Original Article

Menstrual hygiene and health among adolescent girls in basic schools in Fodome- Ghana

Introduction

In low- to middle-income countries, menstrual hygiene management (MHM) is a significant public health concern, with limited access to sanitary products, insufficient knowledge about menstrual hygiene, and inadequate sanitation facilities posing threats to adolescent health.^1-3 Many girls resort to unhygienic alternatives due to the unaffordability or inaccessibility of sanitary products, compounded by a lack of private, clean toilets in schools.⁴ Insufficient knowledge about menstrual health exacerbates this problem, leading to misconceptions and poor hygiene practices.⁵

Menstruation is a natural reproductive process marked by the shedding of blood through the vagina, typically beginning between the ages of 10 and 14, although it can vary from 8-17 years.^6,7 Poor menstrual hygiene can result in severe health consequences, including reproductive tract infections and potential infertility.^8,9 It also disrupts education, as girls may miss school during their periods, resulting in academic setbacks and perpetuating gender disparities.^10,11 Proper menstrual hygiene is essential for the dignity and well-being of women and girls, ensuring both physical and emotional health during this period.^12,13

Globally, over 500 million women and girls lack adequate MHM facilities.³ In countries such as India, Nepal, Bangladesh, and various sub-Saharan African nations, including Uganda, Egypt, Kenya, and Ethiopia, the prevalence of poor MHM ranges widely, highlighting the widespread challenge.^5,14,15

In Ghana, studies have shown that 19.8% to 68% of adolescent girls face challenges in practicing good MHM.¹⁶ These challenges include inadequate facilities, sociocultural barriers, and economic disparities, which increase the risk of infection and educational disruption.¹⁷

In the Volta Region, menstrual hygiene challenges persist due to limited access to water and soap, and sociocultural beliefs portraying menstruation as unclean.¹⁸ Specifically, in Fodome Township, similar issues have been reported by local media, schools, and health facilities, yet no formal studies have been conducted to assess MHM practices among adolescent girls in this area.¹⁹

While research has documented MHM challenges across Ghana, significant knowledge gaps exist, particularly in rural and semi-rural settings. The Volta Region, specifically, faces unique challenges due to limited water access and persistent sociocultural beliefs about menstruation; however, in Fodome Township, despite reported challenges through local health and education authorities, no formal research has systematically assessed MHM practices among adolescent girls.¹⁹

This research gap is particularly significant because existing studies have predominantly focused on urban areas and regional capitals,¹⁸ leaving rural communities understudied. The absence of baseline data in Fodome Township hampers developing and evaluating targeted interventions. Furthermore, regional data may not accurately reflect the specific challenges faced by this community, given its unique sociocultural context.

Therefore, this study aims to assess the menstrual hygiene practices among adolescent girls in basic schools in Fodome Township and investigate the factors influencing these practices. The findings will contribute to multiple outcomes; providing crucial insights into the current MHM practices among adolescent girls in Fodome Township, documenting their challenges, coping strategies, and needs. This local data will reveal barriers such as access to sanitary products, availability of proper facilities, and the influence of cultural beliefs on menstrual practices.

Also, using this evidence, the study will facilitate the development of targeted, culturally appropriate interventions. These recommendations will span school-based solutions (like improved sanitation facilities and educational programs), community-level initiatives (including awareness programs and support systems), and healthcare service improvements. An evidence-based approach will ensure that interventions are practical and effective for the local context.

The study’s findings have several practical implications for improving MHM practices:

The study identified that poor MHM practices can lead to infections, absenteeism, and psychosocial stress. Therefore, public health policies should emphasize improving MHM resources and support services in schools to promote girls’ health and educational outcomes.

Also, the study highlighted a gap in menstrual health knowledge among some girls, underscoring the need for continuous education on menstrual hygiene, dispelling myths and addressing cultural taboos. Integrating menstrual health education into the school curriculum could enhance knowledge and reduce stigma.

Furthermore, limited access to affordable menstrual products was a challenge for many girls. Subsidizing menstrual products or establishing free distribution programs could help girls manage menstruation more comfortably and hygienically.

Lastly, since access to private toilets and dustbins significantly influenced good MHM practices, schools should prioritize the provision of clean, private, and adequately equipped sanitation facilities. This includes installing dustbins for proper disposal and ensuring access to water and soap.

Methods

Study area

Fodome is a traditional area in the Hohoe Municipality of the Volta region, bordering Togo to the east, southeast of the Afadzato district, southwest of Kpando Municipality, and north of the Jasikan district (Ghana Statistical Service, 2021). The area consists of 14 communities primarily inhabited by Ewes, who practice Christianity, Islam, and traditional religion. The study focused on five selected subcommunities—Fodome Helu, Woe, Hloma, Amele, and Ahor—due to the presence of basic schools, these subcommunities are suitable for assessing menstrual hygiene practices among adolescent girls. These communities have an estimated population of 6431, with most residents engaged in farming and fishing(Ghana Statistical Service, 2021).

