- Email: [email protected]
Tampon Use in Adolescence: Differences among European American, African American and Latina Women in Practices, Concerns, and Barriers
Original Study Tampon Use in Adolescence: Differences among European American, African American and Latina Women in Practices, Concerns, and Barriers Laura F. Romo PhD 1,*, Abbey B. Berenson MD 2 1 2
Gevirtz Graduate School of Education, University of California, Santa Barbara, CA Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
a b s t r a c t Purpose: Tampon use is common among European American adolescents, but much less so among African American and Latina adolescents. Reasons are largely unclear. The general goal of this study was to examine differences among European American, African American and English-speaking Latina women and Spanish-speaking women in tampon use, sources of information about tampon use, and concerns and barriers related to tampon use in their adolescent years. Method: The sample included 165 low-income women ages 18 to 35 years (M 5 24.1) who filled out a survey in a family planning clinic. Results: European American women (71%) were significantly more likely to use tampons in adolescence compared to a considerably smaller proportion of African American (29%), English-speaking Latina (22%), and Spanish-speaking Latina women (5%). Mothers were a primary source of explanations about tampons for European American women, but not for ethnic minority women. African American and Latina English-speaking women were more likely to report that their mothers did not approve of tampons compared to none of the European American women. Specific concerns about tampons for Latina and African American women were that they were unsafe and inappropriate for virgins, and also for Latina women, that they could get lost or stuck. Overall, Latina women reported more concerns and barriers to tampon use than European American women which included a lack of knowledge on how to use them. Findings have implications for addressing the health education needs of low-income ethnic minority adolescents to reduce misconceptions and relieve concerns about tampons. Key Words: Tampon use, Menstruation, Latina adolescents, African adolescents
Introduction
Menarche, the onset of the first menses, is a significant milestone in an adolescent's life. While the significance of menstruation as a research topic has attracted interest in previous years, there is scant research on adolescents' beliefs and attitudes toward tampon use, especially among ethnic minorities in the United States. This question is important because research shows that the use of tampons is associated with many misconceptions which indicate a need for accurate information for adolescents. A better understanding of adolescents' beliefs about tampon use can inform the design of school health education programs and improve communication between health professionals and adolescents about menstruation, anatomy, and female hygiene. The general goal of this study was to examine differences among European American, African American, and Latina women in tampon use, sources of information about tampon use, and concerns and barriers related to tampon use in their adolescent years. Different cultures view menstruation differently,1e4 which may affect how adolescents are socialized about menstruation and tampons. Tampon use seems to be common among European American adolescents with The authors indicate no conflicts of interest. * Address correspondence to: Laura F. Romo, PhD, Gevirtz Graduate School of Education, University of California, Santa Barbara, Santa Barbara, CA 93106-9490; Tel. 805-893-3081 E-mail address: [email protected] (L.F. Romo).
rates as high as 75% for high school girls.5,6 However, tampon use may vary by ethnicity. Finkelstein and Von Eye found that African American and Mexican Americans high school adolescents are more likely than European American adolescents to use pads alone.6 Reasons for the lower rate of tampon use among ethnic minority adolescents remain unclear. Mothers are the most typical sources of information about menstruation,7e10 but findings are mixed on the extent to which mothers provide information to their daughters about tampons. In 1 study, about 70% of early adolescent European American girls reported that they had learned about tampons from their mothers, although older adolescents also cited package directions and other relatives such as sisters.5 Similarly, in another study, European American women also report that their mothers were influential in making the decision to use tampons.11 In contrast, in an earlier study conducted with European American adolescents, friends and commercial pamphlets were reported to be the most common source,12 with less than 20% of the adolescents perceiving that their mothers approved of tampon use. These findings are consistent with a study conducted with Australian youth which found that friends and pamphlets were the most common source of information about tampons, because their mothers either did not know how to use tampons themselves, were too embarrassed to talk about it, or did not approve of their daughters using tampons.13 No research has been conducted with African American and Latina women with
1083-3188/$ - see front matter Ó 2012 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2012.06.001
L.F. Romo, A.B. Berenson / J Pediatr Adolesc Gynecol 25 (2012) 328e333
329
respect to sources of information about tampon use and maternal approval in adolescence. Research suggests that many adolescents have limited knowledge about menstruation9,14 and ethnic minority adolescents have less menstrual knowledge than European American adolescents.15 A limited understanding of menstruation and anatomy may contribute to adolescents' concerns about tampons. A common misconception about tampons for many adolescents including their mothers is that they are inappropriate for virgins.8,16 African American and Mexican American women report that 1 reason they did not use tampons in adolescence was because they were afraid.6 Australian adolescents perceive pads to be more safe for young girls13 and European American adolescents report concerns that tampons can get stuck and damage the vagina.12 In 1995, Moore found among a sample of early adolescent Australian girls that 60% were uncertain that young menstruating adolescents could use tampons because their vaginas were too small.10 In the study conducted by Abraham et al in 1985, adolescents reported that 1 reason for not using tampons was because they did not know where the opening of the vagina was.13 In addition, the researchers found that many adolescents reported that they did not use tampons at all because they did not want to touch themselves and the idea of inserting something into one's body was unpleasant.13 Almost nothing is known about beliefs about tampon use among African American and Latina adolescents that may contribute to their concerns about using them. In the present study, European American women, African American, and Latina women were asked to report whether they had used tampons in adolescence, who explained tampon use to them, and what were their concerns and barriers related to tampon use. English-speaking Latina women were examined separately from Spanish-speaking Latina women who were mostly foreign-born. Health belief models highlight that health knowledge is influenced by factors such as culture, acculturation, and exposure to relevant information. Spanish-speaking adolescents who had little or no exposure to U.S. culture may have had different views about menstruation in adolescence compared to acculturated English-speaking adolescents raised in the United States.
women. Roughly, 28% of European American women, 35% of African American women, and 41% of English-speaking Latina women had a high school degree, and 56%, 43%, and 28% had attended college or had a college degree, respectively. About 73% of the Spanish-speaking Latina women had less than a high school education. All of the European American women and African American women and 65% of the English-speaking Latina women had lived in the U.S. their entire lives. About 90% of the Spanishspeaking women had lived in the U.S. for less than 10 years.
