Effect of Health Educational Program on Knowledge and Self-care Practices about Menarche among Preparatory School Girls in Alexandria Governorate

: Background: Menarche and menstruation are taboo topics that many groups, especially adolescent girls, find unsettling. The health educational program was created to help female adolescents get ready for menarche. The study aims were to identify the effect of health educational program on knowledge and self-care practices about menarche among preparatory school girls in Alexandria Governorate. Subjects and Methods: Design: A quasi-experimental study design was used. Setting: A multistage random sampling technique was used. Sample: Students in the selected classes (around 50 preparatory girls from each school) were divided in the sample of 100 female students (study group) and 100 female students (control group). Tools of data collection: Three tools were used for data collection. Tool (I): Preparatory school girl's basic data structured interview schedule. Tool II: Preparatory school girls' puberty related knowledge structured interview schedule. Tool III: Preparatory schoolgirl’s self-care practices regarding puberty and menarche structured schedule. Result: Significant correlations were found between the general self-care practices of students and their knowledge about menses (P=0.001). Significant relationships were found between the number of siblings, the mother’s age, the mother’s education level, and the student’s knowledge (P=0.001). Conclusion: According to the findings of the current study, it can be concluded that menarche education program has significantly impact on improvement of preparatory school student's knowledge and their self-care practices. Recommendation: The application of programs should help to the development of in-service training programs for healthcare providers who take care of adolescent girls about issues related to menstruation and reproductive health.

. No. 2 (SuppL 2 ) , May 2024 Introduction Women's reproductive health, including adolescent females, is one of the focuses of Sustainable Development Goals (SDGs) and it is one of the goals of WHO to improve equality in health, reduce health risks, and promote healthy lifestyles and setting (Setyowati et al., 2019).The World Health Organization (WHO) mentions that self-care is a broad term that includes general and personal hygiene, nutrition, lifestyle factors such as exercises, self-medication, and following treatment plans for current illnesses (World Health Organization: WHO, 2022).During the stage of adolescence, individuals typically fall within the age range of 10 to 19 years.Presently, there are 1.3 billion adolescents globally, constituting 16 percent of the total world population.Among these adolescents, over 600 million are girls aged between 10 to 19 years, with more than 500 million residing in low and middle-income nations (World Health Organization: WHO, 2019).In Egypt, the adolescent population aged 10-19 is estimated to be around 17 million, making up roughly 19% of the overall population.Additionally, girls under the age of 20 in Egypt amount to approximately 19 million, accounting for one-fifth of the country's total population (UNFPA, 2022).Puberty is an endocrine process that involves the physical, emotional, and sexual transition from childhood to adulthood.It happens gradually, under the direction of the hypothalamic-pituitary, in a sequence of distinct events and milestones.Menstruation, also known as the period, is a woman's regular monthly cycle of vaginal bleeding.A woman's body gets ready for pregnancy every month.In the event of no pregnancy, the lining of the uterus, or womb, sheds.Part of the blood from the menstrual cycle is made up of uterine tissue and blood.It exits the body through the vaginal canal.(Beckmann, 2019).
The normal menstruation has many characteristics; the age of onset of menstruation ranges between 10 -16 years, average 13 years, in studies, worldwide the mean age of menarche was 12.1 years and in Egypt the mean age of menarche was 12.3 years, the regular duration of menstruation lasts for a few days usually 3 to 5 days, but anywhere from 2 to 7 days is considered normal, the average blood loss during menstruation is 35 milliliters with 10-80 mL considered normal, the normal menstrual flow follows a "crescendo-decrescendo" pattern; that is, it starts at a moderate level, increases somewhat and then slowly decreases (Eric, 2018).The first menstrual period (menarche), physical, cognitive, and social changes can impact body image and self-esteem and earlier age at menarche has been associated with a higher risk of depression in late adolescence.On the other end of the reproductive spectrum, some people experience mood swings and depression symptoms during the menopausal transition due to hormonal changes, physical symptoms, and psychological factors.During these phases, menstrual symptoms are frequently more bothersome as well; for instance, cycles may become more irregular and people may bleed more heavily.In view of this, it becomes important for parents, teachers, and health care practitioners especially nurses to be adequately involved in the promotion of adolescent menstrual hygiene and self-Vol.33.No. 2 (SuppL 2 ) , May 2024 care.Nurses care for adolescents in a variety of settings, including communities, schools, and public health and acute care clinics, which affords them many opportunities to enhance adolescents' sexual and reproductive health (Adika et al., 2013).In all seven nursing practice sites, school health nurses make ensuring that teenagers have access to sexual and reproductive health care, including treatment and preventive counseling.With their special set of abilities, school health nurses can influence adolescent sexual and reproductive outcomes in a favorable way.School health nurses possess the ability and chance to educate teenagers and their parents about sexual and reproductive health.(Romero et al., 2015).Protecting adolescents' confidentiality is crucial to ensuring their access to health care and is also an essential component of that care.School health nurses can and should offer appropriate sexual and reproductive health screening and counseling to adolescents and their parents as part of annual examinations.School health nurses can advise parents on the importance of confidential access to sexual and reproductive health counseling (Brittain et al., 2015;Romero et al., 2015).Although adolescents are usually too embarrassed to initiate conversations with providers about sexual and reproductive health and risky sexual behavior, wellprepared nurses may be able to ease adolescents' embarrassment and facilitate communication.Parent-child interaction and parental monitoring have been shown to improve sexual and reproductive health outcomes (Brittain et al., 2015;Dittus et al., 2015).School health nurses play a crucial role in providing adolescents with comprehensive sexual and reproductive healthcare services, encompassing preventive counseling and treatment, across all nursing practice sites.Leveraging their distinctive blend of expertise and skills, school health nurses can significantly influence positive outcomes in terms of adolescent sexual and reproductive health.Moreover, they possess the capability and platform to effectively interact and educate both adolescents and their parents about sexual and reproductive health matters (Ramalepa, 2023).This study was conducted to determine the effect of health educational program on knowledge and self-care practices about menarche among preparatory schoolgirls in Alexandria Governorate, Egypt.Significance of the study: Majority of adolescent girls usually have lack of scientific knowledge and hygienic practice during menstruation and puberty, also adolescent girls often are reluctant to discuss this embracing topic with their care-providers and often hesitate to seek help regarding the menstrual problem from external sources.So, girls should be educated about "menstruation and healthy menstrual practices" through expanded program of health education.Data on their level of knowledge and practices are beneficial for planning program for improving their awareness level.

