Menstrual hygiene practices among high school girls in urban areas in Northeastern Ethiopia: A neglected issue in water, sanitation, and hygiene research.

BACKGROUND: Poor menstrual hygiene practices influence school girls' dignity, well-being and health, school-absenteeism, academic performance, and school dropout in developing countries. Despite this, menstrual hygienic practices are not well understood and have not received proper attention by school WASH programs. Therefore, this study examined the extent of good menstrual hygiene practices and associated factors among high school girls in Dessie City, Amhara Region, northeastern Ethiopia.
METHODS: A school-based cross-sectional study was employed to examine 546 randomly selected high school students in Dessie City, northeastern Ethiopia. Pretested interviewer-administered questionnaires and a school observational checklist were used for data collection. EpiData Version 4.6 and the Statistical Package for the Social Sciences Version 25.0 were used for data entry and analysis, respectively. Bivariate and multivariable logistics regression analyses were employed to identify factors associated with good menstrual hygiene practices. During bivariable analysis, variables with P-values less than 0.25 were retained for multivariable analysis. In the multivariable analysis, variables with a P-value less than 0.05 were declared to be significantly associated with good menstrual hygiene practices.
RESULTS: Of the respondents, 53.9% (95% CI [49.6, 58.2]) reported good menstrual hygiene practices. The following factors were found to be significantly associated with good menstrual hygiene practices: age range 16-19 years (AOR = 1.93, 95% CI: [1.22-3.06]); school grade level 10 (AOR = 1.90, 95% CI: [1.18-3.07]); maternal education (primary) (AOR = 3.72, 95% CI: [1.81-7.63]), maternal education (secondary) (AOR = 8.54, 95% CI: [4.18-17.44]), maternal education (college) (AOR = 6.78, 95% CI: [3.28-14.02]) respectively]; having regular menses [AOR = 1.85, 95% CI: (1.03-3.32); good knowledge regarding menstruation (AOR = 2.02, 95% CI: [1.32-3.09]); discussing menstrual hygiene with friends (AOR = 1.79, 95% CI: [1.12-2.86]), and obtaining money for pads from the family (AOR = 2.08, 95% CI: [1.15-3.78]).
CONCLUSION: We found that more than half of high school girls had good menstrual hygiene practices. Factors significantly associated with good menstrual hygiene practices include high school girls age 16-18 years, girls grade level 10, maternal education being completed primary, secondary and college level, having regular menses, good knowledge regarding menstruation, discussing menstrual hygiene with friends and obtaining money for pads from the family. Therefore, educating of high school student mothers about MHP should be a priority intervention area to eliminate the problem of menstrual hygiene among daughters. Furthermore, in order to improve the MHP among high school girls, further attention is needed to improving knowledge regarding menstruation among high school girls, encouraging high school girls' families to support their daughters by buying sanitary pads and promoting discussions among friends about menstrual hygiene. Schools need to focus on making the school environment conducive to managing menstrual hygiene by increasing awareness of safe MHP and providing adequate water/sanitation facilities.

Introduction

Adolescence is the period of transition from childhood to adulthood characterized by major physiological, mental, and social changes [1]. Beginning with menarche, menstruation (ordinarily referred to as having a menstrual period), is a major physiological change that adolescent girls must learn to manage, including healthy menstrual hygiene practices.

Adequate menstrual hygiene practices (MHPs) as defined by United Nations Children Fund (UNICEF) [2] consist of the following:

“Women and adolescent girls use a clean menstrual management material to absorb or collect menstrual blood that can be changed in privacy as often as necessary for the duration of menstrual periods, using soap and water for washing the body as required, and having access to safe and convenient facilities to dispose of used menstrual management materials.” [2].

MHPs have major health and socioeconomic implications, as indicated by their relationship with the United Nation (UN) Sustainable Development Goals (SDGs) [3]. Mostly the economic or financial status of a household determines the menstrual hygiene practice [4].

Despite the fact that menstruation is a natural process, it is linked with several misconceptions, negative attitudes, and punitive practices, all of which result in adverse health outcomes [5]. Poor MHPs influence the dignity, health, and well-being of schoolgirls in low- and middle-income countries, requiring well organized and effective water, sanitation, and hygiene (WASH) interventions [6]. Lack of good menstrual hygiene can have health consequences, including increased risk of reproductive and urinary tract infections [7-11].

Insufficient opportunities to practice healthy menstrual hygiene recently received attention as a barrier to education for girls in low- and middle-income countries [12]. Studies have noted that poor sanitation in schools and absence of access to good quality sanitary products can result in lower enrolment in schools, increased absenteeism, and dropout among girls [13-15]. The absence of sufficient water, sanitation, and hygiene make girls, as well as female instructors, miss school during menstruation [4]. An Indian study showed that nearly 50 per cent girls do not have access to a separate place for bathing or changing the menstrual absorbent [16]. A UNESCO report estimated that 1 in 10 girls in sub-Saharan Africa misses school during her menstrual cycle [17]. A study in Kenya showed that school girls had difficulties managing their menstrual periods at school, causing them to remain at home during their menstruation periods [8].

In Ethiopia, healthy menstrual practices are impeded by stigma and inadequate communication between girls and their mothers, other family members, and community members. Most girls do not converse with their mothers about menstrual hygiene due to fear of being punished and prevented from going to school [18]. Also existing sanitation conditions in many schools in Ethiopia are unsatisfactory, impacting girls’ education [19].

Studies in Ethiopia show that menstruation-related problems resulted in 43.0% - 54.5% of female students being absent from school for 1 to 4 days each menstrual period [20, 21]. In one study, 57.8% of girls reported that menstruation affected their academic performance negatively since menarche, 90.0% did not feel comfortable when they came to school during menstruation, and 20.2% missed exams that coincided with their menstruation days [21].

A qualitative study regarding school absenteeism and menstruation-related problems showed that 24.7% of school girls knew one or more girls who had dropped out of school and 25.4% reported they had heard about girls who had dropped out of school [21]. Although MHP is a pressing issue, not much attention has been given to this subject and studies on menstruation and its hygienic management as well as its influence on girls’ education in Ethiopia [22]. Therefore, this study was designed to address the level of menstrual hygiene practices and associated factors among high school girls in Dessie City, Amhara Region, northeastern Ethiopia. For this, two research questions were addressed.

What is the status of menstrual hygiene practices (MHP) among high school girls in Dessie City, Ethiopia?

What are the factors associated with good MHP among high school girls in Dessie City, Ethiopia?

Methods and materials

Study design and setting

We conducted a school-based cross-sectional study by using an interviewer- administered questionnaire and direct observations from January 27 to March 6, 2020 in five high schools of Dessie City. The interviews were conducted among female students and the observational study focused on the characteristics of the schools’ WASH facilities. The interviews aimed to capture female students’ experiences of menstruation and its hygienic management and the impact of menstruation on their school activities.

Dessie City is located in Amhara Regional State, 400 km north of Addis Ababa. The city is located at an altitude between 2,250 and 2,470 meters and covers an area of 15.1 km2, comprising five sub-cities. Dessie had an estimated population of 245,129 in 2017, 121,177 (49.4%) of them males and 123,952 (50.6%) females [23].

Dessie City has a total of 51 elementary and high schools, including both government and private schools; 20,062 (49.6%) female and 20,350 (50.4%) male students were registered in the 2019/20 academic year. There were 7,805 students in the 9th and 10th grades, of whom 3,759 (48.2%) were males and 4,046 (51.8%) females [24].

Source population, inclusion and exclusion criteria

The source population was all female students in Grades 9 and 10 in Dessie City high schools between January 27 and March 6, 2020. All 9th- and 10th-grade school girls of the selected high schools in Dessie City were included. Ninth and 10th-grade school girls who were absent during data collection were excluded from the study.

Sample size determination

The sample size was determined by using a single population proportion formula [25]

Z is the standard normal variable value at (1-α) % confidence level (α is 0.05 with 95%CI [confidence interval], Zα/2 = 1.96), p is the expected prevalence of good MHPs at 57.0% taken from a similar study in Adama, Ethiopia [26], a margin of error (w) 5.0% of and a design effect (D) of 1.5. The calculated sample sizes became 565. The source population was less than 10,000; therefore, after considering a correction formula, the sample size was 496. Then, to compensate for non-responses, 10.0% of the sample was added to the calculated sample size giving a final sample size of 546.

Sampling technique/procedure

A multistage sampling of the two-stage sampling design was used to select the 546 study participants. In the first stage, five schools (3 from public and 2 from private schools), namely Hotie, Kidame Gebeya, Memihr Akalewold, Catholic Kidanemihret, and Hope Enterprise were randomly selected by the lottery method. Using probability proportionate to size sampling method, the calculated sample of 546 (467 for public and 79 for private schools) was proportionally allocated to the randomly selected schools. Then each selected schools were stratified by grade level and the samples was proportionally allocated to the 9th and 10th grade levels. The proportionally allocated samples in the grade level were further proportionally allocated to each section of the respective grade level. During the second stage, study participants were selected using simple random sampling (lottery method) based on classroom attendance as the sampling frame.

Outcome and explanatory variables

The outcome variable was the practice of menstrual hygiene (good or poor). Explanatory variables were socio-demographic and economic factors; obstetric- and gynecological factors; knowledge, and source of related information; sanitary pad-related factors; and WASH-related factors.

Operational definitions

Menstrual hygiene practices

To measure the respondent’s MHPs, 11 closed-ended questions [21, 27, 28] were presented; each correct answer was assigned 1 point and each incorrect response was scored as 0.

Good or poor menstrual hygiene practices

Respondents who scored equal to or above the mean value (6–11) were considered as having good MHPs whereas a score of less than the mean value (0–5) was considered as poor MHPs.

Homemade absorbents were defined as noncommercial sanitary materials prepared by family members or girls themselves for the purpose of practicing menstrual hygiene.

Girl-friendly WASH facilities in school were identified by the following characteristics [29, 30]:

Gender-specific: well kept, safe, clean, and accessible sanitation facilities

Availability of uninterrupted water supply for 5–7 consecutive days

The continual availability of consumables, particularly soap, water, and culturally appropriate menstrual hygiene management materials

Waste disposal bins inside the latrines for discarded pads or other sanitary materials

Functional toilet—denoted toilet facilities that were not physically broken and could be used [29].

Partially functional toilet—denoted toilets that could be used but had some problems with the physical infrastructure requiring repairs (e.g., deterioration of concrete, loose doors, locks, deteriorating roof) [29].

Non-functional toilet indicated—toilets that were so badly damaged or deteriorated that they were no longer being used (squat plate broken, door missing, etc.).

