Prevalence, Management, and Impact of Dysmenorrhea on the Lives of Nurse and Midwife Trainees in Northern Ghana

Background Dysmenorrhea is the most common gynecological problem affecting the majority of female students in the nursing profession today. They often experience severe pain that is not only incapacitating but also has a significant impact on their day-to-day college life, academic, and clinical performance. Aim This study was conducted to assess the prevalence, management, and impact of dysmenorrhea on the lives of nurse and midwife trainees in northern Ghana. Methods A descriptive cross-sectional design with a quantitative approach to data collection was employed to collect data from nurse and midwife trainees in three colleges of nursing and/or midwifery in the northern region of Ghana. A proportionate stratified random sampling technique was used to recruit 303 respondents for the study. After gaining permission from various institutions, data were collected by using a structured questionnaire from 13th September to 28th October, 2022. Stata (special edition) for Windows version 17.0 was used for the statistical analyses. Results The study revealed a high prevalence of dysmenorrhea among female nursing students (66.7% and 95% CI: 0.611–0.720). More than half of the respondents (67.3%) experienced loss of appetite for food. The most common site of most intense pain was the pelvis and lower abdomen (98.0%). A greater proportion of students (65.8%) used antispastic drugs to reduce pain. The respondents' concentration in the classroom was greatly affected (77.2%) as well as normal physical activities (58.4%). A multivariable logistic regression analysis revealed that the odds of dysmenorrhea are 2.67 times higher when the duration of menstruation is 4-5 days (AOR = 1.82, 95% CI = 1.13–6.28, and p = 0.024) than a duration of 1–3 days. Having urinary tract infections was associated with 3.56 times higher odds of dysmenorrhea (AOR = 3.56, 95% CI = 0.98–12.86, and p = 0.053). Again, the odds of dysmenorrhea were also four times higher among respondents with a family history of the same condition (AOR = 4.05, 95% CI = 2.16–7.61, and p = 0.001). Conclusion The current study revealed a high prevalence of dysmenorrhea among nurse and midwife trainees in the northern part of Ghana. The majority of the respondent experienced loss of appetite and intense pain in the pelvis and lower abdomen, and their concentration during lectures was also significantly affected. The most predominant nonpharmacological method used for reducing the pain was sleep and the application of warm objects on the abdomen.


