Thesis of Sarita Thakur - Nursing - 30.01.2021

A Descriptive Study to Assess the Knowledge and Attitude Regarding
Pubertal Changes and Menarche among Adolescent Teenager Girls: Case

Study in Selected Schools of District Shimla, Himachal Pradesh
TABLE OF CONTENTS
LIST OF TABLES II
ABSTRACT IV
CHAPTER 1: GENERAL INTRODUCTION 1-36
CHAPTER 2: LITERATURE REVIEW 37-56
CHAPTER 3: MATERIALS AND METHODS 57-61
CHAPTER 4: RESULTS 62-89
CHAPTER 5: DISCUSSION 90-105
CHAPTER 6: SUMMARY, CONCLUSION, IMPLICATIONS

AND RECOMMENDATIONS 106-121
REFERENCES 122-140
[I]
LIST OF TABLES
Tables P. No.
Table 4.1: Frequency and percentage of socio-demographic 62
variables
Table 4.2: Association between knowledge level and 64
demographic variables
Table 4.3: Correlation of knowledge and practice scores of 65
participants
Table 4.4: Information regarding Menstruation 65
Table 4.5: Respondents’ Level of Knowledge and Attitude 67
regarding Pubertal Health
Table 4.6: Association between Level of Knowledge regarding 67
Pubertal Health and Socio-demographic Characteristics of
Respondents
Table 4.7: Association between Level of Attitude regarding 69
Pubertal Health and Socio-demographic Characteristics of the
Respondents
Table 4.8: Knowledge regarding MHM 71
Table 4.9: Practice Regarding MHM 72
Table 4.10: Attitude Regarding MHM. 74
[II]
Table 4.11: The knowledge and attitude status of students 76

about puberty
Table 4.12: Status of strategies to deal with the crisis of 76
puberty in adolescents
Table 4.13: Knowledge and attitude regarding selective 78
strategies to cope with puberty
Table 4.14: Knowledge about pubertal changes among 79
adolescent girls according to age Group
Table 4.15: Awareness regarding psychological changes and 80
social relations among adolescent Girls
Table 4.16: Awareness regarding causes of pubertal changes 80
Table 4.17: Frequency and percentage distribution of 81
knowledge regarding pubertal changes among adolescent girls
Table 4.18: Major sources of information regarding puberty 81
among adolescent girls
Table 4.19: Person to whom comfortable to share regarding 82
pubertal changes among adolescent Girls
Table 4.20: Knowledge of reproductive system 83
Table 4.21: Knowledge regarding puberty 84
Table 4.22: Knowledge regarding menstruation 84
Table 4.23: Knowledge regarding teenage pregnancy 85
Table 4.24: Knowledge regarding abortion 86
Table 4.25: Knowledge regarding RTIs 86
Table 4.26: Knowledge regarding STDs 87
Table 4.27: Transmission and symptoms of HIV /AIDS 88
[III]
ABSTRACT
Background of the study: The first critical milestone in the reproductive

history of women's lives is menstruation. The economic, social, cultural
and educational environment in which girls are born, develop into
women, marry and repeat the process of starting their own families is
influenced by menstrual health. In recent years, infection of the
reproductive tract has been increasingly recognized as a major health
issue affecting women around the world. Women are preferentially
affected by reproductive tract infection than men, since women are more
likely to be infected, are less likely to seek treatment, are harder to detect
and have more serious biological and social effects. The aim of the study
was to assess the Knowledge and Attitude Regarding Pubertal Changes
and Menarche among Adolescent Teenager Girls: Case Study in Selected
Schools of District Shimla, Himachal Pradesh.
Materials and Methods: The study conducted was a descriptive cross
sectional study done on 100 adolescent girls from class 9 th to 12th of
Selected Schools of District Shimla, Himachal Pradesh (Convenience
sampling). Prior to the commencement of the study, they were explained
the purpose and nature of the study. Information on demographic
variables which include age, class, type of family, education of mother,
family income, age of menarche were collected from the participants.
Results: The data on knowledge scores revealed that 29% had adequate
knowledge about menstrual hygiene, 71% had inadequate knowledge
about menstrual hygiene. The data revealed on practice scores revealed
that 19%, 69%, 12% samples had poor, fair and good score of practices
[IV]
regarding menstrual hygiene respectively. 67.4% respondents had fair

knowledge and 26.4% respondents had good knowledge on menstrual
hygiene management. Only 56 (40%) were engaged in good menstrual
hygiene practices. Around half of the respondents had positive attitude
towards menstrual hygiene management related issues. About 85.1% of
the participants had high knowledge about puberty and 66.7% had a
good attitude toward it. Nearly, 54.2% of the girls used the avoidance-
oriented coping strategy. Only 25.92% of below 14 year had knowledge of
growth of pubic hair in adolescence. 56.8% respondents reported sudden
mood change during puberty. Mother was the major source of
information related to puberty among 66% adolescent girls. 58.7% found
necessary solution from their peers. Only 50.8% discussed problems
related to puberty with parents.
Conclusion: The lack of menstrual hygiene knowledge can be due to
multiple factors that need to be researched separately. The above results
highlight the need for teenage girls to adopt healthy and hygienic
activities and get them out of traditional menstrual values, stereotypes
and limitations. The researchers strengthened the general understanding
of the cause of menstruation and of the involved organs. The uses of
sanitary napkins and different menstrual regimes have been encouraged.
The students were briefed on their welfare. Early recognition will avoid
students from suffering from different infections of the reproductive tract.
Most respondents had a modest level of awareness, and half of the
respondents had a positive attitude towards public health. Study results
illustrate progress in the schooling of teenage girls Which can help
improve health status and minimize the susceptibility of pubertal health
[V]
to health problems. While awareness of menstrual hygiene management

among school teenagers is fair, there is still a need for improvement in
attitude and practice. The results demonstrate the need for awareness
campaigns to improve behavior along with regular reinforcement of
school health education programs. Continuous training in secondary
schools is important, according to the results, to enhance the awareness
and attitudes of adolescents towards puberty. In addition, more training
is needed to shift the dominant avoidance-oriented coping strategy to a
task-oriented approach, especially in secondary school at the first-grade
level. Adolescents should also address reproductive health issues,
particularly for girls, through health clubs, workshops, lectures, therapy
and school-level intervention programs.
[VI]
CHAPTER 1: GENERAL INTRODUCTION
1.1 INTRODUCTION OF THE STUDY
Adolescence is considered to be a special period of human

development. Menarche is a significant milestone in the growth &
maturation phase of adolescent girls. For all healthy adult women,
however, menstruation is a natural & common physiological
operation, as it has often been surrounded in many cultures by
mystery & myth. Adolescence is one of the most interesting and
dynamic life-span transformations. Puberty is a transitional time
between adolescence and adulthood, during which there is a growth
spurt, secondary sexual features emerge, fertility is achieved, and
there are significant psychological changes. The transition from
childhood to adulthood is a crucial period of human development in
which young adults leave childhood behind and assume new roles and
responsibilities. It is a time of psychological, economic and biological
social transformations and it entails challenging emotional challenges
for many pre-adolescent girls. A time of uncertainty & disagreement is
the phase of growing up. For young people, it is also difficult to fully
appreciate these developments when they encounter them.
It is a time in which sexual characteristics evolve gradually. Deep

biological, morphological and psychological changes are taking place,
leading to complete sexual maturity and ultimately fertility. Breast
enlargement, hip widening, pubic hair development, hair axillaries,
height change and menarche start are morphological. Most of the
changes happen gradually, so you may date the menarche. Puberty
1
refers to the entire developmental phase between childhood and

sexual maturity, menarche is one symptom of puberty usually
occurring in most girls between 9 and 16 years, menarche starts
during breast development, but in others, before the breasts are fully
grown, it will not occur.
Adolescents belong not only to the critical age group because they are
the generation that reaches parenthood, but also because they are the
boundary between maturity and childhood. They face different
physiological, psychological, and developmental shifts when they
attempt to pass this threshold. The term "adolescent" is derived from
the word "adolescere" in Latin, which means rising to maturity,
suggesting the distinguishing characteristics of adolescence. The first
symptom of puberty is menstruation. During puberty, there are
physical changes that turn the child's body into that of an adult,
changes in body size, and changes in body proportions. Any social
taboo concerned with menstruation is a menstrual taboo.
Menstruation is viewed as impure or embarrassing in certain cultures,
extending even to the mention of menstruation both in public (in the
media and advertising) and in private (among the friends, in the
household, and with men). Menstruation is viewed by many
traditional religions as ritually impure. Most girls receive information
on their gynaecology from their mothers, religious books, older sisters,
or peers. Such data, however, was generally provided after menarche
rather than before. There is, therefore, a need to provide women with
healthy family life education, particularly adolescent girls.
Menstruation in Indian culture is still viewed as something unclean or
filthy. The response to menstruation relies on understanding of the
topic and information. The way a girl learns about menstruation and
2
its related changes will influence her reaction to the menarche

occurrence. While menstruation is a natural phenomenon, many
myths and practices are associated with it, often leading to adverse
health outcomes. Isolating menstruating girls and enforcing limits on
them in the family have strengthened a negative attitude towards this
phenomenon. Even today, menstrual practices are clouded by taboos
and social cultural constraints, leading to Adolescent girls being
unaware of the scientific facts and practices of hygienic health
required for preserving positive reproductive health. Women with
improved menstrual hygiene skills and good practices are less prone
to reproductive tract infections and their effects. Increased awareness
of menstruation right from childhood will also escalate healthy
practices and can also alleviate the misery of millions of women. The
social stigma attached to menstruation causes dangerous grooming
activities to be carried out by many girls and women. Girls and women
frequently suffer from discomfort and infection, avoiding urination
during menstruation, and using any kind of cloth available old (or)
unwashed as an, but still girls do not visit medical practitioners,
lacking a forum to share menstrual hygiene problems.
During their adolescent growth, adolescents experience major physical

and cognitive changes that lead to and affect their future development
[1].
In terms of the physical changes that occur, puberty is defined. Due to

diet, wellbeing and weight trends, differences in the physical limits of
puberty exist [2]. Pubertal health refers to the values which have
contributed to physical and psychological health improvements [3]. It
is distressing to experience these changes if pubescent children are
3
not aware of the changes that take place during puberty, and may
develop unfavorable attitudes toward these changes [4]. In the animal
world, human puberty stands out for its correlation with brain
maturation and physical development. This marks a change in the
risk of depression and other psychiatric illnesses, psychosomatic
syndromes, antisocial and drug abuse [5]. The basis for good health in
adulthood is proper diet, safe eating habits and physical activity at
this age [6].
Menstruation is a hormonal mechanism in females, starting with the

initiation of puberty [7]. It has been regarded by Nepali society as a
religiously impure and culturally shameful event [8]. Chhaupadi is a
common practice in which females are discouraged from touching
anything and are forced during menstruation to live in solitude (shed)
[9]. In the Far West area, with recorded cases of rapes and physical
assaults in Chhaupadi [10], the situation is not different. These
activities have adversely affected the ability of females to control their
periods [11,12]. The inadequate access to clean toilets, water and soap
[13,14] further exacerbates these problems. These are significant
factors contributing to absenteeism in Nepal, as high as 53% of girls
[14-17]. Comprehensive awareness-raising at schools is also
important for promoting the management of menstrual hygiene (MHM)
[18,19].
Adolescence is one of the most charming and convoluted periods in

the life span that bridges childhood and adulthood.[20] According to
the definition of the World Health Organization, adolescence covers
the time between the ages of 10 and 19.[21] The adolescent population
is about 1.2 billion and 85% of them live in developing countries.
4
Compared to adults, the International Conference on Population and

Growth (2016) stressed the special needs of adolescents. In addition,
the United Nations Population Fund has defined girls' health as a key
to breaking the cycle of poverty and achieving the Millennium
Development Goals. [23] The International Children's Emergency
Fund of the United Nations has announced the need to concentrate on
improving the fight against poverty, injustice, and gender
discrimination for young people, especially girls. Iran needs to be
matched with these priorities, a country with a young population
where about half of teenagers are children. [24]
Adolescence is also a period of potential major dangers, considering

the tremendous effect of girls' puberty on their families and children's
health. Owing to complex shifts in the brain and endocrine system,
adolescent girls undergo different physical, mental, and behavioral
modifications during puberty. The distinctive essence of puberty
highlights the importance of awareness and coping mechanisms to
solve this period's crisis. [25] Previous research has shown the impact
of puberty on the mood, self-image, and relationship of adolescents
with peers and parents. During puberty, failure to pay adequate
attention to the needs of teenagers can cause various problems, such
as infectious diseases, failed marriages, high-risk pregnancies,
preterm birth, maternal and child morbidity and mortality. Moreover,
due to pubertal changes, more than 50 percent of adolescent girls
experience mild to severe stress.[26] This period is rooted in various
mental and psychological problems in adulthood.[27] Adolescent girls
usually do not receive specific health information and services despite
the potential risks of puberty and the critical needs in this period.
5
Adolescent females lack adequate knowledge about puberty, according

to several reports. A lack of understanding could lead to a negative
attitude towards pubertal changes and inappropriate emotions such
as anxiety and low self-esteem. [28] In turn, illiteracy and adverse
attitudes towards puberty could lead adolescents to choose ineffective
approaches to coping. [29] Studies have also shown that girls use
ineffective coping strategies such as avoidance more than boys,[30]
resulting in ineffective coping strategies. [31,32,33] Increasing
knowledge and improving adolescent girls' attitudes could also build
healthier behavior.[34] Research has shown that good puberty
knowledge and attitudes prepare adolescents not only to promote their
physical wellbeing, but also to gain more experience in dealing with
puberty struggles. [35]
It can lead to a stronger adaptation of adolescents to the world by

being equipped with coping skills to cope with different puberty
changes.[36] Coping techniques are mostly divided into three
categories: emotion-centered, task-oriented, and coping with
avoidance. Emotion-focused coping uses methods such as calming,
crying, and yelling to try and alleviate one's stress. [37] Task-focused
coping requires tactics such as preparation, constructive coping, and
utilizing social support. By avoidance coping, people strive to escape
stressors or their effects. Adolescents who in critical circumstances
choose bad coping styles usually report lower self-esteem in the
future. Therefore, learning awareness of puberty and gaining skills in
this time to deal with the challenges may contribute to healthier
behaviors. [38]
6
However, puberty as a societal construct has been understood across

the globe in several different ways. In general terms, the transition
from childhood to adulthood is known to be a period during which
young people undergo changes marked by physical growth, sexual
maturation and psycho-social development following puberty [39, 40].
There were 1.21 billion teenagers in the world in 2005, the highest
number ever in human history. It is projected that the teenage
population will continue to grow until 2040, eventually reaching 1.23
billion [41].
Adolescence is a period of increased risk-taking and thus

susceptibility at the time of puberty to behavioral issues and to new
reproductive health concerns [42]. Thus, young people need to be
mindful of themselves and others in order to lead good, responsible
and satisfying lives and to protect themselves from reproductive
health problems [43]. Approximately 22 percent of women in India are
adolescent girls, a more vulnerable group, especially in developing
countries. They are the mothers of tomorrow and upon them rest the
load of expected reproduction. Even in subjects such as menstruation,
abortion, pregnancy, studies in different parts of the world have
shown low awareness of adolescent girls - a crucial aspect if India is to
achieve a net reproductive rate of 1 by 2016 AD [44,45].
The time of conflict is puberty; it is the time of life when the child
starts to feel free, sexual maturity is reached and guidance is needed.
It is the time of comparison because the child moves between a child's
emotions and being an adult. This is the moment when they need
clarity about the puberty phase that is happening for everyone and
what changes to anticipate. As most pre-adolescent girls lack
7
information about the changes in puberty and menarche. In certain

situations, because of either shame or ignorance or life obligations,
parents neglect their duty to pass health information to their children.
In this process, they do not understand the difficulty and pain their
kids have and place the burden of educating their kids on the
shoulders of teachers who may also neglect it. Adolescents will go to
peers, siblings and mass media in such situations to get the data they
need. This will contribute to inaccurate or insufficient knowledge and
misunderstanding of the situation. These teenagers may also cause
problems for themselves and their parents, compromising their
physical, psychological, and social wellbeing. So, this study has been
conducted to raise consciousness among adolescent girls about these
problems. There are signs at the beginning of puberty, such as breast
development and pubic hair growth; girls have special needs, and we
need to prepare them and support them through this time of their
lives. However, to the best of our knowledge, none of the adolescent
girls among the age groups between 11 and 19 have tried to find out
the awareness of pubertal changes among adolescent girls and to
identify the probable socioeconomic, caste category, age-wise
knowledge of adolescent girls regarding pubertal changes. It was felt
that there are no credible sources of information related to puberty
changes among girls here because often both parents work in cities
and they cannot provide full puberty-related information because of
lack of time. Information and knowledge relevant to puberty changes
needs to be identified. It is also important to develop awareness and
healthy attitude in the society to reduce the fear related to first period.
Adolescence is characterized by the World Health Organization (WHO)

as a life span of 10-19 years [46]. It is a time of rapid physical and
8
biological changes that can lead to instability, anxiety, resentment,

and a sense of vulnerability. It is the age in which foundations can be
laid for a long and stable life. Adolescence is said to be a period of
stress and strain. Adolescence is a prime time for the promotion of
wellness and the establishment of good habits that in later years will
affect health. Adolescents have been shown to have a negative
approach to healthy diets and are not conscious of dietary
requirements, personal hygiene, menstrual hygiene, etc. Since the
mortality rate is relatively low in this age group, teenagers are
considered healthy, but this is a deceptive indicator of adolescent
health. It is a common observation, considering the definite health
issues they may have, that adolescents do not have access to existing
resources, especially adolescent girls. To date, there are only a few
specified services (which really have an effect) for teenage girls in
India, leading to major unmet service needs. Lack of friendly staff,
lack of family concern about their health, working hours that are
uncomfortable for adolescents and lack of privacy and confidentiality
have been identified as significant barriers to adolescent girls' access
to health services The health sector needs to respond in a more
friendly and non-threatening environment by offering services to
adolescent girls [44].
Various studies have been carried out to assess the extent of

adolescent girls' knowledge of the reproductive system and organs and
awareness of adolescent girls' sexual knowledge (16-20 years) and the
findings have shown that adolescent girls' awareness of HIV/AIDS is
very low, adolescent girls lack adequate knowledge of sexual matter
and contraception resulting in early pregnancy. In India, teenage
pregnancies constitute 10-15% of total pregnancies. This is primarily
9
due to early marriage, a culture popular in the Indian sub-continent

