Pre-menarche adolescent girls’ menstrual knowledge and preparedness to menarche in North Shewa zone of Amhara region, Ethiopia

Background: Many adolescent girls in Ethiopia attain menarche without adequate knowledge and preparation which could have a distressing negative impact on their psychosocial, physical, and emotional wellbeing. This study aimed to assess pre-menarche adolescent girls’ menstrual knowledge and preparedness to menstruation and associated factors in the North Shewa Zone of the Amhara region. Methods: A school-based cross-sectional study was conducted on participants selected through a multistage sampling technique. Data collected through a self-administered questionnaire were entered into Epi Data and exported to SPSS for analysis. Bi-variable and multivariable logistic regressions were computed to identify factors associated with the good menstrual knowledge and preparedness to menarche. An odds ratio with 95%CI was computed to measure the magnitude of the association. Variables with a p-value of <0.05 on multivariable analysis were considered statistically signicant factors associated with the outcome variable. Results: From a total of 424 pre-menarche adolescent girls included in the study, 166(39.2%) had good menstrual knowledge and about a quarter 110(25.9%) had good preparedness towards menarche. An increase in the school grade level of adolescent girls, the educational status of the mother, and occupation of the father (government employment) were positively associated with good menstrual knowledge. Having good menstrual knowledge increased the preparedness of pre-menarche girls to menarche by over 13-fold than poorly knowledgeable girls. Conclusions: Menstrual knowledge and preparedness to menarche of pre-menarche adolescent girls were low in the North Shewa Zone of the Amhara region. The level of preparedness to menarche was also highly dependent on girls' menstrual knowledge. Thus, the school's health program and teachers should address the problem by delivering age-appropriate menstrual information to equip adolescent girls with accurate and adequate menstrual knowledge before the onset of menarche. age-appropriate menstrual information to equip adolescent girls with accurate and adequate menstrual knowledge before the onset of menarche.


Introduction
Adolescence is a period of transition from childhood to adulthood characterized by rapid physical, psychological, and mental development and maturity. It is also the time of rapid development of secondary sexual characteristics including the initiation of menstruation for girls. Menstruation is the physiological process of releasing blood from the uterus through the vagina as part of the menstrual cycle experienced by adolescent girls and women in reproductive age (1)(2)(3). This is the periodic shedding of the inner lining of endometrium, which was prepared to support the growth of the fertilized egg, in the absence of fertilization of egg with sperm. The onset of menstruation for the rst time is known as menarche, which usually occurs during early adolescence (10-14 years of age) (4).
Although menstruation is a natural phenomenon, it is surrounded by socio-cultural and religious beliefs and taboos in low and middle-income countries (LMICs) including Ethiopia. Because of these harmful beliefs and taboos, menstruation is considered as embarrassing, shameful and something that has to be hidden which restrict adolescent girls to discuss menstruation and reproductive health with their parents or other family members, friends and teachers. These restrictions create barriers to access accurate and comprehensive information about menstruation and related hygienic management for adolescent girls. This in turn leads to a misconception of adolescent girls about menstruation (1, 2, 5-7).
As a result, a substantial number of adolescent girls in LMICs attain menarche without adequate knowledge and preparation about menstruation and its hygienic management (1,5,8). Studies in India (9), Gambia (10) and Benin (11) revealed that less than two-thirds of girls were informed about menstruation before its occurrence and most of them felt unprepared for menarche. Unpreparedness was more frequently reported by girls who experienced menarche at a relatively early age. In Ethiopia, the proportion of adolescent girls who had menstrual knowledge before menarche ranges from 27.1-51.4% (7,(12)(13)(14).
In addition to harmful beliefs and taboos in the community, for adolescent girls who lack knowledge and unpreparedness to menstruation, menarche will be a distressing experience of fear, anxiety, embarrassment, tension, and shame (9,11,12,15,16). Inability to manage menstruation with dignity in public spaces like schools intensi es these feelings and increase school absenteeism, school dropout, and poor academic performance of adolescent girls (1,5,17). On the other hand, good menstrual knowledge and preparation for menstruation before menarche effectively improves positive experience to menarche, attitude towards menstruation, and proper menstrual hygienic practice (13,18,19). Thus, menarche is one of the most crucial sudden events of adolescent girls which potentially might profound negative impact on the psychosocial, physical, and emotional wellbeing of adolescent girls and their future lives (1,6,15).
Almost all local studies in Ethiopia were focused on menstrual hygiene management and few of them addressed menstrual knowledge and preparedness before menarche by measuring it retrospectively on post-menarche adolescent girls. As the evidence showed, most adolescent girls considered menarche as a triggering factor to learn about menstruation (1). This knowledge learned after menarche and their menstrual experience could affect their response leading to the overestimation of menstrual knowledge and preparedness to menstruation before menarche. Therefore, this study aimed to assess pre-menarche adolescent girls' menstrual knowledge and preparedness to menstruation and associated factor in North Shewa zone of Amhara region, Central Ethiopia Methods Study setting and period The study was conducted from January 16, 2019, to March 30, 2019, in North Shewa zone. North Shewa zone is one of the eleven zones found in the Amhara national regional state of Ethiopia. The zone is divided into twenty-four woreda and three town administrations. Debre Birhan is zonal administrative town of North Shewa zone which is 130 km northeast of the capital city Addis Ababa at latitude of 9°46'8.4''N and longitude 39°40'4.8''E.

