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Menstrual knowledge and practices of female adolescents in urban Karachi, Pakistan
Journal of Adolescence 33 (2010) 531–541
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Menstrual knowledge and practices of female adolescents in urban Karachi, Pakistan Tazeen Saeed Ali a, *, Syeda Naghma Rizvi b,1 a b
The Aga Khan University, School of Nursing and Department of Community Health Sciences, Stadium Road, PO Box 3500, Karachi 74800, Sindh, Pakistan The Aga Khan University, School of Nursing, Stadium Road, PO Box 3500, Karachi 74800, Sindh, Pakistan
a b s t r a c t Keywords: Menstruation Menstrual practices
Menstruation is a normal physiological process that is managed differently according to various social and cultural understandings. Therefore, this cross-sectional study was conducted to explore the menstrual practices among 1275 female adolescents of urban Karachi, Pakistan from April to October 2006 by using interviews. Data was entered and analyzed in Epi Info Version 9 and SPSS Version 10. Descriptive findings showed that 50% of the girls lacked an understanding of the origin of menstrual blood and those with a prior knowledge of menarche had gained it primarily through conversations with their mothers. Many reported having fear at the first experience of bleeding. Nearly 50% of the participants reported that they did not take baths during menstruation. In univariate analysis, factors of using unhygienic material, using washcloths, and not drying under sun were found to be significant in the Chi square test among those going and not going to schools. This study concludes that there are unhygienic practices and misconceptions among girls requiring action by health care professionals. Ó 2009 The Association for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.
Introduction Background and literature review Menstruation is defined as the ‘‘periodic discharge of blood from the uterus occurring more or less at regular monthly intervals throughout the active reproductive life of a female’’ (Critchley, 1986). Menstruation, a normal physiological process, may be looked at as more than just a physiological process. It may be viewed either positively or negatively by the society. A positive perception of menses would be by considering it a sign of femininity, fertility, youth, or purification of the body. The negative perceptions include a linkage to being vulnerable and susceptible to different illnesses, or creating feelings of disgust and shame. In some societies, these negative perceptions become the basis of certain practices, like placing restrictions on religious, social and domestic activities of a menstruating woman. A woman usually has two kinds of perceptions of bleeding: one from her actual experience and the other she learns from her elders and peers (Kalman, 2003). Menstruation often represents an event with social and cultural implications (Mathews,1995). A number of studies conducted throughout Asia have specifically reported varying cultural beliefs and practices related to menstruation. These beliefs and practices include the use of unhygienic sanitary materials, altered bathing, altered nutritional intake and restriction on women’s social mobility and religious activities. In a study conducted in Egypt, almost half of the women held this belief that bathing was
* Corresponding author. Tel.: þ92 21 4865460. E-mail addresses: [email protected] (T.S. Ali), [email protected] (S.N. Rizvi). 1 Tel.: þ92 21 4865400. 0140-1971/$ – see front matter Ó 2009 The Association for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.adolescence.2009.05.013
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unhealthy; it either prolongs the bleeding period, stops menstrual bleeding, and causes macerations of the skin. However, almost all of the women in the same study practiced thorough washing of their perineal area and used sanitary pads. The majority of the women changed their pad at fixed times of the day (i.e., once or twice; either in the morning, evening, or at night) rather than changing the pad when it was soaked (El-Shazly, Hassanein, Ibrahim, & Nosseir, 1990). Half of the women did not change their sanitary protection for more than 9–10 h (Moawed, 2001). In a South Indian study, approximately 50% of the women abstained from taking shower during menstruation and avoided perineal care. The reported reasons for this abstention were poor habits of cleanliness, and the belief that showers increase pain intensity and would lead to discontinuation of menstrual flow. Czerwinski (2000) endorses this finding in his study of the number of females that avoid bathing during menstruation. According to a literature review report on adolescence by Khan (2000), adolescents and their mothers believed that eating foods considered to be too hot (dry fruits, liver, and eggs) or too cold (ice creams, yogurt, and green leafy vegetables) should be avoided. Many of the foods they avoid are rich in iron. Iron deficiency anemia has thus been reported as a major health concern amongst adolescent females (Khan, 2000). A study conducted in India showed that 42.6% of respondents reused cloths for the absorption of bleeding, which is not a bad practice. However, the cloth needs to be hygienically washed and properly dried under sun to avoid bacterial contamination (Dasgupta & Sarkar, 2008). In another Indian study, it was reported that 77% of women used old pieces of cloth, and, based on a hygienic practices scale, women having low scores also had the highest proportion (34.1%) of white discharge, compared to medium and high scoring women. Information collected from a study conducted in Bangladesh showed that 80% females reused the same cloth for absorption of bleeding, but among them only 42% dried the cloth in sunlight and the rest dried them in hiding (Mathews, 1995). Although females preferred to use sanitary towels, which were more absorbent and thicker, they were unable to afford those (Mathews, 1995). According to a study conducted in Pakistan, the affordability of sanitary pads is not the only reason for it’s under usage; rather, females are more comfortable with either using a cloth or homemade pads. It was found that 82% of Punjabi and 65% Sindhi preferred to use homemade pads, whereas 15% Sindhi females do not use any material. Instead they change the trousers frequently to absorb bleeding (Khan, Qureshi, & Siraj, 1998). Rationale Although reproductive health in Pakistan has received attention in the past 10 or 15 years, issues related to menstrual health and hygiene had never been the focus of policy makers and health professionals. Pakistani studies (published or unpublished) have either focused on knowledge about menstruation or relation of menstruation to family planning. Studies that have been conducted have focused mainly on menstrual knowledge and practices among female adolescents in very general terms. However, none of these studies have, to date, differentiated between school-going and non-school-going girls with regard to their menstrual practices and knowledge. We therefore conducted an in-depth study on issues related to the management of menstruation, and the identification of conceptions and misconceptions related to menstruation among female adolescents living in urban Karachi, Pakistan. This study has the purpose of identifying the menstrual conceptions of adolescent females among those going and not going to school, as well as related practices including social, religion, nutritional and hygienic practices. Finally, this study will compare the socioeconomic factors and practices of adolescent females who are going to government and private schools and those who are non-school-going. Research design and methods Background of the study area Pakistan is an Islamic country situated in South Asia with an estimated population of 152 million (2001) of which 14 million are based in Karachi, Sindh. This study was conducted in Karachi where the population is comprised of different ethnic groups who have migrated from different parts of Pakistan or other countries (e.g. Afghanistan and India), allowing for a diverse sample. There are Sindhis, Balochis, Punjabis, Pathans and Mohajirs living in Karachi (Pakistan Demographic and Health Survey, 2006–07). The study focused on three squatter settlements of low socioeconomic standing: Orangi Town, Azam Basti, and Qayyumabad. Here, school-going and non-school-going adolescents were accessed in order to compare the differences in practices among them. These communities are of lower-to-middle socioeconomic status, and the residents belong to different ethnicities including Mohajir, Punjabi, Sindhi and Pathans. Study design & study population A descriptive comparative study was conducted in three lower-middle socioeconomic communities in Karachi. The participants were unmarried adolescent girls ranging in age from 13 to 19 years. They were selected from private schools2, government schools3, and the general community, which includes those who are not going to school.
2 Girls attending private schools can afford tuition fees, books and school uniforms. Among these schools some health service facility is available like first aids, vaccination, etc. 3 The government schools (public schools) offer free of charge education. School often provides books and uniforms. Public schools don’t offer health services. However, health education sessions often been conducted in these schools by nursing students and non-governmental organizations.
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Sample size and sample selection The sample size was calculated based on power calculation using Epi Info Version 6, in order to be able to detect the difference of menstrual practices among three groups. The proportion of females using hygienic material during menstruation was estimated by taking the prevalence of 15.6% of those using unhygienic material for the absorption of bleeding, and by specifying the significance level of 5% with the bound of error of 5%. The required sample size was maximum 400 adolescent females in each community (Fikree, 2004). To avoid biases, we took extra samples from each community, which was further divided into private, government and community evenly. The maximum required sample size total was determined to be 1275. The studied was limited to female having menstrual cycles of less than 31 days, and living in the selected community based area. Those adolescents or their mothers who refused to participate, are married, suffer from amenorrhea, have cycles of thirty one days of more, or have migrated from another country within the last 5 years were not included in the study. To ensure probability sampling, the data was collected by using a systematic sampling technique. In the initial stage, which targeted the girls in the community who were not in school, the data collectors prepared a list of adolescents meeting the inclusion criteria, with every fourth girl being interviewed. Those who were unable to give an interview for whatever reason were replaced by another girl on the list. At the school level, all the adolescent girls within the age range of 13–19 years were selected. The list of school-going adolescents, fulfilling the inclusion criteria, was provided by the school principals. The interviews were conducted in privacy by the trained data collectors, who work as community health workers. The data was collected followed by acquiring verbal consent from the mother and adolescent. Later, the field supervisor checked the data to assess completion of the questionnaires and accuracy of the data coding. In the case of missing information, the study subjects were approached and in case of incorrect coding, proper coding was done. Ten girls were re-contacted for incomplete questionnaires. Methods of data collection The data was collected from April to October 2006 from the government schools, the private schools and the communities in order to attain diversity of the sample population regarding education, within the similar socioeconomic groups. The data was collected by using a pre-coded questionnaire, which was developed after conducting the four Focus Group Discussions (FDG) and ten in-depth interviews with the adolescents and their mothers. Later, the data was analyzed and categorized into themes. The variables that were included emerged from a conceptual framework based on the literature, expert opinions and from the qualitative interviews. The questionnaire for the current study was developed based on earlier qualitative work that explored 1) social, and religious restrictions; 2) conceptions and misconceptions about menstruation; 3) potential for altered nutritional intake; 4) hygienic practices; and 5) unhygienic material used to absorb menstrual bleeding. Results from this qualitative component were used to provide guidelines and direction to our research. The tools were pre-tested at the field level and translated in Urdu for the convenience of administering it to the study participants. Urdu, being the national language of Pakistan, is widely spoken and understood by the respondents of this study. The Urdu language questionnaire was translated back into English to ascertain the accuracy of the translation and their meanings. Ethical considerations Institutional ethical approval was obtained from The Aga Khan University and Johns Hopkins University. An introduction of the study was given to the study subjects in Urdu (the local language). We followed the consent procedure differently for different groups. For school attending girls, first their principal was approached for verbal consent, after which girls were approached for their verbal and written consent. However, at community level for girls not attending schools, verbal consent was first taken from their mothers. The confidentiality of the information was maintained by assigning identification numbers to each adolescent. After we collected the data and first results’ analysis, the principle investigator and the research supervisor conducted the health education sessions on menstrual management at school and community level for the study subjects. Operational definitions of the variables Socioeconomic status A composite index was computed on fifteen household assets and facilities such as the type of construction of the house, water supply, type of latrine/toilet facility, ownership of the house, possession of a radio or cassette player, TV, grinder/ blender, refrigerator, washing machine, bicycle, motor bike or scooter, sewing machine, pedestal or ceiling fan, iron, livestock (goat, sheep, cattle), and VCR was considered as a proxy indicator for SES. It was further classified into two categories such as better socioeconomic status and low socioeconomic status. The cut-off values were done on the 59th, percentile of the data distribution, done on SPSS Version 9.
