Original Article

Enhancement of Health‑related Quality of Life among

School‑going Adolescent Girls with Improvement in Menstrual
Hygiene Knowledge and Practices
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Akanksha Goyal, Sunita Agarwal

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Department of Home Science, University of Rajasthan, Jaipur, Rajasthan, India

Abstract
Background and Aim: In India, among adolescent girls, the problem associated with menstrual hygiene management (MHM) has a deep
impact on health‑related quality of life (HRQoL). Improvement in knowledge and menstrual hygiene practices may lead to enhancement
in HRQoL. Therefore, the aim of the study was to enhance the HRQoL of adolescent school girls by improvement in menstrual hygiene
knowledge and practices. Materials and Methods: The present study was an interventional, cross‑sectional, questionnaire study conducted
among adolescent school‑going girls. The study was conducted among randomly selected five government secondary schools in Ajmer city
and was conducted among adolescent girls of 7th–10th Class with the age group of 14–16 years. A total of 538 adolescent girls were surveyed
in the pretest, and 503 was the sample size in the posttest with an attrition of 6.5%. Moreover, after the pretest, a workshop was conducted
to educate adolescent girls about MHM. Results: A majority of the study participants (328 [61%]) had poor HRQoL after the pretest, which
was improved to 195 (39%) of the study participants with good HRQoL after 3 months of the workshop during the posttest. The mean general
health scores ([15.35 ± 0.38]) after 3 months of the workshop were significantly (P = 0.01*) higher among the study participants compared to
the pretest scores ([10.93 ± 1.63]). Conclusion: From the above results, it has been concluded that there has been a significant improvement
in knowledge, practice, and HRQoL among adolescent school‑going girls of age 14–16 years when assessed after 3 months of the workshop
on MHM.

Keywords: Adolescent, health, hygiene, menstrual

Introduction and practices by adolescent females.[2,3] As shown in various

Menstrual health or hygiene is a state, can be described as
complete physical, social, and mental well‑being, and not only
the absenteeism of disease or infirmity, which is related to the
menstrual cycle. Good menstrual health or hygiene is very
important to achieve, and this suggests that adolescent girls,
women, and other people who experience a menstrual cycle,
throughout their life course, should have access to appropriate
and accurate information about the menstrual cycle and also
have access to suitable facilities, materials, and services to care
for the body. Moreover, if any disorder or discomfort occurs,
they should have access to appropriate diagnosis and treatment.
Every human is entitled to a positive and respectful environment
and also has the freedom to participate in all spheres of life.[1]
In low and middle‑income countries (LMICs), there is a severe
concern regarding menstrual hygiene management (MHM)
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research, unsatisfactory MHM is followed by more than 50%
of girls in LMICs, with a higher percentage in rural areas than
urban areas.[3‑5]
There is an increased risk of developing reproductive tract
infections due to poor. Achieving the Sustainable Development
Goals affected by direct or indirect hygiene‑related practices
Address for correspondence: Dr. Akanksha Goyal,
Department of Home Science, University of Rajasthan, Jaipur,
Rajasthan, India.
E‑mail: drakanksha2306@gmail.com
Submitted: 11‑May‑2023 Revised: 04‑Jun‑2023
Accepted: 13‑Jun‑2023 Published: 09-Aug-2023
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

How to cite this article: Goyal A, Agarwal S. Enhancement of

DOI: health‑related quality of life among school‑going adolescent girls with
10.4103/amhs.amhs_112_23 improvement in menstrual hygiene knowledge and practices. Arch Med
Health Sci 0;0:0.

