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Impact of a health education program for secondary school Saudi girls about
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Article  in  The Journal of the Egyptian Public Health Association · February 2007

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J Egypt Public Health Assoc Vol. 82 No. 1 & 2, 2007

Impact of a Health Education Program for

Secondary School Saudi Girls About Menstruation
at Riyadh City

Ebtisam M. Fetohy
Health Administration& Behavioral Sciences Dep., High Institute of Public
Health, Alexandria University, Egypt.

ABSTRACT
An experimental study was conducted to assess the impact and suitability of
menstrual education program (MEP) for 1st and 2nd graders at a girls'
secondary school in Riyadh city. The MEP was conducted on 5 classes,
through one session and one assessment. The results revealed that the mean
scores of knowledge, attitude and practice of the intervention classes (1st and
2nd graders) were significantly higher than that of the control classes.
Stepwise linear regression models show that the age of menarche and grade
were the predictors of students' knowledge among the control group and
explained 7.8% of the variation of the knowledge score. Knowledge was a
predictor of students' attitude of both groups (control and intervention)
(ß=0.359, 0.300 respectively). Knowledge was also a predictor of students'
menstrual practice among control group (ß=-2.12). Attitude was a predictor of
students' menstrual practice for both groups (ß=0.360, 0.252 respectively).
The study recommended the replication of the same program among
elementary, preparatory, and other secondary schools for improvement of
students' menstrual knowledge, attitudes and practice.

Keywords: Menstrual education program (MEP), menstrual knowledge,

attitudes, and practices (KAP), menstrual hygiene

Corresponding Author:
Dr. Ebtisam M. Fetohy
Health Education & Behavioral Sciences Dept.,
High Institute of Public Health
Alexandria University
E-mail: ebtisammf@yahoo.com
J Egypt Public Health Assoc Vol. 82 No. 1 & 2, 2007

INTRODUCTION
A woman goes through several developmental milestones that
greatly influence her reproductive health. Menarche, which is the
establishment of menstruation, is one of these milestones. The profile of
the woman's reproductive health is greatly influenced by the girl's
reaction to menarche, her beliefs and attitude towards menstruation,
and more important her behavior during it. (1) Girls need emotional
support and assurance that menstruation is normal and healthy, not
bad, frightening or embarrassing. The practices of menstrual hygiene
and subjective experience of menstruation should be stressed. (2)

Old women tales persist, thus, early in the first few years during
the puberty period; a young girl is conditioned to the idea of
dysmenorrhea. She may be discouraged from somatic, outdoor
activities, discontinue bathing, and she may be encouraged to stay at
home for a day from school or the office. In addition, many young
women have a mindset of avoidance that has to do with an association
of water or environmental conditions, especially cold. They believe that
cold can stop menstrual flow. According to the ancient hot/cold theory,
blood was seen as hot and dry and is opposed by anything cold or wet,
including certain foods, herbs and medicines. (3) The menstruating
Muslim woman is not allowed to enter the mosque for prayer, touch the
Qur'an, or fast in Ramadan. In addition, she cannot engage in sexual
intercourse nor divorce at this time. During Hajj, she can do with the
exception of circumambulating in Makkah. Yet the small girl must keep
clean, tidy, in good condition, and practice all daily activities. (4)

Health education (HE) processes a mixture of knowledge, attitude

and behaviors. The problem under scrutiny may be based in a lack of
knowledge, uncompromising attitude or unrewarding behavior
patterns. In most instances, health problems dealt with by health

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educators include all three components. In order for the educator to

achieve the goal of HE, he/she has to identify the clients' needs and
interests. Needs are identified as a gap between some desirable norm or
standard and actual status. (5)

Heat is soothing and promotes increased blood flow. There is no

evidence that bathing will bring on cramps or interrupt blood flow. A
worm bath should, if possible, be taken daily throughout the period.
Changing perneal pads before permitting leakage virtually prevents
unpleasant odor. During the menstrual period, sanitary napkins should
be changed about every 4 hours, possibly more often during the first
days of the period when the menstrual flow is usually heavier. (6) In the
city of Riyadh, 29% of the attendants at school health units are
complaining of vaginal infection and/or menstrual disorders. (7)