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Autonomy The autonomy variables developed by having the indication including taking decision on spending household earning, able o take decision to work outside the home, able to take decision to go to clinic if she is sick, and if she need permission to go to market. Knowledge about menstruation The subjects were asked about their knowledge of menstruation by asking about their understanding of and the level of information about menstruation they had before menarche. Misconceptions To measure this variable, all the responses related to knowledge were given ‘‘1’’ if they were correct and ‘‘0’’ if they were incorrect. All the correct responses were accumulated from 2 to 4. The variables constitute: the source of bleeding, bathing during menstruation, effects of bathing on menstrual flow and permission to engage in religious practices. Menstrual practices The information regarding the practices was accumulated based on the responses to the following variables: material used to soak blood, reusing of material, drying and storing of the reused material. Storing of washed clothes Subjects, who reused the absorbing material after washing, were asked to mention the ‘‘space of the storage’’ of washed material. For the purpose of verification the data collector observed the place of storage of the washed material. Suitcase, box, cupboard, and shopper were categorized as ‘‘clean and covered places’’ whereas, the room, under cushion, under the bed, behind the door, and in the washroom were categorized as ‘‘unclean and covered places.’’ Gallery and under the kitchen roof were categorized as ‘‘clean and open spaces.’’ Plan of analysis The data was entered on Epi Info Version 9 and then transferred to SPSS Version 10 for descriptive analysis where measures of central tendency and dispersion were calculated. In addition, a univariate analysis was done by comparing three groups’ practices for the school going (private & government) and those never being to school by Chi square test of independence. The results are displayed in tabular form including demographic of the participants, menstrual history, and knowledge about menstruation, and practices. Results Demographic information Overall, our sample included an equal number of respondents in each of the three groups of young womendthose attending a private school, those in a government school, and those who had never been to school. The Mahojir population had a higher number in the sample, but they are significantly different in number in each group. The majority (private school ¼ 74.4, government school ¼ 67.0, and non-school-going ¼ 44.9) of the participants were Urdu speaking and the rest spoke a variety of different languages (e.g. Punjabi, Hindko, Pushto, Sindhi, Balochi) but were still able to read, speak, and respond in Urdu. Among those who are non-school-going, about half of them (40.2%) have never attended any school whereas the rest have completed grade five or less. Those who are school-going are currently studying in grades eight, nine or ten (private ¼ 63%, 13.9%, & 22.2%; government ¼ 65.1%, 20.2%, & 11.3%). The majority of the study participants were living in nuclear family, however there were few who had either their paternal or maternal grand parents living with them. The age range of the respondents was from 12 to 19 years; the majority were between 14 and 17 years of age (private school ¼ 73.5%, government school-going ¼ 80.7% & non-school-going ¼ 56.3%). Socioeconomic characteristics As mentioned in Table 1, about a quarter of the participants who are not going to school are employed as packing. They are packing goods at home or in manufacturing units. However, few participants going to private and government schools were also working (4.2% & 3.8% respectively; p value ¼ 0.000). Among the non-school-going, the majority (51.6%) earn a living by working outside of their home as compared to those girls who attend school (p value ¼ 0.006). Table 1 shows interesting results in regards to autonomy indicators and girls’ school status. It shows that those attending private schools have the least autonomy for making decisions on household spending (4.5%) and going outside the home (3.8%). The variable of autonomy was also checked with the age for its significance of correlation, and came up as insignificant with only a 5% significance level (r ¼ 0.004–0.05; p value with range of 0.1–0.8). The correlation between the socioeconomic variable and the status of schooling (r ¼ 0.132, p value ¼ 0.000) and between the status of schooling with hygienic practices (r ¼ 0.156, p value ¼ 0.000)
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Table 1 Characteristics of adolescent female in Karachi, Pakistan (n ¼ 1275). Variable
Private school, % (n ¼ 425)
Government school, % (n ¼ 425)
Community, % (n ¼ 425)
Chi square
Which language do you speak at home? Urdua Balochi Sindhi Punjabi Pathan Othersc
74.4 1.4 1.4 15.5 6.3 0.9
67 0.9 1.6 16.5 12.2 1.5
44.9 4 7.3 20 20.3 3.6
0.000b
Girls earning money
4.2 (n ¼ 18)
3.8 (n ¼ 16)
21.4 (n ¼ 91)
0.000
Earning inside or outside home Inside (packing jewelry, chilli, toy, etc. for earning) Outside (teaching) Both
38.9 11.1 50.0
42.1 26.3 31.6
24.2 51.6 24.2
0.006
Father’s occupation Job less/retired Father not alive Professionals Molvi/imam Skilled workers Private job Government job Business man/landlord
1.2 6.1 20.1 0.2 53.6 5.9 6.6 5.8
0.7 6.4 20.1 1.2 60.4 2.4 5.6 2.8
0.7 8.7 30.3 0.5 51.6 2.6 2.1 3.5
0.800
92.9 2.1 4.9
97.4 1.9 0.7
91.5 5.6 2.8
0.000
Water supply Government supply (tap water inside) Government supply (communal) Water tanker Hand pump
78.1 12.7 0.2 8.9
85.4 2.4 6.6 5.6
86.4 4.0 1.2 8.5
0.000
Type of latrine/toilet facility Latrine (pour or flush)
100
100
100
0.900
House facilities available Owner of the house Live on rent Office accommodation
70.8 24.9 4.2
67.5 30.9 1.6
62.1 37.2 0.7
0.035
Own a radio/cassette player TV Grinder/blender Refrigerator Washing machine Cycle Motor bike/scooter Sewing machine Pedestal/ceiling fan Iron Livestock [goat, sheep, cattle, etc.] VCR Decision on spending household earnings Able to take decision to work outside the home (yes) Able to take decision to go to a clinic if she is sick (yes) If she need to take permission to go to the local market (yes)
72.2 96.0 76.5 78.8 91.1 26.1 37.2 83.5 99.3 98.6 4.7 36.7 4.5 3.8 14.8 92.9
73.1 91.8 65.4 68.0 89.6 36.0 40.0 87.8 98.6 99.1 10.8 28.7 13.9 9.4 14.1 93.9
68.2 90.1 51.1 62.4 84.9 30.4 33.6 87.5 99.5 99.1 8.9 17.6 8.5 9.2 11.5 92.9
0.219 0.002 0.000 0.000 0.015 0.007 0.157 0.137 0.316 0.757 0.003 0.000 0.000 0.001 0.327 0.817
Socioeconomic statusd Better socioeconomic status Low socioeconomic status
75.3 24.7
68.7 31.3
60.2 39.8
0.000
Type of construction of your house Pakka (walls and roof are cemented) Kacha (walls and roof are made of mud, tin, or asbestos) Kacha–pakka (walls are cemented and roofs are made of mud, tin, asbestos, etc.)
a
People migrated from India. Fisher exact test. c Memni, Gujrati, Marwari, Kathiawari, Dangri, Farsi, Bangali. d All the socioeconomic variables were given score 1 per variable, then after combining them together it has been dichotomized at 59th percentile the upper percentile entitled as better socioeconomic and less then 59th percentile was taken as low socioeconomic status. b
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stays significant. However, the correlation between socioeconomic status with unhygienic practices stayed insignificant (r ¼ 0.052, p value ¼ 0.064). On comparing the type of housing among the school-going and the non-school-going girls, it was found out that 91.5% of the participants not attending school are residing in pakka houses (in which the roof and walls are cemented), which is similar to the type of housing of girls going to private (92.9%) and government schools (97.4%). The percentage of the occupants of kacha houses (in which the roof is made up of mud, tin, asbestos and walls are cemented) is less and belong to the category who have not attended any school at all (p value ¼ 0.000). A low socioeconomic status is high among those not going to school (39.8%), with opposite results for those enrolled (24.7% & 31.3%; p value ¼ 0.0001). Information related to menstruation Menstrual cycle According to our study subjects, the mean length of the menstrual cycle, in each of the three groups is 3 days with a standard deviation of one day. In all three groups, most of the subjects reported their menarche age as 12–14 years and either experienced fear anxiety about seeing the bleeding (Table 2). About seventy percent respondents from three areas reported that their menstrual flow was normal. Sixteen percent respondents from private schools, 17% from government schools and 21% from the community perceived their menstrual flow was heavy. Knowledge and perceptions about menstruation According to our participants, menstruation is a monthly bleeding that happens to every female; it is a natural phenomenon, a sign of adulthood and good for marriage. Some reported that