Menstrual Hygiene Management Practices and Associated Factors among Secondary School Girls in East Hararghe Zone, Eastern Ethiopia

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Introduction
Menstruation is a recurrent, normal physiological phenomenon in women's reproductive life [1]. However, many school girls in developing countries confront different menstrual hygiene management (MHM) challenges. Adequate MHM is defined as "women and adolescent girls using a clean menstrual management material to absorb or collect blood that can be changed in privacy as often as necessary for the duration of the menstruation period, using soap and water for washing the body as required, and having access to facilities to dispose of used menstrual management materials" [2].
In developing countries, nevertheless, many girls cannot access or afford appropriate sanitary materials and often use inferior products such as new or old cloth, cotton wool, toilet paper, underwear alone, sponge, or nothing [3][4][5][6][7]. Additionally, MHM is constrained by inadequate water, sanitation, and hygiene facilities in many school settings in developing countries [3,8]. Survey performed in five sub-Saharan African countries including Ethiopia also showed that majority of adolescent girls reported a lack of safe, private, and clean toilets with washing facilities at schools which is important for MHM practices [4].
It was investigated that unhygienic practices during menstruation increase the risk of reproductive and genitorurinary tract infection. Accordingly, several studies reported infections related to unsafe MHM practices among women and adolescent girls [9][10][11]. Menstruation and MHM-related problems adversely affect girls' school attendance and school performance. e study performed in sub-Saharan African countries revealed that on average, 49% of the school girls missed four school days monthly due to menstruation [4]. Similarly, other studies in Bangladesh and Indonesia revealed that 41% of school girls missed an average of 2.8 school days and 11.1% of school girls missed at least one school day during their last menstruation period, respectively [6,12]. Furthermore, studies identified that many school girls claimed difficulty of concentration and limited participation during class times due to discomfort and humiliation during menstruation [13][14][15]. Besides, MHM practices among school girls can affect multiple areas across the sustainable development goal (SDG) agenda including health, education, and gender equality and women empowerment.
Like many developing countries, in Ethiopia, MHM remains one of the main problems faced by school girls while they are in school. Despite enormous challenges related to menstrual hygiene, adequate attention was not given by the water, sanitation, and hygiene (WASH), sexual and reproductive health, and education sectors. Ethiopia is a country of vast sociocultural diversity and taboos that have an impact on MHM practices. us, it is important to identify the practices of MHM to intervene accordingly. However, there is scarce information about MHM practices in Ethiopia, particularly in the study area. erefore, this study was designed to assess MHM practices and associated factors among secondary school girls in East Hararghe Zone, Eastern Ethiopia.

Study Design, Setting, and Population.
A school-based cross-sectional study design was conducted in East Hararghe Zone, Eastern Ethiopia, from April to May 2017. East Hararghe Zone has three urban and nineteen rural districts. According to the East Hararghe Zone Education Department, of all school age children in the zone, 53% enrolled in primary schools and 10% in secondary schools. In the year 2017, there are 58 secondary schools in the zone serving a total of 30,619 (20,677 male and 9,942 female) students. e target population was all secondary school girls, and the study population was all girls sampled from the selected secondary schools in East Hararghe Zone. Evening class girls and those who are seriously ill at the time of data collection were excluded.

Sample Size Determination and Sampling Procedures.
e required sample size was calculated using a single population proportion formula by considering the following assumptions: 70.2% proportion of girls who had good MHM practices among secondary school girls [16], 95% confidence interval, and 5% margin of error. By considering a design effect of 2 and 5% nonresponse rate, the total sample size was 676. A multistage sampling technique was used to select study participants. First, four secondary schools were randomly selected from the total secondary schools in the zone. e total number of female students in each selected school was taken from the student registration books of the respective school. en, the sample size was proportionally allocated to each selected school based on the number of female students. Finally, the study subjects were selected from each school using a simple random sampling technique considering the list of female students as a sample frame.

Data Collection Instruments and
Procedures. Data were collected using a structured interviewer-administered questionnaire. e questionnaire was developed from relevant literature and adapted to the cultural norms of the study area. e questionnaire comprises of the sociodemographic profile of the study participants, knowledge about menstruation and its hygienic management, and hygiene practices during menstruation. e knowledge status of the girls was measured according to Balqis et al. [17] where the level of knowledge categorized as good when the total score is 76-100%, moderate when it is 56-75%, and poor when it is <56%. e MHM practices score was calculated out of 10 practice specific questions. Each correct answer was given one mark, and any incorrect or do not know answer was given zero marks. e total score of practice ranges from 0 to 10. e mean score of MHM practices (5.64 ± 1.19) was used to decide the cutoff point. Accordingly, respondents who scored 6 and above were categorized as having good MHM practices, while those who scored less than 6 were categorized as having poor MHM practices [18]. e questionnaire was first prepared in English and translated to Afan Oromo (the local language) and back to English to check its consistency. Ten diploma nurses as data collectors and three BSc level public health professionals as supervisors participated in the data collection process.