© 2023 Archives of Medicine and Health Sciences | Published by Wolters Kluwer ‑ Medknow 1
 Goyal and Agarwal: Enhancement of health‑related quality of life among school‑going adolescent girls
during menstruation[4‑7] is critical for the overall development
of these young adolescents and the country.[7]
Among adolescent girls, problems which are related to
menstruation are extensive in India. Different types of
menstrual abnormalities are seen in different populations,
which indicates regional and sociocultural variations. [8]
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It has been observed that 64% of girls have at least one
menstrual‑related issue.[9] Poor menstrual hygiene and lack
of self‑care, especially in the age group of 10–19 years,
are critical factors of morbidity and other problems. Some
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 08/12/2023
of the problems are scabies in the vaginal area, urinary
tract infections, atypical abdominal pain, pregnancy
complications, and absence from school.[10] In India, about
estimated 113 million adolescent girls and around 68
million adolescent girls attend roughly 1.4 million schools.
Major barriers to their school attendance are poor MHM
practices and cultural taboos.[11,12] Menstrual disorders and
abnormalities are commonly associated with social, physical,
mental, psychological, and reproductive issues disturbing
the daily lives of adolescents and their families live through
various psychosocial problems such as anxiety.[13]
Health‑related quality of life (HRQoL) is increasingly
perceived as a central focus in health research.[14] Gender
differences in adolescents’ HRQoL as reported by recent
studies, with significantly lower scores, were seen in females
than males.[15,16] The process of female puberty was the most
important factor as observed by researchers as one of the causes
of the differences.[15]
Among adolescent females, hormonal changes during
menarche and menstruation are remarkable features during
puberty. Among adolescent girls, menstrual problems, such as
menstrual pain, heavy menstrual bleeding, and abnormal and
irregular menstrual cycle, are common.[17] These problems are
associated with poor academic performance and limitations in
daily activities, which lead to decreased HRQoL in adolescent
girls.[18]
As shown by past research, there is an interrelationship
between various factors such as dietary habits, sleep quality,
social support, depression, and menstrual health and HRQoL
in adolescent girls. Social support is also associated with
health behaviors and HRQoL. It impacts health behaviors
through the mechanism of improving the ability to access
new information and developing interpersonal exchanges that
provide encouragement to engage in healthy lifestyle practices,
including dietary habits or exercises.[19,20]
Improvement in menstrual hygiene by imparting knowledge
and change in MHM practices can lead to the enhancement
of HRQoL.[21] Still, not many studies were conducted among
adolescent school girls to assess their knowledge, practice, and
HRQoL. Therefore, the aim of the present study was to assess
the enhancement of HRQoL among school‑going adolescent
girls with improvement in menstrual hygiene knowledge and
practices.
2 Archives of Medicine and Health Sciences ¦ Volume XX ¦ Issue XX ¦ Month 2023
Materials and Methods
The present study was an interventional, cross‑sectional,
questionnaire study conducted among adolescent school‑going
girls. The study was conducted in December 2022 among
randomly selected five government secondary schools in Ajmer
city and was conducted among adolescent girls of 7th–10th Class
with the age group of 14–16 years.
Before the survey, permission was availed from the school, and
a presurvey was conducted with written informed consent which
was taken from every student. Those girls present at the time of
the survey and given their informed consent were included in the
study. A total of 538 adolescent girls were surveyed in the pretest.
All the girls of the 7th–10th Class from five schools were included in
the study; among all, those who had given informed consent were
included in the study to make up the total sample size. Moreover,
after the pretest, a workshop was conducted to educate adolescent
girls about MHM. After 3 months of workshop, a posttest was
conducted, and change in HRQoL was determined. In the posttest,
an attrition of 35 girls was there, due to the absence on the day of
the survey. The total sample size in the posttest was 503.
Before the study, a pilot survey was conducted, before the
main survey on 10% of the total study participants to test the
validity and reliability of the questionnaire. The reliability of
the questionnaire was determined using test‑retest, and the
values of measured kappa (κ) = 0.92 and weighted kappa
(κw) = 0.89. Internal consistency of questionnaires was
measured by applying Cronbach’s alpha (α), and the value
of α = 0.90 was measured. Those questions with less validity
and reliability were removed. For better understanding, the
whole questionnaire was translated into the Hindi language.
The questionnaire consists of three parts. The 1st part consists
of the demographic details of the study participants, which
includes the age of the study participants who belonged to
14–16 years. Religion and caste were also inquired about
and were not mandatory to be filled by the study participants.
Other demographic details were people in the family, monthly
income of the family, type of household, and toilet at home. The
2nd and 3rd parts consist of questions regarding the knowledge
and practice of the study participants toward MHM, which
consists of 25 questions in each section. Answers to these
questions were divided into “yes” and “no.” The 4th part
of the questionnaire had questions to assess the HRQoL.
The questionnaire used to assess the HRQoL was short
form‑36 (SF‑36) which has six subscales, which were: general
health perceptions consisting of six questions, limitation of
activities consisting of ten questions, physical health problem
consisting of four questions, emotional health problems
which have three questions, and social activity subscale of the
questionnaire consisting of two questions. The pain subscale
consists of two questions, and the energy and emotions scale
has nine questions. To each question, in all domains of the
SF‑36 questionnaire, there were three options. To each option,
1, 2, and 3 points were given, with 1 referring to poor HRQoL
and 3 referring to good HRQoL. The total of each domain
 Goyal and Agarwal: Enhancement of health‑related quality of life among school‑going adolescent girls

score, by adding the individual scores of each question and

Table 1: Demographic details of the study participants
each domain, was further divided into poor and good based on
the total scores of each question. The total scores of HRQoL Demographic Pretest (day 1), Posttest (3 months after
were assessed by adding the individual score of each domain variables n (%) the workshop), n (%)
and divided into three categories, with good = 36–60 = 3, Sample size 538 503
moderate = 61–84 = 2, and poor 85–108 = 1. Age (years)
14 194 (36) 186 (37)
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Statistical analysis 15 129 (24) 115 (23)

