Relationship between Female University Students' Knowledge on Menstruation and Their Menstrual Hygiene Practices: A Study in Tamale, Ghana

Positive perception about menstruation and good menstrual hygiene practice safeguards the health of postpubescent females by reducing their vulnerability to reproductive and urinary tract infections. Using a questionnaire, a cross-sectional study involving 293 randomly selected female undergraduate students in northern Ghana assessed the relationship between knowledge on menstruation and the practice of safe menstrual hygiene. Data collected was analyzed using GraphPad 5.01. This study found that although majority of respondents (73.4%) were aware of menstruation before menarche, most of them experienced fear and panic when it occurred. Mothers were the first to be informed when menstruation occurred, although teachers first provided them knowledge on menstruation. Respondents' knowledge on menstruation was average (57.3%) but their menstrual hygiene practice was good (80.2%). Age (p = 0.005) and course of study (p = 0.0008) significantly influenced respondents' knowledge on menstruation with older students as well as the medical and midwifery students being most knowledgeable. Muslim rather than Christian female students practiced better menstrual hygiene (p = 0.0001). Average knowledge score on menstruation indicated a deficit of knowledge on the anatomy and physiology of the female reproductive system. Increasing knowledge on menstruation had a positive and significant effect on practice of good menstrual hygiene.


Introduction
Menstruation, a unique event in the life of a developing girl child, is one of the milestones of puberty. It involves the cyclical shedding of the inner lining of the uterus which is controlled by the hormones produced by the hypothalamus and pituitary glands located in the brain [1]. The age at which women experience their first menstrual flow (menarche) varies widely across the world but generally most studies report that it occurs between ages of 13 and 15 years [2][3][4][5][6][7]. Although the age at which women stop menstruating is not the same in all nations, menopause is reported to usually occur between the ages of 45 and 50 years [2]. A woman therefore spends approximately 2100 days menstruating which is equivalent to almost 6 years of her reproductive life [8].
Whereas in some societies onset of menstruation is celebrated, it is the beginning of imposition of dietary and social restrictions at some other places [1,[9][10][11]. These sociocultural impositions during the period of menstruation make some menstruating females perceive this phenomenon not only as burdensome but also as an event that ushers in fear, disgust, and shame.
Provision of adequate knowledge on menstruation before menarche could make young females view menstruation as an important milestone in their lives and just a natural phenomenon. Parents and close relations are expected to be the foremost source of information on menstruation to young females but unfortunately in Africa, parent-child communication about sexually related matters is poor; hence most adolescents acquire sometimes incorrect information on the reproductive system from their friends [12].
Low knowledge on menstruation increases the risk of contracting reproductive tract infections as well as pelvic 2 Advances in Preventive Medicine inflammatory diseases and urinary tract diseases among millions of women across the world, because they are unable to manage their menstrual periods well enough [1,13]. Good menstrual hygiene management involves women or adolescent females using clean blood-absorbing materials which can be changed often in a secure place in privacy after which soap and water are available to wash hand and body as well as having access to secured used sanitary material disposal facility [14].
Several studies conducted among adolescent and pretertiary students across the world have rather shown inadequate knowledge of menstruation and poor menstrual hygiene practices [11,15,16]. Society considers persons with tertiary education to be knowledgeable in diverse fields and for students in health sciences, their knowledge related to reproductive systems such as menstruation would be highly considered. This study therefore assessed the knowledge of female undergraduate students in Schools of Medicine and Allied Health Sciences in the University for Development Studies in Tamale, Ghana, on menstruation and their practice of good menstrual hygiene. The study also assessed factors that could influence the knowledge of these students on menstruation as well as their practice of good menstrual hygiene.

Study Design and Setting.
This cross-sectional study conducted between March 2015 and April 2015 was among female undergraduate students studying Medicine, Nursing, Midwifery, Health Science Education, and Community Nutrition. The study setting was the Schools of Medicine and Health Sciences and Allied Health Sciences both of the University for Development Studies, Tamale. Tamale, the capital of the Northern region of Ghana and the fourth largest city in Ghana at 2010, had a population of 371,351 [17]. The instrument for this study was a semistructured questionnaire. This questionnaire was initially piloted among 20 students which ensured correction of ambiguous and inconsistent questions before it was administered for the actual data collection.