as a whole [50, 51]. Girls are biologically more vulnerable to sexually
transmitted diseases (STDs) among teenagers, including HIV infection.
Therefore, adolescents need to have sound knowledge about the
physical, psychological and social changes that take place during
childhood and adolescence [52, 53] in order to lead a healthy,
responsible, fulfilling life and to have security from reproductive
health problems. The health needs, behavior and aspirations of
teenagers are unique and routine health care systems are not well
prepared to deliver these services. Data indicate that with respect to
HIV risk caused by unsafe sex, this is the most vulnerable category.
With too little factual knowledge, too little guidelines about sexual
responsibilities, and too little access to health care, most of them face
these risks. Their educational and health status, their readiness to
assume the positions and obligations of adults, and the help they
receive from their families, societies and governments will decide their
own future and their countries' future [54, 55]. Young people have the
right to consider the changes they are experiencing and to develop
positive and mature relationship skills. Through lack of knowledge,
misconceptions, many diseases can occur; hence, among the
vulnerable groups, there is a need to build awareness of reproductive
health. The wellbeing of teenage girls, as direct reproducers of future
generations, affects not just their own health, but also the health of
future generations.
Awareness regarding pubertal changes
When and how teenage girls gain the skills that will prepare them for
the roles of parents and partners in marriage is crucial to understand.
10
In the family, even knowledge about physical maturation is often not

addressed, assuming that secrecy will express the taboo nature of this
topic, preserve the innocence of a child, and discourage improper
behavior. However, it can be concluded that the lack of proper
awareness and the silence surrounding the subject of reproductive
health can lead to health problems. There is a lack of data on the
reproductive and general health issues of this young population,
especially in the country's border areas. The goal of the present study
was to evaluate the awareness of school-going adolescent girls about
pubertal changes by age and to identify the various types of sexual
and reproductive health problems they encounter and the potential
solutions, keeping these problems in mind. Research on adolescent
physical, cognitive, and psychosocial development is growing. This is
especially gratifying because in the past, the amount and quality of
research has been less targeted at teenagers than at any other age
group. In child health reports, high infant death rates, severe infant
mortality and morbidity during childhood from infectious diseases,
and prematurity-related issues were the top priorities. Childhood
infectious diseases have now decreased and are usually preventable,
and remarkable methods of caring for premature infants, especially
over the last two decades, have been established. The decade of the
1960s brought attention to the fact that teenagers exist, that they are
a large demographic group, and that they do have issues, with their
destruction of values, drug experimentation, increased sexual
independence, increasing pregnancy in adolescents, and greater
violence and criminal activity by juveniles. The psychosocial aspects of
puberty and youth have thus become involved in adults. Secular
improvements in physical development have resulted in more rapid
11
adolescent maturation and earlier pubertal changes that have not

necessarily been followed by earlier adult cognitive functioning.
Knowledge of pubertal changes and menstrual hygiene
Puberty is a transitional time between childhood and adulthood,

including the physical, psychological, biological, and social conditions
of the phase of rapid growth, development, and maturation. Transition
through puberty frequently starts with the development of secondary
external sexual features, which occur in girls as breast enlargement
and pubic hair growth. Early in puberty, growth acceleration and peak
height velocity occur, while menarche, the start of menstrual bleeding,
occurs.
When girls reach sexual maturity, puberty is a period of life. This is

the era when teenagers are undergoing changes that are marked by
physical development, sexual maturation, and Development psycho
social. To cope successfully with this transformation, they need details
and a good image of their body changes to protect them from shame,
ambiguity and misunderstanding of the physical issue. Puberty
causes drastic physical and emotional changes that can scare an
unconscious infant. It can also trigger tension and uncertainty, and it
can offer a feeling of pleasure, on the other hand. This is where girls
need family and peers' guidance and supportive relationships to
develop “healthy self”. Therefore, an understanding of adolescent girls'
puberty changes needs to be developed. There were 1.21 billion
teenagers in the world in 2005. It is projected that the teenage
population will continue to grow until 2040, to eventually reach 1.23
billion. It accounts for 1/5th of the total population in India.
12
During this development period, the girls first undergo menstruation

and related problems, marked by feelings of fear and eagerness to
know about this natural phenomenon. In the Indian population, it is
always considered as unclean and filthy. Hygiene-related menstrual
activities are significant because they have a health effect in terms of
increased susceptibility to infections of the reproductive tract (RTI).
Increased awareness of childhood menstruation can also increase
healthy practices and can help alleviate the suffering of millions of
women.
Menarche signifies a rapid shift from girlhood to femininity, unlike

other incremental pubertal shifts, and is regarded as a significant
transformative point in the lives of women. While menstruation is a
natural occurrence, menarche initiates major psychological changes.
Menstrual issues, such as mood swings, which involve menorrhagia,
are common among teenage women, Dysmenorrhea and an irregular
period of the menstrual cycle. Menstruation can be seen as more than
just a physiological process; culture can perceive it either positively or
negatively.
Menstruation is viewed from a positive viewpoint as a symbol of

femininity, vitality, youth, or purification of the body. The adverse
attitudes, on the other hand, include susceptibility in women to
various diseases or feelings of disgust and shame. These negative
views are the foundation of some practises in some cultures, such as
limitations on the ritual, social, and domestic activities of women who
menstruate.
13
Most researchers, who have studied emotional reactions to menarche

worldwide, have found that the majority of girls show either negative
or ambivalent responses to menarche. Positive emotional reactions to
menarche have been related to positive attitudes toward
menstruation, whereas negative responses have been associated with
perceptions of menstruation as a negative event. Menarche emotional
responses are often affected by menstrual behaviors formed by the
immediate atmosphere and society in which a woman grows up. In
other words, positive responses to menarche are connected to a
positive menstrual perception; i.e. viewing it as a normal phenomenon
and a sign of a balanced picture of the body and denying negative
menstrual attitudes. On the opposite, the views of menstruation as a
traumatic occurrence are correlated with negative emotional reactions
to menarche. Menarche's timing is a significant factor in how young
girls feel about menstruation. Girls in India have been found to have
fewer pleasant experiences and more menstrual pain than their on-
time or late maturing counterparts, who enter menarche early relative
to their peers. Regarding menstrual behavior, rather than optimistic
emotions, adolescents received the highest ratings on negative feelings
and confidentiality. Participants who had earlier explored with their
mothers the emotional dimensions of menstruation were more likely to
feel prepared for menstruation. White explored the disparities between
female adolescents in awareness and attitudes regarding
menstruation and feelings of readiness for early menarche. The
research revealed that participants lacked knowledge of menstruation
and felt unprepared for menarche, yet their menstrual attitudes were
ambivalent.
14
Knowledge of Menarche and Menstruation
Menarche is actually the last step in a complicated sequence of

puberty-related biological developments. This represents an important
phase in the female adolescent's life, as it symbolizes the entry into
the female hood. Menarche is the first menstrual or menstrual
bleeding in the first menstrual period. It is often regarded as the key
event of female puberty, as it suggests the likelihood of fertility.
Menarche is the key landmark of puberty in women, typically

occurring, despite geographical and ethnic age, between 13 and 18
years of age. Menarche signifies a drastic transformation from girlhood
to womanhood, unlike other incremental pubertal changes, and is
recognized as a significant transitional point in the lives of women.
While menstruation is a natural occurrence, menarche starts with
major psychological changes.
Menarche, the first menstrual cycle between 09 and 14 years, is

reached by females. One of teenage girls' most memorable and
defining moments is Menarche. It is an occurrence that marks
puberty that is significant, dramatic and concrete. Menarche is
distinctive in that, unlike pubic hair growth and breast development,
which are prolonged pubertal changes, its initiation is abrupt.
Menarche is the most distinct case of female puberty, a precursor of
physical maturity and fertility. Menarche and menstruation is a
dilemma that every girl and woman has to contend with as she gets
through puberty at around the average age of 12, until somewhere in
her 40s she hits menopause.
15
Menstruation is not an uncommon or even unusual experience; it is,

however, a private and mostly secret one in many cultures.
Menstruation was practically unmentionable, and in the man-made
language there are no phrases that could be used respectfully to
explain the experience. About menstruation itself, teenagers have little
to say. Medical discourse is the only discourse they can use to explain
their experience, which explains pain, anxiety and untidiness. They
have nothing to tell because these girls have menstrual discomfort, or
trouble having sanitary towels. In relation to their menstruation, there
is an unspoken "culture of silence." It is also considered taboo to talk
about menstruation, particularly for girls to talk to members of the
opposite sex about it. The menstruating girl is expected to uphold the
taboos imposed on contact about her experience due to social
pressure. Nevertheless, girls have questions and concerns about their
own menstruation, and feel the need to talk with friends about this
subject. The social ban on menstruation conversation with others also
causes parents to avoid talking to their daughters about
menstruation, leaving the girls unprepared for menarche. Girls who
know how to deal with menstruation seem to cope much better with it
than those who are ignorant of it. Preparedness gives girls the power
to do things in a mature way and they also feel assured that these
deeply private moments will not cause any embarrassment. In many
cultures, the setting of menarche is also celebrated and there is a
custom during this time of preparing and giving food rich in iron and
protein content. Modernization has seen the abolition of this
celebration tradition to some degree, but many households still
observe the practice of supplying menarche with nutritional
supplementation.
16
Preparation for Menarche and Menstruation
The transformation from a child to an adult marks the beginning of

the menstruation of a girl, as it is a significant transition, but it is the
culture or religious traditions of the girls that determine it as an
important or unimportant stage of her existence. In many cultures,
prior data about menarche and menstruation among girls is generally
poor. The answer to menstruation often relies on understanding and
awareness of the problem, in addition to cultural structures that
contribute to the creation of a certain notion. There are significant
differences in the perception of menstruation. This distance has been
revealed by many research studies.
Girls are taught directly and implicitly about (mostly negative) cultural
beliefs about menstruation and how they are supposed to act in ways
that affirm these beliefs. In an emphasis on menstrual goods, the
perpetuation of cultural menstrual taboos that menstruation is "dirty,"
that it must be concealed and should not be addressed in "mixed
business," also expresses itself.
Messages of menstruation as shameful and filthy, coupled with

insufficient menstruation details, paint a daunting picture for
menarche girls. Not surprisingly, many scholars (have argued that
mothers should be emotionally supportive and informed about
menstruation because of the crucial function that the mother plays in
preparing her daughter for menstruation. Nevertheless, several
mothers themselves are unprepared for this mission. Most of the
menstruation is silent in Indian society. Girls continue to be puzzled
about menstruation and its associate
17
The explanations for the disparity between the two cultural groups
which derive from the fact that the Americans had more menstrual
awareness and better training for menarche than the Indian women in
the sample. The correspondence obtained by Indian girls continues to
concentrate on menstrual management constraints and advice.
Although girls think themselves ready for menarche and reported that
they had spoken to their mothers about it, their definition of
menstruation reflected partial awareness and a number of
misconceptions or lack of knowledge more typically. Girls correlated
menstruation with a number of adverse physical and psychological
changes, suggesting that they had already studied and internalized
cultural values, theories, taboos and prejudices about menstrual
symptoms, even though they had not yet learned the biology of
menstruation.
For teenage girls, health education services on menstrual hygiene help

promote safe behaviors during menstruation. This entire account
indicates that menarche and menstruation negativity is not limited to
India alone. The mindset and building tends to be negative in many
other nations and girls appear to be unprepared to manage menarche
and menstruation.
Knowledge about and Attitude towards Menstruation
Menstruation is a normal feature of the female reproductive cycle in

which intermittent blood discharge from the uterus passes into the
vagina; it is the natural beginning of puberty. Puberty is a growth and
18
development process in which major emotional, psychological, and

physical changes take place. Menarche is one of the most memorable
and defining moments of puberty for females. It embodies a transition
from childhood to adulthood, and the early adolescent can be full of
anxiety in this transition.
Menstruation has been surrounded by taboos and misconceptions

from many facets of socio-cultural life that eliminate women. Many
societies hold on to various values and misconceptions that exclude
women from everyday activities and hygienic health practices,
resulting in adverse outcomes such as infection.
Studies have shown that many girls have a great deal of confusion
about the physiological changes during menstrual cycles. Most of this
data was collected from their mothers, television, peers, and
educators. Such taboos influence the emotional state, mentality,
lifestyle, and most importantly, health of girls and women.
Distinctive studies have highlighted the importance of menstrual
interactions in exploring the cultural context. In the degree of
awareness of women and their perception of menstruation problems,
demographic characteristics play an important role. It also plays an
important role in their values and attitudes.
The main aim of communication between doctors is to recognize

routine menstrual problems and other associated regenerative
morbidities among the local population. There are co-ordinate
implications for regenerative well-being in a significant number of
works on menstruation. For example, not showering in menstruation
can prompt dropping off in the young lady's hygiene and thus prompt
19
contamination of the regenerative tract. Doctors had to be familiar

with regular theories found in their locale with menstruation prevalent
and treat the woman comprehensively by tending to them in addition.
Else, the problem could be dealt with for some time, but with
increasing seriousness it will continue to repeat.
Despite the fact that menstruation is an important physiological

phase that all girls would undergo with the initiation of puberty,
nevertheless, most girls appear to have inadequate awareness and
even defective information about it in some instances. If enhanced,
this level of awareness can mean better reproductive health and a
positive attitude towards menstruation.
Menstruation is a common biological process for females, beginning

with menarche and lasting until menopause, suggesting their capacity
for procreation. It is the cyclical shedding of the uterus' inner lining,
the endometrium, which is regulated by the hormones released by the
brain-located hypothalamus and pituitary glands. During their
reproductive life span, most women undergo 400 menstrual cycles.
About one seventh and one quarter of the adult life of a woman is
followed by menstruation. Despite the reality that menstruation is a
natural physiological phase, a large proportion of women are affected
by premenstrual symptoms. Premenstrual symptoms are
characterized as symptoms of physical, emotional, and/or actions that
may be encountered immediately before, during, or immediately
following the menstrual phase during the era. Irritability, mood
swings, anxiety, depression, stress, weight gain, breast tenderness,
weakness, cramps, backache, and skin disorders are common
symptoms associated with menstruation. Because of the large number
20
of people affected by premenstrual symptoms and the potentially

devastating effect of these symptoms on the quality of life, economic
and social performance of women, several research studies
concentrate on premenstrual symptoms. There is, however, little
consensus on the cause and treatment of these symptoms among
researchers. It is therefore important to obtain a better understanding
of the factors associated with these symptoms in order to treat
premenstrual symptoms most effectively. Factors such as menstrual
behaviors have a significant influence on the documentation of
premenstrual symptoms, the latest literature suggests. Personal
awareness and experience, social learning, and cultural values
influence attitudes toward menstruation. The connection between
menstrual attitudes and premenstrual symptoms has been
investigated in a limited number of studies.
1.2 BACKGROUND OF THE STUDY
Adolescence, between childhood and adulthood, is a transitional

growth and development process. The World Health Organization
(WHO) describes an adolescent as any person between 10 and 19
years of age. This age range falls under the category of young people
by the WHO, which applies to people between 10 and 24 years of age.
The manifest gulf of maturity that divides younger and older

adolescents makes it useful, according to UNICEF, to perceive this
second decade of life as two parts: early adolescence (10-14 years) and
late adolescence (15-19 years).
21
There were an estimated 1.4 billion teenagers in the world in 2009,

making up about 18% of the world's population. The UN describes an
adolescent as a person aged 10-19. The overwhelming majority of
teenagers in the world, 88 per cent, live in developing nations.
Roughly 16 per cent of all teenagers live in the least developed
countries. Today, 1.2 billion teenagers are at the crossroads of
adolescence and the world of adults. In India, about 243 million of
them live. Today, 1.2 billion teenagers aged 10-19 make up 16 per
cent of the global population.
Adolescence is a transition process from infancy to adulthood. A

young person undergoes rapid changes in the structure of the body,
induced by sex hormones, during this stage of life. Sexual character
appearance is combined with improvements in perception and
psychology. While adolescence refers to this whole phase, the physical
component refers to puberty. The age group of 10-19 years is called
the adolescence phase, and the early half of adolescence is marked by
puberty.
Equally profound are the internal changes in the individual, albeit less
apparent. Recent neuroscientific research suggests that the brain
undergoes a remarkable burst of electrical and physiological growth in
these teenage years. In the course of a year, the number of brain cells
can almost double, as neural networks is dramatically reorganized,
with a consequent effect on mental, physical and emotional capacity.
Girls and boys become more conscious of their gender during puberty
than they were as younger kids, and they can conform to their actions
or appearance in order to fit in with perceived norms. They may
become victims of bullying, or engage in it, and may also feel
22
uncertain about their own personal and sexual identity. Teenagers

gain a greater understanding of their own personal identity during
puberty, including acceptance of a collection of personal moral and
ethical values and a greater awareness of feelings of self-esteem or
self-worth.
Puberty begins with breast growth (thelarche) in girls at any time

between 8 and 13 years. This is accompanied by the development of
pubic hair (pubarche) and subsequent menstruation (menarche),
averaging 12.6 years of menstruation (range 10-16 yr). Girls who
reach puberty have rapid changes in their bodies. During this time,
young girl grow breasts, hair under the arms and around private
parts, oily skin and body odour, which during that time would need to
pay careful attention to personal hygiene.
Menarche is the beginning of menstruation and is one of the most

critical milestones in the life of a woman. Menarche is a discrete
occurrence with a rapid onset, unlike other adult transitions that are
incremental and ongoing. It is closely associated with post-pubertal
characteristics, and is thus favored as a sexual maturation
benchmark. It happens between the ages of 10 and 16 years for most
females, but it shows a surprising range of variation.
The first menstrual cycle is called "Menarche." Menarche is the

indication that the young female's sexual maturation has occurred
and that the body is capable of sustaining pregnancy. A girl becomes
aware of her developing identity as a female capable of reproducing
when menstruation starts. The input she gets from friends, educators
and, most importantly, her parents will profoundly impact her
23
understanding and acceptance of her new identity. Menstruation

happens regularly, except during pregnancy and lactation, during the
child bearing years. The age of onset of menstruation varies from
person to person, but inheritance, ethnic background and nutritional
status seem to be affected.
Menstruation is a hormonal process that occurs in puberty that is

unique to females. Menstruation is often correctly referred to as
menstruation (or) catamenia, and a monthly flow cycle is more
common. Menstruation is not an infirmity. It is a process that is
healthy, natural, and mature. Menarche happens between the ages of
nine and 15. Reproductive maturity is signaled by Menarche. Anxiety,
anxiety, uncertainty and depression frequently come with Menarche.
On the other hand, menarche is celebrated in some cultures and gifts
are given to the young girl.
The risk factor of breast cancer and other diseases has been the early
onset of menarche. It has been noted that the average age of
menarche is steadily declining. Over the past 50 years, the average
rate of decline in Sweden was 10 days per year, in Japan it was one
year for eight years, in India a decrease of 5-7 days per year was
observed in Hindu girls from Bengal. The downward trend of the
menarche period has stopped in Northern and Eastern Europe. The
menarchial age has dropped steeply and is about 13 years stable and
can rise again. There is heterogeneity between females across different
countries or across different ethnic groups for age at menarche.
Menstruation is a cyclic physiological feature common to all adult

females who are well. There are some mild health conditions that may
24
be associated with the pre-menstruation cycle or during

menstruation, such as backache, constipation, stress. The young girl
learns to deal with it if support is provided in time, and does not allow
it to interfere with healthy living.
The first symptom of puberty is menstruation. During puberty, there