The data were analyzed using SPSS statistical software version 16 215 (40) 202 (40)
21.00. (IBM corp released 2012 Armonk, NY: IBM Corp.). The Total 538 (100) 503 (100)
demographic details of the study participants were assessed using Religion
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 08/12/2023

descriptive statistics. The mean scores for knowledge, practice, Hindu 339 (63) 317 (63)
and HRQoL at the pretest and 3 months after the workshop at Muslim 54 (10) 50 (10)
the posttest were determined using a t‑test. HRQoL, knowledge, Christian 11 (2) 10 (2)
and practice regarding MHM were divided into three categories Sikh 54 (10) 50 (10)
Jain 54 (10) 50 (10)
that are good, moderate, and poor, which were assessed using
Others 11 (2) 10 (2)
descriptive statistics. The level of significance was kept at 0.05.
Don’t wanna tell 15 (3) 16 (3)
Total 538 (100) 503 (100)
Results Caste
The response rate in the present study was 98%. Table 1 shows General 307 (57) 287 (57)
that a majority of the study participants (202 [40%]) belonged OBC 124 (23) 116 (23)
to the age of 16 years. Most of them were from the general SC 65 (12) 60 (12)
category (57 [57%]). Most of the study participants (66 [68%]) ST 27 (5) 25 (5)
Don’t know 5 (1) 5 (1)
were having four family members.
Don’t want to tell 10 (2) 10 (2)
Table 2 shows that a majority of the study participants (328 [61%]) Total 538 (100) 503 (100)
had poor HRQoL after the pretest, which was improved to People in family
195 (39%) of the study participants with good HRQoL after 3 97 (18) 91 (18)
3 months of the workshop during the posttest. Knowledge and 4 366 (68) 342 (68)
practice regarding menstrual health management among the 5 53 (10) 50 (10)
study participants were poor among 238 (44%) and 346 (64%) 6 22 (4) 20 (4)
study participants at pretest, while it was improved after Total 538 (100) 503 (100)
3 months of workshop with knowledge and practice were good Monthly income
>20k 167 (31) 151 (30)
among 189 (38%) and 171 (34%) study participants at posttest.
20k–30k 75 (14) 86 (17)
Table 3 shows that the mean general health scores ([15.35 ± 0.38]) 30k–40k 59 (11) 65 (12)
after 3 months of the workshop were significantly (P = 0.01*) >40k 38 (7) 40 (8)
higher among the study participants compared to pretest Don’t know 140 (26) 116 (23)
scores ([10.93 ± 1.63]). The mean emotional health problems Don’t wanna tell 59 (11) 45 (11)
scores ([5.32 ± 1.18]) were significantly (P = 0.05) lower Total 538 (100) 503 (100)
among the study participants compared to the posttest Type of household
scores ([5.68 ± 1.23]) after 3 months of workshop. There was Pucca 495 (92) 463 (92)
a significant (P = 0.00) increase in the mean social activity Semi‑pucca 38 (7) 34 (7)
Kuccha 5 (1) 5 (1)
scores ([6.89 ± 1.60]), 3 months in the posttest, after the
Total 538 (100) 503 (100)
workshop. The overall mean HRQoL score ([70.01 ± 4.82]) was
Toilet at home
significantly (P = 0.01) higher at the posttest, that is 3 months after
Yes 516 (96) 483 (96)
the workshop, compared to the pretest scores ([59.24 ± 4.61]).
No 22 (4) 20 (4)
Table 4 shows the mean knowledge and practice scores at the
Total 538 (100) 503 (100)
pretest and posttest after 3 months of workshop. It has been
observed that the mean knowledge and practice scores, (P = 0.00)
and (P = 0.03), had significantly improved to (41.65 ± 0.56) included. A majority of the houses of the study participants
and (45.88 ± 1.05) in the posttest after 3 months of workshop. in the present study were pucca. As compared to the study
by Shah et al.[22] conducted in rural Gambia, adolescent girls
belonged to the age group of 11–20 years and both primary
Discussion and secondary schools were included. In the same study,[23] a
In the present study, the study participants belonged to the majority of the study participants belonged to the 14–16 years
age group of 14–16 years, and only secondary schools were of age group, and houses were made of mud. This may be due

Archives of Medicine and Health Sciences ¦ Volume XX ¦ Issue XX ¦ Month 2023 3

 Goyal and Agarwal: Enhancement of health‑related quality of life among school‑going adolescent girls

