A Pre-Experimental Study to Assess the Effectiveness of Planned Teaching Programme on Knowledge Regarding Menstrual Hygiene Among Adolescent Girls in Selected Schools of Mohali, Punjab

 

Ms. Kamaljit Kaur¹, Mrs. Vadivukkarassi P² , Ms. Kiran Bala³

¹Clinical Instructor, Gurseva College of Nursing, Panam, Garshankar, Hoshiarpur, Punjab.

²Associate Professor, Obstetrics and Gynecological Nursing, Shri Vinoba Bhave College of Nursing,

Silvassa, Dadra and Nagar Haveli

³Lecturer, Obstetrics and Gynecological Nursing, Mata Sahib Kaur College of Nursing, Mohali, Punjab.

 

ABSTRACT:

The onset of menstruation is one of the most important changes occurring among girls during the adolescent years but it is still regarded as something unclean or dirty in the Indian society. Unhygienic menstrual practices may affect their health such as increased vulnerability to reproductive tract infections and other complications. So, girls should be educated about menstrual hygiene through health education in schools. The aim of the study was to assess the effectiveness of planned teaching programme on knowledge regarding menstrual hygiene among adolescent girls. An evaluative approach was adopted. Total 60 adolescent girls were selected by using purposive sampling technique during the month of February, 2012 from selected schools of Mohali district, Punjab. A self-administered structured knowledge questionnaire was selected to assess the knowledge of the adolescent girls regarding menstrual hygiene. Collected data was analyzed by descriptive and inferential statistics. It was found that most of the subjects were having low (50%) and average (48.3%) level of knowledge during pre-test. But, after planned teaching programme session most of the subjects were having good (50%) and excellent (48.3%) level of knowledge in post-test. The effectiveness of planned teaching Programme was found highly significant (p = 0.000). It was also found that majority of study variables were not significantly associated with knowledge level of adolescent girls except educational status of mother, family income per month and teacher as a source of information. It is concluded that planned teaching programme was an effective method to improve knowledge of adolescent girls regarding menstrual hygiene. The knowledge of adolescent girls has significant association with the educational status of their mother because mother is the primary source of information.

 

 

 

INTRODUCTION:

The human life span can be split into a number of stages: infancy, childhood, adolescence, young adulthood, adulthood and old age.  Sharma¹ in his report “Identity of the adolescent girl” had stated that in the life cycle of a homosapien organism, adolescence is a period of transition from childhood to adulthood. It is characterized by rapid physical, biological and hormonal changes resulting in psychosocial, behavioural and sexual maturation. It is often described as a phase of life that begins in biology and ends in society. It means that physical and biological changes are universal and take place due to maturation but the psychosocial and behavioural manifestations are determined by the meaning given to these changes within a cultural system. The experience of adolescents during teen years would vary considerably according to the cultural and social values of the network of social identities they grow in. WHO² has defined adolescence both in terms of age (between 10 and 19 years) and in terms of a phase of life marked by special attributes. But different policies and programmes has defined the adolescent age group differently. For example, in the draft Youth Policy, adolescents have been defined as the age group between 13-19 years; under the ICDS programme adolescent girls are considered to be between 11-18 years; whereas in the Reproductive and Child Health Programme, adolescents are between 10-19 years of age. Internationally, the age group of 10-19 years is considered to be the age of adolescence. So, it is evident that in India, age limits of adolescents have been fixed differently under different programmes keeping in view the objectives of that policy or programme but keeping in view the characteristics of this age group, it would be most appropriate to consider adolescents as between 10-19 years of age.  Menstruation is a phenomenon unique to the females occurring during the adolescent years. It is part of the female reproductive cycle that starts when girls become sexually mature at the time of puberty. It heralds the onset of physiological maturity in girls and becomes the part of their lives until menopause. Menstruation is the cyclical shedding of the inner lining of the uterus, the endometrium, under the control of hormones of the hypothalamopituitary axis. During a menstrual period, a woman bleeds from her uterus via vagina. The onset of menstruation is one of the most important physiological changes occurring among girls during the adolescent years. Though it is a natural and normal physiological process for all healthy girls and women, yet has been clouded by taboos and socio-cultural restrictions. Menstrual hygiene and management is an issue that is insufficiently acknowledged and has not received adequate attention in the reproductive health. While the anatomy of the genital tract and physiology of menstruation are taught in schools, the practical management of menstruation has often been regarded as inappropriate for public discussion. Myths, superstitious beliefs, and cultural taboos substitute appropriate information in the growing child.³