A clean toilet–was a facility in which toilet compartments were not smelly and were without visible feces/urine, flies or litter in or around the facility.

A somewhat clean toilet had some smell and/or some sign of fecal matter/urine, flies and/or litter.

A dirty toilet had a strong smell and/or presence of fecal matter, urine, significant fly problem and/or a large amount of litter [29].

A well-lit toilet was a facility in which the amount of light was essentially the same inside as outside.

A somewhat dark toilet was a facility with less visibility inside than outside but enough light for girls to be able to look at their uniforms and tell if there is a blood stain.

A dark toilet was a facility that was very dark inside, making it difficult for girls to look at their uniforms and tell if there were stained.

Good or poor knowledge of MHPs- refers to students’ menstrual knowledge calculated from their responses to 12 knowledge-specific questions [21, 28]. Each correct response earned one point whereas any incorrect or “do not know” response received no point. Respondents who scored above the mean value (8–12) were considered to have good knowledge, whereas those who scored below the mean value (0–7) were classified as having poor knowledge.

Data collection tool and procedure

The data were collected using a structured, interviewer-administered pre-tested questionnaire adapted from relevant literature, tools prepared by UNICEF for assessing MHPs [21, 27, 28] and from other studies conducted in Ethiopia [21, 27, 28]. It was first prepared in English and then translated into Amharic. An observational checklist was also adapted from UNICEF and EMORY University [29] which was previously used to assess the school WASH facilities in Ethiopia [31].

Data collection was carried out by three female supervisors who are public health officers and five females who had BSc degrees in midwifery. Study participants were informed about the purpose of the study and data were collected after consent was obtained. The interviews were carried out in a private setting (girls’ club rooms and in quiet corners of the school compounds) to reduce social desirability bias. Before starting the interviews, students were oriented by the trained data collectors.

Direct observations, which assessed the suitability of the WASH facilities, were carried out by data collectors in collaboration with janitors, girls’ club leaders, unit leaders, and directors of the schools. Direct observations evaluated school WASH facilities in regard to their suitability for managing menses, specifically if they had girl-friendly WASH facilities, were gender-specific, well kept, safe, clean and accessible, provided uninterrupted water supply for 5–7 days, the continual availability of soap, water and culturally appropriate MHM materials and disposal waste bins inside the latrines for discarded pads and other sanitary materials [29, 30]. We used same supervisors for all the schools and the data collection were carried out at the same day by assigning one data collector for each school.

Data quality management

To ensure the validity of the data, the instrument was carefully developed and modified by the principal investigator based on the objectives of the research. Published literature was reviewed and tools prepared as recommended by UNICEF for assessing MHPs [21, 27–29]. The questionnaire was prepared in English and translated to the local language (Amharic) by the principal investigator and translated back to English by another translator to ensure consistency.

The questionnaire was pre-tested by interviewing a sample 10% of the total sample size from Nigus Michael High School prior to the actual data collection, with the aim of increasing the validity of the survey and ensuring the students understood the questions. Then, appropriate amendments were made in the tool based on the pretest and the findings were excluded from the main study.

To enhance data quality, supervisors and data collectors received one day of intensive training by the principal investigator on the objectives of the study, the data collection instruments, data collection procedures, how to approach study subjects, and how to ensure ethical practices in the field. The collected data were checked daily for completeness, reliability, and clarity by the principal investigator. In order to make the process convenient for respondents, a specific time frame for administration of the survey questionnaire was set, offering flexible times for respondents. When a study participant declined to respond to any specific questions at any time of the interview, the response was recorded as “missing.”

To verify the accuracy of data entries and minimize errors, a pre-arranged coding sheet was prepared before entering the questionnaire results into the EpiData Version 4.6. Also, after the completion of data entry, randomly selected 10% of the questionnaires were thoroughly checked for errors and inconsistencies. Using SPSS software Version 25.0, missing values and outliers were properly checked and managed. Following this, frequency distributions and cross-tabulations were examined for data cleaning before the statistical analysis was performed.

Data analysis

Data entry was done using EpiData Version 4.6 and exported to Statistical Package for the Social Sciences (SPSS) Version 25.0 for cleaning and analysis. Descriptive and analytical statistics were employed. Descriptive analysis was used to describe the major characteristics of the respondents. To measure the level of MHP, the first step was to record the response for each item as ‘1’ for a correct answer and ‘0’ for an incorrect response or do not know response; then, the sum score of practices was calculated (0–11 points). Second, the mean value was calculated and the mean score of 6 designated as the cut-off point. Respondents who scored 6–11 points were considered as having good practices and those with 0–5 points were classified as having poor practices of menstrual hygiene.

Multicollinearity of the independent variables was checked using the standard error (SE) and correlation matrix. The maximum value in SE was 0.37 and the correlation matrix showed that the Pearson correlation values for the variables were less than 0.7. These values indicate that there was no multicollinearity between the independent variables. The model fitness was checked using the Hosmer-Lemeshow test and the P-value was > 0.05, indicating good fit. The omnibus test of the model was < 0.0001 for all steps, indicating that our model was significantly different from the constant-only model, meaning there was a significant effect of the combined predictors on the outcome variable.

Bivariate and multivariable logistic regression analyses were carried out to identify the factors in good MHPs. Bivariate logistic regression analysis was done after dichotomizing the dependent variable by coding ‘1’ for good and ‘0’ for poor menstrual hygiene. The bivariate analysis identified candidate variables for the multivariable analysis. To control confounding, factors in the association variables with p < 0.25 were entered into the multivariable logistic regression analysis, enabling identification of factors associated with good MHPs. A p-value of 0.05 was used as the cut-off to declare statistical significance in the multivariable analysis. The strength of the association was measured by odds ratio with corresponding 95% confidence interval (CI).

Ethics approval and consent to participate

Ethical clearance for the study was obtained from the Institutional Ethical Review Committee of Wollo University, College of Medicine and Health Sciences. Moreover, a letter of approval and cooperation was secured and submitted to Dessie City Education Department. Participants’ involvement in the study was on a voluntary basis. Before the interviews, the objectives of the study were explained and written consent was obtained from all participants above the age of 18 years. For participants under 18 years of age, assent was obtained from their parents or guardians. Students were informed of their right to skip any question or withdraw their participation at any time. During data collection, personal identifiers such as name and phone numbers of the participants were not recorded to ensure confidentiality; instead, numbers were assigned for coding purposes. In line with ethical principles, 90 sanitary pads were distributed to girls who were using homemade absorbents or none at all, and to the study participants who complained about the unaffordability of pads. The sanitary pads distribution was performed after the interview completed.

Results

Socio-demographic and economic characteristics of the study participants

Of the total 546 study subjects, 536 completed the interview and responded to all questions (98.2% response rate). Most of the participants 457 (85.3%) went to government-owned schools. The participants’ ages were between 13 and 19 years, with a mean age of 15.7 and SD of ± 0.9 years. Of the total number of participants, 328 (61.2%) were Grade 9 students. Regarding religion, 294 (54.8%) participants were Muslims and 226 (42.2%) were Orthodox Christians.

About three-fourth of the respondents (n = 389, 72.6%) lived with both their mother and father. Regarding respondents’ maternal education, 139 (25.9%) had reached the secondary level. Most of the respondents’ mothers (n = 309, 57.7%) were housewives. More than half (n = 296, 55.2%) of the girls did not regularly receive pocket money from their families (Table 1).

Table 1

Socio-demographic and economic characteristics of high school girls of Dessie City, Amhara Region, northeastern Ethiopia, 27 January to 6 March 2020.

Variable	Category	Frequency (n = 536)	Percent (%)
School name	Hotie	204	38.1
	Kidame Gebeya	177	33.0
	Memhir Akalewold	76	14.2
	Catholic	66	12.3
	Hope Enterprise	13	2.4
School type	Public	457	85.3
	Private	79	14.7
Age (years)	13–15	239	44.6
	16–19	297	55.4
Grade	9th	328	61.2
	10th	208	38.8
Religion	Orthodox	226	42.2
	Muslim	294	54.8
	Protestant	15	2.8
	Other*	1	0.2
Residence	Urban	514	95.9
	Peri-urban¥	22	4.1
Marital status	Single	383	71.4
	Married	14	2.6
	Divorced	3	0.6
	No response	136	25.4
Lives with	Both parents	389	72.6
	Mother only	67	12.5
	Father only	11	2.1
	Relatives	49	9.1
	Alone	15	2.8
	Others**	5	0.9
Maternal educational status	Illiterate	74	13.8
	Read and write	99	18.5
	Primary	106	19.8
	Secondary	139	25.9
	College or above	118	22.0
Paternal educational status	Illiterate	33	6.2
	Read and write	85	15.8
	Primary	91	17.0
	Secondary	132	24.6
	College or above	195	36.4
Maternal occupation	Housewife	309	57.7
	Merchant	103	19.2
	Private organization employee	34	6.3
	Governmental employee	77	14.4
	Daily laborer	13	2.4
Paternal occupation	Government employee	182	34.0
	Private employee	63	11.7
	Daily laborer	30	5.6
	Self-employed	189	35.3
	Farmer	65	12.1
	Other***	7	1.3
Receives pocket money from family	Yes	240	44.8
	No	296	55.2

*Jehovah’s Witnesses Church

**Friends, brothers, sisters

***Religious leader.

¥All 22 students living in peri-urban areas attended school in urban areas of Dessie City. Dessie City administration consists of 6 peri-urban kebeles and 10 urban kebeles.

Gynecological characteristics

The timing of the onset of menses experienced by most of the respondents ranged from 11 to 16 years. Mean menarche age was 13.7 with SD of ± 0.92 years. In terms of regularity of menses, 464 (86.6%) of the respondents had a regular cycle of menses. Pain during menstruation was reported by 299 (55.8%) of the girls (Table 2).

Table 2

Gynecological characteristics of the high school girls of Dessie City, Amhara Region, northeastern Ethiopia, 27 January to 6 March 2020.

Variable	Category	Frequency (n = 536)	Percent (%)
Age at menarche (years)	< 12	43	8.0
	13–15	487	90.9
	16–19	6	1.1
Regularity of menses	Regular	464	86.6
	Irregular	72	13.4
Duration of menses flow	Less than 2 days	109	20.3
	3 to 7 days	399	74.5
	More than 7 days	28	5.2
Pain during menstruation	Yes	299	55.8
	No	237	44.2

Knowledge and awareness regarding menstruation

Most of the participants (n = 500, 93.3%) had information about menstruation before attaining menarche. Menstruation was said to be a normal physiological process and hormonal effect by 505 (94.2%) and 343 (64.0%) of the respondents, respectively. Three hundred four (56.7%) of the study subjects knew that the uterus is the source of menstrual blood and 416 (77.6%) said that menstruation is a lifelong process (Table 3).