Study Variable Measurements.
The knowledge of the students on menstruation was based on 10 questions relating to menstrual physiology, female anatomy, and menstrual hygiene. Menstrual hygiene practice was assessed using 6 questions. Each most appropriate or correct response scored one point whereas a wrong or do not know answer attracted no score. The overall maximum scores for knowledge and menstrual practice were 10 and 6 points, respectively. Overall knowledge scores converted to nearest whole numbers from 0 to 4 were adjudged as poor, 5 to 6 as average, and 7 to 8 as good, while those above 9 were adjudged as excellent. For each knowledge and menstrual hygiene practice question, correct mean score of 0.0 to below 0.5 (<50%) was poor, 0.5 to less than 0.7 (50.0% to <70.0%) was considered as average, above 0.7 to less than 0.9 (70.0% to <90.0%) was considered as good, and above 0.9 or 90% was excellent. For menstrual hygiene practice, overall score between 0 and 3 was considered poor while score above 3 was adjudged as good. The mean scores were recorded with their standard deviations (mean value ± standard deviation).

Ethical Consideration.
Prior approval for this study and the procedures were obtained from the Ethics Committee of the School of Medicine and Health Sciences of the University for Development Studies. Verbal consent was obtained based on provision of adequate participant information that enhanced respondents' confidentiality in the research which increased their participation. Respondents were adequately informed that accepting to participate and completing the questionnaire indicated consent with an option of withdrawing from the research at any point.

Study Size Determination and Sampling
Procedure. Study sample size was estimated using Cochran's correction formula for categorical data: 1 = 0 /(1 + 0 /population), where 1 is the required return sample size without estimated response rate factor and 0 is the required sample size which was calculated based on the assumption that 50% of respondents possess good knowledge of menstruation and also practiced good menstrual hygiene, sampling error is 5%, confidence interval is 95%, and the significant level -value at alpha level of 0.05 is 1.96. The calculated return sample size without estimated response factor was therefore 384. With the study population of 990 and an estimated response rate of 70%, the drawn sample size of 389 was obtained for this study. The respondents were drawn using the sampling with replacement method. The number of respondents from a class in a study programme was obtained using a proportional approach based on the number of female students in each class. In each class, respondents were randomly chosen by picking from envelope pieces of paper with name and identity number of each female member of the class printed on it. The response rate for this study was 75.3% ( = 293/389).

Statistical Analysis. Data was entered into Microsoft
Excel and analyzed using GraphPad Prism, Version 5.01 (GraphPad Software Inc., San Diego, CA). Associations between respondents' sociodemographic characteristics and their knowledge of menstruation and practice of good menstrual hygiene scores were assessed using the oneway ANOVA test as well as independent -test, whichever is applicable. Test of association between age, knowledge of respondents about menstruation, and their practice of menstrual hygiene was determined using Pearson correlation coefficient. Statistical significance was assumed at < 0.05 and at a confidence interval of 95%.

Sociodemographic Profile.
The sociodemographic profile of the respondents is as shown in Table 1. In this study, the majority, 221 (75.4%), were between ages of 20 and 25 years, experienced menarche between ages of 13 and 15 (mean age of menarche = 13.66 ± 1.87 years), were Christians, 208 (71.0%), and spent their vacation in urban areas of Ghana, 181 (61.8%). Most of the students were studying Nursing, 99 (33.8%), and were in the second year, 111 (37.9%). At menarche, most respondents, 126 (43.0%), stayed in a selfcontained accommodation, indicative of their parents and guardians belonging to the middle social class. Majority, 181 (61.8%), of the students currently live in urban areas of Ghana.

Level of Awareness of Respondents of Menstruation at Menarche and Their Reaction to First Menstrual Blood.
Majority, 215 (73.4%), of the respondents were aware of menstruation before the onset of menarche with the teachers being the earliest source of information for majority of them, 159 (54.3%). Mothers were however the first persons the majority, 181 (61.8%), discussed menarche with rather than the teachers who were the least consulted, 5 (1.7%). Majority, 198 (72.5%), expressed satisfaction with the level of education on menstruation they got from persons they first discussed their first menstrual episode with. Most, 105 (38.5%), of the respondents were struck by fear and panic on seeing blood flowing from their genitals for the first time at menarche. Table 2 shows respondents' level of awareness of menstruation at menarche and subsequent reaction to menarche.  Table 3 shows the menstrual hygiene practices of respondents.