 

Ten⁴ had stated in his article on menstrual hygiene that in spite of the fact that great progress has been made but still in many developing countries including India, up until now, poor menstrual hygiene has been an insufficiently acknowledged problem. In several areas there are cultural and religious taboos concerning blood, menstruating females as well as menstrual hygiene. Although there are differences by country, culture, ethnic group, social class or family, the oppression of women has its effect on issues concerning reproductive health and other issues related to the reproductive system and its functions and processes. Most striking is the restricted control, which many women and girls have over their own mobility and behaviour during menstruation, including the myths, misconceptions, superstitions and cultural or religious taboos concerning menstrual blood and menstrual hygiene. It is necessary to maintain healthy traditions, customs and healthy practices in the community and prevent harmful practices. Organization of education is essential as an agent of change after adequate training to bring about changes regarding social customs, traditions and health seeking behaviour etc.

 

SIGNIFICANCE OF THE STUDY:

Approximately 1/5^th of the world’s population is adolescent and from this more than 4/5^th is of developing countries. According to Census 2001 in India adolescents accounted for about 22.8%, of the total population that is about 239 million adolescents in age group of 10-19 years.³ Adolescence belongs to a vital age group not only because it is on the threshold between childhood and adulthood as adolescents are no longer children, but not yet adults. As they attempt to cross this threshold, they face various physiological, psychological and developmental changes.⁵

 

Adolescence in girls is a turbulent period, which includes stressful events like menarche, which is considered as a landmark of female puberty. 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 (initiation of menstruation). Percent of the body fat is also a factor in the onset of menarche. A minimal fatness of 17% of body weight is necessary for the onset of menarche. So it may start late in thin built adolescents which does not warrant any therapeutic intervention. Girls may start their menstruation as early as 9 years of age and as late as 16 years old with average age of approximately 12 years which is too early for them to experience these crucial changes as they would not have prepared physically as well as mentally for this. When they attain menarche they feel shy to disclose about this even to their mothers. So there are few chances to maintain hygiene during menstruation. Many studies revealed that even though many girls have knowledge regarding menstrual hygiene yet they fail to apply this practically. It is a common observation that adolescents do not access the existing services, especially girls because they constitute a vulnerable group, particularly in India where female child is neglected one. Menstruation is still regarded as something unclean or dirty in Indian society. The reaction to menstruation depends upon awareness and knowledge about 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. Although menstruation is a natural process, it is linked with several misconceptions and practices, which sometimes result into adverse health outcomes. Some varieties of menstrual dysfunctions occur in about half of the adolescent girls.^{3- 5}

 

The report of a comparative study carried out by Water Aid Nepal regarding menstrual hygiene and management among 204 adolescent school girls (12-20 years) from both urban and rural setting concluded that among adolescent girls both in urban and rural areas, both knowledge regarding menstruation and its perceptions were poor and their practices were also not optimal for proper hygiene. Often ignored issues of privacy affected the hygienic practices and daily life of the adolescent girls particularly school attendance. Their knowledge about availability and affordability of sanitary products to manage menstruation was not satisfactory. It was recommended that schools, home, society and organizations of reproductive health as well as water sanitation and hygiene sectors need to make an effort towards making menstrual hygiene and management better for adolescent population.⁵

 