Method
Tampon Use Concerns
Participants
The women were given a list of 4 statements and asked to indicate which, if any, were concerns they had about tampon use in their adolescent years. The items were: (1) I was worried that tampons were unsafe; (2) I was afraid it would get lost or stuck in my vagina; (3) I was afraid it would hurt; (4) I thought tampons were inappropriate for virgins. Composite scores of tampon concerns were computed by summing up the number of checked items.
The study was conducted at 3 university reproductive health clinics in Southeast Texas, which offer prenatal and family-planning services to mostly women from lowincome backgrounds. After obtaining approval from the University of Texas Medical Branch institutional review board, women between the ages of 18 and 35 years were invited to participate in a survey on their knowledge about reproductive health. The sample included 165 women ages 18 to 35 years (M 5 24.1, SD 5 3.9). The median annual income was $15,000-$25,000 for European American women and English-speaking Latina women, and $10,000$15,000 for African American and Spanish-speaking Latina
Procedure
All study procedures were described in detail in the participant's language of choice (Spanish or English). After obtaining written consent, the participants filled out a selfadministered survey in the clinics as they waited to be called for their appointments. A research assistant sat near the participant throughout survey completion to clarify questions, read the survey aloud, or record the women's responses, if they so requested. All participants were offered a small gift upon completion of the survey(s), such as a small bottle of lotion or shampoo. Measures Demographics
The women responded to survey questions about their ethnicity, education level, household income, country of origin, and years living in the U.S. Household income was reported by checking predetermined income range categories ranked from 1 ($0-$10,000) to 8 ($80,000-$100,000). Education level was reported by checking categories from 1 (less than 7th grade) to 5 (graduate degree). Tampon Use and Sources of Information
The survey included questions about whether women had used tampons in their adolescent years and who had explained tampon use to them. The women were asked to indicate whether they received explanations from (1) no one; (2) their mothers; (3) female relatives; (4) “others.” Women who checked “others” were asked to specify whom.
Tampon Use Barriers
The women were given a list of 4 statements and asked to indicate which, if any, were barriers to tampon use in their adolescent years. The items were: (1) I did not know
330
L.F. Romo, A.B. Berenson / J Pediatr Adolesc Gynecol 25 (2012) 328e333
how to use them; (2) Only pads were available at my home; (3) My mother did not approve of tampon use; (4) I felt awkward touching my body. Composite scores of tampon barriers were computed by summing up the number of checked items. Results Participant Characteristics
Two 1-way ANOVAs were conducted to examine differences in income and education levels across ethnic groups. There were significant differences in household income, F(3,135) 5 3.56, P ! .05, and education level, F(3,163) 5 13.76, P ! .001. Post hoc tests revealed that European American women (M 5 4.1, SD 5 2.1) had higher income levels than African American women (M 5 2.7, SD 5 1.8), but there were no differences among African American, Englishspeaking Latina (M 5 3.6, SD 5 2.0), and Spanish-speaking Latina women (M 5 3.2, SD 5 1.4). Spanish-speaking Latina women (M 5 2.2, SD 5 1.1) had lower levels of education compared to European American (M 5 3.7, SD 5 1.2), African American (M 5 3.3, SD 5 .9), and Englishspeaking Latina women (M 5 3.0, SD 5 1.0). In addition, English-speaking Latina women had lower levels of education compared to European American women. Ethnic Group Difference in Tampon Use
A chi-square analysis was conducted to examine whether the proportion of women who used tampons in their adolescent years differed across ethnic groups. The chisquare test was significant, indicating a significant relationship, c2 (3, N 5 165) 5 38.81, P ! .001. Paired comparisons in proportions between ethnic/language groups (Fisher exact tests, P ! .05) revealed significant differences. European American women (71%) were significantly more likely to use tampons in their adolescent years compared to African American (29%), English-speaking Latina (22%), and Spanishspeaking Latina women (5%). Among ethnic minorities, Spanish-speaking women were significantly less likely to use tampons compared to African American women and Englishspeaking Latina women. Ethnic/language Group Differences in Sources of Explanations about Tampons
A 4 3 chi-square was computed across the 4 sources of explanations about tampon use and the 4 ethnic/language groups. The chi-square test was significant. Results are presented in Table 1. The majority of English-speaking and Spanish-speaking Latina women reported that no one had explained tampon use to them compared to almost half of the European American women and African American women. About one-third of European American women cited their mothers as sources of information about tampon use compared to less than 10% of African American, Englishspeaking, and Spanish-speaking Latina women. The most common source of explanation of tampon use for African American women fell in the ‘other’ category, for example, school health education classes.
Table 1 Percentages of Women Reporting Various Sources of Explanations about Tampon Use in Adolescence by Ethnic Group “Who explained tampon use to you in your adolescent years?”