Participants and procedure

Type of study

A school-based analytical cross-sectional study was conducted to assess menstrual hygiene practices. This design was suitable for capturing a snapshot of practices and related factors.

Sampling

Inclusion and exclusion criteria

The study included adolescent girls aged 10-19 years who were menstruating, able to understand English or the local dialect, and who consented to participate with parental or guardian approval. Adolescent girls (ages 10-19) are typically the primary focus of studies related to menstrual hygiene because this is the stage when they experience menarche and begin managing menstruation regularly. Involving them will allow the researcher to gather in-depth knowledge about the subject matter.

Girls who had not started menstruating and those with serious health conditions or communication impairments were excluded from the study since they would not be in a condition to provide adequate knowledge.

Sample size determination

The sample size for this study was 318 adolescent girls, calculated using the Cochran formula (1977).

Sampling method

A stratified random sampling approach was utilized to select respondents for the study on menstrual hygiene practices among adolescent girls in basic schools in Fodome Township. The Principal Investigator began by dividing the five basic schools in Fodome Township into distinct strata. Each school represented a separate stratum, ensuring that all educational institutions within the township were included in the sampling framework. Sample sizes were allocated to each school proportionally based on the total number of students enrolled and the calculated sample size for each stratum. Within each selected school, individual students were chosen via simple random sampling techniques. This involved creating a list of eligible adolescent girls and using random number generators to select participants, ensuring that each student had an equal chance of being included in the study. Once the participants were selected, data collection was carried out directly in the schools. This method ensured that the sample accurately represented the student population across all three schools.

Data collection tool and procedure

Data collection was conducted by three trained research assistants and the principal investigator using a structured questionnaire to assess menstrual hygiene practices and related factors among adolescent girls. The questionnaire, with a Cronbach’s alpha reliability coefficient of 0.742, was pretested among girls in Hohoe Township to ensure clarity and appropriateness, and to familiarize the data collectors with ethical practices.

The questionnaire comprised four sections:

1. Sociodemographic information: This section of the questionnaire collected data about the participants’ background, such as age, grade level. Sociodemographic information is essential for contextualizing the findings and understanding how various factors might influence menstrual hygiene practices. The sociodemographic section is considered to have face validity as it captures basic demographic information relevant to the study. The questions are straightforward and relevant to the research goals. Since these items are straightforward demographic questions, they are expected to be highly reliable.

2. Menstrual hygiene practices: This section aimed to gather information on how adolescent girls manage their menstrual hygiene, including the materials used for menstrual protection, frequency of changing pads, and disposal methods. The goal was to identify common practices and evaluate their effectiveness. The items were designed to directly assess menstrual hygiene behaviors and are thus considered to have content validity. The questions are based on established practices and norms around menstrual hygiene. A reliability coefficient of 0.742 for the overall questionnaire suggests that the menstrual hygiene practices section is reasonably reliable in capturing consistent responses across participants.

3. Knowledge of menstrual hygiene: This scale assessed the level of knowledge the adolescent girls had about menstrual hygiene, including understanding the importance of hygiene during menstruation and the potential health risks associated with poor menstrual hygiene. The scale has face validity, as the items are directly related to the participants’ knowledge of menstrual hygiene, a key component of the study. To ensure the validity of the knowledge, the questions were aligned with established menstrual health guidelines. While the Cronbach’s alpha for the overall questionnaire is 0.742, the reliability of the knowledge scale could be stronger if items measuring various aspects of menstrual hygiene knowledge were more diverse.

4. Challenges faced: This scale aimed to identify the challenges adolescent girls face regarding MHM. These challenges could include limited access to sanitary products, cultural taboos, lack of knowledge, and stigma. The challenge scale has content validity as it addresses specific barriers identified in previous research on menstrual hygiene. The items are reflective of real-world difficulties faced by adolescent girls. Given that the items are designed to capture varied challenges, the scale’s reliability will likely moderate, depending on the diversity of responses and the consistency with which respondents identify their challenges.

Informed consent was obtained from participants and guardians, and data collectors were trained to maintain confidentiality and respect throughout data collection

Measures

To generate a composite hygiene practice score, all ‘No’ and ‘Don’t know’ responses were combined as ‘NO’. Eight items were used to generate the score, with the lowest possible score of “0” and the highest score of “10.” The average score was found to be 6. Therefore, respondents who scored below the average were considered to have poor menstrual hygiene practices, whereas those who scored average and above were considered to have good menstrual hygiene practices. Similarly, to generate a composite knowledge score, all ‘No’ and ‘Don’t Know’ responses were combined as ‘NO’. Eight items were used to generate the score, with the lowest possible score of 0 and the highest score of 8. The average score was found to be 4. Respondents who scored below the average were considered to have poor knowledge of menstrual hygiene, whereas those who scored the average and above were considered to have good understanding of menstrual hygiene.