it is the removal of dirt from stomach, or is a disease. Regarding the origin of bleeding, 37% (private), 15.9% (government) and 19.7% (community) participants reported that it comes from the uterus; whereas the rest were unsure about it. There was a significant difference in terms of prior knowledge about menstruation. The adolescents going to government schools were the most informed (47%), and the percentage of informed girls going to private school (34%) and not going to school was similar (about 39%). Most of the participants who were educated before menarche reported their mother as their source of knowledge; the remainder were educated by their elder sisters, friends, grandmother, female cousins, teachers and/or nurses. The reactions (fear, worry) to menarche are almost similar in the participants from the government and private school systems. The percentages of respondents in private and government schools who experienced fear and worry were almost same: 55.1–55.8% reported fear and 46.8–48.7% reported being worried; in contrast, the percentage of respondents from the community experiencing fear or worry was slightly higher (62.1% experienced fear and 32.4% was worried) with the Chi square p value of 0.000. Hygienic practices The use of a sanitary pad for absorbing menstrual blood was highest amongst the study participants from private schools (33.5%) as compared to government (16.4%) and community adolescents (13%). The use of pieces of old cloth to absorb blood was highest among the community respondents (70%) as compared to the other two groups. The rest of the participants in all the three groups were using pieces of new cloth, made of either cotton or wool. The girls not attending school were more likely to report that they do not use any material at all and stay in their usual dress (trouser and a tunic) without any protection. Our overall correlative results show that girls with a low education status come from a lower socioeconomic status and have unhygienic practices too. A majority of the private school-going participants (71.1%) reported that they throw away these pieces of cloth without washing, whereas those who do not go to school do not discard it unwashed. Instead, they reuse them after washing, or wash and discard them (60%), or wash the cloth and dry them in hiding. This pattern is similar in all three groups (69.3%, 60.1% and 68.9%). However, some girls reported drying these clothes in sunlight while others discard them after washing. Most of the study participants reported using two pads or materials per day with a range of one to nine. Tables 2 and 3 show that approximately half of the females in each of the three groups take a bath during menstruation (p value ¼ 0.888). Table 3 compares practices of the three categories of participants. Seventy-nine percent of adolescents not going to school are using unhygienic materials for the absorption of menstrual bleeding, as compared to those going to private or government schools (58.65 & 70.1% respectively, p value ¼ 0.0001). Similar results are obtained from all the groups (30%) regarding the drying of washed clothes under sun (0.300). Alternative diets during menstruation are observed in all the three groups and similar practices are being reported among them (p value ¼ 0.370). About half of those who are not going to school have misconception about menstruation (42.4%) with a p value ¼ 0.000. Discussion Our study results are in line with the studies conducted and published in countries other than Pakistan. The age of the study participants ranges from 13 to 19 years. A similar study conducted by Deo et al. reported the age of menstruating girls to range from 12 to 17 years; within that, the common age is reported to be between 13 and 15 years. In our study, some
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Table 2 The information related to menstrual cycle, knowledge, perception and sanitary practices’ conception amongst adolescent girls in Karachi, Pakistan (2006), n ¼ 1275. Variable
Private school, % (n ¼ 425)
Government school, % (n ¼ 425)
Community, % (n ¼ 425)
Menstrual cycle Mean length of menstruation Days girl menstruate in range
31 2–9
31 2–9
31 2–9
Menarche age Before 11 years 12–14 years 15–16 years Don’t know/don’t remember
6.8 88.2 2.9 2.1
7.1 83.8 6.8 2.3
6.4 82.8 6.8 4.0
Feelings at first menarche Fear Worry Normal feelings Anxiety/pain/felt bad/cried/felt shy
55.1 47.8 9.5 8.9
55.8 46.8 9.4 10.8
62.6 32.0 10.8 10.6
Knowledge about menstruation Understanding of menstruation Monthly bleeding Dirty bleeding Happens with every female Good for marriage Natural phenomena Sign of adulthood Others (removal of dirt from the stomach, some disease)
33.1 15.1 11.9 2.2 19.3 16.5 1.8
22.3 19.1 13.6 3.9 19.3 20.9 1.0
28.1 18.2 16.8 3.1 18.8 14.6 0.5
Source of bleeding Uterus Any part of abdomen Stomach Vagina Urinary tract Somewhere from the body
37.2 34.0 2.5 14.5 10.3 1.4
15.9 44.1 5.6 21.5 11.9 1.1
19.7 27.3 5.9 42.9 1.0 3.1
Knowledge of menstruation before menarche
34.1
47.8
38.8
Source of knowledge of menstruation before menarche Mother Elder sister Aunt Friend Others (grandmother/cousin/sister in law/teacher/nurse)
n ¼ 145 (34.1%) 37.9 27.5 6.5 20.9 7.4
n ¼ 203 (47.8%) 29.4 35.5 11.8 21.8 1.4
n ¼ 165 (38.8%) 21.1 49.7 14.1 15.2 1.2
Information given about menstruation before menarche Physical changes Social and religious restriction Bathing practices Use of material for absorption The blood is dirty/food restrictions/less water intake/more water intake/blood comes from vagina
n ¼ 145 (34.1%) 36.0 5.4 10.2 40.9 7.6
n ¼ 203 (47.8%) 20.9 7.3 15.9 46.8 9
n ¼ 165 (38.8%) 21.1 13.3 13.7 49.5 2.6
Multiple response possible
Sanitary and hygienic practices n ¼ 429 n ¼ 465
n ¼ 433
Material use for absorbing blood Sanitary pads Cotton wool Pieces of new clothes Pieces of old clothes Woolen cloth Shalwar/nothing
33.5 4.4 10.6 50.0 1.4 –
16.4 3.6 16.8 62.6 0.6 –
13.0 6.5 8.0 70.4 1.1 1.1
Handling of use materials Discard Do not discard it
n ¼ 425 71.1 28.9
n ¼ 425 46.6 53.4
n ¼ 425 40 60
Those do not discard (multiple response possible) Wash and discard Wash and dry
n ¼ 123 (28.9%) 44.9 55.1
n ¼ 227 (53.4%) 31.5 68.5
n ¼ 225 (60%) 31.8 68.2
Drying of clothes
n ¼ 75 (55.1%)
n ¼ 183 (68.5%)
n ¼ 193 (68.2%) (continued on next page)
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Table 2 (continued) Variable In sunlight In hiding Storing of washed clothes Clean and covered placea Unclean and covered Placeb Clean and open spacec a b c
Private school, % (n ¼ 425)
Government school, % (n ¼ 425)
Community, % (n ¼ 425)
30.7 69.3
39.9 60.1
31.1 68.9
60 30 20
74.2 25.8 3.2
59.4 36.3 6.6
Suit case, box, cupboard, and shopper. Store room, any where in the room, under cushion, under the bed, behind the door, within the washroom. Gallery, under the kitchen roof.
autonomy indicators were also measured in which female adolescents have reported low levels of autonomy. They are unable to take independent decision for their lives, are not allowed to work outside the home and are not allowed to visit the market without permission. This, at times, has nothing to do with schooling status. In Pakistan, women have less autonomy overall; this is particularly evident at young ages (Khan, 1998). Girls face more gender differentials in access to health care and many other facilities. Limitations on female mobility particularly affect younger women under the age of 25, according to a study in rural Punjab, even if they were married (Kazi & Sathar, 1997). Unmarried girls in that province faced the most restrictions on their overall mobility, including access to health services, due to social norms enforcing segregation between the sexes as a means of preserving a girl’s chastity or honor (Khan, 1998). Knowledge and perception about menstruation Similar to our study, available literature from Bangladesh (Mathews, 1995), India (Khanna, Goyal, & Bhawsar, 2005), Saudi Arabia (Moawed, 2001), Nigeria (Abioye-Kuteyi, 2000) and Egypt (El-Shazly et al., 1990), shows that women have considered Table 3 Comparison of menstrual practices using Chi Square p value. Going private school, % (n ¼ 425)
Going govt. school, % (n ¼ 425)
Not going school, % (n ¼ 425)
Chi square test p value
Use of hygienic materiala Yes No
41.4 58.6
29.9 70.1
21.2 78.8
0.000
Drying cloth in sunlight Yes No
30.7 69.3
39.9 60.1
31.1 68.9
0.300
Alteration in diet Yes No
21.65 78.35
27.53 72.47
18.59 81.41
0.370
How do you alter your diet during menstruation? Eat less Eat more Eat same amount of food
n ¼ 92 (21.65%)
n ¼ 117 (27.53%)
n ¼ 79 (18.59%)
65 17 18
62 21 17
53 37 10
0.189
Decrease fluid intake No Yes
92.7 7.3
90.6 9.4
88.2 11.8
0.084
Restrict socialization No Yes
41.9 58.1
32.7 67.3
41.9 58.1
0.07
Have misconceptions (lack of knowledge about menstruation No Yes
65.6 34.4
76.2 23.8
57.6 42.4
0.000
Bathing during menstruation period Yes No
45.2 54.8
44.2 55.8
45.9 54.1
0.888
Washing of premium Yes No
98.1 1.9
99.1 0.9
98.4 1.6
0.499
Prior knowledge of menstruation before menarche
34.1
47.8
3.8
0.000
a
It includes pads, and clean cloth.