are physical changes that turn the child's body into that of an adult,
changes in body size, and changes in body proportions. Any social
taboo concerned with menstruation is a menstrual taboo.
Menstruation is viewed as impure or embarrassing in certain cultures,
extending even to the mention of menstruation both in public (in the
media and advertising) and in private (among the friends, in the
household, and with men). Menstruation is viewed by many
traditional religions as ritually impure. Most girls receive information
on their gynecology from their mothers, religious books, older sisters,
or peers. Such data, however, was generally provided after menarche
rather than before. There is therefore a need for women, especially
adolescent girls, to provide safe family life education.
Menstruation is correlated with a variety of myths and misleading

practices, often contributing to adverse health outcomes. The most
common concern in the teenage age group is menstrual disruptions,
and unhygienic activities during menstruation can lead to adverse
effects such as pelvic inflammatory diseases and even infertility. The
word "Menstrual hygiene" is collectively given to basic health care
needs and requirements of women during the monthly menstrual
cycle.
25
Millions of women today suffer from infection of the reproductive tract

and its complications, and the infection is also transmitted to the
offspring of the pregnant woman. They should be informed about the
reality of menstruation and its physiological effects before introducing
any improvement in menstrual practices.
Menstruation in Indian culture is still viewed as something unclean or

filthy. The response to menstruation relies on understanding of the
topic and information. The way a girl learns about menstruation and
its related changes will influence her reaction to the menarche
occurrence. Isolating menstruating girls and enforcing limits on them
in the family have strengthened a negative attitude towards this
phenomenon. Even today, menstrual behaviors are clouded by taboos
and social cultural constraints, causing teenage girls to remain
unaware of the scientific evidence and hygienic health practices
needed to maintain positive reproductive health. Women with
improved menstrual hygiene skills and good practices are less prone
to reproductive tract infections and their effects. Increased awareness
of menstruation right from childhood will also escalate healthy
practices and can also alleviate the misery of millions of women. The
social stigma attached to menstruation causes dangerous grooming
activities to be carried out by many girls and women. Girls and women
frequently suffer from pain and infection, avoid urination during
menstruation, and use any sort of cloth available as an old (or)
unwashed, but even girls do not visit medical practitioners without a
forum to share menstrual hygiene problems. The use of sanitary pads
and genital washing are important practices for preserving menstrual
hygiene. The health of girls can be compromised by unhygienic
26
menstrual activities, and there is an increased susceptibility to

reproductive tract infections.
Menstruation, with its false beliefs due to ignorance, is still considered

a taboo subject. There was insufficient hygiene standards and
awareness. In the use of sterile sanitary napkins, menstrual hygiene
habits have shown modest change. The facilities for changing pads
and menstrual washing must be properly provided in secure and
hygienic washrooms in schools and workplaces. Before reaching
menarche, information on reproductive health needs to be given to
girls. Trust can be strengthened by health education for girls about
menstruation and its healthy practice by teachers and mothers. The
overall health, education and empowerment of women will be
strengthened by empowering mothers to speak to their daughters and
to eradicate the misconceptions, taboos and stigma associated with
menstruation. It is the duty of policy makers, health practitioners,
women's rights advocates and environmentalists to achieve this aim.
A risk factor for reproductive tract infection and cervical neoplasia is

poor menstrual hygiene. A critical aspect of adolescent girls' health
education is learning about hygiene during menstruation, as habits
are established in puberty that is likely to continue in adult life.
Women can be shielded from misery through good menstrual hygiene

and correct perception. Girls should be trained on menstrual reality,
physiological effects, the importance of menstruation and the creation
of secondary sexual characters, and above all on proper hygienic
practices and the collection of disposable menstrual sanitary
absorbents. This can be done by instructional television shows,
27
compulsory sex education in the school curriculum, and health staff

from schools/nurses. Menstrual health is an integral part of the
approach to women's health in the life cycle, so it is necessary for all
adolescent girls to receive a loud and clear message and service on
this topic.
1.3 STATEMENT OF THE PROBLEM
“A Descriptive Study to Assess the Knowledge and Attitude Regarding

Pubertal Changes and Menarche among Adolescent Teenager Girls:
Case Study in Selected Schools of District Shimla, Himachal Pradesh”
1.4 OBJECTIVES OF THE STUDY
1. To assess the knowledge regarding pubertal changes and menarche

among adolescent girls.
2. To assess the attitude regarding pubertal changes and menarche
3. To find out the association between knowledge and attitude with
demographical variables.
1.5 HYPOTHESIS OF THE STUDY
H1- There will be significant association between knowledge and

attitude regarding pubertal changes and menarche among adolescent
girls
28
H2- There is a significant difference between knowledge and attitude

regarding pubertal changes and menarche among adolescent girls
with selected demography profile?
H3- There is no significant association between knowledge and

girls with selected demography profile?
1.6 SIGNIFICANCE OF THE STUDY
In wealthy countries, proper maintenance of menstrual hygiene is

taken for granted, but insufficient menstrual hygiene is a major
problem for girls and women in resource-poor countries, adversely
affecting the health and growth of adolescent girls. Most research to
date, primarily in sub-Saharan Africa and South Asia, has identified
menstrual hygiene awareness, attitudes, and practices. In a handful of
sub-Saharan African countries and the region of South Asia, studies
are heavily based. Among girls in rural areas and those attending
public schools, many school-based studies show weaker menstrual
hygiene. The few studies that have attempted to improve or modify
menstrual hygiene practices provide moderate to strong evidence that
targeted approaches improve knowledge and understanding of
menstrual hygiene.
Pre-menarche menstrual awareness was found to be poor among both

urban and rural adolescents in the state of Maharashtra. The limited
information available was transmitted informally from mothers who,
due to low levels of literacy and socioeconomic status, were
themselves deficient in knowledge of reproductive health and hygiene.
29
Lack of menstrual hygiene has been shown to result in harmful

effects, such as infections of the reproductive tract. This risk has been
minimised by improved knowledge of menstrual hygiene. Young girls
found it difficult to handle menstrual hygiene in urban slums of
Karachi, Pakistan, due to lack of facilities to dispose of used cloths in
school and lack of privacy for dry washed ones at home.
The use of unhygienic cloths can contribute to the development of

reproductive tract infection, which can seriously impede women's
reproductive ability or even life. In the lives of women, reproductive
health and menstrual hygiene are essential elements. The latter may
include unintended pregnancies, urinary tract infections (UTI) and
pelvic inflammatory diseases in the worst case scenario.
After menarche, dysmenorrhea, menstrual blood flow disturbances

and premenstrual symptoms are typical menstrual anomalies that the
female adolescent will typically experience. Some issues associated
with menstruation are faced by more than 75% of teenage girls, which
may indirectly influence their academic excellence, athletic activities
and their self-esteem. Studies have suggested that menstrual disorder
at the age of 15 or 16 act as a marker for hyperandrogenemia and
hyperlipidemia in their later life.
Reproductive-age women and girls need access to clean and soft-

absorbent sanitary products that protect their health from various
infections in the long run. To this consequence, good menstrual
hygiene practice decreases the occurrence of infection of the
reproductive tract (RTI). The symptoms of reproductive tract infections
are therefore serious and may contribute to a major negative impact
30
on the health of a woman, including constant pelvic pain,

dysmenorrhea (painful periods) and infertility in severe cases.
Infections of the reproductive tract, which have become a secret
disease that devastates the lives of women, are closely connected to
poor menstrual hygiene.
Several studies found that menstrual issues affected more than a

third of the attention, involvement, socializing with friends, evaluating
skills and performance of home work tasks of students.
Dysmenorrhea was substantially associated with absenteeism from
school and reduced academic performance, engagement in athletics,
and peer socialization.
There were various obstacles and restrictions for the majority of girls;
only one in eight girls faced no restrictions at all. Commercial pads
were more widely used in urban environments or schools, with girls
mostly relying on clothes in rural areas and in community-based
studies. Around one in five girls had their soil absorbents disposed of
in inappropriate places. A quarter of girls indicated that during
menstruation, they did not attend school. Absenteeism did not
decrease over time due to menstruation; school absence in univariate
analysis was inversely correlated with the prevalence of pad use, but
not when adjusted for area.
In addition, because of menstrual related issues such as discomfort

and apprehension of sudden menstrual blood leakage, students had a
hard time attending class attentively because they did not use
sufficient sanitary napkins. That menstruation had a negative effect
on their academic performance or rank as opposed to their pre-
31
menarche rank. They still had anxiety and embarrassment sitting in

the class beside male students.
Poor management of menstrual hygiene can increase the susceptibility

of a female to infection of the reproductive tract. In women with
unhygienic menstrual hygiene management habits, bacterial vaginosis
may be more prevalent. Bacterial vaginosis is a poly-microbial disease
that is characterized by an imbalance in the vagina of the resident
bacterial flora. The normal vaginal flora is dominated by lacto bacilli
that produce hydrogen peroxide. There is a decline in the lactobacilli
population in bacterial vaginosis, with a simultaneous rise in a broad
bacterial group like Gardnerella vaginalis, Pretovella species,
Bacterioides species, Peptostreptococcus, Mycoplasma hominis,
Ureoplasma urea, and Mobiluncus species. As agirl progresses from
puberty into womanhood, her reproductive health could be
compromised by reproductive tract infections possibly induced by
inadequate menstrual hygiene management. Bacterial vaginosis may
be at higher risk for consequences of adverse pregnancy, such as
preterm birth, sexually transmitted infection acquisition and pelvic
inflammatory disease growth.
It is important to support the Sustainable Public Health Awareness

Program on the physiological basis of menstruation and the
implementation of proper hygienic practices with the selection of
disposable sanitary pads. In order to deliver such knowledge, formal
as well as informal communication networks such as mothers, sisters
and friends need to be emphasized. Well before the age of menarche,
all mothers should be taught to crack their inhibitions regarding
addressing menstruation with their daughters. All women, especially
32
the vulnerable, should be provided with sanitary pads at subsidized

rates at health facilities and women should be encouraged to use
them. The method of social marketing may be used to encourage
menstrual hygiene and the use of sanitary pads.
For teenage girls, nurses are responsible for appropriate teaching

about menarche, menstruation, and other principles and practices of
health relevant to female reproductive health. A more optimistic
perspective on physiological processes associated with sex is
encouraged by their training and expertise. Their technological
knowledge, coupled with a factual attitude towards menstruation, will
help girls gain faith, shed their inhibitions, and ask questions about
this taboo topic with confidence. There is evidence to demonstrate that
knowledge intervention planned and conducted by nurse’s are
effective in educating patients and clients in different areas of health
care.
Hence the researcher felt that there is need for education for
adolescent girls regarding pubertal changes, menarche and menstrual
hygiene.
1.7 NEED OF THE STUDY
Teenagers in India (21%) tend to be poorly educated about their bodies

and about sexuality and health issues. The data they have is always
incomplete, and they are therefore puzzled. Early menarche
contributes to earlier sexual activity or depression among adolescents.
Girls associate with menstruation a truthful negative physical and
psychological shift representing both misunderstanding and ignorance
33
and fear of being different form peer, as well as negative biassed

attitudes and perceptions of girls about menstruation and have been
found to lead to self-objectification, badly shame, and lack of sexual
decision-making agency.
Early puberty is associated with increased insulin resistance to the

body mass index, which is the total number of metabolic syndromes
contributing to increased cardiovascular risk. Moreover, relative to
later maturing children, elevated blood pressure and glucose
intolerance are displayed with early menarche, regardless of body
composition. During puberty, reproductive and sexual activity was
assumed to be associated with health, and thus little consideration
was paid to female reproductive health. Girls are typically not allowed
to speak about puberty changes or provided room to ask questions.
This research is an effort to find out the current social and cultural
patterns regarding menstruation, levels of knowledge, and behavioral
changes that occur during menstruation in adolescent girls, their
understanding of menarche, how they handle it, and the different
menarche-related taboos, norms, and cultural practices.
1.8 DELIMITATIONS OF THE STUDY
The subjects are limited to those adolescent girls in aged between 11 -

19 years, who are willing to participate in the study and present in the
school. Sample size was limited to only 100 subjects, Adolescent girls
in aged between 11 -19 years having on set of menarche.
34
1.9 OPERATIONAL DEFINITION
1. Knowledge:
It means facts (or) condition of knowing something with familiarity
gained through experience (or) association.
-Oxford Dictionary
In this study knowledge refers to the correct written responses from

the adolescent girls through the structured knowledge questionnaire
on pubertal changes, menarche and menstrual health, which was
measured by the structured knowledge questionnaire.
2. Pubertal Changes:
It refers to the puberty is the process of physical changes through
which a child’s body matures into an adult body capable of sexual
reproduction.
In this study it refers to the changes such as development of breast,

and menarche, broadening of hip, deposition and gaining of fat,
auxiliary and pubic hair growth as well as behavioural changes that
occur in girls in their adolescent age.
3. Menstruation:
Refers to the periodic discharge of blood and mucosal tissue from the
uterus, occurring approximately monthly from puberty to menopause
in non pregnant women and females of other primate species
- Dictionary.com
In this study it refers to the adolescence girls who are all attain
menarche at the age between 12-19 years.
35
4. Menstrual health:
Refers to hygienic practices adopted by the adolescent girls during
their menstruation like bathing, changing napkins, disposal of
napkins, use of undergarment, washing of used cloths, drying of used
clothes, maintaining perineal hygiene during menstruation
5. Adolescent girls:
It refers to the girls who are in the age of 10-19 years.
-WHO
In this study adolescent girls refers the girls in the age extending from
12-15 years , who are all in 7th to 9th standard and she should have
attained menarche and also she had a (28 days) regular menstrual
cycle.
6. School:
It refers, a school is an institution designed to provide learning spaces
and learning environments for the teaching of students (or) pupils
under the direction of teachers.
In this study, school refers to institutions which offer education for

the student’s of seventh to tenth standards.
36
CHAPTER 2: LITERATURE REVIEW
Adolescence is a vital phase of human growth, since it represents a

period of life where a person develops from childhood to adulthood.
For both physiological and psychological maturity, puberty has
connotations and thus signifies a significant change. Adolescence,
ranging from around 12 years to 18 years, is critical for male and
female reproductive maturity. Yet, empirical evidence points to a lack
of physiological as well as psychological knowledge and training
regarding these improvements. On account of menstruation and its
importance for human reproduction and procreation, female
adolescents are particularly vulnerable. According to common views,
cultural characteristics and knowledge gathered within the social
community where the woman lives, menstrual experiences differ.
Though menstruation is a biological process, its perception is strongly
linked to cultural factors, so it is also a social process. Abundant
research literature illustrates how various cultures and nations
experience menstruation.
2.1 KNOWLEDGE AND ATTITUDE REGARDING PUBERTAL CHANGES

AND MENARCHE
Nadira Parvin et al. (2016) [56]. A descriptive cross – sectional study

was conducted to assess the knowledge on menstruation among
adolescent school girls in Manipur high school & college Manipur ,
Dhaka , Bangladesh. Sample size was 240 the age group of girls was
between (12-18 yrs.). The data was collected by using pretested
modified questionnaire. Mean age of respondent was 15.46 +1.17 yrs.
37
Mean monthly family income of respondent was 22500±4256 BBT.

The study revealed that majority of respondent (88%) didn’t have
knowledge about menstruation before onset of their menarche. Most
of the respondent (88%) was not mentally prepared for first period.
About 5.6 % of respondent felt good or normal during menstruation
followed by 51 %, 39.4% & 4% had uncomfortable afraid & disgusting
feeling respectively. Majority of respondent 44% know about
menstruation from TV. Most of respondent had poor knowledge & no
knowledge about menstruation.
Shubhangi Nayak et al. (2014) [57]. A cross sectional study was

conducted to assess the perceptions regarding pubertal changes
among adolescents aged between 10- 19 years from urban areas of
district Jabalpur in 2014. The sample size was 800 adolescents (400
from rural and 400 from urban areas). Data was collected by
predesigned questionnaire for quantitative data, and focused group
discussion for qualitative data. The findings of study revealed that in
urban areas, a higher proportion of adolescents were aware of
pubertal changes than in rural areas. Among boys, acne and
increased in height while among girls, menarche and changes in body
contour and acne were common. Adolescents discussed their
problems with their families (42.6%) and with friends (40%). This
study shown poor level of awareness regarding pubertal changes.
Sidi R et al. (2014) [58]. A descriptive & cross-sectional study was

conducted to assess the knowledge, attitudes & practices of high
school students regarding menarche in Parakou. The sample size was
1100 high school girls in age group of 13-18 years. Upon the
appearance of menarche, the mean age was 13.72±1.37 years. The
38
study revealed that knowledge about menarche was known by

60.72% of the respondent before it occurs. The main source of
information about menarche was mother that is 57.75%. Fear &
anxiety were the feeling that inspired 72.55 % of respondent, on
appearance of 1st menstruation. Conclusion of study was that the
students’ knowledge about menarche & its effects in terms of
reproduction & sexuality is insufficient.
Ksuma M.L. et al. (2013) [59]. A cross sectional study was

conducted to assess the awareness, perception and practices
regarding menstruation among pre-university adolescent girls in
Mysore, India. The sample size was 1500 pre-university adolescent girl
selected by proportional stratified sampling technique. The method of
data collection was direct interview by using pre tested structured
questionnaire. Study result revealed that the mean age of menarche of
study subject was 13.38±0.96 years. 335 (22.33%) students had
awareness about menstrual cycle before attaining menarche.
Statistically significant association was present between absorbent
material used during menstruation with socioeconomic status and
mother’s literacy. 810 (54%) students were using sanitary pads. The
major problems encountered by adolescent girls were backache
575(37.60%) and dysmenorrhea 564 (37.60%). 595 (39.66%) subject
had taken medical advice. The study concluded that there is a
substantial lacuna in the knowledge and perception of girls. The
health seeking behavior of the girls in study was poor.
Vinod Ramdasji Washik et al. (2013) [60]. A prospective

observational study carried out to assess the menstrual pattern and
problems of menstrual pattern among rural school going adolescent
39
girls of Amravati district of Maharastra in India. The study was

conducted among 435 secondary and higher secondary girl student
(12-16) years. Study revealed that total 435 girls had attained
menarche. The mean age for menarche was 13.5 (1.0) years. 17.9% of
adolescent girls reported premenstrual syndrome. 81.3% girls had
abdomen pain during menstruation followed by 28.5% cramps. 11%
were uncomfortable. 11% had backache, 6.6% had headache and
2.5% girls had depression, 3.4% of adolescent girls were did not have
any symptoms during menstruation. Dysmenorrhoea was the most
common menstrual complaint reported, in outcome of study that was
62.3% girls. 33.5% of girls have reported that they used sanitary pad
during menstruation. 41.6% girls had reported that they used of old
cloth during menstruation. 21.8% had irregular menstrual cycle. The
result of observational study depict that all adolescent girls have
knowledge about the menstrual pattern and problems of menstrual
patterns.
Pinar Isguven et al. (2012) [61]. A cross-sectional study was

conducted to determine the level of knowledge and sources of
information about normal puberty and menstrual patterns in Turkish
school girls age between 10– 7 years in Istanbul. The sample size was
922 school girls. The method of data collection was survey methods,
tool was structured questionnaire. The result shows that girls age
group between 10-17 yrs. Having menarche and the score was
82.30%. The leading source of pubertal information was mothers that
are (84.2%), and other source of information of students was their
teacher that is 18%. 31.5% students had first symptom of puberty
was acne, and 50.7% of the students did not have knowledge
regarding the time period beginning of puberty and menarche. The
40
outcome study shown that the school girls had an insufficient

knowledge about the normal puberty.
P.R.G. Paul Reji (2011) [62]. A quasi-experimental study was

conducted to assess the effectiveness of structured teaching program
on menarche among pre-adolescent girls in Stella’s High school at
Anjugramam, Kanyakumari. The sample size was 60 pre-adolescent
girls. The tool used for data collection was structured questionnaire
.The study revealed that the median score of participant before
implementation of Structured teaching program was 5.5 (0-12) but
after implementation of structure teaching program the score was 16
(14-19). The mean score of the pre-test was 5.2±2.8 & of the post test
was 16.2 ±1.4. The difference of mean knowledge score between pre-
test & post-test was statistically significant because (t=25.974df.59 &
p< 0.001).
Mrs. Rajinder Kaur (2011) [63]. A cross-sectional study was

conducted on awareness regarding pubertal changes in selected
school of Baglakot, Karnataka among 502 students in the class of 8th,
9th, & 10th. The data was collected by using pre-tested & pre-designed
Performa. The result obtained that out of 502 students, 394 (78.49 %)
were boys & 108 (21.51 ) were girls but 19.80 % of boys and 9.25%
of girls had correct knowledge regarding secondary sex characteristics.
45.18% of boys discussed sex matter with their friends unlikely the
boys, 55.56% of girls discussed the matters regarding secondary sex
characteristics for their parents. 3/4th that is (74.07%) girls do not
have prior knowledge. 66.7% of girls used unhygienic pads during
menstruation. 41.23% of the students mentioned the inclusion of sex
education from higher secondary school .Half of the students did not
41
specify regarding the inclusion of sex education in the curriculum.