Relationship between Sociodemographic Characteristics and Respondents' Score of Knowledge on Menstruation and
Menstrual Hygiene Practice. Table 5 shows the effect of sociodemographic characteristics of the respondents on their knowledge on menstruation and practice of menstrual hygiene. In this study, females older than 25 years were significantly more knowledgeable about menstruation than their younger colleagues (6.49 versus 5.60-5.73; = 0.005) and also practiced better menstrual hygiene but the difference was not significant. Christians scored higher mean knowledge score than followers of Islam (5.83 versus 5.51) but their mean menstrual hygiene practice score was significantly lower than the Muslims (4.70 versus 5.15; = 0.0001). ANOVA analysis showed a significant difference in knowledge scores among the students based on their courses of study ( = 0.0008) with the medical (6.11) and Midwifery (6.19) students scoring more than 6 out of 10 while Community Nutrition students obtained the least mean knowledge score of 5.08. Course of study did not however influence students' menstrual hygiene practice. As students move to higher levels in their study, their knowledge on menstruation and their menstrual hygiene practice increased since it was the fourthyear students who obtained the highest knowledge (5.93 versus 5.57-5.84) and menstrual hygiene practice (5.07 versus 4.64-4.96) scores. There was however a significant difference in menstrual hygiene practice based on year of study ( = 0.028). Socioeconomic situation of respondents at menarche (indicated by the type of accommodation occupied at menarche) and the living area of respondents did not influence their knowledge on menstruation and their practice of menstrual hygiene. Table 6 shows the association between continuous variables of age, respondents' knowledge on menstruation, and their menstrual hygiene practices. Whereas there was a weak positive but significant relationship between the age of respondents and their knowledge of menstruation ( = 0.14; = 0.0195), it was not so with their menstrual hygiene practices. There was also a positive and significant association between the knowledge of respondents about menstruation and their practice of good menstrual hygiene ( = 0.26; < 0.0001).

Discussion
Hormonal changes during puberty set into motion the transformation of a girl child to a woman who had attained sexual maturity which is accompanied by psychological, cognitive, and physical changes [18]. Menstruation, which is one of the milestones of puberty in a girl, involves the cyclical shedding of the inner lining of the uterus which is controlled by the hormones of the hypothalamopituitary axis [1]. Better appreciation of and attitude towards menstruation are achieved when the girl child is aware or knowledgeable about menstruation [19]. According to Auemaneekul et al. [20] and Bhore and Kumbhar [21], females with greater knowledge on menstruation were better in practicing good menstrual hygiene. Several studies reported low to average levels of awareness of menstruation at menarche between 36.9% and 67.5% [1,13,16,[22][23][24]. This study however recorded 73.4% of respondents stating that they knew what menstruation was before menarche. Teachers were stated by majority (54.3%) of respondents to be their foremost source of information about menstruation not mothers as reported in several previous studies [1,13,15,16,23,24]. One possible reason for teachers rather than mothers being the first source of information on menstruation in this study is because, in Ghana, pupils in primary five are taught human organs and their functions in Natural Science lessons and the teachers would have introduced menstruation when teaching organs of the reproductive system. Furthermore, in the African societal setup, parents shy away from discussing issues related to sex and reproduction with their daughters [9]. This study however found that when menstruation finally occurred, majority of respondents first discussed it with their mothers (61.8%). Mothers were first notified of menarche because they would have to provide the menstruating girl with sanitary materials to handle the flow and most importantly females consider menstruation-related matters as challenges best discussed with other females preferably mothers, rather than males [25,26]. Lack of trust in teachers was reported by female students in Sierra Leone to be one of the reasons they were reluctant to discuss their menstruation issues with their teachers [26]. The situation where males form the majority of teacher population in educational institutions in Sub-Saharan Africa as well as South and West Asia makes teachers even more unattractive to these female students [27]. In Ghana, the female teacher percentages in primary and secondary schools were 33.0% and 22.0%, respectively, as at 2007 when most respondents in this study were at those levels of education [27]. With this low number of female teachers, these female students would rather inform their mothers or elder female relatives about menarche rather than their male teachers. Although almost three-fourths of respondents might have heard of menstruation before menarche, 38.5% exhibited fear and panic when they first saw blood flowing from their genitals at menarche. Negative reactions of fear, discomfort, anxiety, and shame as reported in studies in  other parts of the world could be attributed to the low knowledge on menstruation among the young adults [8,23,28]. Several studies among secondary school students showed that knowledge about menstruation was mostly average or inadequate [11,[21][22][23].
Undergraduate students pursuing health related programmes such as respondents in this study were expected to possess good knowledge on menstruation so the mean knowledge score of 57.3% recorded in this study can best be described as average. Whereas majority of respondents in this study correctly defined menstruation and agreed that poor menstrual hygiene may cause infections, less than a third (26.3%) knew that hormones are responsible for the menstrual cycle, a score worse than the 55.0% recorded among secondary school students in Nepal [15]. Furthermore, threefourths of respondents did not know or stated the normal age of menarche to be 12 years or below. The normal ages of menarche stated by about three-fourths (72.5%) of these females were lower than their own recall age at menarche. Meanwhile, the recall age at menarche from this study was 13.66 years lower than 13.98 years found by Adadevoh et al. [29], which was Ghana's first survey on age at menarche.