Aim of the study:
The present study aimed to identify the effect of health educational program on knowledge and self-care practices about menarche among preparatory school girls in Alexandria Governorate.

Implementation phase:
The program was implemented to study group in the form of five sessions; one session per week it included the following: I. Theoretical part: It was carried out in three lectures combined with a whiteboard presentation: -Session 1(30 minutes): The researcher was discussing the anatomical and physiological characteristics of the female reproductive system (parts and function of reproductive system).
- reward to correct answer, at end of the session repeat the main point and ask questions.

Evaluation phase:
The researcher was assessing for the study group in preparatory school girl's puberty related knowledge and self-care practices regarding menarche for post-test by using tools I&II.This was done immediately after the end of sessions to determine the effect of the health educational program on knowledge and self-care practices about menarche among preparatory school girls in Alexandria Governorate.
Post-test was done for the control group about five weeks after the pretest (at the same week with the study group) 7-After data collection, it was coded and transferred into a specially designed format to be suitable for computer feeding.Following data entry, checking and verification process were carried out to avoid any error during data entry.Statistical analysis was performed using Statistical package for Social Sciences (SPSS version 23) and tabulated.The level of significance selected for this study was p equal to or less than 0.05.The following statistical measures were used: A. Descriptive statistics: 1) Count and percentage: used for describing and summarizing the quantitative data.

B. Analytical statistics:
The following statistical measures were used: -Comparisons between groups for categorical variables were assessed using Chi-square test (Monte Carlo) were used to describe the characteristics of the study sample and main variables.
-Student t-test was used to compare two groups for normally distributed quantitative variables.Pearson coefficient was used to correlate between normally distributed quantitative variables.Regression to detect the most independent/ affecting knowledge and practice.Structure Equation Modeling was assessed using AMOS 23 0 software to detect the direct and Indirect Effect of different variables on knowledge and practice.