Furthermore, 17% of girls who seek medical help from primary health
care centers in Riyadh are suffering from menstrual related disorders. (8)

Before planning for HE programs about menstruation, a study of

adolescents' knowledge of menstruation, and their beliefs and practices
will help the health educator, maternity nurse, school nurse, community
nurse discovers deficiencies in their knowledge and troubling
misconception-related issues. (6) A comparative survey carried out
among all Gulf countries to study the presence or absence of health
related courses in intermediate and secondary school curricula; found
that there were no courses dealing with the reproductive system or
health behaviors related to menstruation. Unfortunately, in Saudi
Arabia the curricula in schools contain nothing in the area of HE. (4)

There is a limited research examining changes in knowledge,

attitude and practices of Saudi students following implementation of
menstrual education program (MEP). Therefore, this study aimed at

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assessing the impact of a short-term MEP for secondary school girls.

The MEP aims to increase students' menstrual knowledge, build
positive attitude to healthy practices and induce positive behavior
change.

SUBJECTS & METHODS

Study design, settings and population:

The randomized posttest only experimental-control groups design was
used in this study. This design reduces one's load without scarifying
much in the way of validity. It controls for the confounding influences
of history, maturation, and pre-testing. Since randomization is
employed, pretest is unnecessary as it can be assumed that groups are
equivalent at the start of the MEP. The study population was the 1stand
2nd graders at a randomly selected governmental girls’ secondary school
in Riyadh. Six classes were chosen randomly from 1st grade, three
classes were subjected for health education intervention and the others
are controls. Four classes were chosen randomly from 2nd grade, two
classes were subjected for health education intervention and the others
were controls. The session of the program started after break-time for
the intervention classes (the school's nurse and two social workers
collected the students in the mosque of the school) and the session took
3 usual class times (120 minutes). The questionnaire was distributed at
the end of school day simultaneously in both intervention and control
classes. Such precaution was taken to avoid information pollution
between intervention classes and the control. For ethical reasons, the
content of the program was presented to the control group in the next
week. Any incompletely filled questionnaire was excluded from the
study. The number of students in all classes was (248).

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Menstrual education program (MEP):

The objectives of MEP were to encourage voluntary changes in
behavior favorable to health. This improvement in behavior could be
attained by improving knowledge (cognitive objectives) and attitude
(affective objectives).

Methods of teaching:
Lecture and group discussion were used. Visual aids in the form of
posters, handouts and pamphlets were used.

Content of the program:

1. General information about definition of menstruation, its source, age
of menarche, menopause, duration of menstruation, problems and
pain of menstruation.
2. Causes of pain, abnormal menstruation, what to do to relieve pain,
washing during menses, type of pads, frequency of change, perineal
hygiene, time of ovulation, life span of ovum, type of soap, normal
secretion, underwear and methods of cleaning.
3. Normal changes, herbal use, cold drink and ice-cream. Exercise
during menses, dangerous behaviors during menses, salty food and
methods used for hair removal.
4. Pain relievers, aspirin use, when to contact doctor, healthy practice to
relieve pain. Bad effect of stress, coffee, fatty and sugary diet. Benefit
of vegetables and coconut.
5. Types of food that should be given and that should be avoided
during menses. Methods of treatment of complications. The
researcher and the school nurse with the help of social workers
presented the content of the program.

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Evaluation procedure:
Impact evaluation is the level of evaluation used to assess short-
term effects of the MEP on students’ menstrual knowledge, attitude and
practices. One assessment was approached through the administration
of predesigned pilot-tested questionnaire to the pupils as a class
activity, so all pupils were encouraged and expected to participate. A
pilot study was done in another, one class from 1st and another from
second. According to the result of the pilot study, some items were
removed and others were changed. Pupils were instructed to use a
cover sheet for their responses and not to answer aloud. The
questionnaire was designed to elicit the following information:

• Personal and socioeconomic data.