Table 3

Knowledge about menstruation among high school girls of Dessie City, Amhara Region, northeastern Ethiopia, 27 January to 6 March 2020.

Variable	Category	Frequency (n = 536)	Percent (%)
Heard about menstruation before menarche	Yes	500	93.3
	No	36	6.7
What is menstruation?	Physiological process	505	94.2
	Pathological process	4	0.8
	Curse from God	14	2.6
	Do not know	13	2.4
Cause of menstruation	Hormones	343	64.0
	Curse from God	43	8.0
	Caused by disease	1	0.2
	Other*	1	0.2
	Do not know	148	27.6
Source of menstrual blood	Uterus	304	56.7
	Vagina	42	7.8
	Bladder	3	0.6
	Abdomen	10	1.9
	Other**	8	1.5
	Do not know	169	31.5
Duration of a normal menstrual cycle	Less than 21 days	114	21.3
	21 to 35 days	243	45.3
	More than 35 days	7	1.3
	Do not know	172	32.1
Normal menstrual bleeding duration	Less than 2 days	33	6.1
	2 to 7 days	411	76.7
	More than 7 days	37	6.9
	Do not know	55	10.3
Learned about menstrual hygiene in school	Yes	429	80.0
	No	107	20.0
There is foul odor during menstruation	Yes	357	66.6
	No	179	33.4
Menstrual blood is unhygienic	Yes	366	68.3
	No	170	31.7
Poor hygiene predisposes to infection	Yes	459	85.6
	No	77	14.4
Personal hygiene during menstruation reduces pain	Yes	380	70.9
	No	156	29.1
Menstruation is a lifelong process	No	120	22.4
	Yes	416	77.6

*Too much water and food

**Heart.

The mean score for the knowledge-based answers was 8.24, with SD of ±1.85. The overall knowledge status of the participants showed that 366 (68.3%) with 95% CI (64.2, 72.2%) and 170 (31.7%) with 95% CI (27.8, 35.8%) had good and poor knowledge, respectively.

Source of information and communication about menstruation

Less than half (n = 209, 41.8%) of the respondents got information about menarche from their mothers and 413 (77.1%) discussed menstrual hygiene with their friends. Regarding open communication about menstruation within the family, 163 (30.4%) of the girls had no communication with any family member. Menstruation was kept as a secret by 80 (49.1%), and 71 (43.6%) reported that it was considered to be a shameful issue in the family (Table 4).

Table 4

Source of information and communication about menstruation among high school girls of Dessie City, Amhara Region, northeastern Ethiopia, 27 January to 6 March 2020.

Variable	Category	Frequency (n)	Percent (%)
Source of awareness about menarche (n = 500)	Mother	209	41.8
	School (media, teacher)	106	21.2
	Friend	91	18.2
	Elder sister	76	15.2
	Television	11	2.2
	Health professional	5	1.0
	Father	2	0.4
Discuss menstrual hygiene with friends (n = 536)	Yes	413	77.1
	No	123	22.9
Communicate about menstruation with your family (n = 536)	Yes	373	69.6
	No	163	30.4
With whom do you frequently communicate? (n = 373)	Mother	227	60.8
	Father	6	1.6
	Sister	123	33.0
	Another member	17	4.6
Why no communication about menstruation in your family? (n = 163)	It is shameful	71	43.5
	It is kept as a secret	80	49.1
	Both shameful and kept secret	7	4.3
	Other*	5	3.1
Communicate about menstruation with teachers (n = 536)	Yes	182	34.0
	No	354	66.0

*Nobody cares about it.

Water, sanitation, and hygiene-related factors

Three-fourths 398 (74.2%) of the study participants stated that running water had been available at the school compound for between 5 and 7 days per week during the month preceding the survey; of the remaining, 91 (17.0%), 47 (8.8%) reported that water had been available for at-least 2 to 4 days per week and 1 to 2 days per week, respectively. Half 292 (54.5%) of the girls reported that they could use a latrine during break time and 244 (45.5%) reported that they used latrines as needed (Table 5).

Table 5

Water, sanitation, and hygiene-related issues among high schools of Dessie City, Amhara Region, northeastern Ethiopia, 27 January to 6 March 2020.

Variable	Category	Frequency (n = 536)	Percent (%)
Water source functionality in the school	5 to 7 days per week	398	74.2
	2 to 4 days per week	91	17.0
	Fewer than 2 days per week	47	8.8
When student is allowed to use the latrine	During breaks only	292	54.5
	Anytime	244	45.5

Practices of menstrual hygiene

Nearly all 517 (96.5%) study participants used some type of absorbent material during menstruation. The absorbent materials differed in type; 492 (95.2%) used commercially available sanitary pads, the remaining 25 (4.8%) used homemade absorbents. Among those who used reusable absorbents, 29 (93.5%) used soap and water for cleaning them and 18 (58.1%) dried them in sunlight. About one-thirds 175 (33.9%) changed absorbent material three times a day and 333 (62.1%) did not take a shower daily during menstruation (Table 6).

Table 6

Menstrual hygiene practices among high school girls in Dessie City, Amhara Region, northeastern Ethiopia, 27 January to 6 March 2020.

Variable	Category	Frequency (n)	Percent (%)
Use absorbent materials during menstruation (n = 536)	Yes	517	96.5
	No	19	3.5
Absorbent material used during the last 6 months (n = 517)	Commercially made sanitary pads	492	95.2
	Homemade absorbents	25	4.8
Materials used for washing reusable absorbent (n = 31)	Soap and water	29	93.5
	Water only	2	6.5
Drying of washed reusable absorbents (n = 31)	In the sunlight	18	58.1
	In the shade (indoors)	13	41.9
Frequency of changing absorbent material per day (n = 517)	Once	89	17.2
	Twice	224	43.3
	Three times	175	33.9
	More than three times	29	5.6
Cleaning genitalia during menstruation (n = 536)	Yes	481	89.7
	No	55	10.3
Material for cleaning genitals (n = 481)	Soap and water	169	35.1
	Water only	295	61.3
	Paper	17	3.6
Showering daily during menstruation (n = 536)	Yes	203	37.9
	No	333	62.1
Materials used for showering (n = 203)	Soap and water	167	82.3
	Water only	36	17.7
Where do you dispose used menstrual material (n = 517)	Open field	20	3.9
	Latrine	201	38.9
	Waste bin	295	57.0
	Other*	1	0.2
Dispose of pads by wrapping them in paper (n = 517)	Yes	398	77.0
	No	119	23.0

*Burying.

Responses on the overall practices showed that 289 (53.9%) of the participants practiced good menstrual hygiene (95% CI [49.6, 58.2%]), and the remaining 247 (46.1%) managed poorly (95% CI [41.8, 50.4%]).

Sanitary pad utilization and related issues

Forty-four (8.2%) out of 536 of the girls did not use commercially made sanitary pads. The main reason given for non-utilization was cost of the commercially available pads (79.5%), followed by their inaccessibility when needed (13.7%), shyness (4.5%), and difficulty disposing of them (2.2%). The majority of the participants 464 (86.6%) asked for money from their families for buying pads and 339 (73.1%) received money from their mothers (Table 7).

Table 7

Sanitary pad-related issues among high -school girls of Dessie City, Amhara Region, northeastern Ethiopia, 27 January to 6 March 2020.

Variable	Category	Frequency (n)	Percent (%)
Reason given for non-utilization of commercial sanitary pads (n = 44)	Cost	35	79.6
	Not available	6	13.7
	Difficulty in disposal	1	2.2
	Shyness	2	4.5
Asked for money from family for pad (n = 536)	Yes	464	86.6
	No	72	13.4
From whom do you get money for buying pads? (n = 464)	Mother	339	73.1
	Father	56	12.1
	Elder sister	51	11.0
	Brother	16	3.4
	Other*	2	0.4

*Niece.

Menstruation and missed school days

Menstrual hygiene-related school absenteeism during the five months preceding the study was reported at 1–2 days and 3–5 days by 57 (79.2%) and 15 (20.8%) girls, respectively. The mean value for missed school days was 1.81 with SD of ±0.98 days. Some of the reasons for absenteeism were dysmenorrhea, fear of staining clothes, and not having sanitary pads (Table 8).

Table 8

Reasons for menstruation-related school absenteeism among high school girls of Dessie City, Amhara Region, northeastern Ethiopia, 27 January to 6 March 2020.

Reason (N = 72)*, #	Frequency (n)	Percent (%)
Afraid of staining my clothes	17	23.6
Afraid of others making fun of me	11	15.3
A period can cause pain	31	43.1
Periods can make me feel uncomfortable	17	23.6
There is no place for girls to wash	9	12.5
There is no disposal system for pads	1	1.4
I do not have sanitary pads	9	12.5
There is no place for girls to change pads	7	9.7

*Out of 72 girls who have been reported school absenteeism, there were multiple responses for the reasons of menstruation-related school absenteeism. Thus, the sum of the percentage for the reasons was more than 100%.

#Fifty seven (79.2%) and 15 (20.8%) out of 72 girls reported 1–2 days and 3–5 days school absenteeism due to menstrual hygiene during the five months preceding the study, respectively.

Factors associated with the practice of menstrual hygiene

In the multivariable analysis, age, grade, maternal education, regularity of menses, knowledge, discussing menstrual hygiene with friends, asking for money from their family for pads were significantly associated with good MHPs. Girls 16–19 years old were 1.9 times more likely to have good MHPs than girls in the 13–15 years age group (AOR = 1.93, 95% CI: [1.22–3.06]). Grade 10 students were 1.9 times more likely to have good MHPs than Grade 9 students [AOR = (1.90, 95% CI: [1.18–3.07]). Girls whose mothers had primary, secondary, or college education were 3.72, 8.54, and 6.78 times more likely to have good MHPs (AOR = 3.72, 95% CI: [1.81–7.63]); AOR = 8.54, 95% CI: (4.18–17.44); AOR = 6.78, 95% CI: [3.28–14.02]), respectively (Table 9).

Table 9

Bivariate and multivariable logistic regression analysis for factors associated with menstrual hygienic practices among high school girls in Dessie City, northeastern Ethiopia, 27 January to 6 March 2020.