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menstruation to be a natural phenomenon. However, a study conducted by Abioye and Dasgupta reported that some girls perceived menstrual period as unclean (Abioye-Kuteyi, 2000; Dasgupta & Sarkar, 2008). Similar perceptions are reflected in our study as well, especially that women avoid prayer and attending religious ceremonies. The reaction to menstruation depends upon awareness and knowledge of the subject. The manner in which a girl learns about menstruation and its associated changes may have an impact on her response to the event of menarche. As in our study girls felt fear and anxiety at the time of menarche. This has been also supported by studies conducted in India and Nigeria (Abioye-Kuteyi, 2000; Dasgupta & Sarkar, 2008; Khanna et al., 2005). In our study, those who had some prior knowledge about menstruation received it mainly from their elder sisters and mothers. Researchers have demonstrated that mothers in many cultures are an important resource for menstrual preparation for their daughters (Dashiff, 1992; Koff & Rierdan, 1995a, 1995b; McGrory, 1995; Tucker, 1990). The poor literacy and the socioeconomic status of females in the community serve as an inhibition to impart the significance, and a healthy attitude towards menstruation, as well as the teaching of hygienic practices in regards to it. This is consistent with the study by Dasgupta and Sarkar (2008). An Indian study conducted on schoolgirls studying in grade nine reported that 97.5% of these study participants did not know the source of bleeding during menstruation. Although the percentage in our study is not as high as the Indian study, less than one-fourth of the participants were ignorant of this fact. Furthermore, this study reported that girls were frightened to see and feel blood at menarche (Khanna et al., 2005). They were worried, they wept and felt ashamed. Similar findings are reported from our study that participants were fearful, worried and had anxiety. Many participants did not have any knowledge regarding menstruation which is similar to the findings reported in Nigerian and Indian studies (Abioye-Kuteyi, 2000; Khanna et al., 2005). However there were significant differences in terms of prior knowledge about menstruation amongst the three groups. The adolescents attending government school were the most informed as compared to the group going to private school. This difference in the level of knowledge is because: first, the government schools are more accessible to researchers and non-governmental organizations (NGOs) for conducting health education sessions as compared to private schools; second, the national curriculum taught in the public schools gives some content related to reproductive health, and in addition community health nurses visit these public school as part of the nursing curriculum and conduct sessions to create awareness of issues related to adolescent reproductive health; third, private schools have their own curriculum which may or may not significantly include reproductive health as part of their curriculum; fourth, with the awareness of discrimination of gender in education at the international level, the government has also set priorities for female education and has taken some concrete steps to promote it. Use of material for soaking blood Generally in Pakistani culture, girls are either unaware of how to manage menstruation in a hygienic manner or they cannot afford to manage it with modern menstrual materials (e.g. commercial sanitary pads). Several people were aware of the fact that it is healthier to use pads than rags, but could not afford them even occasionally (Ali et al., 2007; Fikree, Ali, Durocher, & Rahbar, 2004). Furthermore, due to poverty, sanitary pads were seldom bought. Homemade pads, if used hygienically, are also considered fine (Fikree et al., 2004). It was also noted that for some of the participants the affordability of sanitary pads was not an issue. They reported that pads proved to be uncomfortable and caused irritation or rashes to the user. Some females used new cloths and towels during menstruation, which were reused after being, washed (Ali et al., 2006). According to our study, half of the girls used sanitary pads and the others used old and new, washed or unwashed cloth material. These findings are consistent with a study conducted in Bangladesh where upper middle class women residing in urban areas used disposable sanitary towels. The same study reported that women belonging to the middle class used reusable materials like cotton cloth torn from an old sari (Mathews, 1995). An Indian study reported that most of the girls used old cloth during menstruation and very few used sanitary pads. Those who were using old cloth material did not wash them properly before use (Khanna et al., 2005). A study conducted in Egypt reported that all 513 schoolgirl participants used sanitary pads during menstruation (El-Shazly et al., 1990). In contrast, our study found that most of the girls used homemade pads. According to a Bangali study, women rinsed the stained cloth with soap and water and then dried it in hiding under the bed or in a damp and dark place (Mathews, 1995). According to another study conducted in India, these cloths are washed with soap but are later dried and stored in hidden and secret places for reuse (Khanna et al., 2005). Another study conducted by Walraven et al. found that women who washed used cloths but did not dry them under the sun did this in order to keep the cloth away from eyes of others. The cloth was viewed as a source of vulnerability and potential embarrassment, and great efforts were made to avoid this situation (Ullrich, 1992). The findings of an Egyptian study are almost consistent with them. Similarly, most of the girls in both studies used 1–3 pads daily while some used 5–8 pads (El-Shazly et al., 1990). It is very difficult to verify the thickness of the pads and the material used as absorbent because the homemade could vary. Even the commercially available pads have different absorbing capacity. Dietary changes during menstruation We found that girls consider themselves as unclean during menstruation and were restricted from social outings, bathing, and nutritional intake (with the belief that certain foods would either make them ill in the present or in future). Many foods which are avoided during menstruation are high in iron (e.g. liver, eggs) which could relate to the fact that anemia is a major
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health concern amongst adolescent females. Saudi Arabian girls altered their nutritional intake, including foods and drinks, and other activities as well (Moawed, 2001). Similarly, Bengali women also altered their food intake and were restricted from eating meat, eggs, fish and leafy vegetables (Mathews, 1995). According to our study, half of the subjects were restricted by their family members and friends from eating hot and cold foods like eggs and meat. These practices are worrisome from both a health and hygiene point of view. Social limitations According to a study conducted in Egypt, girls do not go to school and prefer to stay at home during menstruation, either because of the pain or fear of bleeding (El-Shazly et al., 1990). Similar findings were found in this study where about 60% of girls avoid socialization and limit their movements. Furthermore, they avoided religious practices. This finding has been supported by literature. In India, during their menstrual period women were not allowed to cook and enter or touch any kitchen item. In rural areas, girls are restricted from passing through cross roads for fear that they may be caught by evil spirits and become mad, and were also prohibited from attending religious activities such as visiting temples and performing poojas (Dasgupta & Sarkar, 2008). A Saudi Arabian study reported that girls were restricted for fasting, reciting Holy Koran, attending mosque and cannot be divorced during this period (Moawed, 2001). According to our study, 50% of our subjects did not take bath during menstruation as they were restricted by their mothers from doing so. Similar findings were consistent with Saudi Arabian and Egyptian girls. However an Egyptian study reported that 75.63% of girls bathed during menstruation. This study also reported that bathing was thought to be unhealthy and that there were many disadvantages to doing so during menstruation: backache, hair loss, menorrhagia, cessation of bleeding, and maceration of the skin (El-Shazly et al., 1990). One of the important findings of our study is that the adolescents who did not go to school held more misconceptions and their practices were unhygienic as compared to the school-going girls. This has been supported by another study conducted in 2007 at Hyderabad, Pakistan, stating that married women with higher education were more likely to indulge in hygienic practices than those with no formal education (p 0.0001); there was no significant difference in menstrual management practices among the income levels, as measured in our study (Ali et al., 2007). According to a review article, women with higher education manage menstruation more hygienically (Ullrich, 1992). This indicates that literacy among adolescent girls would ensure a healthier reproductive life. Schooling provides an environment that gives an insight into this natural phenomenon of menstruation along with the ability to rationalize the related conceptions and misconceptions and adopt the healthy and hygienic practices accordingly. There is no defined curriculum in schools that talks directly about the process and management of menstruation but in fact emphasizes healthier living. Study limitations The main limitation of this study is that the sample is from low and middle socioeconomic squatter settlements of Karachi, Pakistan; therefore it can be generalized only for similar communities. However, it can still apply to about 50% of the female adolescent population in Pakistan, where, given that it is a developing country, the affordability and accessibility of information are limited. Nevertheless, it is the recommendation of the authors that a similar study be conducted among higher socioeconomic strata. The researcher of this study has faced multiple challenges to conduct this study. Initially, mothers of some potential adolescents refused their daughters to become part of the study. Due to cultural sensitivity certain steps were taken to encourage the mothers for the provision of consent. First the data collectors explained the importance of study to mothers, then the supervisor explained it further and finally, if required, the principle investigator intervened. Aside from 10 subjects, we were able to gain the consent from the subjects and their mothers. Furthermore, as expected, that our subjects were shy about sharing such information; thus we trained our data collectors in advance to be patient, caring and sensitive towards the participants and if required, to repeat the question. Systematic sampling was time consuming because of the unavailability of the required subjects. Therefore, data collectors had to revisit each house a number of times. Although permission was initially granted by the school principals, two schools later refused the data collector, so a similar school was approached. The reported reason is lack of consent from the parents of the students. Although we collected information on the use of pads or material per day, we cannot compare this to the ‘‘perceived menstrual flow’’ information, because of varying absorption capacities between commercial sanitary pads and homemade ones. This might have introduced the measurement bias. Conclusion There are a number of unhygienic practices and misconceptions regarding menstruation that prevail among female adolescents in Pakistan. In particular, these practices are more common among girls who do not go to school. These girls, because of limited or no exposure to an educational setting, are less likely to have access to health related information, particularly in regards to menstrual hygiene. To break the continuum of transfer of knowledge and practices to the next generation it is imperative for health professionals to intervene among adolescents at different level. Strategies may include: education given at the home level, at religious centers or in health care facilities, or health education sessions for mothers in
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the communities who could later translate this information to their daughters; skills development programs for those of low SES standings in order to enhance their economic bar and encourage better reproductive health practices like the use of sanitary pads. With more emphasis by the United Nations on the education of females in developing countries, where women’s health is traditionally given a low priority, policy makers should include female adolescent reproductive health in the school curriculum. This inclusion in the curriculum would impact the overall reproductive health of the females, specifically the socioeconomically marginalized population. References Abioye-Kuteyi, E. A. (2000). Menstrual knowledge and practices amongst secondary school girls in Ile Ife, Nigeria. The Journal of the Royal Society for the Promotion of Health, 120(1), 23–26. Ali, T.S., Fikree, F.F., Rahbar, M.H., Mahmud, S. (2006). Frequency and determinants of vaginal infection in postpartum period: a cross-sectional survey from low socioeconomic settlements, Karachi, Pakistan. J Pak Med Assoc. 2006 Mar;56(3):99–103. Ali, T. S., Karmaliani, R., Salam, A., Ladak, R., Moss, N., Harris, H., et al. (2007). Hygiene practices during menstruation and its relationship with income and education of women in Hyderabad, Pakistan. Pakistan Journal of Women’s Studies: Alam-e-Niswan, 13(2), 185–199. Critchley, M. (1986). Medical dictionary. UK: Butterworths & Publisher Ltd. Czerwinski, B. S. (2000). Variation in feminine hygiene practices as a function of age. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 29(6), 625–633. Dashiff, C.J. (1992). Self-care capabilities in black girls in anticipation of menarche. Health Care Women Int, 13(1), 67–76. Dasgupta, A., & Sarkar, M. (2008). Menstrual hygiene: how hygienic is the adolescent girl? Indian Journal of Community Medicine, 2(33), 77–80. El-Shazly, M. K., Hassanein, M. H. A., Ibrahim, A. G., & Nosseir, S. A. (1990). Knowledge about menstruation and practices of nursing students affiliated to university of Alexandria. Journal of the Egyptian Public Health Association, 65(5–6), 509–523. Fikree, F. F., Ali, T., Durocher, J. M., & Rahbar, M. H. (2004). Health service utilization for perceived postpartum morbidity among poor women living in Karachi. Social Science & Medicine, 59(4), 681–694. Kalman, M. (2003). Taking a different path: menstrual preparation for adolescent girls living apart from their mothers. Health Care for Women International, 24(10), 868–879. Kazi, S., & Sathar, Z. A. (1997). Pakistani husbands and wives: different productive and reproductive realities. In Paper presented at the Population Association of American annual meeting, Washington, D.C., March 1999. Khan, A. (1998). Female mobility and access to health and family planning services. Islamabad: Ministry for Population Welfare and London School of Hygiene and Tropical Medicine. Khan, A. (2000). Adolescent and reproductive health in Pakistan: A literature review. United Nation Populations Funds and Population Council. Khan, T., Qureshi, M. S., & Siraj, M. (1998). Patterns and perception of menstruation. Karachi, Pakistan: National Research Institute of Fertility Control Pakistan Secretariat. Khanna, A., Goyal, R. S., & Bhawsar, R. (2005). Menstrual practices and reproductive problems. A study of adolescent girls in Rajasthan. Journal of Health Management, 7(1), 91–107. Koff, E., Rierdan, J. (1995). Preparing girls for menstruation: recommendation from adolescent girls. adolscence, 30(120), 795–811. Koff, E., Rierdan, J. (1995). Early adolescent girls’ understanding of menstruation. Women Health, 22(4), 1–21. Mathews, A. (1995). Menstruation issues in Bangladesh. Footsteps, 24, 2–3. McGrory, A. (1995). Education for the menarche. Pediatr. Nurs, 21, 439–440. Moawed, S. (2001). Indigenous practices of Saudi girls in Riyadh during their menstrual period. Eastern Mediterranean Health Journal, 7(1–2), 197–203. Pakistan Demographic and Health Survey 2006–07. Available at. http://www.measuredhs.com/pubs/pdf/FR200/FR200.pdf. Accessed 02.03.09. Tucker, S.K. (1990). Adolescent patterns of communication about the menstrual cycle, sex, and contraception. Journal of Pediatric Nursing, 5(6), 393–399. Ullrich, H. E. (1992). Menstrual taboos among Havik Brahmin women: a study of ritual change. Sex Roles, 26(1–2), 19–40.
