Menstrual pain and psychosocial wellbeing among adolescent girls in Hohoe, Ghana

Menstrual pain and psychosocial wellbeing among adolescent girls in Hohoe, Ghana | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Menstrual pain and psychosocial wellbeing among adolescent girls in Hohoe, Ghana Sitsofe Gbogbo, Israel Wuresah, Priscilla Klutse, Francis Agyei This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7075276/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Menstrual pain, or dysmenorrhea, is a prevalent issue among adolescent girls, affecting their psychosocial well-being. In Ghana, where cultural stigmas and limited healthcare access persist, the psychosocial impact of menstrual pain remains underexplored. This study investigated the effect of menstrual pain on psychosocial well-being among adolescent girls in Hohoe, Ghana. This cross-sectional study was conducted in a basic school in Hohoe, involving 98 adolescent girls aged 10–19 (mean = 13.4, SD = 1.4). The participants were selected through random sampling, and data were collected using the Strengths and Difficulties Questionnaire (SDQ), which assessed their emotional, social, and behavioral difficulties. Descriptive statistics and MANOVA were performed. Half of the participants (50%) reported severe menstrual pains and 23.5% and 9.2% reported moderate and mild pain respectively. Overall, 20.4% reported high psychosocial difficulties, with higher difficulties were reported in emotional challenges (25.5%), conduct problems (21.4%). Menstrual pain had significant effect on psychosocial wellbeing, with those reporting severe pain reporting higher difficulties in conduct problems. This study found that while many teenage girls showed normal prosocial behavior, some also faced emotional and behavioral challenges, with menstrual pain linked to conduct issues. The study stresses the need for holistic support, addressing both physical and mental health in schools. Menstrual health mental health dysmenorrhea adolescent health Figures Figure 1 Figure 2 Introduction Menstrual pain, or dysmenorrhea, is a common issue among adolescent girls, significantly affecting their psychosocial well-being and overall quality of life [ 1 ]. Research indicates that dysmenorrhea can lead to considerable absenteeism from school and decreased participation in daily activities, which in turn can exacerbate feelings of anxiety and depression among affected individuals [ 2 – 4 ]. The impact of menstrual pain extends beyond physical discomfort, affecting various aspects of an adolescent girls’ life. For instance, girls experiencing severe pain may withdraw from social activities, sports, or academic pursuits, potentially leading to a sense of isolation or reduced self-esteem. These effects can accumulate over time, influencing academic performance, social relationships, and future career aspirations. The psychosocial implications of menstrual pain are particularly concerning in low- and middle-income countries, where cultural stigmas and lack of access to healthcare resources may further hinder adolescents from seeking appropriate care [ 5 , 6 ]. In many such settings, menstruation itself is often surrounded by myths, taboos, and misinformation, creating additional barriers to open discussion and proper management of menstrual health issues. In Ghana, the intersection of menstrual pain and psychosocial well-being among adolescent girls remains underexplored, despite the global recognition of the issue. The country’s diverse cultural landscape, varying levels of education, and disparities in healthcare access contribute to a complex environment for addressing menstrual health concerns [ 7 – 9 ]. Urban and rural differences in Ghana also play a role in shaping girls’ experiences with menstrual pain and their access to information and care. The psychosocial effects of dysmenorrhea are not merely a consequence of physical pain, they are intertwined with the social and emotional dimensions of adolescent life. Girls experiencing severe menstrual pain often report lower quality of life scores, indicating that the impact of dysmenorrhea extends beyond physical discomfort to include emotional distress and social withdrawal [ 2 , 3 ]. This can manifest in various ways, such as reduced confidence, increased irritability, mood swings, and difficulties in maintaining consistent academic performance or participation in extracurricular activities. The use of standardized tools, such as the Self-Reported Strengths and Difficulties Questionnaire (SDQ), can provide valuable insights into the psychosocial challenges faced by these adolescents, allowing for a comprehensive understanding of how menstrual pain influences their mental health and social interactions [ 10 , 11 ]. The SDQ assesses various aspects of adolescent mental health, including emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behavior. Given the significant implications of menstrual pain on adolescent girls’ psychosocial well-being, this research investigated these relationships within the context of Hohoe, Ghana. This study contributes to the growing body of literature on menstrual health and its psychosocial ramifications, ultimately informing better health education and intervention strategies tailored to the needs of this vulnerable population [ 12 , 13 ]. The findings from this research have the potential to inform policy decisions, educational programs, and healthcare interventions in Ghana and similar settings. Understanding the specific psychosocial challenges faced by adolescent girls with dysmenorrhea will help stakeholders to develop targeted interventions that address not only the physical aspects of menstrual pain but also its emotional and social implications. This holistic approach is important for improving the overall well-being and future prospects of adolescent girls, ensuring that menstrual health issues do not become barriers to their personal, academic, and professional development. Methods and Materials Setting The Hohoe Municipal is one of Ghana’s 275 Metropolitan, Municipal, and District Assemblies. It is practically in the middle of the area with longitudes of 00 15’E and 00 45’E and latitudes of 6045’N and 7015’N. The Educational System in Ghana is divided into various levels of schooling including, Kindergarten, Primary, Junior High, Senior High, TVET and Tertiary. Currently, the Municipality has 149 schools with 1,303 teachers at Kindergarten to Technical and Vocational level. The tertiary schools are made up