Variable	Menstrual hygiene practice status		COR (95% CI)	AOR (95% CI)
	Good (N = 289)	Poor (N = 247)
	n (%)	n (%)
Age (years)
13–15	104(36.0)	135(54.7)	Ref	Ref
16–19	185(64.0)	112(45.3)	2.14(1.50–3.01)	1.93(1.22–3.06)
Grade
9th	149(51.6)	179(72.5)	Ref	Ref
10th	140(48.4)	68(27.5)	2.47(1.72–3.55)	1.90(1.18–3.07)
Marital status
Single	207(71.6)	176(71.3)	Ref	Ref
Married	7(2.4)	10(4.0)	0.59(0.16–1.44)	0.38(0.10–1.46)
Not applicable	75(26.0)	61(24.7)	1.04(0.71–1.55)	1.02(0.65–1.61)
Live with
Both parents	218(75.4)	171(69.2)	Ref	Ref
Mother only	31(10.7)	36(14.6)	0.68(0.40–1.14)	0.58(0.32–1.04)
Father only	3(1.0)	8(3.2)	0.29(0.08–1.13)	0.51(0.11–2.35)
Relatives	23(8.0)	26(10.5)	0.69(0.38–1.26)	0.96(0.48–1.93)
Alone	14(4.8)	6(2.4)	2.16(0.68–6.89)	1.28(0.34–4.85)
Maternal education
Illiterate	16(5.5)	58(23.5)	Ref	Ref
Read and write	39(13.5)	60(24.3)	2.36(1.19–4.67)	1.89 (0.91–3.93)
Primary	57(19.7)	49(19.8)	4.22(2.15–8.26)	3.72 (1.81–7.63)
Secondary	97(33.6)	42(17.0)	8.37(4.32–16.22)	8.54(4.18–17.44)
College	80(27.7)	38(15.4)	7.63(3.89–14.99)	6.78 (3.28–14.02)
Paternal education
Illiterate	9(3.1)	24(9.7)	Ref	Ref
Read and write	39(13.5)	46(18.6)	2.26(0.94–5.43)	1.28(0.45–3.66)
Primary	43(14.9)	48(19.4)	2.39(1.00–5.70)	0.91(0.32–2.58)
Secondary	82(28.4)	50(20.3)	4.37(1.88–10.16)	0.99(0.35–2.79)
College	116(40.1)	79(32.0)	3.92(1.73–8.87)	0.71(0.25–2.01)
Maternal occupation
Housewife	154(53.3)	155(62.8)	Ref	Ref
Merchant	56(19.4)	47(19.0)	1.20(0.77–1.88)	1.06(0.61–1.82)
Private organization employee	18(6.2)	16(6.5)	1.13(0.56–2.30)	0.67(0.29–1.57)
Governmental employee	55(19.0)	22(8.9)	2.52(1.46–4.33)	1.18(0.58–2.39)
Daily laborer	6(2.1)	7(2.8)	0.86(0.28–2.63)	1.36(0.33–5.67)
Paternal occupation
Government employee	102(35.3)	80(32.4)	Ref	Ref
Private employee	39(13.5)	24(9.7)	1.28(0.71–2.29)	1.30(0.63–2.67)
Daily laborer	13(4.5)	17(6.9)	0.60(0.28–1.31)	0.96(0.35–2.68)
Self-employed	105(36.3)	84(34.0)	0.98(0.65–1.48)	1.03(0.60–1.77)
Farmer	28(9.7)	37(15.0)	0.59(0.34–1.05)	1.00(0.44–2.27)
Other	2(0.7)	5(2.0)	0.31(0.06–1.66)	0.34(0.04–2.64)
Regular menses
No	31(10.7)	41(16.6)	Ref	Ref
Yes	258(89.3)	206(83.4)	1.66(1.00–2.73)	1.85(1.03–3.32)
Duration of menses flow
< 2 days	60(20.8)	49(19.8)	1.89(0.81–4.42)	1.79(0.64–5.01)
3 to 7 days	218(75.4)	181(73.3)	1.86(0.85–4.08)	1.54(0.58–4.09)
>7 days	11(3.8)	17(6.9)	Ref	Ref
Knowledge status
Poor	68(23.5)	102(41.3)	Ref	Ref
Good	221(76.5)	145(58.7)	2.29(1.58–3.32)	2.02 (1.32–3.09)
Discuss menstrual hygiene with friends
No	52(18.0)	71(28.7)	Ref	Ref
Yes	237(82.0)	176(71.3)	1.84(1.22–2.76)	1.79 (1.12–2.86)
Communicate about menstruation with family
No	77(26.6)	86(34.8)	Ref	Ref
Yes	212(73.4)	161(65.2)	1.47(1.02–2.13)	1.19(0.76–1.85)
Water source functionality in the school
Fewer than 2 days per week	18(6.2)	29(11.7)	Ref	Ref
2 to 4 days per week	49(17.0)	42(17.0)	1.88(0.92–3.85)	1.41(0.61–3.23)
5 to 7 days per week	222(76.8)	176(71.3)	2.03(1.09–3.78)	1.62(0.78–3.36)
Ask for money for pads from family
No	24(8.3)	48(19.4)	Ref	Ref
Yes	265(91.7)	199(80.6)	2.66(1.58–4.50)	2.08 (1.15–3.78)

COR, crude odds ratio; AOR, adjusted odds ratio; CI, confidence interval; Ref, reference category.

The duration between two consecutive menstruation episodes was associated with the practice status. Girls who had regular menses were 1.9 times more likely to have good practices than their irregular counterparts (AOR = 1.85, 95% CI: [1.03–3.32]). High school girls with good knowledge of menses had 2.0 times better menstrual practice than those with poor knowledge (AOR = 2.02, 95% CI: [1.32–3.09]). Students who openly discussed menstrual hygiene with friends were 1.7 times more likely to practice good menstrual hygiene than those who did not discuss it (AOR = 1.79, 95% CI: [1.12–2.86]). Girls who asked for money to purchase pads were two times more likely to practice good menstrual hygiene than those who did not ask (AOR = 2.08, 95% CI: [1.15–3.78]) (Table 9).

Observational findings

Water observations

The main water source at all the schools was piped water in the school yard. Four out of five Schools, the main water sources were not functional during the survey. The water taps in every school were easily accessible even for the youngest children.

Sanitation observations

All five schools had gender-based toilets on their compounds. In terms of functionality, most toilets could be used, but there were problems with the physical infrastructure such as deterioration of concrete, missing doors, and deteriorating roofs. Thus, most of the toilets were partially functional and some were not functional. There was smell, signs of fecal matter and urine in most toilets, and some toilets had a strong smell and more visible signs of excreta. These toilets were classified as either somewhat clean or not clean. The interior of the toilets in most schools was fairly dark. If girls were able to look at their uniforms and tell if there was a bloodstain, those toilets were classified as being somewhat dark. Some toilets were too dark for girls to see if their uniforms were stained. None of the toilets had doors lockable from the inside and some had no door at all. There was a waste bin in most toilets but no anal cleaning materials were available. None of the toilets were accessible for disabled persons.

Hygiene observations

There were hand-washing facilities in all five schools. The locations of hand-washing facilities were a long way from the toilet blocks. Water and soap or ash were not available in any of the five schools during the observation period. Sanitary napkins were not available for emergency/accidental situations in any governmental school but were made available in the private school when needed. None of the schools had private facilities where girls could bathe or change sanitary pads.

Discussion

This school-based cross-sectional study examined selected socio-demographic, and gynecological variables, knowledge about menstruation, sources of information, communication, sanitary pad-related and WASH variables about MHPs. The study assessed whether menstrual hygiene was associated with the aforementioned factors. Our findings show that 53.9% (95%CI: 49.6, 58.2%) of the schoolgirls practiced good menstrual hygiene. Age 16–19 years, grade level of 10, maternal education (primary, secondary, and college), having regular menses, good knowledge, discussing menstrual hygiene with friends, and asking family for money for pads were significantly associated with good MHPs. Observational findings revealed that none of the five high schools had girl-friendly WASH facilities.

The prevalence of good MHPs in Dessie is similar to the 57.0% reported by a study in Adama City in Ethiopia [26], the (50.8%) reported in Ghana [32], and the 47.5% reported in West Bengal (India) [33]. Lower rates (39.7% and 35.4%) were reported in southern Ethiopia [27] and in Habru Town, Ethiopia [21], respectively. Possible reasons for the low number in Habru could be the measurement used to assess the practice status (a single question: sanitary pad utilization), a difference in the study period, and the fact that most of the study participants were from rural areas. The southern Ethiopia study had data discrepancies, mainly due to the participants’ poor knowledge of menstrual hygiene compared to the knowledge level in the current study.

A study in Egypt found that 90% of students had acceptable MHPs [34]. The reason for this high rate may be the relatively high socioeconomic level of participants, good WASH facilities, and the presence of bathing facilities in this industrial and agricultural community, all of which facilitated good MHPs. In Dessie, by contrast, our observations showed that schools had poor WASH services, toilets lacked doors and locks, and none of the schools had facilities for bathing. This situation was also found in Tanzania, where the lack of soap, hand washing facilities, emergency pads, or privacy were important determinants of poor MHPs [35].

The rate of changing pads with adequate frequency among girls in this study was similar with Ghanaian and West Bengal (India) studies, where the proportions were 45.2% and 42.3%, respectively [32, 33]. This low frequency may emanate from the high cost of pads, unawareness of the need to change pads frequently, failure of the schools to provide sanitary pads at least in emergencies, and lack of changing rooms. Higher rates (51.9% and 62.4%) of satisfactorily changing pads were reported by western and southern Ethiopian studies, respectively [27, 28]. These discrepancies may be due to the fact that most participants in some of these studies used homemade absorbents that were affordable and therefore more likely to be changed frequently than the commercial pads that were used by most girls in Dessie schools.

Among those who used reusable absorbents, 41.9% dried them without sunlight. This rate was comparable with those found in other Ethiopian studies, and the explanation could be that girls did not want to be seen handling absorbents outside [27, 28]. In a West Bengal (India) study, 72.2% of schoolgirls dried the reusable cloth without sunlight because of the underprivileged status of West Bengal (India) adolescents and their fear of being seen in public drying their reusable pads [33]. Another study in India indicated that rural participants dried their sanitary pads inside their houses because menstruation is considered impure and dirty, something that should be hidden due to taboos in that society [16, 36]. Washing reusable absorbents and drying them in sunlight may be a sustainable sanitary option because the sun is a natural sterilizer. To avoid contamination, the materials need to be stored in a clean, dry place for reuse.

In the current study, only 35.1% of participants used soap and water to clean their genitalia, a percentage lower than in similar studies in southern Ethiopia and West Bengal (India) [27, 33]. The discrepancy may be due to the unavailability of soap on school compounds and also lack of awareness in the current study. The present study showed that only 37.9% of participants took a daily shower during menstruation. Studies in southern Ethiopia and Ghana reported 56.4% and 94.4% daily showering, respectively [27, 32]. These discrepancies are possibly due to the warmer climate in Ghana than in Dessie and the requirement for frequent bathing among Muslims in Ghana, where almost all study participants were Muslims. Inadequate availability of water, lack of soap, and lack of showers for girls in the school compounds, as observed during our survey, may be additional reasons.

