This chapter provides the background of the study, statement of the problem, research general objective, specific objectives, research questions, significance, scope, conceptual framework, and well as the justification of the study.

Background

Menstrual hygiene management (MHM) remains a public health concern globally, as every day millions of women and girls have to manage their menstruation [1]. It is estimated that at least 500 million women and girls globally lack adequate facilities for MHM [2]. Menstruation is an entirely natural physiological process yet still considered too ‘private’ to discuss [3]. The onset of menstruation means a new phase and new vulnerabilities in the lives of girls [4]. Girls face a multitude of challenges beyond the immediate practicalities of learning to manage a monthly inconvenience and in many cultures, the onset of menstruation affects not just a girl's body, but also her role and status in the community [1]. Girls are disproportionately affected by the challenges posed by menstruation in the least developed countries, where often a majority of adolescent girls are not told about menstruation before experiencing their first period and where sanitary products are all too often un affordable [5].

There is evidence of 'inadequate' menstrual hygiene, in terms of personal hygiene or products used among girls from around the world, and it has been demonstrated that menstruating girls in school environments face several challenges which include a lack of adequate, clean, safe, private toilets with water and disposal mechanisms for used menstrual materials, a lack of information, guidance and support on their changing bodies and new menstrual management needs, and insufficient materials for managing monthly menstrual flow [6] Lack of access to basic hygiene products has led girls to use unhygienic materials, such as rags, leaves, and papers which expose them to urinogenital infections [7]. Girls also absent from school or are less attentive in class during menstruation due to a lack of WASH (water, sanitation, and hygiene) facilities and support from the school community which affects their education [8]. In Uganda, 28% of adolescent girls miss at least four school days per cycle [9]. School girls also engage in transactional sex to pay for menstrual products which increases their risk of HIV (Human Immunodeficiency Virus), unintended pregnancy, and school dropout that come with other far-reaching consequences [10, 11].

In the last decade, interest has grown globally on the issue of menstruation in schools. In an effort to ensure dignity for women and girls, the United Nations in 2014, declared May 28th of every year a Menstrual Hygiene Day that aims to create awareness and highlight the importance of MHM to different stakeholders [12]. In 2014, UNICEF and Columbia University organized the MHM in Ten meeting with a wide range of actors, to map out a ten-year agenda for MHM in schools with a vision of; “Girls in 2024 around the world are knowledgeable and comfortable with their menstruation, and able to manage their menses in school in a comfortable, safe and dignified way” [13]. In Uganda, the Ministry of Education and Sports (MoES) has taken several steps towards improving MHM in schools; along with UNICEF, SNV, and Plan International, developed a national program in 2021 aiming at addressing challenges surrounding MHM in schools [14]. As part of this national strategy, the MoES developed and distributed a Menstrual Reader to schoolgirls to increase their education regarding MHM [15]. It also issued a circular that instructed all schools and local governments to support menstrual hygiene management [16].

Despite the above efforts, there is inadequate literature about menstrual hygiene management practices and associated factors among secondary school girls in Lira Sub- County Lira City West. Yet knowledge of MHM practices and associated factors would be a cornerstone in enabling adolescent school girls to manage their menstrual cycle and helping the responsible stakeholders in making informed decisions and actions. Therefore, it was against this background that this study assessed the MHM practices and associated factors among secondary school girls in Lira Sub- County Lira City West.

Statement of the Problem

Menstrual Hygiene Management (MHM) remains a public health concern globally with more ground in Low and Middle-Income Countries (LMICs), like Uganda [17]. In a survey conducted in rural Uganda, 90.5% of the respondents had poor MHM practices [18]. Schools have not been adequately provided with MHM guidance, information, sanitation facilities, and materials for girls making it difficult for them to adapt to their body changes and the external environment [19]. They suffer from stigma, and a lack of services and facilities to help them cope with the physical and psychological pains they undergo during their menstrual periods [20].

Limited access to basic hygiene products has led school girls to use unhygienic materials, such as rags, leaves, and papers exposing them to urogenital infections [7]. Some engage in transactional sex to pay for menstrual products which increases their risk of Human Immunodeficiency Virus (HIV), unintended pregnancy, and school dropout [10, 11]. In Uganda, 28% of girls miss at least four school days per cycle, and about 23% drop out of school when they begin menstruation [21, 9].