of 2 teacher training schools, 1 midwifery training school and 1 University. The Municipality has about eighty-four junior high schools (Ghana Education Service Hohoe, 2019). The study was conducted in a basic school among pupils in primary six to junior high school (JHS) two. Study design A quantitative descriptive cross-sectional study design was employed to assess the psychosocial well-being of adolescent girls in relation to their menstrual health, herein defined as pain during menstruation, in a basic school in Hohoe. This design was use because it provided insights into the psychological and social strengths and difficulties faced by adolescent girls regarding menstrual health in basic schools in Hohoe, Ghana, at a single point in time. It is a relatively inexpensive approach and can be conducted within a short period. Study population The study population included adolescent girls between the ages of 10 and 19 who are menstruating in basic schools in the Hohoe municipality. Sample size and sampling procedure At a confidence level of 95% such that the real value is within ± 5% of the population surveyed, the study included 98 adolescent girls in the study as computed below using Cochran’s formula [ 14 ]: n= \(\:\:\frac{{z}^{2}*p(1-p)}{{e}^{2}}\) where n = sample size, z = z-score at 95% confidence level, p = proportion of female adolescents in the Volta region, and e = margin of error. This implied that; z = 1.96, p = 6.6% [ 15 ] and e = 0.05 That is, n= \(\:\frac{{1.96}^{2}*0.066(1-0.066)}{{0.05}^{2}}\) = 94.7 = > 95. The study purposively selected the basic school due to limited resources. Once in the selected school, classrooms from which students were sampled were selected on a convenience basis, specifically primary six to JHS two. A simple random sampling technique was then used to enroll 98 adolescent girls into the study. Once in the classroom, a ‘yes or no’ probability sampling style was employed, where students who picked the pieces of paper with the ‘yes’ inscription were enrolled onto the study. Data Collection Instruments and Methods The Strengths and Difficulties Questionnaire (SDQ, UK English version) which is globally used to screen for behavioral markers of potential mental health problems in children and adolescents [ 16 – 18 ] was adopted for this study. Preceding the administration of the questionnaires is a clear explanation of the nature of the questionnaire to the study participant. Moreover, participants were well informed about the risk and the benefits of participating in the study, that their anonymity and confidentiality was assured. Adolescent girls who consented to participate were asked to sign a consent form after parental approval. An interviewer administered the questionnaire to the participants to ensure accurate response, using mobile devices. A database created in Kobo Toolbox was the server for receiving the data after each day’s work. Data processing and analysis The data was extracted as an excel file and exported into STATA 17.0 for analysis. Also, Microsoft Excel 2021 was used to generate graphs. Descriptive statistics including frequencies and percentages, and summary statistics were used to summarize the data. Analysis of Variance (ANOVA), and Multivariate analysis of variance (MANOVA) were used to determine association between menstrual pain and psychosocial well-being in adolescent girls. The dependent variable was menstrual pain and independent variables were the subscales and total strengths and difficulties scale. The statistical significance threshold of p < 0.05 was used. Ethical considerations This research was conducted in accordance with the Declaration of Helsinki. Ethical approval was issued by the University of Health and Allied Sciences’ Research Ethics Committee [UHAS-REC A.6 l2l23-24]. Permission was sought from the Ghana Education Service and E.P Basic school administration. Participation in the study was voluntary, and anonymity and the right to withdraw were honored. In addition, we collaborated with school officials to get formal (written) informed consent from parents. Prior to each session, participants signed off a provided written informed consent and assent. There were no direct or reputational risks for individuals who participated in the research study. Participants’ confidentiality was strictly protected. Results Characteristics of the study participants The study involved adolescent schoolgirls aged between 10–19 years in a cluster of basic schools in Hohoe Ghana. Table 1 presents the sociodemographic descriptions of the participants. Majority (78.6%) of the participants were aged 10–15 years old. The predominant ethnic group was Ewe (51.0%), followed by Hausa (19.4%). Most participants identified as Christian (67.4%). The majority were in Junior High School (JHS), with 42.9% in JHS 2. Most girls (98%) experienced menarche at age 10+. About 72.4% of the girls reported being able to discuss menstruation openly, and 56.1% felt they had adequate information on menstruation. Table 1 Sociodemographic and basic menstruation information Variable Frequency, N = 98 Percentages Age ( Mean→SD ) 14.4 1.4 10–15 77 78.6 16–19 21 21.4 Ethnicity Ewe 50 51.0 Akan 9 9.2 Guan 7 7.1 Hausa 19 19.4 Kotokoli 8 8.2 Other 5 5.1 Religion Christian 66 67.4 Islamic 27 27.6 Traditional 5 5.1 Class Primary 23 23.5 JHS 1 33 33.7 JHS 2 42 42.9 Age of Menarche Less than 10 2 2.0 10+ 96 98 Are you able to discuss openly about menstruation? No 27 27.6 Yes 71 72.4 Do you have adequate information on menstruation? Yes 43 56.1 No 55 43.9 Pain during menstruation Participants reported different levels of pain during menstruation. Severe menstrual pain was reported by half of the participants while 23.5% had moderate pains and 17.4% reported no menstrual pains as shown in the figure below (Fig. 1). Strengths and Difficulties of Adolescent Schoolgirls Table 2 presents mean scores and standard deviations from the Strengths and Difficulties Questionnaire (SDQ) administered to adolescent schoolgirls. The results show that the girls generally exhibit strong prosocial behavior, with a high average score of 7.99 out of a possible 10, indicating empathy, cooperation, and helpfulness. In contrast, the difficulty areas – hyperactivity (3.59), emotional problems (4.99), conduct issues (2.67), and peer problems (3.06), all show moderate average scores, suggesting these adolescents face some behavioral and emotional challenges, particularly in managing emotions and navigating peer relationships. The overall