58.62% of boys and 60.18% of girls had either correct & some
knowledge regarding HIV transmission. 51.52% of boys, 40.74% of
girls got the information through TV.
Saraswati C Hunshal et al. (2010) [64]. A descriptive study was

conducted in Dharwadtaluk of Karnataka state on the knowledge of
adolescent girls regarding pubertal changes among adolescent girls in
the age group of 10-12year. The data was collected through Interview
method and the study revealed that half of them attained sexual
maturity at 13.1 years of age (50.96%) and most of adolescent girls
knew about pubertal changes particularly. Primary sex characteristics
(56.73%), less no. of respondent knew about secondary sex
characteristics such as height & weight 75%, pubic hair 19.23%,
breast enlargement 14.42%, hip enlargement 9.61% respectively. the
study depict that (50.6%) of the adolescent girls had lack of
knowledge regarding pubertal changes. Hence the study revealed that
majority of adolescent was lack of knowledge regarding pubertal
changes.
Dorle AS et al. (2010) [65]. A cross-sectional study was conducted in

Bagalkot district of Karnataka regarding awareness related to puberty
changes in secondary school students. The sample size was 502
students. The tool was predesigned Performa. The result obtained
from 502 students in which (21.51%) had correct knowledge regarding
secondary sex characteristics. (55.56%) discussed sex matter
regarding secondary sex characteristics with their friends. (74.07%)
girls did not have prior knowledge about menstruation. (66.7%) of
42
adolescent girls were lack of knowledge regarding pubertal changes.

The result showed that awareness related to puberty changes was low.
Nemade D et al. (2009) [66]. An interventional study was conducted

in Navi, Mumbai to assess the impact of health education on
knowledge regarding pubertal changes. The sample size was 217
adolescent school girls. In this study pre- test and post- test was
carried out. In pre-test result shown poor level knowledge .In post-
test after health education there was a significant difference in the
level of knowledge (p < 0.01). But There was no significant difference
in pre-test and post-test knowledge regarding changes in pubertal
(p > 0.05). The result revealed that the girls had poor knowledge
regarding pubertal changes before implementation health teaching
which was shown in result.
Ram Bilas Jain et al. (2009) [67]. A cross- sectional study was
conducted in Block Beri, District Jhajjar, Haryana to assess the extent
of awareness regarding adolescent physical changes or problems
among school going adolescents. The sample size was 320 structured
interviews. The study findings showed that out of 320, 212 (66.3%)
adolescents were aware of at least one adolescent physical changes
and 272 out of 320 (85%) adolescents could narrate at least one such
change. Out of those 272, 24 (8.82%) adolescents either did not
consider these changes as normal or they did not know whether the
changes were normal or abnormal. This study concluded that
adolescents lack correct information related to their body’s
physiological, psychological and sexual changes.
43
Papadimitriou A et al. (2008) [68]. A longitudinal study was

conducted to examine the distribution of timing of the onset of normal
puberty in school of Greek. The sample size was 311 pre-pubertal
school girls. Onset of puberty, i.e. Breast development (B2), was
studied longitudinally in pre-pubertal school girls aged 6.4 to 8.2 year
until the onset of puberty. The tool for data collection was physical
examination at 6 month interval. The result revealed that median of
distribution of age at B2 was 10.0 years. Skewness was -0.45 (p =
0.001), suggesting a negatively skewed distribution. Therefore, up-to-
date studies in pubertal maturation are much needed the distribution
of the timing of the onset puberty girls might have changes.
Nair P et al. (2006) [69]. A cross-sectional study was conducted in

Gazipur village in East Delhi on awareness, practices of pubertal
changes and menstruation. The sample size was 251 adolescent girls
between the age group of 10-19 years. The method used interview for
data collection, tool used structured questionnaires. The outcome of
the study showed that. 2/3 of the study subject had knowledge about
menstruation. 1/3 (33.4%) of the girls had awareness of all pubertal
changes. The association between awareness of pubertal changes
increasing as per age increasing was statistically significant. 45.5% of
the girls had knowledge of menstruation prior to menarche. The
majority of adolescent had awareness of menarche & pubertal
changes, but very low knowledge regarding breast development & the
appearance of axillaries & pubic hair.
H. Tiwari et al. (2006) [70]. A descriptive study was conducted in

Anand district, Gujarat to assess the knowledge, attitude and beliefs
towards menstruation. The sample size was 900 school girls in age
44
group between 11to 17 years. The method of data collection was

questionnaire survey. The study revealed that only 38.5% felt
comfortable about menarche and only 31.0% believed that
menstruation was normal physiological process, 37.2% had been
informed about menarche before its onset. 48.2% felt they were not
mentally prepared. The major sources of information were the mother
(60.7%) or an elder sister (15.8%), teacher and other relatives play a
small role. The study revealed that the need for health education
regarding the pubertal changes and menstrual education needs to be
on-going process.
2.2 PREPARATION FOR MENARCHE AND MENSTRUATION
Jogdand and Yerpude (2013) [71] found that only 36.19% girls were
aware regarding menstruation prior to the attainment of menarche.
For 61.29% of girls, mother was found to be the first source of
information regarding menstruation. Shanbhag et al (2012) found that
99.6% of the students had heard of menstruation and 57.9% had
acquired this knowledge even before attaining menarche. 73.7% knew
that menstruation was a normal phenomenon but only 28.7% had
knowledge regarding menstruation.
Bartky (2002) [72] stated that the changes at menarche are

constructed through language and practices loaded with signifiers of
cultural meaning. Girls from the remote areas were more aware of the
cultural constructions than girls from the urban areas. Young girls in
developing countries often receive limited information on menstrual
hygiene management because menstruation is visualized as taboo,
which makes it very hard for adolescent girls to acquire needed
45
information and support from family and school teachers. It’s indeed
true that much as the instance of looking at menstruation as a taboo
is fading in most western countries, many countries in the south still
have this perception. Despite the many sources of information, girls
often report that the education they receive is insufficient in preparing
them for menstruation.
Shannon et al, (2011) [73] conducted a research in Kenya and

observed that young girls are not generally taught how to control or
manage their menstruation, which is a monthly aspect of their lives
and has a tremendous impact on the way a girl views herself and her
roles within society. As a result their experience has been confusing,
frightening, and shame-inducing and can result in stress, fear and
embarrassment, and social exclusion during menstruation.
Shanbhag et al (2012) [74] studied the perception regarding

menstruation and practices during menstrual cycles among high
school going adolescent girls around Bangalore city, Karnataka, India.
It was found that 99.6% of the students had heard of menstruation
and 57.9% had acquired this knowledge even before attaining
menarche. A study that compared the menstrual attitudes and
experiences of 67 Indian college students to 61 American students
concluded that Indian women tend to describe the experience of
menarche as horrifying.
Sehar et al (2012) [75] found that the information provided to girls

was need based and related to occurrence of menarche; no prior
information was shared regarding it as a taboo. It was also found that
there was no space available for unmarried girls where they can sit
46
together and discuss amongst themselves about the problems and

issues related with puberty. The researcher reported that, norms and
taboos surrounding the issues around puberty and menstruation were
complex and were handled in a particular manner that the adolescent
girls faced a number of issues that at times had serious impacts on
them. This practice was going on for generations which needed
change, and the way forward was through education, awareness and
building trust amongst each other.
Khanna et al (2005) [76] carried out a study on menstrual practices

and reproductive problems in Rajasthan and found that a significantly
large proportion of girls were not aware of menstruation when they
first experienced it. The major sources of information were found to be
mothers, sisters and friends. However, most of this information
imparted to a young girl is in the form of restrictions on her
movements and behaviour.
Kamath et al (2013) [77] conducted a study on knowledge and

practices regarding menstrual hygiene among rural and urban
adolescent girls in Udupi Taluk, Manipal, India. He found that
around 34% participants were aware about menstruation prior to
menarche, and mothers were the main source of information among
both groups.
Kamaljit et al (2012) [78] found that 61.3% adolescent girls of

Amritsar, Punjab had awareness about menstruation prior to
initiation of menarche. Mother was the first informant regarding
menstruation in case of 53.3% girls.
47
2.3 KNOWLEDGE ABOUT AND ATTITUDE TOWARDS

MENSTRUATION
Dube and Sharma (2012) [79] assessed the knowledge, attitude and
practice regarding reproductive health among 200 school girls in the
age 15-19 years from rural and urban settings of Jaipur. It was found
that 40% rural girls and 60% urban girls considered menstruation as
natural phenomena while 39% of urban girls and 56% of rural girls
took it as disease. 11% of urban and 28% of rural girls was not aware
about the gap of periodic menstruation cycle. Differences were evident
in the perception of urban and rural respondents regarding the right
age of menarche. 33% urban respondent had prior information
regarding menstruation, 62% rural respondent were unaware of the
right age of menarche. Awareness among rural girls was significantly
more as compared to urban girls of district of Dehradun of
Uttarakhand state. Friends were the first informant in about 31.8 %
girls. But most of the respondents did not know about the cause and
source of bleeding during menstruation.
Patle and Kubde (2014) [80] found that, awareness regarding

menstruation is also more in urban adolescent girls (63.38%) as
compared to rural (47.57%). The variation in the awareness may be
due to socio-economic status and also literacy status of the adolescent
girls and their mothers.
Anusree et al. (2014) [81] analyzed knowledge regarding menstrual

hygiene among adolescent girls in selected school of Mangalore.
Results show that 46.7% had good knowledge and 48.3% had average
knowledge. Analysis of the association between the level of knowledge
48
regarding menstrual hygiene among adolescent girls and their selected

demographic variables reveals that there was significant association
between the level of knowledge and religion (p < 0.05) and mother’s
occupation (p < 0.05). It was also evident from the study that there
was no significant association between the level of knowledge related
to menstrual hygiene and age, education, family, occupation of father,
family income, and age at first menstruation, pre-existing knowledge
and source of information (p > 0.05). Nemade et al. (2009) found that
the knowledge regarding the organ from where menstrual blood comes
was correctly reported as uterus by 73 (33.64%) girls whereas 113
(52.07%), 16 (7.38%), and 15 (6.91%) reported urethra, ovary and
stomach respectively. The girls were not able to differentiate between
urethral and vaginal opening. This shows the low level of knowledge
among girls about female anatomy.
Akanksha et al. (2014) [82] study in village Limbgaon, District,

Maharashtra about knowledge regarding menstruation shows that
28.33% of the respondent said that the menstruation starts at the age
of 14years while 25% had knowledge of normal age of menstruation of
13 years. Most of them i.e. 83.33% and 96.67% were aware of the
normal flow of menstruation to be 2–5 days and that next cycle comes
after 28-35 days respectively. 28% of them thought that the cause of
menstruation is hormonal change and 26% of them thought it to be
due to aging. Mother (24.64%) was the most common source of
information about menstruation among girls followed by teachers
(16.57%), friends (10.45%) and relatives (3.34%), however many of
them 45% did not have any prior knowledge about menstruation.
49
Arora et al. (2013) [83] conducted a study on impact of health

education on knowledge and practices about menstruation among
adolescent school girls of rural part of district Ambala, Haryana. His
study shows that, in the pre-test, menstrual perceptions amongst
them were found to be poor and practices were incorrect while in the
post-test, there was a significant difference in the level of knowledge
(p < 0.05). The study also found no significant difference in pre and
post-test with regard to restrictions practiced during menses (p >
0.05) whereas in the post-test following health education, significant
improvements were noticed in their practices.
Bilas et al. (2013) [84] conducted a study on assessment of self-

awareness among rural adolescents in Beri Block of Jhajjar District
(Haryana). Results reveal that adolescents greatly lack correct
information related to their bodies' physiological, psychological and
sexual changes. 66.3% adolescents are aware of changes, which occur
during adolescence. Awareness regarding emotional/social change(s)
is very less i.e., only 7.19% among adolescents. 8.82% adolescents do
not recognize these changes as normal. Female adolescents (65%) are
more aware of sexual developmental changes in comparison to male
adolescents (33.13%) (p = 0.015). Furthermore, more females, in
comparison with male adolescents, have correct knowledge of the
sexual changes (p = 0.015).
Kamaljit et al. (2012) [85] found that mothers, was the first
informant regarding menstruation followed by friends and sisters.
Similarly in Nepal the menstruation cycle physiology, sanitation
habits and its management are introduced to adolescent girls mainly
by their mother, elder sister at home and female teachers or friends at
50
school. However, internet access is the next option for the source of
information.
Mundey et al. (2010) [86] carried out a study among 300 school
going adolescent girls (10–19 years) in the rural area of Wardha
district, Maharashtra, India. Majority of the girls received the
information regarding menstruation from their mothers (41%),
followed by media (24%) and friends (19%).
Bayray, (2012) [87] found that friends were 50% the main
contributors for getting the knowledge followed by mothers (36%) and
aunts/relatives (19%).
Tiwari et al. (2006) [88] conducted a survey on knowledge, attitude

and beliefs towards menstruation, in Anand District, Gujarat and
found that only 31.0% believed that menstruation was normal
physiological process. The major sources of information were the
mother (60.7%) or an elder sister (15.8%), teachers and other relatives
play a small role.
Costos et al. (2002) [89] conducted interviews with 138 women

between the ages of 26 and 60. Their analysis revealed that the
majority of the mother-daughter menstrual conversations were
negative in tone. The negative messages presented by mothers were
conveyed in various ways, including being unwilling to talk about
menstruation, only giving instructions on the use of menstrual
products, using negative labels, such as “the curse,” to refer to
menstruation, and urging discretion and secrecy where menstruation
is concerned.
51
Adinma and Adinma (2008) [90] reported that the information on

menstruation given by mothers is often incomplete and incorrect,
usually being based on cultural myths, and therefore probably
perpetuating negative and distorted perceptions and practices of
menstruation. Studies have shown that many taboos are internalized
at a young age and influence menstrual behaviors and attitudes.
Senol et al. (2010) [91] examined the attitude, behaviour and

knowledge regarding menarche and menstruation in adolescent
schoolgirls in Kayseri. 76% of the girls described menarche as a
positive change such as “preparation to be a mother”, 21% as “a
transition to adolescence”, whereas 62% described it as a negative
change such as “discharging dirty blood”. The girls who reported
positive menarcheal experiences would tend to show positive current
menstrual attitudes/behaviors and the opposite was true for the girls
who reported negative menarcheal experiences.
2.4 OVERVIEW ON MENSTRUATION & MENSTRUAL HYGIENE
Juyal et al. (2012) [92] emphasized on the need to educate the girls
about menstruation, its importance and hygiene maintenance; so as
to enable them to lead a healthy reproductive life in future. Menstrual
hygiene among adolescent girl in West Bengal is far from satisfactory
among a large proportion of the adolescents while ignorance, false
perceptions, unsafe practices and reluctance of the mother to educate
her child are also quite common among them.
52
Khanna et al. (2005) [93] conducted a study on menstrual practices

and reproductive problems in Rajasthan. Regression analysis in this
study identified schooling, residential status and occupation of father,
caste and exposure to media to be the major predictors of safe
menstrual practices among the adolescent girls. The occurrence of
RTIs was more than three times higher among girls having unsafe
menstrual practices. The article makes a strong case that lack of
knowledge; wrong perceptions and unsafe practices related
menstruation are common.
Baridalyne & Reddaiah (2004) [94] conducted community-based

cross-sectional study on knowledge, beliefs and practices on
menstruation among the reproductive age group women, residing in
an urban resettlement colony of Delhi. The findings highlight the need
for health education among women so as to increase awareness and
correct knowledge regarding various aspects of menstruation and
menstrual hygiene.
Anju and Patil (2013) [95] found that the respondents were not
properly maintaining menstrual hygiene. It was also reported that
though knowledge was better but taking into account the health
implications and prevailing socio-cultural and economic factors, there
is need for a continuous school education program. There is also a
need for improving access to sanitary pads and advanced provision of
it.
Bassiouny et al. (2013) [96] studied the impact of health education

program on menstrual beliefs and practices of adolescent Egyptian
Girls at Secondary Technical Nursing School. It was found that there
53
was a negative correlation between mothers' education and students’

practices. It was concluded that level of students' knowledge regarding
menstruation and menstrual hygiene practices improved after the
program.
Mundey et al. (2010) [97] conducted a study to understand the

perceptions, source of information and status of menstrual hygien
among 300 school going adolescent girls (10- 19 years) in the rural
area of Wardha district, Maharashtra, India. Majority of the girls who
developed genital tract infections, 66% used cloth. 37% girls do not
disclose about their menstruation. Cleanliness of external genitalia
was unsatisfactory in most cases. In a city of south India also found
that disposable pads were used by two-thirds of the selected girls
(68.9%) regardless of age, while 45.1% reported to use both disposable
and non disposable materials. Frequency of changing pads was 2-3
times a day by 78.3% girls. Socioeconomic Status (SES) of the girls
and their age influenced selection of napkin/pads and other practices
like, storage place of napkins; change during working hour and
personal hygiene. Older girls had good hygienic practices than the
younger ones. Seventy six percent of the participants desired for more
information regarding menstruation and hygienic practices.
Adhikari et al. (2007) [98] conducted a study on the adolescent girls