Advances in Preventive Medicine
The age at menarche and the cause of menstruation are basic important information that girls should know so they can better appreciate menstruation and the accompanying physiological and psychological changes in the life of a woman. The discord between the perceived age at menarche and the average normal age at menarche and for more than half (51.9%) to state that normal menstrual flow should last more than 5 days can be a source of anxiety for many of these female students. In this study, two factors, namely, the age of respondents ( = 0.005) and the course of study ( = 0.0008), significantly influenced a respondent's knowledge on menstruation. The Midwifery class which scored the highest knowledge score had some older but lower certificated students who have enrolled in the university to further their studies. The working environments of these practicing midwives may possibly have provided them with extra knowledge on menstruation which might have been the reason for their relatively higher knowledge scores.
Poor menstrual hygiene increases the vulnerability of postpubescent females to reproductive tract, urinary tract, and perineum infections [30,31]. This study found a positive and significant association between the knowledge of respondents on menstruation and their practice of good menstrual hygiene management ( = 0.25; < 0.0001) which is contrary to a study in India by Shanbhag et al. [23].
Despite the average knowledge on menstruation exhibited by the undergraduate female students in this study, their practice of menstrual hygiene score of 80.2% was good. Earlier studies especially in developing countries reported poor menstrual hygiene practices [8,22,32]. In this study, all the females used disposable sanitary pads but other studies have some females still using other materials such as reuseable pieces of cloth for absorbing menstrual blood [8,26]. All respondents use disposable sanitary pads because majority come from urban areas and have parents of the middle class; hence accessibility and affordability of sanitary pads should not be a challenge. Respondents who change their sanitary pad twice in the day were in the majority in this study similar to that reported in other countries such as Nepal [15] and India [8]. Cleaning of the genitals regularly after urinating prevents unpleasant odour as excess blood would not stay long enough in the skin between the labia or crust around the opening of the vagina to create the odour. The regular cleaning of genitals during menstruation recorded a low practice rate of 24.8% in Pokhrel et al. [8] study but respondents in this study scored 69.3%. Most of those who clean their genitals after urinating use toilet tissue only because taps in the washrooms on campus do not always flow and also the washrooms were not designed to make washing convenient. Those who do not clean the genitals did not find it necessary or for heavy bleeding females the fear of spilling blood prevents them from attempting any cleaning while on campus. The need for more regular baths during menses enables the female to clean the genitals with water more often but majority of females in this study did not find it necessary to increase the number of daily baths which was their worst menstrual hygiene practice score (34.5%). This study, just as that by Shanbhag et al. [23], did not report residential status and living area influencing the practice of safe menstrual hygiene. Among the sociodemographic characteristics of respondents in this study, religion and year of study are the factors that were associated with the female's practice of safe menstrual hygiene. Anusree et al. [11] reported effect of religion on menstrual hygiene practice with Muslims doing better than followers of other religions. This study also found Muslims scoring significantly better than Christians in safe menstrual hygiene practice. According to Dunnavant and Roberts [33] women whose religions prescribed various rituals and prohibited them from some activities have more negative attitude towards menstruation. Islam is one of such religions which consider menstruation a period of impurity and prohibition from several religions activities [33,34] which could be the reason female Muslims would put in more effort to attain better menstrual hygiene than their Christian colleagues.
Several limitations associated with this study are worth stating. This study involved the use of self-administered questionnaires rather than interviews; hence reliability of answers could not be verified. Again, the menstrual hygiene practice score may contain some social desirability biases since some respondents may state they practice safe menstrual hygiene but do otherwise. This study was undertaken among female students of one of the campuses of the University for Development Studies. The results of this study can therefore not be generalized for all females in Ghana. The use of simple random sampling removed bias in relation to the selection of respondents which invariably is one of the strengths in this study.

Conclusion
Female university students possessed average knowledge on menstruation but they practiced good menstrual hygiene. There was a positive and significant association between knowledge of students on menstruation and their practice of good menstrual hygiene. Of all the sociodemographic factors, age and course of study of students positively influenced their knowledge about menstruation, while religion and year of study were associated with their practice of safe menstrual hygiene. The mean age at menarche was 13.66 years which means that education on menstruation and menstrual hygiene management should start from upper primary so that females would be well informed on this normal phenomenon before menarche.