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Development & validation of a health education module on menstrual health for adolescent girls: A Pilot study
#Present address: Department of Community Medicine, Kanachur Institute of Medical Sciences, Mangaluru, Karnataka, India
For correspondence: Dr Farzana Ummer B.K., Department of Community Medicine, Kanachur Institute of Medical Sciences, Mangaluru 575 018, Karnataka, India e-mail: farzana.ummer@yahoo.com
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Received: ,
Accepted: ,
Abstract
Background & objectives
Adolescent females must practise proper menstrual hygiene to avoid any misconceptions or myths about the menstrual cycle. A health education module for a school-based intervention was created with the goal of enhancing knowledge among adolescents. The study was conducted to develop and validate a health education module and to assess the feasibility of the module.
Methods
Following a thorough literature review, a module pertaining to various components of menstrual health for adolescent females was developed. The developed module was validated by experts. Ratings provided were used to calculate content validity index (CVI) for items, CVI for scale (S-CVI) and Universal agreement (UA). The final module was pilot tested at two schools using random sampling.
Results
For computation of the content validity index (CVI) [CVI for item (I-CVI) and CVI for scale (S-CVI)] and Universal agreement (UA) was used. S-CVI/Ave was found to be 1, and S-CVI/UA was found to be 1. UA was 1, and I-CVI was 1. Post health education, there was a significant increase in knowledge scores among participants (P<0.001). Among adolescents, 74.6 per cent agreed that the tables/diagrams were well presented and easy to understand and 83.6 per cent of participants comprehended the various self-care practices during the menstrual cycle. Based on the computations from the formulas employed, the module was found to be satisfactory for usage. Almost all the adolescent participants had rated either 4 or 5 on the Likert scale for acceptance of the module.
Interpretations & conclusions
The I-CVI, S-CVI/Ave, and S-CVI/UA meet the satisfactory level, meaning that the module’s content validity was at a satisfactory level. There was a noteworthy rise in knowledge scores (P<0.001) post health education. The participants gave the module positive feedback and reported that it increased their understanding regarding menstruation.
Keywords
Adolescents
health education
menstruation
module
validation
Adolescence is the transitional period between childhood and adulthood, from ages 10 to 19. With 253 million adolescents, India has the biggest adolescent population globally, with 10 to 19 yr olds making up every fifth of the population. It is a unique period in human growth and a crucial time to establish the groundwork for long-term health1.
Menarche is the term used to describe a female adolescent’s first menstrual cycle. The average age at which menarche begins is 12.4 yr old, and it usually happens between the ages of 10 and 16. Menarche typically comes on suddenly and without any pain. In many nations, the menstrual cycle causes unthinkable disruptions to females’ lives. In India, a minimum of 42 per cent of girls choose to use cloth sanitary napkins over disposable ones2. Menarche is closely linked to the continuous development of secondary sexual characteristics and marks the onset of reproductive capacity3.
Negative emotions that girls experience during their periods are caused by a variety of factors, including inadequate knowledge and advice regarding menstruation, inadequate infrastructure for water, sanitation, and hygiene in schools, restricted access to menstruation supplies, and unsupportive social environments where girls must deal with bullying, secrecy, and social norms that dictate a range of behavioural restrictions4. Unfortunately, teachers and caregivers frequently feel unprepared to impart this knowledge to these adolescents5.
Effective menstrual hygiene is crucial for all adolescent females, and they should have talks about menstrual hygiene to dispel any misconceptions and myths that may exist regarding menstruation. Giving girls the information and tools they need to maintain their menstrual hygiene helps them to attend school regularly, and without these, they would not attend at all or might even stop during those days6. Moreover, giving them health education boosts their confidence and self-worth, enabling them to handle the situation as a typical occurrence in life. This study was conducted as the initial part of a large study, and the objectives and findings presented in this article are limited to module development and validation and the findings of field testing this module as a pilot study. This study was done to develop and validate a health education module to use among adolescents, which has domains regarding puberty, menstruation-related aspects, and to debunk common myths and misconceptions. Also, this study was done to assess the feasibility of the developed validated module in a pilot sample.