difficulties score, which sums all negative aspects (excluding prosocial behavior), averages 14.31 with a relatively large standard deviation of 6.18. This suggests a moderate level of psychological and behavioral difficulties across the group, with notable individual variation. While most girls are coping reasonably well, the wide range of scores implies that a significant subset may be experiencing more serious mental health challenges. These findings are supported by the data in Fig. 2 below, and the frequency distribution of the individual items under each scale are attached in supplemental file S1 Table. Table 2 Strengths and Difficulties of Adolescent Schoolgirls Variable Mean Standard deviation Prosocial score 7.99 1.98 Hyperactivity score 3.59 2.20 Emotional score 4.99 2.30 Conduct Problem score 2.67 2.09 Peer Problem score 3.06 2.16 Total difficulties score (- prosocial score) 14.31 6.18 Menstrual pain and psychosocial wellbeing of adolescent schoolgirls Table 3 presents a MANOVA assessing whether menstrual pain has a statistically significant effect on the overall strengths and difficulties scores of adolescent schoolgirls. The table includes four multivariate test statistics; Wilks’ Lambda, Pillai’s Trace, Hotelling’s Trace, and Roy’s Largest Root, each evaluating the same hypothesis but with different sensitivities. Most of the test statistics (Wilks’ λ, Pillai’s T, and Hotelling’s T²) showed non-significant results (p-values > 0.05), suggesting that overall, menstrual pain does not significantly influence the combined strengths and difficulties outcomes when considering all subscales together. However, Roy’s Largest Root test shows a statistically significant effect (F = 3.28, p = 0.015), indicating that menstrual pain may have a significant impact on at least one of the SDQ subscale scores. The Roy’s Root is sensitive to the largest single effect, indicating that menstrual pain might meaningfully affect one specific dimension of psychological functioning even if the overall multivariate effect is modest. Table 3 Multivariate analysis of variance of strengths and difficulties of adolescent schoolgirls Source Statistic Value df1 df2 F p-value Menstrual pain Wilks’ λ 0.8287 12 241.1 1.48 0.133a Pillai’s T 0.1782 12 279.0 1.47 0.136a Hotelling’s T² 0.1984 12 269.0 1.48 0.130a Roy’s Root 0.1409 4 93.0 3.28 0.015u Residual 94 Total 97 a = approximate; u = upper bound; df = degree of freedom Table 4 provides follow-up (post-hoc) univariate ANOVAs to explore which specific SDQ outcome variables may have been influenced by menstrual pain, following the MANOVA in Table 3. Among all the subscales, Conduct Problems is the only one showing a statistically significant difference (F = 2.59, p = 0.0177), suggesting that menstrual pain may be associated with differences in conduct-related behaviors. This supports the Roy’s Root result from Table 3, which suggested an effect on at least one subscale. Prosocial Behavior (p = 0.0683) and Hyperactivity (p = 0.0530) approached significance and may indicate a trend, but they do not meet the conventional threshold (p < 0.05). The remaining variables, Emotional Symptoms, and Peer Problems show no significant differences, suggesting that menstrual pain does not appear to strongly influence these dimensions. Additionally, all Bartlett’s test p-values are > 0.05, indicating homogeneity of variances across groups, thus the ANOVA results were statistically sound. Table 4 Pos-hoc analysis of variance of strengths and difficulties of adolescent schoolgirls Outcome Variable df (Between) df (Within) F p-value Bartlett’s χ² (df) p-value (Bartlett) Prosocial Behavior 9 88 1.86 0.0683 6.81 (6) 0.339 Emotional Symptoms 10 87 0.88 0.5557 5.81 (9) 0.759 Conduct Problems 7 90 2.59 0.0177* 4.16 (5) 0.526 Hyperactivity 8 89 2.02 0.0530 5.86 (8) 0.663 Peer Problems 8 89 0.88 0.5352 3.76 (8) 0.878 Total Difficulty Score 24 73 0.91 0.5865 16.23 (18) 0.577 * Statistically significant at p < 0.05 Discussion This study examined the association between menstrual pain and psychosocial wellbeing among adolescent schoolgirls, utilizing the SDQ to assess behavioral and emotional health of adolescent schoolgirls in a basic school in Ghana. The findings offer several important insights that can inform policy around menstrual health and psychosocial wellbeing for adolescent girls. This study identified a high prevalence of severe menstrual pain among adolescent girls. This finding is supported by literature coming from other parts of Ghana, however, with smaller proportion of participants experiencing severe menstrual pains. For instance, a study conducted among junior high school girls in the Upper East Region of Ghana reported a dysmenorrhea prevalence of 85%, with 11% experiencing severe pain [ 19 ]. Although, the study population was much older, research among female students at the University for Development Studies in Northern Ghana found a dysmenorrhea prevalence rate of 83.6%, with more than half describing their pain as moderate [ 20 ]. These findings indicate the widespread nature of menstrual pain and given the populations understudied, there is the of potential of menstrual pain disrupting daily activities, including school attendance and participation in social events. The SDQ results indicated that while the overall multivariate analysis did not show a statistically significant effect of menstrual pain on combined psychosocial outcomes, Roy’s Largest Root test suggested a significant impact on at least one subscale. Specifically, the Conduct Problems subscale showed a statistically significant difference, indicating that menstrual pain may be associated with increased conduct-related behaviors. This finding is consistent with literature suggesting that chronic pain conditions can influence behavioral responses in adolescents [ 21 ]. This finding has important implications for both clinical practice and educational settings. It suggests that menstrual pain may influence behavioral responses such as irritability or rule-breaking, highlighting the need for healthcare providers and educators to consider menstrual health as a potential underlying factor when addressing conduct issues in adolescents. As such, integrating menstrual health education and pain management strategies into school health programs and behavioral interventions could help reduce the impact of pain on conduct, ultimately supporting better psychosocial outcomes for adolescent girls. Although not reaching conventional levels of statistical significance, the