Magnitude of safe menstrual hygiene management practice and its associated factors among adolescents’ girls in secondary and preparatory schools in Dire Dawa city, Eastern Ethiopia, 2023

INTRODUCTION

Menstruation refers to the regular shedding of the uterine lining through the vagina, accompanied by blood, regulated by the hormones of the hypothalamus-pituitary-ovarian axis. The onset of menstruation, known as menarche, marks a significant milestone in female puberty and signifies reproductive maturity.¹ Typically, girls begin menstruating around the age of 13 and continue until approximately 51 years of age. The menstrual cycle averages 28 days, although it can vary between 21 and 35 days. The duration of bleeding can range from two to seven days, with variations in flow intensity. It is common for the menstrual cycle to be irregular during the first two years following menarche.²

MHM encompasses personal hygiene practices during menstruation, which include selecting appropriate sanitary products, ensuring their correct usage and disposal, and maintaining body cleanliness. Effectively managing menstruation involves addressing menstrual blood flow while also engaging in daily activities such as attending school, participating in sports, and performing routine tasks.^3,4

Worldwide, approximately 2.3 billion girls and women face challenges in managing their menstruation due to insufficient MHM facilities, prohibitive costs, and a lack of awareness. Consequently, many resort to using unsuitable alternatives, such as old clothing or other unsanitary materials, which heightens their risk of infections and other health issues.^5,6 Recent research indicates that around 10% of women globally are susceptible to genital infections, including urinary tract infections and bacterial vaginosis, with 75% having experienced a genital infection at some point. Notably, common risk factors for vaginal infections include pregnancy and inadequate hygiene practices.^7,8

In low-income nations, the challenges associated with menstruation and inadequate menstrual hygiene contribute to the school absenteeism of millions of girls and women, thereby increasing the risk of school dropout.⁹ UNESCO reports that numerous adolescent girls in Africa are unable to attend school due to menstrual cramps, inadequate menstrual hygiene supplies, and insufficient water and sanitation facilities in educational institutions, unwelcoming environments, and anxiety regarding potential menstrual accidents.¹⁰

In Ethiopia, similar to other African nations, MHM represents a significant challenge for adolescent girls during their schooling. Many schools lack essential resources for managing menstruation, including menstrual products, designated areas for changing, access to running water, and proper disposal facilities. Research conducted in Southern Ethiopia, Western Ethiopia, and Ambo City indicates that the prevalence of safe MHM was recorded at 39.7%, 39.9%, and 46.7%, respectively.^8,11,12

Various factors influence menstrual hygiene practices, such as the age of the adolescents, their educational background, the educational levels of their parents, family size, place of residence, living conditions, household income, inadequate WASH facilities, lack of privacy in latrines, women's knowledge about menstruation, and the fear of being teased by boys.^10,12-15

Furthermore, there is a scarcity of information regarding menstruation and its hygienic management, as well as its impact on girls' education in Ethiopia. A previous study revealed that approximately 43.0% to 54.5% of female students missed school for 1 to 4 days during each menstrual cycle due to menstruation-related issues.^16,17 Therefore, the current study was aimed at assessing the magnitude of safe MHM practice and its associated factors among adolescents’ girls in secondary and preparatory schools in Dire Dawa City, Eastern Ethiopia, in 2023.

METHODS

Study setting and design

A facility-based cross-sectional study was conducted from September 1 to October 30, 2023, in Dire Dawa, Eastern Ethiopia. Dire Dawa is one of the most known and ancient cities in Eastern Ethiopia, It is located around 515 km from Addis Ababa. The Somali Regional State borders it in the east, west, and north, and the Oromia Regional State in the south and east. Dire Dawa has a total area of 1,558.64 square kilometers with an estimated density of 237.2 people per square kilometer. According to an unpublished report from the Dire Dawa Bureau of Education, the 2024 academic year saw a total enrollment of 19,954 students in secondary education. This includes 10,537 male and 9,417 female students. These students are distributed across 33 secondary and preparatory schools, which consist of 14 public and 19 private institutions.