The findings showed that 57.1% of participants disposed of used menstrual materials in waste bins. Similar results were reported by other studies: 44.7% in Ethiopia and 43.3% in Nigeria [27, 37]. A descriptive study in Zambia showed that girls preferred to dispose used menstrual materials in pit latrines rather than waste bins for fear that they could be retrieved for witchcraft against them [38]. Improper disposal of pads can increase solid waste, and the practice of not wrapping the absorbent materials and disposing them in the toilet is unsightly and may create breeding places for insects and vermin, leading to the spread of disease [32, 37]. Our observations at one of the schools found that some used pads that were not wrapped in paper in waste bins.

Identifying factors associated with good MHPs was the second objective of the study. The prevalence of good menstrual hygiene in the 16-to-18 age group was higher than in the 13-to-15 age group. Similar associations of age and practices were reported from southern Ethiopia and Nigeria [27, 37]. Older girls have had more opportunities to obtain relevant information about menstrual hygiene and practicing safe hygiene during menstruation than younger girls [27]. Also, girls in our study had more experience regarding menarche and menstruation management compared to their counterparts.

In this study, Grade 10 students practiced better menstrual hygiene than Grade 9 students. This association is also supported by studies in Oromia Region in Ethiopia and in Indonesia [31, 39]. The possible explanation might be that older students can increase their awareness of menstruation and proper MHP through the school curriculum and informal communication among classmates.

Similarly, maternal educational status, with an academic completion of primary, secondary, or college levels, was associated with good menstrual hygiene. Various studies worldwide noted this association, including other studies in Ethiopia, Nigeria, and West Bengal (India) [16, 21, 28, 33, 37]. The reason may be that educated mothers are more familiar with good MHPs, are more willing to discuss menstruation with their daughters, provide sanitary pads, and insist that girls clean their genitalia during menstruation.

This study further discovered that study participants with a regular menstruation cycle had better MHPs than their irregular counterparts. The explanation may be that girls with irregular menses cannot anticipate their onset, and may therefore be less prepared for proper menstrual hygiene (i.e., they may not buy or obtain sanitary pads in time). The unpredictability of their menstruation may affect their psychological and emotional states, diminishing their motivation and commitment to engaging in good hygienic practices. We found no studies supporting this finding, but a study conducted in Bahir Dar University, Ethiopia showed an association of irregular menstruation with premenstrual syndrome [40]. This finding suggests that the regularity of menses associated with premenstrual syndrome, which affects a girl’s emotions, physical health, and behavior during certain days of the menstrual cycle before the onset of her menses and, in turn, influences her hygienic practices during menstruation.

Another finding of this study was that knowledge about menstruation helps girls maintain good menstrual hygiene. Study subjects with a good level of knowledge regarding menstruation and menstrual hygiene practiced safer menstrual hygiene than their counterparts. Studies conducted in southern Ethiopia, Nigeria and Indonesia also found that knowledge about menstruation was significantly associated with good MHPs [27, 31, 41]. Thus girls should have sufficient knowledge surrounding menstruation, the menstrual cycle, and menstrual hygiene even before menarche. The collective knowledge of age at menarche, menstrual cycle, and duration of menstrual flow in adolescents is useful for allaying fears and psychological trauma that may arise from an unexpected appearance of blood at menarche. Besides, sufficient knowledge of menstruation is expected to empower adolescents to distinguish between physiologic and abnormal uterine bleeding [16, 41]. Overall, better knowledge about menses and menstrual hygiene helps girls accept the natural phenomenon as a normal physiological process and follow proper hygienic practices.

Discussing menstrual hygiene with friends was another significant factor in this study. Study subjects who discussed menstrual hygiene with friends practiced safer menstrual hygiene than those who did not. An Indian study indicated that women who openly discussed menses experiences enhanced ones understanding of menstruation [16]. These discussions can raise the level of knowledge about menstrual hygiene, inform where to borrow sanitary pads when needed, enable them to share experiences and receive emotional support, decrease psychological stress, and boost confidence. Information from peers is simpler to obtain and process because peer conversations about a sensitive subject take place in a casual atmosphere that encourages girls to share their concerns without apprehension.

Moreover, good MHPs of the participants were associated with receiving a regular allowance from the family to purchase pads. Girls who received a regular allowance for sanitary products had better menstrual hygiene management than those who did not receive such an allowance. This finding is supported by studies in western Ethiopia and Ghana [29, 32]. The explanation for this may be that girls who receive money whenever they need it for purchasing sanitary pads regularly utilize sanitary pads, leading to safer practices of menstrual hygiene. Otherwise, they are forced to ask peers for pads [42].

Limitations of the study

Since the study used a cross-sectional study design, it is difficult to build up causal relationships between the outcome and exposure variables. Further studies are encouraged using randomized control trial to address this gap and also to identify socially acceptable, sustainable, affordable, and environmentally friendly sanitary pads. Our study used only quantitative data collection and analysis, and it is not triangulated with qualitative evidence. During data collection, using close–ended questions required study participants to select among the listed options in most questions, which may limit further options and more nuanced evaluation. To address this limitation, we explored different previous qualitative and quantitative studies and tried to include all possible options for each question.

Conclusions

We found that more than half of high school girls had good menstrual hygiene practices. Factors significantly associated with good menstrual hygiene practices include age (16–19 years), grade level, maternal education, regular menses, good knowledge regarding menstruation, discussing menstrual hygiene with friends and obtaining money for pads from the family. Schools should take the pivotal role towards the awareness creation of safe MHP. In addition, educating high school student’s mothers should be a prioritized intervention area to eliminate the problem of menstrual hygiene among daughters. Furthermore, in order to improve the MHP among high school girls, further attention is needed for increasing knowledge regarding menstruation among high school girls, encouraging high school girls’ family to support by buying sanitary pads and promoting discussion among friends about menstrual hygiene. This should include educating mothers about safe MHPs and encouraging them to teach their daughters about menstrual hygiene. Implementation of girl-friendly WASH services in all schools should be prioritized by programmers, managers, concerned stakeholders (governmental and non-governmental organizations) and policy makers.

English version of the questionnaire.

Survey of menstrual hygiene practices among high school girls in urban areas in northeastern Ethiopia: A neglected issue in water, sanitation, and hygiene research.

(DOCX)

Click here for additional data file.

Amharic (local language) version of the questionnaire.

Survey of menstrual hygiene practices among high school girls in urban areas in northeastern Ethiopia: A neglected issue in water, sanitation, and hygiene research.

(DOCX)

Click here for additional data file.

Minimal data for survey of menstrual hygiene practices among high school girls in urban areas in northeastern Ethiopia: A neglected issue in water, sanitation, and hygiene research.

(XLSX)

Click here for additional data file.

19 Jan 2021

PONE-D-20-39090

Menstrual Hygiene Practices among High School Girls in Urban Areas in Northeastern Ethiopia: A Neglected Issue in Water, Sanitation, and Hygiene Research

PLOS ONE

Dear Dr. Adane (PhD),

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Considering the reviewer comments and my own reading of the paper, I am going with a decision of major revision.  The paper needs to improve the Introduction and Background. Specifically, it needs to bring what the study is adding to the literature .  Explain the design of the study carefully addressing the reviewer 1 comments.  Refer to following articles while revising the paper and also to compare your results with other developing countries to enrich the discussion.

MALHOTRA A, GOLI S, COATES S, MOSQUERA-VASQUEZ MA. Factors associated with knowledge, attitudes, and hygiene practices during menstruation among adolescent girls in Uttar Pradesh. waterlines. 2016 Jul 1:277-305.

Goli S, Sharif N, Paul S, Salve PS. Geographical disparity and socio-demographic correlates of menstrual absorbent use in India: A cross-sectional study of girls aged 15–24 years. Children and Youth Services Review. 2020 Oct 1;117:105283.

Please submit your revised manuscript by Mar 05 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Srinivas Goli, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments:

Considering the reviewer comments and my own reading of the paper, I am going with a decision of major revision. The paper needs to improve the Introduction and Background. Specifically, it needs to bring what the study is adding to the literature . Explain the design of the study carefully addressing the reviewer 1 comments. Refer to following articles while revising the paper and also to compare your results with other developing countries to enrich the discussion.

MALHOTRA A, GOLI S, COATES S, MOSQUERA-VASQUEZ MA. Factors associated with knowledge, attitudes, and hygiene practices during menstruation among adolescent girls in Uttar Pradesh. waterlines. 2016 Jul 1:277-305.

Goli S, Sharif N, Paul S, Salve PS. Geographical disparity and socio-demographic correlates of menstrual absorbent use in India: A cross-sectional study of girls aged 15–24 years. Children and Youth Services Review. 2020 Oct 1;117:105283.

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.  If the original language is written in non-Latin characters, for example Amharic, Chinese, or Korean, please use a file format that ensures these characters are visible.

3. You indicated that you had ethical approval for your study. In your Methods section, please ensure you have also stated whether you obtained consent from parents or guardians of the minors (<18 years old) included in the study or whether the research ethics committee or IRB specifically waived the need for their consent.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors attempted to explore menstrual hygiene practices among high school girls in an urban setting of North-eastern Ethiopia. The study has several issues with the research design. The research design is not appropriate and, therefore, needs significant revision. How a study conducted in the urban area can have sample from rural areas. The authors have chosen five schools; however, the sample size from school varies drastically. What was the basis for choosing respondents from various schools? The formation of certain variables is not up to the mark. The close-ended questions that have limited options have the potential to include other options to choose from—thus limiting the study potential. The study failed to write a proper conclusion section. The study is full of limitations yet failed to include limitations in the text. The sampling procedure is confusing. The authors failed to write about sampling correctly. The study failed to impress, as it has a poor research design. Maybe the research design is not so poor- possibilities that authors failed to describe it adequately—suggested that the author describe the research design adequately. It is not clear whether the consent was written or verbal as information related to both modes of consent is given in text separately. Further, how distributing sanitary pads affected the response can be discussed. The article is written in standard English, however, failed to impress with its study design.

Reviewer #2: I have read the manuscript with interest. This article is interesting; however, it lacks conceptualization. I have some suggestion to make the article a better version.

Abstract:

1. Abstract seems clumsy. Background can be improved. The authors failed to build a proper rationale in the background section. The third line of the abstract shall not start with ‘but.’ Consider rewriting it.

2. The heading in the abstract – Methods, results, and Conclusion must be assigned to a different line. Currently, the heading is placed at the end of the sentence.

