Journal of Nursing Research Vol. 16, No.

1, 2008

Menstrual Health Care Behavior and Associated Factors Among Female Elementary Students in the Hualien Region
Yu-Ting Chang Yueh-Chih Chen*
ABSTRACT: The purposes of this study were to measure menstrual knowledge, assess menstrual health care behavior

and investigate the factors associated with menstrual health care behavior among fifth and sixth grade female students. The subjects were 417 female students from 12 elementary schools in the Hualien region of Taiwan. The stratified cluster random sampling method was adopted. The questionnaire used in the study consisted of three sections: personal information, a menstrual knowledge questionnaire, and a menstrual health care behavior questionnaire. The results of this study show that the majority of the respondents felt that menstruation had an influence on their emotions (74.8%), daily life (73.1%), schoolwork (61.6%), and social interaction (50.1%). The total correct response rate for the menstrual knowledge questionnaire was 45.1%. There was a significant difference between aboriginal and non-aboriginal female students in terms of the correct answer rate for the menstrual knowledge questionnaire. The mean score for menstrual health care behavior was 2.66 (SD = 0.82). Elementary level female students who had better menarche preparation scored higher on the menstrual knowledge questionnaire, and those whose first period had already occurred felt more confident in their ability to execute proper menstrual health care behavior. The results prompted the recommendation to families and elementary schools to encourage students to improve their menstrual health care behavior during menses. Key Words: elementary female students, menstrual knowledge, menstrual health care behavior.

Introduction
The International Council of Nurses made a position statement on Womens Health in 2002. It emphasized that womens right to health and wellbeing must be protected throughout their lifespan, particularly during the vulnerable phase of childhood, wherein the rights to education, health and social support are especially important. Furthermore, during their reproductive years, women need access to health care and the protection of their reproductive health rights (International Council of Nurses, 2002). Menarche is an important event that signifies physical maturation and childbearing capability. It can greatly affect an adolescents recognition of her adult self, the establishment of self-esteem, and the assumption of

female sexual roles (Griffin, 1999). Menarche has been described as the most discrete event of female puberty (Crouch & McKenzie, 1999), because one cannot predict when it will occur. Due to its less predictable timing in comparison with the other physical changes that occur during puberty, such as breast and pubes development, menarche makes a more dramatic emotional impact on female adolescents perspective of having achieved womanhood. It is therefore necessary to help female adolescents to endure the age of puberty smoothly, and encourage them to develop a positive self-image when entering womanhood. Health care professionals must pay particular attention to a female adolescents menstrual knowledge and menstrual health care behavior during this critical transition.

RN, MSN, Instructor, Department of Nursing, Tzu Chi College of Technology & Doctoral Student, Graduate Institute of Nursing, National Taiwan University; *RN, PhD, Professor, School and Graduate Institute of Nursing, College of Medicine, National Taiwan University. Received: September 6, 2007 Revised: November 26, 2007 Accepted: December 28, 2007 Address correspondence to: Yueh-Chih Chen, No. 1, Jen Ai Rd. Sec. 1, Taipei 10051, Taiwan, ROC. Tel: +886 (2) 2312-3456 ext. 8243; Fax: +886 (2) 2321-9913; E-mail: ychichen@ntu.edu.tw

