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\begin{document}


\def\RunningAuthor{Bhupalam Pradeepkumar et al.}
\firstPage{3083}
\articleType{Original Article}
\receivedDate{12.05.2019}
\acceptedDate{10.08.2019}
\revisedDate{05.08.2019}
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\journalDoi{ijrps.v10i4.1598}
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\title{Impact of pharmacist mediated educational program on knowledge and practice of menstrual hygiene among adolescent girls}
\author{Bhupalam~Pradeepkumar\textsuperscript{*}\textsuperscript{1},  
            Narayana~G\textsuperscript{2},  
            Haranath~Chinthaginjala\textsuperscript{3},  
            Ramalingam~P\textsuperscript{4},  
            Somasekhar~Reddy~K\textsuperscript{1},  
            Sudheer~A\textsuperscript{1},  
            Veerabhadrappa~KV\textsuperscript{5}, 
            Vijayajyothi~M\textsuperscript{4}~\\[5pt]{\textsuperscript{1}Department of Pharmacology\unskip, Raghavendra Institute of Pharmaceutical Education \& Research, Anantapur- 515721, Andhra Pradesh, India}~\\{\textsuperscript{2}Department of Pharmacy Practice\unskip, Raghavendra Institute of Pharmaceutical Education \& Research, Anantapur - 515721, Andhra Pradesh, India}~\\{\textsuperscript{3}Department of Pharmaceutics\unskip, Raghavendra Institute of Pharmaceutical Education \& Research, Anantapur - 515721, Andhra Pradesh, India}~\\{\textsuperscript{4}Department of Medicinal Chemistry\unskip, Raghavendra Institute of Pharmaceutical Education \& Research, Anantapur - 515721, Andhra Pradesh, India}~\\{\textsuperscript{5}Department of Pharmacognosy\unskip, Raghavendra Institute of Pharmaceutical Education \& Research, Anantapur - 515721, Andhra Pradesh, India}}

\begin{abstract}
In India, awareness about menstruation before menarche was low, and it is viewed as unclean or dirty in society. In adolescent girls who attained menstruation for the first time, menstrual hygiene management is constrained by social, practical and economic factors such as the expense of sanitary pads, lack of water facilities, lack of private rooms for changing sanitary pads, and limited education about the facts of menstrual hygiene. The practice of good menstrual hygiene reduces the incidence of reproductive tract infections. The aim of the present study was to assess the impact of pharmacist mediated educational program on menstrual hygiene practice. A self-administered questionnaire comprises socio-demographic characteristics, knowledge related to menstruation and menstrual hygiene practice was used to collect data. The collected data was analyzed to assess the knowledge related to the menstrual hygiene practice, school attendance during the menstrual period at baseline and after providing education on menstrual hygiene.  Pharmacist mediated program had a positive impact on menstrual hygiene practice, Government of India need to conduct more educational programs on menstrual hygiene management at a community level.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Menstrual hygiene practice,\newline Menstruation,\newline Knowledge,\newline Adolescent girls
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Bhupalam~Pradeepkumar~\\ Phone:\ +91 9985968504~\\  Email:\ bhupalampradeep@gmail.com 
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
        \textsc{DOI:}\ \href{https://doi.org/10.26452/\@journalDoi}{\textcolor{blue}{\underline{\smash{https://doi.org/10.26452/\@journalDoi}}}}\par%
        \vspace*{-11pt}\hrulefill\\{\fontsize{9.12}{10.12}\selectfont Production and Hosted by}\par{IJRPS |~\href{https://ijrps.com}{https://ijrps.com}}\par%
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\section{Introduction}
Adolescence is an inimitable period of age characterized by substantial Physical, emotional, cognitive and social changes \unskip~\citep{591293:13727030}. Menstruation is one of the milestones of puberty and an inimitable event in life \unskip~\citep{591293:13727024}.