Study design and population
An institute based cross-sectional study was conducted among pre-menarche adolescent school girls. Pre-menarche adolescent female students from grade 5 to 10 who attended education at public school were our study population. Those students found from grade 5 to 10 but aged less than 10 years or greater than 19 years were excluded from the study. Similarly, students with visual or hearing impairment and from private schools were not involved in this study.

Sample size and sampling procedure
We used Epi Info version 7.1.5.0 software to determine the required sample size. The sample size for descriptive study on Epi Info was computed by considering the following assumptions: source population of the study less than 10,000, 77.1% prevalence of menstrual knowledge of adolescent girls before menarche (20), 5% con dence limits, 95% con dence level and 1.5 design effect for a single cluster. From the computed value of 407 by adding a 10% non-response rate we got 448 as the nal sample size. A multistage sampling technique was employed to get these study participants. First, we selected four woreda administrations (Debre Sina, Basona Werena, Hagere Mariam, and Jiru Enuari) through the lottery method. Second, we chose three schools, each from rural 2nd cycle primary schools (grade 5-8), urban 2nd cycle primary schools, and high schools (grade 9-10) randomly using lottery method to include a total of 12 schools in the study. Finally, study participants were selected by proportionate systematic random sampling after listing out of all pre-menarche adolescent girls from those schools. Data collection procedures and tools Data were collected using a semi-structured self-administered questionnaire. The questionnaire was developed by reviewing different pieces of literature and contextually adapted to the socio-cultural norms of the area. The questionnaire was divided into three sections designed to assess pre-menarche adolescent girls' socio-demographic characteristics, menstrual knowledge, and preparedness to menarche. Selected students were appointed to come back to school on the class free time of the next day for data collection. At the same time, those consent minors (≤ 15 years of age) were informed to get oral consent from their parents. Data collectors instruct study participants on how to ll the questionnaire and facilitate the data collection process. The questionnaire took on average 20-25 minutes.
Knowledge of pre-menarche adolescent girls about menstruation was measured used a series of closeended 10-item questions developed after reviewing related literature (5,10,18,21,22) and by consulting senior researchers who were more familiar to the area. Each correct response got one mark whereas any wrong or don't know response got no mark. The sum score of knowledge questions was calculated out of 10 points. Those who scored ≥ 7 were categorized as having good knowledge about menstruation.
The preparedness of pre-menarche adolescent girls was measured with 8-item questions. The response of each item was scored as "1" for correct response and "0" for wrong or don't know responses. The total sum score of the tool ranges from 0 to 8 and those who scored ≥ 5 were considered as well prepared for menarche. Data quality assurance The questionnaire, which was initially prepared in the English language, was translated to local (Amharic) language then re-translated back to English to check its consistency. The Amharic version of the questionnaire was pre-tested on 5% of the study subjects to ensure its understandability, internal consistency and ability to address the study objectives. According to the pre-test result, few modi cations to the expression of terminologies were made. Besides, the internal consistency (reliability) of items in the menstrual knowledge and preparedness measurement tools was determined using Cronbach's alpha. It was 0.626 and 0.561 for knowledge and preparedness measurement tools. A one-day training about the objective of the study, methods of participant selection and data collection tool, and procedure for four female data collectors and one supervisor. Daily monitoring and supervision of the data collection, checking for completeness and consistency of collected data was carried out by supervisors. The principal investigator also examined the collected data for completeness and consistency before data entry. Data analysis procedures Collected data were entered Epi Data version 3.1 software and exported to SPSS version 24 for analysis. Both descriptive and analytical statistics were performed and presented using tables and graphs.
Variables found to have a p-value of < 0.2 on bi-variable analysis were included in the multivariable binary logistic regression analysis. Multivariable binary logistic regression analyses were carried out to identify socio-demographic factors associated with menstrual knowledge and to see the effect of menstrual knowledge on preparedness to menarche of pre-menarche adolescent girls. Odds ratios with 95% con dence intervals were computed and a p-value of < 0.05 was used to declare the presence of a statistically signi cant association between the covariates and dependent variable.

