Introduction

Adolescents (10–19 years) make up 16% of the world population and 23% of the Sub-Saharan Africa population. An adolescent is a critical time of rapid physical, psychological, and cognitive changes that affect how they feel, think, make the decision, and interact with the world around [1–4].

Menarche is a developmental milestone and is a transition period of girls from childhood to womanhood that happens during the adolescent period [5]. It is the foundation of menstruation, which is part of the female reproductive cycle that starts when girls become sexually mature during puberty [6].

Menstrual hygiene management (MHM) refers to personal hygiene during menstruation, which includes bathing, using sanitary pads and change pads regularly, and proper disposal of used materials [7]. A safe and effective menstrual hygiene management is a trigger for better development for adolescent girls, equipping them with knowledge and skills on MHM, which enhance their self-esteem, and positively impact their academic performance [8]. In this regard, safe MHM will play a role in the achievement of the sustainable development goals (SDG), including; good health and well-being (SDG 3), inclusive and impartial quality education (SDG 4), gender equality, and women’s empowerment (SDG 5), clean water and sanitation (SDG6) [9,10]. Yet, many adolescents are facing challenges in managing their menstruation at school especially in low and middle-income countries [9].

Poor MHM negatively influences the health, dignity, and privacy of millions of girls [11,12]. Menstrual hygiene-related problems have negative impacts on girl’s lifestyle, health, and developmental opportunities including absence from their school. Girls may also become worried due to consequences of poor MHM including, offensive smell, symptoms of reproductive tract infection such as itching of the vulva, pain during urination, and vaginal discharge [13–15].

In low and middle-income countries, MHM is a challenge for many girls mainly when attending school [6]. Girl’s education is a foundation of development and an entry point to many activities including politically, economically, socially participation. However, globally schoolgirls miss their classes during menstruation. In Bangladeshi, for example, about 38% of the urban schoolgirls and 42% of the rural schoolgirls reported missing classes during menstruation [12]. In India, one out of four girls is absent to attend school during the menstrual period [16]. Other studies conducted in India showed the proportion of good MHM practice among urban adolescents was almost two times compared to rural girls [17,18].

In Africa, studies revealed that 50% up to 70% of girls missed on average 1.6–2.1 days from school every month due to menstrual-related issues such as shame, pain, and uncomfortable among others [19,20]. In Ethiopia, about 43% up to 51% of students missed their class during the menstruation period [21,22]. Despite this huge problem, MHM did not receive the attention of educational policies and countries’ school curriculums in low and middle-income countries [23].

Studies in other countries have depicted that the magnitude of menstrual hygiene problems was higher in rural adolescent girls [17,18,24]. Whereas awareness of menstrual hygiene management among rural adolescents was low[18]. This indicates that urban-rural and area-based studies are important to understand the level of problems and develop evidence-based strategies to tackle the MHM-related problems. There are some studies conducted in Ethiopia among school adolescent girls [25–27], but didn’t analysis and interpret by urban and rural settings. In Ethiopia, there is cross-sociocultural diversity among the urban and rural community which affect mensural hygiene management practice. As the authors are aware there is one comparative study conducted in Ethiopia among urban and rural girls [28], but it was a community-based study that didn’t show the problem of MHM practice at school. Because of this, we believe that there is limited information about the proportion of good MHM practice and determinants for variation among adolescent girls by residences in Ethiopia.

Therefore, this study aimed to assess menstrual hygiene management practice and its associated factors among urban and rural schoolgirls in Northeast Ethiopia.

Materials and methods

Results

Socio-demographic characteristics

Five hundred and thirty-nine girls from each group (urban and rural) participated in this study. The mean (±SD) age of urban and rural schoolgirls was 17.2 (±1.3) and 17.5 (±1.6) years, respectively. The highest proportion, 395(73.3%) of urban and 309(57.3%) of rural schoolgirls were below 18 years. The mean(±SD) age of menarche was 13.3 (±1.10) and 13.89 (±1.03) years in urban and rural schoolgirls, respectively. Four hundred and sixty-three (85.9%) of the urban and 514(95.4%) of rural schoolgirls were Orthodox Christian followers (Table 1).

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Table 1. Socio-demographic characteristics of urban and rural schoolgirls in Northeast, Ethiopia, 2020 (N = 1078: 539 urban and 539 rural).

https://doi.org/10.1371/journal.pone.0257853.t001

Knowledge about menstrual hygiene

Overall, 670 (62.2%) of schoolgirls (74.4% among urban and 49.9% rural girls) were knowledgeable about menstrual hygiene. Four hundred twenty-nine (79.6%) of the urban and 158(29.3%) of the rural schoolgirls reported menstruation as a physiological process, while only 7(1.3%) of the urban and 15(2.8%) of the rural schoolgirls had no idea about the cause of it (Table 2).