Several interventions have been put in place in Uganda for example; the MoES developed a “menstrual reader” distributed to school girls to increase their education regarding MHM. Also, the National Strategy for Girls’ Education was revised to emphasize the importance of addressing MHM [22]. However, the actual proposed actions to address MHM are still largely underdeveloped despite all the efforts to improve MHM in schools. In Lira, there is inadequate literature about MHM and associated factors among secondary school girls and yet this could help in improving menstrual hygiene practices in schools. It was against this background that this study assessed the MHM practices and associated factors among secondary school girls in Lira Sub- County Lira City West.

Objectives of the Study

Main objective: The main objective was to assess the menstrual hygiene management practices and associated factors among secondary school girls in Lira Sub-County Lira City west.

Specific Objectives: The study was guided by the following specific objectives,

• To determine the menstrual hygiene management practices among secondary school girls of Lira Sub-County Lira City West.
• To assess the socio-cultural factors associated with menstrual hygiene management practices among secondary school girls of Lira Sub-County Lira City West.
• To assess school-related factors associated with menstrual hygiene management practices among secondary school girls of Lira Sub-County Lira City West.

Research Questions

• The study sought to answer the following research questions:
• What are the menstrual hygiene management practices among secondary school girls of Lira Sub-County Lira City West?
• What are the socio-cultural factors associated with menstrual hygiene management practices among secondary school girls of Lira Sub-County Lira City West?
• What are the school-related factors associated with menstrual hygiene management practices among secondary school girls of Lira Sub-County Lira City West?

Significance of the Study

Stakeholder: The research findings are beneficial for the Government and stakeholders of Secondary Schools in Lira Sub-County Lira City West, considering the fact that the Government through the ministry of health including partners is willing to do everything possible to promote good MHM practices as a measure to further reduce the incidence and prevalence of school dropouts.

Policy: The results of this study help policy makers in planning, policy preparation, and developing appropriate interventions.

Research: It provides data and literature for future researchers in the same field.

Practice: The findings of this study highlight gaps and improve the management of menstrual hygiene.

Education: This study findings provide information to teach health workers and students about MHM.

Justification of the Study

Menstrual hygiene management practices are crucial in the prevention of urogenital tract infections. However, little is known about MHM practices and associated factors, particularly among secondary school girls in Lira Sub- County lira district. Therefore, in order to achieve sustainable development goals (SDG) targets in education, gender equality, reduction of maternal mortality, and water and sanitation, this study assessed MHM practices and associated factors among secondary school girls in Lira Sub-County Lira City West.

Scope of the Study

Content Scope: The study assessed the practice of menstrual hygiene management and associated factors among secondary school girls in Lira Sub-County Lira City West.

Geographical Scope: It was carried out in Lira Sub- County Lira City West division, Lira City, Lango sub-region in Northern Uganda.

Time Scope: It was conducted February 2022 to August 2022.

Conceptual Framework

Figure 1: Conceptual framework.

Showing MHM practices and associated factors-Adapted from [23].

Conceptual Framework Narrative

The conceptual framework was developed through a literature review as a guide to Factors influencing sanitation and hygiene practices among students in a public university in Bangladesh [23].

As shown in the diagram above, it was conceptualized that Menstrual Hygiene Management practices are determined by school-related factors, socio-demographic factors, and socio-cultural factors. The dependent variable was menstrual hygiene management practices and the independent variables were the factors associated with MHM practices.

Socio-cultural factors are factors related to society and culture such as Knowledge regarding menstrual hygiene, perceived health benefits, and cultural beliefs.

Socio-demographic factors are personal factors such as age, mother's education level, and mother’s occupation.

School-related factors are factors related to conditions at school for example pit latrine for both boys and girls separately, availability of clean water, and provision of pads by the school teasing by boys.

All these factors can result in good or poor MHM practices.

This chapter reviewed literature in relation to; the various menstrual hygiene management practices, and the factors associated with menstrual hygiene management practices by secondary school girls.

Overview of Menstrual Hygiene Management Practices and Associated Factors

Adequate MHM would require having access to a clean menstrual management material that can be changed in privacy as often as necessary for the duration of a menstrual period, using soap and water for washing the body as required, and having access to safe and convenient facilities to dispose of used menstrual management materials.

Girls suffer from poor menstrual hygiene, originating from lack of knowledge, culture, tradition, socio-economic and environmental constraints leading to inconveniences and stress. This leads to reduced school attendance and even dropouts, and ultimately violates the girls’ human rights [24].