• The menstrual knowledge instrument consisted of 24 multiple
choice questions regarding pupils' knowledge about definition
of menstruation, duration of menstruation, age of menarche,
menopause, problems and pains associated with menses, causes
of pain, methods of pain relieving. Abnormal menses, bathing
during menses, perineal hygiene, types of pads, frequency of
their changes, underwear and methods of cleaning. Fifteen
questions were scored as 1 for correct answer and 0 for wrong
or don't know. Nine questions were scored as 2 for complete
correct answer, 1 for incomplete correct answer and 0 for wrong
or don't know. Thus, the total score ranged from 0 to 33.
Standardized item alpha reliability coefficients was .772 for
knowledge instrument.
• The students' menstrual attitude scale was measured through
22 statements measuring the latent construct of the children's
attitude toward healthy and unhealthy practices during
menstruation. Responses were designed as three points Likert-

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like format (not sure, sure or very sure), and scored from 1 to 3
with higher score indicating positive attitude. The total score
ranged from 22-66. Standardized item alpha reliability
coefficients was .736
• The menstrual behavior questionnaire: included 32 multiple
choices items designed as (never, rarely, sometimes, always)
assessing behaviors that are practiced by the students during
menstruation, like bathing and care of perineal pads and
methods for managing any menstrual problems and type of
food and drink used or avoided. Each item was scored from 1 to
4 with higher score for the best menstrual practice. Thus, the
total score ranged from 32 to 128.

Data analysis
Data from the completely filled questionnaires were analysed using
SPSS program (version 11). The influence of MEP on the knowledge,
attitude and practice scores was assessed by examining the mean
posttest-data at each grade level of the experimental versus the control
group using independent t test. Also, examining the two means of 1st
and 2nd graders of the intervention versus the control group using
independent t test. A general linear model procedure from SPSS was
employed.

RESULTS
The intervention and control groups were comparable with no
statistically significant difference as regard socio-demographic factors
except that most of the control group (66.9%) belonged to age group 14-
16years, compared to 54% of the intervention group. The difference was
statistically significant, X² =4.319, p<0.05 (Table 1).

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Table (1): Distribution of the Sample According to Their Sociodemographic

Characteristics.
Intervention Control Total
Sociodemographic Characteristics N=124 N=124 N=248
No % No % No %
Grade
1st secondary 80 64.5 82 66.1 162 65.3
2nd secondary 44 35.5 42 33.9 86 34.7
Age*
14- 67 54.0 83 66.9 150 60.5
17+ 57 46.0 41 33.1 98 39.5
Order
1st 27 21.8 29 23.4 56 22.6
2-4 71 57.2 68 54.8 139 56.0
5+ 26 21.0 27 21.8 53 21.4
Family size
<5 16 12.9 19 15.3 35 14.1
6-9 85 68.5 78 62.9 163 65.7
10+ 23 18.6 27 21.8 50 20.2
Education of Father
Illiterate+ Primary 10 8.1 17 13.7 27 10.9
Intermediate 16 12.9 18 14.5 34 13.7
Secondary 43 34.4 34 27.4 77 31.0
University 55 44.4 55 44.4 110 44.4
Education of Mother
Illiterate+ Primary 22 17.7 26 21.0 48 19.4
Intermediate 26 21.0 20 16.1 46 18.5
Secondary 48 38.7 45 36.3 93 37.5
University 28 22.6 33 26.6 61 24.6
Work of Mother
Housewife 104 83.9 102 82.3 286 83.1
Working 20 16.1 22 17.7 42 16.9
Type of house
Apartment 67 54.0 66 53.2 133 53.6
Villa 57 46.0 58 46.8 115 46.4
Age of menarche**
9- 11 8.9 21 16.9 32 12.9
12- 95 76.6 89 71.8 184 74.2
15+ 18 14.5 14 11.3 32 12.9

* χ² =4.319, p<0.05 ** The mean age for menarche=13.1± 0.6 years

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There was no statistically significant difference between

intervention and control groups concerning sources of information
about menstruation, χ² =4.22, p>0.05 (Figure 1). Higher proportions of
the intervention groups mentioned school nurse, grandmother and
friends as sources of information. Meanwhile, higher proportions of the
control group mentioned mother, mass media and sister as sources of
information.

70
60.2
56.7
60

50

40
%
Control
30
Intervention Group

20 15 14.7 15.3
9 11.3
10 5.3 5.3
3.8 2.7
0.8
0
Mass Media School Nurse Mother Grangmother Sister Friends
Sources of information

χ² =4.22, p>0.05
Figure (1) Distribution of the Sample According to Their Sources of
Information about Menstruation and Menstrual Hygiene.