Study population, sample size determination, and sampling procedure

The source of population of this study was all adolescents’ girls who were attending their education at the selected secondary and preparatory schools in Dire Dawa City, but the study population was all adolescents’ girls sampled from the selected secondary and preparatory schools in Dire Dawa City, Eastern Ethiopia. All 14-19-year-old female adolescents who started menses and who were willing to participate in the study were included in the study. Female adolescents who had no history of menstruation before data collection day, evening class girls, and those who were seriously ill at the time of data collection were excluded from the study.

The determination of the sample size was conducted using a single population proportion formula, referencing a previous study in Ambo town that reported a safe management proportion of menstrual hygiene practices at 46.4%.¹² With a confidence level of 95% and a margin of error set at 5%, the total sample size was adjusted to 422 after accounting for a 10% non-response rate.

A multistage sampling approach was employed to identify the study participants. The student population was categorized into two groups: public and private schools. From these categories, 30% of the schools were randomly selected using a lottery method, resulting in the inclusion of 8 schools (4 public and 4 private) in the study. The total number of female students in each selected school was obtained from the respective student registration records. The sample size was then proportionally distributed among the selected schools based on the number of female students enrolled. Finally, participants were chosen from each school through a simple random sampling method, utilizing the list of female students as the sampling frame.

Data collection tool and procedure

Data were collected through a self-administered interview using a standardized questionnaire developed from previous similar studies and UNICEF.^2,4,8,13,18 A structured and pre-tested questionnaire was employed to gather data, which included inquiries regarding sociodemographic characteristics, knowledge of menstruation, practices related to MHM, and the availability of WASH facilities in schools. The initial questionnaire was drafted in English, subsequently translated into Afan Oromo and Somaligna to enhance comprehension for both data collectors and participants, and then translated back into English to ensure consistency. A team comprising eight BSc nurses and four MSc graduates specializing in maternity was assembled for the data collection and oversight tasks. To uphold the quality of the data, the data collectors underwent a two-day training session focused on the study's objectives and the questionnaire's content prior to the commencement of data collection. A pretest was conducted with 5% of the sample from a high school, which was excluded from the main study. To ensure the validity of the data collection tools, discussions were held among data collectors and supervisors to address any inconsistencies or ambiguities in the questionnaire before the actual data collection began. Furthermore, the collected data were subjected to daily cross-checks for consistency and completeness. The integrity of the data quality was maintained through comprehensive training and effective supervision of the data collectors.

Operational definitions

Safe MHM practices refer to the use of clean menstrual materials by female students to absorb or collect menstrual blood, which can be changed in a private setting as needed throughout the menstrual period. Additionally, it includes the use of soap and water for washing as required and the availability of facilities for the disposal of used menstrual materials. This practice was evaluated through a set of 10 questions, where each correct answer was assigned one point, while incorrect answers and responses indicating uncertainty were scored as zero. The total score for MHM practices was derived from these 10 points, with participants achieving a mean score or higher classified as practicing safe MHM, and those scoring below the mean classified as unsafe.^13,18

Knowledge of MHM was assessed using 8 questions, with each correct answer earning one point, while incorrect answers and uncertain responses received zero points. The total knowledge score was calculated from these 8 points, with participants scoring at or above the mean considered to have good knowledge of MHM, and those scoring below deemed to have poor knowledge.^9,13,18

Access to water supply was defined as the availability of adequate water collection and usage points within the school, facilitating convenient access to water for drinking and personal hygiene purposes.¹⁸

Data processing and analysis

The data were entered into into Epi Data version 4.1, and the data was exported to SPSS version 24 for analysis. First descriptive analysis was done, and then, bivariate analysis was done. In multivariable logistic regression analysis, a variable with a p<0.2 in bivariate logistic regression analysis was entered, and the point degree of association was declared at a p=0.05. An odds ratio with a 95% confidence interval was used to measure the degree of association between those significant independent variables and safe MHM practice. The dependent variable was classified as a dummy variable. The model fit was checked by the Hosmer and Lemeshow test, which is the most reliable test of model fit available in SPSS. Hence, the chi-square value for the Hosmer-Lemeshow test is 4.024 with a significance level of 0.74. This value is greater than 0.05, therefore indicating the goodness of model fit.