Ethical Considerations:
-Prior to data collection; research consent form was given to the director of each school in order to assume protection of human rights of the study subjects.-Written informed consent was obtained from the study subjects after explanation of the aim of the study.Privacy and confidentiality: -Confidentiality and anonymity of participants' response was guaranteed by statement in the cover page.
-A code number was used instead of names.
-Participants' privacy was assured.
-Students were informed that their participation in the study is voluntary, and they can withdraw from the study at any time if they wish.Result Table (1) shows the distribution of the studied subjects according to their demographic data.It was found that all students in the study and control groups lived in urban areas (100% for each).About half of the students in the control group (49.0%) were 15 years old, compared to 55.0% of the students in the study group, with a mean ± SD of 14.75 0.67 and 14.91 0.66, respectively.Concerning the student's height, it was observed that the mean ± SD of the student's height in the control group was 144.68.56 compared to 144.98.60 in the student in the study group, while the mean ± SD of the student in the control group was 69.4418.62 compared to 70.0518.0 in the student in the study group.It was also found that an equal percent of students in both groups had two siblings (45.0% for each), with a ± SD of 2.250.78 and 2.210.88,respectively.It was also clarified from the same table that less than half of students in the control group were in the second birth order compared to 37.0% of students in the study group, with a mean of 2.79 1.14 and 2.70 1.17, respectively, in the control and study groups.Table (1) also portrays that more than half of mothers in both groups (57.0% and 55.0%, respectively) were 35 to less than 45 years old, with a mean SD of 48.78 9.04 and 48.93 8.76, respectively.Onehalf of the mothers in the control group had attended secondary school (50.0%), compared to 44.0% of the mothers in the study group.48.0% of mothers in the control group were housewives, compared to more than half of mothers in the study group (53.0%).Regarding father's education, it was found that two-thirds of fathers in the control group had preparatory education, compared to 72.0% of fathers in the study group.Nearly half of fathers' jobs in both groups were trades or business (40.0%and 45.0%, respectively), and the majority of fathers in both groups reported insufficient monthly income (85.0%and 80.0%, respectively).Table (2) portrays the distribution of the studied sample according to menstrual data.It was found that all students in the control and study groups had their first menstrual period (100.0%for each).Fifty percent of the students in the control group answered that the menstrual cycle was explained before it occurred, compared to 43.0% of the students in the study group.More than half of the students in both groups identified the internet as the source of their knowledge (53.0% and 55.0%, respectively).It was also revealed that more than half of the students in both groups reported moderate amount of menstrual blood (57.0% and 59.0%, respectively).More than two-thirds of students in the control group reported a regular menstrual cycle (68.0%)compared to 65.0% of students in the study group, and more than one-half of the students in both groups reported the number of days of their menstrual bleeding were 3-5 days (54.0% and 59.0%, respectively).It was also revealed that small percentages of students correctly answered about using cloth pads and the time of taking a shower during their menstrual period preprogram (12.0% and 20.0%, respectively), compared to the majority of them postprogram (97.0% and 95.0%, respectively).It was found from the same table that small percentages of students correctly answered about the cleansing of themselves from the menstrual cycle and the frequencies of washing external genitalia preprogram (16.0% and 27.0%, respectively), and these percentages increased to more than half of them postprogram (62.0% and 59.0%, respectively).In addition, it was also observed that nearly one-third of students correctly answered the direction of the external rinsing of the external genitalia (31.0%) preprogram compared to more than threequarters of them post-program (79.0%).On the other hand, less than half of students (40.0%) correctly answered the question about the frequency of changing sanitary pads during their menstrual cycle preprogram, and this percent decreased to only 1.0% of them post-program.The majority of students correctly answered the correct way to dispose of a single-use sanitary pad (89.0%) preprogram compared to all of them post-program (100.0%).Only 8.0% of students correctly answered how to prevent infections preprogram, compared to the majority of them post-program.Table (7) Correlation table between the study variables.This table portrays the correlation between the study variables.It was found that significant correlations were found between the general self-care practices of students and their knowledge about menses (0.509*: P 0.001).It was also shown that significant correlations were found between the following study variables: student age, number of siblings, mother's age, mother's education level, father's education level, family monthly income, and knowledge about menses and their general self-care practices (P 0.001* for each).While significant correlations were found between the father's job, the mother's job, and their general self-care practices only (P = 0.001 for each).