European American (%, n 5 31)
African American (n 5 48)
EnglishSpeaking Latina (%, n 5 46)
SpanishSpeaking Latina (%, n 5 40)
No one Mother Female relatives Other source (e.g., school health classes)
46.9 37.5 12.5 3.1
45.8 16.7 16.7 20.8
76.1 8.7 6.5 6.5
67.5 10 15 7.5
Ethnic/language Group Differences in Tampon Concerns in Adolescent Years
A series of chi-square analyses were conducted to examine whether the proportion of women who reported various tampon concerns in adolescence differed across ethnic groups. The top of Table 2 displays the percentages of each ethnic/language group for each item. Statistically significant ethnic/language group differences existed with regard to whether women were worried in adolescence that tampons were unsafe, c2 (3, N 5 167) 5 17.29, P ! .001, had been afraid a tampon would get lost or stuck in the vagina, c2 (3, N 5 167) 5 8.15, P ! .05, and whether they believed in adolescence that tampons were inappropriate for virgins, c2 (3, N 5 167) 5 11.11, P ! .01. Paired comparisons in proportions between ethnic/language groups (Fisher exact tests P ! .05) revealed significant differences. With respect to concerns that tampons were unsafe, a statistically higher percentage of African American, English-speaking and Spanish-speaking Latina women reported that they were concerned about this in adolescence compared to European American women. English-speaking Latina women were also more likely to report that they had held this concern compared to AfricanAmerican women. In addition, compared to European American women, a significantly higher percentage of African American, English-speaking and Spanish-speaking Latina women perceived in adolescence that tampons were inappropriate for virgins. English-speaking and Spanish-speaking women were more likely to report that they had been concerned in adolescence that tampons would get lost or stuck. There were no significant differences between English-speaking and Spanish-speaking Latinas in concerns about tampon use in adolescence. Ethnic/language Group Differences in Barriers to Tampon Use
The bottom of Table 2 displays the percentages of each ethnic/language group for each reported barrier to tampon use. Statistically significant ethnic/language group differences existed with regard to whether women knew how to use tampons in adolescence, c2 (3, N 5 167) 5 11.37, P ! .01, whether only pads were available in their homes, c2 (3, N 5 167) 5 17.00, P ! .01, and whether they had felt awkward touching their bodies, c2 (3, N 5 167) 5 8.15, P ! .05. Paired comparisons in proportions between ethnic/language groups (Fisher exact tests P ! .05) revealed that Englishspeaking and Spanish-speaking Latina women were more likely to report that they did not know how to use tampons
L.F. Romo, A.B. Berenson / J Pediatr Adolesc Gynecol 25 (2012) 328e333
331
Table 2 Percentages of Women Reporting Various Concerns and Barriers by Ethnic Group European American (EA) (%, n 5 31) Used Tampons in Adolescent Years
Tampon Concerns I was worried that they were unsafe I was afraid it would get lost or stuck in my vagina I was afraid it would hurt I thought they were inappropriate for virgins Barriers to Tampon use I did not know how to use them Only pads were available at my home My mother did not approve of tampon use I felt awkward touching my body
African American (AA) (%, n 5 48)
English-Speaking Latina (EL) (%, n 5 46)
Spanish-Speaking Latina (SL) (%, n 5 40)
Group differences (Fisher Exact tests, P ! .05)
29.2
21.7
5
EAOAA, EL, SL AAOSL ELOSL
3.1
20.4
43.5
25
9.4 15.6 0
16.3 26.5 14.3
32.6 37 26.1
30 25 25
EA!AA, EL, SL AA!EL EA!EL, SL
12.5 6.3
28.6 22.4
45.7 37
42.5 47.5
0 9.4
18.4 4.1
7.4 13
12.5 25
71
in adolescence compared to European American women. Similarly, English-speaking and Spanish-speaking Latina women were more likely to report that only pads were available in their homes, and this difference was also significant for African American and Spanish-speaking Latina women, with more Spanish-speaking Latina women reporting this barrier. A higher percentage of African American and English-speaking Latina women reported that their mothers did not approve of tampon use in adolescence than European American women. More Spanish-speaking women reported that they had felt awkward touching their bodies in adolescence compared to African American women. There were no significant differences between English-speaking and Spanish-speaking Latinas for any of the barriers to tampon use. Ethnic Group Differences in the Number of Concerns and Barriers
A 1-way MANCOVA was conducted to examine group differences on the number of tampon concerns and barriers. Income and education levels were included as covariates given ethnic group differences. The MANCOVA revealed significant differences across ethnic groups, Wilks L 5 .99, F (2, 132) 5 4.63, P ! .001, h2 5 .02. Follow-up ANOVAs revealed that English-speaking Latina women (M 5 1.4, SD 5 1.4) had a higher number of concerns about tampons than European American women (M 5 .7, SD 5 .7), F (3,163) 5 5.56, P ! .001. The number of concerns reported by African American women (M 5 .8, SD 5 1.2) were not significantly different from the other ethnic groups. Both English-speaking Latina (M 5 1.1 5 SD 5 1.0) and Spanish-speaking Latina women (M 5 1.3, SD 5 1.1) reported more barriers to tampon use compared to European American women (M 5 .3, SD 5 .63), F(3,163) 5 7.88, P ! .001. The number of barriers reported by African American women (M 5 .7, SD 5 .9) did not differ significantly from the other ethnic groups. Discussion
A considerable number of European American women reported using tampons in their adolescent years compared
EA!AA, EL, SL EA!EL, SL EA!EL, SL AA!SL EA!AA, EL AA!SL
to significantly smaller proportions of African American women and Latina women, consistent with 1 other study conducted with ethnic minority adolescents in the U.S.6 Tampon usage was the lowest for Spanish-speaking Latina womendless than 5%. The high prevalence of tampon usage among European American women may be attributed to increased maternal support. About one-third of the European American women reported that their mothers had explained tampon use to them, a similar finding obtained from Brooks-Gunn and Ruble5 with senior high school adolescents. In contrast, less than 17% of African American and 10% of English-speaking and Spanishspeaking Latina women reported that their mothers had explained tampon use. Additional evidence for the lack of maternal support for tampon use in adolescence comes from our finding that African American and Englishspeaking Latina women were more likely to report that their mothers did not approve of tampon use compared to European American women. Tampon use may also be related to their mothers' personal use of menstrual products. English-speaking Latinas and Spanish-speaking Latinas were more likely than European American women to report that only pads were available at home. Together, these findings contribute to the notion that maternal support is a key determinant of tampon use in adolescence11 and may help explain why ethnic minority adolescents do not use tampons. A major reason why the majority of English-speaking and Spanish-speaking Latina women did not use tampons in adolescence is also related to the fact that no one had explained tampon use to them. A lack of information about tampon use may have increased their concerns. Compared to European American women, Latina women were more likely to report that in adolescence they believed that tampons were unsafe and inappropriate for virgins and that they had had fears that tampons could get lost or stuck. Not surprisingly then, a statistically higher percentage of both English-speaking and Spanish-speaking women reported that they lacked knowledge in adolescence on how to use them. Interestingly, there were no differences between English-speaking and Spanish-speaking Latina women in