Stubbs  overviewed and reviewed the details of many research studies to know about cultural perceptions and practices about menarche and menstruation in the United States. The research suggested that girls were not very knowledgeable about menstruation, and their menstrual education provide them mixed messages, such as: menstruation is a normal, natural event, but it should be hidden. These kind of folk messages prevented girls from asking anything and promoting negative attitude towards menstruation. The study suggested clearance of their folk doubts and imparting healthy practices with education in girls.⁶

 

Simes and Berg conducted a study to examine the messages conveyed in menstrual management product advertisements with specific concern given to information that could be learned about menstruation by menarcheal girls in Canada. Over 200 advertisements from popular women's magazines were analyzed using constant comparative analysis. The findings revealed that the advertisements highlighted negative societal views of menstruation and heighten insecurities among girls which led to maintain the silence and shame regarding menstruation in the society and kept the girls away from getting right information.⁷

 

Garg et al reported that in India, menstruation is surrounded by myths and misconceptions with a long list of “do’s” and “don’ts” for women. Poor menstrual hygiene was one of the major reasons for the high prevalence of reproductive tract infections in the country and contributed significantly to female morbidity. Adolescents constitute 1/5^th of India’s population and yet their sexual health needs remained largely unaddressed in the national welfare programs. Poor menstrual hygiene in developing countries has been an insufficiently acknowledged problem.⁸

 

Khan reported on ‘Menstrual Hygiene Management’ in Pakistan stated that negligence in menstrual hygiene can result in biological disorders like reproductive tract infections but unfortunately awareness concerning this area of life is not highlighted due to socio- cultural trends of our society. In present age menstrual hygiene needs more attention because of rapidly increasing active participation of females in different walks of life. It has become necessary to analyze their relevant problems and prepare different strategies for solution. These solutions should be in accordance with social norms and traditions. It suggests that promotion of menstrual hygiene will be an indirect support to gender equality, nation development, high literacy rate and Millennium Development Goals accomplishment.⁹

 

Hoerster et al revealed the attitudes toward menstruation and its experience in a comparative study in USA. The study was conducted on 61 US and 67 Indian female students by Menstrual Attitude Questionnaire (Indian version), the Menstrual Distress Questionnaire, and a test of knowledge about the menstrual cycle. American women scored significantly higher than Indian women on the knowledge test and they also reported that they had better preparation for menarche than Indian women did. Hence, a need to impart the knowledge regarding menstruation among Indian female students was identified.¹⁰

 

The researcher felt the need after taking views of school girls on menstruation and menstrual hygiene while doing school visit programme during her post basic bachelor degree and also from the review of literature that there is need to develop and administer a planned teaching programme on menstrual hygiene and evaluate its effectiveness in school going adolescent girls. A great need is perceived from the previous studies conducted in India and other parts of the world about teaching this topic in the schools and communities for adolescent girls with enough teaching material which would enable them to acquire knowledge, healthful practices and a positive attitude towards menstruation and menstrual hygiene. Moreover the reports of many personnel of health and family welfare department have also emphasized on providing health education to adolescent girls regarding menstrual hygiene for the improvement of reproductive health and reducing complications in females which will indirectly support to gender equality, women empowerment and reducing maternal mortality for Millennium Development Goals accomplishment.

 

OBJECTIVES OF THE STUDY:

1.      To assess the pre-test level of knowledge regarding menstrual hygiene among adolescent girls.

2.      To administer a planned teaching programme on knowledge regarding menstrual hygiene among adolescent girls.

3.      To assess the post-test level of knowledge regarding menstrual hygiene among adolescent girls.

4.      To evaluate the effectiveness of planned teaching programme on knowledge regarding menstrual hygiene among adolescent girls.

5.      To associate the pre-test and post-test level of knowledge of adolescent girls on menstrual hygiene with selected socio demographic variables.