Table (8) multiple Linear Regression
Analysis Showing the Effect of demographics on knowledge and practice (n =200): Table 8 displays the Effect of demographics on knowledge and practice through Multiple Linear Regression Analysis.It was found that significant relationships were found between the number of siblings, the mother's age, the mother's education level, and the student's knowledge (P = 0.001*).On the other hand, the same table found that significant relationships were found between the mother's educational level, the father's job, and their practices (P: 0.049* and P:< 0.001*, respectively).Table (9, 10) direct and indirect effect of study variables on students' knowledge and their practices: Tables 9 and 10 show the direct and indirect effects of study variables on students' knowledge and practices.It was found that there were direct and significant relationships between students' knowledge and the number of siblings, the mother's age, and the mother's education level (P = 0.001* for each).Moreover, it was revealed that there were direct and significant relationships between students' practice and their knowledge, their mother's education level, and their father's job (P: <0.001*, 0.001*, and 0.041*, respectively).0.97±0.17(Alharbi, 2018).The discussion of the study results will be presented under three main headings: (1) knowledge assessment (2) self-care practice assessment, (3) choices, care, and disposable sanitary pad.Generally speaking, in relation to the study subjects' socio-demographic data, the results of the present study that both the study and control groups were matching in almost all aspects of their professional characters and their menstrual pattern, (Tables I & II).This can be interpreted in the light that most female preparatory school students are from the same socioeconomic class.Also, this matching is valued in controlling extraneous factors which could interfere with the effect of the proposed menarche educational program on knowledge and self-care practice on female preparatory school.It also aided in comprehending and ensuring the validity and relevance upcoming findings of the current study.As regarding to knowledge assessment, Pre educational program at a glance the results of this study showed that the study and control groups had low level of knowledge regarding menarche with no statistically significant difference between them.This result is probably attributed to the fact that both groups had not attended any teaching classes about physiology of puberty and menarche hygiene.In fact, they did study puberty through only one lecture in the theoretical part of the science course during their third academic year.This result is consistent with the findings of two other researchers.First: (Parasuraman et al., 2022).They had investigated the impact of health education intervention on menstruation and its hygiene among urban school-going adolescent girls, in Thiruvallur, Tamilnadu.Their results revealed that a majority of the students had low mean knowledge score pre intervention.Second (Mohamed et al., 2018).They had conducted a study entitled '' Effect of Health Education Program on Menstrual Practices among Secondary School Girls''.Their results showed that the presence of low knowledge level pre intervention among the adolescent girls with no statistically significant differences between the study and control groups.Post educational program, the findings of the present study showed that the majority of the study group had higher knowledge level than the control group with a statistically significant difference between them in favor of the study group.This result may be attributed to many reasons.First, communicating the high expectations to study group pre-program implementation had motivated them to exert effort for achieving a high score in the knowledge test.Second, the integration of knowledge acquired through the educational training sessions as well as the use of different learning activates such as power point presentation, diagrams, and photos about physiology of menarche and its hygiene.In addition to the use of brain storming, and problem-based learning scenarios all of these techniques encourage the retention and repletion of knowledge.This result is consistent with the findings of the previously mentioned study by (Parasuraman et al., 2022) their results revealed that an improvement in the median scores of knowledges is more observed among the girls who attained menarche education at late age.Second the previously mentioned study by (Mohamed et al., 2018).Their results explored the presence of a statistically significant increase in knowledge level post intervention among the study group.Third the study conducted by (El-Mowafy et al., 2014) they had conducted a study entitled'' Effect of Health Education Program on Knowledge and Practices about Menstrual Hygiene among Adolescents Girls at Orphanage Home.Their results showed that participants' knowledge regarding puberty and menstruation was improved significantly after the intervention (p < .005).
