Because of the scarcity of literature reported from Quetta city, the current study was aimed to assess the menstruation-related knowledge and practices of adolescent females. Results of our study revealed mothers as major source of menstruation-related information for the respondents followed by their sisters Table 2). Our results are in line to what is reported from India, Nepal and South Africa [28, 29]. Even though the evidence declared menstruation as an uncomfortable topic especially for preteen girls to discuss; mothers and sisters do play a significant role in conveying information about physiological changes and also about social, emotional and cultural issues. However, the reliability of the menstruation-related information provided by mothers and sisters is questionable as they are not necessarily well equipped to fill gaps in girls’ knowledge [14]. It is important to make sure that accurate and reliable information is transferred so that the menstruating girls are prepared to handle menstruation-related issues. Hennegan et al. in their response to the editorial did mention that majority of the menstruation-related findings and figures are not substantiated by published peer-reviewed studies and the original sources remain known [30]. Thus, assessment and correction of mothers’ and sisters’ menstruation-related knowledge is important and should be a matter of concern for healthcare professionals and local support groups.
Parallel to our study results, study respondents from Saudi Arabia and India considered menstruation a natural phenomena and a normal physical change [31, 32]. Importantly and as expected, 80% of our study participants had no prior classes or discussions about menstruation and hygiene at school. The finding is not surprising from a developing world as many girls receive no information or training from schools on how to manage menstruation-related issues [33]. Continuing with our arguments, Kaur et al. discussed that the education sector of developing countries avoids issues related to the menstruation and menstrual hygiene management by considering it a personal matter. Besides, teachers are also not ready to discuss menstruation and menstrual hygiene management with their students. Due to the unsupportive environment, girls remain unfamiliar with menstrual-related issues, and how to take care of personal hygiene [34].
In contrast to the findings of Khanna et al., where 97.5% of their participants didn’t know the source of bleeding, majority of the respondents, in the current study knew that vagina is the organ from where the menstrual blood flows [32]. In our study, 69.6% respondents knew that menstruation is caused by hormonal changes and adolescent girls had adequate knowledge of the duration of the menstrual cycle, similar to that found in Nigeria [35]. In continuation, Dasgupta and Sarkar in their study revealed that few adolescent females perceived menstrual blood as unhygienic, which is similar to the perception of our participants [9].
Almost 40% of our study respondents missed their school which is also supported by literature. The relationship between menstruation and school absenteeism is multi factorial. Even though, the present study was not able to identify such factors, we do hypothesize lack of facilities at schools and privacy as major factors. To support our hypothesis, Miiro and colleagues reported that menstruation was strongly associated with school attendance [36]. The United Nations Children’s Fund (UNICEF) estimated that about one in ten school-age African girl didn’t attend school during menstruation due to lack of cleanliness and separate toilet facilities for female students at schools [37]. Girls are frequently faced with difficulties in managing menstrual periods at school due to lack of adequate privacy and sanitary facilities [38]. As a result girls preferred to stay at home during their menstruation period. In addition to the school, our study respondents also missed out other activities, particularly religious ceremonials. In India, girls were restricted from cooking food and visiting temples during the menstruation period [6]. The influence of religion in the developing world is not to be underestimated and the same influence can be used to answer menstruation-related issues. Religious leaders of the developing world (Imams, Pandits, Monks and Priests) can be trained and used as a source of evidence based knowledge about menstruation and because of their influence on general public can prove to be a useful resource in handling issue related to menstruation.
Adolescent females of the current study were frightened and felt discomfort during their menarche which is supported by a study conducted in Mashhad, Iran [39]. Our findings are further strengthened as Hennegen et al. in their systematic review and qualitative meta-synthesis stated that menstruation is experienced with discomfort and fear [40]. Furthermore, a large number of our respondents reported usual eating habits during menstruation time. This is against to what is reported by Meyer-Rochow who explained food taboos are directly related to certain events including menstruation [41]. According to Khan (2000), adolescents and their mothers believed that eating foods considered to be too hot (dry fruits, liver, and eggs) or too cold (ice creams, yogurt, and green leafy vegetables) should be avoided [42]. A possible explanation of this difference is the negligible or poor existence of food taboos in the Pakistani society. Other then what is prohibited by the religion, food is considered as a source of vitality and is the reason of regular heating habits among the adolescent girls during their menstruation time.
Almost 70% of our respondents were using commercially available sanitary pads or napkins as an adsorbent material. This finding is against to another study conducted in Pakistan whereby an under usage of napkins due to lack of affordability was reported. The author also reported comfort of using homemade pads [43]. A possible explanation of this difference is the long gap between the two studies and since then much has evolved in terms of knowledge dissemination (especially the evolution of social media). Besides that, our respondents are urban residents while the participants of Khan’ study belonged to a rural settings. Nonetheless, the use and reuse of homemade napkins is frequently reported from low and middle income countries [17]. Additionally 80% of the current study respondents reported to use water and soap for cleaning their genitalia. On the contrary, a study done in Andhra Pradesh revealed that only 4.6% of the students used water and soap to clean their genitalia that again is related to economical and availability issues [35].
Most of the participants in the present study used commercially available pads and changed their sanitary pads on a daily basis. On average, our respondents used two pads in a day. This is against to the findings of a study conducted in Karachi, Pakistan where the authors claimed that girls in Karachi are either unaware of how to manage menstruation in a hygienic manner or they cannot afford to manage it with modern menstrual materials [20]. In other studies, although the use of pads was preferred over homemade rags and clothes, affordability was rates as a barrier [44, 45]. In certain cases there was no issue of affordability, the pads were thought to be uncomfortable as irritation or rashes were reported by the users. Hence, some female preferred new cloths and towels during menstruation, which were reused after being, washed [46]. Within this context, it is to remember that all those who menstruate need access to their choice of menstrual materials that are affordable, safe and comfortable. We have to remember that menstruation is a normal physiological process in females, but poor hygiene can bring serious health issues like urinary and reproductive tract infection. Therefore, females, especially adolescents, must be psychologically prepared about the physical changes that occur during this period. They should be well aware of the menstruation, menstrual hygiene, and menstrual cycle even before their menarche as well as how to maintain hygiene during the cycle.