Data analysis/statistics

The data collected were compiled and entered into EpiData software version 4.0. After data entry, the data were exported into STATA 17.0 for analysis. Data cleaning and validation were performed to ensure data quality before analysis. Descriptive statistics such as frequencies and proportions were performed for categorical variables, whereas means and standard deviations were computed for continuous variables and are presented in tables and charts. Logistic regression was used to assess the relationship between menstrual hygiene practices and various independent variables, with statistical significance determined at a P value of 0.05 and a 95% confidence interval.

Results

Sociodemographic characteristics of basic school girls in Fodome Township

In the study involving 318 primary school girls with a mean age of 13 years ( ± 1.64), half (50%) were aged 13–14 years, and 38.4% were in Basic 8. Most participants were Ewes (64.8%) and identified as Christians (83.6%). A majority (61.6%) lived with their parents. Regarding parental education, 30.2% of fathers had no formal education, while 43.1% of mothers had a basic education. Nearly all (93.7%) had received information on menstruation management before menarche, with mothers being the main source for 59.4% of them (Table 1).

Knowledge of menstruation and the menstrual cycle among basic school girls in Fodome township

The majority of respondents, 293 (92.1%), recognized menstruation as a natural process, with 268 (84.3%) correctly identifying its cause. Most reported a menstrual flow of 5–6 days (n = 203, 63.8%) and a cycle length of 26–30 days (n = 141, 44.3%). While 217 (68.2%) did not associate menstruation with foul odor, 298 (93.7%) viewed menstrual blood as unhygienic. Additionally, 286 (89.9%) knew that menstruation indicated a girl’s ability to conceive, and 253 (79.6%) preferred disposable sanitary pads (Table 2).

Menstrual hygiene practices among adolescent girls in basic schools in the Fodome township

The majority, 259 (81.4%), used disposable sanitary pads during their last menstrual period, and 182 (57.2%) changed their sanitary products twice daily. Nearly all 314 (98.7%) bathed twice a day. While 200 (62.9%) did not change sanitary products at school due to a lack of functional toilets, 118 (37.1%) used a school washroom. For menstrual tracking, 133 (41.8%) used a calendar, and 121 (38.1%) used a diary or other book (Table 3).

Availability of sanitary facilities in basic schools in the Fodome township

In a survey of basic schools, 84.0% had toilet facilities, predominantly latrine pits (90.6%) compared to water closets (9.4%). Only 9.4% of toilets had water access, and just 13.1% provided soap. Most schools (86.9%) offered separate toilets for girls, though 13.1% did not. Doors were present in 79.0% of toilets, and 88.4% were roofed. Dustbins for waste disposal were available in 39.3% of the toilets, while 60.7% lacked them (Table 4).

Preferred menstrual hygiene products among adolescent girls in basic schools in the Fodome township

Most adolescent girls in basic schools used disposable sanitary pads (88.0%), with a small percentage using alternatives like cotton wool, reusable cloths, or tissue paper. While 95.9% found their product comfortable, only 23.6% reported easy access, and 35.8% considered it affordable. Ease of use and absence of side effects were noted by 41.2% and 43.4%, respectively. Parental and peer influences on product choice were minimal. Satisfaction with menstrual hygiene products varied, with 33.6% satisfied or very satisfied and 28.6% dissatisfied (Table 5).

Associations between sociodemographic characteristics, knowledge of menstrual hygiene and the menstrual cycle, and menstrual hygiene practices among adolescent girls in basic schools in the Fodome township

In a binary logistic regression analysis, factors such as age, class, ethnicity, religion, living arrangements, parental education, and knowledge about menstruation were assessed. The multivariable analysis revealed that adolescent girls living with their fathers were significantly more likely (AOR = 5.22) to practice good menstrual hygiene than those living only with their mothers. Girls living with guardians were twice as likely (AOR = 2.04) to have good practices, though this was not statistically significant. Additionally, girls with good menstruation knowledge were 1.6 times more likely to practice good hygiene, though this association was also not statistically significant.

Association between the availability of sanitary facilities in basic schools, preferred menstrual hygiene products and menstrual hygiene practices among adolescent girls in basic schools in the Fodome township

In a logistic regression analysis, factors influencing MHM practices were assessed. The adjusted model showed that girls with access to separate toilets were significantly more likely (AOR = 3.63) to have good MHM practices. The presence of dustbins in toilets also increased good MHM likelihood by more than three times (AOR = 3.06). Conversely, girls who were very dissatisfied with their menstrual products were significantly less likely to maintain good MHM practices (AOR = 0.07).