Table 2: Health‑related quality of life, knowledge, and practice scores among the study participants
Health‑related quality of life, knowledge, and practice regardiing MHM Pretest, n (%) Posttest (after 3 months), n (%)
Health‑related quality of life
Good 54 (10) 195 (39)
Moderate 156 (29) 178 (35)
Poor 328 (61) 130 (26)
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Total 538 (100) 503 (100)

Knowledge
Good 89 (17) 189 (38)
Moderate 211 (39) 215 (43)
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Poor 238 (44) 99 (19)

Total 538 (100) 503 (100)
Practice
Good 38 (7) 171 (34)
Moderate 154 (29) 203 (40)
Poor 346 (64) 129 (26)
Total 538 (100) 503 (100)
MHM: Menstrual health management

Table 3: Difference between the mean health‑related quality of life and its subscale scores pretest and posttest
(3 months later)
Mean±SD t P Mean±SD t P
General health 10.93±1.63 1.889 1.21 15.35±0.38 0.561 0.01*
Limitation of activities 16.22±2.64 3.560 0.59 23.68±2.63 2.906 0.71
Physical health problems 6.12±1.30 4.021 1.45 7.05±1.56 1.738 0.43
Emotional health problems 5.32±1.18 0.259 0.05* 5.68±1.23 2.673 1.23
Social activities 3.34±1.06 3.100 0.23 6.89±1.60 0.943 0.00*
Pain 3.37±1.03 0.387 0.44 4.46±0.746 2.902 0.11
Energy and emotions 13.95±2.32 1.009 1.76 19.0±2.27 0.543 1.90
Health‑related quality of life 59.24±4.61 1.788 0.08 70.01±4.82 5.882 0.01*
*P≤0.05. HRQoL: Health‑related quality of life, SD: Standard deviation

girls < 15 years of age. In the present study, absorbent material

Table 4: The mean knowledge and practice score toward
was used by a majority of the study participants; the same
menstrual hygiene among the study participants
was reported in studies by Belayneh and Mekuriaw[24] and
Knowledge Pretest Posttest (after 3 months) Shanbhag et al.[25]
and practice
Mean±SD t P Mean±SD t P As observed from the results above, the HRQoL of a majority
Knowledge 27.09±3.65 0.378 0.98 41.65±0.56 1.654 0.00* of girls was poor in the pretest, and there was an improvement
Practice 26.78±0.76 1.877 1.09 45.88±1.05 2.489 0.03* after 3 months of workshop. The same results were shown in
*P≤0.05. SD: Standard deviation
the study by Unsal et al.,[26] in which HRQoL was poor during
dysmenorrhea. In a study by Shah et al.[27] HRQoL was poor
to the fact that according to the WHO, the adolescent age group among those girls using old cloth compared to those using
belonged to 11–19 years, and the age group of 14–16 years sanitary pads.
covers the majority of adolescent girls and as the study was
In the present study, the mean general health, social activity
conducted[23] in the rural area in which majority of the houses
domains, and overall HRQoL, knowledge, and practice scores
were made of mud.
have significantly increased after 3 months of the workshop
In the present study, a majority of the study participants were among adolescent girls in the posttest. In a cluster randomized
having poor knowledge and practice scores in the pretest controlled trial by Austrian et al., [28] it was determined
before the workshop, which was improved in the posttest after that health education sessions on reproductive health have
3 months of the workshop. Same results were reported in a improved the knowledge and practice of adolescent girls
study by Belayneh and Mekuriaw,[24] in which Adolescent girls toward MHM. The present study was localized to government
were having poor knowledge and practice regarding MHM. In a schools of Ajmer city. The study was done in only girls’ school.
study by Shanbhag et al.,[25] knowledge and practice regarding Impact on coeducation was not considered. In the present
menstrual hygiene were inadequate among adolescent study, the module did not include sanitary waste disposal.

4 Archives of Medicine and Health Sciences ¦ Volume XX ¦ Issue XX ¦ Month 2023

 Goyal and Agarwal: Enhancement of health‑related quality of life among school‑going adolescent girls
Future studies should be conducted encompassing larger areas
for better generalization of results. More studies should also
13.
include coeducation, and private schools should be undertaken.
14.
Conclusion
From the above results, it has been concluded that there
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has been a significant improvement in knowledge, practice, 15.
and HRQoL among adolescent school‑going girls of age
14–16 years when assessed after 3 months of the workshop 16.
on MHM. According to the present knowledge of literature,
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 08/12/2023
not many studies have been conducted on the present topic.
Financial support and sponsorship 17.
Self‑supported.
Conflicts of interest 18.
There are no conflicts of interest.
19.
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