Objective: To determine the effect of health education on menstrual hygiene management in adolescents.
Methods: The quasi-experimental study was conducted from April to July 2021 in Sampit, Kalimantan, Indonesia, after approval from ethics review committee of the Nursing University of Airlangga, Surabaya, East Java, Indonesia. The sample comprised grade VII female students at a public junior high school in Sampit. The sample was divided into intervention group A and control group B. Group A was given a health education intervention through video conferences in two meetings and was given a leaflet after each meeting which lasted 90 minutes. The control group was only given a leaflet. Baseline and post-intervention data was compared. Data was analysed using SPSS 16.
Results: There were 70 subjects; 35(50%) in each of the two groups. The age range was 12-14 years, with 25(71.4%) subjects in group A and 28(80%) in group B being aged 13 years. The age of menarche was 12 years for 17(48.6%) subjects in each of the two groups. Knowledge level of group A increased significantly post-intervention (p<0.05), but group B showed no significant difference (p=0.144).
Conclusion: Health education on menstrual hygiene management was found to have a beneficial influence on knowledge and attitudes among adolescents.
Keywords: Adolescent, Hygiene, Menstruation, Health education, Health knowledge, Attitudes, Practice.(JPMA 73: S-13 [Suppl. 2]; 2023)
Adolescence is a very important phase for building development in the first decade of life. When menstruating, many teenagers in Indonesia do not have a good knowledge on menstrual hygiene management (MHM).1 MHM means that women and girls can use clean materials during menstruation, have privacy when changing materials during menstruation, use water and soap, and have facilities to dispose of menstrual materials after use.2 The level of knowledge about menstruation and MHM that girls have when they enter puberty has a significant effect on their emotional condition.3 However, there are still significant knowledge gaps, particularly in the context of school life. There has been no in-depth research on its impact on school participation and outcomes. Research conducted in Indonesia on MHM in adolescent girls at elementary and junior high school levels is still limited. As a result, the determinants and impact of MHM on adolescent girls are not fully understood, and the evidence as a basis for formulating remedial programmes and interventions for MHM is lacking.4
According to the United Nations International Children’s Emergency Fund (UNICEF), most of the adolescents’ problems are due to infection with germs during menstruation and include reproductive tract infections (RTIs), bacterial vaginosis (BV) and urinary tract infections (UTIs).2 Based on a survey conducted by the World Health Organisation (WHO) in several countries, adolescent girls aged 10-14 years have problems with their reproduction in later life.1 The highest incidence of RTIs occurs globally in adolescents (35-42%).1 Data from the Indonesian Demographic Health Survey (IDHS) in 2017 stated that the behaviour of adolescent girls in maintaining hygiene during menstruation was still poor at 63.9%.5
The main problem for adolescents about menstruation is the lack of knowledge about MHM and poor water sanitation.6 Personal hygiene during menstruation in adolescents can be further improved by acquiring information and knowledge that can be obtained from searching for information through mass media, peers, parents, family and books.7 The WHO Regional Office for South-East Asia, the ‘Global Strategy on Women’s, Children’s and Adolescents’ Health (2016-30)’ recommended interventions to be given to adolescents, like information, counselling and services on comprehensive reproductive and sexual health.8 Health education is an effort to provide psychological conditions and targets so that a person has knowledge, attitudes and skills that are in accordance with the demands of health values.9
Inaccurate and incomplete knowledge about menstruation is a major barrier in the practice of MHM.10 A study in 2017 stated that many adolescent girls in low- and middle-income countries (LMICs) lack adequate facilities and support in schools to regulate menstruation. In addition, menstruation that is not managed properly can result in children dropping out of school, absenteeism, and other sexual and reproductive health problems that have long-term health and socioeconomic consequences for young women.11 Meanwhile, a study on increasing MHM knowledge in adolescents concluded that the provision of counselling interventions had a positive impact on knowledge and practice of menstrual hygiene.12 The current study was planned to examine the impact of MHM education on knowledge levels and attitudes in adolescents.