Data Quality Assurance.
e training was given for data collectors and supervisors on the purpose of the study, study tools, and data collection techniques for two days. e questionnaire was pretested on 5% of the sample size among secondary school girls in the district out of the main study area, and necessary amendments were made accordingly. During data collection, supportive supervision was made by supervisors, and the collected data were checked for completeness and consistency by the supervisors and the principal investigator daily.

Data Processing and Analysis.
e data were entered into Epi-Data version 3.1 and exported to the Statistical Package for Social Science (SPSS) version 20 for analysis. Descriptive analysis was computed to describe the sociodemographic characteristics of the participants and measure the level of knowledge and hygienic practices during menstruation. Furthermore, bivariate and multivariable analyses were performed to identify the determinant factors of MHM practices among schoolgirls. Crude odds ratio (COR) and adjusted odds ratio (AOR) with 95% confidence intervals were used to measure the associations, and the level of significance was set at a p value less than 0.05 in multivariable analysis.

Ethical Consideration.
Ethical clearance was obtained from the Institutional Health Research Ethics Review Committee (IHRERC) of the College of Health and Medical Sciences of Haramaya University. Permission to conduct the study was also obtained from the Zonal Education Department and principals of the selected schools. A written and signed consent was obtained from homeroom teachers, and a written and signed consent or assent was obtained from the girls regarding their agreement to participate in the study after the objective of the study was explained to them. e students were interviewed one by one separately using an anonymous questionnaire to ensure the confidentiality of the information.

Sociodemographic Characteristics of the Study
Participants. From the total of 676 secondary school girls asked to participate in the study, 672 completed the interview making a response rate of 99.4%. More than half (399 (59.4%)) of the girls were in the age group of more than 16 years with the mean (±SD) age of 16.5 (±1.12) years. Majority (467 (69.5%)) of the girls were living with their parents, followed by 110 (16.4%) living with peers. Majority (423 (63%)) of the girls were rural by resident, 490 (72.9%) were Muslim by religion, and 632 (94.0%) were single by marital status. Higher number (190 (28.3)) of the girls were from Kombolcha Secondary School and more than half (373 (55.5%)) were from grade nine. Around half (343 (51.0%)) of the girl's mothers and (308 (45.8%)) of their fathers had no formal education, while only 120 (17.9%) of their mothers and 150 (22.3%) of their fathers attained a secondary and above level of education (Table 1).

Knowledge of Menstruation and its Hygiene Management.
Overall, 460 (68.5%) girls had good knowledge. Majority (517 (76.9%)) of them knew that menstruation was a physiological process, and 40 (6.0%) thought that it was a pathologic process. Regarding causation, 491 (73.1%) knew that the cause of menstruation was hormonal, 33 (4.9%) thought that it was caused by a disease, and 24 (3.6%) thought that it was caused by curses. Nearly three-fourth (493 (73.4%)) of girls knew the origin of the menstrual blood was from the uterus, while 75 (11.2%) thought that it was from vagina. Most (626 (93.2)) of the girls knew that taking care of personal hygiene during menstruation is important. Regarding the ideal menstrual absorbent, most (586 (87.2)) of them stated that sanitary pad was good absorbent ( Table 2).

Factors Associated with MHM Practices.
In multivariate analyses, residency, mother's educational status, and girls' knowledge status towards menstruation and its hygienic practices were found to be independent predictors of MHM practices. Girls from urban areas were 2.59 times more likely to have good MHM practices compared to their counterparts (AOR � 2.59, 95% CI: 1.77-3.80). Girls whose mother's educational status was secondary school and above were about 2 times more likely to have good MHM practices compared to those whose mothers had no formal education (AOR � 1.83, 95% CI: 1.01-3.30). e likelihood of practicing good MHM was 2.78 times higher among those students who had moderate knowledge (AOR � 2.78, 95% CI: 1.64-5.28) and 3.87 times more likely among those who had good knowledge (AOR � 3.87, 95% CI: 2.21-6.77) compared to those who had poor knowledge (Table 4).