near-threshold p-values for Prosocial Behavior (p = 0.0683) and Hyperactivity (p = 0.0530) suggest possible emerging patterns worth further exploration. These trends hint that menstrual pain may subtly influence adolescents’ capacity for social engagement and behavioral regulation. Specifically, the slight reduction in prosocial scores among those reporting higher levels of menstrual pain could indicate that physical discomfort interferes with empathic behavior, cooperation, and willingness to help others, traits central to prosocial functioning. This corroborates with findings from prior studies, where adolescent girls experiencing dysmenorrhea reported social withdrawal, irritability, and reduced participation in peer activities during menstruation [ 19 , 22 ]. Pain and fatigue may lower the emotional and cognitive resources available for outward-focused behaviors like helping peers or resolving conflict peacefully. In terms of hyperactivity, the observed trend toward higher scores among girls with more severe menstrual pain may reflect increased restlessness, concentration difficulties, or behavioral dysregulation. These manifestations could result from the discomfort itself or from secondary factors such as sleep disruption and anxiety commonly associated with dysmenorrhea [ 13 ]. Though the hyperactivity scores did not differ significantly across pain levels in this dataset, the p-value approaching significance suggests a potentially meaningful relationship that may be better captured with larger sample sizes or repeated measures designs. Collectively, these near-significant findings reinforce the notion that even in the absence of clinically elevated scores or statistically robust differences, menstrual pain may exert subtle but important influences on adolescents’ psychosocial behavior. Future studies employing longitudinal or mixed-methods approaches could clarify these associations and help determine whether these behavioral shifts have longer-term developmental implications. The lack of significant differences in Emotional Symptoms and Peer Problems subscales suggests that menstrual pain may not strongly influence these dimensions. However, it is important to consider that emotional responses to pain can be complex and influenced by various factors, including individual coping mechanisms and social support systems [ 21 ]. The relatively high standard deviation in total difficulties scores points to significant variability in psychosocial wellbeing within the group. This variation reinforces the importance of tailored support systems within schools to address the diverse needs of students experiencing menstrual pain. Strengths and Limitations A key strength of this study is its multidimensional approach to adolescent wellbeing, incorporating both physical and psychosocial health. Using MANOVA allowed for a comprehensive view of how menstrual pain might impact various aspects of psychological functioning. However, the cross-sectional nature of the data limits causal interpretation. Additionally, the reliance on self-reported measures may introduce reporting bias, particularly given the sensitivity of both menstrual health and psychological issues in adolescent populations. Conclusion Overall, this study suggests that menstrual pain is not just a physical health issue, it can intersect with psychosocial wellbeing, particularly in the form of increased conduct problems. These findings call for more integrated approaches in schools and health services to address menstrual health as part of broader adolescent mental health interventions. Future research should adopt longitudinal designs and consider biological, emotional, and environmental mediators to better understand the pathways through which menstrual pain affects psychosocial outcomes. Declarations Data Availability The dataset is available from the corresponding author upon request. Acknowledgments The authors acknowledge the support of the school health education program coordinators for their assistance during data collection, and are grateful for the assistance of school authorities in obtaining permission and consent to conduct the study. Funding This research received no specific funding. Author Information 1 Department of Population and Behavioral Sciences, Fred N. Binka School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana 2 Department of Epidemiology and Biostatistics, Fred N. Binka School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana 3 Department of Family and Community Health, Fred N. Binka School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana Contributions Conceptualization: SG, IW; Data curation: IW; Formal analysis: IW; Investigation: IW, PK, SG; Methodology: IW, SG; Project administration: PK; Supervision: SG, FA; Writing—original draft: IW, Writing—reviews and editing: all authors. + Ethics declarations This research was conducted in accordance of the Helsinki declaration. Ethical approval was issued by the University of Health and Allied Sciences’ Research Ethics Committee [UHAS-REC A.6 l2l23-24]. Written informed assent and consent was obtained from all participants and their local guardians involved in the study. Consent for publication Not applicable. Competing interests The authors declare no competing interest References Fernández-Martínez E, Onieva-Zafra MD, Parra-Fernández ML. The Impact of Dysmenorrhea on Quality of Life Among Spanish Female University Students. Int J Environ Res Public Health. 2019;16:713. 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Ziba FA, Adams Y, Dapare PPM, Nanoa EY-O, Ayalbire MA, Baba EM. Dysmenorrhea and Associated Risk Factors among Adolescent Girls in Junior High School of Upper East Region, Ghana. Int J Res Rep Gynaecol. 2019;13–24. Ameade EPK, Garti HA. Relationship between Female University Students’ Knowledge on Menstruation and Their Menstrual Hygiene Practices: A Study in Tamale, Ghana. Adv Prev Med. 2016;2016:1056235. Hasford KE, Amponsah SK, Yawson AE. Dysmenorrhea Among University of Ghana Medical and Dental Students: Prevalence and Management Options. Postgrad Med J Ghana. 2023;12:2–7. Aziato L, Dedey F, Clegg-Lamptey JNA. The experience of dysmenorrhoea among Ghanaian senior high and university students: pain characteristics and effects. Reprod Health. 2014;11:58. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfiles.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 30 Aug, 2025 Reviewers agreed at journal 30 Aug, 2025 Reviewers invited by journal 28 Aug, 2025 Editor invited by journal 24 Jul, 2025 Editor assigned by journal 24 Jul, 2025 Submission checks completed at journal 23 Jul, 2025 First submitted to journal 23 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7075276","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":508986646,"identity":"67d1208f-828d-4b2f-81fa-24eaf52e4c0d","order_by":0,"name":"Sitsofe Gbogbo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYFACHgYGxgYGOQYJMI8ZIkKMFmPStSQ2EK1Fvn/twYdfd9ikb7jd/PgDQ4V1YgP/2gN4tRjceJdsLHsmLXfDnWNmEgxn0oHWvUvAr0XijJm0ZNvh3A03EswYGNsOA7WcMcDvsBkQLekGN9I/f2D8R4QWhvM9ZpIf2w4nGNzIMZBgbABq4e/Br8XgBl+yMeOZNMOZN3LKJBKOpRu3SfAQcFj/2YMPf+6wkee7kb75w4caa9l+fkIOk0hgYIZHRAIQs0kk4NfBwH+AgfEHusgoGAWjYBSMAmQAAJFlTZ78OH2ZAAAAAElFTkSuQmCC","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":true,"prefix":"","firstName":"Sitsofe","middleName":"","lastName":"Gbogbo","suffix":""},{"id":508986647,"identity":"44a2a724-330a-469f-998a-8763a9a2c6ad","order_by":1,"name":"Israel Wuresah","email":"","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Israel","middleName":"","lastName":"Wuresah","suffix":""},{"id":508986648,"identity":"5c3b0bda-cdf9-461a-a0aa-59ddd15558bd","order_by":2,"name":"Priscilla Klutse","email":"","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Priscilla","middleName":"","lastName":"Klutse","suffix":""},{"id":508986650,"identity":"6215d819-662d-471d-9460-52b899140b03","order_by":3,"name":"Francis Agyei","email":"","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Francis","middleName":"","lastName":"Agyei","suffix":""}],"badges":[],"createdAt":"2025-07-08 13:23:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7075276/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7075276/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90803641,"identity":"0376e9bb-9ea5-40d4-b3cb-1e56e862418b","added_by":"auto","created_at":"2025-09-08 10:36:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":19683,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eLevel of pain during menstruation\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7075276/v1/9bbd50a80dc110654671a49c.png"},{"id":90803642,"identity":"3d66a388-579d-4667-8738-c6dbfba705fb","added_by":"auto","created_at":"2025-09-08 10:36:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":20675,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eCategorization of Strengths and Difficulties subscale and total scores\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7075276/v1/1fd1985a7d6696ea2b5aa836.png"},{"id":90805438,"identity":"8c93d889-67ff-40a3-9c86-7d428a5d3ac2","added_by":"auto","created_at":"2025-09-08 10:52:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":824713,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7075276/v1/c661cc4a-9fd3-4a9c-bc0e-64906ba04715.pdf"},{"id":90803644,"identity":"8384255f-1ff9-4139-857c-dab1f2c966dd","added_by":"auto","created_at":"2025-09-08 10:36:14","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":17167,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfiles.docx","url":"https://assets-eu.researchsquare.com/files/rs-7075276/v1/22247f412acc43d8112ed518.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Menstrual pain and psychosocial wellbeing among adolescent girls in Hohoe, Ghana","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMenstrual pain, or dysmenorrhea, is a common issue among adolescent girls, significantly affecting their psychosocial well-being and overall quality of life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Research indicates that dysmenorrhea can lead to considerable absenteeism from school and decreased participation in daily activities, which in turn can exacerbate feelings of anxiety and depression among affected individuals [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e–\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe impact of menstrual pain extends beyond physical discomfort, affecting various aspects of an adolescent girls’ life. For instance, girls experiencing severe pain may withdraw from social activities, sports, or academic pursuits, potentially leading to a sense of isolation or reduced self-esteem. These effects can accumulate over time, influencing academic performance, social relationships, and future career aspirations.\u003c/p\u003e\u003cp\u003eThe psychosocial implications of menstrual pain are particularly concerning in low- and middle-income countries, where cultural stigmas and lack of access to healthcare resources may further hinder adolescents from seeking appropriate care [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In many such settings, menstruation itself is often surrounded by myths, taboos, and misinformation, creating additional barriers to open discussion and proper management of menstrual health issues.\u003c/p\u003e\u003cp\u003eIn Ghana, the intersection of menstrual pain and psychosocial well-being among adolescent girls remains underexplored, despite the global recognition of the issue. The country’s diverse cultural landscape, varying levels of education, and disparities in healthcare access contribute to a complex environment for addressing menstrual health concerns [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e–\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Urban and rural differences in Ghana also play a role in shaping girls’ experiences with menstrual pain and their access to information and care.\u003c/p\u003e\u003cp\u003eThe psychosocial effects of dysmenorrhea are not merely a consequence of physical pain, they are intertwined with the social and emotional dimensions of adolescent life. Girls experiencing severe menstrual pain often report lower quality of life scores, indicating that the impact of dysmenorrhea extends beyond physical discomfort to include emotional distress and social withdrawal [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This can manifest in various ways, such as reduced confidence, increased irritability, mood swings, and difficulties in maintaining consistent academic performance or participation in extracurricular activities.\u003c/p\u003e\u003cp\u003eThe use of standardized tools, such as the Self-Reported Strengths and Difficulties Questionnaire (SDQ), can provide valuable insights into the psychosocial challenges faced by these adolescents, allowing for a comprehensive understanding of how menstrual pain influences their mental health and social interactions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The SDQ assesses various aspects of adolescent mental health, including emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behavior.