Contents lists available at ScienceDirect
Journal of Adolescence journal homepage: www.elsevier.com/locate/jado
Menstrual knowledge and practices of female adolescents in urban Karachi, Pakistan Tazeen Saeed Ali a, *, Syeda Naghma Rizvi b,1 a b
The Aga Khan University, School of Nursing and Department of Community Health Sciences, Stadium Road, PO Box 3500, Karachi 74800, Sindh, Pakistan The Aga Khan University, School of Nursing, Stadium Road, PO Box 3500, Karachi 74800, Sindh, Pakistan
a b s t r a c t Keywords: Menstruation Menstrual practices
Menstruation is a normal physiological process that is managed differently according to various social and cultural understandings. Therefore, this cross-sectional study was conducted to explore the menstrual practices among 1275 female adolescents of urban Karachi, Pakistan from April to October 2006 by using interviews. Data was entered and analyzed in Epi Info Version 9 and SPSS Version 10. Descriptive findings showed that 50% of the girls lacked an understanding of the origin of menstrual blood and those with a prior knowledge of menarche had gained it primarily through conversations with their mothers. Many reported having fear at the first experience of bleeding. Nearly 50% of the participants reported that they did not take baths during menstruation. In univariate analysis, factors of using unhygienic material, using washcloths, and not drying under sun were found to be significant in the Chi square test among those going and not going to schools. This study concludes that there are unhygienic practices and misconceptions among girls requiring action by health care professionals. Ó 2009 The Association for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.
Introduction Background and literature review Menstruation is defined as the ‘‘periodic discharge of blood from the uterus occurring more or less at regular monthly intervals throughout the active reproductive life of a female’’ (Critchley, 1986). Menstruation, a normal physiological process, may be looked at as more than just a physiological process. It may be viewed either positively or negatively by the society. A positive perception of menses would be by considering it a sign of femininity, fertility, youth, or purification of the body. The negative perceptions include a linkage to being vulnerable and susceptible to different illnesses, or creating feelings of disgust and shame. In some societies, these negative perceptions become the basis of certain practices, like placing restrictions on religious, social and domestic activities of a menstruating woman. A woman usually has two kinds of perceptions of bleeding: one from her actual experience and the other she learns from her elders and peers (Kalman, 2003). Menstruation often represents an event with social and cultural implications (Mathews,1995). A number of studies conducted throughout Asia have specifically reported varying cultural beliefs and practices related to menstruation. These beliefs and practices include the use of unhygienic sanitary materials, altered bathing, altered nutritional intake and restriction on women’s social mobility and religious activities. In a study conducted in Egypt, almost half of the women held this belief that bathing was
* Corresponding author. Tel.: þ92 21 4865460. E-mail addresses: [email protected] (T.S. Ali), [email protected] (S.N. Rizvi). 1 Tel.: þ92 21 4865400. 0140-1971/$ – see front matter Ó 2009 The Association for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.adolescence.2009.05.013
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unhealthy; it either prolongs the bleeding period, stops menstrual bleeding, and causes macerations of the skin. However, almost all of the women in the same study practiced thorough washing of their perineal area and used sanitary pads. The majority of the women changed their pad at fixed times of the day (i.e., once or twice; either in the morning, evening, or at night) rather than changing the pad when it was soaked (El-Shazly, Hassanein, Ibrahim, & Nosseir, 1990). Half of the women did not change their sanitary protection for more than 9–10 h (Moawed, 2001). In a South Indian study, approximately 50% of the women abstained from taking shower during menstruation and avoided perineal care. The reported reasons for this abstention were poor habits of cleanliness, and the belief that showers increase pain intensity and would lead to discontinuation of menstrual flow. Czerwinski (2000) endorses this finding in his study of the number of females that avoid bathing during menstruation. According to a literature review report on adolescence by Khan (2000), adolescents and their mothers believed that eating foods considered to be too hot (dry fruits, liver, and eggs) or too cold (ice creams, yogurt, and green leafy vegetables) should be avoided. Many of the foods they avoid are rich in iron. Iron deficiency anemia has thus been reported as a major health concern amongst adolescent females (Khan, 2000). A study conducted in India showed that 42.6% of respondents reused cloths for the absorption of bleeding, which is not a bad practice. However, the cloth needs to be hygienically washed and properly dried under sun to avoid bacterial contamination (Dasgupta & Sarkar, 2008). In another Indian study, it was reported that 77% of women used old pieces of cloth, and, based on a hygienic practices scale, women having low scores also had the highest proportion (34.1%) of white discharge, compared to medium and high scoring women. Information collected from a study conducted in Bangladesh showed that 80% females reused the same cloth for absorption of bleeding, but among them only 42% dried the cloth in sunlight and the rest dried them in hiding (Mathews, 1995). Although females preferred to use sanitary towels, which were more absorbent and thicker, they were unable to afford those (Mathews, 1995). According to a study conducted in Pakistan, the affordability of sanitary pads is not the only reason for it’s under usage; rather, females are more comfortable with either using a cloth or homemade pads. It was found that 82% of Punjabi and 65% Sindhi preferred to use homemade pads, whereas 15% Sindhi females do not use any material. Instead they change the trousers frequently to absorb bleeding (Khan, Qureshi, & Siraj, 1998). Rationale Although reproductive health in Pakistan has received attention in the past 10 or 15 years, issues related to menstrual health and hygiene had never been the focus of policy makers and health professionals. Pakistani studies (published or unpublished) have either focused on knowledge about menstruation or relation of menstruation to family planning. Studies that have been conducted have focused mainly on menstrual knowledge and practices among female adolescents in very general terms. However, none of these studies have, to date, differentiated between school-going and non-school-going girls with regard to their menstrual practices and knowledge. We therefore conducted an in-depth study on issues related to the management of menstruation, and the identification of conceptions and misconceptions related to menstruation among female adolescents living in urban Karachi, Pakistan. This study has the purpose of identifying the menstrual conceptions of adolescent females among those going and not going to school, as well as related practices including social, religion, nutritional and hygienic practices. Finally, this study will compare the socioeconomic factors and practices of adolescent females who are going to government and private schools and those who are non-school-going. Research design and methods Background of the study area Pakistan is an Islamic country situated in South Asia with an estimated population of 152 million (2001) of which 14 million are based in Karachi, Sindh. This study was conducted in Karachi where the population is comprised of different ethnic groups who have migrated from different parts of Pakistan or other countries (e.g. Afghanistan and India), allowing for a diverse sample. There are Sindhis, Balochis, Punjabis, Pathans and Mohajirs living in Karachi (Pakistan Demographic and Health Survey, 2006–07). The study focused on three squatter settlements of low socioeconomic standing: Orangi Town, Azam Basti, and Qayyumabad. Here, school-going and non-school-going adolescents were accessed in order to compare the differences in practices among them. These communities are of lower-to-middle socioeconomic status, and the residents belong to different ethnicities including Mohajir, Punjabi, Sindhi and Pathans. Study design & study population A descriptive comparative study was conducted in three lower-middle socioeconomic communities in Karachi. The participants were unmarried adolescent girls ranging in age from 13 to 19 years. They were selected from private schools2, government schools3, and the general community, which includes those who are not going to school.
2 Girls attending private schools can afford tuition fees, books and school uniforms. Among these schools some health service facility is available like first aids, vaccination, etc. 3 The government schools (public schools) offer free of charge education. School often provides books and uniforms. Public schools don’t offer health services. However, health education sessions often been conducted in these schools by nursing students and non-governmental organizations.
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Sample size and sample selection The sample size was calculated based on power calculation using Epi Info Version 6, in order to be able to detect the difference of menstrual practices among three groups. The proportion of females using hygienic material during menstruation was estimated by taking the prevalence of 15.6% of those using unhygienic material for the absorption of bleeding, and by specifying the significance level of 5% with the bound of error of 5%. The required sample size was maximum 400 adolescent females in each community (Fikree, 2004). To avoid biases, we took extra samples from each community, which was further divided into private, government and community evenly. The maximum required sample size total was determined to be 1275. The studied was limited to female having menstrual cycles of less than 31 days, and living in the selected community based area. Those adolescents or their mothers who refused to participate, are married, suffer from amenorrhea, have cycles of thirty one days of more, or have migrated from another country within the last 5 years were not included in the study. To ensure probability sampling, the data was collected by using a systematic sampling technique. In the initial stage, which targeted the girls in the community who were not in school, the data collectors prepared a list of adolescents meeting the inclusion criteria, with every fourth girl being interviewed. Those who were unable to give an interview for whatever reason were replaced by another girl on the list. At the school level, all the adolescent girls within the age range of 13–19 years were selected. The list of school-going adolescents, fulfilling the inclusion criteria, was provided by the school principals. The interviews were conducted in privacy by the trained data collectors, who work as community health workers. The data was collected followed by acquiring verbal consent from the mother and adolescent. Later, the field supervisor checked the data to assess completion of the questionnaires and accuracy of the data coding. In the case of missing information, the study subjects were approached and in case of incorrect coding, proper coding was done. Ten girls were re-contacted for incomplete questionnaires. Methods of data collection The data was collected from April to October 2006 from the government schools, the private schools and the communities in order to attain diversity of the sample population regarding education, within the similar socioeconomic groups. The data was collected by using a pre-coded questionnaire, which was developed after conducting the four Focus Group Discussions (FDG) and ten in-depth interviews with the adolescents and their mothers. Later, the data was analyzed and categorized into themes. The variables that were included emerged from a conceptual framework based on the literature, expert opinions and from the qualitative interviews. The questionnaire for the current study was developed based on earlier qualitative work that explored 1) social, and religious restrictions; 2) conceptions and misconceptions about menstruation; 3) potential for altered nutritional intake; 4) hygienic practices; and 5) unhygienic material used to absorb menstrual bleeding. Results from this qualitative component were used to provide guidelines and direction to our research. The tools were pre-tested at the field level and translated in Urdu for the convenience of administering it to the study participants. Urdu, being the national language of Pakistan, is widely spoken and understood by the respondents of this study. The Urdu language questionnaire was translated back into English to ascertain the accuracy of the translation and their meanings. Ethical considerations Institutional ethical approval was obtained from The Aga Khan University and Johns Hopkins University. An introduction of the study was given to the study subjects in Urdu (the local language). We followed the consent procedure differently for different groups. For school attending girls, first their principal was approached for verbal consent, after which girls were approached for their verbal and written consent. However, at community level for girls not attending schools, verbal consent was first taken from their mothers. The confidentiality of the information was maintained by assigning identification numbers to each adolescent. After we collected the data and first results’ analysis, the principle investigator and the research supervisor conducted the health education sessions on menstrual management at school and community level for the study subjects. Operational definitions of the variables Socioeconomic status A composite index was computed on fifteen household assets and facilities such as the type of construction of the house, water supply, type of latrine/toilet facility, ownership of the house, possession of a radio or cassette player, TV, grinder/ blender, refrigerator, washing machine, bicycle, motor bike or scooter, sewing machine, pedestal or ceiling fan, iron, livestock (goat, sheep, cattle), and VCR was considered as a proxy indicator for SES. It was further classified into two categories such as better socioeconomic status and low socioeconomic status. The cut-off values were done on the 59th, percentile of the data distribution, done on SPSS Version 9.