332
L.F. Romo, A.B. Berenson / J Pediatr Adolesc Gynecol 25 (2012) 328e333
the number and types of concerns, suggesting that they may be exposed to similar kinds of input about tampons in their environment despite the fact that the majority of English-speaking women grew up in the U.S. and the majority of the Spanish-speaking women were foreignborn. One reason perhaps is that two-thirds of the mothers of the English-speaking women were foreign-born and these mothers may have socialized their daughters about menstruation in ways that are consistent with girls being raised in their native country. With the exception of maternal approval of tampon use, there were no differences in the number and types of barriers reported by African American women compared to European American women, and the overall number of concerns was generally low for both groups. Yet, some African American women shared Latina women's concerns that tampons were unsafe and inappropriate for virgins and the proportion of African American women who used tampons in adolescence was considerably lower compared to European American women. A significant proportion of African American adolescents reported that they had turned to other sources of information for explanations about tampon use, such as school-based education, but it is unclear whether the explanations adequately addressed their concerns. Although adolescents may hear about tampons in health classes, the extent to which the mechanics of tampon use are sufficiently explained is not certain. It is also unclear whether instructions on packaged materials are developmentally appropriate to promote knowledge of tampons, an interesting area for future research. Because many of the women did not specify who their source of tampon use information was, and we unfortunately did not probe specifically for friends, it cannot ruled out that friends are a major source for African American women as has been found in the literature with other ethnic groups.12,13 One-fourth of Spanish-speaking Latina women reported that they felt awkward touching their bodies compared to only roughly 4% African Americans, and less than 13% of European American women and English-speaking women. For some European American adolescents, inserting a tampon was the first time they ever manually or visually explored the body,12 a process that Latina adolescents from traditional cultural backgrounds may not be comfortable with, especially if they believe it interferes with virginal innocence. In addition, communication about tampon use may be embarrassing for adolescents because it requires discussion about an object that penetrates into a women's body,12 leading adolescents to experience shame in using them. Research suggests that Latina mothers have a difficulty communicating about sexuality with their daughters due to embarrassment17,18 and this may extend to the mechanics of tampon use. Limitations
Women's reports of concerns about tampon use were retrospective, raising the possibility that the participants' recollections of their experiences were not entirely accurate. Also, because the women are reporting these experiences
about 10 years ago on average, caution should also be taken to generalize these findings to the current time period especially given that adolescents can access health information more readily on the internet. It is possible that the current adolescent population is different than the one surveyed. In addition, the questions did not adequately probe for input about tampons from peers. Moreover, the generalizability of these findings to all women from European American, Latina, and African American backgrounds is limited because this study focused on a sample of lowincome women. It is possible that a different pattern of results would have been obtained with a sample of women from higher income and educational backgrounds. Implications and Contribution
Findings from this study have implications for the health education needs of low-income ethnic minority adolescents. School-based education which provides information to adolescents about menstruation and menstrual products should include mothers in the education of their daughters to address the mothers' concerns about tampon use and ensure that they have the knowledge to communicate about it with their daughters. Mothers would also benefit from recommendations on how to communicate with their daughters about this topic in ways that reduce feelings of embarrassment and discomfort. In addition, health care professionals should be aware that many ethnic minority adolescents may be coming from environments where even pads are minimally discussed.8 Physician input about tampon use is not standard practice11 and discussing tampon use has the potential of correcting adolescents' misperceptions and relieving their concerns, especially for ethnic minority adolescents. Acknowledgments
We thank Helen Wu for her help in facilitating data collection for this project. References 1. Anson O: Exploring the bio-psychoesocial approach to premenstrual experiences. Soc Sci Med 1999; 49:67 2. Hoerster KD, Chrisler JC, Rose JG: Attitudes toward and experience with menstruation in the US and India. Women Health 2003; 38:77 s-Iniestra S, et al: Development of 3. Marv an ML, Ramırez-Esparza D, Corte a new scale to measure Beliefs about and Attitudes Toward Menstruation (BATM): Data from Mexico and the United States. Health Care Women Int 2006; 27:453 4. Uskul AK: Women's menarche stories from a multicultural sample. Soc Sci Med 2004; 59:667 5. Brooks-Gunn J, Ruble DN: Psychological correlates of tampon use in adolescents. Ann Intern Med 1982; 96(6 Pt 2):962 6. Finkelstein JW, von Eye A: Sanitary product use by white, black, and Mexican American women. Public Health Rep 1990; 105:491 7. Beausang CC, Razor A: Young western women's experiences of menarche and menstruation. Health Care Women Int 2000; 21:517 8. Costos D, Ackerman R, Paradis L: Recollections of menarche: communication between mothers and daughters regarding menstruation. Sex Roles 2002; 46:49 9. Koff E, Rierdan J: Early adolescent girls' understanding of menstruation. Women Health 1995; 22:1 10. Moore SM: Girls' Understanding and social construction of menarche. J Adolesc 1995; 18:87 11. Omar HA, Aggarwal S, Perkins KC: Tampon use in young women. J Pediatr Adolesc Gynecol 1998; 11:143 12. Whisnant L, Brett E, Zegans L: Adolescent girls and menstruation. Adolesc Psychiatry 1979; 7:157
L.F. Romo, A.B. Berenson / J Pediatr Adolesc Gynecol 25 (2012) 328e333 13. Abraham S, Knight C, Mira M, et al: Menstrual projection: young women's knowledge, practice, and attitudes. J Psychosom Obstet Gynecol 1985; 23:229 14. Whisnant L, Zegans L: A study of attitudes toward menarche in white middle-class American adolescent girls. Am J Psychiatry 1975; 132:809 15. Orringer K, Gahagan S: Adolescent girls define menstruation: a multiethnic exploratory study. Health Care Women Int 2010; 31:831
333
16. Berg DH, Coutts LB: Virginity and tampons: the beginner myth as a case of alteration. Health Care Women Int 1993; 14:27 17. Guilamo-Ramos V, Jaccard J, Dittus P, et al: Parent-adolescent communication about sexual intercourse: an analysis of maternal reluctance to communicate. Health Psychol 2008; 27:760 18. Wilson EK, Dalberth BT, Koo HP, et al: Parents' perspectives on talking to preteenage children about sex. Perspect Sex Reprod Health 2010; 42:56
Gevirtz Graduate School of Education, University of California, Santa Barbara, CA Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