\begin{table*}[!htbp]
\caption{\boldmath {Socio demographic characteristics of study population } }
\label{tw-a45f8ad5012d}
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\ignorespaces 
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\begin{tabulary}{\linewidth}{p{\dimexpr.1047\linewidth-2\tabcolsep}p{\dimexpr.5095\linewidth-2\tabcolsep}p{\dimexpr.22400000000000006\linewidth-2\tabcolsep}p{\dimexpr.1618\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S. No & Variables (n=423) & Frequency & \%\\
\tblmidrule 
1 &
  Age at menarche &
   &
  \\
 &
  9 - 12 years \mbox{}\protect\newline 13 - 16 Years \mbox{}\protect\newline MT 16 Years &
  48 \mbox{}\protect\newline 368 \mbox{}\protect\newline 7 &
  11.35 \mbox{}\protect\newline 87 \mbox{}\protect\newline 1.65\\
2 &
  Occupational status of father &
   &
  \\
 &
  Farmer \mbox{}\protect\newline Merchant \mbox{}\protect\newline Employee \mbox{}\protect\newline Daily labor \mbox{}\protect\newline Others &
  144 \mbox{}\protect\newline 93 \mbox{}\protect\newline 86 \mbox{}\protect\newline 91 \mbox{}\protect\newline 9 &
  34.04 \mbox{}\protect\newline 22 \mbox{}\protect\newline 20.33 \mbox{}\protect\newline 21.51 \mbox{}\protect\newline 2.13\\
3 &
  Occupational status of mother &
   &
  \\
 &
  Housewife \mbox{}\protect\newline Merchant \mbox{}\protect\newline Employee \mbox{}\protect\newline Daily labor \mbox{}\protect\newline Others &
  309 \mbox{}\protect\newline 35 \mbox{}\protect\newline 59 \mbox{}\protect\newline 11 \mbox{}\protect\newline 9 &
  73.05 \mbox{}\protect\newline 8.27 \mbox{}\protect\newline 13.95 \mbox{}\protect\newline 2.6 \mbox{}\protect\newline 2.13\\
4 &
  Educational status of father &
   &
  \\
 &
  Primary and below \mbox{}\protect\newline Secondary and above &
  67 \mbox{}\protect\newline 356 &
  15.84 \mbox{}\protect\newline 84.16\\
5 &
  Educational status of mother &
   &
  \\
 &
  Primary and below \mbox{}\protect\newline Secondary and above &
  114 \mbox{}\protect\newline 309 &
  26.95 \mbox{}\protect\newline 73.05\\
6 &
  Financial status (Income) of the parents per annum (Rs.) &
   &
  \\
 &
  BPL \mbox{}\protect\newline 1-3 lacs \mbox{}\protect\newline MT 3 lacs &
  112 \mbox{}\protect\newline 279 \mbox{}\protect\newline 32 &
  26.48 \mbox{}\protect\newline 65.96 \mbox{}\protect\newline 7.56\\
7 &
  Source of information about menstruation &
   &
  \\
 &
  Mother \mbox{}\protect\newline Friends \mbox{}\protect\newline Teachers \mbox{}\protect\newline Others &
  97 \mbox{}\protect\newline 252 \mbox{}\protect\newline 53 \mbox{}\protect\newline 21 &
  22.93 \mbox{}\protect\newline 59.57 \mbox{}\protect\newline 12.53 \mbox{}\protect\newline 4.97\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
Globally, 20\% of the total populations were adolescents, and 85\% were living in developing countries \unskip~\citep{591293:13727032}. In India, awareness about menstruation before menarche was low. The limited knowledge available was passed down informally from mothers, who were themselves lacking in knowledge of reproductive health and hygiene due to low literacy levels and socioeconomic status \unskip~\citep{591293:13727039,591293:13727027}. Adolescent girls were the highly vulnerable group with respect to social status and health, and the menstruation is viewed unclean or dirty in society \unskip~\citep{591293:13727041,591293:13727027,591293:13727040,591293:13727023}. During menstruation, adolescent girls restricted in mobility, from participating in household and spiritual events and extend to eating certain foods like papaya and jiggery \unskip~\citep{591293:13727039,591293:13727040,591293:13727037}. In rural areas of India, even today's also menstruation is a secret of mother and daughter in many families \unskip~\citep{591293:13727040}. 