\u003c/p\u003e\u003cp\u003eGiven the significant implications of menstrual pain on adolescent girls’ psychosocial well-being, this research investigated these relationships within the context of Hohoe, Ghana. This study contributes to the growing body of literature on menstrual health and its psychosocial ramifications, ultimately informing better health education and intervention strategies tailored to the needs of this vulnerable population [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe findings from this research have the potential to inform policy decisions, educational programs, and healthcare interventions in Ghana and similar settings. Understanding the specific psychosocial challenges faced by adolescent girls with dysmenorrhea will help stakeholders to develop targeted interventions that address not only the physical aspects of menstrual pain but also its emotional and social implications. This holistic approach is important for improving the overall well-being and future prospects of adolescent girls, ensuring that menstrual health issues do not become barriers to their personal, academic, and professional development.\u003c/p\u003e"},{"header":"Methods and Materials","content":"\u003cp\u003e\u003cb\u003eSetting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe Hohoe Municipal is one of Ghana’s 275 Metropolitan, Municipal, and District Assemblies. It is practically in the middle of the area with longitudes of 00 15’E and 00 45’E and latitudes of 6045’N and 7015’N. The Educational System in Ghana is divided into various levels of schooling including, Kindergarten, Primary, Junior High, Senior High, TVET and Tertiary. Currently, the Municipality has 149 schools with 1,303 teachers at Kindergarten to Technical and Vocational level. The tertiary schools are made up of 2 teacher training schools, 1 midwifery training school and 1 University. The Municipality has about eighty-four junior high schools (Ghana Education Service Hohoe, 2019). The study was conducted in a basic school among pupils in primary six to junior high school (JHS) two.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA quantitative descriptive cross-sectional study design was employed to assess the psychosocial well-being of adolescent girls in relation to their menstrual health, herein defined as pain during menstruation, in a basic school in Hohoe. This design was use because it provided insights into the psychological and social strengths and difficulties faced by adolescent girls regarding menstrual health in basic schools in Hohoe, Ghana, at a single point in time. It is a relatively inexpensive approach and can be conducted within a short period.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy population\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study population included adolescent girls between the ages of 10 and 19 who are menstruating in basic schools in the Hohoe municipality.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSample size and sampling procedure\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAt a confidence level of 95% such that the real value is within ± 5% of the population surveyed, the study included 98 adolescent girls in the study as computed below using Cochran’s formula [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]:\u003c/p\u003e\u003cp\u003en=\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\:\\frac{{z}^{2}*p(1-p)}{{e}^{2}}\\)\u003c/span\u003e\u003c/span\u003e where n = sample size, z = z-score at 95% confidence level, p = proportion of female adolescents in the Volta region, and e = margin of error.\u003c/p\u003e\u003cp\u003eThis implied that;\u003c/p\u003e\u003cp\u003ez = 1.96, p = 6.6% [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and e = 0.05\u003c/p\u003e\u003cp\u003eThat is, n= \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\frac{{1.96}^{2}*0.066(1-0.066)}{{0.05}^{2}}\\)\u003c/span\u003e\u003c/span\u003e = 94.7 = \u0026gt; 95.\u003c/p\u003e\u003cp\u003eThe study purposively selected the basic school due to limited resources. Once in the selected school, classrooms from which students were sampled were selected on a convenience basis, specifically primary six to JHS two. A simple random sampling technique was then used to enroll 98 adolescent girls into the study. Once in the classroom, a ‘yes or no’ probability sampling style was employed, where students who picked the pieces of paper with the ‘yes’ inscription were enrolled onto the study.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Collection Instruments and Methods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe Strengths and Difficulties Questionnaire (SDQ, UK English version) which is globally used to screen for behavioral markers of potential mental health problems in children and adolescents [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e–\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] was adopted for this study. Preceding the administration of the questionnaires is a clear explanation of the nature of the questionnaire to the study participant. Moreover, participants were well informed about the risk and the benefits of participating in the study, that their anonymity and confidentiality was assured. Adolescent girls who consented to participate were asked to sign a consent form after parental approval. An interviewer administered the questionnaire to the participants to ensure accurate response, using mobile devices. A database created in Kobo Toolbox was the server for receiving the data after each day’s work.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData processing and analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe data was extracted as an excel file and exported into STATA 17.0 for analysis. Also, Microsoft Excel 2021 was used to generate graphs. Descriptive statistics including frequencies and percentages, and summary statistics were used to summarize the data. Analysis of Variance (ANOVA), and Multivariate analysis of variance (MANOVA) were used to determine association between menstrual pain and psychosocial well-being in adolescent girls. The dependent variable was menstrual pain and independent variables were the subscales and total strengths and difficulties scale. The statistical significance threshold of p \u0026lt; 0.05 was used.