires access to 6 necessary resources (menstrual materials to absorb or collect menstrual blood, soap and water), 7 facilities (private place to wash, change and dry re-usable menstrual materials, in addition to an 8 adequate disposal system for menstrual materials), and education about MHM (1). 9 Schools, particularly those in developing countries, often completely lack drinking-water and 10 sanitation and hand washing facilities; even, where such facilities exist they are often inadequate 11 in both quality and quantity. Girls are likely to be affected in different ways from inadequate 12 water, sanitation and hygiene conditions in schools, because the lack of such facilities they 13 cannot attend school during menstruation (4). Girls are particularly vulnerable to dropping out of 14 school, partly because when toilet and washing facilities are not private, not safe or simply not 15 available in schools. Girls who reached puberty and female school staff need gender-related 16 privacy; otherwise they may not use the facilities. This may result in absenteeism rates that can 17 reach 10-20 per cent of school time (5). 18 Menstrual hygiene and management has not received adequate attention in the health and water, reached 27%, 40% and 26% respectively in 2015 compared to 20%, 30% and 12% respectively 30 in 1990 (7). As a matter of fact, the existing sanitation condition for many of the school in 31 Ethiopia is horrendous. Most school latrines are filthy and unclean, and the poor condition is 32 contributing to high level disease prevalence, creates poor learning environments and especially 33 impacting on girls' education (8). 34 However, much attention is not given to this problem and studies on menstruation and its 35 hygienic management as well as its influence on girls' education are limited in Ethiopia. This 36 study therefore, will be conducted with the aim of assessing menstrual hygiene management 1 among primary and secondary school girls at both private and public schools. To assess the menstrual hygiene management and its determinant among private and public adolescent 3 school girls in Addis Ababa, Ethiopia. 4 Specific objective 5 To measure level of knowledge about menstrual hygiene management among adolescent school girls. 6 To measure level of menstrual hygiene management practice among adolescent school girls. 7 To determine factors affecting menstrual hygiene management knowledge and practice among adolescent 8 school girls. The study was conducted among primary and secondary school girls in Addis Ababa a capital of Ethiopia,3 from April 1 to May 15, 2017. 4 Addis Ababa was established in 1886 by Emperor Taitu and Minilik II and is the capital city of Federal 5 Democratic Republic of Ethiopia. Addis Ababa is located in an area of 540.1 square kilometers and 6 located at 9°2'0" North and 38°42'0" East at range of 2200 -2800 meters above sea level. Despite its 7 proximity to the equator, its lofty altitude -the third-highest capital in the world -means that it enjoys a 8 mild climate with an average temperature of 16°C (61°F). The hottest, driest months are usually April and 9 May. The city has administrative structures: one city council, 10 sub-cities and 116 woredas. The total 10 population of the city projected for the year 2016, by Population Census Commission, was 3.3 million 11 with male to female ratio of 0.92 (29). 12 The city has a total of 203 government and 612 private schools. Of the total number of 107,106 students 13 enrolled from grade 7 th to 10 th education in the year 2016/17 were females (26). 14 Study design 15 School based cross-sectional study with a quantitative research methods was employed. The survey was 16 conducted among female adolescent students. The interviews were explored female students' views about 17 menstruation and its hygienic management and availability, accessibility and adequacy improved 18 sanitation and hygiene keeping facilities for menstrual hygiene management. 19 Population 20 Source population 21 The source population of the study was all grade 7th to 10th students in public and private schools of the 22 selected sub cities of Addis Ababa. 23

Study population 24
The study population was all grade 7 th to 10 th students from the selected public and private schools. 25

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The study subjects were 770 randomly selected students and from whom data were collected. 27 Inclusion and Exclusion criteria 28 Inclusion criteria: 29 All students who were from grade 7 th to 10 th and has monarchy was included in the study. 30 Exclusion criteria: 31 All female students who had sight problems and with mental disorders were not be included in this study. 32 To determine the number of adolescent school girls to be included in the study, a two-population 3 proportion formula were used. Since the specific objectives are three, were calculated a sample size for 4 each in order to take a large sample size. 5 Specific objective 1 6 The sample size of this study was determined using a single proportion formula n = ( 2 ) 2 (1− ) 2 where 7 2 = 95% level of confidence (1.96), p= proportion of menstrual hygiene management practice among 8 adolescent school girls in previous study (prevalence of use of sanitary napkins 35.38%) (13) and d= 9 margin of error (5%), based on these assumption that sample size found to be 350 and to maximize the 10 response rate of the study sample size population correction were made by multiplying design effect 2 and 11 10% non-response rate. Based on the above assumptions the total sample size for objective one "n" was 12 770 school girls. 13