Menstrual Hygiene Management Practices

In a study conducted to assess factors influencing menstrual hygiene practice among late adolescent girls in an urban area of Belgaum, Suhasini and Belgaumndra reported that less than half, 43.4% of the adolescent girls used sanitary pads and around 52.8% of the girls practiced cleaning of external genitalia during menstruation [25]. However, this study was carried out in communities compared to mine which was conducted in schools.

A study conducted among adolescent school girls in Dang District, Nepal to determine menstrual hygiene practice and associated factors reported a total of 272 (67.0%) adolescents had good menstrual hygiene practice [26]. However, this was carried out in a developed country, unlike mine which was carried out in a developing country.

In a study on factors affecting menstrual hygiene management practice among school adolescents in Ambo, Western Ethiopia, of the 336 respondents, 53.6% of participants' MHM practices were unsafe. And the frequency of washing genitalia during menses was the most poorly managed Followed by the disposal of used pads [27]. Unlike my study which was only quantitative, this was a mixed-method study.

According to a study conducted on MHM practices and associated health outcomes among school- going adolescents in the rural Gambia, reusable cloths/towels were the most commonest absorbent materials used by the girls (192, 53%), majority reported that they used soap and water to wash their absorbent material (302, 98%) and dried them in the “bathroom” at home (264, 85%), and majority reported that during their menstrual period they changed their absorbent material 3 times a day (200, 56%) and had a bath including vaginal wash at least twice a day (339, 95%) [28]. However, this was a mixed-method study compared to mine which was only quantitative.

Social Demographic Factors Associated With Menstrual Hygiene Management Practices

In a community-based cross-sectional study conducted in an Urban Area of Belgaum, factors like age, religion, socio-economic status, and mothers' literacy were significantly associated both with the use of sanitary pads and the practice of perineal hygiene [25]. Similarly, a study conducted in Dang District Nepal reported that parents with literate educational background, family size greater than or equal to 5, and living with relatives were significantly associated with good menstrual hygiene practice [29]. However, these were carried out in developed countries where people have higher access to knowledge unlike mine which was carried out in an under developed country.

In a cross-sectional survey about menstrual hygiene management practices among primary school girls from a pastoralist community in Kenya, socio-demographic factors associated with poor MHM practices were age and religion [30]. However, this study was carried out among primary school girls, unlike my study which was carried out among secondary school girls.

A study conducted to examine the extent of good menstrual hygiene practices and associated factors among high school girls in Dessie City, Amhara Region, and northeastern Ethiopia reported that; age, school grade level, and maternal education, were significantly associated with good menstrual hygiene practices [31]. However, this study was carried out in a country where people are well informed.

Socio-Cultural Factors Associated With Menstrual Hygiene Management Practices

In a systemic review mapping the knowledge and understanding of menarche, menstrual hygiene, and menstrual health among adolescent girls in low- and middle-income countries, exclusion and shame were found to lead to practices during menstruation [32]. However, this was reported in a systemic review compared to mine which was a cross-sectional study.

A cross-sectional study to assess the knowledge and menstrual hygiene practice among adolescent school girls in southern Ethiopia reported that 68.3% of adolescent school girls in Gedeo zone had poor knowledge regarding menstrual bleeding [33]. However, this study was done in a region where people have more access to information.

A study conducted among adolescent school girls in Dang District, Nepal to determine menstrual hygiene practice and associated factors reported that a total of 87.7% of adolescents had good knowledge regarding menstrual hygiene and thus good MHM practices [26]. This study was carried out in a developed country, unlike my study which was carried out in the least developed country.

A study conducted on factors impacting on menstrual hygiene and their implications for health promotion in Mongu District, Western Province of Zambia, shows that the girls suffer from poor menstrual hygiene, originating from lack of knowledge, culture, and tradition constraints [24]. This was reported in an explorative study design unlike mine which was a descriptive cross-sectional study.

In a study conducted to examine the extent of good menstrual hygiene practices and associated factors among high school girls in Dessie City, Amhara Region, northeastern Ethiopia, good knowledge regarding menstruation, discussing menstrual hygiene with friends, and obtaining money for pads from the family was associated with good MHM practices [31]. However, this study was carried out in a more developed country than Uganda.

Most of the girls in a study conducted on MHM practices and associated health outcomes among school-going adolescents in the rural Gambia reported that they had learnt about menstruation before menarche (228, 64%) [28]. However, this was a mixed-method study compared to my study which was only quantitative.