Table 2 shows that the mean knowledge scores of the intervention

classes (1st & 2nd graders) were significantly higher than that of the
control, (t=15.840, 9.408, p<0.001) respectively. There is no significant
difference between 1st & 2nd classes among the intervention and control
groups.

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Table (2) : Impact of Menstrual Education Program on Menstrual

Knowledge of Secondary School Saudi Girls.

Total knowledge score № χ +SD T

First grade
Intervention 82 27.84+2.30* 15.840***
Control 80 19.75+3.96**
Second grade
Intervention 42 27.98+2.16 9.408***
Control 44 21.23+4.21
*t between intervention groups 1st& 2nd grade=-0.322, p=0.753,
**t between control groups 1st& 2nd grade=-1.907, p=0.060
*** p<0.001
Regarding students' attitude toward menstruation and menstrual
practice, Table 3 demonstrates that mean attitude scores of the
intervention classes among 1st &2nd graders were significantly higher
than that of their controls, (t=11.679, 8.339, p<0.001 respectively). The
difference between mean attitude scores of 1st &2nd graders of the
control group was not statistically significant. (t=0.283, p>0.05). The
mean attitude score of the 1st graders of the intervention group was
significantly higher than that of 2nd graders (t=2.274, p<0.05).

Table (3) Impact of MEP Attitude towards Menstruation and Menstrual

Practice of Secondary School Saudi Girls.

Total attitude score № χ +SD T

First grade
Intervention 82 54.76+5.89* 11.679***
Control 80 43.06+6.81**
Second grade
Intervention 42 52.36+5.38 8.339***
Control 44 42.75+5.30
*t between intervention groups 1st& 2nd grade=2.274, p<0.05,
**t between control groups 1st& 2nd grade=0.283, p=0.777
*** p<0.001
Table 4 points out that the mean practice scores of the intervention
classes among 1st & 2nd graders were significantly higher than that of
their controls, (t=6.240, 4.433, p<0.001 respectively). There is no

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significant difference between the mean practice scores of 1st & 2nd
graders among control group. The mean practice score of the 1st graders
among intervention group was significantly higher than that of the 2nd
graders (t=2.33, p<0.05).

Table (4) Impact of Menstrual Education Program on Menstrual Practice

of Secondary School Saudi Girls.

Total attitude score № χ +SD T

First grade
Intervention 82 99.23+9.01* 6.240***
Control 80 89.33+11.07**
Second grade
Intervention 42 95.60+8.36 4.433***
Control 44 85.73+12.04

*t between intervention groups 1st& 2nd grade=2.233, p<0.05,

**t between control groups 1st& 2nd grade=1.638, p=0.105, ***p<0.001
The stepwise linear regression in table 5 shows that factors entered
the regression of model (1, 2) of students' knowledge were: socio-
demographic (age, grade, order between siblings, family size, father's
education, mother's education, mother working status, residence)and
age of menarche. The table illustrates that only two out of 9 studied
factors have predicted students' knowledge of the control group: age of
menarche and grade. The two factors together explained 7.8% of the
variation of the knowledge score. Among the intervention group, the 9
variables entered and no variable was selected.

Regarding students' attitudes, ten variables were entered: those of

the knowledge and total knowledge score and the only predictor among
the control group was students' total knowledge score, which explained
12.9% of the variation in menstrual attitude score (β=0.359). Among the
intervention group, only 4 variables were selected: total knowledge
score, grade, order and age. The four variables explained 7.2% of the
variation of the attitude score.

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Table (5) Summary of Stepwise Multiple Regression Analysis for

Menstrual Knowledge, Attitude and Practices for Control
and Intervention group.