Discussion

This study aimed to assess MHM practices among girls in Fodome township’s basic schools and identify influencing factors. Findings showed that 62.0% of respondents reported good MHM practices (Table 6), aligning with similar studies yet showing higher rates than those from Harari (44.2%), Ambo (46.7%),²⁰ and southern Ethiopia (39.7%),¹⁰ but lower than in Hararge (58.3%),²¹ and Northeast Ethiopia (52.9%). In Ghana, a North Gonja District study reported 64.5% of girls using sanitary pads and 71.0% exhibiting adequate MHM practices,²² while 84.9% practiced good MHM in the West Gonja Municipality despite access challenges.²³

The variation in MHM across regions is attributed to socioeconomic conditions, educational programs, and the availability of WASH facilities, which are often inadequate in certain areas. Despite Fodome limitations, relatively high MHM practices may reflect better awareness and access to menstrual products and WASH (Table 7). Poor MHM is linked to negative outcomes like reproductive tract infections, school absenteeism, and psychosocial stress, underscoring the need for interventions to improve access to sanitary products, menstrual health education, and school facilities. Community engagement and cultural sensitivity are also crucial for sustainable improvements.

The study further found that 64.5% of girls had good menstruation knowledge, consistent with findings from North Gonja (78.8%), Mohammed et al²² and West Gonja (63.7%),²³ while Ethiopia reported slightly higher knowledge levels (72.5%).²⁴ In Nepal, widespread awareness was marred by misconceptions.²⁵ Educational interventions and cultural beliefs heavily influence menstruation knowledge, with efforts across Ghana and Ethiopia aiming to enhance menstrual health education, whereas stigma in Nepal hinders effective information dissemination. Access to separate toilets was associated with a higher likelihood of good MHM practices (AOR = 3.63), consistent with studies in Ghana’s Savannah Region showing that private sanitation facilitates proper MHM,²³ and in Kenya, where inadequate facilities contribute to unsafe practices and absenteeism.²⁶ However, disparities in sanitation access remain, with economic limitations impacting MHM infrastructure, particularly in rural Ethiopia and Nepal.²⁵

These findings underscore the need for improved school sanitation facilities to support MHM and mitigate public health impacts, including infections and psychosocial challenges. Recommendations include prioritizing school infrastructure improvements, ensuring water and soap availability, and integrating MHM awareness programs into broader health initiatives. By fostering a supportive environment for managing menstruation, girls can experience better health outcomes, reduced absenteeism, and greater educational participation.

Study limitations

The cross-sectional nature of the study limits its ability to establish causality or observe changes over time. Nonresponse bias is a concern, as nonrespondents may differ from respondents. Self-reported data may be inaccurate due to response bias.

Conclusion

The study revealed that good menstrual hygiene practices among adolescent girls in Fodome Township are significantly influenced by access to proper facilities and quality menstrual products. Girls with access to separate toilets and dustbins are much more likely to practice good hygiene, whereas dissatisfaction with menstrual products hinders proper practices. Improving access to sanitary facilities and providing affordable, high-quality menstrual products are essential to support better MHM in this community.

Implication of the study for practice

The study’s findings have several practical implications for improving MHM practices:

The study identified that poor MHM practices can lead to infections, absenteeism, and psychosocial stress. Therefore, public health policies should emphasize improving MHM resources and support services in schools to promote girls’ health and educational outcomes.

Also, the study highlighted a gap in menstrual health knowledge among some girls, underscoring the need for continuous education on menstrual hygiene, dispelling myths and addressing cultural taboos. Integrating menstrual health education into the school curriculum could enhance knowledge and reduce stigma.

Furthermore, limited access to affordable menstrual products was a challenge for many girls. Subsidizing menstrual products or establishing free distribution programs could help girls manage menstruation more comfortably and hygienically.

Lastly, since access to private toilets and dustbins significantly influenced good MHM practices, schools should prioritize the provision of clean, private, and adequately equipped sanitation facilities. This includes installing dustbins for proper disposal and ensuring access to water and soap.

Competing Interests

The authors declare no competing interests.

Ethical Approval

Approval for this study was obtained from the University of Health and Allied Sciences Research Ethics Committee, with approval number UHAS-REC A.4[092] 23-24. Written permission was also obtained from the Hohoe Municipal Ghana Education Directorate and the heads of the selected basic schools. Before data collection, written informed consent was obtained from both the participants and their parents or guardians. To ensure confidentiality and anonymity, all questionnaires were coded, and personal identifiers were removed. The completed questionnaires were stored securely under lock and key and were accessible only to the research team. All research activities adhered to relevant ethical guidelines and regulations to safeguard participants’ rights and data privacy.

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