In a study conducted to investigate menstruation management practices, barriers and facilitators, and the influence of menstruation on school absenteeism among secondary school students in a peri-urban district of Uganda, Girls reported substantial embarrassment and fear of teasing related to menstruation in the qualitative interviews and said that this together with menstrual pain and lack of effective materials for menstrual hygiene management, led to school absenteeism [8]. However, this study was carried out in Entebbe district which is more developed compared to Lira district where my study was carried out.

In the study analysis of menstrual hygiene practices in Nepal, many girls reported feeling scared, confused and embarrassed when their menstruation started, and many did not know what was happening to them [34]. This study included both students and teachers as respondents unlike mine which only included students.

School-Related Factors Associated With Menstrual Hygiene Management Practices

Unavailability of water in college, absence of soap for hand washing, no bins for disposal of used pads, and missing door locks on hostel toilets were said to contribute to poor menstrual hygiene in a study conducted to explore the MHM knowledge, attitudes, and practices of female college students in Bhutan [35]. This study was carried out among college students unlike the mine which was carried out among secondary school students.

In a study conducted in Malawi to investigate the acceptability of menstrual products, girls highlighted their lack of facilities to effectively wash and dry reusable pads which affected their menstrual hygiene [36]. However, this was an explorative qualitative study, unlike my study which was a descriptive cross-sectional quantitative study.

School factors found to be significantly associated with poor MHM practices included lack of provision of pads, lack of water, lack of latrine privacy, and teasing by boys also the long distance to private changing areas and no water at school were found to promote poor MHM practices in a study conducted among primary school girls from a pastoralist community in Kenya [30]. However, this was conducted among primary school girls, unlike mine which was among secondary school girls.

In a study conducted on factors impacting on menstrual hygiene and their implications for health promotion in Mongu District, Western Province of Zambia, girls reported living in permanent fear that their male classmates might detect their condition, either when they mess themselves accidentally or a boy noticing a used pad in a girl's bag [24]. However, this was an explorative study, unlike my study which was a descriptive cross-sectional study.

Most girls (81.4%) reported improved school toilet facilities, which improved their comfort managing menstruation in a study that was carried out to pilot test an intervention to improve menstrual hygiene health (MHH) and school attendance in Uganda [37].

However, this was a pilot intervention longitudinal study compared to mine which was a cross- sectional quantitative study

The supply of disposable pads for the girls by the school was found to promote good menstrual hygiene in a study conducted on MHM practices and associated health outcomes among school- going adolescents in rural Gambia [28]. Unlike my study which was only quantitative, this study was a mixed-method study.

Summary of Literature Review

From the review of literature, studies have reported poor MHM practices and some good ones. Most reported factors to be associated with MHM practices were; socio-demographic factors like age, level of education of parents, and other factors like latrine privacy, and knowledge about menstruation among others. However, there were limited studies conducted in Uganda and Northern Uganda in particular. No study has been conducted in Lira Sub-County Lira City thus the need to conduct a study assessing MHM practices and associated factors among secondary school girls in Lira Sub-County Lira City.

This chapter describes the research study design, study site/area and setting, study procedure, study population, sample size determination, sampling techniques, eligibility criteria, data collection techniques/methods and instruments, data analysis, quality control, ethical considerations, and dissemination of results.

Study Design

This was a cross-sectional study using quantitative techniques of data collection and analysis because the exposure and the outcome was assessed at the same time.

Study Site and Setting

The study was carried out in mixed secondary schools of Lira Sub- County, Lira City West Division, Lira City.

Lira City is the main administrative, and commercial centre of Lira District. It is located approximately 100 kilometres (62 miles), southeast of Gulu City the largest city in northern Uganda, along the high way of Gulu and Mbale. Lira city lies 124 kilometres northwest of Soroti City. This location lies approximately 337 kilometres (209 miles), by road, north of Kampala.

The city has two divisions of Lira city east (comprising of Adekwok Sub County, Ngetta and Lwal Sub County, Lira central division and railways division) and Lira city west (comprising of Ojwina Sub County, Adyel Sub County and Lira Sub County). Lira Sub County comprises of 9 secondary schools of which 7 are mixed secondary schools.

Study Population

Target population: All secondary school girls who have reached menarche in Lira Sub-County Lira City West.

Accessible population: All secondary school girls who have reached menarche and were present on the day of data collection.

Eligibility Criteria

Inclusion Criteria: All Secondary School girls who have reached menarche were included in the study.