Subjects and methods
The quasi-experimental study conducted from April to July 2021 in Sampit, Kalimantan, Indonesia, after approval from ethics review committee of the Nursing University of Airlangga, Surabaya, East Java, Indonesia. The sample size was calculated using the Slovin’s formula.13
The sample was raised using purposive sampling technique. Those included were female students in grade VII at a public junior high school who had already experienced menarche. The sample was randomly divided into intervention group A and control group B after taking informed consent from all the participants. Those who did not want to participate were excluded.
Group A was given a health education intervention through video conferences in two meetings and was given a leaflet after each meeting that lasted 90 minutes. Group B was given only a leaflet.
Data was collected using predesigned questionnaire regarding sociodemographic characteristics, including age, age of menarche, father’s education and mother’s education. The questionnaires were developed using items based on MHM literature by UNICEF3. While preparing the questionnaire, the researchers were assisted by two experienced nurses in the field of maternity nursing. Translation was accomplished by a qualified translator. The questionnaire was tested for validity and reliability on a sample of 17 female students of a junior high school.
Data was analysed using SPSS version 16. Data was expressed as frequencies and percentages. Mann-Whitney U test was used for comparing knowledge and attitude between the groups, and Wilcoxon test was used for intra-group comparison. P<0.05 was considered statistically significant.
There were 70 subjects; 35(50%) in each of the two groups. The age range was 12-14 years, with 25(71.4%) subjects in group A and 28(80%) in group B being aged 13 years. The age of menarche was 12 years for 17(48.6%) subjects in each of the two groups (Table 1).
Knowledge level of group A increased significantly post-intervention (p<0.05), but group B showed no significant difference (p=0.144) (Table 2).
In terms of attitude, both the groups showed significant change post-intervention compared to the baseline (Table 3).
The study showed a positive impact of the intervention on MHM knowledge and attitude of the subjects.
Health education encourages young girls to obtain the right information, be able to communicate and be open with parents or teachers.9
According to a study14, knowledge is influenced by predisposing factors, which include education, attitudes, beliefs and the information received.
After the health education intervention, the respondents in the current study could provide correct answers. This is similar to the provision of stimuli through sight and hearing to a child who may find information which is processed in the brain to recall the original material.15 The respondents were in the adolescent phase, which is a potential phase in terms of cognitive, emotional and physical aspects. The cognitive aspect makes teenagers curious, and they try to find information that can increase knowledge. The level of physical and psychological development achieved by a teenager affects changes in knowledge and attitude.16 Health education is required to change the knowledge that will affect the perception of adolescents about MHM.10
Knowledge of young women about MHM can be obtained through the provision of health education in the school environment.17 However, most of the adolescents who were research respondents had never been exposed to information, or had received health education from teachers or health workers. As such, not many knew about MHM. Health education is one of the factors that play an important role in influencing individual knowledge.18 If adolescent girls do not have sufficient knowledge during menarche, this can lead to errors and adverse effects in menstrual hygiene practices.19
According to the behavioural theory14, providing appropriate health education can manipulate predisposing factors, one of which is attitude. Education that leads to change in knowledge and attitudes is more important than providing information without real attitude formation and behaviour change.20 Preventive health services, such as health education, can reduce health costs and reduce the burden on individuals, families and communities.
Techniques and methods of delivering information are important factors that support the success of information.21 The purpose of delivering information is adjusted to the needs and motivation of the respondents in digesting the information provided. Individuals can be motivated to process further information or not depending on the quality of the interaction between the facilitator and the participants. Using video-conferencing is very helpful in the learning process in formal and non-formal education, especially for generation Z teenagers born in the era of advanced technology.22 This method can develop listening skills, careful observation and enhancement of the experience which brings into play all the five senses while learning.21
The provision of health education using video-conferencing media has three stages that can increase adolescent knowledge; the process of entering the information received into memory (learning), storing the information obtained (retention), and its retention.23 By recalling the information obtained (recall), individuals are able to improve understanding and remember the information that has been obtained. Changes in knowledge level from the baseline were significant in the current study. Changes in knowledge are divided into several stages, namely knowing, understanding, analysing, synthesising and evaluating.24 Before a change in behaviour occurs, individuals will have perceptions related to the level of knowledge obtained from the information, so that if the information received is not clear, the learning outcomes obtained are also less than optimal.