evaluated the knowledge and practice on different aspects of
menstrual hygiene. Results reveal that the sample adolescent girls did
not maintain proper menstrual hygiene. Only 6.0% of girls knew that
menstruation is a physiologic process, 36.7% knew that it is caused
by hormonal changes. In rural Western Kenya girls were unprepared
and demonstrated poor reproductive knowledge, but devised practical
54
methods to cope with menstrual difficulties, often alone. Home and

school support of menstrual requirements is incomplete, and
information provided is inaccurate. Girls remain absent from school
during menstruation, due to physical symptoms or inadequate
sanitary protection. They face difficulties while in class, due to fear of
smelling and leakage, and subsequent teasing. Sanitary pads were
valued resource and time constraints result in prolonged use causing
chafing. Improvised alternatives, including rags and grass, were prone
to leak, caused soreness, and were perceived as harmful.
Pugalenthi et al. (2013) [99] revealed that there was positive

association between use of sanitary napkins and education. It was
observed that the socioeconomic status of family had a great effect on
the use of sanitary napkins.
Poureslami and Ashtiani (2002) [100] analyzed the attitudes of

female adolescents about dysmenorrhea and menstrual hygiene in
Tehran and found that 77% of the subjects had adequate knowledge
of dysmenorrhoea. But only 32% of these practiced personal hygiene,
such as taking a bath, and used hygienic materials (i.e. sterile pads).
About 33% of the subjects, avoided any physical activity or even mild
exercise during menstrual period. Over 67% of the girls reported
taking palliative medicine for their menstrual pain without consulting
a doctor. 15% of the subjects stated that dysmenorrhoea had
interfered with their daily life activities and caused them to be absent
from school from between 1 to 7 days a month.
Santina and Nancy (2013) [101] assessed beliefs and practices

relating to menstrual hygiene of adolescent girls in Lebanon reported
55
that a significant association was found between menstrual hygiene

practices based on socio-cultural beliefs and type of school, religion,
both parents’ education levels, as well as family monthly income.
Logistic regression analyses indicated that significant variables
predicting describe menstrual hygiene practices based on socio-
cultural beliefs were mother level education (OR = 2.8; p < 0.001), and
religion (OR = 0.7; p = 0.002).
Sapkota and Sharma (2014) [102] analyzed the knowledge and

practices regarding menstruation among school going adolescents of
rural Nepal. It was found that traditional beliefs regarding
menstruation still persist and menstrual hygiene among the
adolescents was found to be unsatisfactory. It indicates the need of
targeted interventions to raise awareness and provision of family
health education package to all adolescent girls.
Quazi et al. (2006) [103] also documented similar results with most
of the rural girls using cloth as a menstrual pad, and reusing the cloth
after washing it with soap and water for about 4 - 5 months. Very few
rural girls used sanitary napkins available in the market, perhaps due
to high prices, less availability and lack of awareness in rural areas.
Patle and Kubde (2014) [104] also conducted a comparative study on

menstrual hygiene in rural and urban adolescent of Indira Gandhi
government medical college, Nagpur on the 310 adolescent girls in the
age group of 10-19 years. The results reveal that, 62.03% of urban
girls were using commercially available sanitary pads.
56
CHAPTER 3: MATERIALS AND METHODS
The methodology of analysis offers a brief overview of the approach

used in this study by the investigator. This includes research
methodology, research design, climate, population, sample, sample
size, sampling method, sample selection criteria, tool definition,
validity, reliability, pilot study, data collection procedure, data
analysis strategy, and human rights security.
3.1 RESEARCH APPROACH
Quantitative approach was used for the present study. The present
study is aimed at A Descriptive Study to Assess the Knowledge and
Attitude Regarding Pubertal Changes and Menarche among
Adolescent Teenager Girls: Case Study in Selected Schools of District
Shimla, Himachal Pradesh
3.2 STUDY DESIGN
This cross-sectional study used a multistage random sampling

method. First, simple random sampling was used to select schools in
each stratum (study region). Then, in each school, a number of
classes were selected randomly.
3.3 STUDY SETTING AND PARTICIPANTS
The participants of this study were adolescent girls between ages 11

and 19 years and who were willing to participate in the study.
57
3.4 SAMPLE SIZE
The sample size was determined using a formula for estimation of

single population proportion with the assumption of 90% confidence
interval, 5% margin of error, and prevalence of knowledge about
menstruation at 50%, and sample size was calculated using open Epi
version 3.01 as 96. The study conducted was a descriptive cross-
sectional study done on 100 adolescent girls from schools of district
shimla, Himachal Pradesh (convenience sampling). Before the
commencement of the study, they were explained the purpose and
nature of the study. Those who all were present on the day of study
and were willing to participate were included in the study.
3.5 SAMPLING TECHNIQUE
In the present study, socio-demographic variables, knowledge,

attitude, and coping strategies toward puberty among adolescent girls
were evaluated. Socio-demographic variables such as age, grade, child
order in the family, area of residence, education, employment status of
the parents, and participants’ source of information on puberty were
examined using multiple choice questions.
A self-administered, structured, pretested, closed-ended anonymous

questionnaire consisting of questions on knowledge and practices
regarding menstrual hygiene was used as a study tool. Information on
demographic variables which include age, class, type of family,
education of mother, family income, and age of menarche was
collected from the participants. The questionnaire consisted of
questions regarding knowledge and practices regarding menstruation.
58
Knowledge questions consisted of questions such as source of

knowledge of menstrual cycle before menarche, knowledge of organ
from where bleeding occurs, and cause of menstruation. Awareness
about menstruation including physiological process, sources of
information, and the best informant for information on the subject.
Practice questions included type of absorbent used while
menstruation, for example, sanitary pads, new cloth, old-washed cloth
or both, about personal hygiene during menstruation, and frequency
of changing pads, personal hygiene methods, for example, daily bath
and hand washing (regular/irregular, water/soap).
There were 20 multiple choice questions regarding knowledge and 17

multiple choice questions regarding practices on menstrual hygiene
among AGs. For each correct response a score of “1” (one) and for
wrong “0” (zero) score was given. Adequate knowledge was labeled if
the participant scored ≥10/20 and <10/20 was labeled as inadequate
knowledge. Similarly, practice scores were labeled as good (>14/17),
fair (10-14/17), and poor (<10/17). Following data collection, queries
from the participants relating to menstrual and reproductive health
were clarified by the investigator. The pretested questionnaire was
administered under supervision of the investigator to prevent the
participants from sharing responses.
59
3.6 CRITERIA FOR SAMPLE SELECTION
The samples were selected based on following criteria.
Inclusion Criteria:
 Adolescent girls who are willing to participate in the study.
 Adolescent girls who can read and understand Hindi/ English.
 Adolescence girls who had attained menarche.
 Adolescence girls who between the age group of 12-19 years.
 Adolescence girls who are in their 14th day of her menstruation.
Exclusion Criteria:
 Adolescent girls who are not available at the time of data collection
 Adolescent girls who didn’t have good auditory or listening capacity
3.7 DATA COLLECTION PROCEDURE
After coordination with education districts and schools, a trained

individual was sent to the selected schools to speak with students
concerning the purpose of the study. The data collection procedure
was done for 5 weeks. The permission was obtained the authorities
concerned from the school before the pilot study and actual
data collection was started. The nature of the study was explained to
the adolescent girls and oral consent was obtained.
3.8 PROTECTION OF THE HUMAN RIGHTS
Data were gathered after obtaining the informed consent from the
students and providing explanations about the confidentiality of
60
information. Oral consent was obtained from the study samples before
starting data collection. Assurance was given and confidentiality was
maintained. The adolescent girls who were participated in the study
were explained that they have the rights to withdraw from the study at
any point of time. There was absence of physical and psychological
strain to the adolescent girls who were participated in the study
3.9 STATISTICAL ANALYSIS
Data were cleaned and entered in Microsoft Excel 2007 spreadsheet,

and frequencies are presented in along with the percentages wherever
appropriate. Data obtained were analyzed using SPSS statistical
software package, version 16 (SPSS Inc., Chicago, IL, USA), and
findings were reported in the form of descriptive statistics,
quantitative variables using Chi-square test, and Fischer exact test
and Pearson’s correlation coefficient to assess the correlation between
the knowledge and practice scores. A p ≤ 0.05 was used to indicate a
statistically significant association.
61
CHAPTER 4: RESULTS
4.1 KNOWLEDGE AND PRACTICE REGARDING MENSTRUAL

HYGIENE AMONG ADOLESCENT GIRLS
Table 4.1 shows frequency and percentage of socio-demographic

variables of the sample. The data on knowledge scores revealed that
29% had adequate knowledge about menstrual hygiene, and 71% had
inadequate knowledge about menstrual hygiene. The data revealed on
practice scores revealed that 19%, 69%, and 12% samples had poor,
fair, and good score of practices regarding menstrual hygiene,
respectively.
Table 4.1: Frequency and percentage of socio-demographic

variables
Demographic variables Percentage (%)

Age (years)
12-13 4
14-15 48
16-17 48
Class
9th 19
10th 26
11th 24
12th 31
Type of family
62
Nuclear 46
Joint 51
Any other specified 3
Education of mother
Illiterate 10
Primary 32
Secondary 41
Graduate 17
Family income
<5000 28
5000-10,000 28
10,000-15,000 21
>15,000 23
Age of menarche (years)
9-14 12
12-14 72
14-16 16
Any prior information regarding menstrual
hygiene
Yes 86
No 14
If yes, source of information
Family member 61
Friend 20
Health worker 3
Mass media 2
63
Table 4.2: Association between knowledge level and demographic

variables
Demographic Adequate Inadequate χ2/Fischer P

variables knowledge knowledge exact
Type of family 4.091 0.13
Nuclear 10 36
Joint 19 32
Any other 0 3
specified
Education of 9.420 0.02*
mother
Illiterate 15 5
Primary 14 18
Secondary 7 34
Graduate 3 14
Family income 2.026 0.57
<5000 11 17
5000-10,000 7 21
10,000-15,000 5 16
>15,000 6 17
Age of menarche 1.449 0.48
(years)
9-14 2 10
12-14 21 51
14-16 6 10
*P<0.05 is considered as statistically significant
64
Table 4.2 shows that the education of mother had the significant effect
on the knowledge scores of the participants.
Table 4.3: Correlation of knowledge and practice scores of

participants
Correlation of Mean Correlation (r)

knowledge and
practice
Mean knowledge score 12.25 0.394*
Mean practice score 12.34
*P<0.05 is considered as statistically significant
Table 4.3 shows the correlation between the knowledge and practice
scores of participants which shows positive correlation between the
two scores (*P < 0.001).
4.2 KNOWLEDGE AND ATTITUDE REGARDING PUBERTAL

HEALTH AMONG ADOLESCENT GIRLS
Table 4.4: Information regarding Menstruation
Variables Percent
Occurrence of Menarche
Yes 90.7
No 9.3
If yes, age in years at menarche
≤12 46.9
65
>12 53.1
Mean age (in years)±SD 12.55 ±0.90; Min=10, Max=16
If yes, experience at menarche
Scared 63.9
Unpleasant 2.4
Pleasant 2.4
No feeling 31.3
Received information on puberty
Yes 92.3
No 7.7
Sources of information**
Mother 79.8
Father 6.0
Friends 39.9
Sister 38.7
Teacher/School 44.0
Relatives 14.3
Information Media 3.0
Table 4.4 shows that majority (90.7%) had occurrence of menarche

and among them 46.9 % were ≤12 years. The mean age of menarche
was 12.55 ± 0.90. Regarding experience at first menstruation, more
than half (63.9%) were scared and 2.4% had pleasant and unpleasant
experience. Regarding received information on puberty, 92.3% had
previously received information on puberty and among them, the
major source of information was mother which is 79.8% followed by
teacher/school which is 44%.
66
Table 4.5: Respondents’ Level of Knowledge and Attitude

regarding Pubertal Health
Level Percent
Level of Knowledge
Good knowledge (>66.7%) 1.7
Moderate knowledge (33.4- 66.7%) 80.3
Poor knowledge (≤33.33%) 18.0
Level of Attitude
Negative Attitude (≤78) 51.4
Positive Attitude (>78) 48.6
Table 4.5 shows that out of 100 respondents, 80.3% had moderate
knowledge, 18% had poor knowledge and 1.7% had good knowledge
regarding pubertal health whereas regarding attitude, 48.6% had
positive attitude and 51.4% had negative attitude towards pubertal
health.
Table 4.6: Association between Level of Knowledge regarding

Pubertal Health and Socio-demographic Characteristics of
Respondents
Variables Level of χ2 p
Knowledge value
Fair (%) Poor (%)
Age group (in years)
Early adolescence (11-14) 79.6 20.4 1.077 0.299
Middle adolescence & above 85.7 14.3
67
(15- 19)
Level of education
Class 8 73.8 26.2 13.243 0.001*
Class 9 78.5 21.5
Class 10 96.2 3.8
Ethnic group
Janjati 78.9 21.1 0.914 0.633
Brahmin/ Chhetri 85.1 14.9
Othersª 82.5 17.5
Elder Siblings
Yes 79.3 20.7 1.669 0.196
No 87.1 12.9
Relation to sibling
Brother 80.0 20.0 0.019 0.890
Sister 78.9 21.1
Yes 82.2 17.8 0.000 1.000¥
No 78.6 21.4
Sources of information (n=169)
Friends 89.6 10.4 4.114 0.043
Teachers/ School 93.2 6.8 10.687 0.001
Significance level at 0.05, *Likelihood ratio
Table 4.6 shows that there is statistically significant association

between level of knowledge regarding pubertal health and level of
education (p=0.001), sources of information of friends (p=0.043) and
source of information of teachers/school (p=0.001) and there is no
significant association with other socio-demographic variables.
68
Table 4.7: Association between Level of Attitude regarding

Pubertal Health and Socio-demographic Characteristics of the
Respondents
Variables Level of Attitude χ2 p

Positive Negative value
(%) (%)
Age group (in years)
Early adolescence (11-14) 46.9 53.1 0.354 0.552
Middle adolescence (15-19) 51.4 48.6
Level of education
Class 8 43.1 56.9 4.150 0.126
Class 9 44.6 55.4
Class 10 60.4 39.6
Ethnic group
Janjati 42.1 57.9 3.967 0.138
Brahmin/Chhetri 58.2 41.8
Othersª 45.0 55.0
Elder Siblings
Yes 47.9 52.1 0.070 0.791
No 50 50
Relation to Sibling
Brother 33.3 66.7 6.120 0.013
Sister 56.6 43.4
Yes 49.7 50.3 1.013 0.314
No 35.7 64.3
69
Sources of information
Sisters 60.0 40.0 5.213 0.022
Teachers/School 58.1 41.9 4.464 0.035
Significance level at 0.05
Table 4.7shows that there is statistical significant association between

level of attitude and relation to the sibling (p=0.013), sources of
information of sisters (p=0.022) and sources of information of
teachers/school (p=0.035) and there is no significant association with
other socio-demographic variables.
4.3 KNOWLEDGE, ATTITUDE, AND PRACTICE ON MENSTRUAL

HYGIENE MANAGEMENT AMONG SCHOOL ADOLESCENTS
Only four out of 11 schools had a separate toilet available for students
and teachers. Seven schools had gender-friendly toilets. Only three
schools had running water available in the toilets but only one school
had the availability of soap for washing hands in the toilet. At the time
of observation, marks of open urination/ defecation were found in four
schools. None of the schools had mirror available at toilets. Rest room
for use during menstruation was not available in any of the schools.
Only five schools had enough drinking water for students during
school time. About the knowledge on Menstruation Hygiene
Management, 6.2% of the respondents had poor knowledge, 67.4%
had fair knowledge and 26.4% had good knowledge of menstrual
hygiene management. 83% of the respondents agreed that
menstruation is a physiological process. 44% of the respondents were
aware of the age of menarche and 70% knew the age of
menopause.90% of the participants were aware of the reason to use
70
sanitary pad. 35% of the participants were of the opinion that time
interval to change pad is daily. 97% of respondents knew the reason
for washing hands after handling used pad and 98.9% of respondents
knew about the proper way of disposing used pad.
Table 4.8: Knowledge regarding MHM
Variables Percent (%)

Menstruation
Physiological process 83
Curse from god 1.1
Untouchability 10.5
Disease 0.4
Don’t know 5.1
Reason to use sanitary pad
Manage blood flow and maintain hygiene 90.6
To relieve pain 2.5
Instead of taking shower 1.8
Don’t know 5.1
Time interval to change pad
Every hour 28
Every 4-6 hours 21
Daily 35
Don’t know 16
Way to dispose of used pad
Burning 38.4
Burying 18.5
Throw away 1.1
71
Both a or b 42
Knowledge (Summary index)
Poor knowledge 6.2
Fair knowledge 67.4
Good knowledge 26.4
Table 4.8 shows that on the practices related to menstruation, out of

100 adolescent respondents, 40% had good menstrual hygiene
practices. 51% girls had a fair practice and 9% had poor menstrual
hygiene practices. 30% of the respondents used factory made sanitary
pads followed by 76% of them using homemade and reusable pads.
However, only 39% of respondents changed pads in every 4 –6 hour
period. 68% of the respondents washed hands after changing a
sanitary pad and 61 % used soap and water for washing hands.
Table 4.9: Practice Regarding MHM

Parameters of practice Percent (%)
Uses commercially made sanitary pad as absorbent 21.3
during menstruation
Uses homemade reusable pad 53.9
Changing pad every 4-6 hours during menstruation 27.7
Washes hands after changing pad 68.1
Uses soap water to wash hands after pad change 61.4
Clean genitalia after every toilet visit during 59.6
menstruation
Clean genitalia after pad change 56
Change underwear during changing pad 45.4
72
Clean genitalia in front to back motion during 39.7

menstruation
Properly manages used pads during menstruation 67.4
Takes bath daily during menstruation 78.7
Use school toilet during menstruation 90.1
Practice (summary index)
Good practice 40
Fair practice 51
Poor practice 9
Table 4.9 shows that 49% of the respondents had a positive attitude
towards MHM issues whereas 51% required improvement on their
attitude towards MHM. Data showed that 52.5% of the respondents
agreed restrictions for carrying out household chores during
menstruation are significant. Only 47% thought that violation or
nonobservance of cultural traditions and taboos during menstruation
will not lead to god or deities cursing their family members. 77% of
respondents agreed that, increase in supplementation of
nutrients/food is necessary during menstruation. Only 54% of
respondents thought that men do not become sick if a menstruating
female touches him. 65% of respondents agreed that menstruating
females should take bath. Only 45% of respondents agreed that
menstruating females can consume dairy and sour food items.
73
Table 4.10: Attitude Regarding MHM.
Statements Percent (%)