Demographic pro le of study participants
Out of 448 pre-menarche adolescent girls selected for study, 424 were involved in this study giving the response rate of 94.6%. Table 1 demonstrates the demographic characteristics of the study participants. The mean (± SD) age of study participants was 13 (± 1.4) years. Adolescent girls aged 10-14 years were School teachers 108 (37.0%) and mothers 100 (34.2%) were frequently mentioned primary source of information. Over half 214 (50.5%), 232 (54.7%), and 221 (52.1%) pre-menarche adolescent girls knew the common age of menarche, average length of a menstrual cycle and average duration menstrual blood ow respectively. Over two-third 296 (69.8%) recognized that menstruation is unique to females and 214 (50.5%) considered it as sign of sexual maturity. Nearly half 210 (49.5%) pre-menarche adolescent girls did not knew the cause of menstruation, while 118 (27.8%) and 28 (6.6%) mentioned biological process and hormonal effect as the cause of menstruation respectively. Regarding the origin of menstrual blood; 121 (28.7%) said uterus, 203 (48.1%) abdomen, and 67 (15.9%) didn't knew (Table 2).    (Table 5).

Discussion
Menstruation is surrounded by taboos and cultural beliefs which consider menstruation as an embarrassing, shameful, and secret thing that restrict adolescent girls to discuss it freely. This limit adolescent girls from accessing accurate information about menstruation and a signi cant number of adolescent girls experience menarche with poor knowledge and misconception about menstruation (1,2,6,7,15,22,23). This study nding also indicated a similar result that 39.2% of pre-menarche adolescent girls had good general knowledge and 60.8% had poor knowledge about menstruation. Misconception about speci c areas of menstruation was common like 48.1% and 6.2% of adolescent girls thought that menstrual blood originates from the abdomen and vagina respectively. Nearly one-fourth (23.1%) believed menstruation during pregnancy and 11.4% thought menstruation is caused by the curse of God.
The magnitude of 39.2% good knowledge about menstruation in this study is in line with 39.4% report in central India (24) but slightly higher than 31.7% and 31.4% report in Gedeo district of Southern Nations, Nationalities and Peoples' Regional states of Ethiopia (13) and Tumkur, India (25). This study nding is lower than 77.1%, 70.9%, and 51.4% study reports in Adama (20), Boset (26), and Harbu (14) districts of Ethiopia respectively. Studies in Rajasthan India (9) and Benin (11) also reported that 66% and 60.7% of adolescent girls had menstrual knowledge before menarche. This disagreement between those studies might be because of the difference in the de nition of menstrual knowledge and the tool used to measure it. The difference in study participants' menstrual status at the time of investigation might also have an important role in the observed inconsistency. A study in the rural Gambia (10) revealed that 26.6% and 66.0% pre-menarche and post-menarche adolescent girls had good menstrual knowledge which indicates menarche is a triggering factor for girls to learn about menstruation. The knowledge and experience after menarche of post-menarche girls could affect their response to questions related to menstrual knowledge before menarche. Therefore, including post-menarche adolescent girls for the assessment of menstrual knowledge before menarche could lead to the overestimation of menstrual knowledge of adolescent girls before menarche.
Previous studies on adolescent girls irrespective of their menstrual experience showed that menstrual knowledge depends on age adolescent girls. An increase in age leads to the onset of menarche which triggers adolescent girls to learn about menstruation. This means the onset of menarche is the intermediate variable between age and menstrual knowledge of adolescent girls. Perhaps, this might be the reason why, in our study, the age of pre-menarche girls was not associated with menstrual knowledge.