Background of the Study
Dysmenorrhea is one of the most common gynecological conditions that afect young women and has a grave impact on their education, social activities, and quality of life [1,2].
Dysmenorrhea accounts for an estimated 140 million missed work or school days each year. As a result, home remedies and self-medication with NSAIDs, naproxen sodium, and mefenamic acid are the most common methods used by women to alleviate menstrual discomfort [3][4][5]. Te American College of Obstetricians and Gynecologists (ACOG) defnes dysmenorrhea as the "pain associated with menstruation." Dysmenorrhea was reported worldwide to afect between 15.8% and 89.5% of menstruating women, with 2% to 29% reporting severe pain [6].
More than half of women of all ages sufer from dysmenorrhea, and the prevalence rates of the condition vary by age and country. Japan (15.8%), India (79.7%), the United States (85.0%), Australia (88.0%), Nigeria (83.1%), and Ethiopia (85.1%) have reported its incidence [7,8]. Menstruation is the cyclical shedding of the mucosal layer of the uterine endometrium that occurs during a woman's reproductive years and is accompanied by bleeding from the vagina [9]. Nearly, 90% of young women experience some degree of pain and distress during their menstruation, which is a common reason for frequent gynecological consultations [10,11]. Te most common symptom of dysmenorrhea is severe pain in the lower abdomen (sharp spasms), along with other symptoms such as sweating, fatigue, headache, backache, moodiness, irritability, tachycardia, constipation, nausea, vomiting, diarrhea, breast tenderness, and painful urination [12,13].
Tere are two types of dysmenorrhea: primary and secondary dysmenorrhea [14]. Menstrual pain without pelvic disease is called primary dysmenorrhea. It typically does not occur until ovulatory menstrual cycles are established, which typically begin 6-12 months after menarche [15]. Secondary dysmenorrhea is menstrual pain caused by an underlying condition like endometriosis, pelvic infammatory disease, or another similar condition. It can start years after frst menarche [16,17]. Primary dysmenorrhea has been linked in previous studies to reduce daily activity, social withdrawal, absenteeism from school or work, lower academic performance, and higher healthcare costs [18]. Younger age, low BMI, smoking, early menarche, nulliparity, prolonged or abnormal menstrual fow, premenstrual somatic complaints, previous suspected pelvic infections, psychological disturbance, and genetic infuence are all factors that afect the prevalence and severity of dysmenorrhea [5,8].
Te profession of nursing is extremely emotionally taxing and stressful. Nursing professionals have to deal with a wide range of people, at diferent times of the day, in varied situations [19]. One way to describe nursing, the most important profession in the healthcare industry, is that it is "a process of action, reaction, interaction, and transaction in which nurses provide patients with medical care and then become afected by a variety of complex interactive factors, such as social, cultural, economic, and political circumstances." Dysmenorrhea is one of the most common gynecological conditions that make it harder for female nursing students to focus, take part, use their test-taking skills [20,21], and to skip college class sessions [22]. It is evident that dysmenorrhea has a signifcant efect on their academic performance as well as their experiences [23].
Dysmenorrhea is very common among female students in Ghana. For instance, Ameade et al. [3] discovered 83.8 percent, and Acheampong et al. [24] found 68.1 percent among a large number of young women. However, the general public is still unaware of the social and economic efects of dysmenorrhea on female students [3].
Research on in-depth qualitative and quantitative studies of dysmenorrhea and coping techniques employed by nursing students with dysmenorrhea is lacking, particularly in Ghana [25]. It is common knowledge that nursing students' health and professional identity are negatively impacted by their exposure to unbearable situations. Nursing students' academic and clinical performance may be afected by dysmenorrhea. Te current study was therefore designed to assess the prevalence, management, and impact of dysmenorrhea on the lives of nurse and midwife trainees in northern Ghana.

Study Design.
A descriptive cross-sectional design with a quantitative approach to data collection was employed to obtain data from the trainees in three nursing and/or midwifery colleges in the northern region of Ghana.

Study Area and Population.
Te study was conducted in three colleges of nursing and/or midwifery. Tese were Nurses' and Midwives' Training College, Tamale and Yendi College of Health Sciences located in the northern region, and Damongo Nursing Training College located in the Savannah region. Te northern and Savannah regions are among the sixteen regions, located in the northern part of Ghana and cover an area of 70,384 square kilometres or 31 percent of Ghana's landmarks.
Tese three training colleges are public nursing schools in northern Ghana accredited to train skillful, competent, and disciplined nurses and midwives for the provision of quality healthcare. Nurses' and Midwives' Training College, Tamale has a female student population of 872, the Yendi College of Health Sciences has a female student population of 142, and Damongo Nursing Training College has a female student population of 233.

Inclusion and Exclusion
Criteria. Female students who were within the reproductive age of 15-49 and have experienced mensuration, those who have been on the campus for more than one semester, and were willing and able to provide consent were included in the study. Female students who were ill and those on clinical grounds were excluded. In addition, trainees who had chronic medical conditions or used medication that may afect the menstrual cycle or pain perception such as thyroid disorders and neuropathic pain medication were excluded.

Sample Size and Sampling Procedure.
A sample size of 303 respondents was used in the study. It was determined using the Yamane [26] sample size calculation formula for a fnite population.
Also, to determine the number of respondents for each college, a proportionate sampling was employed which states that sample size population size × stratum size. (1) A proportionate stratifed random sampling technique was used to recruit respondents for the study from each year group.

