Background
Adolescence can be defined as the transitional period in life that spans from childhood to adulthood, comprisingthe ages of 10 to 19. It represents a distinctive phase in human growth and serves as a critical juncture for establishing the fundamental basis of good health [
1]. In most countries of the world, especially developing countries, a significant part of the population is made up of adolescents [
2]. Addressing adolescents’ health issues is beneficial not only for them but also for their families, society and the future generation, and special attention should be paid to their issues in the government policies of countries [
3].
Adolescents experience rapid physical, cognitive and psychosocial growth. The most important change and evolution of this period, which is of particular importance and is considered as the turning point of adolescence, is puberty [
4]. Although puberty and its issues are important in both adolescent girls and boys, it seems that paying attention to adolescent girls is more important compared to boys due to many physiological, reproductive health, cultural and social reasons [
5].
One of the unique experiences of girls’ puberty is menstruation. Menstruation is a natural phenomenon of reproductive years [
6] that women are faced to it during many years of their lifespan [
7]. Menarche is a critical milestone in a girl’s life [
8] and unlike other puberty changes that are slow and continuous, it has a sudden onset, so that it stays in the minds of adolescents girls and can be remembered easily [
9]. Menstrual health is vital and an integral part of the health of adolescent girls and provides health for their adulthood [
10]. Menstruation regularly and often disastrously stir ups their physical, mental, and social well-being of girls and women around the world and affects adversely on daily life and activities [
11]. Most of the girls do not have proper knowledge about changes during puberty and healthy behaviors during menstruation and they face problems due to getting incorrect information from unreliable sources. In many cases, girls get their information from their mothers, unfortunately, mothers also do not have enough information in this field [
12].
Based on the results of studies, adolescent girls do not have proper practice during the menstruation. They may change and restrict their diet [
13], social performance [
14] bathing [
15] and religious functions [
14,
16]. The lack of proper education and the avoidance of discussing about the changes during puberty and issues related to menstruation are another challenges of adolescent’s girl. Lack of accurate information and misconceptions regarding menstruation result in unhealthy behaviors [
11]. Poor menstrual hygiene and unhealthy behaviors can face adolescent’s girl to health problems such as reproductive tract infections and also reduce the quality of life [
6,
17]. People’s practice often stems from their beliefs [
18]. Qualitative studies can provide an in-depth understanding of phenomena or experiences and are effective to capture beliefs, opinions, and behaviors of different groups of people [
19]. It is necessary to perform qualitative studies to develop the health interventions they need, and improve the health behaviors [
20].
Since, the menstrual practices can be influenced by various factors, and engaging in unhealthy behaviors during menstruation can have negative consequences for adolescent girls, by understanding adolescent female’s beliefs and their practice related to menstruation, we can establish necessary plans for appropriate effective interventions. This study aimed to investigate Iranian adolescent females’ menstrual practices and beliefs.
Discussion
This qualitative study aimed to explore how Iranian adolescent girls explain their menstrual practice and related beliefs. he results showed that despite the availability of information through books, media, social networks and the internet, etc., adolescent girls still had incorrect practices and wrong beliefs. Our findings highlight the influence of inadequate knowledge and misconceptions on wrong practices of Iranian adolescent girls regarding menstruation, as well as the influence of the environment and the people who surround them, especially mothers.
According to our findings, most participants changed their lifestyle during menstruation, including diet, exercise, daily activities, personal hygiene behaviors, etc. Other researchers have also reported restrictions on work activities, exercise or physical activity, attending social functions [
24], bathing [
25], washing genitalia area [
26], participate in religious activities [
27], and eating certain foods [
28].
Consistent with our study, results of a study conducted in Iran showed that women and girls limit eating some foods (cold foods, sour foods, salty food, foods causing gas, dairy, citrus) during menstruation and even one week before it, as they believe it causes cramping, may have an effect on the sex of the child in the future, cause smelly menstrual secretions and decrease chance of future pregnancy [
27]. There is this belief that certain foods can hasten or delay menstruation [
29]. Also, change in appetite and food craving during the menstrual cycle has been reported that is consistent with our finding [
30].
Participants’ preferences and beliefs regarding genital washing and bathing varied widely. There are prevalent misconceptions among girls about these practice during menstruation; for example, taking a bath during menstruation increases the flow of menstrual blood and intricacies during pregnancy [
25] and, washing during menstruation impact blood flow [
31]. In studies conducted in India, washing the genital area during menstruation varied from 30 to 94% [
14,
26]. Unhealthy behaviors such as not bathing and washing the genitals [
32] and not using sanitary pads [
33] cause reproductive tract infections, and other vaginal diseases that adversely affect the health of girls and their future fertility. Genital infection was higher in those who took a bath in a sitting position or once or less per week and did not do genital cleaning [
34,
35].
Menstruation is a topic surrounded by culture and menstrual practices are strongly influenced by cultural beliefs, unfortunately, most of these beliefs are wrong and rooted in unawareness [
25]. In our study, adolescent girls considerd their family member especially their mothers, as appropriate sources of information and their influence from their mothers was evident in most of their beliefs and behaviors. Unfourtunetly, in the most of the time, the mothers themselves do not have correct knowlege or their information is insufficient [
36,
37]. Although menstruation is a subject that is related to more than half of the world’s population, nearly all cultures are uncomfortably discussing it. Therefore, most girls experiencing their menarche without prior information and being unprepared for menarche.