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthical considerations\u003c/b\u003e\u003c/p\u003e\u003cp\u003e This research was conducted in accordance with the Declaration of Helsinki. Ethical approval was issued by the University of Health and Allied Sciences’ Research Ethics Committee [UHAS-REC A.6 l2l23-24]. Permission was sought from the Ghana Education Service and E.P Basic school administration. Participation in the study was voluntary, and anonymity and the right to withdraw were honored. In addition, we collaborated with school officials to get formal (written) informed consent from parents. Prior to each session, participants signed off a provided written informed consent and assent. There were no direct or reputational risks for individuals who participated in the research study. Participants’ confidentiality was strictly protected.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eCharacteristics of the study participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study involved adolescent schoolgirls aged between 10–19 years in a cluster of basic schools in Hohoe Ghana. Table 1 presents the sociodemographic descriptions of the participants. Majority (78.6%) of the participants were aged 10–15 years old. The predominant ethnic group was Ewe (51.0%), followed by Hausa (19.4%). Most participants identified as Christian (67.4%). The majority were in Junior High School (JHS), with 42.9% in JHS 2. Most girls (98%) experienced menarche at age 10+. About 72.4% of the girls reported being able to discuss menstruation openly, and 56.1% felt they had adequate information on menstruation.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eSociodemographic and basic menstruation information\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency, N = 98\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentages\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge \u003cstrong\u003e(\u003c/strong\u003eMean→SD\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10–15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16–19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEthnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEwe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAkan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGuan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHausa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKotokoli\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReligion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChristian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIslamic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraditional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJHS 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJHS 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge of Menarche\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLess than 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAre you able to discuss openly about menstruation?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDo you have adequate information on menstruation?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003ePain during menstruation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported different levels of pain during menstruation. Severe menstrual pain was reported by half of the participants while 23.5% had moderate pains and 17.4% reported no menstrual pains as shown in the figure below (Fig. 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Difficulties of Adolescent Schoolgirls\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 presents mean scores and standard deviations from the Strengths and Difficulties Questionnaire (SDQ) administered to adolescent schoolgirls. The results show that the girls generally exhibit strong prosocial behavior, with a high average score of 7.99 out of a possible 10, indicating empathy, cooperation, and helpfulness. In contrast, the difficulty areas – hyperactivity (3.59), emotional problems (4.99), conduct issues (2.67), and peer problems (3.06), all show moderate average scores, suggesting these adolescents face some behavioral and emotional challenges, particularly in managing emotions and navigating peer relationships.\u003c/p\u003e\n\u003cp\u003eThe overall difficulties score, which sums all negative aspects (excluding prosocial behavior), averages 14.31 with a relatively large standard deviation of 6.18. This suggests a moderate level of psychological and behavioral difficulties across the group, with notable individual variation. While most girls are coping reasonably well, the wide range of scores implies that a significant subset may be experiencing more serious mental health challenges. These findings are supported by the data in Fig. 2 below, and the frequency distribution of the individual items under each scale are attached in supplemental file S1 Table.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eStrengths and Difficulties of Adolescent Schoolgirls\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStandard deviation\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProsocial score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHyperactivity score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmotional score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConduct Problem score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePeer Problem score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal difficulties score (- prosocial score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eMenstrual pain and psychosocial wellbeing of adolescent schoolgirls\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 presents a MANOVA assessing whether menstrual pain has a statistically significant effect on the overall strengths and difficulties scores of adolescent schoolgirls. The table includes four multivariate test statistics; Wilks’ Lambda, Pillai’s Trace, Hotelling’s Trace, and Roy’s Largest Root, each evaluating the same hypothesis but with different sensitivities.\u003c/p\u003e\n\u003cp\u003eMost of the test statistics (Wilks’ λ, Pillai’s T, and Hotelling’s T²) showed non-significant results (p-values \u0026gt; 0.05), suggesting that overall, menstrual pain does not significantly influence the combined strengths and difficulties outcomes when considering all subscales together. However, Roy’s Largest Root test shows a statistically significant effect (F = 3.28, p = 0.015), indicating that menstrual pain may have a significant impact on at least one of the SDQ subscale scores. The Roy’s Root is sensitive to the largest single effect, indicating that menstrual pain might meaningfully affect one specific dimension of psychological functioning even if the overall multivariate effect is modest.