A Multicollinearity test was also done to assess how much the variance of an estimated regression coefficient increases if the predictors are correlated. All values of the variance inflation factor were less than two. All values of the tolerance test were also above 0.2. These values show that there was no problem with multicollinearity in this study. The results are presented in the form of narrations, tables, and graphs.

RESULTS

A total of 422 adolescent girls who were enrolled in the secondary and preparatory schools of Dire Dawa City, Eastern Ethiopia, were invited to the study. Eight collected questionnaires were omitted since they were considered invalid (no response, incomplete response, or the same response to each item). Finally, 414 questionnaires were considered valid, and the response rate was approximately 98.1%.

Sociodemographic characteristics of the study participants

Regarding the socio-demographic characteristics of the respondents, the majority (72.5%) of the girls were in the age category of 13-16, and the mean age of the study participants was 15.34±1.01 years. About two-thirds of the students (73.7%) were from urban areas. About half (213, or 51%) of the female students were from preparatory schools (grades 11 and 12). More than half, 233 (56.3%) of the girl’s mothers had formal education, and more than three-fourths, 341 (82.4%) of their fathers had no formal education.

Nearly three-fourths 305 (73.7%) of participants were less than 15 years of age at menarche, and more than half (230, or 55.6%) of the girls were living with their parents. Regarding the family size and pocket money of female students, 184 (44.4%) of them have less than five family sizes, and more than half 224 (54.1%) of the female students did not obtain regular pocket money from their parents, respectively (Table 1).

Knowledge of menstruation and its hygiene management among adolescent’s girls in secondary and preparatory schools in Dire Dawa City, Eastern Ethiopia, 2023

Overall, in the present study, 350 (84.5%) of the adolescent's girls had good knowledge of menstruation and its hygiene management (Figure 1).

Majority 333 (80.4%) of them knew that menstruation was a physiological process, and, about 301 (72.7%) knew that the cause of menstruation was hormonal. Nearly three-fourths of 310 (74.9%) of girls knew the origin of the menstrual blood was from the uterus, while 104 (25.1%) thought that it was from the vagina. Regarding the duration of menstruation, 288 (69.6%) of them responded that, on average, the duration of menstruation lasts up to five days.

Regarding the normal menstrual cycle, the majority 288(69.6%) of them responded that, in the category of 20-35 days. Most 361 (87.2%) of the girls knew that taking care of personal hygiene during menstruation was important. Regarding the good absorbent during menstruation, most 339 (81.9%) of them stated that the sanitary pad was good absorbent (Table 2).

Safe MHM practice among adolescent’s girls in secondary and preparatory schools at Dire Dawa City, Eastern Ethiopia, 2023

In general, in the present study, of the overall MHM practices, 259 (62.6%) of the students had safe MHM practices (Figure 2).

The majority, 385 (93%) of the respondents, used sanitary pads to absorb menstrual blood, and about 346 (84.1%) of them used commercial disposable sanitary pads. More than half, of the study participants have changed pads more than two times per day during menstruation and washed their hands after they change pads/sanitary materials. Most of the study participants, 388 (93.7%), had washed their genitalia during menstruation. Regarding the disposal of the used sanitary pads, 279 (67.4%) of the respondents disposed of them in dustbins, and about 198 (47.8%) of them disposed of them by wrapping them in paper (Table 3).

Sociocultural and environmental factors for the management of menstrual hygiene in schools

About 259 (62.6%) adolescent girls reported that they had access to clean water at school. Regarding accessibility of toilet facilities at school, a majority of 359 (86.7%) of adolescent girls had access to toilet facilities, but 149 (36%) of students reported that toilets do not contain a container to dispose of the sanitary napkins.