Experience of physical and mental symptoms was reported by the participants during or before menstruation. In a survey of 42,879 women between the ages of 15 and 45, the reported symptoms included abdominal pain during period, heavy bleeding, headache, back pain, tiredness, and premenstrual psychological complaints [
38]. These symptoms can affect on different aspects of life, such as attendance and performance in school, activities of daily living [
39], and quality of life [
40]. Menstrual symptoms even lead to a significant economic burdens, mainly due to work productivity loss. A study in Japan estimated that annual financial burden extrapolated to the Japanese female population was ∼8.6 billion Dollars [
41].
Dysmenorrhea is a common menstrual problem that affects adolescent girls’ life [
42]. It reported as the most common cause of short-term absence from school, and about 1 in 8 girls aged 14 to 20 years missing school or work due to dysmenorrhea [
43]. In our study, most participants suffered from dysmenorrhoea and believed that dysmenorrhoea is inevitably part of the menstrual cycle. They were self–medicating and their preference for treatment was non-medical management rather than medical management. According to the evidence, methods such as rest, sleeping, heat, herbal drugs, hot drinks, or sports, and medicine (such as paracetamol ibuprofen, aspirin, or a spasmolytic, etc.) for managing pain have been reported [
44]. Despite the high prevalence of dysmenorrhea, it is often underdiagnosed, inadequately treated, and normalized even by patients themselves, who may accept the symptoms as an inevitable response to menstruation. Women with menstrual pain should not be dismissed; thus, increasing public awareness of the recently available medical treatments can improve the overall burden of menstrual problems [
45].
Participants expressed some concerns related to menstruation, including shame and embarrassment and stained and bloodied clothing not to be understood by others (such as their family members and teachers). Also, some of them stated sometimes there was not a supportive environment in some schools in terms of educating about menstruation and providing sanitary napkins. Unfortunately, most did not have adequate information about healthy and proper behaviors during menstruation and had wrong practices. In addition, they complained about the lack of appropriate and adequate education about menstruation and lack of information and stated that they needed education about menstruation.
Although menstruation is a normal biological process and more than half of the world’s population experience it, nevertheless there is many concerns and challenges about it. Still, people are not comfortable to talk and discuss about it, and female are still ashamed of staining their clothing, menstrual products, going to outlet and buying the sanitary napkin and hide their menstruation especially from men [
46]. Many young adults and adolescents feel unprepared for menstruation [
47].
Menstruation can be both physically and emotionally distressing. Therefore, instrumental, informational, and emotional support can help to manage related concerns and issues [
47]. Emotional support from parents, friends, and other important persons can reduce the psychological and emotional problems associated with it [
48]. Adolescent girls need information about hygiene products, pain management, medication, and other health-related information; they need informational support in detail about menstruation and related issues. It reported when information is provided as an in-depth explanation about the menstruation process would be more effective [
23]. Consistent with our study, previous studies indicated mothers as the most important information source regarding menstruation, followed by peers and school nurses [
44]. Mothers’ attitudes toward menstruation shape the menstrual information girls receive, which, if inadequate, might negatively affect their daughters’ practice of menstruation [
46]. Based on the results of studies, mothers did not want to openly discuss about menstruation and were secretive and uncommunicative on this issue, wich reflects traditional feminine gender roles [
48,
49]. In this kind of circumstances, social media platforms can use as a tool for addressing knowledge gaps, breaking the silence around menstruation, and building a caring community among participants. The online communities and social networks focused on menstrual health can serve as platforms for collective learning, knowledge sharing, knowledge co-creation, and emotional-relational support, empowerment, solidarity, and the potential for social change [
23].
The weak knowledge of mothers and even teachers regarding menstruation and adherence to some traditions can result in unfair practices in adolescent girls and damage their health. Some restrictions (such as avoidance of eating some foods, bathing, washing genital area and, etc.) can hurt physical health; some (such as hiding menstruation, embarrassed of bloody and stained clothes, and restrictions on participation in social interactions and events) can affect the mental health or social inclusion. Mothers, teachers and, etc. themselves should prepare for the task of educating their adolescent girls about menstruation. The function of the mothers in menstrual education is particularly crucial because girls may learn related behaviors primarily from them. Reproductive and menstrual health and hygiene should include in the school curriculum. Teachers hardly talk and guide the girls about menstrual health and hygiene. There should be orientation programs for teachers and school counselors. Holding educational sessions on menstruation can help correct these false beliefs and misconceptions among mothers and their children. Interventions that are practical, sustainable, and culturally acceptable must inform the community, especially parents and their adolescent girls, to empower them in their transition to womanhood. Local Health Committees should be involved in education and awareness programs. A specific handbook and website should be developed on menstruation and menstrual hygiene management, clarifying myths, misconceptions, and taboos. Therefore, socializing messages, support from parents, educators, and healthcare providers, and other interpersonal communication about menstruation are needed to promote healthy behaviors in adolescent girls.
This study had a number of limitations. First, generalization of the results of this study, considering its qualitative approach, should be done cautiously that could be considered as a limitation. Although qualitative studies do not make for the generalization of the results, they might be necessary for those who are willing to use the results of these studies. Second, we did not triangulate the results of our study with quantitative approaches for this component. Conversely, the strengths of the study were selecting participants with maximum variations, guidance and supervision of experts, and external reviewing, the effort was to increase the accuracy and transferability of the data.