Predictors B Beta SE T R² F ratio P

Models 1,2
knowledge:
Control group
Constant 27.213 3.730 7.297 0.078 5.097 0.000
Age of menarche -0.726 -0.221 -0.290 -2.502 0.014
Grade 1.776 0.208 0.754 0. 208 0.020
Intervention group
Variables entered/
removed
Models 3,4 Attitude:
Control group
Constant 31.772 2.682 4.845 0.129 18.077 0.000
Knowledge score 0.551 0.359 0.130 4.252 0.000
intervention group
Constant 20.563 10.617 1.937 0.072 6.244 0.055
Knowledge score 0.777 0.300 0.217 3.580 0.000
Grade -4.911 -0.401 1.619 -3.034 0.003
Order -0.541 -0.190 0.239 -2.269 0.025
Age 1.210 0.270 0.595 2.032 0.044
Models 5,6 practice:
Control group
Constant 41.892 0.354 7.060 5.933 0.372 17.596 0.000
Attitude 0.647 0.360 0.143 4.524 0.000
Knowledge 1.010 -0.212 0.223 4.519 0.000
Grade -5.077 0.152 1.778 -2.855 0.005
House type 1.810 0.871 2.077 0.040
Intervention group
Constant 77.116 7.299 10.565 0.064 8.281 0.000
Attitude 0.387 0.252 2.878 0.005

Factors entered the regression :

Models 1&2: Sociodemographic variables (age, grade, order between siblings,
family size, father education, mother education, mother work,
residence), age of menarche.
Models 3&4: Sociodemographic variables, age of menarche, total knowledge score.
Models 5&6: Sociodemographic variables, age of menarche, total knowledge score,
total attitude score.

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Eleven variables were entered the models of students' menstrual

hygienic practice: ten of the attitude and total attitude score. Only four
variables were selected to explain 37.2% of the variation of the practice
score among the control group : higher attitude score, higher
knowledge score, being 1st grader and reside in villa (β=0.354, 0.36, -
0.212, and 0.152) respectively. Among the intervention group, students'
total attitude score was the only predictor, which explained 6.4% of the
variation in menstrual hygienic practice.

DISCUSSION
Menstruation is a normal physiologic process, and girls and
women need not restrict their usual daily routine work, social and
athletic activities in any way during their period. Indigenous practices
of some girls prior to menstruation will influence their behavior toward
it. They usually share whatever local customs and beliefs their parents
practice. Some traditional practices are useful, while some are harmful
and some are harmless. Every girl should be prepared for her first
menstruation as it is preceded with the general development and
changes. (6)

The present results reveal that mean age of menarche was 13.1+0.6
years. This is in accordance with findings from other studies. (9, 10)

Studies done in Riyadh 1999, 2001 demonstrated that the mean age at
menarche was 12.8+1.1 and 12+1 years respectively. (11, 12) In a study in
Mansoura, Egypt 2004, the mean age of menarche was 12.9 years. (13)

While in Alexandria 2004, it was 11.91+0.93 years. (14) In a study among

Jordanian girls 2004, (15) the mean age was 13.8 years. This difference
could be attributed to the influence of both heredity and socioeconomic
conditions especially nutrition. (16)

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The present study demonstrates that the students' mean knowledge

score was low for the control group among 1st and 2nd graders, Table 2.
This result coincides with those of other studies which revealed a great
lack of knowledge about the physiological aspects and psychology of
menstruation, as well as menstrual hygiene. (3, 11, 14) Also, Hassanen et al
2004., in Egypt, found that all girls had poor level of knowledge before
the program. (17) Such lack of knowledge was attributed to lack of either
formal or informal pre-menarche preparation. (3) On the other hand,
Drakshayani devi and Venkata Ramaiah 1994 in India, found that
majority of the girls were having correct knowledge about
menstruation. (18)

The results of the present study revealed that the mean score of
students' attitudes was low among the control group, Table 3. Studies
revealed that girls' reasons for avoiding bathing, perneal care and pad
changing included the fear of causing increased blood loss (12,17) or pain
or hair loss(17) or of trapping menstrual flow within the body, (11-13, 17)
leading to insanity. (12) Similar beliefs have been reported among African
tribes. (19, 20) Studies also revealed that one to three fifths of the students
were absent from school or work and stayed home fearing the pain on
the first day of menstruation. (11, 13, 17, 21) In addition, the majority of girls
avoided exercising during menstruation due to fear of the pain;
increased bleeding (3, 11-13); uterine displacement (12) and they consider
exercising as a harmful activity. (11)

Studies also demonstrated that most of the students in Kingdom of

Saudia Arabia (KSA) prohibit themselves from eating eggs; chicken and
meat as they believed this prevent nausea and vomiting during
menstruation. (11, 12) Foods containing vitamin C are also avoided, as they
are believed to stop menstrual flow and lead to amenorrhea. (12)