Materials & Methods
This study was undertaken by the department of Community Medicine, KS Hegde Medical Academy, Mangaluru, Karnataka, India. The PALMS (P for puberty and physiology, A for adolescents and anatomy, L for learning to live with it, M for menstruation, menstrual hygiene, myths, misconceptions, S for symptoms and self-care practices) module development included four phases conducted over a course of six months, starting from July 2022 to December 2022.
Study participants
For validation of the module a total of six experts who agreed to validate the module were selected from different parts of the State. Experts included faculty working in medical teaching hospitals with more than five yr of experience. Of the six experts, five belonged to the community medicine specialty of whom six were from within Karnataka State and one from outside the State. The panel of experts also included a pediatrician. For the pilot study adolescent girls studying in standard eight were selected from two schools to conduct the pilot study. Consent from parents was taken. Assent forms were from students participating were also provided. Ethical clearance from the Institution was taken and study was conducted. Required permissions were taken from the block education officer and the principal of the schools visited.
Phase 1
The initial phase consisted of an extensive literature survey via electronic databases, including PubMed and Google Scholar. Relevant articles and education modules related to menstruation were referred to obtain more clarity on the topic. Different training materials for Accredited Social Health Activist (ASHA) and Anganwadi workers regarding menstruation by the National Health Mission were also taken into account. Phase 1 of module development was an iterative process of literature survey and review by the researchers. The module was divided into six sections under the following headings, (i) set induction, introduction, and puberty; (ii) overview of Anatomy and Physiology; (iii) symptoms during menses/periods; (iv) self-care and remedial measures during menses/periods; (v) menstrual hygiene management; and (vi) myths and misconceptions regarding menses/periods (Table I).
| No. | Topics | Content |
|---|---|---|
| 1 | Set induction & introduction |
Story telling Introduction to puberty Puberty changes Secondary sexual changes Menarche |
| 2 | Overview of anatomy & physiology |
Introduction to female reproductive organs Introduction to physiology of menstruation. |
| 3 | Symptoms during menses/periods |
Menstrual symptoms Pre-menstrual symptoms Other symptoms |
| 4 | Self-care & remedial measures during menses/periods |
Ways to live with menstruation Coping mechanism Food habits Different types of yoga poses Measures to reduce dysmenorrhea Measures to reduce stains Measures to reduce odour |
| 5 | Menstrual hygiene management |
Menstrual hygiene Different types of absorbents Ways of absorbent disposal |
| 6 | Myths & misconceptions regarding menses/periods | Debunking the most common misconceptions & myths related to periods |
Phase 2
After continuous brainstorming, a module named “PALMS” was created. Where ‘P’ stands for ‘puberty and physiology,’ ‘A’ stands for ‘adolescents and anatomy,’ ‘L’ stands for ‘learning to live with it,’ ‘M’ stands for ‘menstruation, menstrual hygiene, myths, and misconceptions,’ ‘S’ stands for ‘symptoms and self-care practices’. This module contains all these aspects in regard to menstruation. Simple pictorial diagrams, which were non-copyrighted using the Canva web-based application, were placed wherever necessary. To meet the reading levels of readers, the PALMS module was produced with fewer texts, appropriate font sizes, and simpler phrases. To guarantee a better comprehension of the module, bright images and pictures with captions were used. Culturally appropriate information, since lifestyle recommendations are closely tied to cultural norms, was considered as common food practices and customs ought to be incorporated into the cultural component. Apart from a thorough literature review, general perceptions regarding myths, practices at home during menstruation and sources of information regarding menstruation were asked from ten random adolescent girls around the study setting area and a free list was created in order to incorporate issues/concerns while being culturally appropriate.
Phase 3
PART 1: General content validation:
The expert panel comprised two medical healthcare professionals belonging to the speciality of community medicine with experience ranging between ten to fifteen yr who have worked in the field of adolescent health were the experts for validation. The content validation had the questions regarding various domains including content of the module, language of the module and the presentation of the module. Each domain had further sub questions rating from 1 to 4, with 1 indicating’not relevant’, 2 for ‘somewhat relevant’, 3 for ‘quite relevant’, 4 for ‘highly relevant’. Based on recommendations provided, the necessary modifications were done in the PALMS module.