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Table 2. Knowledge about menstrual hygiene among urban and rural schoolgirls in North Wollo Zone, Northeast Ethiopia, 2020 (N = 1078; 539 urban and 539 rural).

https://doi.org/10.1371/journal.pone.0257853.t002

Menstrual hygiene management practice

The overall prevalence of good menstrual hygiene management practice was 52.9% (95%CI: 50.3%-56.5%), which was 65.9% (95% CI: 62.8%-70.7%) among urban and 39.9% (95% CI: 36.2%- 44.6%) among rural schoolgirls (p<0.001). Four hundred and nine (88.9%) of the urban and 285(54.7%) of the rural girls were used commercial sanitary pads. The majority, 475 (88.1%) of urban and 455(84.4%) of rural school girls clean their external genitalia during menstruation. Almost a similar proportion, which was of the urban 448(83.1%) and the rural 439(81.4%) school girls had a habit of changing sanitary material during menstruation (Table 3).

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Table 3. Menstrual hygiene practice among urban and rural schoolgirls in Northeast, Ethiopia, 2020 (N = 1078; 539 urban and 539 rural).

https://doi.org/10.1371/journal.pone.0257853.t003

Factors associated with MHM practice among urban schoolgirls

Age of girls, discussions with parents about MHM, awareness on MHM before the onset of menarche, and learned about menstrual hygiene at school were significantly associated with MHM practice in the multivariable analysis. Schoolgirls below 18 years of and those who learned about menstrual hygiene at the school level were almost twice more likely to have good MHM practice as compared to their counterparts (AOR = 1.58, 95%CI = 1.05, 2.39) and (AOR = 1.89, 95%CI = 1.21, 2.97), respectively. The odds of good MHM practice among schoolgirls who heard about menstrual hygiene before the onset of menarche was 4.98 higher compared to their counterparts (AOR = 4.98, 95%CI = 2.71, 9.13). Those girls who did have an open discussion with parents on issues related to MHM were 2.56 more likely as compared to schoolgirls who did not have an open discussion about menstrual hygiene with their parents (AOR = 2.56, 95% CI = 1.25, 5.27) (Table 4).

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Table 4. Factors associated with menstrual hygiene management practice among urban schoolgirls in Northeast, Ethiopia, 2020 (n = 539).

https://doi.org/10.1371/journal.pone.0257853.t004

Factors associated with MHM practice among rural schoolgirls

Knowledge of menstrual hygiene, awareness of MHM before the onset of menarche, and learned about menstrual hygiene at school were significantly associated with good practice of MHM in the multivariate analysis. Schoolgirls who were knowledgeable about MHM were 5.47 more likely to have good MHM practice as compared to their counterparts (AOR = 5.47, 95%CI = 3.68, 8.12). The odds of good MHM practice among schoolgirls who learned about menstrual hygiene at school was 1.75 higher compared to schoolgirls who didn’t learn about menstrual hygiene (AOR = 1.75, 95%CI = 1.13, 2.70). Schoolgirls who awarded/heard about MHM before attaining their menarche were more likely to have good MHM practice as compared to their counterparts (AOR = 3.34, 95%CI = 1. 44, 7.76) (Table 5).

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Table 5. Factors associated with menstrual hygiene management practice among rural schoolgirls in Northeast, Ethiopia, 2020 (n = 539).

https://doi.org/10.1371/journal.pone.0257853.t005

Discussion

The overall prevalence of good menstrual hygiene management practice among schoolgirls was 52.9% (95%CI: 50.3%-56.5%), higher compared with the studies done in Bahir Dar (24.5%) [28] and western Ethiopia (39.9%) [31]. The reason for variation could be explained as the sociodemographic difference of study participants, about 18% and 36.4% of participants in the study Bahir Dar and western Ethiopia were didn’t attend formal education, and 67% of participants in the study Bahir Dar were rural residents, negatively affect good MHM practice [36]. However, it was lower compared to studies done in Bahir Dar (84.3%) [37], Mehalmeda (90.9%) [30], and Batu (66.8%) [38]. It could be explained that most of the participants in the above studies were urban residents, which enable them to access sanitary materials. Besides Bahir Dar and Mehalmeda’s studies had included grade 11 and 12 schoolgirls, which may positively affect practicing of good MHM.