Nearly three-fourths (74.3) of the participants reported that their school has handwashing facilities. Regarding school absenteeism during menstruation, nearly one third (136, or 32.6%) of adolescent girls reported that they had missed class during menstruation, and about one-fourth 109 (26.3) of the adolescent girls reported that menstruation interfered with the school performance (Table 4).

Factors associated with safe MHM practice and its associated factors among adolescent’s girls in secondary and preparatory schools in Dire Dawa City, Eastern Ethiopia, 2023

In the current study, residence, mother educational status, family size, regular pocket money, hearing about menstruation before menses start, knowledge about menstruation, communication about menstruation with families or friends, and having access to clean water at school were associated with safe MHM practice only at COR at p<0.05.

Multivariate logistic regression analysis was used to minimize the effect of confounding variables and identify real factors in safe MHM practice. Accordingly, residence, mother educational status, family size, and regular pocket money were all significantly associated with safe MHM practice at both crude and adjusted odd ratios at p<0.05.

In this study, the residence of adolescent’s girls was significantly associated with safe MHM practices. The odds of safe MHM practice were almost two [AOR=2.58, 95% CI=1.37-4.83] times higher in students with urban residence as compared to their counterparts.

This study also revealed that a mother's educational status was significantly associated with safe MHM practices. Girls whose mother’s educational status was formal were about three [AOR=2.94, 95% CI=1.26-5.05] times more likely to have safe MHM practices as compared to their counterparts.

The present study revealed that having regular pocket money from parents’ adolescent girls was significantly associated with safe MHM practices. Students who have regular pocket money from their parents were almost two [AOR=1.9, 95% CI=1.2-2.98] times more likely to have safe MHM practices as compared to their counterparts.

Finally, the present study revealed that family size was significantly associated with safe MHM practices. Adolescent’s girls with a family size less than five were almost three [AOR=5.5, 95% CI=3.12-9.89] times more likely to have safe MHM practices as compared to their counterparts (Table 5).

DISCUSSIONS

The main objective of this study was to determine the magnitude of safe MHM practices and their associated factors among adolescent’s girls in secondary and preparatory schools in Dire Dawa City, Eastern Ethiopia, in 2023. Accordingly, study revealed that magnitude of safe MHM practice among adolescents' girls in secondary and preparatory schools in Dire Dawa City was 62.6%. This finding was almost comparable with the previous studies conducted in the East Hararghe Zone (58.3%, Northeast Ethiopia (62.4% Batu Town, East Shewa (60.8%) and Dang District, Nepal (64%).^17,19-21

However, the result of this finding was lower than the studies done at Goba Town, South East Ethiopia (71.4%, Bahir Dar city (84.3%), Lucy Village of Ethiopian Great Rift Valley (70.2%), Ogbomoso, Oyo State, Nigeria (88.7%), adolescent school girls in Kano (92%), Indonesia (98.3%), Nelamangala, India (80.4%) and pastoralist community in Kenya (71.2%).^22-29 The observed discrepancy may stem from various factors, including differences in socioeconomic status that affect the ability to purchase suitable sanitary products, the availability and accessibility of appropriate sanitary materials, and the level of knowledge regarding menstrual hygiene.

However, the current finding is higher than the study’s done in Southern Ethiopia (39.7%), Western Ethiopia (39.9%, Ambo City, Oromia (46.7%), Akaki Kality Sub-city, Addis Ababa (45.2%), rural Uganda (9.5%) and Ghana (50.8%).^{8,11,12,30-32} A variations in sociodemographic characteristics and the composition of the study population could contribute to these differences. Another potential explanation lies in the differing methodologies employed to assess MHM in the current study compared to previous research.

In this study, the odds of safe MHM practice were almost higher in students with urban residence as compared to their counterparts. This finding was in line with studies conducted at East Hararghe Zone, Mehalmeda high school students in Amhara Regional State, Northeast Ethiopia, Central Ethiopia, Kembata Tembaro Zone, South Ethiopia, Harari Region, Kano Northwestern Nigeria, and India.^{2,4,11,17,19,33,34} It is plausible that girls residing in urban areas have greater access to information on MHM and are more likely to obtain sanitary pads available in the market. This finding underscores the necessity for targeted support for girls in rural areas, who face sociocultural barriers that hinder effective menstrual management.