a b s t r a c t Purpose: Tampon use is common among European American adolescents, but much less so among African American and Latina adolescents. Reasons are largely unclear. The general goal of this study was to examine differences among European American, African American and English-speaking Latina women and Spanish-speaking women in tampon use, sources of information about tampon use, and concerns and barriers related to tampon use in their adolescent years. Method: The sample included 165 low-income women ages 18 to 35 years (M 5 24.1) who filled out a survey in a family planning clinic. Results: European American women (71%) were significantly more likely to use tampons in adolescence compared to a considerably smaller proportion of African American (29%), English-speaking Latina (22%), and Spanish-speaking Latina women (5%). Mothers were a primary source of explanations about tampons for European American women, but not for ethnic minority women. African American and Latina English-speaking women were more likely to report that their mothers did not approve of tampons compared to none of the European American women. Specific concerns about tampons for Latina and African American women were that they were unsafe and inappropriate for virgins, and also for Latina women, that they could get lost or stuck. Overall, Latina women reported more concerns and barriers to tampon use than European American women which included a lack of knowledge on how to use them. Findings have implications for addressing the health education needs of low-income ethnic minority adolescents to reduce misconceptions and relieve concerns about tampons. Key Words: Tampon use, Menstruation, Latina adolescents, African adolescents
Introduction
Menarche, the onset of the first menses, is a significant milestone in an adolescent's life. While the significance of menstruation as a research topic has attracted interest in previous years, there is scant research on adolescents' beliefs and attitudes toward tampon use, especially among ethnic minorities in the United States. This question is important because research shows that the use of tampons is associated with many misconceptions which indicate a need for accurate information for adolescents. A better understanding of adolescents' beliefs about tampon use can inform the design of school health education programs and improve communication between health professionals and adolescents about menstruation, anatomy, and female hygiene. The general goal of this study was to examine differences among European American, African American, and Latina women in tampon use, sources of information about tampon use, and concerns and barriers related to tampon use in their adolescent years. Different cultures view menstruation differently,1e4 which may affect how adolescents are socialized about menstruation and tampons. Tampon use seems to be common among European American adolescents with The authors indicate no conflicts of interest. * Address correspondence to: Laura F. Romo, PhD, Gevirtz Graduate School of Education, University of California, Santa Barbara, Santa Barbara, CA 93106-9490; Tel. 805-893-3081 E-mail address: [email protected] (L.F. Romo).
rates as high as 75% for high school girls.5,6 However, tampon use may vary by ethnicity. Finkelstein and Von Eye found that African American and Mexican Americans high school adolescents are more likely than European American adolescents to use pads alone.6 Reasons for the lower rate of tampon use among ethnic minority adolescents remain unclear. Mothers are the most typical sources of information about menstruation,7e10 but findings are mixed on the extent to which mothers provide information to their daughters about tampons. In 1 study, about 70% of early adolescent European American girls reported that they had learned about tampons from their mothers, although older adolescents also cited package directions and other relatives such as sisters.5 Similarly, in another study, European American women also report that their mothers were influential in making the decision to use tampons.11 In contrast, in an earlier study conducted with European American adolescents, friends and commercial pamphlets were reported to be the most common source,12 with less than 20% of the adolescents perceiving that their mothers approved of tampon use. These findings are consistent with a study conducted with Australian youth which found that friends and pamphlets were the most common source of information about tampons, because their mothers either did not know how to use tampons themselves, were too embarrassed to talk about it, or did not approve of their daughters using tampons.13 No research has been conducted with African American and Latina women with
1083-3188/$ - see front matter Ó 2012 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2012.06.001
L.F. Romo, A.B. Berenson / J Pediatr Adolesc Gynecol 25 (2012) 328e333
329
respect to sources of information about tampon use and maternal approval in adolescence. Research suggests that many adolescents have limited knowledge about menstruation9,14 and ethnic minority adolescents have less menstrual knowledge than European American adolescents.15 A limited understanding of menstruation and anatomy may contribute to adolescents' concerns about tampons. A common misconception about tampons for many adolescents including their mothers is that they are inappropriate for virgins.8,16 African American and Mexican American women report that 1 reason they did not use tampons in adolescence was because they were afraid.6 Australian adolescents perceive pads to be more safe for young girls13 and European American adolescents report concerns that tampons can get stuck and damage the vagina.12 In 1995, Moore found among a sample of early adolescent Australian girls that 60% were uncertain that young menstruating adolescents could use tampons because their vaginas were too small.10 In the study conducted by Abraham et al in 1985, adolescents reported that 1 reason for not using tampons was because they did not know where the opening of the vagina was.13 In addition, the researchers found that many adolescents reported that they did not use tampons at all because they did not want to touch themselves and the idea of inserting something into one's body was unpleasant.13 Almost nothing is known about beliefs about tampon use among African American and Latina adolescents that may contribute to their concerns about using them. In the present study, European American women, African American, and Latina women were asked to report whether they had used tampons in adolescence, who explained tampon use to them, and what were their concerns and barriers related to tampon use. English-speaking Latina women were examined separately from Spanish-speaking Latina women who were mostly foreign-born. Health belief models highlight that health knowledge is influenced by factors such as culture, acculturation, and exposure to relevant information. Spanish-speaking adolescents who had little or no exposure to U.S. culture may have had different views about menstruation in adolescence compared to acculturated English-speaking adolescents raised in the United States.
women. Roughly, 28% of European American women, 35% of African American women, and 41% of English-speaking Latina women had a high school degree, and 56%, 43%, and 28% had attended college or had a college degree, respectively. About 73% of the Spanish-speaking Latina women had less than a high school education. All of the European American women and African American women and 65% of the English-speaking Latina women had lived in the U.S. their entire lives. About 90% of the Spanishspeaking women had lived in the U.S. for less than 10 years.