According to this study, menstrual knowledge of pre-menarche adolescent girls increased depends on their educational level. For a unit increase in school grade level, menstrual knowledge increased by 63.1%. Parents' education and occupation had also associated with pre-menarche adolescent girls knowledge about menstruation. This is consistent with a study in Denpasar City (27) reports that the level of education and surrounding people, from whom they acquire information, in uences menstrual knowledge of girls.
According to the present study, about one-fourth 25.9% pre-menarche adolescent girls were better prepared and 74.1% were poorly prepared for menarche. This nding lower than the nding of a study in Mexico (18) which reported 38% of adolescent females were badly prepared and 19% were well prepared for menarche. Similarly, 33% of adolescent girls were not well prepared for menarche in Gambia (10), and in the Udupi district of Karnataka (21), 47.5% had poor psychosocial preparation for menarche. This disagreement could be due to the study area's socio-cultural and demographic differences or variation in the measurement tools.
Menstrual knowledge of pre-menarche girls had a strong association with their preparedness for menarche. Having good menstrual knowledge increased the preparedness of pre-menarche girls to menarche by over 13-fold than poorly knowledgeable girls. Similarly, a study in Indonesia revealed (5) that lack of preparation for menarche of adolescent girls is due to insu cient menstrual knowledge.
As a cross-sectional study, this study has limitation in establishing causality based on the observed association between the covariates and the dependent variable. Not all adolescent girls attends school, so this study results can't be inferred to the total pre-menarche adolescent girls the area. Despite several measures were taken to minimize, due to sensitivity nature of menstruation the possibility of social desirability bias by study participants is unavoidable. Addressing this sensitive issue using quantitative data only without triangulation with qualitative approach is another limitations of this study. Therefore, further research with mixed study design approach is recommended to exhaustively explore those sensitive variables related to menstrual knowledge and preparedness to menarche among pre-menarche adolescent girls.

Conclusions
According to this study, menstrual knowledge and preparedness to menarche were very low. The cause and origin of menstrual blood were common misconceptions among pre-menarche adolescent girls. Maternal education, fathers' occupation, and girls' school grade level had an independent association with pre-menarche adolescent girls' menstrual knowledge. The level of preparedness to menarche was also highly dependent on girls' menstrual knowledge. Thus, adolescent girls should acquire accurate and adequate knowledge as early as possible; schools should deliver age-appropriate menstrual information.

List Of Abbreviations
LMICs: Low and Middle Income countries Declarations Ethics approval and consent to participate Ethical clearance was obtained from the Ethical Review Committee of Debre Berhan University. A letter of support written to participating Woreda was obtained from the zonal health o ce. Permission letter was also obtained from the Woreda education o ce and each selected school. Permission to proceed with the study was obtained from each participating school following an explanation of the objective of the study for school directors. Data was collected after each study participants were adequately informed about the purpose, bene ts, and risks of the study and their right to discontinue or refuse to participate in the study.
Written consent was obtained from ≥15 years old study participants, and for those <15 years old verbal consent from parents and assent from participants was obtained. For con dentiality purpose, the names of participants and other personal identi ers related questions were excluded in the questionnaire. The collected data were stored in a safe place where no one can access it except the research teams.

Consent for publication
Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.