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The present study shows that the mean score of practice was low
among control group, Table 4. The study of Hassanen et al., (2004)
revealed that 59% of the girls had poor practice during menstruation
before the program.(17) Mobarak et al., (2004) concluded reported that
Alexandria girls adopt some unhealthy practices during menstruation
which were found to have sociocultural origin. (14) Several studies
revealed that a substantial proportion of the sample avoided bathing
and perineal care during menstrual period. (3, 11, 12, 14, 18, 22) Furthermore,
they refrained from their sanitary protection while at school or work for
up to 8 hours. (11, 12) Such behaviors indicate very poor menstrual
hygiene. (12) This is one of the leading causes of later difficulties such as
infertility precipitated by salpingitis and similar conditions. (19, 20)

Moreover, other studies pointed out that there are many of the
restricting activities, such as refraining from doing any housework,
going out of house (3, 17, 21) and being absent from school(11, 14) In
addition, other studies showed that there were many useful behaviors
such as drinking worm milk(11), and avoiding cold drink, (3) and other
harmful practices like drinking tea and coffee, (11) increasing the intake
of both salty and sweet food(12), avoiding eggs, chicken, meat(11, 12) and
foods containing vitamin C(12) and the use of self-medication. (11, 18)

The most appropriate source of information was the girl's mother.

(23) Traditionally, education about menstruation and puberty was a part
of the maternal role. It was an opportunity for the mother to share with
her daughter the realization of the girl's evolving physical maturity.
Such discussion could strengthen the mother daughter relationship. (24)
Because of cultural and religious beliefs in Kingdom of Saudia Arabia
(KSA), menstruation is not considered an appropriate topic of
discussion, leading to the lack of accurate and available information. In
the present study more than half of the girls in both groups reported

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that they got information from their mothers. Higher proportions of the
control group mentioned mother, mass media and sister as sources of
information. Meanwhile, higher proportions of the intervention groups
mentioned school nurse, grandmother and friends as sources of
information (figure 1). Al Ayafi (1999) found that 61.5% of the students
went to their mothers for answers to their questions. Religious books as
Fikgh Al-Sunnah were the second source of information. Peers,
teachers, medical personnel, television and other media were the last
sources of information. (11) Several studies, demonstrated that mothers
were the main source of information. (3, 14, 17, 21, 25) Drakashayani Devi
and Venkata Ramaiah (1994) reported that 73.8% of the girls received
information from their mothers. Other information sources included
grandmothers, friends and sisters. (18) On the other hand, In Egypt, in
Mansoura, El-Gilany et al., (2005) found that 92.2% of the girls reported
mass media as their source of information followed by mothers
(45%).(10) These sources not only vary in quality of information provided
but also show how girls value potential information.

Although, 60.2% of the girls of the control group got their

information from their mothers (Figure 1), their mean score of
knowledge was poor (Table 2). This may be due to ignorance of the
mothers themselves about menstruation irrespective to their
educational level. (17) Shrwen et al., (1995) mentioned that not all
parents however were able to do this because of lack of parental
knowledge, inability of parents to feel comfortable talking about
puberty with their child, and the belief that menstruation is "sinful" or
"dirty". All these had negative effect on girls. (24) Alexander and La Rosa
(1994) added that some mothers had difficulty in preparing their
daughters for sexuality and menstruation. This may be due to ignorance

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and menstrual taboo, which says that menstruation, is something not to

be talked about. (23)

Physicians are an expected source of authoritative information

about menses, but often are uncomfortable with discussing the topic of
menstruation and sexuality in general. (25) Al Ayafi (1999) reported that
5.6% of the students mentioned physicians as a source of information.
(11) This is consistent with a similar finding in this study where 5.3% of
the students of the intervention group mentioned school nurse as a
source of information (figure 1).