Discussion
is study aimed to assess the practices of MHM and associated factors among secondary school girls in East Hararghe Zone. It was observed that 58.3% of the girls had good MHM practices in this study. is is similar to the study done in Adama town, Ethiopia, [19], but higher than the study conducted in Nekemte town, Western Ethiopia [18], where 57% and 39.9% of the girls practiced good MHM, respectively. e discrepancy could be due to the difference in cultural beliefs about MHM practices in the study areas and the study period.
In this study, only 66.1% of the girls used commercial disposable sanitary pads, which is much lower than the Advances in Public Health   [20], and 80.4% in India [21]. e possible reasons for this discrepancy might be due to the difference in socioeconomic status to buy appropriate sanitary products, availability and accessibility of appropriate sanitary materials, and knowledge towards menstrual hygiene.
Regarding the frequency of changing menstrual absorbents, only 379 (56.4%) of the girls changed absorbents more than three times a day. is is lower than another study from southern Ethiopia [22] where 62.4% of the girls changed absorbents more than three times a day, and other studies from Kenya where 60.6% of the respondents keep changing pads every 3-4 hours a day [8], and Indonesia where 75.6% of the respondents keep changing pads every 4-6 hours a day [23]. e disparity in the frequency of changing menstrual absorbents could be attributed to the difference in access to adequate sanitary materials and sanitary facilities (water and private latrine) at school.
It was investigated that 459 (68.3%) of the girls cleaned their external genitalia with water and soap during menstruation, which is in line with another study in Ethiopia  Advances in Public Health 5 (69.5%) [22]. Furthermore, 321 (47.8%) of the girls took bath daily during menstruation. is is consistent with the study conducted in Kenya that reported 47.5% daily bathing during menstruation days among adolescent girls [8]. However, it is lower than other studies from Indonesia [17] and Nepal [24] that reported 99.8% and 78.7% daily bathing during menstruation, respectively. e possible explanation for this variation might be related to the difference in cultural beliefs about MHM practices and availability of sanitary facilities in the study areas.
Regarding the determinant factors of MHM practices, several studies revealed that girls' place of residence was significantly associated with their MHM practices [12,14,16,25,26]. Similarly, this study showed that girls living in urban areas were more likely to have good MHM practices compared to their counterparts. e discrepancy between urban and rural girls towards hygienic practices could be due to the differences in access to appropriate information about menstrual hygiene, access to appropriate and affordable sanitary products, and access to sanitary facilities at the household and school levels. It may also be partly attributed to socioeconomic differences between urban and rural residents, since the majority of Ethiopia's poor live in rural areas.
Furthermore, higher maternal education was positively associated with girls' good MHM practices in this study. Accordingly, girls whose mothers' educational status was secondary school and above were about 2 times more likely to have good MHM practices compared to girls whose mothers had no formal education. is finding is consistent with several other studies across the world that identified a positive association between higher maternal education and girls' good menstrual hygiene practices [18,[27][28][29][30][31]. is can be explained by the fact that educated mothers might have a better awareness of menstrual hygiene practices, and thus, they could have an open discussion with their daughters about menstruation and/or more likely provide appropriate sanitary materials for them to keep their menstrual hygiene during menstruation.
is study also revealed that a better knowledge about menstruation and its hygiene management was positively associated with good MHM practices of secondary schoolgirls.
is supports other studies done in Ethiopia [7,22], Nigeria [31], and India [32]. is is also in agreement with the findings of other studies that demonstrated that educational interventions on menstrual hygiene lead to more knowledge and better practices of MHM [5,9,33,34]. e possible explanation might be due to the fact that sufficient knowledge of menstruation could empower the girls to overcome the negative influences of cultural beliefs and social taboo surrounding menstruation and its hygienic practices attributed by the community they live in, and hence, they could keep their hygiene during menstruation. e study has its own limitations. First, the cross-sectional nature of the study design cannot establish the cause and effect relationships between the outcome and explanatory variables. Second, this study follows only quantitative data collection; hence, it lacks a qualitative component for triangulation. us, further longitudinal and mixed methods study is recommended for researchers. Finally, since the study addressed the sensitive topic about menstruation, there may be social desirability bias. But the interviews were conducted in a private circumstance using well-trained female data collectors to minimize this bias.

Conclusions
In this study, more than half of secondary school girls had good MHM practices. e girls' living areas, knowledge status towards menstruation and its hygiene, and mothers' educational status were significantly associated with MHM practices.
erefore, there is a high need for awareness creation about menstruation and its appropriate management for schoolgirls. Mass media could be used to disseminate accurate information about menstrual hygiene management, particularly for rural settings. Policymakers and stakeholders should also give special attention towards making the school environment a comfortable place for girls to manage their menstrual hygiene.

Data Availability
e data used to support the findings of this study are available from the corresponding author upon request.

Conflicts of Interest
e author declares that there are no conflicts of interest.