Method
Tampon Use Concerns
Participants
The women were given a list of 4 statements and asked to indicate which, if any, were concerns they had about tampon use in their adolescent years. The items were: (1) I was worried that tampons were unsafe; (2) I was afraid it would get lost or stuck in my vagina; (3) I was afraid it would hurt; (4) I thought tampons were inappropriate for virgins. Composite scores of tampon concerns were computed by summing up the number of checked items.
The study was conducted at 3 university reproductive health clinics in Southeast Texas, which offer prenatal and family-planning services to mostly women from lowincome backgrounds. After obtaining approval from the University of Texas Medical Branch institutional review board, women between the ages of 18 and 35 years were invited to participate in a survey on their knowledge about reproductive health. The sample included 165 women ages 18 to 35 years (M 5 24.1, SD 5 3.9). The median annual income was $15,000-$25,000 for European American women and English-speaking Latina women, and $10,000$15,000 for African American and Spanish-speaking Latina
Procedure
All study procedures were described in detail in the participant's language of choice (Spanish or English). After obtaining written consent, the participants filled out a selfadministered survey in the clinics as they waited to be called for their appointments. A research assistant sat near the participant throughout survey completion to clarify questions, read the survey aloud, or record the women's responses, if they so requested. All participants were offered a small gift upon completion of the survey(s), such as a small bottle of lotion or shampoo. Measures Demographics
The women responded to survey questions about their ethnicity, education level, household income, country of origin, and years living in the U.S. Household income was reported by checking predetermined income range categories ranked from 1 ($0-$10,000) to 8 ($80,000-$100,000). Education level was reported by checking categories from 1 (less than 7th grade) to 5 (graduate degree). Tampon Use and Sources of Information
The survey included questions about whether women had used tampons in their adolescent years and who had explained tampon use to them. The women were asked to indicate whether they received explanations from (1) no one; (2) their mothers; (3) female relatives; (4) “others.” Women who checked “others” were asked to specify whom.
Tampon Use Barriers
The women were given a list of 4 statements and asked to indicate which, if any, were barriers to tampon use in their adolescent years. The items were: (1) I did not know
330
L.F. Romo, A.B. Berenson / J Pediatr Adolesc Gynecol 25 (2012) 328e333
how to use them; (2) Only pads were available at my home; (3) My mother did not approve of tampon use; (4) I felt awkward touching my body. Composite scores of tampon barriers were computed by summing up the number of checked items. Results Participant Characteristics
Two 1-way ANOVAs were conducted to examine differences in income and education levels across ethnic groups. There were significant differences in household income, F(3,135) 5 3.56, P ! .05, and education level, F(3,163) 5 13.76, P ! .001. Post hoc tests revealed that European American women (M 5 4.1, SD 5 2.1) had higher income levels than African American women (M 5 2.7, SD 5 1.8), but there were no differences among African American, Englishspeaking Latina (M 5 3.6, SD 5 2.0), and Spanish-speaking Latina women (M 5 3.2, SD 5 1.4). Spanish-speaking Latina women (M 5 2.2, SD 5 1.1) had lower levels of education compared to European American (M 5 3.7, SD 5 1.2), African American (M 5 3.3, SD 5 .9), and Englishspeaking Latina women (M 5 3.0, SD 5 1.0). In addition, English-speaking Latina women had lower levels of education compared to European American women. Ethnic Group Difference in Tampon Use
A chi-square analysis was conducted to examine whether the proportion of women who used tampons in their adolescent years differed across ethnic groups. The chisquare test was significant, indicating a significant relationship, c2 (3, N 5 165) 5 38.81, P ! .001. Paired comparisons in proportions between ethnic/language groups (Fisher exact tests, P ! .05) revealed significant differences. European American women (71%) were significantly more likely to use tampons in their adolescent years compared to African American (29%), English-speaking Latina (22%), and Spanishspeaking Latina women (5%). Among ethnic minorities, Spanish-speaking women were significantly less likely to use tampons compared to African American women and Englishspeaking Latina women. Ethnic/language Group Differences in Sources of Explanations about Tampons
A 4 3 chi-square was computed across the 4 sources of explanations about tampon use and the 4 ethnic/language groups. The chi-square test was significant. Results are presented in Table 1. The majority of English-speaking and Spanish-speaking Latina women reported that no one had explained tampon use to them compared to almost half of the European American women and African American women. About one-third of European American women cited their mothers as sources of information about tampon use compared to less than 10% of African American, Englishspeaking, and Spanish-speaking Latina women. The most common source of explanation of tampon use for African American women fell in the ‘other’ category, for example, school health education classes.
Table 1 Percentages of Women Reporting Various Sources of Explanations about Tampon Use in Adolescence by Ethnic Group “Who explained tampon use to you in your adolescent years?”