Restriction in household task during menstruation is 52.5
not significant
Self-esteem increases after menarche 38
Menarche signals the body is functioning normally 48.2
God will not curse family members if cultures/ taboos 46.7
are not followed during menstruation
Increase in supplementation of nutritious food is 76.8
necessary during menstruation
Men will not become sick when menstruating female 54
touch them
Menstruating female should take bath 65.2
Menstruating females can eat dairy and sour items 44.6
Positive attitude 49
Need improvement 51
Table 4.10 shows that in regards to accessibility of MHM and Water,

Sanitation & Hygiene (WASH) facilities and services, 47.5% of
respondents first heard about menstruation at the age 10-12 years
mostly getting information on menstruation from school additionally
followed by friends, mother, and guardian.
Over 70% of respondents had heard message on menstruation from

the local radio station. About 45% of respondents had not got any
MHM education class/orientation. Data showed that NGOs are mainly
providing MHM education/orientation/training in school.
74
Only 28.3% of female respondents had ever participated in a sanitary

pad making training and 27.2% had made reusable sanitary pads
after participating in the training.
About 70% respondents replied unavailability of supplies for

managing menses at school. Different questions about their belief,
tradition and culture related to menstruation were asked to
adolescent girls and boys.
Among a total of 100 respondents, 39% responded ‘feeling shame to

talk about menstrual status’ followed by pain and then by leaks,
stains, and menstruation related odor leading to teasing by boys as
major challenges faced during menstruation. Although knowledge
score was high, more than half of female respondents stayed at a
separate room at their home during menstruation and were not
allowed to participate in cultural/religious functions. Not surprisingly,
only 29 respondents said they got psychological support from their
family during menstruation. Thus, findings indicate the need of
behavior change communication campaigns along with frequent
reinforcement of school health education programs.
The results indicate that majority of the respondent girls have

knowledge of MHM but it hasn’t clearly translated into the right
attitude and practice, hence, behavior change programs should be
conducted in those communities. Massive advocacy campaigns are
also required to combat the deeply ingrained religious and cultural
malpractices, restrictions, and taboos related to menstruation.
Interventions to increase access to hygienic absorbents and disposal
75
of MHM items are the issues that should be addressed. School WASH
facilities are currently acutely inadequate for the girls to safely
manage their menses; enough water is not available, gender friendly
toilets, both for students and teachers are missing and hand washing
facilities are absent. Hence, MHM friendly WASH infrastructures and
facilities must be created at schools.
4.4 KNOWLEDGE, ATTITUDES, AND COPING STRATEGIES

REGARDING PUBERTAL CHANGES AMONG ADOLESCENT GIRLS
Table 4.11 shows more than half of the participants (50.5%) had
moderate knowledge about puberty and 66.7% of the participants had
a good (positive) attitude toward puberty. Table 4.12 shows the most
frequent coping strategy selected was avoidance oriented (54.2%).
Table 4.13 shows Spearman test showed a significant relationship
between knowledge and attitude (Spearman coefficient = 0.54) (P =
0.000). However, Chi-square test did not reveal a significant
relationship between knowledge and attitude regarding selective
strategies to cope with pubertal changes.
Table 4.11: The knowledge and attitude status of students about

puberty
Knowledge and attitude Percentage (%) Mean ± SD
Knowledge
Low 14.9 38.5 4±9.02
Medium 50.5 76.46±4.28
76
Knowledge and attitude Percentage (%) Mean ± SD
High 34.6 60.8 4±6.05
Attitude
Weak 33.3 51.45±16.35
Good 66.7 81.68±7.98

SD=Standard deviation
Table 4.12: Status of strategies to deal with the crisis of puberty

in adolescents
Coping strategies Percentage (%) Mean ± SD
Task oriented 6.1 38.4±9.8
Emotion oriented 39.6 47.1±10.1
Avoidance oriented 54.2 50.2±10.6
SD=Standard deviation
Regarding the effects of parents’ education on adolescents’ knowledge,

we did not see a significant relationship between student's knowledge
and mother's education (P = 0.07). However, there was a significant
association with father's education (P = 0.005). Moreover, the results
of Chi-square test showed significant relationship between students’
attitude and mother's and father's education (P = 0.003, P = 0.001)
but the significant relationship between students’ coping strategy and
mother's and father's education (P = 0.35, P = 0.084) was not seen.
77
Table 4.13: Knowledge and attitude regarding selective strategies

to cope with puberty
Knowledge Coping strategies Test P

and attitude Avoidance Emotion Task
oriented oriented (%) oriented
(%) (%)
Knowledge
Low 4.7 43.5 51.8 χ2 0.88
Medium 5.9 39.6 54.5
High 7.1 38.1 54.8
Attitude
Weak 7.4 43.2 49.5 χ2 0.25
Good 5.5 37.9 56.6
Fisher's exact test showed no significant association between coping

strategy (P = 0.52), attitude (P = 1), and knowledge level (P = 0.26) with
place of residency. Chi-square test showed that maternal occupancy
had a non-significant association with coping strategy (P = 0.66) and
knowledge (P = 0.24) but a significant relation with attitude (P =
0.007). There was no significant relationship between father's
occupation status with coping strategy (P = 0.12) and attitude (P =
0.71). However, there is a significant one with knowledge (P = 0.016).
Furthermore, Chi-square test results indicated that the students in
the second grade had higher knowledge (P = 0.049) and attitude (P =
78
0.005) compared to the first-grade students in the secondary school.

Chi-square test also showed a significant relationship between coping
strategies and school turnout (P = 0.01). Second-grade secondary
school students (9.8%) used a task-oriented coping strategy more
frequently than the first-grade secondary school students (3.3%).
4.5 AWARENESS REGARDING PSYCHOLOGICAL CHANGES,

CAUSES OF PUBERTAL CHANGES AND SOCIAL RELATIONS
ADOLESCENT GIRLS
Majority of the girls (62%) were in mid adolescence (14-16 yrs) while
the mean age of participants was 14.61 yrs.
Table 4.14: Knowledge about pubertal changes among adolescent

girls according to age Group
Knowledge Age Up to 14 Age Above 14

Breast Enlargement 19.75 19.75
Pubic Hair 25.92 15.90
Hips Enlargement 4.32 14.77
Increase in height and weight 19.13 19.31
Pimples or Acne 15.43 11.36
Facial Hair 1.2 6.81
No Changes Feel 14.19 9.09
Table 4.14 shows perception of pubertal change with increasing age of

the participant. The most common knowledge perceived by one third
girls below 14 years were growth of pubic hair in the private parts.
79
The knowledge perceived by majority of girls above 14 years were

breast enlargement in this period.
Table 4.15: Awareness regarding psychological changes and social

relations among adolescent Girls
Psychological changes during puberty Percentage (%)

Frequent argument with parents 10.4
Less dependent on family 2.8
Spend more time with friends 19.2
Future planning 3.2
Sudden mood changes 56.8
Involuntary increase in sexual feeling and fantasies 7.6
Table 4.15 shows Result revealed that majority of girls reported

sudden mood change during puberty.
Table 4.16: Awareness regarding causes of pubertal changes
Causes of pubertal changes Percentage (%)

Due to hormone 67.2
Nutritional imbalance 22.0
Due to disease 2.0
Don't know 8.8
Table 4.16 shows Results reveals that majority of girls were aware that
changes occur in their body are due to hormones.
80
Table 4.17: Frequency and percentage distribution of knowledge

regarding pubertal changes among adolescent girls
Knowledge Percentage (%)

Adequate 28.8
Moderate Knowledge 63.2
Inadequate 12
The result presented in Table 4.17 revealed that the majority of girls
have moderate knowledge about pubertal changes. Benefit from
government programs is now increasing slowly in the school regarding
menstruation cycle and girls are now moderately aware about it.
Table 4.18: Major sources of information regarding puberty

among adolescent girls
Sources of information Percentage(%)

Mother 66
Elder Sister 12.8
Teacher 3.6
Book 4
Television 2.4
Govt. Program 2.4
Relative Friends 7.6
None of the Above 1.2
The results presented on Table 4.18 shows the various sources of

information to adolescent girls about pubertal changes. The result
81
revealed that 66% of adolescent girls get the information from mother,
12.8% adolescent girls’ source of information were elder sister, teacher
were the source of information among 3.6% adolescent girls, 4% of
adolescent girls get the information from books, 2.4% of adolescent
girls get the information from television and government program and
among 7.6% of adolescent girls’ relative and friends were the source of
information. Result revealed that among majority of girls’ mother was
the major source of knowledge about pubertal changes.
Table 4.19: Person to whom comfortable to share regarding

pubertal changes among adolescent
Girls
Person to whom Comfortable to Share Percentage (%)

Mother 50.8
Elder Sister 12.4
Teacher 2.4
Relative 1.6
Friends 10.4
No Menstruation 3.6
More Than One 18.8
The result revealed in Table 4.19 shows that 53.2% of adolescent girls
share problems related to menstruation to mother, 12.4% share with
elder sister, 2.4% share with teacher, 1.2% of adolescent girls share
with relatives, 10.4% of adolescent girls with friends and 18.8% of
adolescent girls share with both mother and elder sister. Results
82
revealed that majority of adolescent girls feel comfortable to share

problems related to puberty to the mother.
4.6 KNOWLEDGE OF REPRODUCTIVE HEALTH AMONG

ADOLESCENT GIRLS
Table 4.20: Knowledge of reproductive system
Knowledge of reproductive system Percentage (%)

Identification of Reproductive System 93.33
Labeling of female Reproductive System
Uterus 4.67
Ovary 2.67
Vagina 2.67
Fallopian tube 0.67
Cervix 0
Table 4.20 shows the knowledge of adolescent girls regarding

reproductive system; it mainly focuses on [a] Identification of
Reproductive System. [b] Labeling of different organs of Reproductive
System. Majority (93.33%) could identify the diagram of female
reproductive system but very few adolescent girls could Label the
different organs of Reproductive System, (4.67%) girls identified
‘Uterus’, (2.67%) identified ‘Ovaries’, (2.67%) identified ‘Vagina’,
(0.67%) identified ‘Fallopian tube’, but no one could identify ‘Cervix’.
The mean score for reproductive system was very low 1.04±0.54.
83
Table 4.21: Knowledge regarding puberty
Knowledge regarding puberty Percentage (%)

Pubertal changes 81.33
Age of attaining Puberty 78.67
Difference between Puberty and Menarche 28
Table 4.21 depicts the knowledge regarding puberty; it mainly focuses

on [a] pubertal changes [b] age of attaining puberty [c] difference
between puberty and menarche. Majority (81.33%) of respondents had
knowledge regarding pubertal changes. Majority (78.67%) of girls
knew the age of attaining puberty. Only (28%) respondents knew the
difference between puberty and menarche. The girls scored average
(1.88 ± 0.73) in knowledge regarding puberty.
Table 4.22: Knowledge regarding menstruation
Knowledge regarding menstruation Percentage (%)

Meaning of Menstruation 31.33
Meaning of Menarche 8.67
Average length of Menstruation cycle 62.67
Process of Menstrual cycle 9.33
Table 4.22 depicts the knowledge regarding menstruation; it mainly

focuses on [a] meaning of menarche [b] meaning of menstruation [c]
average length of menstruation [d] process of menstrual cycle Only
(31.33%) knew the meaning of menstruation. Only (8.67%)
respondents knew the meaning of menarche. The knowledge regarding
84
average length of menstrual cycle was (62.67%). Only (9.33%)

respondents knew the process of menstruation cycle. The students
scored low (1.12 ± 0.83) in the knowledge regarding menstruation.
Table 4.23: Knowledge regarding teenage pregnancy
Knowledge regarding teenage pregnancy Percentage (%)

Meaning 88.33
Fertile period 22.67
Right age of pregnancy 4.67
Pregnancy prevention 46
Adverse effects of early pregnancy
Mother 66
Child 78.67
Table 4.23 depicts knowledge regarding teenage pregnancy; it mainly

focuses on [a] meaning of pregnancy [b] Fertile period [c] Right age of
pregnancy [d] Pregnancy prevention [e] adverse effects of early
pregnancy. Majority (88.33%) and (84.67%) of girls knew the meaning
of pregnancy and right age of child bearing respectively. But the
knowledge regarding fertility period among girls was very low
(22.67%). About (46%) knew that pregnancy can be prevented by
various contraceptives. Knowledge about adverse effects of early
pregnancy on mother and child was (66%) and (78.67%) respectively.
85
Table 4.24: Knowledge regarding abortion
Knowledge regarding abortion Percentage (%)

Meaning 86
Legal 80.67
Illegal 81.33
Unsafe Abortion 30.67
Harmful effects 76
Table 4.24 depicts the knowledge regarding abortion; it mainly focuses

on [a] meaning of abortion [b] legal abortion [c] illegal abortion [d]
unsafe abortion [e] harmful effects of abortion. The students had
adequate knowledge regarding abortion. Majority (86%) of the
respondents had the knowledge about the meaning of abortion.
Majority (80.67%) and (81.33%) had knowledge regarding legal
abortion, and illegal abortion respectively. Only (30.67%) respondents
had the knowledge about unsafe abortion while 76% girls knew the
harmful effects of abortion.
Table 4.25: Knowledge regarding RTIs
Knowledge regarding RTIs. Percentage (%)

Full form of RTI 15.33
Transmission
Use of dirty clothes 42.67
Physical relation with infected partner 36.67
Unclean delivery place 22.67
Symptoms
86
Itching/boils in vulva 6.67

Lower abdominal pain 58
This table 4.25 reveals the knowledge of respondents about RTIs; it

mainly focuses on [a] Full form of RTIs. [b] Mode of transmission of
RTIs. [c] Symptoms of RTIs. Few respondents (15.33%) knew the full
form of RTIs. (42.67%) girls knew that use of dirty clothes during
menstruation was the most common mode of transmission of RTIs.
Followed by physical relation with infected partner (36.67%) and
Unclean delivery place (22.67%). Most (58%) girls were aware that
lower abdominal pain was a symptom of RTIs. Only (6.67%) were
aware that itching and boils in/over vulva were symptoms of RTIs.
Table 4.26: Knowledge regarding STDs
Knowledge regarding STDs Percentage (%)

Full form of STDs 48.6
Meaning 39.3
Full form of HIV 30.67
Meaning 35.33
Full form of AIDs 36.6
Meaning 54.6
Diseases related to STDs
Syphilis 25.3
Gonorrhoea 23.3
Chlamydia 10
HIV/AIDs 80
87
Table 4.26 reveals the knowledge of respondents about STDs; it

mainly focuses on [a] Full form of the STDs. [b] Meaning of the term
STDs. [c] full form of HIV. [d] Meaning of the term HIV. [e] Full form of
AIDs. [f] Meaning of the term AIDs. [g] Diseases related to STDs About
(48.6%) respondents knew the full form of STDs and only (39.3%)
respondents knew the meaning of STDs. Only (30.67%) respondents
knew the full form of HIV and about (35.33%) knew its meaning.
About (36.67%) respondents knew the full form of AIDs and (25.33%)
knew its meaning. The findings of present study indicated that
knowledge about STDs other than HIV/AIDS was very poor among
adolescent girls.
Table 4.27: Transmission and symptoms of HIV /AIDS
Transmission and symptoms of HIV /AIDS Percentage (%)

Transmission
Homosexual Relationship 8.6
Unprotected sex 37.3
Transfusion of Infected Blood 28.6
Having Sex with multiple Partners 28
Infected needles 22
Mother to child 28
Symptoms
Fatigue/weakness 34
Fever 32.67
Rashes on body 6.6
Rapid weight loss 58
88
This table 4.27 reveals the knowledge of respondents about

transmission and symptoms of HIV/AIDS; it mainly focuses on [a]
Symptoms of HIV/AIDS. [b] Transmission of HIV/AIDS. Girls scored
low in knowledge about the transmission of HIV/AIDS, only (8.6%),
(37.5%), (28.6%), (28%) , (22%) and (28%) knew that HIV can be
transmitted through homosexual relation, unprotected sex,
transfusion of infected blood, having multiple sex partners, infected
needles and from infected mother to her new born child respectively .
89
CHAPTER 5: DISCUSSION
5.1 KNOWLEDGE AND PRACTICE REGARDING MENSTRUAL

HYGIENE AMONG ADOLESCENT GIRLS
Numerous related researches on the understanding and

comprehension of menstrual hygiene in the past have been performed
nationally and globally. [105-112] The current study found that 29
percent had adequate menstrual hygiene information, and 71 percent
had insufficient menstrual hygiene knowledge. Composite practice
scores suggested that 19%, 69% and 12% of samples had bad, fair
and decent menstrual hygiene habits, respectively. Indeed, the results
showed a strong positive correlation between good Menstrual
consciousness and just the educational status of the woman. The lack
of menstrual hygiene knowledge can be due to multiple factors that
need to be researched separately. The above results highlight the need
for the AGs to promote healthy and hygienic activities and to get them
out of conventional menstrual values, stereotypes, and restrictions.
The investigators strengthened the general understanding of the cause
and the organs involved in menstruation. The use of sanitary napkins
was encouraged, and the students were briefed on different menstrual
health regimes.
Early recognition will avoid students from suffering from different

infections of the reproductive tract. Pamphlets about the do's and do
not's during menstruation were distributed among the AGs, and they
were asked to show their mothers the same at home to strengthen
their awareness of menstruation, menstrual, and personal hygiene so
90
that they can educate their daughters at home. Often because of

prejudice, taboos and stereotypes, and socio-cultural factors that
discourage women from voicing their needs, the problem of
menstruation is overlooked or misunderstood. Implications of ignoring
this issue are serious and at times life threatening. Sanitary napkins,
if manufactured in hygienic manner, are universally accepted as a
safe method of menstrual hygiene. Following are the barriers to use of
sanitary napkins:
1. Lack of awareness
2. Poor health-seeking behavior
3. Limited availability of the product at economical prices
4. Non-availability in the rural and interior areas
5. No space for cleaning/changing
6. Absence of toilets for girls
7. Shyness to buy napkin in shops
8. Lack of disposal facilities
9. Financial constraints.
To a certain extent, the above issues have been addressed in the state
of Himachal Pradesh through Convergence of Ministry of Women and
Child Development with Health Department. Under Menstrual Hygiene
Program for AGs, sanitary napkins are made available at AWC/Sub
Centre Level for further distribution among the AGs at a very nominal
cost (under the scheme, a pack of six sanitary napkins is provided
under the National Rural Health Mission’s brand “Freedays.” These
napkins are sold to the AGs at Rs. 6 for a pack of six napkins in the
village by the Accredited Social Health Activist (ASHA). On sale of each
pack, the ASHA gets an incentive of Rs. 1 per pack besides a free pack
of sanitary napkins per month.
91
Anganwadi workers get trained for imparting knowledge regarding

menstrual hygiene and get incentivized for distributing sanitary
napkins to the Adolescent girls and the former. SABLA scheme was
introduced as Centrally Sponsored Scheme for benefiting Adolescent
girls in shimla districts of Himachal Pradesh on November 19, 2010,
which aims at covering Adolescent girls of the age group of 11–18
years, with main focus on out of school Adolescent girls. Menstruation
and puberty hygiene are seldom discussed both at home and in
schools; the current study was conducted especially in the regions.
Many young girls in this country lack accurate and appropriate
knowledge on menstrual hygiene, causing incorrect and unhealthy
actions during their menstrual cycle, due to certain cultural and
religious restrictions. Girls should be informed about the value of
menstruation, the production of secondary sexual characteristics, the
collection and proper disposal of sanitary menstrual absorbents. It
would implicitly wash away the age-old misconceptions and make her
feel free to address menstrual issues without any inhibition so that
she does not develop psychological anger and obtain education. The
drawback of the analysis was that for sample size estimation, a
smaller confidence interval was taken, so the sample size was lower.
In addition, we were unable to research the variables responsible for
low awareness and practice scores in the present study due to time
constraints.
92
5.2 KNOWLEDGE AND ATTITUDE REGARDING PUBERTAL