Exclusion Criteria: Girls who were too ill on the day of data collection and those who declined to participate were excluded from this study.

Sample Size

The sample was determined using Leslie Kish formula (1965) for single proportion.

Where

n = Estimated sample size

Zα/2=confidence level of significance for a 95% to confidence interval (Zα/2=1.96)

P= percentage of good MHM practices among secondary school girls is 71.2% taken from a similar study done in Kenya [30]

q= (1-p), probability of poor menstrual hygiene practices, (1-0.712) = 0.288

d= precision of the study which is 5% (0.05).

Hence sample size = 315 participants.

Sampling Technique and Procedure

The study used multistage sampling method which involved two mixed secondary schools being selected by simple random sampling. Names of mixed secondary schools in Lira Sub County (Amuca SDA Secondary School, Lira high school, Odokomit Secondar School, Bulluge Comprehensive Secondary School, Cotn Marani Honors High school, Lira Secondary School, and Townside High School, Lira) were written on separate papers, folded, and then shuffled. Two papers were picked randomly and the schools on those papers were taken for my study population. This study also employed convenience random sampling technique given the availability of the study participants who met the inclusion criteria. The first participant was selected randomly then subsequent participants were selected depending on their availability until the desired sample size of 315 was realized. An approximation of 60 study participants were interviewed each day and this took about 5 days to hit the targeted study population, thus this procedure was repeated until the targeted number was reached. This sampling procedure was selected to achieve the target sample population with limited resources and time.

Data Collection Methods

Semi-structured questionnaires were administered to study participant and the questionnaires were in written English.

Data Collection Instruments

Data was collected using a semi-structured questionnaire that was designed based on the literature of the previously conducted similar studies in other parts of the world.

It contained four sections; a social-demographic section, a section on socio-cultural factors, school-related factors, and the menstrual hygiene management practices of secondary school girls in Lira Sub- County Lira City West. All questions in this questionnaire were having corresponding answers therefore the study participants were choosing from those alternatives.

Data Collection Procedure

The data collection process started with seeking permission from the school. The session then started by building rapport with the respondents followed by introducing the study topic, purpose of the study, then seeking their consent and assent to participate in the study. Upon Informed consent, semi-structured questionnaires were administered in a quiet, safe place observing high levels of confidentiality and comfort of the study participant. Students were giving their responses under the guidance of the researcher.

Quality Control

Validity:

• The questionnaires were double-checked by my supervisor, edited, and modified to suit the interest of the research.
• Questionnaires were pretested prior to data collection and sticking to the inclusion and exclusion criteria.
• Data collected was checked daily for completeness of the questionnaires before leaving the field
• Getting feedback on the research process and data itself from the participants to increase the chances of results being implemented.

Reliability: Reliability was used to measure the degree to which the questionnaire will produce consistent results under similar and different conditions. The questionnaires were pretested on 10 secondary school girls who have reached menarche in Standard High School.

Data Analysis

Data entry and cleaning was done using Excel software, then imported in SPSS version 23 for data analysis. Data analysis was done using SPSS (Statistical Package for Social Sciences) version 23 computer software. The data analysis composed of univariate analysis where descriptive statistics of the socio-demographic characteristics, socio-cultural factors, and school-related factors of the respondents were analyzed and presented using numbers, percentages, and measures of central tendency (mean, mode) where appropriate. A bivariate analysis was used to describe the association between variables and multivariate to find predictors of MHM practices.

Data was presented in frequencies, percentages, tables, and graphs. On bivariate, a variable that was found to have a P-value <0.05 was considered significant.

Ethical Considerations

Approval: The proposal was presented to the department of nursing and midwifery and thereafter to the Faculty of Health Science. Approval letter was issued and taken to the school authorities where the study was to be conducted requesting for permission.

Consent: Written consent and assent were sought from students who participated in the study.

Confidentiality: The researcher avoided identifiers like names on participants’ information, Data was coded to ensure confidentiality

A password was put on the laptop containing participants' data. Honesty was maintained throughout the research process; in collecting and reporting data, results, methods, and procedures used during data collection in order to avoid fabrication, falsification, misrepresentation, and or misreporting of data. The questionnaires were kept in a lockable cupboard.

All quotations used and sources were clearly distinguished and acknowledged by means of references.

Dissemination of Results

The findings of the study will be presented to the department of nursing and midwifery, Lira University. Presentation will be made and copies submitted to Lira University library and to the schools where data was collected.

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