In adolescent girls who attained menstruation for the first time, menstrual hygiene management (MHM) is constrained by social, practical and economic factors such as the expense of sanitary pads, lack of water facilities, lack of private rooms for changing sanitary pads, and limited education about the facts of menstrual hygiene \unskip~\citep{591293:13727030}. Worldwide 10 \% of women are exposed to UTIs, due to lack of menstrual hygiene \unskip~\citep{591293:13727041,591293:13727036,591293:13727027,591293:13727035}. In low-income settings, school dropouts increase when the girl reach puberty \unskip~\citep{591293:13727026}. In India, very limited social and health-related research on menstruation problems \unskip~\citep{591293:13727040}.


\begin{table*}[!htbp]
\caption{\boldmath {Knowledge related to menstruation and menstrual hygiene practice at base line} }
\label{tw-6ddf93b6dd28}
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\tbltoprule \rowcolor{kwdboxcolor}S. No & Variables (423) & Frequency & \%\\
\tblmidrule 
1 &
  What is Menstruation? &
   &
  \\
 &
  Physiological process \mbox{}\protect\newline Pathological process \mbox{}\protect\newline Curse from god \mbox{}\protect\newline Don't know &
  271 \mbox{}\protect\newline 29 \mbox{}\protect\newline 87 \mbox{}\protect\newline 36 &
  64.07 \mbox{}\protect\newline 6.86 \mbox{}\protect\newline 20.57 \mbox{}\protect\newline 8.51\\
2 &
  What is the cause of Menstruation? &
   &
  \\
 &
  Hormones \mbox{}\protect\newline Pathological process \mbox{}\protect\newline Curse from god \mbox{}\protect\newline Don't know &
  198 \mbox{}\protect\newline 87 \mbox{}\protect\newline 96 \mbox{}\protect\newline 42 &
   46.80 \mbox{}\protect\newline 20.56 \mbox{}\protect\newline 22.7 \mbox{}\protect\newline 9.92\\
3 &
  Knowledge about menstrual ygiene &
   &
  \\
 &
  Yes \mbox{}\protect\newline No &
  198 \mbox{}\protect\newline 225 &
   46.8 \mbox{}\protect\newline 53.2\\
4 &
  Knowledge about menstruation (Before first menstruation) &
   &
  \\
 &
  Yes \mbox{}\protect\newline No &
  321 \mbox{}\protect\newline 102 &
  75.89 \mbox{}\protect\newline 24.11\\
5 &
  Path of urine and menstruation &
   &
  \\
 &
  Same \mbox{}\protect\newline Separate \mbox{}\protect\newline Don't know &
  227 \mbox{}\protect\newline 53 \mbox{}\protect\newline 143 &
  53.67 \mbox{}\protect\newline 12.53 \mbox{}\protect\newline 33.80\\
6 &
  Knew that there is foul smelling during menstruation &
   &
  \\
 &
  Yes \mbox{}\protect\newline No &
  251 \mbox{}\protect\newline 172 &
  59.33 \mbox{}\protect\newline 40.67\\
7 &
  Knew that menstrual blood is unhygienic &
   &
  \\
 &
  Yes \mbox{}\protect\newline No &
  263 \mbox{}\protect\newline 160 &
  62.17 \mbox{}\protect\newline 37.83\\
8 &
  Knowledge summary index &
   &
  \\
 &
  Good \mbox{}\protect\newline Poor &
  222 \mbox{}\protect\newline 201 &
  52.52 \mbox{}\protect\newline 47.48\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
The Ministry of Health and Family Welfare, Government of India, declared a new scheme for raise of menstrual hygiene among adolescent girls in the age group of 10-19 year in rural areas \unskip~\citep{591293:13727038}. Good hygienic practices, such as the practice of sanitary pads and adequate washing of the genital areas, are important during menstruation period; the practice of good menstrual hygiene reduces the incidence of reproductive tract infection \unskip~\citep{591293:13727034,591293:13727041,591293:13727033}. The present study is planned to assess the  impact of menstrual hygiene practice on knowledge and practice of menstrual hygiene among adolescent girls in backward areas of Andhra Pradesh, India.\textbf{\space }
    