HEALTH AMONG ADOLESCENT GIRLS
In this sample, with 61.7 percent of adolescent girls in the early

adolescence period, the mean age of adolescent girls was 14.27±1.33,
which was close to the mean age of adolescent girls in similar
studies[113]. In the present study, most (92.3 percent) had obtained
puberty information that was similar in the 93.6 percent study
conducted in Iran. High parental literacy may be the potential
explanation for obtaining knowledge about puberty. In this sample,
63.9 percent of the respondents attending menarche were scared
during their first menstruation, which was comparable to 44 percent
in the study conducted in Pakistan [114]. Despite obtaining puberty
information, more than half of the respondents were terrified during
their first menstruation, which may be attributable to insufficient and
irrelevant puberty health information from various sources.
Major source of information regarding puberty in this study was

mother followed by teachers, friends and sister which was 79.8%,
44%, 39.9% and 38.7% respectively. Similarly, 76.1% stated mother
was their source of information in the study in Gujrat, India, 56% in
Iran, and 64.9% in U.P India [115,116]. As an adolescent girl feels
more comfortable talking about her health to her mother, she became
the major source of information in most of the studies including this
study.
The present study shows positive co-relation between knowledge and

attitude which is contrary to the findings in a study done by Rani et al
[117] which revealed no significant positive correlation. Reasons for
93
contrary findings between two studies may be due to moderate level of

knowledge and attitude in the present study as compared to low level
of knowledge and attitude.
In the present study, majority of participants (82%) had fair

knowledge. A similar finding was observed by Saghi et al in Iran that
showed 85.8% in moderate category. The similarity in both the study
may be because of the majority of participants receiving previous
information regarding puberty.
In the present study, we observed that participants with higher level of

education possessed good knowledge compared to those with lower
level of education which was similar to findings observed. Reasons for
similarity may be due to same educational level of the sample
population in both the settings.
In our study, we observed that information regarding puberty from

teacher/school and friends has significant association with level of
knowledge which is not in accordance with the study done by Alosaimi
et al [118] in Saudi Arabia and by Saghi et al in Iran where
information source from mother had good knowledge than information
source from others. The dissimilarity may be due to information
provided by school curriculum via teachers and friends is more
reliable than information provided by mothers in the present study.
In our study, 48.6% had positive attitude towards pubertal health

which is similar to the observations done by Manizheh et al which was
54.4%. There was significant association between level of attitude and
relation with their siblings which was similar to the observation done
94
by Manizheh et al. [119]. In participants with elder brother, the

existence of positive attitude was more prominent, which may be due
to the inclusion of reproductive health material in the school
curriculum that makes all children aware of it.
In the present study, the level of attitude was significantly associated

with source of information which was not in accordance with the
study done by Saghi et al. In the present study we observed that
positive attitude was more common in participants when the source of
information was teachers and sisters whereas Saghi et al observed
that positive attitude was more common when source of information
was health members compared other sources. In the present study,
the opposite findings could be due to lack of communication with
health members before any health problem and lack of presence of
health care members in school leading to teacher or school as a
source of data.
5.3 KNOWLEDGE, ATTITUDE, AND PRACTICE ON MENSTRUAL

HYGIENE MANAGEMENT AMONG SCHOOL ADOLESCENTS
Our findings indicate that most school teens have fair knowledge of
menstrual hygiene management, although there is still substantial
scope for development of menstrual-related hygiene-related activities
and attitudes towards taboos. Results showed that 83 percent of
respondents had the understanding that menstruation is a hormonal
process, far higher than other research results. [120]. Majority of
respondents knew the reason to use sanitary pad during
menstruation which is in contrast with finding of study conducted by
Dasgupta in which just 48.75% knew the use of sanitary pad
95
[121].This increment in knowledge indicates exposure and readiness

of school adolescents to adopt hygiene behavior. Though majority of
students know about menstruation which might be attributed to the
inclusion of reproductive health education in school curricula and
exposure to a wide range of information media like television, radio,
internet; still misperceptions persist in this matter. More than 50
percent still thought that if they do not obey cultures/taboos
associated with menstruation, God would curse family members. This
is confirmed by the study of Adhikari et al, who reported that women
will sprinkle gold water to purify themselves [122]. In addition, it was
also discovered that during menstruation, boys tease their female
peers, which causes an atmosphere of embarrassment and fear among
teenage girls. Previous studies have also shown a higher percentage of
respondents who perceive menstruation to be uncomfortable and
humiliating. Among the main factors for menstrual hygiene are the
promotion of adolescent sexual and reproductive health and the
prevention of diseases. Our study found that majority of school girls
used sanitary pads (commercial or reusable) during their
menstruation. This is similar to reports from Lawan and colleagues
from Nigeria [123] but in contrast to the study conducted in India and
Adinma’s study where the majority was found to be using toilet rolls to
manage menstrual blood [124].
Data revealed that only 40 percent of respondents practiced fair

practices with 51 percent females, and nine percent had implemented
a bad collection of practices with a strong standard of menstrual
hygiene management practices. The findings indicate that there is a
distance between current expertise and experience that is in
accordance with other results. One of the potential challenges, along
96
with the lack of disposal facilities, may be the lack of accessibility of

sanitary pads in rural environments to follow appropriate hygienic
menstruation practice. 55.4 percent thought that menstruating
females could not eat poultry and sour food products, according to the
results of our research. These results on food taboos were accepted
with another rural Nepal report. Despite the widening of the
awareness horizon, cultural taboos in culture hinder shift in mindset,
which is why school students practice menstrual hygiene
management. In the name of history, this case shows the desperate
need to counter harmful practices.
5.4 KNOWLEDGE, ATTITUDES, AND COPING STRATEGIES

REGARDING PUBERTAL CHANGES AMONG ADOLESCENT GIRLS
Adolescence involves physical, cognitive, mental, and social changes

as a time of transition from childhood to adulthood.[125] Different
negative results can result from a lack of awareness and skills to deal
with puberty changes.
More than half of the adolescents had common knowledge of the signs
of puberty that coincided with the findings of other studies, the
results of the current study showed. [126-133] Abdollahi [134] and
Malekshahi [135], however, recorded poor knowledge among female
adolescents about puberty changes. More than half of the girls had a
strong (positive) attitude towards puberty signs in the current
research, which is consistent with the outcomes of other related
studies. Sedighi Sabet et al., however, found that most girls had an
apathetic attitude to puberty and that only <5% of respondents had a
positive attitude.
97
In addition, in a study in Nepal, Sandhya and Bimala found that more

than 80% of adolescents had an unfavorable attitude about puberty
changes. The disparity in findings may be attributable to the
discrepancy in the questionnaires used and discrepancies in the
position of the educational level of the studies, community, and
parents. In the current research, the explanation for the strong
awareness and attitude of adolescent girls can be attributed to
accessing more developed information outlets such as the internet and
media over the past few years, as well as improved parental education
and better girls' educational environments. The advent of technology
such as mobile devices, satellites, and expanded family awareness are
the key factors in improving the education of girls. In addition, a
review study by Simbar et al. found that in recent years, the effects of
increasing puberty awareness and positive attitudes among girls have
contributed to a greater understanding of puberty health issues. In
addition, we found an important relationship between awareness and
attitude ratings. Most related studies in Iran also showed that because
of the impact of knowledge on attitude, the knowledge and attitudes of
students towards puberty are consistent in one domain.
In the current study, the following coping strategies were chosen by

adolescent girls, including avoidance-oriented, emotion-oriented, and
final task-oriented approach. Task-oriented, avoidance-oriented, and
emotion-oriented types were the most preferred coping methods used
by girls in a study by Kadivar et al. on the relationship between the
structure of family interactions (i.e., family function) with coping
styles and gender differences in pre-university students. The findings
of the Bafekri et al. study showed that task-oriented, emotion-
98
oriented, and avoidance-oriented types were used by second and

third-grade high school girls, respectively. [136]
In terms of the order of the use of techniques, the findings of this

study are not in line with the results of the present analysis. The
explanations for the disparity in the findings are the difference in age,
culture, and study environment, as well as psychological issues (e.g.,
depression, the degree of teenage anxiety, the economic status of
families, and parental divorce). The rationale for preferring the
avoidance-oriented coping approach, however, needs further study.
Other research indicates that girls use more task-oriented coping
mechanisms to cope with crises by adjusting cultural and social
systems as well as educational activities. [137]
The findings of this study showed that students in the second grade of
secondary school had more experience and a better attitude toward
puberty relative to first-grade secondary school students with respect
to the impact of age on knowledge and actions. In comparison, these
second-grade secondary school students used the task-oriented
coping approach strategy considerably more than first-grade
secondary school students. The findings will illustrate the role of age
in the degree of awareness and attitude towards puberty, as well as
the type of coping strategy being chosen. It seems that the skills of
teenagers in solving issues will increase through rising age and
schooling. The findings of other research have showed that the age of
the student is related to awareness and attitude. The need to enhance
education and awareness on puberty issues should be considered at
lower ages, considering the impact of age on knowledge. In addition,
Hojjatkhah et al. found that in dealing with stressful circumstances,
99
the 17-year-old boys who participated in the study were substantially

more likely to use a task-oriented coping style compared to the 15-
year-old boys, which is consistent with the findings of the present
study. It can be said that in both sexes, as the age increases, the use
of the task-oriented approach is also increased. Also, in some studies,
the dominant approach used by adolescents during puberty is task-
oriented strategy, which emphasizes the validity of the current study's
results. [138]
The present study showed that the level of education of parents was
productive in the awareness and attitudes of students about puberty.
Interestingly, teenage girls mainly receive knowledge about puberty
from their mothers about health habits, which is consistent with the
findings of different research. The level of maternal education is the
most significant factor influencing the level of awareness, attitude and
practice of adolescents on puberty health issues, based on numerous
research studies. The findings of a Sajjadi et al. study In 2010, it was
shown that fathers with higher education were more experienced and
had stronger attitudes towards signs of puberty. Moreover, Afsari et
al. in 2017 in a study found that father's education had a direct
impact on adolescents’ knowledge about puberty health. [139]
The higher level of culture education of Father provides the basis for
further sharing of information on puberty and more successful
contact between fathers and daughters to solve the puberty
crisis.[140] However, in a study by Kashefi et al., this study did not
have a significant relationship between the awareness of the student
and the education of the mother. In other words, in girls whose
mothers had elementary schooling, the average knowledge of puberty
100
was more than the average knowledge of girls who had mothers with a
high-school diploma. [141] Variations in the study climate and
community may be one of the explanations for the differential results.
Mothers in larger cities have less educational experiences with their
daughters, so the amount of time parents spend on improving the
awareness of teenage girls is as significant as the educational level of
parents.
The results of the current study demonstrated the need to add

physical, psychological, and social health training courses in puberty
and the establishment of puberty health therapy offices. In addition,
mothers need to be educated by conducting training sessions as the
principal source of knowledge acquisition for teenage girls. In view of
the fact that the dominant preferred approach was avoidance-
oriented, which is linked to lower self-esteem and higher levels of
anxiety in adolescents, it is suggested that further studies explore the
design of the type of successful training that will contribute to
increasing adolescents' awareness and positive attitude towards more
effective task-oriented coping strategies.
5.5 AWARENESS REGARDING PSYCHOLOGICAL CHANGES,

CAUSES OF PUBERTAL CHANGES AND SOCIAL RELATIONS
ADOLESCENT GIRLS
The lives of teenagers are marked by the passage through puberty

along with genetic, cognitive, emotional and social changes. In
families, communities and cultures, age-related and gender-related
risks and opportunities interfere with individual developmental
processes to create conditions for both positive and negative health
101
outcomes. To lead safe, responsible and fulfilling lives, young people

need to be informed about themselves and others in order to protect
themselves from reproductive health issues. Moderate information was
discovered among the girls subjects linked to puberty changes in this
current research. Awareness of puberty changes has been
substantially related to age. Almost all girls were aware of the weight
and height gain that occurs with puberty in a study among teenage
girls in East Delhi by Nair et al; 59.7 percent were aware of breast
enlargement and 33.8 percent of puberty-accompanying axillary and
pubic hair. Awareness of menstruation was one third of the topic of
the research. Just one-third of girls were conscious of all the changes
in puberty. Statistically important was the correlation between
awareness of adolescent changes and rising age. (p<0.001) [142].
Another research conducted in Karnataka found that more rural

adolescent girls knew about puberty changes, particularly primary sex
characteristics (53.73 percent), and fewer respondents knew about
secondary sex characteristics such as height and weight, pubic hair,
breast enlargement and hip enlargement (75, 19.23, 14.42, and 9.61
percent, respectively), which occurred during the course of the study.
The students prioritized the issues faced in adolescence rank wise in
this report. General health issues (54.3%), reduced academic
performance (26.1), diet and nutrition related problems were the main
problems of the study population (37.0 percent). In the study done by
Geetha et al showed similar finding, that the adolescents faced
headaches, body pains, and fatigue as common physical problems
which was revealed in focus group discussions. A few of them
mentioned weight loss, domestic problems, alcoholism in fathers and
family conflicts [144].
102
The dietary status of Indian adolescents has long been a matter of

great concern. The second most significant issue facing the students
in the present study was related to diet and nutrition. The diet
available to adolescents in India is insufficient for all major nutrients,
according to NCERT [145]. Inadequate food supply in relation to
quality and quantity, psychological factors influencing appetite, food
fats and cultural attitudes and parasitosis are the factors that can
interfere with nutrition [146]. Most of them depend on their mother as
their first choice to solve the problem and their next choice was found
to be an elder sister. The result is consistent with the study by Dorle
et al, which found that about 43.18% of boys discussed sex with their
peers, where 55.56% of girls discussed it with their parents [147]. It
could be due to parents lacking privacy and confidentiality. A main
characteristic of middle adolescence is the urge to enter a peer group
and attempt to gain popularity among friends [148].
In all phases of program development, study and novel methods

involving adolescents are useful. Therefore, in order to provide
accurate and authentic awareness of reproductive health, related
crucial issues and responsible actions to these problems, an
educational intervention is urgently required to enable them to make
the right choices in life.
5.6 KNOWLEDGE OF REPRODUCTIVE HEALTH AMONG

ADOLESCENT GIRLS
The majority (93.33%) could identify the female reproductive system

diagram, but very few teenage girls could name the various
Reproductive System organs, (4.67%) girls identified 'Uterus', (2.67%)
103
identified 'Ovaries', (2.67%) identified 'Vagina', (0.67%) identified

'Fallopian tube', but no one could identify 'Cervix'. There was a very
poor mean score of 1.04 ± 0.54 for the reproductive system. A similar
study was conducted in urban and rural areas of Varanasi, where the
majority of girls scored well in reproductive system recognition, while
female reproductive organs scored low [149].
Most respondents (81.33 percent) had experience of puberty

modifications. The majority (78.67%) of girls knew the age to hit
puberty. The disparity between puberty and menarche was only
understood by (28%) respondents. The girls had an average (1.88 ±
0.73) puberty awareness score. A research conducted in Gazipur, East
Delhi, found that only 33.4% of girls were aware of all the adolescent
changes [151].
The definition of menarche was only understood by (8.67 percent)

respondents. Awareness of the average period of the menstrual cycle
was (62.67 percent). Only respondents (9.33 percent) knew the
menstruation cycle process. In menstruation awareness, the students
ranked low (1.12 ± 0.83). Similar research conducted in Bijapur's
urban slums found that teenage girls had little awareness of
menstruation [152].
Only (8.6 percent), (37.5 percent), (28.6 percent), (28 percent), (28
percent), (22 percent) and (28 percent) knew that HIV can be
transmitted by homosexual relationships, unprotected sex,
contaminated blood transfusion, multiple sex partners, infected
needles and from infected mother to her newborn baby respectively. In
Colkata, low levels of awareness on general aspects and HIV/AIDS
104
transmission have also been observed among secondary school

students [118]. There were very few girls with knowledge of the
symptoms of HIV/AIDS. Just (34 percent), (32.67 percent), (6.6
percent) and (58 percent) of girls knew that fatigue/weakness, fever,
body rashes and rapid weight loss were the symptoms of HIV/AIDS.
The Wong Similar Analysis. L.P (2008) found that HIV/AIDS
awareness among teenage girls was very low. [153].
105
CHAPTER 6: SUMMARY, CONCLUSION, IMPLICATIONS

AND RECOMMENDATIONS
This chapter deals with the summary of the study and the conclusion
drawn. It also deals with the limitation of the study, the implications
and recommendations given for different areas of nursing and health
care delivery system.
SUMMARY OF THE STUDY
The present study was undertaken to assess the Knowledge and

Attitude Regarding Pubertal Changes and Menarche among
Adolescent Teenager Girls: Case Study in Selected Schools of District
Shimla, Himachal Pradesh.
Objectives of Study
1. To assess the knowledge regarding pubertal changes and menarche
2. To assess the attitude regarding pubertal changes and menarche
3. To find out the association between knowledge and attitude with
demographical variables.
Hypothesis
H1- There will be significant association between knowledge and
girls
106
H2- There is a significant difference between knowledge and attitude

regarding pubertal changes and menarche among adolescent girls
with selected demography profile?
H3- There is no significant association between knowledge and

girls with selected demography profile?
Major Findings of the Study
Knowledge and practice regarding menstrual hygiene among

adolescent girls
Table 4.1 shows frequency and percentage of socio-demographic

variables of the sample. The data on knowledge scores revealed that
29% had adequate knowledge about menstrual hygiene, and 71% had
inadequate knowledge about menstrual hygiene. The data revealed on
practice scores revealed that 19%, 69%, and 12% samples had poor,
fair, and good score of practices regarding menstrual hygiene,
respectively.
Table 4.2 shows that the education of mother had the significant effect
on the knowledge scores of the participants.
Table 4.3 shows the correlation between the knowledge and practice
scores of participants which shows positive correlation between the
two scores (*P < 0.001).
107
Knowledge and Attitude Regarding Pubertal Health among