European American (%, n 5 31)
African American (n 5 48)
EnglishSpeaking Latina (%, n 5 46)
SpanishSpeaking Latina (%, n 5 40)
No one Mother Female relatives Other source (e.g., school health classes)
46.9 37.5 12.5 3.1
45.8 16.7 16.7 20.8
76.1 8.7 6.5 6.5
67.5 10 15 7.5
Ethnic/language Group Differences in Tampon Concerns in Adolescent Years
A series of chi-square analyses were conducted to examine whether the proportion of women who reported various tampon concerns in adolescence differed across ethnic groups. The top of Table 2 displays the percentages of each ethnic/language group for each item. Statistically significant ethnic/language group differences existed with regard to whether women were worried in adolescence that tampons were unsafe, c2 (3, N 5 167) 5 17.29, P ! .001, had been afraid a tampon would get lost or stuck in the vagina, c2 (3, N 5 167) 5 8.15, P ! .05, and whether they believed in adolescence that tampons were inappropriate for virgins, c2 (3, N 5 167) 5 11.11, P ! .01. Paired comparisons in proportions between ethnic/language groups (Fisher exact tests P ! .05) revealed significant differences. With respect to concerns that tampons were unsafe, a statistically higher percentage of African American, English-speaking and Spanish-speaking Latina women reported that they were concerned about this in adolescence compared to European American women. English-speaking Latina women were also more likely to report that they had held this concern compared to AfricanAmerican women. In addition, compared to European American women, a significantly higher percentage of African American, English-speaking and Spanish-speaking Latina women perceived in adolescence that tampons were inappropriate for virgins. English-speaking and Spanish-speaking women were more likely to report that they had been concerned in adolescence that tampons would get lost or stuck. There were no significant differences between English-speaking and Spanish-speaking Latinas in concerns about tampon use in adolescence. Ethnic/language Group Differences in Barriers to Tampon Use
The bottom of Table 2 displays the percentages of each ethnic/language group for each reported barrier to tampon use. Statistically significant ethnic/language group differences existed with regard to whether women knew how to use tampons in adolescence, c2 (3, N 5 167) 5 11.37, P ! .01, whether only pads were available in their homes, c2 (3, N 5 167) 5 17.00, P ! .01, and whether they had felt awkward touching their bodies, c2 (3, N 5 167) 5 8.15, P ! .05. Paired comparisons in proportions between ethnic/language groups (Fisher exact tests P ! .05) revealed that Englishspeaking and Spanish-speaking Latina women were more likely to report that they did not know how to use tampons
L.F. Romo, A.B. Berenson / J Pediatr Adolesc Gynecol 25 (2012) 328e333
331
Table 2 Percentages of Women Reporting Various Concerns and Barriers by Ethnic Group European American (EA) (%, n 5 31) Used Tampons in Adolescent Years
Tampon Concerns I was worried that they were unsafe I was afraid it would get lost or stuck in my vagina I was afraid it would hurt I thought they were inappropriate for virgins Barriers to Tampon use I did not know how to use them Only pads were available at my home My mother did not approve of tampon use I felt awkward touching my body
African American (AA) (%, n 5 48)
English-Speaking Latina (EL) (%, n 5 46)
Spanish-Speaking Latina (SL) (%, n 5 40)
Group differences (Fisher Exact tests, P ! .05)
29.2
21.7
5
EAOAA, EL, SL AAOSL ELOSL
3.1
20.4
43.5
25
9.4 15.6 0
16.3 26.5 14.3
32.6 37 26.1
30 25 25
EA!AA, EL, SL AA!EL EA!EL, SL
12.5 6.3
28.6 22.4
45.7 37
42.5 47.5
0 9.4
18.4 4.1
7.4 13
12.5 25
71
in adolescence compared to European American women. Similarly, English-speaking and Spanish-speaking Latina women were more likely to report that only pads were available in their homes, and this difference was also significant for African American and Spanish-speaking Latina women, with more Spanish-speaking Latina women reporting this barrier. A higher percentage of African American and English-speaking Latina women reported that their mothers did not approve of tampon use in adolescence than European American women. More Spanish-speaking women reported that they had felt awkward touching their bodies in adolescence compared to African American women. There were no significant differences between English-speaking and Spanish-speaking Latinas for any of the barriers to tampon use. Ethnic Group Differences in the Number of Concerns and Barriers
A 1-way MANCOVA was conducted to examine group differences on the number of tampon concerns and barriers. Income and education levels were included as covariates given ethnic group differences. The MANCOVA revealed significant differences across ethnic groups, Wilks L 5 .99, F (2, 132) 5 4.63, P ! .001, h2 5 .02. Follow-up ANOVAs revealed that English-speaking Latina women (M 5 1.4, SD 5 1.4) had a higher number of concerns about tampons than European American women (M 5 .7, SD 5 .7), F (3,163) 5 5.56, P ! .001. The number of concerns reported by African American women (M 5 .8, SD 5 1.2) were not significantly different from the other ethnic groups. Both English-speaking Latina (M 5 1.1 5 SD 5 1.0) and Spanish-speaking Latina women (M 5 1.3, SD 5 1.1) reported more barriers to tampon use compared to European American women (M 5 .3, SD 5 .63), F(3,163) 5 7.88, P ! .001. The number of barriers reported by African American women (M 5 .7, SD 5 .9) did not differ significantly from the other ethnic groups. Discussion
A considerable number of European American women reported using tampons in their adolescent years compared
EA!AA, EL, SL EA!EL, SL EA!EL, SL AA!SL EA!AA, EL AA!SL
to significantly smaller proportions of African American women and Latina women, consistent with 1 other study conducted with ethnic minority adolescents in the U.S.6 Tampon usage was the lowest for Spanish-speaking Latina womendless than 5%. The high prevalence of tampon usage among European American women may be attributed to increased maternal support. About one-third of the European American women reported that their mothers had explained tampon use to them, a similar finding obtained from Brooks-Gunn and Ruble5 with senior high school adolescents. In contrast, less than 17% of African American and 10% of English-speaking and Spanishspeaking Latina women reported that their mothers had explained tampon use. Additional evidence for the lack of maternal support for tampon use in adolescence comes from our finding that African American and Englishspeaking Latina women were more likely to report that their mothers did not approve of tampon use compared to European American women. Tampon use may also be related to their mothers' personal use of menstrual products. English-speaking Latinas and Spanish-speaking Latinas were more likely than European American women to report that only pads were available at home. Together, these findings contribute to the notion that maternal support is a key determinant of tampon use in adolescence11 and may help explain why ethnic minority adolescents do not use tampons. A major reason why the majority of English-speaking and Spanish-speaking Latina women did not use tampons in adolescence is also related to the fact that no one had explained tampon use to them. A lack of information about tampon use may have increased their concerns. Compared to European American women, Latina women were more likely to report that in adolescence they believed that tampons were unsafe and inappropriate for virgins and that they had had fears that tampons could get lost or stuck. Not surprisingly then, a statistically higher percentage of both English-speaking and Spanish-speaking women reported that they lacked knowledge in adolescence on how to use them. Interestingly, there were no differences between English-speaking and Spanish-speaking Latina women in