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Marvan, Vacio, and Espinosa-Hernandez (2003) conducted a study with Mexican pre-menarcheal adolescents living in a metropolis, who regarded menstruation as an incident of weakness. Likewise, in India, when young females have their first period, they are forbidden to worship the gods, must not consume fermented foods, and are not allowed to run, lift heavy objects, or work in the kitchen. The girls completely accept these negative concepts (Mahajan & Sharma, 2004). Adolescent females receive menstrual knowledge mainly from their mothers or teachers (Cheng, Yang, & Liou, 2007; Houston, Abraham, Huang, & DAngelo, 2006; Jou, Chen, Lee, & Yin, 2003). However, mothers and teachers often provide only the facts about menstruation, and might not have enough accurate menstrual knowledge (Jou et al., 2003; Marvan & Bejarano, 2005). The school setting is the first formal information source for the menstruation education of female elementary students. School nurses who have knowledge about menstruation should actively provide information and discuss menstrual issues with students (Cheng et al., 2007), and should be included in the curriculum design and teaching, as they are frequently the person who is responsible for menstrual education or consultation (Jou et al., 2003). Teitelman (2004) showed that girls who were better prepared for the physical changes at menarche were better able to acknowledge and accept this bodily change. Koff and Rierdan (1995) conducted a study with 157 ninth grade female students, and found that a calm, supportive and reassuring environment was the most important factor. With regard to menstrual health care education, Griffin (1999) emphasized that menstrual teaching should occur within a developmental framework that focuses on the immediate needs of younger girls at menarche, and be modified later when these needs change. McGrory (1995) suggests that it should include: maintaining physiological hygiene, the use of sanitation methods, and preparation for the transitions in physiology, psychology, and societal position. Females with more accurate and useful menstrual knowledge had a more positive menstrual experience, including better general health behaviors and a more satisfactory body image (McPherson & Korfine, 2004). In Taiwan, 36.1% of female elementary students were found not to have a basic knowledge about menstruation when they had their first period (Yen, Shu, & Li, 2001). Likewise, an Australian study of sixth grade elementary female students revealed a lack of menstrual knowledge,

with only a 45.1% correct answer rate (Moore, 1995). Similarly, female students in Taipei scored only 56.8% on a test of menstrual knowledge (Ou Yang, 2004). Although menstrual education is widespread, most adolescents obviously have inaccurate menstrual knowledge. Huang (2003) indicates further that those female adolescents who have inaccurate menstrual knowledge may be fearful about their menstruation, exhibiting signs of mental confusion, emotional irritation, and social shame. They were often unable to adopt proper menstrual health care behaviors that could positively influence their personal, physiological and psychological health. The aim of this study is to explore menstrual knowledge, menstrual health care behavior, and related factors among female elementary students in the Hualien region of Taiwan.

Methods
A cross-sectional study design was conducted. A structured questionnaire was used for data collection. Stratified random sampling was used to recruit all of the participants. According to geographical position, we divided the Hualien region into three sections, each containing townships of predominantly aboriginal and non-aboriginal populations. The elementary schools were randomly selected from the aboriginal and non-aboriginal population centers of each section. All fifth and sixth grade female students, aged from 10 to 12 years, in the 12 selected elementary schools were invited to participate. This study was permitted by the school officials. In the first stage, the consent form and information were given to all students and their parents. Once permission had been obtained, the researcher and two research assistants explained how to fill in the questionnaire. Giving each participant a code number protected the anonymity of the students, and they were informed that they could withdraw at any stage without any consequence to them. The questionnaires took approximately 20 minutes to complete. Four hundred and seventeen questionnaires were completed, with a response rate of 86.2%.

Measurement
A structured questionnaire was utilized as the research tool for the data collection. The structured questionnaire consisted of three major dimensions: basic personal information, scale of menstrual knowledge, and scale of menstrual health care behavior. The basic per-

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Yu-Ting Chang et al.