In the current study, mother's education status was significantly associated with safe MHM practice, which is also supported by several studies, such as those done in Adama, Weliso District, South West Shoa Zone, East Hararghe Zone, Pakistan and Lebanon.^14,19,35-37 This can be explained by the fact that mothers with higher levels of education are more likely to possess a comprehensive understanding of menstrual hygiene practices, enabling them to engage in open discussions with their daughters about menstruation and to provide appropriate sanitary materials to ensure proper menstrual hygiene.

Adolescent girls with a family size less than five were more likely to engage in safe MHM practices than those with a family size greater than five, which is in line with studies done in the northern region of Ghana, adolescent girls in a resettlement colony of Delhi, Dang District, Nepal, and Ogbomoso, Oyo State, Nigeria.^21,25,37,38 This might be due to the fact that Adolescent girls from smaller families may possess greater knowledge and more favorable attitudes toward sexual and mental health (SMH) compared to their counterparts from larger, extended families.

Furthermore, the concentrated attention and education they receive in smaller family settings facilitate enhanced guidance and awareness regarding SMH.

In the present study, having pocket money from their families was significantly associated with the safe MHM practice in which adolescents Girls who earn permanent pocket money from their families were more likely to have safe MHM practices compared to those who don’t earn permanent pocket money from their families. This finding was in line with studies conducted in western Ethiopia, Harari Region and Eastern Ethiopia, and south India.^8,19,33,39 This could be due to the fact that the fact that girls who get money from their parents can easily buy sanitary napkins for their menstrual hygiene.

Limitations

The cross-sectional design of this research presents challenges in establishing a causal relationship between the dependent variable and its associated factors. To address these limitations, longitudinal studies are recommended. Additionally, the sensitive nature of the topic may lead to a heightened risk of social desirability bias. To mitigate this, we employed female data collectors and female educators to assist in the data collection process. Furthermore, there was a potential for recall bias regarding the precise age of menarche. To reduce this bias, we correlated the participants' first menstruation with the grade level they were in at that time.

CONCLUSION

The findings of this study indicate that over fifty percent of adolescent girls in secondary and preparatory schools in Dire Dawa City engage in safe MHM practices. Factors such as residing in urban areas, having mothers with formal education, belonging to families with fewer than five members, and receiving regular pocket money are associated with a higher likelihood of practicing safe MHM.

This study advocates for the implementation of educational initiatives aimed at rural adolescent girls regarding safe menstrual hygiene practices, fostering family support through resources and guidance, promoting financial independence to facilitate access to hygiene products, and collaborating with the community to cultivate a supportive environment for safe menstrual hygiene practices. By adopting these recommendations, we can empower adolescent girls to embrace and sustain safe menstrual hygiene practices, ultimately enhancing their health outcomes and overall well-being.

ACKNOWLEDGMENTS

Authors would like to thank to Dire Dawa University and to college of medicine and health for its monitoring.