 

Hypotheses:

H₁: The post-test level of knowledge of adolescent girls regarding menstrual hygiene will be significantly higher than the pre-test level of knowledge

 

H₂: There will be a significant association between pre-test levels of knowledge of adolescent girls regarding menstrual hygiene with selected socio-demographic variables.

H₃: There will be a significant association between post-test levels of knowledge of adolescent girls regarding menstrual hygiene with selected socio demographic variables.

 

METHODOLOGY:

Research approach:

A quantitative evaluative research approach was adopted to assess the effectiveness of planned teaching programme on knowledge regarding menstrual hygiene among adolescent girls.

 

Research design:

One group pre-test post-test research design, which belongs to pre-experimental design, was selected to assess the knowledge of the adolescent girls regarding menstrual hygiene.

 

Research setting:

The study was conducted in Golden Bells Public Senior Secondary School, Sector-77, Mohali and Pathfinder Public High School, Sector-69, Mohali.

 

Target population:

The target population of present study was adolescent girls in the age group of 10-19 years studying in selected schools of Mohali, Punjab.

 

Sample size and Sampling technique:

In the present study the 60 adolescent girls in age group of 10-19 years studying in selected schools in Mohali, Punjab, were selected as subjects by using purposive sampling technique.

 

Ethical consideration:

Prior to data collection, the researcher had taken permission from ethical committee of Mata Sahib Kaur College of Nursing, Mohali. Written approval was taken from the Principals of selected schools of Mohali, Punjab for the conduction of study in their schools. The written permission was taken from the participants of the study and they were ensured that confidentiality will be maintained under all circumstances.

 

Description of tool:

The tool consisted of two sections:

 

Section - 1:

Socio demographic data consisted of 9 items which included age in years, class, ordinal position in the family children, religion, type of family, educational status of mother, income of the family per month in rupees, age at menarche in years and source of information regarding menstrual hygiene.

 

Section – 2:

A self-administered structured knowledge questionnaire was prepared consisting of 34 items of knowledge questionnaire regarding menstrual hygiene. The each item was given, one score for correct answer and zero score for wrong answer.

Description of planned teaching programme:

The planned teaching programme was titled “Teaching on Menstrual Hygiene”. The planned teaching programme was prepared to enhance the knowledge of adolescent girls regarding menstrual hygiene. It consisted of Anatomy, Menstruation, Menstrual hygiene, Materials to manage menstruation, Changing of napkins and cloth pads, Disposal, Complications due to poor menstrual hygiene and Management as content areas.

 

Data collection:

The data collection was carried out from 6^th to 14^th February, 2012 after taking written approval from Principals of selected schools. From 6^th February to 13^th February, 2012 data was collected from Golden Bells Public Senior Secondary School, Sector-77, Mohali. From 7^th February to 14^th February, 2012 data was collected from Pathfinder Public High School, Sector-69, Mohali. The procedure adopted for data collection was same in both the schools. On day one, the purpose of study was explained to the subjects and an informed verbal consent was taken before starting data collection for the study. A pre-test was conducted by administering self-administered structured knowledge questionnaire to the selected 60 adolescent girls. On the same day the planned teaching programme was administered to the subjects. The post-test was conducted by using the same self-administered structured knowledge questionnaire after seven days of the administration of planned teaching programme. The average time taken by the subjects to complete the questionnaire was 20 minutes, the average time taken by the researcher to administer planned teaching programme was 30 minutes for and the average time taken for discussion was 10 minutes.

 

Data analysis:

Data was analyzed by using descriptive and inferential statistics. The frequency distribution of adolescent girls according to their socio-demographic variables was computed by frequency and mean percentage. Effectiveness of planned teaching programme and association between the findings of pre-test and post-test with selected socio demographic variables was  found by Chi square test.