sonal information asked for the participants age, ethnic origin, menstrual age, menarche preparation, and menstruation influences on school activity, emotions, daily life, social interaction, and so on. For menarche preparation a five-point response scale was used, in which 0 represented 0% preparation and 4 represented 100% preparation; the higher the score, the better the perceived preparation for menarche. The researcher obtained permission to use the original menstrual knowledge questionnaire (MKQ) developed by Ou Yang (2004). It was developed to gather data on menstrual knowledge among fifth grade elementary to eighth grade junior high school students. The original MKO content validity was confirmed by six experts. The original MKQ had item discrimination between .22 and .85, and item difficulty between .26 and .72. The questionnaire contained 13 items. Correct responses were given a score of 1. The Correct Answer Rate was calculated by using the individuals score divided by 13. A higher correct answer rate implied a greater knowledge of menstruation issues. In our study, the reliability was tested by the Kuder-Richardson formula 20 (KR-20) for scales with dichotomous answers. The KR-20 for the questionnaire in this study was .64. A menstrual health care behavior questionnaire (MHCQ) was developed by the authors based on information in the literature and from advice gathered during peer reviews. The questionnaire asked for the participants confidence in performing menstrual health care behaviors. Some sample questions were: I can use sanitary pads correctly during my period, and I can change sanitary pads in a timely way according to the amount of menstrual blood. Items scored 0 indicated strongly disagree and 4 indicated strongly agree. A higher score represented greater confidence in performing menstrual health care behaviors. The content validity was confirmed by six experts. Expert validity was performed by inviting a professor and an assistant professor in the field of pediatric nursing, an associate professor in the field of the womens health, and two elementary school teachers. The questionnaire was tested with 18 female elementary students to confirm the internal consistency and face validity. The construct validity was tested by factor analysis. Using Varimax rotation, the principal components analysis, along with the scree plot, revealed four factors as the best solution, accounting for 59.1% of the total variance. Thus, the MHCQ had four subscales.

These included: maintaining physiological hygiene, preventing menstrual blood seepage, awareness of emotional condition and symptoms, and managing menstrual discomfort. In this studys sample, the MHCQ and its subscales had adequate internal consistency (coefficient a = .76 to .92, N = 417).

Data Analysis
SPSS version 12.0 was used for the data analysis. Descriptive statistics, such as the frequency, mean, and standard deviation, were used to describe the sample and the main variables. Stepwise multiple linear regressions were used to determine the best subset of predictors of MHCQ. The significance level was set at p < .05.

Results
Characteristics of the Subjects
A total of 417 female students participated in the study. The subjects demographic characteristics are presented in Table 1. Among the participants, 30.9% indicated that menarche had come. Post-menarcheal students recollected their preparation for menarche; pre-menarcheal students imagined their preparation level as if their menarche were to happen immediately. In their subjective responses, about half of the female students indicated that they were less than fifty percent prepared for menarche. A majority of the respondents felt that menstruation had an influence on their emotions (74.8%), daily life (73.1%), schoolwork (61.6%), and social interaction (50.1%). The three most important categories of menstrual information were menstrual management, physical knowledge, and menstruation and maturation issues. A Chi-square analysis revealed no significant demographic differences between the aboriginal and non-aboriginal groups.

Basic Knowledge about Menstruation

As shown in Table 2, the correct answer rate for the menstrual knowledge of all participants was 45.1% (range = 0% to 92.3%). Although the subjects were, for the most part, aware of the truth that girls who have periods are able to get pregnant, over 88.7% did not know about ovulation time, 77.9% believed that menstrual blood comes from the urethra, and 75.5% did not know that it is a normal to lose about 30-100 ml blood during a period. There was a significant difference between aboriginal and non-aboriginal female students in terms of correct answer

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Table 1. Demographics and Responses of Participant Female Students (N = 417) Total (n = 417) Variables Grade 5th 6th Menarche PrePostSelf-perceived Menarche Preparation 50% > 50% Menstruation Influences Schoolwork No Yes Menstruation Influences Emotions No Yes Menstruation Influences Daily Life No Yes Menstruation Influences Social Interaction No Yes Important Menstrual Informationa Menstrual management Physical knowledge Menstruation and maturation issues Menstrual Information Sourcesa Mothers School teachers School nurses Preferred Menstrual Information Sourcesa Mothers School nurses School teachers Note. a Multiple choice. n 208 209 288 129 193 224 160 257 105 312 112 305 208 209 300 187 185 373 216 205 376 211 184 % 49.9 50.1 69.1 30.9 46.3 53.7 38.4 61.6 25.2 74.8 26.9 73.1 49.9 50.1 71.9 44.8 44.4 89.4 51.8 49.2 90.2 50.6 44.1 Aboriginal (n = 187) n 99 88 1260 61 77 1100 69 1180 52 1350 49 1380 88 99 1350 83 89 1680 87 81 1640 83 78 % 52.9 47.1 67.4 32.6 41.2 58.8 36.9 63.1 27.8 72.2 26.2 73.8 47.1 52.9 72.2 44.4 47.6 89.8 46.5 43.3 87.7 44.4 41.7 Non-aboriginal (n = 230) n 109 121 162 068 116 114 091 139 053 177 063 167 120 110 165 104 096 205 129 124 212 128 106 % 47.4 52.6 .524 70.4 29.6 .062 50.4 49.6 .613 39.6 60.4 .307 23.0 77.0 .825 27.4 72.6 .325 52.2 47.8 71.7 45.2 41.7 89.1 56.1 53.9 92.2 55.7 46.1 c2/p .279