Funding: Dire Dawa University

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Oakley Oliver R, Frazer Michele L, Oliver CK, Oakley R, Frazer Michele L. Pituitary-ovariansplenic axis in ovulation. Trends Endocrinol Metab. 2012;22(9):345-52.
2. 2. Gultie T. Practice of Menstrual Hygiene and Associated Factors among Female Mehalmeda High School Students in Amhara Regional State, Ethiopia. Sci J Public Health. 2014;2(3):189.
3. 3. Nepal W. Is Menstrual Hygiene and Management an Issue for Adolescent School Girls? A Comparative Study of Four Schools in Different Settings of Nepal. Kathmandu: Wateraid. 2009.
4. 4. Deriba BS, Garedew G, Gemeda D, Geleta TA, Jemal K, Bala ET, et al. Safe menstrual hygiene management practice and associated factors among female adolescent students at high schools in central Ethiopia: A mixed–method study. Front. Public Health. 2022;10:913262.
5. 5. UNICEF, WHO. United Nations Children Fund and World health Organization. Progress on Drinking Water, Sanitation and Hygiene-Joint Monitoring Programme 2017 Update and SDG Baselines. WHO. 2017;66.
6. 6. Kuhlmann H. Walle. Menstrual Hygiene Management in Resource-Poor Countries. Obstet Gynecol Surv. 2017;72(6):356-76.
7. 7. Mulugeta Demmu Y, Shifera GM, Ayana GM, Adare D, Yazew B, Damtew YT, et al. Menstrual hygiene management and associated factors among adolescent school girls in gursum district, Eastern Ethiopia: Institution-based a cross-sectional study. BMC Women's Health. 2023;23(1):328.
8. 8. Upashe SP, Tekelab T, Mekonnen J. Assessment of knowledge and practice of menstrual hygiene among high school girls in Western Ethiopia. BMC Women's Heal. 2015;15:84.
9. 9. UNESCO, Puberty Education and Menstrual Hygiene Management. Booklet 9, United Nations Educational, Scientific and Cultural Organization, Paris, France, 2014, Available at: https://www.susana.org/en/knowledge-hub/resources-and-publications/library/details/2213. Accessed on 14 December 2024.
10. 10. Mohammed S, Larsen-Reindorf RE, Awal I. Menstrual hygiene management and school absenteeism among adolescents in Ghana: results from a school-based cross-sectional study in a rural community. Int J Reprod Med. 2020;21:2020.
11. 11. Belayneh Z, Mekuriaw B. Knowledge and menstrual hygiene practice among adolescent school girls in southern Ethiopia: a cross-sectional study. BMC public health. 2019;19:1-8.
12. 12. Shallo SA, Willi W, Abubekar A. Menstrual hygiene management practice and factors affecting it among high school females in Ambo City, Oromia state, Ethiopia, 2018: A cross-sectional mixed method. BioRxiv. 2019;806422.
13. 13. Biruk E, Tefera W, Tadesse N, Sisay A. Assessment of menstrual hygiene management and its determinants among adolescent girls: a cross-sectional study in school adolescent girls in Addis Ababa, Ethiopia. BioRxiv. 2018;450007.
14. 14. Anchebi H, Shiferaw B, Fite R, Abeya S. Practice of menstrual hygiene and associated factors among female high school students in adama town. J Womens Health Care. 2017;6:2167-420.
15. 15. Azage M, Ejigu T, Mulugeta Y. Menstrual hygiene management practices and associated factors among urban and rural adolescents in Bahir Dar city administration, northwest Ethiopia. Ethiop J Reprod Health. 2018;10:10-20.
16. 16. Fehr E. Effects of Water Security on adolescent girls in South Gondar Ethiopia. Emory University. 2011.
17. 17. Tegegne S. Menstrual hygiene management and school absenteeism among female adolescent students in Northeast Ethiopia. BMC Public Health. 2014;14:1118.
18. 18. Abrahim J. Practice of Menstrual Hygiene Management and Associated Factors among High School Female Students in Meta District, Eastern Ethiopia. 2020.
19. 19. Mohammed Gena H. Menstrual hygiene management practices and associated factors among secondary school girls in East Hararghe Zone, Eastern Ethiopia. Adv Publ Heal. 2020;2020:1-7.
20. 20. Serbesa ML, Iffa SM. Assessment of menstrual hygiene practices and its associated factors among adolescent students in Batu High School in Batu Town, East Shewa, Ethiopia: a descriptive school-based cross-sectional study. J Heal Med Sci. 2018;1(1):71-80.