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Autonomy The autonomy variables developed by having the indication including taking decision on spending household earning, able o take decision to work outside the home, able to take decision to go to clinic if she is sick, and if she need permission to go to market. Knowledge about menstruation The subjects were asked about their knowledge of menstruation by asking about their understanding of and the level of information about menstruation they had before menarche. Misconceptions To measure this variable, all the responses related to knowledge were given ‘‘1’’ if they were correct and ‘‘0’’ if they were incorrect. All the correct responses were accumulated from 2 to 4. The variables constitute: the source of bleeding, bathing during menstruation, effects of bathing on menstrual flow and permission to engage in religious practices. Menstrual practices The information regarding the practices was accumulated based on the responses to the following variables: material used to soak blood, reusing of material, drying and storing of the reused material. Storing of washed clothes Subjects, who reused the absorbing material after washing, were asked to mention the ‘‘space of the storage’’ of washed material. For the purpose of verification the data collector observed the place of storage of the washed material. Suitcase, box, cupboard, and shopper were categorized as ‘‘clean and covered places’’ whereas, the room, under cushion, under the bed, behind the door, and in the washroom were categorized as ‘‘unclean and covered places.’’ Gallery and under the kitchen roof were categorized as ‘‘clean and open spaces.’’ Plan of analysis The data was entered on Epi Info Version 9 and then transferred to SPSS Version 10 for descriptive analysis where measures of central tendency and dispersion were calculated. In addition, a univariate analysis was done by comparing three groups’ practices for the school going (private & government) and those never being to school by Chi square test of independence. The results are displayed in tabular form including demographic of the participants, menstrual history, and knowledge about menstruation, and practices. Results Demographic information Overall, our sample included an equal number of respondents in each of the three groups of young womendthose attending a private school, those in a government school, and those who had never been to school. The Mahojir population had a higher number in the sample, but they are significantly different in number in each group. The majority (private school ¼ 74.4, government school ¼ 67.0, and non-school-going ¼ 44.9) of the participants were Urdu speaking and the rest spoke a variety of different languages (e.g. Punjabi, Hindko, Pushto, Sindhi, Balochi) but were still able to read, speak, and respond in Urdu. Among those who are non-school-going, about half of them (40.2%) have never attended any school whereas the rest have completed grade five or less. Those who are school-going are currently studying in grades eight, nine or ten (private ¼ 63%, 13.9%, & 22.2%; government ¼ 65.1%, 20.2%, & 11.3%). The majority of the study participants were living in nuclear family, however there were few who had either their paternal or maternal grand parents living with them. The age range of the respondents was from 12 to 19 years; the majority were between 14 and 17 years of age (private school ¼ 73.5%, government school-going ¼ 80.7% & non-school-going ¼ 56.3%). Socioeconomic characteristics As mentioned in Table 1, about a quarter of the participants who are not going to school are employed as packing. They are packing goods at home or in manufacturing units. However, few participants going to private and government schools were also working (4.2% & 3.8% respectively; p value ¼ 0.000). Among the non-school-going, the majority (51.6%) earn a living by working outside of their home as compared to those girls who attend school (p value ¼ 0.006). Table 1 shows interesting results in regards to autonomy indicators and girls’ school status. It shows that those attending private schools have the least autonomy for making decisions on household spending (4.5%) and going outside the home (3.8%). The variable of autonomy was also checked with the age for its significance of correlation, and came up as insignificant with only a 5% significance level (r ¼ 0.004–0.05; p value with range of 0.1–0.8). The correlation between the socioeconomic variable and the status of schooling (r ¼ 0.132, p value ¼ 0.000) and between the status of schooling with hygienic practices (r ¼ 0.156, p value ¼ 0.000)
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Table 1 Characteristics of adolescent female in Karachi, Pakistan (n ¼ 1275). Variable
Private school, % (n ¼ 425)
Government school, % (n ¼ 425)
Community, % (n ¼ 425)
Chi square
Which language do you speak at home? Urdua Balochi Sindhi Punjabi Pathan Othersc
74.4 1.4 1.4 15.5 6.3 0.9
67 0.9 1.6 16.5 12.2 1.5
44.9 4 7.3 20 20.3 3.6
0.000b
Girls earning money
4.2 (n ¼ 18)
3.8 (n ¼ 16)
21.4 (n ¼ 91)
0.000
Earning inside or outside home Inside (packing jewelry, chilli, toy, etc. for earning) Outside (teaching) Both
38.9 11.1 50.0
42.1 26.3 31.6
24.2 51.6 24.2
0.006
Father’s occupation Job less/retired Father not alive Professionals Molvi/imam Skilled workers Private job Government job Business man/landlord
1.2 6.1 20.1 0.2 53.6 5.9 6.6 5.8
0.7 6.4 20.1 1.2 60.4 2.4 5.6 2.8
0.7 8.7 30.3 0.5 51.6 2.6 2.1 3.5
0.800
92.9 2.1 4.9
97.4 1.9 0.7
91.5 5.6 2.8
0.000
Water supply Government supply (tap water inside) Government supply (communal) Water tanker Hand pump
78.1 12.7 0.2 8.9
85.4 2.4 6.6 5.6
86.4 4.0 1.2 8.5
0.000
Type of latrine/toilet facility Latrine (pour or flush)
100
100
100
0.900
House facilities available Owner of the house Live on rent Office accommodation
70.8 24.9 4.2
67.5 30.9 1.6
62.1 37.2 0.7
0.035
Own a radio/cassette player TV Grinder/blender Refrigerator Washing machine Cycle Motor bike/scooter Sewing machine Pedestal/ceiling fan Iron Livestock [goat, sheep, cattle, etc.] VCR Decision on spending household earnings Able to take decision to work outside the home (yes) Able to take decision to go to a clinic if she is sick (yes) If she need to take permission to go to the local market (yes)
72.2 96.0 76.5 78.8 91.1 26.1 37.2 83.5 99.3 98.6 4.7 36.7 4.5 3.8 14.8 92.9
73.1 91.8 65.4 68.0 89.6 36.0 40.0 87.8 98.6 99.1 10.8 28.7 13.9 9.4 14.1 93.9
68.2 90.1 51.1 62.4 84.9 30.4 33.6 87.5 99.5 99.1 8.9 17.6 8.5 9.2 11.5 92.9
0.219 0.002 0.000 0.000 0.015 0.007 0.157 0.137 0.316 0.757 0.003 0.000 0.000 0.001 0.327 0.817
Socioeconomic statusd Better socioeconomic status Low socioeconomic status
75.3 24.7
68.7 31.3
60.2 39.8
0.000
Type of construction of your house Pakka (walls and roof are cemented) Kacha (walls and roof are made of mud, tin, or asbestos) Kacha–pakka (walls are cemented and roofs are made of mud, tin, asbestos, etc.)
a
People migrated from India. Fisher exact test. c Memni, Gujrati, Marwari, Kathiawari, Dangri, Farsi, Bangali. d All the socioeconomic variables were given score 1 per variable, then after combining them together it has been dichotomized at 59th percentile the upper percentile entitled as better socioeconomic and less then 59th percentile was taken as low socioeconomic status. b
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stays significant. However, the correlation between socioeconomic status with unhygienic practices stayed insignificant (r ¼ 0.052, p value ¼ 0.064). On comparing the type of housing among the school-going and the non-school-going girls, it was found out that 91.5% of the participants not attending school are residing in pakka houses (in which the roof and walls are cemented), which is similar to the type of housing of girls going to private (92.9%) and government schools (97.4%). The percentage of the occupants of kacha houses (in which the roof is made up of mud, tin, asbestos and walls are cemented) is less and belong to the category who have not attended any school at all (p value ¼ 0.000). A low socioeconomic status is high among those not going to school (39.8%), with opposite results for those enrolled (24.7% & 31.3%; p value ¼ 0.0001). Information related to menstruation Menstrual cycle According to our study subjects, the mean length of the menstrual cycle, in each of the three groups is 3 days with a standard deviation of one day. In all three groups, most of the subjects reported their menarche age as 12–14 years and either experienced fear anxiety about seeing the bleeding (Table 2). About seventy percent respondents from three areas reported that their menstrual flow was normal. Sixteen percent respondents from private schools, 17% from government schools and 21% from the community perceived their menstrual flow was heavy. Knowledge and perceptions about menstruation According to our participants, menstruation is a monthly bleeding that happens to every female; it is a natural phenomenon, a sign of adulthood and good for marriage. Some reported that