rate in the MKQ (t = -4.19, p = .00). The non-aboriginal students (48.8%) scored higher than the aboriginal students (40.6%).

Menstrual Health Care Behavior Among Female Elementary Students

As shown in Table 3, the mean score on the MHCQ for all participants was 2.66 (SD = 0.82; the possible score

ranged from 0-4). The lowest of the four subscale scores was on the subscale for managing menstrual discomfort; its mean score was 2.23 (SD = 0.80). In the MHCQ, the highest mean score was for: At home, if I had menstrual discomfort, I would tell my mother or my family immediately (3.21 1.15) and the lowest mean score was for: I can monitor my emotional state during my period (2.23 1.31). There were no significant difference between the

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Yu-Ting Chang et al.

Table 2. Knowledge of Menstruation: Percentage of Correct Responses by Female Elementary Students (N = 417) Content of questions Menstrual Knowledge Questionnaire Girls who have periods are able to get pregnant. The physical changes occurring during puberty are caused by hormones. During menstruation, girls should not take baths or exercise in order to avoid losing too much blood. The composition of menses is blood, interior membrane tissue, uterine secretions, etc. Suffering from abdominal pain before or during menstruation indicates that the body is unwell. Periods come approximately every 21 to 35 days, and menses last from 3 to 7 days. Women do not experience menstruation while pregnant. Menses come because the ovum has not been inseminated, and the interior membrane tissue peels off. The menstrual cycle can be divided into four stages: menstrual period, hyperplasia period, ovulation period, and corpus luteum period. During the first 2 years of menstruation, irregular cycles are abnormal. The total amount of blood lost during a period is about 30 to 100 ml. Menstrual blood comes from the urethra. Womens ovulation time is around the 14th day after the beginning of menses. Note. T means the correct answer is True, and F means the correct answer is False. Answer T T F T F T T T T F T F F Percentage correct 45.1 72.2 65.2 64.7 57.8 57.1 56.1 48.4 42.2 35.5 29.7 24.5 22.1 11.3 Rank 01 02 03 04 05 06 07 08 09 10 11 12 13

Table 3. Distribution of MHCQ Responses From Participants (N = 417) Content of questions Menstrual Health Care Behavior Health Care Behavior (By Subscale) Prevent menstrual blood seepage Maintain physical hygiene Be aware of ones emotional status during menstruation Manage menstrual discomfort Highest and Lowest Ranking Single Items At home, if I had menstrual discomfort, I would tell my mother or my family immediately I will maintain physical sanitation during my period Before my period, I will carry menstrual products in my school-bag I can manage menstrual discomfort by myself I can choose among different hygienic products according to the amount of menstrual blood and physical activity I can monitor my emotional state during my period M 2.66 2.77 2.76 2.42 2.23 3.21 3.12 3.08 2.28 2.24 2.23 SD 0.82 0.96 0.99 0.96 0.80 1.15 1.11 1.29 1.40 1.44 1.31 01 02 03 19 20 21 Rank

aboriginal and non-aboriginal female students in menstrual health care behavior.