3. Why menstrual hygiene practice is higher among girls whose mothers had secondary level education than those whose mothers had only primary level education; when menstrual hygiene practice is lower among girls whose mothers had college-level education than those whose mothers had secondary level education. Need to elaborate on this finding.

4. The conclusion is erratic. Implications are not concrete. Moreover, keeping point number 3 cited above in mind- what level of education among mothers may be significant, as discussed in the study conclusion?

Declaration Section:

5. In the ethics statement, the authors stated that 90 disposable sanitary pads were distributed to those individuals who were menstruating and could not afford them. Did the authors ask the respondents about their ongoing menstruation? If yes, how authors concluded that they could not afford the sanitary pads? Further, what implications this may have on the study design as it is clear from the beginning that such respondents were poor (Since they cannot afford sanitary pads)? Moreover, the distribution of sanitary pads not influencing the respondents’ decision to participate in the study.

6. Authors stated that all relevant data are within the manuscript and its supporting files. However, I could not find any relevant data associated with this submission.

Manuscript:

7. Line number 94-95; the reference in the study context is a bit old. Try citing the latest reference and current prevalence.

8. Authors have used ‘good menstrual hygiene practices’ and ‘menstrual hygiene practices’ interchangeably, which is confusing.

9. Introduction is nicely articulated; however, it needs a bit of editing for ease of flow.

10. Authors have mentioned in the abstract as well as in the manuscript text that the questionnaire was pre-tested. However, the information regarding the same is not given in full. When was it tested? Under whom guidance it was tested? The population upon which it was tested? - and other such details are missing.

11. Did authors use 5 percent of margin of error conveniently or reached after consensus among various authors or some other relevant authority?

12. The study was conducted in an urban area of Dessie city. However, to calculate the sample size, the prevalence used was that of Adama town. It may be highly likely that menstrual hygiene practices' prevalence may be contrasting in these two cities.

13. Representation of ‘z’ in the sample size formula needs to be written in full for a general understanding of the readers.

14. How do authors reach the distribution of sample size between public (467) and private (79) schools? It is stated that distribution was proportionally done? Please elaborate on the proportion used.

15. The sampling procedure is confusing. Consider presenting it through a flow chart. The authors stated that it was a two-stage sampling procedure; however, it is confusing in detailed text.

16. There is a contradiction in the statement by the authors. Somewhere, written consent was used, and at some places, verbal consent (Line- 199) was used in the text. Was the consent written or verbal or a mix of both- clarify. If verbal, how does the authenticity of the same can be produced?

17. It is suggested to give the number of field investigators used for data collection. Were the same set of investigators used for all the schools, or different schools were covered by different investigators? Data collection was carried out simultaneously in various schools, or was it collected one after the other?

18. Direct observations were made to assess the suitability of the WASH facilities (Line- 201-202). How do investigators conclude the suitability of WASH facilities?

19. Line number 206-207. Unpublished and published research was reviewed. Kindly elaborate on what kind of unpublished literature?

20. It is suggested to give the equation for the statistics used in the study.

21. The study design is having severe issues. The number of respondents varies from 13 students in a school to 204 students from other school. Moreover, students were chosen from only two classes- 9th and 10th standard- Then, under what circumstances, it is possible that the age of the respondents varies from 13-19 years. It will be better if age-wise classification is presented in table 1.

22. Study title clearly state that the study is conducted in urban area. Also, the methodology states the same. Then how is it possible to have a rural sample in the study? Are these respondents traveling from rural areas to urban schools?

23. Authors stated that the response rate was around 98 percent. The study says that 98 percent of the respondents responded to all the questions. If so, how can 25 percent of the respondents have not recorded their answer (no response) for the marital status category? Is it like 98 percent agreed to record their responses and then left unanswered questions leading to an incomplete questionnaire?

24. Table 3- option related to What is menstruation and other such questions may also have various other options than provided in the questionnaire. The questions asked might have included other categories also.

25. Table 4- why sample is different for each variable?

26. Table 4- Source of awareness about menarche- the total adds to 500, and it was stated that n is 500. I wonder that the sources cannot be single for such information. Girls may receive information about menarche from both parents as well as their friends simultaneously and also from the media. Single source of information is undermining the study potential.

27. Table 4- With whom do you communicate frequently?- The question is confusing- communication for what?

28. Table 5- water source functionality in the school- It is confusing how water functionality can be fewer than two days or 2-4 days in a school. The water functionality might be regular, and only in case of some service disruption, the water functionality in the school may be an issue.

29. Table 5- When student is allowed to use latrine- The question has limited options. It is not possible that every time a respondent may be allowed to go to the latrine either in the break. It may also depend upon the ongoing situation/lecture importance in school. Sometimes, teachers may or may not allow students to go to latrine. So, the options are not correct.

30. Table 6- result found that 517 (96.5%) of the respondent use absorbent material. Moreover, all of these respondents change their absorbent at least once daily. At other places, the authors noted that they distributed certain sanitary pads as respondents could not afford one. How can this be the case when 96 percent of the respondent are using and changing their absorbents daily?

31. In the odds ratio table 9- the age-group can be divided into two groups only; 13-15 and remaining.

32. What is not applicable category in marital status?

33. Why father’s occupation is not significant in the odds ratio in table 9. It is understood that if a father is working, it is more likely that a girl may afford sanitary napkin. Elaborate on this finding in the context of this study.

34. Water source functionality in the school is not significant in the odds ratio model- elaborate on this finding.

35. The authors shall include the strength and limitation of this study.

36. Conclusions are erratic. The study did not include the disabled; however, in the conclusion section, the authors propose policies for the disabled.

37. It Seems that conclusion is not relevant to the study objective and just written haphazardly after going through certain available literature.

38. Please define what is environmental friendly sanitary napkin as discussed in conclusion section and why authors are proposing that special attention is to be given to lower grade levels students when the study population include 9th and 10th grade students?

39. On the other hand, the use of drugs for irregular menses, especially contraceptive pills, may currently not be feasible in Ethiopia due to negative cultural attitudes of parents toward their use- How does this sentence used in conclusion section is relevant to the study context?

Reviewer #3: The paper on “Menstrual Hygiene Practices among High School Girls in Urban Areas in Northeastern Ethiopia: A Neglected Issue in Water, Sanitation, and Hygiene Research” is well written paper by the respective authors. The topic is of the prime importance in the field of public health domain and can be published after minor revisions.

Abstract

The abstract is well written

Introduction

Overall the introduction is well-written and covered all domains that need to be highlighted in the Introduction. I request authors to please write hypothesis in the last para of the Introduction.

Methods and materials

The section is very well explained and detailed write-up is provided for the same.

Results

Well written.

Please do not highlight the text in page -18 line 357.

Discussion

All the findings are well discussed in the respective section.

Just a small suggestion where ever “West Bengal” is being written, please write in brackets (India) as far as I know it’s the same region which is from India.

I request the authors to write one para (3-4 lines) as limitations and strength of the study. Please write that in the end of the discussion .

References

Some references do not have publisher’s name. Please do amend those references.

Tables

Tables are well structured.

The highlighted estimates are not needed. I mean do not highlight anything in the tables.

COR and AOR full forms can be written in the end of the table (Table-9)

Overall the paper is well written and conceptualized. Authors have given each and details regarding the research carried out.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

23 Feb 2021

Date: Feb 21 2021

Manuscript ID: PONE-D-20-39090

Menstrual Hygiene Practices among High School Girls in Urban Areas in Northeastern Ethiopia: A Neglected Issue in Water, Sanitation, and Hygiene Research

Corresponding authors: Metadel Adane (PhD)

Dear Dr. Srinivas Goli, (Ph.D)

Academic Editor

PLOS ONE

Thank you for your letter dated 19 Jan 2021 with a decision of revision required. We were pleased to know that our manuscript was considered potentially acceptable for publication in PLoS ONE, subject to adequate revision as requested by the reviewers, academic editor and the journal. Based on the instructions provided in your letter, we uploaded the file of the rebuttal letter; the marked up copy of the revised manuscript highlighting the changes made in the original submitted version and the clean copy of the revised manuscript.

We have revised the manuscript by modifying the abstract, introduction, methods, results, discussion and other sections, based on the comments made by the reviewers and using the journal guidelines. Accordingly, we have marked in red color all the changes made during the revision process. Appended to this letter is our point-by-point response (rebuttal letter) to the comments made by the reviewers.

We agree with almost all the comments/questions raised by the reviewers and provided justification for disagreeing with some of them. We would like to take this opportunity to express our thanks to the reviewers for their valuable comments and to thank you for allowing us to resubmit a revision of the manuscript.

I hope that the revised manuscript is accepted for publication in PLoS ONE.

Sincerely yours,

Metadel Adane (PhD)

Response to the Journal Requirements Questions

Question #1: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response: Thank you for this remark. We re-formatted the revised manuscript using the PLoS ONE format guidelines. The whole content of the manuscript, including the abstract, introduction, methods, discussion and reference are formatted using the guidelines (please see the revised version for each section).

Question #2: Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Response: We provided the questionnaire in English version and original language (Amharic) and as supporting information S II and S II, respectively.

Question #3: You indicated that you had ethical approval for your study. In your Methods section, please ensure you have also stated whether you obtained consent from parents or guardians of the minors (<18 years old) included in the study or whether the research ethics committee or IRB specifically waived the need for their consent.

Response: Written consent was obtained from the participants age 18 and above and for study participants whose age were less than 18 years, parental assent consent was obtained. This also clearly added to revised version of the manuscript.

Response to Reviewer Comments

Reviewer #1

The authors attempted to explore menstrual hygiene practices among high school girls in an urban setting of North-eastern Ethiopia. The study has several issues with the research design. The research design is not appropriate and, therefore, needs significant revision. How a study conducted in the urban area can have sample from rural areas. The authors have chosen five schools; however, the sample size from school varies drastically. What was the basis for choosing respondents from various schools? The formation of certain variables is not up to the mark. The close-ended questions that have limited options have the potential to include other options to choose from—thus limiting the study potential. The study failed to write a proper conclusion section. The study is full of limitations yet failed to include limitations in the text. The sampling procedure is confusing. The authors failed to write about sampling correctly. The study failed to impress, as it has a poor research design. Maybe the research design is not so poor- possibilities that authors failed to describe it adequately—suggested that the author describe the research design adequately. It is not clear whether the consent was written or verbal as information related to both modes of consent is given in text separately. Further, how distributing sanitary pads affected the response can be discussed. The article is written in standard English, however, failed to impress with its study design.

Response: Dear reviewer, we really appreciate your comments on the content of our paper. The comments are duly acknowledged and accepted.