it is the removal of dirt from stomach, or is a disease. Regarding the origin of bleeding, 37% (private), 15.9% (government) and 19.7% (community) participants reported that it comes from the uterus; whereas the rest were unsure about it. There was a significant difference in terms of prior knowledge about menstruation. The adolescents going to government schools were the most informed (47%), and the percentage of informed girls going to private school (34%) and not going to school was similar (about 39%). Most of the participants who were educated before menarche reported their mother as their source of knowledge; the remainder were educated by their elder sisters, friends, grandmother, female cousins, teachers and/or nurses. The reactions (fear, worry) to menarche are almost similar in the participants from the government and private school systems. The percentages of respondents in private and government schools who experienced fear and worry were almost same: 55.1–55.8% reported fear and 46.8–48.7% reported being worried; in contrast, the percentage of respondents from the community experiencing fear or worry was slightly higher (62.1% experienced fear and 32.4% was worried) with the Chi square p value of 0.000. Hygienic practices The use of a sanitary pad for absorbing menstrual blood was highest amongst the study participants from private schools (33.5%) as compared to government (16.4%) and community adolescents (13%). The use of pieces of old cloth to absorb blood was highest among the community respondents (70%) as compared to the other two groups. The rest of the participants in all the three groups were using pieces of new cloth, made of either cotton or wool. The girls not attending school were more likely to report that they do not use any material at all and stay in their usual dress (trouser and a tunic) without any protection. Our overall correlative results show that girls with a low education status come from a lower socioeconomic status and have unhygienic practices too. A majority of the private school-going participants (71.1%) reported that they throw away these pieces of cloth without washing, whereas those who do not go to school do not discard it unwashed. Instead, they reuse them after washing, or wash and discard them (60%), or wash the cloth and dry them in hiding. This pattern is similar in all three groups (69.3%, 60.1% and 68.9%). However, some girls reported drying these clothes in sunlight while others discard them after washing. Most of the study participants reported using two pads or materials per day with a range of one to nine. Tables 2 and 3 show that approximately half of the females in each of the three groups take a bath during menstruation (p value ¼ 0.888). Table 3 compares practices of the three categories of participants. Seventy-nine percent of adolescents not going to school are using unhygienic materials for the absorption of menstrual bleeding, as compared to those going to private or government schools (58.65 & 70.1% respectively, p value ¼ 0.0001). Similar results are obtained from all the groups (30%) regarding the drying of washed clothes under sun (0.300). Alternative diets during menstruation are observed in all the three groups and similar practices are being reported among them (p value ¼ 0.370). About half of those who are not going to school have misconception about menstruation (42.4%) with a p value ¼ 0.000. Discussion Our study results are in line with the studies conducted and published in countries other than Pakistan. The age of the study participants ranges from 13 to 19 years. A similar study conducted by Deo et al. reported the age of menstruating girls to range from 12 to 17 years; within that, the common age is reported to be between 13 and 15 years. In our study, some
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Table 2 The information related to menstrual cycle, knowledge, perception and sanitary practices’ conception amongst adolescent girls in Karachi, Pakistan (2006), n ¼ 1275. Variable
Private school, % (n ¼ 425)
Government school, % (n ¼ 425)
Community, % (n ¼ 425)
Menstrual cycle Mean length of menstruation Days girl menstruate in range
31 2–9
31 2–9
31 2–9
Menarche age Before 11 years 12–14 years 15–16 years Don’t know/don’t remember
6.8 88.2 2.9 2.1
7.1 83.8 6.8 2.3
6.4 82.8 6.8 4.0
Feelings at first menarche Fear Worry Normal feelings Anxiety/pain/felt bad/cried/felt shy
55.1 47.8 9.5 8.9
55.8 46.8 9.4 10.8
62.6 32.0 10.8 10.6
Knowledge about menstruation Understanding of menstruation Monthly bleeding Dirty bleeding Happens with every female Good for marriage Natural phenomena Sign of adulthood Others (removal of dirt from the stomach, some disease)
33.1 15.1 11.9 2.2 19.3 16.5 1.8
22.3 19.1 13.6 3.9 19.3 20.9 1.0
28.1 18.2 16.8 3.1 18.8 14.6 0.5
Source of bleeding Uterus Any part of abdomen Stomach Vagina Urinary tract Somewhere from the body
37.2 34.0 2.5 14.5 10.3 1.4
15.9 44.1 5.6 21.5 11.9 1.1
19.7 27.3 5.9 42.9 1.0 3.1
Knowledge of menstruation before menarche
34.1
47.8
38.8
Source of knowledge of menstruation before menarche Mother Elder sister Aunt Friend Others (grandmother/cousin/sister in law/teacher/nurse)
n ¼ 145 (34.1%) 37.9 27.5 6.5 20.9 7.4
n ¼ 203 (47.8%) 29.4 35.5 11.8 21.8 1.4
n ¼ 165 (38.8%) 21.1 49.7 14.1 15.2 1.2
Information given about menstruation before menarche Physical changes Social and religious restriction Bathing practices Use of material for absorption The blood is dirty/food restrictions/less water intake/more water intake/blood comes from vagina
n ¼ 145 (34.1%) 36.0 5.4 10.2 40.9 7.6
n ¼ 203 (47.8%) 20.9 7.3 15.9 46.8 9
n ¼ 165 (38.8%) 21.1 13.3 13.7 49.5 2.6
Multiple response possible
Sanitary and hygienic practices n ¼ 429 n ¼ 465
n ¼ 433
Material use for absorbing blood Sanitary pads Cotton wool Pieces of new clothes Pieces of old clothes Woolen cloth Shalwar/nothing
33.5 4.4 10.6 50.0 1.4 –
16.4 3.6 16.8 62.6 0.6 –
13.0 6.5 8.0 70.4 1.1 1.1
Handling of use materials Discard Do not discard it
n ¼ 425 71.1 28.9
n ¼ 425 46.6 53.4
n ¼ 425 40 60
Those do not discard (multiple response possible) Wash and discard Wash and dry
n ¼ 123 (28.9%) 44.9 55.1
n ¼ 227 (53.4%) 31.5 68.5
n ¼ 225 (60%) 31.8 68.2
Drying of clothes
n ¼ 75 (55.1%)
n ¼ 183 (68.5%)
n ¼ 193 (68.2%) (continued on next page)
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Table 2 (continued) Variable In sunlight In hiding Storing of washed clothes Clean and covered placea Unclean and covered Placeb Clean and open spacec a b c
Private school, % (n ¼ 425)
Government school, % (n ¼ 425)
Community, % (n ¼ 425)
30.7 69.3
39.9 60.1
31.1 68.9
60 30 20
74.2 25.8 3.2
59.4 36.3 6.6
Suit case, box, cupboard, and shopper. Store room, any where in the room, under cushion, under the bed, behind the door, within the washroom. Gallery, under the kitchen roof.
autonomy indicators were also measured in which female adolescents have reported low levels of autonomy. They are unable to take independent decision for their lives, are not allowed to work outside the home and are not allowed to visit the market without permission. This, at times, has nothing to do with schooling status. In Pakistan, women have less autonomy overall; this is particularly evident at young ages (Khan, 1998). Girls face more gender differentials in access to health care and many other facilities. Limitations on female mobility particularly affect younger women under the age of 25, according to a study in rural Punjab, even if they were married (Kazi & Sathar, 1997). Unmarried girls in that province faced the most restrictions on their overall mobility, including access to health services, due to social norms enforcing segregation between the sexes as a means of preserving a girl’s chastity or honor (Khan, 1998). Knowledge and perception about menstruation Similar to our study, available literature from Bangladesh (Mathews, 1995), India (Khanna, Goyal, & Bhawsar, 2005), Saudi Arabia (Moawed, 2001), Nigeria (Abioye-Kuteyi, 2000) and Egypt (El-Shazly et al., 1990), shows that women have considered Table 3 Comparison of menstrual practices using Chi Square p value. Going private school, % (n ¼ 425)
Going govt. school, % (n ¼ 425)
Not going school, % (n ¼ 425)
Chi square test p value
Use of hygienic materiala Yes No
41.4 58.6
29.9 70.1
21.2 78.8
0.000
Drying cloth in sunlight Yes No
30.7 69.3
39.9 60.1
31.1 68.9
0.300
Alteration in diet Yes No
21.65 78.35
27.53 72.47
18.59 81.41
0.370
How do you alter your diet during menstruation? Eat less Eat more Eat same amount of food
n ¼ 92 (21.65%)
n ¼ 117 (27.53%)
n ¼ 79 (18.59%)
65 17 18
62 21 17
53 37 10
0.189
Decrease fluid intake No Yes
92.7 7.3
90.6 9.4
88.2 11.8
0.084
Restrict socialization No Yes
41.9 58.1
32.7 67.3
41.9 58.1
0.07
Have misconceptions (lack of knowledge about menstruation No Yes
65.6 34.4
76.2 23.8
57.6 42.4
0.000
Bathing during menstruation period Yes No
45.2 54.8
44.2 55.8
45.9 54.1
0.888
Washing of premium Yes No
98.1 1.9
99.1 0.9
98.4 1.6
0.499
Prior knowledge of menstruation before menarche
34.1
47.8
3.8
0.000
a
It includes pads, and clean cloth.