 

RESULTS:

The result is presented in three parts:

Section - 1:

Frequency and percentage distribution of adolescent girls according to their socio demographic variables

 

Section - 2:

(a) Level of knowledge regarding menstrual hygiene among adolescent girls in pre-test and post-test

(b) Effectiveness of planned teaching programme on knowledge regarding menstrual hygiene amongadolescent girls

 

Section - 3:

Association between level of knowledge among adolescent girls regarding menstrual hygiene with selected demographic variables

 

Section – 1

Table 1.1: Frequency and Percentage Distribution of Adolescent Girls According to Their Socio Demographic Variables       N = 60

S. No.	Characteristics	Frequency	Percentage
1.	Age (in years) 11-12 13-14 15-16	08 32 20	13.3 53.3 33.4
2.	Class 7th-8th 9th-10th	20 20	50.0 50.0
3.	Ordinal position in the family children First Second More than second	34 22 04	56.7 36.7 06.7
4.	Religion Hindu Muslim Sikh Christian	22 00 38 00	36.7 00.0 63.3 00.0
5.	Type of family Nuclear Joint	34 26	56.7 43.3
6.	Educational status of the mother Illiterate Primary Matric Higher secondary Graduation Post-graduation	00 03 14 05 25 13	00.0 05.0 23.3 08.3 41.7 21.7
7.	Income of the family per month (in rupees) ≤ 10,000 10,001-30,000 ≥30,001	06 24 30	10.0 40.0 50.0
8.	Age at menarche (in years) ≤10 11-13 ≥14	03 50 07	05.0 83.3 11.7
9.	Source of information regarding Menstrual Hygiene Mother Friends Teachers Mass media	51 12 36 02	85.0 20.0 60.0 03.3

 

Table 1.1 shows that Maximum numbers of subjects (53.3%), who participated in research study, were in the age group 13-14 years and minimum (13.3%) were in the age group 11-12 years. All the subjects were equally distributed in both the class group of 7^th-8^th (50%) and 9^th-10^th (50%). Majority of girls (56.7%) were first child followed by second child (36.7%) in their family and rest of them (6.7%) were at more than second ordinal position. Majority of the subjects were Sikh (63.3%) and rest of them were Hindu (36.7%). Majority of the subjects (56.7%) were from nuclear families and rest of them (43.3%) were from joint families. Maximum numbers of subject’s mothers were graduate (41.7%) and minimum were (5%) up to primary standard. The family income of most of the subjects (50%) was more than or equal to 30,001 rupees per month and minimum (10%) were having income less than or equal to 10,000 rupees per month. Maximum subjects (83.3%) attained menarche between 11-13 years of age group and minimum (5%) of them attained menarche at or before 10 years of age. Major source of information regarding menstrual hygiene to maximum subjects (85%) was their mother and to minimum subjects (3.3%) was mass media.

 

Section – 2

Table 2.1: Level of Knowledge Regarding Menstrual Hygiene Among Adolescent Girls in Pre-test and Post-test   N = 60

S. No.	Selected aspects of Menstrual Hygiene	Pre-test		Post-test
		Mean frequency	(%)	Mean frequency	(%)
1.	Anatomy	37.0	61.7	56.0	93.3
2.	Menstruation	37.0	61.7	56.8	94.7
3.	Menstrual hygiene	44.5	74.2	56.0	93.3
4.	Materials to manage menstruation	36.5	60.8	57.0	95.0
5.	Changing of napkins and cloth pads	40.7	67.8	57.7	96.2
6.	Disposal	37.0	61.7	57.0	95.0
7.	Complication due to poor menstrual hygiene	44.0	73.3	54.0	90.0
8.	Management	41.0	68.3	57.6	96.0

 

Table 2.1 depicts that in pre-test maximum numbers of subjects (74.2%) were having knowledge in the area of menstrual hygiene and minimum (60.8%) were having knowledge for the area of material to manage menstruation. In post-test maximum numbers of subjects (96.2%) were having knowledge in the area of changing of napkins and cloth pads and minimum (90%) were having knowledge in the area of complications due to poor menstrual hygiene.