PART 2
Content validation of each item included in the module was done by computing the content validity index (CVI). CVI for item (I-CVI) and CVI for scale (S-CVI) Universal agreement (UA) were used. I-CVI is the percentage of content experts who rank an item as relevant in either a 3 or a 47,8 and was calculated as follows:
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(a)
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(b)
S-CVI/Ave was calculated as the sum of I-CVI scores divided by the number of items. S-CVI based on the UA method (S-CVI/UA) is the percentage of scale items that receive a relevance score of three or four from all experts. When there was a 100 per cent agreement among experts on a subject, the UAscoreis1. Otherwise, it was 07,8.
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(c)
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(d)
Experts in agreement was calculated by simply adding up the pertinent ratings given by experts for each item.
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(e)
UA was calculated as the score of ‘1’ was given to the item that received unanimous agreement from all experts.
The permissible CVI cut-off score according to the number of experts varied dependingon the number of experts7,8.
For two experts, the CVI should typically be 0.80, for 3-5 experts CVI should be 1, and for 6-8 experts CVI should be at least 0.83 for it to be considered as a validated tool for the usage.
Based on the reference articles7,8, the following computational formulas were used to get the UA, I-CVI, S-CVI scores and Relevance rating
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1.
I-CVI=(items agreed upon)/ (number of experts).
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2.
S-CVI/Ave=(sum of I-CVI scores)/ (number of items)
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3.
S-CVI/Ave=(sum of proportion relevance rating)/ (number of experts)
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4.
S-CVI/UA=(sum of universal agreement scores)/ (number of items)
Procedure undertaken for Validation
‘Theoretical analysis’ or ‘content validity’ refers to the ‘adequacy with which a measure assesses the domain of interest’7,8. Experts were given clear access to the definition of the domain and the items that were reflected in the content validation form. Since more experts were willing to do more comprehensive validation in terms of each item of the PALMS module, six experts did another content validation of each item per se. Experts were from different parts of the State, and one expert was from outside the State to make sure the module can be used in different settings, apart from the study site. Though from one State, experts belonged to areas from different parts of the State. Also, the expert from a different State was selected based on his/her experience in research particularly in adolescent health. Keeping all this in mind, the selected experts were requested to validate the module.
The content validation had a further rated scale ranging from 1, which was ‘not relevant’, to 4, which was ‘highly relevant’. Experts were asked to rate the module under the headings: feasibility of the module, length of the module, usefulness of the module and reproducibility of the module. Further changes were incorporated in the module based on deliberation and as suggested by the experts.
Phase 4
The final stage of the module was testing at the ground level. Two schools were selected by convenience sampling to test the module. Narratives, flipcharts, and PowerPoint presentations were used for the content delivery. As a set induction, narratives with a storytelling of an imaginary character, a girl named Maya, belonging to the same age as the selected students, were taken. The story started with Maya getting her first period and how she handled it, and the challenges she faced were put across so that students could understand the story. As the narrative went on, this was interspersed with an understanding of anatomy and physiology of menstruation, symptoms, and self-care practices, myths, and misconceptions regarding menses and information about how to tackle problems and whom and how to seek help from. The session was conducted with active involvement of the adolescents, for whom this module was provided as a health education, as we start to deliver every aspect of menstruation.
The content delivery was made by a PowerPoint presentation, having pictorial representations of each topic of the module in a simpler manner. Flip charts were used when the group size was small enough or there was no provision for PowerPoint presentation. The content in both flipchart and PowerPoint presentation was the same, having easy pictorial representation and easy-to-understand written information in a concise format. Photographs of a peer with remedial poses to combat dysmenorrhea were included in the module.
Materials that can be used during menstruation, such as sanitary pads, tampons, and menstrual cups were also kept handy during the dissemination of the module. Pictorial demonstration regarding their use was made to ensure that the content was delivered more efficiently by every means possible. The health education thus delivered was not just a one-way communication; rather it was more interactive for better comprehension.