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menstruation to be a natural phenomenon. However, a study conducted by Abioye and Dasgupta reported that some girls perceived menstrual period as unclean (Abioye-Kuteyi, 2000; Dasgupta & Sarkar, 2008). Similar perceptions are reflected in our study as well, especially that women avoid prayer and attending religious ceremonies. The reaction to menstruation depends upon awareness and knowledge of the subject. The manner in which a girl learns about menstruation and its associated changes may have an impact on her response to the event of menarche. As in our study girls felt fear and anxiety at the time of menarche. This has been also supported by studies conducted in India and Nigeria (Abioye-Kuteyi, 2000; Dasgupta & Sarkar, 2008; Khanna et al., 2005). In our study, those who had some prior knowledge about menstruation received it mainly from their elder sisters and mothers. Researchers have demonstrated that mothers in many cultures are an important resource for menstrual preparation for their daughters (Dashiff, 1992; Koff & Rierdan, 1995a, 1995b; McGrory, 1995; Tucker, 1990). The poor literacy and the socioeconomic status of females in the community serve as an inhibition to impart the significance, and a healthy attitude towards menstruation, as well as the teaching of hygienic practices in regards to it. This is consistent with the study by Dasgupta and Sarkar (2008). An Indian study conducted on schoolgirls studying in grade nine reported that 97.5% of these study participants did not know the source of bleeding during menstruation. Although the percentage in our study is not as high as the Indian study, less than one-fourth of the participants were ignorant of this fact. Furthermore, this study reported that girls were frightened to see and feel blood at menarche (Khanna et al., 2005). They were worried, they wept and felt ashamed. Similar findings are reported from our study that participants were fearful, worried and had anxiety. Many participants did not have any knowledge regarding menstruation which is similar to the findings reported in Nigerian and Indian studies (Abioye-Kuteyi, 2000; Khanna et al., 2005). However there were significant differences in terms of prior knowledge about menstruation amongst the three groups. The adolescents attending government school were the most informed as compared to the group going to private school. This difference in the level of knowledge is because: first, the government schools are more accessible to researchers and non-governmental organizations (NGOs) for conducting health education sessions as compared to private schools; second, the national curriculum taught in the public schools gives some content related to reproductive health, and in addition community health nurses visit these public school as part of the nursing curriculum and conduct sessions to create awareness of issues related to adolescent reproductive health; third, private schools have their own curriculum which may or may not significantly include reproductive health as part of their curriculum; fourth, with the awareness of discrimination of gender in education at the international level, the government has also set priorities for female education and has taken some concrete steps to promote it. Use of material for soaking blood Generally in Pakistani culture, girls are either unaware of how to manage menstruation in a hygienic manner or they cannot afford to manage it with modern menstrual materials (e.g. commercial sanitary pads). Several people were aware of the fact that it is healthier to use pads than rags, but could not afford them even occasionally (Ali et al., 2007; Fikree, Ali, Durocher, & Rahbar, 2004). Furthermore, due to poverty, sanitary pads were seldom bought. Homemade pads, if used hygienically, are also considered fine (Fikree et al., 2004). It was also noted that for some of the participants the affordability of sanitary pads was not an issue. They reported that pads proved to be uncomfortable and caused irritation or rashes to the user. Some females used new cloths and towels during menstruation, which were reused after being, washed (Ali et al., 2006). According to our study, half of the girls used sanitary pads and the others used old and new, washed or unwashed cloth material. These findings are consistent with a study conducted in Bangladesh where upper middle class women residing in urban areas used disposable sanitary towels. The same study reported that women belonging to the middle class used reusable materials like cotton cloth torn from an old sari (Mathews, 1995). An Indian study reported that most of the girls used old cloth during menstruation and very few used sanitary pads. Those who were using old cloth material did not wash them properly before use (Khanna et al., 2005). A study conducted in Egypt reported that all 513 schoolgirl participants used sanitary pads during menstruation (El-Shazly et al., 1990). In contrast, our study found that most of the girls used homemade pads. According to a Bangali study, women rinsed the stained cloth with soap and water and then dried it in hiding under the bed or in a damp and dark place (Mathews, 1995). According to another study conducted in India, these cloths are washed with soap but are later dried and stored in hidden and secret places for reuse (Khanna et al., 2005). Another study conducted by Walraven et al. found that women who washed used cloths but did not dry them under the sun did this in order to keep the cloth away from eyes of others. The cloth was viewed as a source of vulnerability and potential embarrassment, and great efforts were made to avoid this situation (Ullrich, 1992). The findings of an Egyptian study are almost consistent with them. Similarly, most of the girls in both studies used 1–3 pads daily while some used 5–8 pads (El-Shazly et al., 1990). It is very difficult to verify the thickness of the pads and the material used as absorbent because the homemade could vary. Even the commercially available pads have different absorbing capacity. Dietary changes during menstruation We found that girls consider themselves as unclean during menstruation and were restricted from social outings, bathing, and nutritional intake (with the belief that certain foods would either make them ill in the present or in future). Many foods which are avoided during menstruation are high in iron (e.g. liver, eggs) which could relate to the fact that anemia is a major
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health concern amongst adolescent females. Saudi Arabian girls altered their nutritional intake, including foods and drinks, and other activities as well (Moawed, 2001). Similarly, Bengali women also altered their food intake and were restricted from eating meat, eggs, fish and leafy vegetables (Mathews, 1995). According to our study, half of the subjects were restricted by their family members and friends from eating hot and cold foods like eggs and meat. These practices are worrisome from both a health and hygiene point of view. Social limitations According to a study conducted in Egypt, girls do not go to school and prefer to stay at home during menstruation, either because of the pain or fear of bleeding (El-Shazly et al., 1990). Similar findings were found in this study where about 60% of girls avoid socialization and limit their movements. Furthermore, they avoided religious practices. This finding has been supported by literature. In India, during their menstrual period women were not allowed to cook and enter or touch any kitchen item. In rural areas, girls are restricted from passing through cross roads for fear that they may be caught by evil spirits and become mad, and were also prohibited from attending religious activities such as visiting temples and performing poojas (Dasgupta & Sarkar, 2008). A Saudi Arabian study reported that girls were restricted for fasting, reciting Holy Koran, attending mosque and cannot be divorced during this period (Moawed, 2001). According to our study, 50% of our subjects did not take bath during menstruation as they were restricted by their mothers from doing so. Similar findings were consistent with Saudi Arabian and Egyptian girls. However an Egyptian study reported that 75.63% of girls bathed during menstruation. This study also reported that bathing was thought to be unhealthy and that there were many disadvantages to doing so during menstruation: backache, hair loss, menorrhagia, cessation of bleeding, and maceration of the skin (El-Shazly et al., 1990). One of the important findings of our study is that the adolescents who did not go to school held more misconceptions and their practices were unhygienic as compared to the school-going girls. This has been supported by another study conducted in 2007 at Hyderabad, Pakistan, stating that married women with higher education were more likely to indulge in hygienic practices than those with no formal education (p 0.0001); there was no significant difference in menstrual management practices among the income levels, as measured in our study (Ali et al., 2007). According to a review article, women with higher education manage menstruation more hygienically (Ullrich, 1992). This indicates that literacy among adolescent girls would ensure a healthier reproductive life. Schooling provides an environment that gives an insight into this natural phenomenon of menstruation along with the ability to rationalize the related conceptions and misconceptions and adopt the healthy and hygienic practices accordingly. There is no defined curriculum in schools that talks directly about the process and management of menstruation but in fact emphasizes healthier living. Study limitations The main limitation of this study is that the sample is from low and middle socioeconomic squatter settlements of Karachi, Pakistan; therefore it can be generalized only for similar communities. However, it can still apply to about 50% of the female adolescent population in Pakistan, where, given that it is a developing country, the affordability and accessibility of information are limited. Nevertheless, it is the recommendation of the authors that a similar study be conducted among higher socioeconomic strata. The researcher of this study has faced multiple challenges to conduct this study. Initially, mothers of some potential adolescents refused their daughters to become part of the study. Due to cultural sensitivity certain steps were taken to encourage the mothers for the provision of consent. First the data collectors explained the importance of study to mothers, then the supervisor explained it further and finally, if required, the principle investigator intervened. Aside from 10 subjects, we were able to gain the consent from the subjects and their mothers. Furthermore, as expected, that our subjects were shy about sharing such information; thus we trained our data collectors in advance to be patient, caring and sensitive towards the participants and if required, to repeat the question. Systematic sampling was time consuming because of the unavailability of the required subjects. Therefore, data collectors had to revisit each house a number of times. Although permission was initially granted by the school principals, two schools later refused the data collector, so a similar school was approached. The reported reason is lack of consent from the parents of the students. Although we collected information on the use of pads or material per day, we cannot compare this to the ‘‘perceived menstrual flow’’ information, because of varying absorption capacities between commercial sanitary pads and homemade ones. This might have introduced the measurement bias. Conclusion There are a number of unhygienic practices and misconceptions regarding menstruation that prevail among female adolescents in Pakistan. In particular, these practices are more common among girls who do not go to school. These girls, because of limited or no exposure to an educational setting, are less likely to have access to health related information, particularly in regards to menstrual hygiene. To break the continuum of transfer of knowledge and practices to the next generation it is imperative for health professionals to intervene among adolescents at different level. Strategies may include: education given at the home level, at religious centers or in health care facilities, or health education sessions for mothers in
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the communities who could later translate this information to their daughters; skills development programs for those of low SES standings in order to enhance their economic bar and encourage better reproductive health practices like the use of sanitary pads. With more emphasis by the United Nations on the education of females in developing countries, where women’s health is traditionally given a low priority, policy makers should include female adolescent reproductive health in the school curriculum. This inclusion in the curriculum would impact the overall reproductive health of the females, specifically the socioeconomically marginalized population. References Abioye-Kuteyi, E. A. (2000). Menstrual knowledge and practices amongst secondary school girls in Ile Ife, Nigeria. The Journal of the Royal Society for the Promotion of Health, 120(1), 23–26. Ali, T.S., Fikree, F.F., Rahbar, M.H., Mahmud, S. (2006). Frequency and determinants of vaginal infection in postpartum period: a cross-sectional survey from low socioeconomic settlements, Karachi, Pakistan. J Pak Med Assoc. 2006 Mar;56(3):99–103. Ali, T. S., Karmaliani, R., Salam, A., Ladak, R., Moss, N., Harris, H., et al. (2007). Hygiene practices during menstruation and its relationship with income and education of women in Hyderabad, Pakistan. Pakistan Journal of Women’s Studies: Alam-e-Niswan, 13(2), 185–199. Critchley, M. (1986). Medical dictionary. UK: Butterworths & Publisher Ltd. Czerwinski, B. S. (2000). Variation in feminine hygiene practices as a function of age. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 29(6), 625–633. Dashiff, C.J. (1992). Self-care capabilities in black girls in anticipation of menarche. Health Care Women Int, 13(1), 67–76. Dasgupta, A., & Sarkar, M. (2008). Menstrual hygiene: how hygienic is the adolescent girl? Indian Journal of Community Medicine, 2(33), 77–80. El-Shazly, M. K., Hassanein, M. H. A., Ibrahim, A. G., & Nosseir, S. A. (1990). Knowledge about menstruation and practices of nursing students affiliated to university of Alexandria. Journal of the Egyptian Public Health Association, 65(5–6), 509–523. Fikree, F. F., Ali, T., Durocher, J. M., & Rahbar, M. H. (2004). Health service utilization for perceived postpartum morbidity among poor women living in Karachi. Social Science & Medicine, 59(4), 681–694. Kalman, M. (2003). Taking a different path: menstrual preparation for adolescent girls living apart from their mothers. Health Care for Women International, 24(10), 868–879. Kazi, S., & Sathar, Z. A. (1997). Pakistani husbands and wives: different productive and reproductive realities. In Paper presented at the Population Association of American annual meeting, Washington, D.C., March 1999. Khan, A. (1998). Female mobility and access to health and family planning services. Islamabad: Ministry for Population Welfare and London School of Hygiene and Tropical Medicine. Khan, A. (2000). Adolescent and reproductive health in Pakistan: A literature review. United Nation Populations Funds and Population Council. Khan, T., Qureshi, M. S., & Siraj, M. (1998). Patterns and perception of menstruation. Karachi, Pakistan: National Research Institute of Fertility Control Pakistan Secretariat. Khanna, A., Goyal, R. S., & Bhawsar, R. (2005). Menstrual practices and reproductive problems. A study of adolescent girls in Rajasthan. Journal of Health Management, 7(1), 91–107. Koff, E., Rierdan, J. (1995). Preparing girls for menstruation: recommendation from adolescent girls. adolscence, 30(120), 795–811. Koff, E., Rierdan, J. (1995). Early adolescent girls’ understanding of menstruation. Women Health, 22(4), 1–21. Mathews, A. (1995). Menstruation issues in Bangladesh. Footsteps, 24, 2–3. McGrory, A. (1995). Education for the menarche. Pediatr. Nurs, 21, 439–440. Moawed, S. (2001). Indigenous practices of Saudi girls in Riyadh during their menstrual period. Eastern Mediterranean Health Journal, 7(1–2), 197–203. Pakistan Demographic and Health Survey 2006–07. Available at. http://www.measuredhs.com/pubs/pdf/FR200/FR200.pdf. Accessed 02.03.09. Tucker, S.K. (1990). Adolescent patterns of communication about the menstrual cycle, sex, and contraception. Journal of Pediatric Nursing, 5(6), 393–399. Ullrich, H. E. (1992). Menstrual taboos among Havik Brahmin women: a study of ritual change. Sex Roles, 26(1–2), 19–40.