Data Collection Tool.
A structured questionnaire was used for data collection in the study. Te questionnaire was adopted from a previous study [27] and designed to ft the current study. Te questionnaire had the following three sections: Section A: demographic information of respondents' twenty-one (21) items Section B: dysmenorrhea characteristics of the respondents' eighteen (18) items Section C: impact of dysmenorrhea on the quality of life ten (10) items. Each question was coded with a unique number to facilitate easy identifcation 2.5. Validity and Reliability of Tools. To guarantee the instrument content and face validity, the questionnaire received peer review from health experts in order to ensure that the questions refected the study objectives. Te research instrument was pretested with 20 respondents, and their feedback was used to modify questions which were ambiguous and also to correct grammar errors.

Data Collection
Procedure. Data collection commenced after gaining permission from various institutions. Te data collection period was from 13 th September to 28 th October, 2022, after permission was granted.
Te respective institutions provided a list of nurse and midwife trainees who met the specifed criteria. To ensure that each trainee had an equal chance of being chosen, the trainees were randomly assigned numbers using a random number generator. Selected trainees were gathered in a lecture hall and informed of the aims of the study. Te researchers obtained verbal and written consent from the trainees to participate in the study.
Te questionnaires were distributed to the trainees after their consent was obtained. Te researchers made sure that the trainees understood the questions and had enough time to complete them without interfering with their school work, and the trainees were given up to 3 days to return the completed questionnaire. Te completed questionnaires were sealed in envelopes after being reviewed for completeness. Te confdentiality of the information provided by respondents was protected.

Statistical Analysis.
Categorical data were summarized using frequencies and percentages, while continuous data were summarized using the mean and standard deviation. Te prevalence of dysmenorrhea was summarized using a simple proportion and a 95% confdence interval. Bivariate and multivariable logistic regression models were used to determine the factors associated with the prevalence of dysmenorrhea. Confdence intervals were computed at a 95% confdence level, and a p value of 0.05 or less was considered statistically signifcant. Stata (special edition) for Windows version 17.0 was used for the statistical analyses.

Ethical Consideration.
Approval was obtained from the institutions with reference numbers MOH/NMTC/51/334-22, YCHS/24/10/22, and NTC/A1/22/063 before conducting the study in the three colleges. Te consenting process of respondents involved a verbal explanation of the purpose of the study. Emphasis was laid on the voluntary nature of participation and that they could withdraw at any time during the study. A written consent form was signed by the respondents who agreed to voluntarily participate to help facilitate the study. Privacy, anonymity, and confdentiality of the respondents were ensured throughout the data collection process.

Characteristics of Respondents.
In all, 303 students from three health training institutions participated in the study. Te mean age of the students was 22.61 ± 2.35 years, with a majority of 80.2%, within the age group of 20-24 years. 91.4% were not married and only 7.6% had given birth. Te majority, that is, 56.4%, had their frst menstruation at the age of 12-14 years, with 77.6% having regular menstrual cycles. More than half, that is, 56.8%, have their period between 4 and 5 days, with 75.9% experiencing normal bleeding.
About 64.0% engaged in sexual activity, 89.5% had premenstrual syndrome, 54.5% engaged in regular physical activity, and 57.8% had a sleep duration of about 5-9 hours. More than one-third (37.0%) had a family history of dysmenorrhea (Table 1).