\section{Materials and Methods}
\textbf{Ethical approval}

The study protocol was submitted to the Institutional Review Board (IRB). The study was initiated after ethical clearance from the Institutional Review Board with the approval number: RIPER/IRB/2016/028.\textbf{\space }


\begin{table*}[!htbp]
\caption{\boldmath {Impact of Pharmacist mediated educational program on knowledge and Practice of menstrual hygiene at base line and after follow up} }
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\begin{tabulary}{\linewidth}{p{\dimexpr.05890000000000001\linewidth-2\tabcolsep}p{\dimexpr.04620000000000001\linewidth-2\tabcolsep}p{\dimexpr.3822000000000001\linewidth-2\tabcolsep}p{\dimexpr.1241\linewidth-2\tabcolsep}p{\dimexpr.15389999999999999\linewidth-2\tabcolsep}p{\dimexpr.12710000000000003\linewidth-2\tabcolsep}p{\dimexpr.1076\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\multicolumn{2}{p{\dimexpr(.10510000000000002\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{S. No}} & {\multirow{2}{*}{Question}} & \multicolumn{2}{p{\dimexpr(.27799999999999997\linewidth-2\tabcolsep)}}{\cAlignHack Baseline} & \multicolumn{2}{p{\dimexpr(.23470000000000002\linewidth-2\tabcolsep)}}{\cAlignHack Follow-up}\\
\rowcolor{kwdboxcolor} &  &  & Frequency & \% & Frequency & \%\\
\tblmidrule 
\multicolumn{2}{p{\dimexpr(.10510000000000002\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{1}} &
  Type of material used during menstruation &
   &
   &
   &
  \\
 &
   &
  Old Cloth \mbox{}\protect\newline Falalin Cloths \mbox{}\protect\newline Sanitary Pads &
  189 \mbox{}\protect\newline 63 \mbox{}\protect\newline 171 &
  44.68 \mbox{}\protect\newline 14.89 \mbox{}\protect\newline 40.42 &
  16 \mbox{}\protect\newline 12 \mbox{}\protect\newline 395 &
  3.78 \mbox{}\protect\newline 2.83 \mbox{}\protect\newline 93.38\\
\multicolumn{2}{p{\dimexpr(.10510000000000002\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{2}} &
  Did you use the same Cloth/ Falalin/ Pads during menstrual period more than once? &
   &
   &
   &
  \\
 &
   &
  Yes \mbox{}\protect\newline No &
  209 \mbox{}\protect\newline 214 &
  49.41 \mbox{}\protect\newline 50.59 &
  11 \mbox{}\protect\newline 412 &
  2.61 \mbox{}\protect\newline 97.39\\
\multicolumn{2}{p{\dimexpr(.10510000000000002\linewidth-2\tabcolsep)}}{3} &
  Absent from school/ Work? &
   &
   &
   &
  \\
\multicolumn{2}{p{\dimexpr(.10510000000000002\linewidth-2\tabcolsep)}}{} &
  Yes \mbox{}\protect\newline No \mbox{}\protect\newline  &
  234 \mbox{}\protect\newline 189 &
  55.32 \mbox{}\protect\newline 44.68 &
  31 \mbox{}\protect\newline 392 &
  7.33 \mbox{}\protect\newline 92.67\\