Major Predictive Variables of MHCQ Among Female Elementary Students

Stepwise multiple linear regression analysis was conducted to examine the important predictors of menstrual

health care behavior. Dichotomous data were generated prior to the analysis. For example, the onset of menarche was coded as one, pre-menarcheal coded zero. The correlation matrix and collinearity diagnostics were carried out to examine the collinearity among independent variables. The variance inflation factors (VIF) of all independent variables are lower than 10, suggesting the absence of non-collinearity. Table 4 shows

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Table 4. Summary of Stepwise Multiple Linear Regressions for the Variables Predicting Menstrual Health Care Behavior Among the Participants (N = 417) Variable Intercept Menarche preparation Menstrual knowledge scores The onset of menarche ***p < .001. B 38.20 16.83 00.16 04.04 b .49 .19 .11 t value 22.25*** 12.06*** 04.60*** 02.66*** R2 .30 .34 .35 R2 change .30 .04 .01 F 174.01*** 107.01*** 074.74***

the results of the stepwise multiple regression analysis. The results show that greater menarche preparation, greater menstrual knowledge, and the onset of menarche were significant predictors of positive menstrual health care behavior. These variables can explain 35.2% of the total variance in menstrual health care behavior.

Discussion
Among the respondents, post-menarcheal students recollected their preparation for menarche; pre-menarcheal students imagined their preparation level as if their menarche was to happen immediately. In their subjective responses, about half of the female students in this study were less than 50% prepared for menarche. Compared with the relevant literature on menarche preparation, in which Ou Yang (2004) found that 59.0% of female students had menarche preparation of less than 50%, the menarche preparation found in this study is relatively low. This indicates that many female students had not made enough preparation for their menarche. Teitelman (2004) shows that girls who were prepared for the physical changes at menarche were better able to acknowledge and accept this bodily change. This indicates that teaching menstrual knowledge, menstrual bodily change, and psychological change is very important. Doing so can help female adolescents to make a healthy transition into womanhood. In this study, more than half of the female students felt that menstruation had an influence upon their schoolwork, emotions, daily life, and social interaction. In these aspects, there were no statistically significant differences between pre- and post-menarcheal students in terms of schoolwork, emotions, daily life, or social interaction. The results indicate that, even though pre-menarcheal elementary students had yet personally to experience menstruation, they nonetheless perceived the influences of menstruation in the same way as post-menarcheal girls.

Marvan, Espinosa-Hernandez, and Vacio (2002) pointed out that pre-menarcheal girls with no personal menstrual experience had been influenced by cultural stereotypes which were of a negative nature. Yeung, Tang, and Lee (2005) conducted a study with 476 Chinese pre-menarcheal teenage girls that showed that the participants expectations of menarche were largely negative and heavily influenced by cultural beliefs about menstruation. Subjects personal menstruation perspective in combination with the status of having had menstruation experience showed a positive correlation with female self-awareness and attitudes towards self-health (Chang, 2003). Therefore, adolescent menstrual education programs should emphasize the affective components and positive experiences of menstruation. Such programs should also avoid using negative slang and stereotypes in describing menstruation. An understanding of teenage girls emotional expectations of menarche is vital in preparing them for this important developmental milestone. In our study, the correct answer rate for the female elementary students on a test of menstrual knowledge was 45.1%. Compared with the results of other studies using the same questionnaire on menstrual knowledge, wherein Ou Yang (2004) found female elementary and junior high school students correct answer rate to be 56.8%, the level of menstrual knowledge derived in this study was relatively low. As an indicator that female elementary students had inadequate knowledge, more than 70% of the female students did not know about the timing of ovulation, that menstrual blood comes from the uterus, or that it is normal to lose about 30-100 ml of blood during a period. Teaching about ovulation time, the source of menstrual blood, and the normal blood loss during a period is very important. Further, the content can help female adolescents to prevent unexpected pregnancy, better understand the female reproductive system, and take note of any abnormal blood loss during menstruation.