Soon after the health education delivery, immediate feedback from the pilot study from two schools that were randomly selected was collected to calculate the difficulty index of the module. The steps involved in the development of the module are shown in the form of a flow chart (figure).
- Steps in development of the PALMS (P for puberty and physiology, A for adolescents and anatomy, L for learning to live with it, M for menstruation, menstrual hygiene, myths, misconceptions, S for symptoms and self-care practices) module.
Sample calculation for the pilot study
For the larger study, the sample size was calculated by taking the proportion of knowledge of menstruation among adolescent girls (39.4%) from a previous study9. Using this proportion and relative precision of 5 per cent, the sample size was calculated to be 382 using the formula Z=4pq/d2. Upon adding 10 per cent of the sample size for non-responders, the total number was calculated to be 420.2, which was rounded off to 420.
Therefore, this study required 10 per cent of sample size (n=42). To get this pilot study sample, two schools were visited, and the health education module was delivered to the respective adolescent girls in the schools. The total number of these participants in this study was 67.
Results
In this study, the non-face-to-face method of content validity was used, detailed instructions were given to experts, and an online content validation form was also issued. The calculated I-CVI was 1 for all items, Proportion relevance and average proportion was also 1, respectively. This shows a high relevance on various factors assessed in our study (Table II). The relevance rating on all four domains i.e., feasibility, length, usefulness of the module and reproducibility of the module was rated between 4 and 5 by the experts, thus showing a good relevance of module contents with regard to menstrual hygiene (Table III). None of the experts disagreed on the module, and a higher percentage of ratings were seen for agreement, which consisted of good and very good for the various aspects that were covered in the module.
| Sl. No. | Items | Expert 1 | Expert 2 | Experts in agreement | I-CVI | UA |
|---|---|---|---|---|---|---|
| 1 | The content of each section is simple & easy to understand | 1 | 1 | 2 | 1 | 1 |
| 2 | The content is appropriate for the age group chosen | 1 | 1 | 2 | 1 | 1 |
| 3 | The topics of each section are fully discussed | 1 | 1 | 2 | 1 | 1 |
| 4 | The topics are supported by illustrative pictures & explanatory | 1 | 1 | 2 | 1 | 1 |
| 5 | Each topic is given equal emphasis in the individual section | 1 | 1 | 2 | 1 | 1 |
| 6 | The language used is easy to understand | 1 | 1 | 2 | 1 | 1 |
| 7 | The topics are presented in a logical and sequential order | 1 | 1 | 2 | 1 | 1 |
| 8 | The format/layout is well organized | 1 | 1 | 2 | 1 | 1 |
| 9 | The addition of a story format makes the module easy to deliver | 1 | 1 | 2 | 1 | 1 |
| 10 | The usage of flipcharts will make it easy for the module delivery | 1 | 1 | 2 | 1 | 1 |
| Proportion relevance | 1 | 1 | S-CVI/Ave | 1 | ||
| Average proportion | 1 | S-CVI/UA | 1 | |||
UA, universal agreement; I-CVI, item-level content validity index; S-CVI, scale-level content validity index; Sl. No., serial number
| Domains under relevance rating | Expert 1 | Expert 2 | Expert 3 | Expert 4 | Expert 5 | Expert 6 |
|---|---|---|---|---|---|---|
| Feasibility of the module | 5 | 5 | 5 | 5 | 5 | 5 |
| The length of the module | 4 | 4 | 5 | 5 | 4 | 5 |
| Usefulness of the module | 5 | 5 | 5 | 5 | 4 | 5 |
| Reproducibility of the module | 5 | 4 | 5 | 5 | 4 | 5 |
With regard to pilot testing of the module the post test scores after the delivery of health education as per the module developed was much higher than the pre test scores and this was found to be highly significant in the study. Pre- and post-tests were done among selected schools to find out the effectiveness of the module. Pre-test scores and post-test scores were compared using Wilcoxon signed rank test (w=16). Post health education, there was a significant increase in knowledge scores among study participants as the average knowledge score increased post health education (Table IV).
| Variables | N | Median (Q1-Q3) |
|---|---|---|
| Pre-test | 67 | 12 (11-13.5) |
| Post-test | 21(19-23)* |
P*<0.001 is considered significant
The relevance ratings on the item scale by six experts for the content validation in a Likert scale of 5, where 1 stands for very poor to 5 for very good, are shown in table III. None of the experts disagreed on the module, and a higher percentage of ratings were seen for agreement, which consisted of good and very good for the various aspects that were covered in the module.