Prevalence of Dysmenorrhea among Nurses and Midwife
Trainees. Te majority, that is, 202 (66.7% and 95% CI: 0.611-0.720), of the respondents have experienced dysmenorrhea. Out of the 202 respondents who have experienced dysmenorrhea, the majority (51.5%) started experiencing it from the frst menstruation, 64.3% have their pain begin on the frst day of menstruation, 98% have Obstetrics and Gynecology International Obstetrics and Gynecology International pain in the pelvis and lower abdomen, 50.5% experienced severe pain, and 59.9% experienced the pain for two days or more ( Table 2). Table 3 shows both bivariate and multivariable logistic regression analyses showing the factors associated with the prevalence of dysmenorrhea among nurse and midwife trainees. At the bivariate level, marital status, childbearing, blood fow during menstruation, history of a urinary tract infection, premenstrual syndrome, and family history of dysmenorrhea were signifcantly associated with dysmenorrhea (p < 0.05). Te multivariable logistic regression analysis revealed that the odds of painful menstruation was 2.67 times higher when the duration of menstruation is 4-5 days (AOR = 1.82, 95% CI = 1.13-6.28, and p = 0.024) than when the duration of menstruation is 1-3 days. Having urinary tract infections was associated with 3.56 times higher odds of painful menstruation (AOR = 3.56, 95% CI = 0.98-12.86, and p = 0.05). Again, the odds of painful menstruation were also four times higher among respondents with a family history of painful menstruation (AOR = 4.05, 95% CI = 2.16-7.61, and p = 0.001). Table 4 shows the symptoms associated with dysmenorrhea. It revealed that the most prevalent symptom was the loss of appetite for food (67.3%), followed by fatigue/feeling dizzy (46.5%) and headache (42.6%). Te most annoying symptom reported to accompany menstruation was fatigue (24.7%), followed by loss of appetite (24.3%).

Management of Dysmenorrhea among Nurse and Midwife
Trainees. Table 5 shows that nearly half of the respondents (47.5%) do nothing to reduce the pain. However, 20.8% use pharmacological methods, 13.4% use nonpharmacological methods, and 18.3% use both pharmacological and nonpharmacological methods to reduce menstrual pains. Te most predominant nonpharmacological method used for reducing menstrual pain is sleep (59.4%) followed by the application of liquids or hot objects on the abdomen (50.0%). Table 6 shows that the majority of the respondents indicated that dysmenorrhea afects their quality of life (74.8%). More than half of them reported that they could not perform normal physical activities (58.4%), 53.5% felt tired, and 50.5% could not have a normal diet. Again, dysmenorrhea had a negative efect on the academic work of most students (62.4%) and their social life (54.0%). More than two-third of the students could not concentrate in class when having dysmenorrhea (77.2%).

Discussion
Te aim of this cross-sectional study was to assess the prevalence, management, and impact of dysmenorrhea among nurse and midwife trainees. In this present study, the prevalence of dysmenorrhea among trainee nurses and midwives was 66.7%. Tis fnding is similar to other research studies conducted in various countries such as 63.3% in southern Spain [16], 60% in Canada [28], and 70.6% in Saudi Arabia [29]. Tis fnding is also similar to a study conducted in the southeastern part of Ghana 68.1% [24]. However, other studies conducted have reported a higher prevalence rate of dysmenorrhea such as 88% in Australia [30], 89.6% in Lebanon [31], 85.1% in Palestine [32], 84.2% in Lithuania [33], 84.1% in Italy [34], and 83.6% in northern Ghana [3].
Tere are a number of reasons that could account for this variation in prevalence rates across studies, such as the lack of a method to defne dysmenorrhea that is universally recognized, the age group of females chosen for the study populations, and how respondents perceive pain [35] and stress [36].
Te study revealed that the majority of the respondents (51.5%) started experiencing dysmenorrhea from the frst menstruation, have their pain begin on the frst day of menstruation, and have pain in the pelvis and lower abdomen. Tis fnding is in line with the previous studies [13,27,37]. Our study also identifed that more than 50% of the respondents experienced severe pain similar to the studies conducted in Bangladesh [38], but in the majority of the previous studies, respondents classifed their pain as moderate [29,34,39] and some even mild [40]. Te difference in pain intensity across studies could be attributed to diferences in pain perception among respondents, as well as       diferent assessments of pain intensity scales used to assess pain severity. In this study, the odds of painful menstruation was 2.67 times higher when the duration of menstruation is 4-5 days than when the duration of menstruation is 1-3 days. A menstrual duration of 4-5 days was a factor associated with the prevalence of dysmenorrhea. Females who had a menstrual duration of 4-5 days were more likely to experience dysmenorrhea. Tis fnding is consistent with a previous study showing that dysmenorrhea is higher in females with longer menstrual duration [37,41]. Te odds of dysmenorrhea was 3.56 times higher in respondents with urinary tract infections. Tis might happen when one starts menstruating and has UTIs at the same time, and one common symptom of both dysmenorrhea and UTIs is cramping pain in the lower abdomen, which may intensify menstrual pain. Dysmenorrhea appears to run in families, and the odds of dysmenorrhea are 4 times higher among respondents with a family history of painful menstruation. Tis is in line with previous research that found a link between a family history of predisposition and dysmenorrhea [35,37,42]. Tis could be explained by the fact that daughters of mothers with dysmenorrhea also experience dysmenorrhea, which is connected to a learned behavior from the mother. Again, it could be because of a similar lifestyle and way of life [37].