Adolescent Girls
Table 4.4 shows that majority (90.7%) had occurrence of menarche

and among them 46.9 % were ≤12 years. The mean age of menarche
was 12.55±0.90. Regarding experience at first menstruation, more
than half (63.9%) were scared and 2.4% had pleasant and unpleasant
experience. Regarding received information on puberty, 92.3% had
previously received information on puberty and among them, the
major source of information was mother which is 79.8% followed by
teacher/school which is 44%.
Table 4.5 shows that out of 100 respondents, 80.3% had moderate
knowledge, 18% had poor knowledge and 1.7% had good knowledge
regarding pubertal health whereas regarding attitude, 48.6% had
positive attitude and 51.4% had negative attitude towards pubertal
health.
Table 4.6 shows that there is statistically significant association

between level of knowledge regarding pubertal health and level of
education (p=0.001), sources of information of friends (p=0.043) and
source of information of teachers/school (p=0.001) and there is no
significant association with other socio-demographic variables.
Table 4.7shows that there is statistical significant association between

level of attitude and relation to the sibling (p=0.013), sources of
information of sisters (p=0.022) and sources of information of
teachers/school (p=0.035) and there is no significant association with
other socio-demographic variables.
108
Knowledge, Attitude, and Practice on Menstrual Hygiene

Management among School Adolescents
Table 4.8 shows that on the practices related to menstruation, out of

100 adolescent respondents, 40% had good menstrual hygiene
practices. 51% girls had a fair practice and 9% had poor menstrual
hygiene practices. 30% of the respondents used factory made sanitary
pads followed by 76% of them using homemade and reusable pads.
However, only 39% of respondents changed pads in every 4 –6 hour
period. 68% of the respondents washed hands after changing a
sanitary pad and 61 % used soap and water for washing hands.
Table 4.9 shows that 49% of the respondents had a positive attitude
towards MHM issues whereas 51% required improvement on their
attitude towards MHM. Data showed that 52.5% of the respondents
agreed restrictions for carrying out household chores during
menstruation is significant. Only 47% thought that violation or
nonobservance of cultural traditions and taboos during menstruation
will not lead to god or deities cursing their family members. 77% of
respondents agreed that, increase in supplementation of
nutrients/food is necessary during menstruation. Only 54% of
respondents thought that men do not become sick if a menstruating
female touches him. 65% of respondents agreed that menstruating
females should take bath. Only 45% of respondents agreed that
menstruating females can consume dairy and sour food items.
Table 4.10 shows that in regards to accessibility of MHM and Water,

Sanitation & Hygiene (WASH) facilities and services, 47.5% of
respondents first heard about menstruation at the age 10-12 years
109
mostly getting information on menstruation from school additionally

followed by friends, mother, and guardian. Over 70% of respondents
had heard message on menstruation from the local radio station.
About 45% of respondents had not got any MHM education
class/orientation. Data showed that NGOs are mainly providing MHM
education/orientation/training in school. Only 28.3% of female
respondents had ever participated in a sanitary pad making training
and 27.2% had made reusable sanitary pads after participating in the
training. About 70% respondents replied unavailability of supplies for
managing menses at school. Different questions about their belief,
tradition and culture related to menstruation were asked to
adolescent girls and boys.
Knowledge, Attitudes, and Coping Strategies Regarding Pubertal

Changes among Adolescent Girls
Table 4.11 shows more than half of the participants (50.5%) had
moderate knowledge about puberty and 66.7% of the participants had
a good (positive) attitude toward puberty.
Table 4.12 shows the most frequent coping strategy selected was
avoidance oriented (54.2%).
Table 4.13 shows Spearman test showed a significant relationship

between knowledge and attitude (Spearman coefficient = 0.54) (P =
0.000). However, Chi-square test did not reveal a significant
relationship between knowledge and attitude regarding selective
strategies to cope with pubertal changes.
110
Awareness Regarding Psychological Changes, Causes of Pubertal

Changes and Social Relations Adolescent Girls
Table 4.14 shows perception of pubertal change with increasing age of

the participant. The most common knowledge perceived by one third
girls below 14 years were growth of pubic hair in the private parts.
The knowledge perceived by majority of girls above 14 years were
breast enlargement in this period.
Table 4.15 shows Result revealed that majority of girls reported

sudden mood change during puberty.
Table 4.16 shows Results reveals that majority of girls were aware that
changes occur in their body are due to hormones.
Table 4.17 revealed that the majority of girls have moderate knowledge
about pubertal changes. Benefit from government programmes is now
increasing slowly in the school regarding menstruation cycle and girls
are now moderately aware about it.
Table 4.18 shows the various sources of information to adolescent

girls about pubertal changes. The result revealed that 66% of
adolescent girls get the information from mother, 12.8% adolescent
girls’ source of information were elder sister, teacher were the source
of information among 3.6% adolescent girls, 4% of adolescent girls get
the information from books, 2.4% of adolescent girls get the
information from television and government programme and among
7.6% of adolescent girls’ relative and friends were the source of
111
information. Result revealed that among majority of girls’ mother was

the major source of knowledge about pubertal changes.
Table 4.19 shows that 53.2% of adolescent girls share problems

related to menstruation to mother, 12.4% share with elder sister,
2.4% share with teacher, 1.2% of adolescent girls share with relatives,
10.4% of adolescent girls with friends and 18.8% of adolescent girls
share with both mother and elder sister. Results revealed that
majority of adolescent girls feel comfortable to share problems related
to puberty to the mother.
Knowledge of Reproductive Health among Adolescent Girls
Table 4.20 shows the knowledge of adolescent girls regarding

reproductive system; it mainly focuses on [a] Identification of
Reproductive System. [b] Labeling of different organs of Reproductive
System. Majority (93.33%) could identify the diagram of female
reproductive system but very few adolescent girls could Label the
different organs of Reproductive System, (4.67%) girls identified
‘Uterus’, (2.67%) identified ‘Ovaries’, (2.67%) identified ‘Vagina’,
(0.67%) identified ‘Fallopian tube’, but no one could identify ‘Cervix’.
The mean score for reproductive system was very low 1.04±0.54.
Table 4.21 depicts the knowledge regarding puberty; it mainly focuses

on [a] pubertal changes [b] age of attaining puberty [c] difference
between puberty and menarche. Majority (81.33%) of respondents had
knowledge regarding pubertal changes. Majority (78.67%) of girls
knew the age of attaining puberty. Only (28%) respondents knew the
112
difference between puberty and menarche. The girls scored average

(1.88 ± 0.73) in knowledge regarding puberty.
Table 4.22 depicts the knowledge regarding menstruation; it mainly

focuses on [a] meaning of menarche [b] meaning of menstruation [c]
average length of menstruation [d] process of menstrual cycle Only
(31.33%) knew the meaning of menstruation. Only (8.67%)
respondents knew the meaning of menarche. The knowledge regarding
average length of menstrual cycle was (62.67%). Only (9.33%)
respondents knew the process of menstruation cycle. The students
scored low (1.12 ± 0.83) in the knowledge regarding menstruation.
Table 4.23 depicts knowledge regarding teenage pregnancy; it mainly

focuses on [a] meaning of pregnancy [b] Fertile period [c] Right age of
pregnancy [d] Pregnancy prevention [e] adverse effects of early
pregnancy. Majority (88.33%) and (84.67%) of girls knew the meaning
of pregnancy and right age of child bearing respectively. But the
knowledge regarding fertility period among girls was very low
(22.67%). About (46%) knew that pregnancy can be prevented by
various contraceptives. Knowledge about adverse effects of early
pregnancy on mother and child was (66%) and (78.67%) respectively.
Table 4.24 depicts the knowledge regarding abortion; it mainly focuses

on [a] meaning of abortion [b] legal abortion [c] illegal abortion [d]
unsafe abortion [e] harmful effects of abortion. The students had
adequate knowledge regarding abortion. Majority (86%) of the
respondents had the knowledge about the meaning of abortion.
Majority (80.67%) and (81.33%) had knowledge regarding legal
abortion, and illegal abortion respectively. Only (30.67%) respondents
113
had the knowledge about unsafe abortion while 76% girls knew the
harmful effects of abortion.
Table 4.25 reveals the knowledge of respondents about RTIs; it mainly

focuses on [a] Full form of RTIs. [b] Mode of transmission of RTIs. [c]
Symptoms of RTIs. Few respondents (15.33%) knew the full form of
RTIs. (42.67%) girls knew that use of dirty clothes during
menstruation was the most common mode of transmission of RTIs.
Followed by physical relation with infected partner (36.67%) and
unclean delivery place (22.67%). Most (58%) girls were aware that
lower abdominal pain was a symptom of RTIs. Only (6.67%) were
aware that itching and boils in/over vulva were symptoms of RTIs.
Table 4.26 reveals the knowledge of respondents about STDs; it

mainly focuses on [a] Full form of the STDs. [b] Meaning of the term
STDs. [c] full form of HIV. [d] Meaning of the term HIV. [e] Full form of
AIDs. [f] Meaning of the term AIDs. [g] Diseases related to STDs About
(48.6%) respondents knew the full form of STDs and only (39.3%)
respondents knew the meaning of STDs. Only (30.67%) respondents
knew the full form of HIV and about (35.33%) knew its meaning.
About (36.67%) respondents knew the full form of AIDs and (25.33%)
knew its meaning. The findings of present study indicated that
knowledge about STDs other than HIV/AIDS was very poor among
adolescent girls.
Table 4.27 reveals the knowledge of respondents about transmission

and symptoms of HIV/AIDS; it mainly focuses on [a] Symptoms of
HIV/AIDS. [b] Transmission of HIV/AIDS. Girls scored low in
knowledge about the transmission of HIV/AIDS, only (8.6%), (37.5%),
114
(28.6%), (28%) , (22%) and (28%) knew that HIV can be transmitted
through homosexual relation, unprotected sex, transfusion of infected
blood, having multiple sex partners, infected needles and from
infected mother to her new born child respectively .
CONCLUSION
Menstruation and puberty hygiene are seldom discussed both at home

and in schools; the current study was conducted especially in the
regions. Many young girls in this country lack accurate and
appropriate knowledge on menstrual hygiene, causing incorrect and
unhealthy actions during their menstrual cycle, due to certain
cultural and religious restrictions. Girls should be informed about the
value of menstruation, the production of secondary sexual
characteristics, the collection and proper disposal of sanitary
menstrual absorbents. It would implicitly wash away the age-old
misconceptions and make her feel free to address menstrual issues
without any inhibition so that she does not develop psychological
anger and obtain education.
Awareness and attitude about adolescent health vary with the level of
education of adolescent girls, the relationship with siblings, and the
source of knowledge from older sisters, teachers/schools, or peers. In
order to improve awareness about puberty and related health issues,
education at home and in schools at an early age is important.
The findings show that most of the respondent girls have MHM
awareness, but it has not clearly translated into the right attitude and
practice, so in those groups, behavior change initiatives should be
115
conducted. In order to combat the deeply entrenched religious and

cultural malpractices, prohibitions, and menstrual taboos, major
advocacy campaigns are also needed. The problems that should be
tackled are measures to improve access to hygienic absorbents and
the disposal of MHM materials. School WASH facilities are currently
seriously inadequate for girls to handle their menses safely; ample
water is not available, gender-friendly toilets are lacking for both
students and teachers, and there are no hand washing facilities.
Therefore, in schools, MHM-friendly WASH infrastructures and
facilities must be built.
While the adolescent girls had a strong level of understanding and a

positive attitude towards pubertal changes, in terms of using task-
oriented coping strategies, they suffered from a lack of adequate
coping skills. It seems that the degree and attitude of good information
will not only motivate teenagers to deal with puberty struggles.
Further study is needed to determine the best approach to teaching
and training the requisite coping skills, and to include more realistic
and precise plans for adolescent girls to incorporate these coping
strategies. In addition, first-grade students had low awareness and
less favorable attitudes in the present sample, which led them to use
less task-oriented coping strategies relative to second-grade students.
Therefore, to reduce the vulnerability of this group, the need to
concentrate on education and training plans in younger age groups is
crucial.
In all phases of programme development, study and novel methods

involving adolescents are useful. Therefore, in order to provide
accurate and authentic awareness of reproductive health, related
116
crucial issues and responsible actions to these problems, an

educational intervention is urgently required to enable them to make
the right choices in life.
We can infer that the awareness of adolescent girls in government

schools was poor on the basis of this report. It is therefore important
to correct misconceptions through health education about various
aspects of reproductive health. Reproductive health issues among
adolescents should be addressed, especially for girls, through health
clubs, seminars and lectures at school level. Counseling can be
undertaken with the aid of specialists from time to time to recognise
and address their reproductive health issues. Such educational
intervention programs must be given due importance, which will help
the adolescent girls to take care of their own health and protect
themselves from the risk of Reproductive health problems.
IMPLICATIONS
One of the main reproductive health issues among women is

menstrual problems. This includes dysmenorrhea and abnormal
menstrual bleeding, the protection-related skin problems used, and
the unhygienic management problems associated with this cyclic
process. Endogenous infections, a group of infections of the
reproductive tract, occur from the overgrowth of species usually found
in the genital tract, both bacterial and fungal. Inadequate personal,
menstrual and sexual hygiene practises are linked to these infections.
In fact, it is believed that reproductive tract infections are extremely
prevalent in resource-poor environments around the world, with
recurrent and potentially catastrophic implications for the health and
117
social well-being of women and children in particular. Moreover, rural

women in developing countries are usually the most vulnerable
category because of the lack of access to basic services such as water
and privacy. Understanding the traditions of menstrual hygiene and
challenges associated with its preservation has consequences for the
reproductive health of women. It helps the health planners and
policy makers to decide upon interventions, which have far
reaching effect on reproductive health of women.
Implications for nursing practice
 School health services are an essential competent of

community health. Community health nurse has the vital role
in Health educating the adolescent girls through school health
programme there is a need to develop educational programmes
for parents and teachers. So parents should be persuaded
to provide anticipatory guidance to their daughters who are
about to attain puberty.
 Nursing personnel are in the best position and accountable to
impart health education to the adolescent girls and young
females in the hospital and community area regarding the
menstrual health & menstrual hygiene.
 The nursing personnel working in various health care settings
should be given in service education to update their knowledge,
practice and abilities in identifying the learning needs of
adolescent girls on menstrual hygiene and planning for
appropriate intervention.
118
 The study findings signify the importance of formulating

and implementing video assisted teaching programme by
nursing personnel at the community level.
Implications for nursing education
 Nursing curriculum should emphasize on menstrual health &

menstrual hygiene as a current emerging problem among
adolescent girls.
 The study proved that improved knowledge related to menstrual
health could change their practices. To impart the knowledge
about menstrual hygiene among adolescent girls and women
in reproductive age group in the community the nursing
students need to be educated well about menstrual health.
 Health education module should be prepared especially in
the area of menstrual hygiene, the nursing personnel should
be imparted with current knowledge and practice regarding
menstruation and menstrual hygiene to the adolescent girls.
Implications for nursing administration
 Nursing administration should arrange in service education

programme for the teachers for preparing them to function
effectively as a counsellor for adolescent girls.
 Cost effective production of adolescent reproductive health
educational materials by the nursing staff should be
encouraged. Necessary administrative support to be provided to
conduct such activities.
119
 The administrators should emphasize and encourage the nurses to

conduct periodic school health programmes.
Implications for nursing research
 It is essential to develop evidence based strategies for

reproductive tract infection related to improper menstrual hygiene.
 This study also brings about the facts that more studies are
needed to be done in different setting using other prevention
strategies.
RECOMMENDATION
Based on the findings of the study the recommendations for the future
studies follow
 Similar study can be conducted for longer samples for a longer
period
 Similar study can be done in varies settings.
 Study can be done in female with different age group. School
health education programmes has to be strengthened and
education with respect to menstruation should be a major
component of health education for girls in the upper classes.
 A study that incorporates clinical examination and
laboratory investigations will have to be undertaken to
establish the causal relationship between the menstrual
hygiene and reproductive tract infections beyond reasonable
doubts.
120
 Study can be done in participant’s perception about menstruation,

including the perception of boys in the school.
 Hygiene of menstruation should be included in the teachers
training programme, so that they are equipped with adequate
knowledge to guide their students.
121
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A Descriptive Study to Assess the Knowledge and Attitude Regarding

Pubertal Changes and Menarche among Adolescent Teenager Girls: Case

CHAPTER 1: GENERAL INTRODUCTION 1-36

CHAPTER 2: LITERATURE REVIEW 37-56

CHAPTER 3: MATERIALS AND METHODS 57-61

CHAPTER 4: RESULTS 62-89

CHAPTER 5: DISCUSSION 90-105

CHAPTER 6: SUMMARY, CONCLUSION, IMPLICATIONS

Table 4.11: The knowledge and attitude status of students 76

Background of the study: The first critical milestone in the reproductive

regarding menstrual hygiene respectively. 67.4% respondents had fair

to health problems. While awareness of menstrual hygiene management

CHAPTER 1: GENERAL INTRODUCTION

1.1 INTRODUCTION OF THE STUDY

Adolescence is considered to be a special period of human

It is a time in which sexual characteristics evolve gradually. Deep

refers to the entire developmental phase between childhood and

its related changes will influence her reaction to the menarche

During their adolescent growth, adolescents experience major physical

In terms of the physical changes that occur, puberty is defined. Due to

Menstruation is a hormonal mechanism in females, starting with the

Adolescence is one of the most charming and convoluted periods in

Compared to adults, the International Conference on Population and

Adolescence is also a period of potential major dangers, considering

Adolescent females lack adequate knowledge about puberty, according

It can lead to a stronger adaptation of adolescents to the world by

However, puberty as a societal construct has been understood across

Adolescence is a period of increased risk-taking and thus

information about the changes in puberty and menarche. In certain

Adolescence is characterized by the World Health Organization (WHO)

biological changes that can lead to instability, anxiety, resentment,

Various studies have been carried out to assess the extent of

due to early marriage, a culture popular in the Indian sub-continent

Awareness regarding pubertal changes

In the family, even knowledge about physical maturation is often not

adolescent maturation and earlier pubertal changes that have not

Knowledge of pubertal changes and menstrual hygiene

Puberty is a transitional time between childhood and adulthood,

When girls reach sexual maturity, puberty is a period of life. This is

During this development period, the girls first undergo menstruation

Menarche signifies a rapid shift from girlhood to femininity, unlike

Menstruation is viewed from a positive viewpoint as a symbol of

Most researchers, who have studied emotional reactions to menarche

Knowledge of Menarche and Menstruation

Menarche is actually the last step in a complicated sequence of

Menarche is the key landmark of puberty in women, typically

Menarche, the first menstrual cycle between 09 and 14 years, is

Menstruation is not an uncommon or even unusual experience; it is,

Preparation for Menarche and Menstruation

The transformation from a child to an adult marks the beginning of

Messages of menstruation as shameful and filthy, coupled with

For teenage girls, health education services on menstrual hygiene help

Knowledge about and Attitude towards Menstruation

Menstruation is a normal feature of the female reproductive cycle in

development process in which major emotional, psychological, and

Menstruation has been surrounded by taboos and misconceptions

The main aim of communication between doctors is to recognize

contamination of the regenerative tract. Doctors had to be familiar