Feedback on the difficulty index by the adolescents who participated in the pilot study
Using a Likert scale, the participants were asked to rank their thoughts on the health education module’s components (Table V). Where score 1 indicated ‘strongly disagree’ and score 5 for ‘strongly agree’. Opinions on how easy it was to comprehend the module were more evenly split, despite the fact that participants generally believed that the teaching approach improved knowledge. The results showed that the module was well-received generally and that it was successful in increasing participants’ understanding of menstruation and associated topics. Among the adolescents 74.6 per cent agreed that the tables/diagrams were well presented and easy to understand. Furthermore, 83.6 per cent participants comprehended about the various self-care practices during menstrual cycle. Among the pilot study participants 88.1 per cent agreed upon that the session was interesting. Lastly, almost everyone had rated either 4 or 5 on Likert scale for acceptance of the module. The relevance rating by all six experts on each items of the module is given in supplementary table.
| Questions | Strongly disagree | Disagree | Neutral; n (%) | Agree; n (%) | Strongly agree; n (%) |
|---|---|---|---|---|---|
| The tables/diagrams are well presented and easy to understand. | 0 | 0 | 3 (4.5) | 14 (20.9) | 50 (74.6) |
| I understood the concepts better in general | 0 | 0 | 1 (1.5) | 20 (29.9) | 46 (68.6) |
| I understood the physiology of menstruation | 0 | 0 | 0 | 20 (29.9) | 47 (70.1) |
| I understood about menstrual symptoms | 0 | 0 | 4 (6) | 11 (16.4) | 52 (31.1) |
| I understood about the various self-care practices during menstrual cycle | 0 | 0 | 2 (3) | 9 (13.4) | 56 (83.6) |
| I got a better understanding about the myths and facts about menstruation | 0 | 0 | 1 (1.5) | 21 (31.3) | 45 (67.2) |
| The stories helped me to understand the concept better. | 0 | 0 | 5 (7.5) | 9 (13.4) | 53 (79.1) |
| The session was interesting | 0 | 0 | 0 | 8 (11.9) | 59 (88.1) |
Discussion
Content validity delineates content representations and relevance, i.e., that the items accurately reflect the pertinent experience of the community under investigation10,11. Since the primary objective of the study was content validation of the developed module pertaining to various aspects around menstruation including anatomy, physiology, changes during puberty, myths and misconceptions, pre-menstrual and menstrual symptoms, menstrual hygiene, easy to use lifestyle strategies, the I-CVI, S-CVI/Ave, and S-CVI/UA scores reached a satisfactory level, indicating that the module had attained a satisfactory degree of content validity. With respect to the knowledge change in the pilot sample, the findings showed a significant increase in knowledge scores post health education using the module (P<0.001).The feedback from the participants involved in the pilot sample was positive with respect to their understanding of menstruation and related subjects, which was scored using the difficulty index.
Menarche marks a significant turning point in girls’ journey towards womanhood. But if girls are not prepared for effective menstrual hygiene management, menstruation can pose serious barriers to their access to health, education, and future opportunities. To practise good menstrual hygiene management, one must have access to the required supplies (such as menstrual blood absorbers or collectors, soap, and water), facilities (such as a private area for washing, changing, and drying reusable menstrual materials in addition to a suitable menstrual waste system), and information about menstrual hygiene management. Further studies are necessary to determine whether adolescent girls in low-income countries will accept and use alternative menstrual hygiene management (MHM) products, as it is uncertain which products are suitable for them. One example is that of a menstrual cup among these girls’12. Girls are likely to miss school or find it difficult to focus and engage in class when they are menstruating. In many low- and middle-income countries, there is a shortage of adequate information, resources and facilities for appropriate MHM13. A study done in Nepal found that a lot of females dealt with fear, anxiety, perplexity, bullying, and a lack of reliable information and guidance. Due to their periods, approximately 15–20 per cent of girls missed school14. Menarche and menstruation were mostly portrayed in feminist writing as unpleasant, shameful, and something to be concealed, especially in the setting of schools. Additionally, menstruation is portrayed as a disease15.