Specific objective two and three 14
For the second objectives: factors affecting menstrual hygiene management knowledge and practice 15 among adolescent school girls, sample size was calculated using two population proportion formula (13). 16 Where 19 Z α/2 : 95% confidence level Z β: power P1: the probability of event in the unexposed P2: the probability of event in the exposed r: ratio of exposed to unexposed OR: 1.5 It was calculated using statcalc sample size and power calculation for descriptive study of Epi info version 7 So, decision was made based on the comparison between the first specific objective (770) and second 1 objectives (434). Finally, due to the issue of representativeness a sample size of 770 were used in the 2 study. By using sample proportional to size, determine sample size to each school. Twenty primary and 3 secondary schools at private and public were selected systematically from the list of schools from the 4 selected sub-cities of Addis Ababa. A total of 770 school girls were randomly selected from students 5 networking list of selected schools based on the proportion to the size of grade seven to ten of each 6 school. 7

Sampling procedures 8
The target participants for this study was adolescent school girls from grade 7 th to 10 th in very selected 9 schools of five sub cities of Addis Ababa. A multi-stage probability sample procedure was used to select 10 participant schools. twenty Primary and secondary schools were selected randomly from the list of 11 schools which have grade seven to ten in the Regional Education bureau. A total of 770 School girls were 12 randomly selected from students networking list of selected schools based on the proportion to the size of 13 grade seven to ten of each school. The reason for the choice of school girls in grade seven to ten was 14 because they start their menarche. 15

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A self-administered pre-test close ended Amharic questionnaire at school setting were used. The 17 questionnaire was contained variables related to socio-demographic characteristics, knowledge about 18 menstruation and menstrual hygiene management, practice about menstrual hygiene. Study subjects were 19 invited to take part voluntarily by explaining the purpose of the study and data were collected after 20 obtaining verbal consent. Data was collected by ten female health professional data collectors with health 21 background one supervisor. 22 Students were instructed on how to fill the questionnaire. Data quality was assured through careful design 23 of the questionnaire. Data collectors and supervisor were received a one-day training on the purpose and 24 procedure of data collection related to this research. During the training, special emphasis was given to 25 establishing trust before asking questions. The training session were also pay attention to careful 26 consideration for sensitive questions, observations where needed, and avoidance of participation bias. 27 Data were checked for completeness and consistency after each day of data collection checking filled 28 questionnaires by supervisors. The overall data collection process was coordinated by the principal 29 investigator. 30

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All responses to the survey questionnaires were coded on pre-arranged coding sheet by the principal 47 investigator to minimize errors. The coding will be using the original English version and were entered to 48 EPI-7 software. The data file will export to statistical package for social studies (SPSS) version 25.0 49 software for analysis. Descriptive analysis including frequency, proportions, and measures of mean were 50 done. Cross tabulations were made to calculate Crude and adjusted odds ratio. All variables with p<=0.20 51 in bivariate analysis were fitted in to the multiple logistic regression model to identify factors associated 52 with menstrual hygienic practice. P value <= 0.05 were considered as a level of significance. 53

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The quality of data was assured at the maximum attainable level by using standardized adapted 55 questionnaire and following the necessary procedures in order to get the intended results. To ensure 56 quality of data, pre-test of data collection tools was done on primary school girls in New Era primary 57 school by taking 5% of the total sample size. The data collectors were got orientation. Besides, the 58 questionnaire was checked for completeness and correctness on daily basis by immediate supervisors. 59