 

 

 

Table 2.2: Effectiveness of Planned Teaching Programme on Knowledge Regarding Menstrual Hygiene among Adolescent Girls

N = 60

S. No.	Category	Pre-test		Post-test		χ2	p-value
		f	%	f	%
1.	Low (≤ 25%)	30	50.0	0	0.0	112.3	0.000***
2.	Average (25-50%)	29	48.3	1	1.7
3.	Good (50-75%)	1	1.7	30	50.0
4.	Excellent (≥ 75%)	0	0.0	29	48.3

***= High significance of p-value < 0.05

Table 2.2 depicts that most of the subjects were having low (50%) and average (48.3%) level of knowledge during pre-test. But, after planned teaching programme session most of the subjects were having good (50%) and excellent (48.3%) level of knowledge during post-test. Chi square test was used to find out the effectiveness. The obtained value (112.3) shows that (p _(3,0.05) = 0.000) planned teaching programme was highly significant. Hence, the research hypothesis (H₁) was accepted.

 

Section – 3

Table 3.1 a: Association between Level of Knowledge Among Adolescent Girls Regarding Menstrual Hygiene with Selected Demographic Variables

N = 60

S. No.	Characteristics	Test	χ2	p-value
1.	Age (in years)	Pre-test	3.141	0.535 NS
		Post-test	1.412	0.842 NS
2.	Class	Pre-test	4.823	0.090 NS
		Post-test	1.444	0.486 NS
3.	Ordinal position in the family children	Pre-test	0.974	0.914 NS
		Post-test	3.656	0.455 NS
4.	Religion	Pre-test	1.985	0.371NS
		Post-test	4.979	0.083 NS
5.	Type of family	Pre-test	1.470	0.480 NS
		Post-test	2.139	0.343 NS
6.	Educational status of the mother	Pre-test	15.407	0.052 NS
		Post-test	23.175	0.003**
7.	Income of the family per month (in rupees)	Pre-test	12.759	0.013*
		Post-test	11.367	0.023*
8.	Age at menarche (in years)	Pre-test	0.690	0.953 NS
		Post-test	4.567	0.335 NS

NS= Non Significant, *= Mild significance of p-value< 0.05**= Significance of p-value < 0.05

 

Table 3.1 a depicts that level of knowledge was not significantly associated with age, class, ordinal position in the family children, religion and age at menarche of the subjects as calculated by Chi square test in both pre-test and post-test. Hence, the research hypotheses (H₂ and H₃) were rejected. In case of association with educational status of mothers of the subjects there was no significance with level of knowledge during pre-test while during post-test it was found Highly significant. Hence, research hypothesis was rejected in pre-test (H₂) and accepted in post-test (H₃). In case of income o the family per month level of knowledge was found significant in both pre-test and post-test. Hence, the research hypotheses (H₂ and H₃) were accepted both in pre-test and post-test.

 

Table 3.1 b: Association between Level of Knowledge Among Adolescent Girls Regarding Menstrual Hygiene with Sources of Information in Pre-test and Post-test

N = 60

NS= Non Significant, *= Mild significance of p-value< 0.05

 

Table 3.1 b depicts that in the pre-test, there was no significant association between levels of knowledge with any of the selected sources of information. Hence, the research hypothesis (H₂) was rejected. While in post-test there was found significant mild association between level of knowledge and teacher as a source of information. Hence, research hypothesis (H₃) was accepted for teacher as a source of information and rejected in case of mother, friends and mass media.

 

RECOMMENDATIONS:

Based on the findings of the study the following recommendations were made:

1.      A similar study can be done on subjects with different socio demographic characteristics.

2.      A similar study can be done by randomly selecting the subjects in quasi-experimental group.

3.      Taking a control group in a quasi-experimental design a similar study can be done.

4.      A comparative study can be done between a rural and urban community.

5.      A comparative study can be done between government and private school settings.

6.      Similar study can be done on a larger sample for wider generalization.

 

CONCLUSION:

The following conclusions were drawn on the basis of the findings of the study:

1.         In pre-test maximum subjects had knowledge in the area of menstrual hygiene and minimum subjects had knowledge for the area of materials to manage menstruation. In post-test maximum subjects were having knowledge in the area of changing of napkins and cloth pads and minimum subjects were having knowledge in the area of complications due to poor menstrual hygiene.