Obstetrics and Gynecology International
Dysmenorrhea may be accompanied by other symptoms afecting trainees' quality of life such as diarrhea, nausea, vomiting, headache, and dizziness [16]. In our study, the most common symptoms associated with dysmenorrhea were loss of appetite for food, fatigue/feeling dizzy, and headache. Tese symptoms have also been reported to be among the most common in respondents in other studies [21,27,32]. A study found that the most prevalent symptom (51.9%) associated with menstrual pain was loss of appetite for food [43].
As the majority of our respondents reported experiencing severe pain, it would have been expected that most would use various methods to reduce the pain. However, nearly half of the respondents (47.5%) do nothing to reduce the pain. Tis is consistent with other studies, where most of the respondents ignored their menstrual pain [3,24]. In our study, 20.8% used pharmacological methods; out of this, the majority used antispasmodic drugs which is similar to a study conducted in Egypt where spasmolytic drugs were mostly used [43]. However, in our study, only a few trainees used the nonpharmacological method that had been reported in most previous studies [21,44]. As a result, there is an urgent need for health education regarding nonpharmacological pain relief techniques for the management of dysmenorrhea for trainees. Te most predominant nonpharmacological methods used for reducing menstrual pain were sleep (59.4%) and the application of liquids or hot objects on the abdomen (50.0%). Similar results about nonpharmacological methods have been reported in the literature [43].
Regarding the impact of dysmenorrhea, the majority (74.8%) of the respondents indicated that dysmenorrhea afects their quality of life. Tis fnding is not surprising as most trainees revealed that they experience severe pain during menstruation. More than half of them reported they could not perform normal physical activities, felt tired, and could not have a normal diet. Also, dysmenorrhea had a negative efect on the academic work of most students and their social life. More than two-third of the students could not concentrate in class when having painful menstruation. All these could subsequently result in having a negative impact on the academic performance of trainees [10]. Our results confrm the conclusion of other reports [23,27,45].

Limitation.
In the current study, responses from the respondents were based on past experiences of dysmenorrhea and introduced a risk of recall bias, so the fndings of this study should be interpreted with caution. We were unable to distinguish between primary and secondary dysmenorrhea, and for this reason, period pain was treated as a whole. Also, the majority of the questions were closedended and limited the chances to explore deeper views or opinions from the respondents.

Conclusion
Te fnding from this current study revealed a high prevalence of dysmenorrhea among nurse and midwife trainees in the northern part of Ghana. Te majority of the respondent experienced loss of appetite and intense pain in the pelvis and lower abdomen, and their concentration during lectures was also signifcantly afected. Te most predominant nonpharmacological method used for reducing the pain was sleep and warm objects on the abdomen.

Data Availability
Te data used to support the fndings of the study are available from the corresponding author upon request.

Conflicts of Interest
Te authors declare that they have no conficts of interest.