In another study, it was observed that menstruation pads were being disposed off in more covert locations, such as latrine pits, bushes near schools, under rocks at beaches, communal trash piles, and backyard fires. The girls detailed their attempts to dispose of the garbage secretly. The private nature of menstruation and personal hygiene concerns made teachers reluctant to discuss them in a formal classroom setting16. Improving menstrual management and ensuring that absorbent materials do not compromise the efficiency of sanitation systems requires knowledge of appropriate menstrual material disposal practices, as well as the actual provision of disposal facilities17.
In every country, there is a persistent unfavourable perception of menstruation that limits the activities of girls and requires them to follow menstrual etiquette. While most of the scant research that has been conducted so far has focused on the necessity of bettering school water and sanitation systems, other studies have also emphasised how crucial it is to create and offer realistic, culturally relevant menstrual guidance to girls going through puberty18. There is insufficient research on the effects of inadequate MHM environments or guidance on schoolgirls’ self-esteem, their confidence in their ability to manage their menstruation in school, and their capacity to focus in class rooms without enough WASH facilities or teachers and peers who are sensitive to the issue. Furthermore, not enough studies have been done to evaluate the effects of programmes meant to boost girls’ self-confidence and lessen bullying connected to menstruation19.
Adolescent girls often have limited understanding about menstruation as they grow up, and since their mothers and other women are reluctant to talk to them about the topic20. Also, adult women may convey cultural taboos and regulations that must be followed rather than knowing the biological truths or appropriate hygiene procedures to these adolescent girls20. Therefore, community-based health education as well as more education about menstruation must be provided to school teachers as well20.
In another study done in rural Kenya21, girls frequently stated that they had never heard of menstruation before, only realising that it existed after they started bleeding. Furthermore, many parents also acknowledged this, recognising that they had not prepared their daughters for menstruation prior to menarche21. Without preparation, a female adolescent’s menarche may continue to be a stressful experience. In a study done among adolescents, the girls stressed the importance of receiving emotional support, in order to ensure that menstruation is natural and healthy and not awful, terrifying, or shameful22.
Enhancing knowledge about menstruation, including cycle duration and hygiene needs, is thought to boost self-efficacy, enhance management techniques, and lessen anxiety23. Enhancing the ability to properly manage menstruation, boosting confidence in menstrual-related management, and education interventions will help the girls to increase their school attendance and classroom engagement24,25.
The study limited itself to six experts, which is the minimum requirement as per literature review7,8. Most of the experts belonged to various parts of the single State, while one expert was selected from a different State. Though the domain expertise was taken into consideration prior to obtaining validation of the module, the study could have looked into other experts from a few other States as well; however, this was not be achieved in this study. This was a self-funded study; hence, the conduction of this study was done only in a limited setting in South India. Also, attitude and behaviour changes could not be assessed owing to the fact that it requires more than one contact for information collection from the participants. Feasibility issues, considering consent from parents and schools also was a challenge and limitation in this study. Though the entire session with respect to the module developed was delivered to the students, time constraints faced was another limitation as menstrual health is a wide topic to be covered to provide comprehensive knowledge, which would empower adolescents with the right amount of awareness.
The computation leads us to the conclusion that the I-CVI, S-CVI/Ave, and S-CVI/UA indicated satisfactory scores with a significant increase in knowledge score post health education using the module (P<0.001). Overall, participants gave the module positive feedback and reported that it increased their understanding of menstruation and related subjects. Overall, the PALMS module developed in this study can be used at the local level as well as across States. The module can be further expanded in different languages, retaining the same content and used in different settings among adolescent girls.
Financial support & sponsorship
It is a self-funded study.
Conflicts of Interest
None.
Use of Artificial Intelligence (AI)-Assisted Technology for manuscript preparation
The authors confirm that there was no use of AI-assisted technology for assisting in the writing of the manuscript and no images were manipulated using AI.
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