At the baseline in the current study, most subjects were in the negative attitude category. This was because they had never received information about MHM in schools before. It improved significantly post-intervention. Changes in attitude values are influenced by the cognitive component or the respondent’s lack of knowledge. This affects the respondent’s perception of MHM. Negative perceptions affect the affective component. The process of forming attitudes is the same as forming habits; individuals receive information and facts about different objects and learn the feelings and values that are associated with these facts.25
The findings of the current study support the theory of Lawrence Green14 according to which, health education can affect predisposing factors. Education is a system that has an influence in the formation of attitudes because it can lay the basis of understanding and moral concepts in a person.26
The current study has some important limitations. Respondents had various economic levels, and the water, sanitation and hygiene (WASH) facilities that were enquired only related to the school and did not explore how it was at home.
Further research is necessary for comparing the effectiveness of video-conferencing media with other methods and media in order to obtain better health education methods for adolescents and to increase students’ motivation and enthusiasm for learning.
Health education with video-conferencing media had an effect on knowledge and attitude about MHM in adolescent girls.
Acknowledgment: We are grateful to the Universitas Airlangga, Surabaya, SMP Negeri 1, Sampit, and to all those who participated in the study.
Disclaimer: The text is based on an undergraduate thesis, and was presented as an Abstract at the 13th International Nursing Conference of the Faculty of Nursing, Universitas Airlangga, in 2022.
Conflict of Interest: None.
Source of Funding: None.
1. Pertiwi TI, Megatsari H. Gambaran Tingkat Pengetahuan Dan Praktik Menstrual Hygiene Pada Siswi Sdn 4 Pacarkembang Surabaya. Jurnal Promkes 2018;6:142-54. Doi: 10.20473/jpk.V6.I2.2018.142-154.
2. Sommer M, Robles P, Comey D, Yamakoshi B, Burgers L, Cavill S. WASH in Schools Empowers Girls’ Education: Proceedings of the 5th Annual Virtual Conference on Menstrual Hygiene Management in Schools. New York, USA: United Nations Children’s Fund (UNICEF) and Columbia University; 2016.
3. Dutta D, Badloe C, Lee H, House S. Supporting the Rights of Girls and Women Through Menstrual Hygiene Management (MHM) in the East Asia and Pacific Region; Realities, progress and opportunities. Bangkok, Thailand: UNICEF East Asia and Pacific Office (EAPRO), 2016; pp 10-80.
4. Hastuti, Dewi RK, Pramana RP. Menstrual Hygiene Management (MHM): A Case Study of Primary and Junior High School Students in Indonesia. Jakarta, Indonesia: The SMERU Research Institute, 2019; pp 107.
5. The National Population and Family Planning Agency (BKKBN), Central Bureau of Statistics (BPS), Ministry of Health Indonesia, The United States Agency for International Development (USAID). Demographic Survey and Indonesian Health: DKI Jakarta Province 2017. Jakarta, Indonesia: 2018.
6. Umami A, Paulik E, Molnár R, Bhisma M. The relationship between genital hygiene behaviors and genital infections among women: A systematic review. Jurnal Ners 2022;17:89-101. Doi: 10.20473/jn.v16i1.34402.
7. Bujawati E, Raodhah S, Indriyanti I. Faktor-faktor yang berhubungan dengan personal hygiene selama menstruasi pada santriwati di Pesantren Babul Khaer Kabupaten Bulukumba, Provinsi Sulawesi Selatan tahun 2016. HIGIENE: Jurnal Kesehatan Lingkungan 2017;3:1-9.
8. World Health Organization (WHO). Handout New Modules: Orientation Programme on Adolescent Health for Health-care Providers. Geneva, Switzerland: WHO Press, 2006; pp 06.
9. Fitriana H, Siswantara P. Adolescent reproductive health education at SMPN 52 Surabaya. The Indonesian Journal of Public Health 2018;13:107-18. doi: 10.20473/ijph.v13i1.2018.110-121.
10. Triharini M, Nastiti AA, Armini NKA, Kurnia ID, Rachmawati PD, Krisnana I, et al. Education and Training Regarding Menstrual HygieneManagement (MHM) as an Effort to Care Reproductive Organs in Adolescent. J Pengabdian Masyarakat dalam Kesehatan 2022;4:17-24. Doi: 10.20473/jpmk.v4i1.31203.