The need for HE on menstruation and hygienic practice and

nutritional guidance will help decrease anxiety level and improve
healthy behavior of students that will in the end benefit their future. (26)
A review of literature shows that there is a positive correlation between
the knowledge and behavior. Although behavioral changes are usually
the ultimate goal for HE programs, an increase in knowledge does not
always cause behavior to change. It is, however, a prominent element in
HE and is a necessary factor in changing some health behaviors. (5) The
present work was in agreement with Seidman who stated that women's
knowledge seemed to affect their practices during menstruation(27), as it
revealed that knowledge score was a predictor of attitude of both
intervention and control groups. It was also one of the predictors of the
practice of the control group. Attitude was a predictor of practice of
both groups. Table 5. Olds et al., (1988) mentioned that when
individuals had adequate knowledge about lifestyle, they only have at
least some control over their situation. (28) On the other hand, Mobarak et
al., (2004) concluded that there is insignificant correlation between girls'
percent score of knowledge and that of health take caring practice. (14)

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Several factors play a role in modeling the girls' attitudes towards

menstruation that, in turn, influence the girl's behavior during
menstruation. Among these factors are: family size, her position among
her siblings, her relationship with her mother and/or older female
sisters, her cultural background, her body image, self-esteem and
feminine, as well as her premenarch preparations for this exciting event.
(29) The present study pointed out that girl order between her siblings is
one of the predictors of girls' attitudes towards menstrual practice,
table 5.

Concerning the elements of menstruation and menstrual hygiene,

the results indicated that there were highly significant differences
regarding the level of students' knowledge and practices between
intervention and control groups. This revealed significant improvement
in student's' knowledge and practices regarding menstruation and
menstrual hygiene. The change of practices was unexpected as the
assessment was done immediately after the session. The students might
mention the correct practices after they knew them in the content of the
session. These results were in line with Hassanen et al., (2004) and
Hassan (1997) who mentioned that students' knowledge and unhealthy
behaviors during menstruation were significantly changed after the
implementation of the program. (17, 30) Many studies have demonstrated
that teaching and counseling by health professionals is effective in
changing people's erroneous health behaviors. (6). Moreover, Mobarak et
al., (2004) reported that the percent score of health take caring practice
of girls who were prepared and informed before menarche were
significantly higher than that of unprepared ones. (14)

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CONCLUSION & RECOMMENDATIONS

The higher proportion of the control group's girls received advice
regarding menstruation from their mothers together with their low
knowledge score among them, shows that the mothers of these girls
were lacking of right knowledge and the same thing was transferred to
their offspring. The menstrual education program can have positive
effects on the menstrual knowledge, attitude and practice of secondary
school students.

The study recommended the replication of same program among

elementary, preparatory, and other secondary schools for improvement
of students' menstrual knowledge, attitudes and practice.

Health educators in Saudi community must concentrate on rules of

good hygiene from the Qur'an and El Figh during their teaching. This
will make the mothers qualified enough to handle this phase of their
girl's education. Before bringing any change in girls' menstrual
practices, they should be educated about the facts of menstruation& its
physiologic implications. They should be educated about the
significance of menstruation and development of secondary sexual
characteristics, selection of sanitary menstrual absorbent and its proper
disposal. This can be achieved through educational television programs,
school nurse/health personal, education in school curriculum and
knowledgeable parents, so that she does not develop psychological
upset and the received education would indirectly wipe away the old
wrong ideas and make her free to discuss menstrual matters without
any inhibitions.

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REFERENCES:
1. Coupey M, Susan S. Menstrual disorders in adolescents. Emergency
Medicine Journal. 1995; 40(1): 13-8.
2. Rierdan I, Rise I. Living arrangement and health behaviors in
adolescence and young adulthood. Health Education Research Theory
and Practice. 1995;8(4):494-503.
3. El Shazly MK, Hassanein MH, Ibrahim AG, Nosseir SA. Knowledge
about menstruation and practice of nursing students affiliated to
University of Alexandria. J of Egyptian Public Health Assoc. 1990; 65(5,
6): 509-23.
4. Karachi N, Elzubian A. Health knowledge among students of Saudi
girls college. Saudi Medical Journal. 1997; 18(3):219-23.
5. Hamburg BA. Education for healthy futures. Health promotion and life
skills training. In: Takanishi R, Hamburg DA, Eds. Preparing adolescents
for the 21st century: Challenges facing Europe and United states. New
York: Cambridge University Press. 1997; 108-35.
6. Burns G. Toward healthy people 2000. The role of the nurse practitioner
and health promotion. Journal of the American Academy of Nurse
practitioners. 1994; 6(1):29-35.
7. MOH-(Ministry of Health) 1993, School health report.
8. MOH-(Ministry of Health) in Saudi Arabia (1993).
9. Kirchstein R. Research on woman health. American Journal of Public
Health. 1991; 81(3):291-3.
10. El-Gilany A, Badawi K, El-Fedawy. Menstrual hygiene among
adolescent schoolgirls in Mansoura, Egypt. Reproductive Health
Matters. 2005; 13(26):147-52.
11. Al Ayafi AS. Factors associated with health behavior regarding
menstruation among Saudi intermediate school girls in Riyadh city.
Thesis, MPH, King Saud University, Nursing College 1999.
12. Moawed S. Indigenous practices of Saudi girls in Riyadh during their
menstrual period. Eastern Mediterranean Health Journal. 2001; 7(1/2):
197-203.

