The adolescence ages in females signal the transition from girlhood to womanhood, marked with the onset of menarche and puberty (4). Before menarche, a girl child is expected to be informed (25) about psychological, cognitive, hormonal, physical body changes (3) and individual modifying factors that contributed to preformed attitude on menstruation and menstrual hygiene behaviour (26); and subsequently adolescents reproductive health transition to adulthood, especially for in-school adolescents. We evaluated the attitude of adolescents from six domains, towards an overall attitude formation by female adolescents on drivers of menstruation in a developing economy, among public school and private school attending adolescents.
Sociodemographic characteristics of respondents
The age of female adolescents studied corresponds to those reported among adolescence in similar studies in Nigeria and elsewhere (5,27–34) since the age range of adolescent is between 10 and 19 years. While the mean age of adolescents’ studies in public schools remains at between 15-17 years, indicating demographic stagnation among females attending public schools in contrast to reducing ages (14.3±1.18 years) of adolescents attending private schools. Also, adolescents attending private schools have higher socio-economic status when compared with those attending public schools (25,35–37), which is also expected since parents/guardians pay tuition and other associated fees in private schools, in contrast to largely free education in public schools.
The attitude of in-school adolescent girls to menstruation
The outcome of the six attitude indicators revealed no difference between female adolescents attending public and private schools. The positive feelings regarding the perception of menstruation as a natural physiological event were captured in positive feelings domain and as a matter of fact, female adolescents are expected to be prepared for menarche before experiencing it. However, most respondents in public (36.2%) and private (30.6%) schools perception was negative on positive feelings domain and therefore are ill-prepared to experience it, in congruence with a study by Marvan and Molina-Abolnik in Mexico (38) and in Ghana, which however changed after strategic intervention where more girls became aware of when to expect their menses monthly with 92% of girls reported positive feelings about menstruation (39).
Similarly, negative emotions, which entails embarrassment, rejection and wishing they could stop menstruation showed that most respondents had a weak attitude. In our study, negative feelings, through a feeling of shame, embarrassment and hope menstruation could stop, rather than being happy about their transition to womanhood was predominant in private schools (12.2%) when compared to public schools (20.3%), respectively, in congruence to findings of Marvan and Molina-Abolnik in Mexico (38) and Nigeria (30,32,33) and elsewhere (5,40,41).
The derived menstrual symptoms variable showed that only 22.6% and 30.0% among respondents in public and private school respectively had a positive attitude while others showed a negative attitude, as in previous studies (42–44). The signs and symptoms that herald menarche, and subsequent menstruations on monthly basis vary from one adolescent to another, as also in the post-menarche female adolescents where a significant negative correlation between menstrual attitudes and perimenstrual symptoms in Uganda (45), a product of inadequate and skewed awareness, and preparedness to manage some menstruation and associated discomforts (19,32,42).
The ease with which adolescents communicate about menstruation, including but not limited to feelings about the purchase and handling menstruation materials, information seeking pattern, as part of openness, was largely negative, in congruence with findings in Uganda, and other climes where a silent culture of secrecy, inadequacy, shame and insecurity pines menstruation and menstrual hygiene management (38,45–48). Also, on their acceptance of menarche, adolescents attending public and private schools had 28.2% and 35.6% positive rating scores respectively, a pointer to the inherent challenges experienced. The study findings were in agreements with similar studies that considered menarche experience as debilitating, bothersome and scary (30,42,49–51); associated with negative emotions (5), perhaps due to inadequate menarche education and preparedness for menstruation (48). This has persisted despite several decades of awareness creation and interventions to improve the situation among adolescents globally (11,19,52–55)
It was, however, only living with menstruation that had 51.3% overall positive attitude scores in agreement with a previous study in Egypt (56). They have accepted menstruation and its management as a routine that should happen monthly despite being negatively affected by friction burns on their thighs during journeys to school (57) and experiences of cramps, fatigue and feeling discomfort, backache and types of absorbents used could affect their attitude and contribute to school absenteeism and performance (42,58,59).
The positive scores in a composite of the 58 attitude items of adolescents in public (8.5%), private (16.7%) and overall (12.6%) were poor and lower than those reported by Yadav et al. (60) and Padmanabhanunni and Fennie (61), where 49% and 78% of adolescents and university students respectively had positive attitudes towards menstruation and menstrual hygiene management. Lawal, Idemudia and Balogun reported that adolescent girls with lower anxiety reported positive menstrual attitude by anticipating the onset of menstruation (30) and therefore, the poor attitude could have been occasioned by low, to skewed awareness prior menarche and information received from divergent sources due to the culture of silence that herald menarche. These agreed with previous findings where most respondents had a negative attitude attributed to negative beliefs about menstruation in beliefs, and culture (38,62,63). However, adolescents may consider menstruation and its management more positively if they are surrounded and equipped with the right knowledge, encouraging societal perceptions, removal of negative socio-cultural beliefs and practices, aspects of menstruation (48,62).
Though previous studies identify religious affiliation and income level as factors that predict attitude to menstrual attitudes and experiences (7) in contrast to the current study where adolescent girls’ attitude to menstruation was a function of ethnicity. Adolescents attending private schools have a better attitude when compared to those in public schools and therefore, the inherent factors need to be further researched.
The study findings are applicable to female in-school adolescents attending public and private schools in developing economies.
The study was prone to response bias among adolescents attending public and private schools in Nigeria and reported a low Cronbach’s alpha reliability coefficient (66.3%). The responses were self-facilitated after the questions were explained to participants spaced out to avoid undue influence on their responses.