The study was conducted in the urban settings, where all schools situated in the city. However, for your concern of how the study was conducted, all peri-urban areas have no schools of their own. A small fraction of the study participant in our study lived in peri-urban areas attending classes in the urban schools. They travel up to 10km each day. So we did the revision in Table 1. Both urban and peri-urban areas are under Dessie City administration.

Twenty-two study participants (4.1%) lived in the peri-urban and 95.9% areas of Dessie. Thank you for your key comment. In the footnote of Table 1, we noted this issue for clarification.

The five schools were randomly selected among the 13 schools to meet the probability sampling criteria. The number off enrolled students in the 5 selected schools varied from 835 to 53 which leads to enormous variation in the sample size allocation (We provided the details of sample size allocation among schools and their grades in Fig 1 and supporting information SI I files under Sampling technique/procedure (Please see the Methods section on page 8 and Fig 1 and S I.). Due to the tuition fee in private schools, most students attend classes in public schools. This also leads to enormous variation in the sample size allocation.

The study variables were selected after reviewing the literature. As we noted in the Methods section under the Data collection tool and procedure, the data were collected using a structured, interviewer-administered pre-tested questionnaire adapted from different relevant publications and tools prepared by UNICEF for assessing MHPs (Belayneh and Mekuriaw, 2019, Tegegne and Sisay, 2014, Upashe et al., 2015). The questionnaire was adapted from other studies conducted in Ethiopia (Belayneh and Mekuriaw, 2019, Tegegne and Sisay, 2014, Upashe et al., 2015).

Being exclusively a quantitative study was one of our limitations; the close-ended questions have limited options. Thus we added possible options in the questions by reviewing different literatures (Please see the questionnaire as supporting information SI II and SI III). The conclusion part has been modified and incorporated in the revised version of the manuscript (See the conclusion in the abstract and below the discussion) and the limitations of the study also revised accordingly. We simplify the sampling procedure and hope it will clear the confusion. We also adequately describe the research design on the revised version.

Written consent was obtained from all participants above the age of 18 years. For participants under 18 years of age, assent was obtained from their parents or guardians (See in page 14 from lines 285 to 287). Since the distribution of the sanitary pads was done after the interviews, it had no effect on their responses.

Overall, your comments are well taken. Thank you.

Reviewer # 2

Abstract:

Question #1: - Abstract seems clumsy. Background can be improved. The authors failed to build a proper rationale in the background section. The third line of the abstract shall not start with “but”. ‘Consider rewriting it.

Response: Thank you for your comment, we modified the background section based on your comment. Please see in page 2 and 3 and also from lines 23 to 25 for the background improvemnt.

Question #2: - The heading in the abstract – Methods, Results, and Conclusion must be assigned to a different line. Currently, the heading is placed at the end of the sentence.

Response: Yes, the heading for each section has its own line number (please see the revised version of the abstract and heading and sub-heading of the manuscript.

Question #3: - Why menstrual hygiene practice is higher among girls whose mothers had secondary level education than those whose mothers had only primary level education; when menstrual hygiene practice is lower among girls whose mothers had college-level education than those whose mothers had secondary level education. Need to elaborate on this finding.

Response: This might be due to the fact that those college level educated mothers had less time to follow up with their daughters due to lack of time, whereas secondary level educated mothers ware mostly housewives who tended to advice their daughters. As indicated in our study, having literate mothers had a positive implication on girl’s menstrual hygiene practice. The discrepancies among literacy levels may emanate from the proportion of time mothers spent in the house versus time spent on to work. For example, mothers who had college level education spent more time in governmental office than at home. This effects the contact time of daughter-mother. However, as you can see in Table 9, our findings showed that both secondary level and college level education of mothers had positive implications for good MHP compared to illiterate mothers.

Question #4: - The conclusion is erratic. Implications are not concrete. Moreover, keeping point number 3 cited above in mind- what level of education among mothers may be significant, as discussed in the study conclusion?

Response: Thank you for your comment. The conclusion part has been modified and incorporated in the revised version of the manuscript. As indicated in our study, overall, literate mothers had a positive influence on girl’s menstrual hygiene practices. The discrepancies among the literacy level may emanate from spending much time in the house over spending much time on to work. For example mothers who had college level education mostly spent their time in governmental office than their home. This consequently have an effect on the contact time of daughter-mother.

Declaration Section:

Question #5: - In the ethics statement, the authors stated that 90 disposable sanitary pads were distributed to those individuals who were menstruating and could not afford them. Did the authors ask the respondents about their ongoing menstruation? If yes, how authors concluded that they could not afford the sanitary pads? Further, what implications this may have on the study design as it is clear from the beginning that such respondents were poor (Since they cannot afford sanitary pads)? Moreover, the distribution of sanitary pads not influencing the respondents‘ decision to participate in the study.

Response: We appreciate your comment. The distribution of the sanitary pads was done to meet ethical criteria. After the completion of each interview, the interviewer asked whether a study participant was on menses or not? Then yes and no access for sanitary pad, the pad will be dispensed. Since the dispensing done after the interview, it has nothing to do with their participation. Due to funding limitation we could give pads to only 90 girls.

Question #6: - Authors stated that all relevant data are within the manuscript and its supporting files. However, I could not find any relevant data associated with this submission.

Response: Sorry for not attaching the data set during the original submission. We attached the data as supporting information (See S IV).

Manuscript:

Question #7: - Line number 94-95; the reference in the study context is a bit old. Try citing the latest reference and current prevalence.

Response: the reference has been updated.

Question #8: - Authors have used good menstrual hygiene practices ‘and ‗menstrual hygiene practices‘ interchangeably, which is confusing.

Response: those interchangeably used words have been corrected and please see the revised version of the manuscript.

Question #9: - Introduction is nicely articulated; however, it needs a bit of editing for ease of flow.

Response: we modified the introduction part (See the revised version of the introduction).

Question #10: - Authors have mentioned in the abstract as well as in the manuscript text that the questionnaire was pre-tested. However, the information regarding the same is not given in full. When was it tested? Under whom guidance it was tested? The population upon which it was tested? - and other such details are missing.

Response: all those missed data have been add to the edited version

Question #11: - Did authors use 5 percent of margin of error conveniently or reached after consensus among various authors or some other relevant authority?

Response: We considered a prevalence of good MHP about 57% based on other studies and during the prevalence from 50% and around 50-60%; using of 5% margin of error is recommended for most epidemiological research. However, if the prevalence is about 40%, margin of error is 0.4, when around 30% margin of error is 0.3, when around 20%, margin of error 0.2 and when the prevalence around 10% margin of 0.1 is the most common approaches need for sample size determination.

Question #12: - The study was conducted in an urban area of Dessie City. However, to calculate the sample size, the prevalence used was that of Adama town. It may be highly likely that menstrual hygiene practices' prevalence may be contrasting in these two cities.

Response: Thank you for your concern. During the previous study, where the prevalence taken, Adama were considered as a town. But currently Dessie and Adama are registered as cities in Ethiopia, with more than 100,000 population each. They also share common sociocultural settings (i.e. religion, community life style etc.).

Question #13: - Representation of ‗z‘ in the sample size formula needs to be written in full for a general understanding of the readers.

Response: Thank you for this key comment. It is re-written and see in page 7 form lines 140.

Question #14: - How do authors reach the distribution of sample size between public (467) and private (79) schools? It is stated that distribution was proportionally done? Please elaborate on the proportion used.

Response: The Five schools randomly selected out of 13 schools to meet probability sampling requirements. Of the five schools, 2 of them were private and 3 schools were public. Most students attend classes in tuition-free public schools. So the actual student numbers in the public overweighs the private one. The proportional allocation of samples to each grade and their respective sections has been presented in table; please find in supporting files and figures (SI 1 and Fig 1).

Question #15: - The sampling procedure is confusing. Consider presenting it through a flow chart. The authors stated that it was a two-stage sampling procedure; however, it is confusing in detailed text.

Response: Sorry for the confusion, the sampling procedure modified and presented and attached the flow in Fig. 1 and SI I.

Question #16: - There is a contradiction in the statement by the authors. Somewhere, written consent was used, and at some places, verbal consent (Line- 199) was used in the text. Was the consent written or verbal or a mix of both- clarify. If verbal, how does the authenticity of the same can be produced?

Response: Written consent was obtained from all participants whose age 18 years and above. For participants under 18 years of age, assent obtained from their parents or guardians, in addition to the guardians/parents’ assent was obtained from the participant themselves (See the revised version of the ethical issues in page 14 from lines 284 to 287).

Question #17: - It is suggested to give the number of field investigators used for data collection. Were the same sets of investigators used for all the schools, or different schools were covered by different investigators? Data collection was carried out simultaneously in various schools, or was it collected one after the other?

Response: Data collection was carried out by 3 supervisors, 5 female midwifery professional data collectors, and the principal investigator. We used the same supervisors for all the schools and the data collection was carried out the same day by assigning one data collector for each school for preventing information flow among students. (See the revised version in page 11 from lines 226 to 228).

Question #18: - Direct observations were made to assess the suitability of the WASH facilities (Line- 201-202). How do investigators conclude the suitability of WASH facilities?

Response: An observational checklist by UNICEF and EMORY University clearly stipulated “when to say a school is convenient to manage menses”

Girl-friendly WASH facilities in school includes:

• Gender-specific, well kept, safe, clean and accessible sanitation facilities.

• Availability of uninterrupted water supply for 5-7 days.

• The continual availability of consumables, with particular attention on soap, water and culturally appropriate MHM materials.

• Disposal waste bins inside the latrines for discarded pads or their sanitary materials.

Please the revised version in the operational definitions of page 9 from 175 to 187-

Question #19: - Line number 206-207. Unpublished and published research was reviewed. Kindly elaborate on what kind of unpublished literature?

Response: Unpublished literature included mostly government reports about MHP by the Ethiopian Ministry of Health and NGOs working on MHP. However, since our tool was developed based on published evidence, we deleted unpublished. Thank for this comment.

Question #20: - It is suggested to give the equation for the statistics used in the study.

Response: We used binary logistic regression model and providing the formula of the model is not as such relevant for readers. In public health research, providing model education is not common, however, it is common for research by statisticians and math’s experts. Nevertheless, we can provide the formula by the next round of revision, if necessary.

Question #21: - The study design is having severe issues. The number of respondents varies from 13 students in a school to 204 students from other school. Moreover, students were chosen from only two classes- 9th and 10th standard- Then, under what circumstances, it is possible that the age of the respondents varies from 13-19 years. It will be better if age-wise classification is presented in table 1.