11. Alam MU, Luby SP, Halder AK, Islam K, Opel A, Shoab AK, et al. Menstrual hygiene management among Bangladeshi adolescent schoolgirls and risk factors affecting school absence: results from a cross-sectional survey. BMJ Open 2017;7:e015508. doi: 10.1136/bmjopen-2016-015508.
12. Hennegan J, Montgomery P. Do Menstrual Hygiene Management Interventions Improve Education and Psychosocial Outcomes for Women and Girls in Low and Middle Income Countries? A Systematic Review. PLoS One 2016;11:e0146985. doi: 10.1371/journal.pone.0146985.
13. Black TR. Doing Quantitative Research in the Social Sciences: An Integrated Approach to Research Design, Measurement and Statistics, 1st ed. London, UK: SAGE Publications Ltd, 2005; pp 751.
14. Green LW, Kreuter M. Health Program Planning: An Educational and Ecological Approach, 4th ed. New York, USA: McGraw Hill Higher Education; 2005.
15. Andani PR. Knowledge, Attitude and Practice of Menstrual Hygiene among Primary School Adolescents in Surabaya, Indonesia. Indian J Med Forensic Med Toxicol 2020;14:110-13.
16. Arifin H, Ibrahim K, Rahayuwati L, Herliani YK, Kurniawati Y, Pradipta RO, et al. HIV-related knowledge, information, and their contribution to stigmatization attitudes among females aged 15-24 years: regional disparities in Indonesia. BMC Public Health 2022;22:637. doi: 10.1186/s12889-022-13046-7.
17. Mohammed S, Larsen-Reindorf RE. Menstrual knowledge, sociocultural restrictions, and barriers to menstrual hygiene management in Ghana: Evidence from a multi-method survey among adolescent schoolgirls and schoolboys. PLoS One 2020;15:e0241106. doi: 10.1371/journal.pone.0241106.
18. Levin-Zamir D, Bertschi I. Media Health Literacy, eHealth Literacy, and the Role of the Social Environment in Context. Int J Environ Res Public Health 2018;15:1643. doi: 10.3390/ijerph15081643.
19. Chandra-Mouli V, Patel SV. Mapping the knowledge and understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low- and middle-income countries. Reprod Health 2017;14:30. doi: 10.1186/s12978-017-0293-6.
20. Sebayang SK, Astutik E, Sintha DM, Dewi K, Mandagi AM, Puspikawati SI. Health care-seeking behaviour of coastal communities in Banyuwangi, Indonesia: Results of a cross-sectional survey. Jurnal Ners 2017;12:66-73.
21. Alqahtani AY, Rajkhan AA. E-learning criticalsuccessfactors during the covid-19pandemic:Acomprehensive analysis of e-learning managerial perspectives. Educ Sci 2020;10:2-16. Doi: 10.3390/educsci10090216.
22. Ismawati D, Prasetyo I. Efektivitas Pembelajaran MenggunakanVideo Zoom Cloud Meeting pada Anak Usia Dini Era Pandemi Covid-19. Jurnal Obsesi:Jurnal Pendidikan Anak Usia Dini 2021;5:665-75. DOI: 10.31004/obsesi.v5i1.671.
23. Jarvis-Selinger S, Chan E, Payne R, Plohman K, Ho K. Clinical telehealth acrossthe disciplines: lessonslearned. Telemed J E Health 2008;14:720-5. doi: 10.1089/tmj.2007.0108.
24. Notoatmodjo S. Health Promotion and Health Behavior Revised Edition. Jakarta, Indonesia: Rineka Cipta 2014.
25. Milenkova V, Peicheva D, Marinov M. Towards defining media socialization as a basis for digital society. International Journal of Cognitive Research in Science, Engineering and Education (IJCRSEE) 2018;6:21-32. DOI: 10.5937/ijcrsee1802021M.
26. Febriyanti E. Perineal Hygiene Behavior During Menstruation in Early Adolescents. Central Java, Indonesia: Diponegoro University (UNDIP); 2017.