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In this study, we compared aboriginal and non-aboriginal female students menstrual knowledge and menstrual health care behavior scores. The results show that there was a statistically significant difference between aboriginal and non-aboriginal students in terms of MKQ scores, with aboriginal students scoring lower. However, there was no significant difference between aboriginal and non-aboriginal students in terms of their MHCQ scores. It may be useful to perform further study to explore the reasons for this disparity. Nonetheless, our results indicate that elementary schools should enhance aboriginal female students menstrual education. Overall, the female elementary students menstrual health care behavior, as measured in our study, was satisfactory (the mean of the MHCQ was 2.66 0.82 and the possible score ranged from 0-4). Based on the MHCQ results, 74.8% of the female students felt that menstruation had an influence upon their emotions. However, the lowest confidence expressed by female elementary students was the inability to monitor my emotional state during my period (mean score 2.23). Female elementary students face emotional difficulties during their transition into adulthood. They are confronted with obvious physical, psychological, and social changes (Jou, 2001). Menses is an emotionally charged event (McGrory, 1995). Therefore, stress adaptation and emotional management should be included in elementary classes. Doing so can help female adolescents to manage their emotional status and make a healthy transition into womanhood. In this study, I can choose among different hygiene products according to the amount of menstrual blood and physical activity and I can manage menstrual discomfort by myself exhibited lower scores. This suggests that we should pay greater attention to providing lectures that emphasize and effectively convey menstrual health care knowledge to female elementary students. Greater menarche preparation, greater menstrual knowledge, and the onset of menarche were significant predictors of positive menstrual health care behavior in this study. This study supports Teitelman (2004) which showed that girls who had better preparation for the physical changes at menarche were better able to acknowledge and accept this bodily change. Likewise, female students who had greater menarche preparation exhibited greater confidence in their menstrual health care behavior. Therefore, instruction strategies that are limited to providing knowledge of menstruation alone are insufficient to improve adolescents menstrual health care behavior, and improving adolescents menarche preparation should be emphasized.

Menarche is the hallmark maturational event of female childhood. In general, women undergo the onset of menarche at about 13 years of age, and experience the menopause at around 50 years old. During their lifespan, they will experience approximately four hundred menstruations (Chang, 1998). Therefore, adopting appropriate menstrual health care attitudes, habits, and behaviors as early as possible is very important. Doing so will influence the physiological and psychological health of female adolescents, and influence their body image and female sexual identity. Based on our results, we made some recommendations to the elementary schools and families who participated in our study. Firstly, they must enhance the female students preparation for menarche, and arrange for adequate menstrual instruction. Menstrual instruction should include information on physiological changes with an emphasis on menstruation management and the social impact of this maturation process. Beyond providing oral lectures, the content of menstrual education should include a variety of menstrual products that are available for students to see and touch. Group discussions can be utilized for sharing personal menstrual experiences and perspectives, and offering a means to correct any misconceptions about menstruation. Secondly, education for menarche should ideally begin in the early years at home (Soefer, Scholl, Sobel, Tanfer, & Levy, 1985). In this study, mothers are the primary and preferred source of menstrual information for adolescents. Therefore, mothers should recognize when their daughters are approaching puberty, and care for their physical and psychological development. Thirdly, schools and families should collaborate to help adolescents during their puberty. School nurses and adolescents mothers should collaborate to provide menstrual instruction to adolescents. Moreover, school nurses should focus on developing long-term relationships with students, and providing accurate menstrual information. Through a cooperative effort, adolescents can receive continuous, quality care, both at home and at school. There were some limitations to the study. Firstly, the samples in this study are limited to fifth and sixth grade elementary school students in the Hualien region of Taiwan. As a result, the implications drawn from the study may not be applicable to all elementary students in Taiwan. Secondly, this study was a cross-sectional design, so it can only illuminate the current situation. In the future, it would be beneficial to direct a longitudinal study of this topic, exploring the changes that female students undergo in pro-

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gressing from the pre- to post-menarche stages. Nevertheless, our study succeeded in providing useful information about menstrual health care issues among Taiwanese fifth and sixth grade elementary school female students, and can be used as a reference for related research in other countries.

Acknowledgements
The authors would like to express their gratitude to school officials, our subjects and their families. In addition, we wish to thank our English language editor, Orrin Hoopman, of Hualien, Taiwan. Finally, the authors were grateful to obtain research funding from Tzu Chi College of Technology, Research Grant No. TCCT-952A03.

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