124
J Egypt Public Health Assoc Vol. 82 No. 1 & 2, 2007

13. El-Gilany A, Khalil A, Shady I. KAP of adolescent schoolgirls about

menstruation in Mansoura, Egypt. Bulletin of High Institute of Public
Health. 2004; 34(2):377-96.
14. Mobarak E, Mohey A, Kishk N. Experience of menarche among girls in
Alexandria: Community-based study, Alexandria 2003. Bulletin of High
Institute of Public Health. 2004; 34(2):335-56.
15. Fawaz LA, Heitham KA, Kamel MA. Age at menarche in Jordanian girls.
Saudi Med J. 2004; 25(20; 144-5.
16. Rahman MA. Early adolescent girl's understanding of menstruation.
Women and Health Journal. 1997; 19(2):10-5.
17. Hassanen RH, Tosson MM, Abd El-Elkareem HE. Effect of health
education and training program for secondary school students on
menstruation at Assiut Governorate. Bulletin of High Institute of Public
Health. 2004; 34(3): 575-94.
18. Drakashayani Devi K, Venkata Ramaiah P. A study on menstrual
hygiene among rural adolescent girls. Indian J Med Sci. 1994; 48(6): 139-
43.
19. Schrefer S. Quick reference to cultural assessment. St Louis, CV Mosby
Incorporated, 1994.
20. United States Department of Health and Human services. Public Health
Service. Clinician's handbook of preventive service. Washington DC,
united States Government, 1994.
21. Moustafa MF. Assessment of knowledge and practice of secondary
school students in Assiut about menstruation and menstrual hygiene.
Thesis. (Master) Assiut University, High Institute of Nursing, 1990.
22. Sobhy S, Morad M. Assessment of knowledge and practice related to
menstruation. Journal of Public Health. 1986; 14(1):5-6.
23. Alexander LL, La Rosa JK. New dimension in women's health. Boston:
Jones and Bartlett Co., 1994; p.196-199.
24. Sherwen VL, Scoloveno AM, Weingarten GT. Nursing care of the
childbearing family. 2nd ed. USA. Appleton and Lang. 1995; p.83-86.

125
 J Egypt Public Health Assoc Vol. 82 No. 1 & 2, 2007

25. Koff E, Rierdan J. Premenstrual expectations and post menarcheal

experiences of positive and negative menstrual related changes. Journal
of Adolescent Health. 1996; 18(4):286-91.
26. Koff E, Rierdan J. Preparing girls for menstruation: Recommendations
from adolescent girls. Adolescent Journal. 1995; 30:120-7.
27. Seidman RY. Effects of a premenstrual syndrome education program on
premenstrual symptomatology. Health Care for Women International.
1990; 11(4):491-501.
28. Olds SB, London ML, Ledwing PA. Menstruation and premenstrual
syndrome. Maternal newborn nursing: a family centered approach. 3rd
ed. California. 1988; p.133.
29. Lark M. Macronutrient intake, eating habits and exercise as moderators
of menstrual distress. Nursing Times. 1992; 35(1): 127-9.
30. Hassan M. Impact of nursing intervention on the relief of premenstrual
syndrome among students of the High Institute of Nursing in
Alexandria and Tanta. Thesis. (Doctorate) Alexandria. Alexandria
University, Faculty of Nursing, 1997.

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