Such an agreement between the results of the present study and the previously mentioned studies is probably attributed to the fact that repetition of knowledge in theoretical part through educational sessions more than one time brought additional improvement and increased knowledge retention among the study subjects.As regard to self-care practices, the result of the present study showed that the majority of the participants had poor self-care practices related to menstrual hygiene with no statistically significant difference between the study and control groups at pretest.Whereas as in the post-test, the majority of the study group had good selfcare practices related to menstrual hygiene, and there is a significant difference between the pre-test and post-test level of practice regarding menstrual physiology and hygiene in favor of the study group, which implies that the conducted health education program had a good impact on improving the level of practice among the adolescent girls.This result is coinciding with two other studies conducted by (Arasteh, 2019), they conducted a study entitled '' Effect of group counseling on adolescent girls in improving knowledge and practice of menstrual hygiene in welfare boarding centers''.The second one (Vandana, 2016) they had investigated the knowledge of adolescent school-going girls regarding menstruation and menstrual hygiene.Both studies mentioned that there was a significant improvement in the level of practice after the intervention program.Specifically speaking, good hygiene practices such as use of sanitary napkins and adequate washing of genital area are essential during menstruation to decrease the incidence of morbidity rate.The results of the present study revealed that the overall hygienic practice was insignificantly improved after menstrual educational program.There was a significant improvement in number of students washing their hands every time using the toilet, cleaning the genital area as well as changing their sanitary pads every 4-6 hours.These findings are similar to the findings by (Santhanakrishnan et al., 2018) they investigated the ''Impact of health education on menstrual hygiene: An intervention study among adolescent schoolgirls''.Their results concluded that menstrual hygiene practices such as cleaning external genitalia and washing with water and soap the cloths was improved after intervention among the study group.This agreement between the finding of this study and the current studyin this respect-may be attributed to the fact that the present study sample size was almost equal to that of the Santhanakrishnan, I. et al study's sample (200 adolescent girls) also the similarity in the study area, as well as the study design.Concerning the choices, care and the disposable of sanitary pad, the result of the present study showed that there is no statistically significant difference between the study group was observed pre intervention.this picture was changed at post intervention period whereas, a statistically significant difference was noticed between the study and control groups in favor of the study group.About one half of the study group had used the disposable sanitary pads preprogram compared to the majority of them postprogram.It was also showed that more than one third of preparatory female students in study group had reported that they wash their clothes alone pre-program compared to the majority of them post program.Meanwhile less than one third of students in study exposed their clothes to sun as a method of drying pre-program compared to more than half of them post program.This result is probably attributed to the fact that following each education session, the researcher provided a debriefing as an intuitive activity.This lasted about 15 minutes; it included constructive feedback, correction, clarification, and discussion of the most important points; to identify the strength and weakness in the students' hygienic practice and how to improve it.This same result is almost congruent with the findings of (Nuganti, 2020) they conducted a study entitled '' Impact of Menstrual Health Education: A Community Based Interventional Analytical Study Among Rural Women of Eastern Telangana Regarding hygienic practices'' their result revealed that all students' hygienic practices as using of Sanitary napkins, methods of washing their clothes as well as the way of dryness are significantly improved post intervention among the study group.From these results and discussion in addition to more previous studies confirmed that menarche education program improves the knowledge and self-care practices among the adolescent girls.

Conclusion
Based on the present study's findings, it can be concluded that menarche education program has significantly impact on improvement of preparatory school student's knowledge and their self-care practices.Hence, our study aim and hypothesis were achieved within the framework of the present study.Recommendation 1. Development of in-service training programs for health care providers who take care of adolescent girls about issues related to menstruation and reproductive health.2. Maternal and Child Health Centers (MCH) or health setting should provide health teaching for adolescent Community campaigns using various educational media is essential to increase knowledge and improve self-care practices about menstruation among all girls.3. Preparatory school students need to be supported with clean school environment supplied with clean bathrooms in addition to other basic hygienic products to help them manage their hygiene.4. Further additional studies may be needed using a wider geographic scope and a larger sample size that should include young girls and their mothers emphasizing cultural variations in order to provide sufficient and comprehensive information in all Egyptian governorates.5.The mothers of young girls should be educated about the appropriate puberty hygiene, and be empowered with the necessary skills to communicate with and transfer the obtained information to their children.

Table ( 5
): Knowledge about menstruation in the study group pre and post program

Table ( 7
): Correlation table between the study variables