The prevalence of good menstrual hygiene management practice among urban schoolgirls was 65.9% (95% CI: 62.8%-70%.7) higher compared to 39.9% (95% CI: 36.2%- 44.6%) among rural schoolgirls, which was made statistically significant (p<0.001). The urban-rural difference in MHM practice was reported from the studies done in other countries [17,18,24,39]. The reason for variation in menstrual hygiene management between urban and rural in Ethiopia might be the accessibility of sanitary materials to keep menstrual hygiene, which is more accessible and available in an urban setting. The other reason might be a sexual and reproductive discussion with parents is high in urban settings, which may enable them to be knowledgeable and pre-informed on mensural hygiene. Urban girls have better exposure to media, increasing the chance to acquire health information and communication on menstrual hygiene management practices than rural girls. However, study done in Bahir didn’t show significant variation between urban and rural adolescents, it was 29.5% among urban schoolgirls and 21.9% among the rural schoolgirls. In addition, it was very low compared to the current study in both settings [28]. It could be explained that 18% of participants in the study Bahir Dar were not attended formal educations negatively affect MHM practice. The other might be due to enhancement in accessibility and availability of sanitary pads, improvement in the understanding of schoolgirls about menstrual hygiene management, enrichment in water, and sanitary facilities in the school environment.

On multivariable logistic regression analysis, heard about MHM before the onset of menarche and learned about MHM at school were associated with MHM practice at both settings. Besides, the age of girls and discussion on MHM in urban schoolgirls and Knowledge of MHM in rural schoolgirls were significantly associated with Good MHM practice.

Rural schoolgirls who were knowledgeable on menstrual hygiene were more likely to practice good menstrual hygiene as compared to their counterparts. This finding was supported by studies conducted in Wogera [33], Mehalmeda [30], Gedeo [40], and Ghana [41]. The reason for this might be the more they are aware of menstrual hygiene, the more likely they will develop confidence. However, it didn’t associate MHM practice among urban schoolgirls, might be the majority of urban schoolgirls are committed to it.

The current study also, reveals that urban schoolgirls aged below 18 years were more likely to practice good menstrual hygiene compared to schoolgirls aged 18 or above years. This finding was supported by studies conducted in Ambo [42] and Iran [43]. This could be explained that most of the time younger age girls are more likely to be supported by family, enable them to practice good menstrual hygiene [44], yet didn’t associate with rural schoolgirls. The reason might be most rural mothers are not using a sanitary pad, they may not encourage their daughters to practice good menstrual hygiene.

Urban schoolgirls who had an open discussion with parents about menstrual hygiene were more likely to practice good MHM practices than their counterparts. This result was supported by studies conducted in Addis Ababa [45] and Ambo [42]. The reason for this might be the more they discuss menstrual hygiene and other sexual and reproductive health issues, the more likely they will develop confidence and get support from their families, and also easy for schoolgirls to get hygiene-related materials without frustration.

Being learned about menstrual hygiene in the school, and hearing about menstrual hygiene before the onset of menarche were found to be associated with good MHM practice among both urban and rural schoolgirls, was agreed with other studies done in Addis Ababa [45], Ambo [42], and Mehalmeda [30]. The reason might be schoolgirls who are exposed to information regarding menstrual hygiene may increase their knowledge and confidence in menstrual hygiene management. The other reason might be sexual and reproductive education enables them to easily appreciate the potential threat and complication of the poor menstrual hygiene management.

The strength of this study was that, showed what looks menstrual hygiene management practice among urban and rural schoolgirls using separate sample sizes for each. The other strength was some observational information, not collected by other studies such as water and toilet availability and WASH facilities that could affect the menstrual hygiene management practice are reported. The limitation of this study was that the cross-sectional nature of this study may not show a causal-effect relationship between the outcome and explanatory variables.

Conclusions

The overall good menstrual hygiene practice was low, it was relatively higher among urban schoolgirls than rural residents. There were disparities and similarities in factors of menstrual hygiene practice among the two settings. Learned about menstrual hygiene at school and being aware of the subject before the menarche were common factors both in urban and rural school girls. Among urban schoolgirls; age and discussed menstrual hygiene with their parents were also significantly associated with Good MHM. Knowledge on menstrual hygiene also associated with good MHM practice in rural schoolgirls.

This calls for more effort from the stakeholders to solve these problems and achieve sustainable development goals (goal 3, 4, 5, and 6). Therefore, strengthening adolescent girls’ education and awareness creation about menstrual hygiene at school even before menarche may improve good menstrual hygiene management practice among schoolgirls in both settings. In addition, encouraging open discussions with families on menstrual hygiene, particularly urban schoolgirls, may also improve menstrual hygiene management. At any effort, more emphasis should be given to rural school girls.

Supporting information

Acknowledgments

We would like to express our gratitude to the north wollo Zonal education office, schools, study participants and their parents, data collectors, and Bahir Dra university, college of Medicine and Health Sciences for their contribution to do this study.