\multicolumn{2}{p{\dimexpr(.10510000000000002\linewidth-2\tabcolsep)}}{4} &
  Skin abrasions &
   &
   &
   &
  \\
 &
   &
  No \mbox{}\protect\newline Yes &
  284 \mbox{}\protect\newline 139 &
  67.14 \mbox{}\protect\newline 32.86 &
  87 \mbox{}\protect\newline 336 &
  20.57 \mbox{}\protect\newline 79.43\\
\multicolumn{2}{p{\dimexpr(.10510000000000002\linewidth-2\tabcolsep)}}{5} &
  Feel unclean &
   &
   &
   &
  \\
 &
   &
  No \mbox{}\protect\newline Yes &
  292 \mbox{}\protect\newline 131 &
   69.03 \mbox{}\protect\newline 30.97 &
  94 \mbox{}\protect\newline 329 &
   22.22 \mbox{}\protect\newline 77.78\\
\multicolumn{2}{p{\dimexpr(.10510000000000002\linewidth-2\tabcolsep)}}{6} &
  Spoils dress &
   &
   &
   &
  \\
 &
   &
  No \mbox{}\protect\newline Yes &
  254 \mbox{}\protect\newline 169 &
   60.04 \mbox{}\protect\newline 39.96 &
  25 \mbox{}\protect\newline 398 &
  5.91 \mbox{}\protect\newline 94.09\\
\multicolumn{2}{p{\dimexpr(.10510000000000002\linewidth-2\tabcolsep)}}{7} &
  Stains visible to others on absorbent pad while drying &
   &
   &
   &
  \\
 &
   &
  No \mbox{}\protect\newline Yes &
  204 \mbox{}\protect\newline 219 &
  48.23 \mbox{}\protect\newline 51.77 &
  9 \mbox{}\protect\newline 414 &
  2.13 \mbox{}\protect\newline 98.87\\
\multicolumn{2}{p{\dimexpr(.10510000000000002\linewidth-2\tabcolsep)}}{8} &
  Feels uncomfortable &
   &
   &
   &
  \\
 &
   &
  No \mbox{}\protect\newline Yes &
  326 \mbox{}\protect\newline 97 &
   77.07 \mbox{}\protect\newline 22.93 &
  124 \mbox{}\protect\newline 299 &
  29.31 \mbox{}\protect\newline 70.69\\
\multicolumn{2}{p{\dimexpr(.10510000000000002\linewidth-2\tabcolsep)}}{9} &
  Cleaning of external genital organs with soap and water after every change of pads/ cloths. &
   &
   &
   &
  \\
 &
   &
  No \mbox{}\protect\newline Yes &
  228 \mbox{}\protect\newline 195 &
  53.9 \mbox{}\protect\newline 46.1 &
  316 \mbox{}\protect\newline 107 &
  74.7 \mbox{}\protect\newline 25.3\\
\multicolumn{2}{p{\dimexpr(.10510000000000002\linewidth-2\tabcolsep)}}{10} &
  Smells  &
   &
   &
   &
  \\
 &
   &
  No \mbox{}\protect\newline Yes &
  264 \mbox{}\protect\newline 159 &
  62.41 \mbox{}\protect\newline 37.59 &
  67 \mbox{}\protect\newline 356 &
  15.84 \mbox{}\protect\newline 84.16\\
\multicolumn{2}{p{\dimexpr(.10510000000000002\linewidth-2\tabcolsep)}}{11} &
  Drying problem &
   &
   &
   &
  \\
 &
   &
  No \mbox{}\protect\newline Yes &
  204 \mbox{}\protect\newline 219 &
  48.22 \mbox{}\protect\newline 51.78 &
  10 \mbox{}\protect\newline 413 &
  2.36 \mbox{}\protect\newline 97.64\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
\textbf{Study design and sample size}