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The students' knowledge and practices was scored using a scoring system adapted from a past study. 61 Students' menstrual knowledge score was calculated out of the 12 knowledge specific questions ( Table  62 3). Each correct response earned one point, whereas any wrong or don't know response attracted no mark 63 and thus the sum score of knowledge was calculated (12 points). Accordingly, the mean score of 64 menstrual knowledge (7 ± 1.67) was used to decide the cutoffs of the rank. Good knowledge of 65 menstruation and menstrual hygiene was given to those respondents who scored 7-12 points and Poor 66 Knowledge of menstruation and menstrual hygiene was given to those respondents who scored 0-6 67 points. Students' practice of menstrual hygiene score was calculated out of the practice specific questions 68 (Table 4). Each correct response earned one point, whereas any wrong or don't know response attracted 69 no mark and thus the sum score of practice was calculated (15 points). And also, the mean score of 70 menstrual practice (8± 3.619) was used to decide the cutoffs of the rank. Good practice of menstrual 71 hygiene was given to those respondents who scored 8-15 points and poor knowledge of menstruation and 72 menstrual hygiene was given to those respondents who scored 0-7 points. Each correct response earned 73 one point, whereas any wrong or don't know response attracted no mark (12). 74 Hygienic menstrual management practice in schooladolescent school girls using a clean menstrual 75 management material to absorb or collect blood that can be changed in privacy as often as necessary for 76 the duration of the menstruation period, using soap and water for washing the body as required, and 77 having access to facilities to disposed of used menstrual management materials (4). 78 Secondary schoola high school or a senior high school which provides secondary education, between 79 the ages of 14-19, after primary school and before higher education(26). 80 Primary school -a primary school or elementary school which provides primary education, between the 81 ages of 6-14, after kinder-garden school and before secondary education(16). 82 Access to water supply-Sufficient water-collection points and water-use facilities are available in the 83 school to allow convenient access to, and use of, water for drinking, personal hygiene, cleaning and 84 laundry (4). 85 Address the gender-related needs: The number, location, orientation of school WASH facilities should 86 take into consideration of the gender factor (gender mainstreaming) (8). 87 Adequacy of safe water-is the availability of 5 liters per person per day for all schoolchildren and staff 88 at day schools(4). 89 Appropriate designs for different age groups: The detailed design of the facilities provided must also 90 be young child friendly. Steps must be easy to climb. Door handles must be easy to reach. The toilet 91 interior cannot be too dark. Squatting plates must be designed to accommodate a child's feet rather than 92 those of an adult (8). 93 Improved sanitation -are those more likely to ensure privacy and hygienic use /easily cleanable which is 94 not full, do not have fecal matter in the squat (24) 95 Physically separate facilities: Physically separated facilities must be provided for girls, spaced 96 sufficiently apart to ensure that girls do not feel embarrassed but secure when approaching and using the 97 facilities. Separate hand-washing areas should also be provided, affording privacy for girls who may need 98 to wash and dry menstrual cloths (8). 99 Use appropriate orientation of facilities: Specifically, the direction that the toilet entrance faces, must 100 also take into account the perceived security and safety of girls. The orientation of the squatting plate 101 should also take into account cultural and religious norms (8). 102

Ethical consideration 103
Ethical clearance was secured from School of Public Health, College of Health Sciences, Addis Ababa 104 University Research Ethics Committee. Approval letter was obtained from Addis Ababa City 105 Administration Education Bureau in the respective schools included in this study. School directors and 106 directresses were briefed on the objectives of the study and permission to conduct the study was obtained 107 from participating schools. The questions from the questionnaire prove not to affect the morale and 108 personality of study subjects. Informed verbal consent was obtained from each study subject after 109 explanation of the objective of the study. Confidentiality was ensured from all data collectors via using 110 code numbers than names and keeping questionnaires locked. Data collectors also give health education 111 and advice to the subjects during the data collection process.

Socio-demographic characteristics of study population 138
A total of 756 primary and secondary school girls were participated from twenty primary and secondary 139 schools, with response rate of 98%. Among these participants 38.1 % (288) were from private and the rest 140 61.9 % were from government schools. Among the total respondent 156 (20.6%), 160 (21.2%), 220 141 (29.1%) and, 220 (29.1%) were grade seven, eight, nine and ten respectively. The mean age of the study 142 participants was 14.89 with SD + 1.285 years, while their age range between 12-20 years. The mean age 143 of menarche of the respondents was 12.84 with SD +0.745 years. 144 The study also indicated that 267 (35.3%) and 226 (29.9 %) of the respondents' father completed 145 secondary and higher level of education respectively. Regarding respondent's mother occupation