332
L.F. Romo, A.B. Berenson / J Pediatr Adolesc Gynecol 25 (2012) 328e333
the number and types of concerns, suggesting that they may be exposed to similar kinds of input about tampons in their environment despite the fact that the majority of English-speaking women grew up in the U.S. and the majority of the Spanish-speaking women were foreignborn. One reason perhaps is that two-thirds of the mothers of the English-speaking women were foreign-born and these mothers may have socialized their daughters about menstruation in ways that are consistent with girls being raised in their native country. With the exception of maternal approval of tampon use, there were no differences in the number and types of barriers reported by African American women compared to European American women, and the overall number of concerns was generally low for both groups. Yet, some African American women shared Latina women's concerns that tampons were unsafe and inappropriate for virgins and the proportion of African American women who used tampons in adolescence was considerably lower compared to European American women. A significant proportion of African American adolescents reported that they had turned to other sources of information for explanations about tampon use, such as school-based education, but it is unclear whether the explanations adequately addressed their concerns. Although adolescents may hear about tampons in health classes, the extent to which the mechanics of tampon use are sufficiently explained is not certain. It is also unclear whether instructions on packaged materials are developmentally appropriate to promote knowledge of tampons, an interesting area for future research. Because many of the women did not specify who their source of tampon use information was, and we unfortunately did not probe specifically for friends, it cannot ruled out that friends are a major source for African American women as has been found in the literature with other ethnic groups.12,13 One-fourth of Spanish-speaking Latina women reported that they felt awkward touching their bodies compared to only roughly 4% African Americans, and less than 13% of European American women and English-speaking women. For some European American adolescents, inserting a tampon was the first time they ever manually or visually explored the body,12 a process that Latina adolescents from traditional cultural backgrounds may not be comfortable with, especially if they believe it interferes with virginal innocence. In addition, communication about tampon use may be embarrassing for adolescents because it requires discussion about an object that penetrates into a women's body,12 leading adolescents to experience shame in using them. Research suggests that Latina mothers have a difficulty communicating about sexuality with their daughters due to embarrassment17,18 and this may extend to the mechanics of tampon use. Limitations
Women's reports of concerns about tampon use were retrospective, raising the possibility that the participants' recollections of their experiences were not entirely accurate. Also, because the women are reporting these experiences
about 10 years ago on average, caution should also be taken to generalize these findings to the current time period especially given that adolescents can access health information more readily on the internet. It is possible that the current adolescent population is different than the one surveyed. In addition, the questions did not adequately probe for input about tampons from peers. Moreover, the generalizability of these findings to all women from European American, Latina, and African American backgrounds is limited because this study focused on a sample of lowincome women. It is possible that a different pattern of results would have been obtained with a sample of women from higher income and educational backgrounds. Implications and Contribution
Findings from this study have implications for the health education needs of low-income ethnic minority adolescents. School-based education which provides information to adolescents about menstruation and menstrual products should include mothers in the education of their daughters to address the mothers' concerns about tampon use and ensure that they have the knowledge to communicate about it with their daughters. Mothers would also benefit from recommendations on how to communicate with their daughters about this topic in ways that reduce feelings of embarrassment and discomfort. In addition, health care professionals should be aware that many ethnic minority adolescents may be coming from environments where even pads are minimally discussed.8 Physician input about tampon use is not standard practice11 and discussing tampon use has the potential of correcting adolescents' misperceptions and relieving their concerns, especially for ethnic minority adolescents. Acknowledgments
We thank Helen Wu for her help in facilitating data collection for this project. References 1. Anson O: Exploring the bio-psychoesocial approach to premenstrual experiences. Soc Sci Med 1999; 49:67 2. Hoerster KD, Chrisler JC, Rose JG: Attitudes toward and experience with menstruation in the US and India. Women Health 2003; 38:77 s-Iniestra S, et al: Development of 3. Marv an ML, Ramırez-Esparza D, Corte a new scale to measure Beliefs about and Attitudes Toward Menstruation (BATM): Data from Mexico and the United States. Health Care Women Int 2006; 27:453 4. Uskul AK: Women's menarche stories from a multicultural sample. Soc Sci Med 2004; 59:667 5. Brooks-Gunn J, Ruble DN: Psychological correlates of tampon use in adolescents. Ann Intern Med 1982; 96(6 Pt 2):962 6. Finkelstein JW, von Eye A: Sanitary product use by white, black, and Mexican American women. Public Health Rep 1990; 105:491 7. Beausang CC, Razor A: Young western women's experiences of menarche and menstruation. Health Care Women Int 2000; 21:517 8. Costos D, Ackerman R, Paradis L: Recollections of menarche: communication between mothers and daughters regarding menstruation. Sex Roles 2002; 46:49 9. Koff E, Rierdan J: Early adolescent girls' understanding of menstruation. Women Health 1995; 22:1 10. Moore SM: Girls' Understanding and social construction of menarche. J Adolesc 1995; 18:87 11. Omar HA, Aggarwal S, Perkins KC: Tampon use in young women. J Pediatr Adolesc Gynecol 1998; 11:143 12. Whisnant L, Brett E, Zegans L: Adolescent girls and menstruation. Adolesc Psychiatry 1979; 7:157
L.F. Romo, A.B. Berenson / J Pediatr Adolesc Gynecol 25 (2012) 328e333 13. Abraham S, Knight C, Mira M, et al: Menstrual projection: young women's knowledge, practice, and attitudes. J Psychosom Obstet Gynecol 1985; 23:229 14. Whisnant L, Zegans L: A study of attitudes toward menarche in white middle-class American adolescent girls. Am J Psychiatry 1975; 132:809 15. Orringer K, Gahagan S: Adolescent girls define menstruation: a multiethnic exploratory study. Health Care Women Int 2010; 31:831
333
16. Berg DH, Coutts LB: Virginity and tampons: the beginner myth as a case of alteration. Health Care Women Int 1993; 14:27 17. Guilamo-Ramos V, Jaccard J, Dittus P, et al: Parent-adolescent communication about sexual intercourse: an analysis of maternal reluctance to communicate. Health Psychol 2008; 27:760 18. Wilson EK, Dalberth BT, Koo HP, et al: Parents' perspectives on talking to preteenage children about sex. Perspect Sex Reprod Health 2010; 42:56