An interventional study  was carried out at various schools of Anantapur district, AP, India for six months during June {\textendash} November 2016. The required sample size was calculated by using Epi-info 7 for Dos version 3.5.1 software (Centers for Disease Control and Prevention, Clifton Road, Atlanta, USA) with an assumption of confidence interval  95\%, a margin of error 5\% and proportion of knowledge about menstrual hygiene practice 50\%. Considering the above assumption, the sample size became 384. Finally, 10 \% of the determined sample was added to compensate for the non-response rate, and the sample size was found to be 423.\textbf{\space }

\textbf{Study criteria}

Adolescent girls in the age group of 10{\textendash}19 years who had attained menarche, and willing to participate were recruited in the study.  Adolescent girls who are sick and not attained menarche were excluded from the study. \textbf{\space }

\textbf{Study procedure}

The consent was obtained from the head of the school, parents and from the girls by explaining the objectives and details of the study. Privacy was ensured, and nobody was present during the collection of data. To collect the data, a self-administered questionnaire was prepared after a thorough literature review and validated. Finally, questionnaire was translated into local language Telugu. The questionnaire comprised variables on socio-demographic characteristics, knowledge related to menstruation and menstrual hygiene practice. The collected data was analyzed to assess the knowledge related to the menstrual hygiene practice, school attendance during the menstrual period at baseline and after providing education on menstrual hygiene practice. 

\textbf{Statistical analysis}

The collected data was checked for the completeness and analyzed to assess the knowledge related to the menstrual hygiene practice, school attendance during the menstrual period at baseline and after providing education on menstrual hygiene. Graph Pad Prism 3.0 software (San Diego, California, USA) was used for the statistical analysis. Descriptive statistics like mean, frequency and percentage were used to represent demographic details of subjects. 
    
\section{Results and Discussion}
Total of 423 adolescent girls were participated in the study. The present study revealed that the Mean age of the menarche was found to be 13.52 \ensuremath{\pm} 1.33 years. Among the participants, 87 \% were attained the menarche at 13-16 years (Table~\ref{tw-a45f8ad5012d}). This is almost similar to the studies from Egypt, Saudi Arabia, Ghana and Japan \unskip~\citep{591293:13727025,591293:13727031,591293:13727028,591293:13727029}. However, it is lesser with the studies from Ethiopia \unskip~\citep{591293:13727030}. This may due to variation in heredity, socioeconomic conditions and nutrition of the girls. Most of the students (59.57\%) acquire information about menstruation from their friends, followed by mother (22.93\%). It indicates that students are more interested and free to talk with their friends rather than mother and teachers. These findings were consistent with the study done at Egypt\unskip~\citep{591293:13727028}.

Among the participants, the majority (73.05 \%) of their mothers were housewives, and 26.95 \% of mothers have education at primary school level only (Table~\ref{tw-a45f8ad5012d}). 26.48\% of the participants parents income was below the poverty line (BPL), and only 7.56 \% of them have income more than INR 3 lacs (Table~\ref{tw-a45f8ad5012d}). In this study, 52.52 \% of the participants had good knowledge about menstruation hygiene (Table~\ref{tw-6ddf93b6dd28}). Majority of the students (64.07 \%) knew that menstruation was a physiological process, whereas few of them (20.57 \%) believed that it was from a curse of god (Table~\ref{tw-6ddf93b6dd28}). The results were lesser than previous studies in Ethiopia \unskip~\citep{591293:13727030}. This may be due to poor literacy among their parents.

The study showed that most of the respondents are unaware about menstrual hygiene and practices, due to social restrictions and lack of knowledge on the physiology of the reproductive system.

At baseline, 44.68\% were used old cloths, and 40.42\% were used sanitary pads. This was greatly improved after providing an educational program with 93.38\% were used the sanitary pads (Table~\ref{tw-70158f893588}). These results states that community-based educational programs could bring significant improvement in awareness of menstrual hygiene and practices. 

At baseline, most of the students have a higher rate (55.32\%) of absents to schools due to menstrual-related discomfort, Reproductive tract infections, skin abrasions due to improper menstrual hygiene practice. After educational interventional program regarding menstrual hygiene and practice, the rate of absentees for school work was greatly declined to 7.33\% (Table~\ref{tw-70158f893588}). 
    
\section{Conclusion}
The study concludes that the pharmacist mediated educational program will have a positive impact on menstrual hygiene and practices on adolescent girls in a resource-limited setting of south India. Govt. of India need to take initiation to conduct an educational program on menstrual hygiene and practices at a community level and also need to supply sanitary pads at the secondary school level with free of cost.
    

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