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Association between overall practice of menstrual hygiene management and socio demographic factors 224 Based on the bivariate analysis, among the ten socio-demographic variables, level of grade (secondary), 225 respondent's mother's educational status (college and above), respondent's father educational status 226 (college and above), both respondent's mother and father occupational status, Age at first menarche 227 (>=13) and pocket money were significantly associated with 95 % CI COR at P<0.05 with overall 228 practice of menstrual hygiene management among respondents. 229 The crude value also showed that the odds of overall practice of menstrual hygiene management among 230 secondary school girls were 2.364 (95% C.I: 1.759-3.177) times higher compared to primary school girls. 231 In this study, it was found that pocket money was associated with overall practice of menstrual hygiene 232 management. The odds of overall practice of menstrual hygiene management among girls 2.177 (95% 233 C.I: 1.575-3.009) times higher for respondent who had earned pocket money from their families. The 234 odds of overall practice of menstrual hygiene management among girls 2.330 (95% C.I: 1.720-3.156) 235 times higher among respondent who were from private school than government school girls. (see table 7) 236

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After controlling interaction effect of all the variables, it was found that the current age of school menstrual hygiene management practice than those who were daily laborer family. This study 246 also found that girls whose age at first menarche greater than thirteen were 2.572 times more

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Association between overall knowledge and practice of menstrual hygiene management and other 256 menstrual related factors 257 The regression model also evidenced other menstrual related factors like learning and discussing about 258 MHM in the school and with parents and friend and also hearing about it before menarche were 259 significantly associated with both the outcome variables. The odds of good knowledge about menstrual 260 hygiene management among those who learn about menstrual hygiene at school were 3.110 (95% CI: 261 1.569-6.162) times higher than those who didn't learn at their school. (See table 9) 262  In this study, three hundred ninety-seven (52.5%) of the respondents had good practice of menstrual 320 hygiene. The finding of this study was lower than studies conducted in the Amhara region of Ethiopia and 321 Jammu and Kashmir, India which were 84.28 % and 59.09%, respectively (30,33 with girl's menstrual practice (34). Possibly due to information provided about menstrual hygiene 347 management at schools. Students whose age above fifteen were 2.832 times more likely to have good 348 practice than age less than fifteen a similar study done in northeast Nigeria. A significant association was 349 also observed between girls whose first menarche were above thirteen (AOR= 2.572) and below with the 350 practice of MHM. Which was also significant in another study done in south India (24). 351 352 Conclusion 353 Seventy percent of the participants had good knowledge of menstruation and menstrual hygiene and it 354 was better among private school girls than the government. Half of the total respondents had good 355 practice of menstrual hygiene among respondents, and alike to that of knowledge, the large proportion of 356 them were from private school. 357 Good knowledge of menstruation showed a significantly positive association with the level of grade, 358 educational status of the mother, and mother's occupational status. Except for the level of grade, all the 359 above variables plus current age of respondents' and age at first menarche were positively associated with 360 practice of menstrual hygiene management. 361 All those factors considered in addition to socio demographic variables, which assume to be predictive of 362 the outcome variables including learn about menstrual hygiene in the school, discuss about menstrual 363 hygiene with their parents and friends and hear about menstruation before attaining menarche were 364 positively associated. 365

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Federal level managers are recommended to: 367 Strengthen the enabling environment through advocacy and policy initiatives for improved WASH and 368 MHM education. 369 Promote an innovative, intercultural, multi-sectorial and gender approach in all programming, ensuring 370 that MHM aspects are included in planning processes and budget allocation processes by the water and 371 sanitation, health, and education ministries. 372 Regional Level: in addition to federal recommendations, regional level managers are advised to: 373 Give technical assistance and advocacy to prioritize budgets and investment in WASH facilities in 374 schools by health, and education bureau. 375 Strengthen teachers' capacities and equips them with tools to provide in-depth and medically accurate 376 information to students in a safe learning environment by education bureau. 377 Strengthen school health packages provided by health extension professionals by health bureau. 378

School level managers suggested to: 379
Establish coordination between students, teachers and parents to improve MHM conditions at schools. 380 Complement menstrual hygiene management as part of the school health programs and should also give 381 special attention towards making schools a comfortable place for girl's menstrual hygiene practice by 382 continuous provision of sanitary pad especially for the neediest ones. 383 Consult parents about the need to support their children with sanitary materials for menstrual hygiene in 384 addition to other basic hygienic products during parent-school teacher meeting. 385 Educate and counsel girls about the important and the need for good personal hygiene including hand 386 washing practice during menstruation by using peer group discussion which supposedly mediated by 387 female school teachers. 388 Parents are advised to: 389 Educate their daughters about the process, good personal hygiene, use of proper pads, and its proper 390 disposal. 391 Support their children with sanitary materials for menstrual hygiene.