2.         It was concluded that research hypotheses H₂ and H₃ were rejected in case of age, class, ordinal position in family, religion, type of family, age of menarche of the subjects as these socio demographic variables were not associated with their knowledge levels.

3.         It was concluded that research hypotheses H₂ and H₃ were accepted in case of family income per month in rupees as there was association between knowledge level of subjects with this socio demographic variable.

4.         There was no association of knowledge level of the subjects with educational status of their mother and source of information in pre-test. Hence, research hypothesis H₂ was rejected in case of above mentioned socio demographic variables.

5.         There was an association of knowledge level of the subjects with educational status of their mother and teacher as a source of information. Hence, research hypothesis H₃ was accepted in case of above mentioned socio demographic variables.

 

REFERENCES:

1.       Sharma N. Identity of the adolescent girl. [Internet]. New Delhi: Discovery Publishing. ISBN: 8171413471; 2011. Pages 188. [Cited on 2011 Jan, 24]. Available from: delhi.quikr.com/Identity-of-the-Adolescent-Girl-N-Sharma-8171413...

2.       Adolescents in India a profile. [Internet]. UNFPA for UN system in India; 2003 December. Pages 220. [Cited on 2011 March, 11]. Available from: whoindia.org/.../Adolescent_Health_and_Development_(AHD)_UNFPA

3.       Dubey A. Health for Adolescent girls. Pages 5. [Cited on 2011 Dec, 30]. Available from: www.vigyanprasar.gov.in/.../Health_for_Adolescent_girls.pdf

4.       Ten VTA. Menstrual Hygiene: A Neglected Condition for the Achievement of Several Millennium Development Goals. European Commission – EuropeAid; 2007 October, 10. Pages 24. [Cited on 2011 Jan, 20]. Available from: www.eepa.be/wcm/dmdocuments/BGpaper_Menstrual-Hygiene.pdf.

5.       Is menstrual hygiene and management an issue for adolescent school girls?.[Internet]. Nepal: A Water Aid in Nepal publication; 2009 March. Pages 32. [Cited on 2011 Feb, 6]. Available from: www.wateraid.org/nepal

6.       Stubbs ML. Cultural perceptions and practices around menarche and adolescent menstruation in the United States. Annals of the New York Academy of Sciences. [Internet]. 2008;1135:58-66. [Cited on 2011 Dec, 16]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18574209

7.       Simes MR, Berg DH. Surreptitious learning: menarche and menstrual product advertisements. Health care for women international. [Internet]. 2001 Jul-Aug;22(5):455-69. [Cited on 2012 Feb, 10]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11508098

8.       Garg R, Goyal S, Gupta S. India Moves Towards Menstrual Hygiene: Subsidized Sanitary Napkins for Rural Adolescent Girls—Issues and Challenges. [Internet].  [Cited on 2011 Nov, 4]. Available from: http://www.indiasanitationportal.org/category/category/menstrual-hygiene.

9.       Khan S. Menstrual Hygiene Management in Pakistan. [Internet]; Dec 2010. [Cited on 2011 Dec, 26]. Available from: http://www.watersanitationhygiene.org/forum/phpBB3/viewtopic.php?f=310&t=1003

10.     Hoerster KD, Chrisler JC, Rose JG. Attitudes toward and experience with menstruation in the US and India. Women & health. [Internet]. 2003;38(3):77-95. [Cited on 2011 Dec, 16]. Available from: http://www.ncbi.nlm.nih.gov/pubmed /14664306

 

 

Received on 11.10.2014                Modified on 30.10.2014

Accepted on 08.11.2014                © A&V Publication all right reserved