Response: We appreciate your concern, the number of respondents’ variation was explained in the above (#14) section. Due to tuition fee in private schools, most students attend classes in the public ones. So the actual student numbers in the public overweighs the private one. This leads to enormous variation in the sample size allocation. The two extreme ages (13 & 19) only represent only 2.9 % from all respondents in this age group. Most of the students category (80.8%) were 15-16 years old. The small proportion of extreme values was the result of;

A. starting school at early age

B. starting school at late age

C. students who failed the grade 10 national examination had to repeat classes.

Question #22: - Study title clearly state that the study is conducted in urban area. Also, the methodology states the same. Then how is it possible to have a rural sample in the study? Are these respondents traveling from rural areas to urban schools?

Response: Thank you again for this comment. Of course they are travelling from peri-urban areas to urban schools. They travel up to 10 KM from their homes in peri-urban areas to schools in the city each day. We explained this in the footnote of Table 1. We changed rural to peri-urban since Dessie city administration consists of peri-urban areas and urban areas (See Table 1).

Question #23: - Authors stated that the response rate was around 98 percent. The study says that 98 percent of the respondents responded to all the questions. If so, how can 25 percent of the respondents have not recorded their answer (no response) for the marital status category? Is it like 98 percent agreed to record their responses and then left unanswered questions leading to an incomplete questionnaire?

Response: 25% of the students were afraid and shy to state their marital status due to complicated, broken relationships or unwanted marriages. So in order not to make the interview process tense, we added the option afraid to state. The amendment of the option was done after we performed the pre-test and by reviewed the literature. Thus we accepted the response being ‘afraid to state or mention” as an option for marital status.

Question #24: - Table 3- option related to What is menstruation and other such questions may also have various other options than provided in the questionnaire. The questions asked might have included other categories also.

Response: One of our study limitation was being a quantitative study only. Consequently close–ended questions forced them to select the options available. But to cope this we explored different previous both qualitative and quantitative studies and we tried to include all possible options for each questions.

Question #25: - Table 4- why sample is different for each variable?

Response: Some questions depend on the previous question responses (i.e. if a sample responds “no” for the question of “whether she heard about menses before menarche?” the sample will not be able to answer the “what was your source of awareness”. all other sample variations happen with the same phenomena.

Question #26: - Table 4- Source of awareness about menarche- the total adds to 500, and it was stated that n is 500. I wonder that the sources cannot be single for such information. Girls may receive information about menarche from both parents as well as their friends simultaneously and also from the media. Single source of information is undermining the study potential.

Response: Actually they may hear information from different source but for easy of recommendation, it’s better if we get the very first and most frequent source, despite of the likelihood of multiple sources

Question #27: - Table 4- With whom do you communicate frequently?- The question is confusing- communication for what?

Response: The data collection was interviewer- based, hence they asked the interviewees “with whom do you frequently communicate in your family?” Also the question comes after “do you communicate about menstruation with your family?”. Thus confusion may be minimal with the use of trained data collectors.

Question #28: - Table 5- water source functionality in the school- It is confusing how water functionality can be fewer than two days or 2-4 days in a school. The water functionality might be regular, and only in case of some service disruption, the water functionality in the school may be an issue.

Response: Water source functionality was assessed based on personal/sample experience which helped us to evaluate the effect of WASH facilities on to a student. Most of the students (74%) stated that water was available 5-7 day, (26%) of the students experience shortage of water. The possible reasons for this could be,

• During their search for water, other than at break time, they may get nothing. Our observational findings strengthen the idea.

• During break-time, they may reach the water points when the reservoir was empty.

Question #29: - Table 5- When student is allowed to use latrine- The question has limited options. It is not possible that every time a respondent may be allowed to go to the latrine either in the break. It may also depend upon the ongoing situation/lecture importance in school. Sometimes, teachers may or may not allow students to go to latrine. So, the options are not correct.

Response: Irrespective of ongoing learning/lectures, a girl should be allowed to visit a toilet especially during her menses. Unless otherwise she may be unable to attend her class properly, her cloths may stain with blood or she may need to change her pads. Forcing a girl to go to toilet at specific times may have thus effect proper menstrual hygiene practice.

Question #30: - Result found that 517 (96.5%) of the respondent use absorbent material. Moreover, all of these respondents change their absorbent at least once daily. At other places, the authors noted that they distributed certain sanitary pads as respondents could not afford

one. How can this be the case when 96 percent of the respondent are using and changing their absorbents daily?

Response: As we previously responded, the distribution of the sanitary pads was done for the study participants who had no sanitary pads for alternative use or were unable to afford them during menstruation. Furthermore, 44 study participants were either using homemade absorbents or not using any at all, which indicates a need for sanitary pads, which we provided. Besides the remaining 46 pads were given to participants who complained about the cost of pads. We explained this on the ethical issues page 14 from lines 290 to 293.

Question #31: - In the odds ratio table 9- the age-group can be divided into two groups only; 13-15 and remaining.

Response: the age classification was done after reviewing similar literature and for ease of discussion and recommendation purpose only. Under the current age category, we can discuss, compare and contrast with similar studies as you can see in the discussion section. Since in the multivariable logistic regression model, the age category was significantly associated good MHP, we kept that category within the paper. If we change the category as you suggested, the data analysis would have to be done again.

Question #32: - What is not applicable category in marital status?

Response: 25% of the students were afraid (shy) to state their marital status due to complicated, broken relationships or unwanted marriages. So in order not to make the interview process tense, we added the option being “afraid” after we performed pre-testing and reviewing previous literature. Thus we considered being afraid as an a not applicable option for marital status. Make sure this is correctly worded

Question #33: - Why father‘s occupation is not significant in the odds ratio in table 9. It is understood that if a father is working, it is more likely that a girl may afford sanitary napkin. Elaborate on this finding in the context of this study.

Response: Thank you for your concern. Theoretically, a father who has income would buy sanitary pads. But in reality, this depends in Ethiopia on:

• the father’s knowledge of to menses (i.e. at least menarche age)

• the cost of sanitary pads

• Periodically allocated money for groceries may not include sanitary pads and also depends on the mother’s use of money.

Question #34: - Water source functionality in the school is not significant in the odds ratio model- elaborate on this finding.

Response: Water source functionality may have an effect on to MHP but in our study it was not significant. This may be because girls may cope with water the shortage (i.e. they may used plastic bottles filled with water at periods of water unavailability). Furthermore, the number of water sources for each school is the same, which did not show variation in the data within the school

Question #35: - The authors shall include the strength and limitation of this study.

Response: We thank for this pertinent comment. The strength and limitations have been included in the edited version of the manuscript (See the revised version of the manuscript in page 25- from lines 523 to 531).

Question #36: - Conclusions are erratic. The study did not include the disabled; however, in the conclusion section, the authors propose policies for the disabled.

Response: since we did not use purposive sampling (we used probability sampling) the disabled were missed by chance. But when we reviewed the UNICEF/EMORY university girl’s friendly WASH facilities checklist, WASH services in all schools should have access for the disabled. Our observational studies found that the WASH facilities were not considering disabled students. To avoid confusion for readers, we avoid the recommendation about the disabled although our observational data showed that no school has facilities for the disabled. Please see the revised version of the conclusion and the recommendation, which is updated as per your point of view.

Question #37: - It Seems that conclusion is not relevant to the study objective and just written haphazardly after going through certain available literature.

Response: We updated the conclusion carefully based on our findings from the multivariable analysis and observation data. Please it again in page 26 from lines533 to 547.

Question #38: - Please define what is environmental friendly sanitary napkin as discussed in conclusion section and why authors are proposing that special attention is to be given to lower grade levels students when the study population include 9th and 10th grade students?

Response: We agreed your concern and we moved the sentence to the limitation section and recommended further studies to identify environmentally friendly sanitary napkins. However, environmentally friendly sanitary napkins includes

• reusable sanitary cloth pads or

• being biodegradable

Regarding the lower grade, we mean grade 9th. But to minimize confusion, we deleted from the recommendation as you can see in the revised version. Our result showed that higher grade level (10th grade) has better menstrual hygiene practices than lower grade levels means (grade 9), so special attention should be given to the lower grade (grade 9).

Question #39: - On the other hand, the use of drugs for irregular menses, especially contraceptive pills, may currently not be feasible in Ethiopia due to negative cultural attitudes of parents toward their use- How does this sentence used in conclusion section is relevant to the study context?

Response: we revised the conclusion and your concern is no longer within the paper. Your comment is well taken.

Reviewer # 3:

Introduction

Question #1: - Overall the introduction is well-written and covered all domains that need to be highlighted in the Introduction. I request authors to please write hypothesis in the last para of the Introduction.

Response: Dear reviewer, we would like to thank you for the valuable comments and we research questions at the introduction. We did not used hypothesis during the research rather we used research questions which are included at the end of the introduction on page 6 form lines 110 to 115.

Results

Question #2: - Please do not highlight the text in page -18 line 357

Response: we edited based on your comment. Thank you.

Discussion

Question #3: All the findings are well discussed in the respective section. Just a small suggestion where ever ―West Bengal‖ is being written, please write in brackets (India) as far as I know it‘s the same region which is from India.

Response: we revised based on the comment.

Question #4: - I request the authors to write one para (3-4 lines) as limitations and strength of the study. Please write that in the end of the discussion

Response: We add our limitations as per the request, but the nature of cross-sectional studies, it would have been difficult to explain about the strength of the study (See the limitations in the revised version in page 25).

References

Question #5: - Some references do not have publisher‘s name. Please do amend those references.

Response: Thank you we updated those that have information on publishers.

Tables

Question #5: - The highlighted estimates are not needed. I mean do not highlight anything in the tables. COR and AOR full forms can be written in the end of the table (Table-9)

Response: Thank you, we updated as suggested without highlighting.

I hope that the revised manuscript is accepted for publication in PLoS ONE.

Sincerely yours,

Metadel Adane (PhD in Water and Public Health)

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

4 May 2021

Menstrual Hygiene Practices among High School Girls in Urban Areas in Northeastern Ethiopia: A Neglected Issue in Water, Sanitation, and Hygiene Research

PONE-D-20-39090R1

Dear Dr. Adane,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Srinivas Goli, Ph.D.

Support Staff - Editorial

PLOS ONE

Additional Editor Comments (optional):

Considering favourable opinions from the reviewers, I am going with a decision of Accept.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have carried out all the revisions carefully and the same has been visible from the revised version of manuscript.

Reviewer #3: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Ratna Patel

Reviewer #3: No

27 May 2021

PONE-D-20-39090R1

Menstrual Hygiene Practices among High School Girls in Urban Areas in Northeastern Ethiopia: A Neglected Issue in Water, Sanitation, and Hygiene Research

Dear Dr. Adane:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Srinivas Goli

Academic Editor

PLOS ONE