21. 21. Bhusal CK. Practice of menstrual hygiene and associated factors among adolescent school girls in Dang district, Nepal. Adv Preventive Med. 2020;2020:1292070.
22. 22. Niguse R, Ababe A, Wakjira G, Ketema G, Bekele Y. Assessment of Knowledge, Attitude and Practice towards Menstrual Hygiene among Goba High School Female Students in Goba Town, Southeast Ethiopia. 2019.
23. 23. Zeleke B. Menstrual hygiene management and associated factors among high school girls:-a case of Bahir Dar city administration (Doctoral dissertation, Addis Ababa University). 2016.
24. 24. Kitesa B, Getahun T, Wako K. Assessment of knowledge and practice of adolescent in-school girls towards menstrual hygiene management and determining factors in Lucy village of Ethiopian great Rift valley, 2016. Int J Immunol. 2016;4(6):52-63.
25. 25. Fehintola FO, Fehintola AO, Aremu AO, Idowu A, Ogunlaja OA, Ogunlaja IP. Assessment of knowledge, attitude and practice about menstruation and menstrual hygiene among secondary high school girls in Ogbomoso, Oyo state, Nigeria. Int J Reproduct Contracept Obstetr Gynecol. 2017;6(5):1726-32.
26. 26. Garba I, Rabiu A, Abubakar IS. Menstrual hygiene among adolescent school girls in Kano. Trop J Obstetr Gynaecol. 2018;35(2):153-7.
27. 27. Davis J, Macintyre A, Odagiri M, Suriastini W, Cordova A, Huggett C, et al. Menstrual hygiene management and school absenteeism among adolescent students in Indonesia: evidence from a cross‐sectional school‐based survey. Trop Med Int Heal. 2018;23(12):1350-63.
28. 28. Kavitha M, Jadhav J, Ranganath TS. Vishwanatha. Assessment of knowledge and menstrual hygiene management among adolescent school girls of Nelamangala. Int J Community Med Publ Heal. 2018;5:4135-9.
29. 29. Korir E, Okwara FN, Okumbe G. Menstrual hygiene management practices among primary school girls from a pastoralist community in Kenya: a cross sectional survey. Pan Afr Med J. 2018;31(1):222.
30. 30. Abebe M. Harar Bulletin of Health Sciences Extract Number 5, Menstrual Hygiene Practices in Adolescent Students in Akaki Kality Sub-city, Addis Ababa, Harar Bull Health Sci. 2012;5:127-40.
31. 31. Hennegan J, Dolan C, Wu M, Scott L, Montgomery P. Measuring the prevalence and impact of poor menstrual hygiene management: a quantitative survey of schoolgirls in rural Uganda. BMJ open. 2016;6(12):e012596.
32. 32. Mohammed S, Larsen-Reindorf RE, Awal I. Menstrual hygiene management and school absenteeism among adolescents in Ghana: results from a school-based cross-sectional study in a rural community. Int J Reprod Med. 2020;2020:6872491.
33. 33. Alemayehu A, Ahmed A, Abdalla M. Assessment of menstrual hygiene practice and associated factor among High school female students in Harari Region, Eastern Ethiopia. 2019.
34. 34. Gopalakrishnan L. Determinants of Menstrual Hygiene Practices among Young Women in India: Evidence From District-Level Household Survey. 2019.
35. 35. Kedir T. Knowledge And Practice of Menstrual Hygiene and Associated Factors Among Adolescent Girls In Weliso District, South West Shoa Zone, Oromia, Ethiopia. MPH thesis, Madda Walabu University, Bale-Goba, Ethiopia. 2021.
36. 36. Manzoor T, Azam N, Pervaiz F. Assessment of knowledge and practices menstrual hygiene management among adolescent school girls. Pak Armed Forces Med J. 2019;69(2):S247-53.
37. 37. Santina T, Wehbe N, Ziade FM, Nehme M. Assessment of beliefs and practices relating to menstrual hygiene of adolescent girls in Lebanon. Int J Health Sci Res. 2013;3(12):75-88.
38. 38. Sharma S, Mehra D, Kohli C, Singh MM, Shantanu S, Mehra D. Menstrual hygiene practices among adolescent girls in a resettlement colony of Delhi: a cross-sectional study. Int J Reprod Contracept Obstet Gynecol. 2017;6(5):1945-51.
39. 39. Omidvar S, Begum K. Factors influencing hygienic practices during menses among girls from south India: a cross sectional study. Int J Collaborat Res Internal Med Publ Heal. 2010;2(12):411-23.