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eMultivariate analysis of variance of strengths and difficulties of adolescent schoolgirls\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSource\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStatistic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eValue\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003edf1\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003edf2\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eMenstrual pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWilks’ λ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8287\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e241.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.133a\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePillai’s T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1782\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e279.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.136a\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHotelling’s T²\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1984\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e269.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.130a\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRoy’s Root\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1409\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.015u\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResidual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003cem\u003ea = approximate; u = upper bound; df = degree of freedom\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTable 4 provides follow-up (post-hoc) univariate ANOVAs to explore which specific SDQ outcome variables may have been influenced by menstrual pain, following the MANOVA in Table 3.\u003c/p\u003e\n\u003cp\u003eAmong all the subscales, Conduct Problems is the only one showing a statistically significant difference (F = 2.59, p = 0.0177), suggesting that menstrual pain may be associated with differences in conduct-related behaviors. This supports the Roy’s Root result from Table 3, which suggested an effect on at least one subscale. Prosocial Behavior (p = 0.0683) and Hyperactivity (p = 0.0530) approached significance and may indicate a trend, but they do not meet the conventional threshold (p \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003eThe remaining variables, Emotional Symptoms, and Peer Problems show no significant differences, suggesting that menstrual pain does not appear to strongly influence these dimensions. Additionally, all Bartlett’s test p-values are \u0026gt; 0.05, indicating homogeneity of variances across groups, thus the ANOVA results were statistically sound.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003ePos-hoc analysis of variance of strengths and difficulties of adolescent schoolgirls\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOutcome Variable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003edf (Between)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003edf (Within)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBartlett’s χ² (df)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value (Bartlett)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProsocial Behavior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0683\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.81 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.339\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmotional Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5557\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.81 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.759\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConduct Problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0177*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.16 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.526\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHyperactivity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0530\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.86 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.663\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePeer Problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5352\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.76 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.878\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal Difficulty Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5865\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.23 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.577\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e*\u003cem\u003eStatistically significant at p \u0026lt; 0.05\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the association between menstrual pain and psychosocial wellbeing among adolescent schoolgirls, utilizing the SDQ to assess behavioral and emotional health of adolescent schoolgirls in a basic school in Ghana. The findings offer several important insights that can inform policy around menstrual health and psychosocial wellbeing for adolescent girls.\u003c/p\u003e\u003cp\u003eThis study identified a high prevalence of severe menstrual pain among adolescent girls. This finding is supported by literature coming from other parts of Ghana, however, with smaller proportion of participants experiencing severe menstrual pains. For instance, a study conducted among junior high school girls in the Upper East Region of Ghana reported a dysmenorrhea prevalence of 85%, with 11% experiencing severe pain [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Although, the study population was much older, research among female students at the University for Development Studies in Northern Ghana found a dysmenorrhea prevalence rate of 83.6%, with more than half describing their pain as moderate [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These findings indicate the widespread nature of menstrual pain and given the populations understudied, there is the of potential of menstrual pain disrupting daily activities, including school attendance and participation in social events.\u003c/p\u003e\u003cp\u003eThe SDQ results indicated that while the overall multivariate analysis did not show a statistically significant effect of menstrual pain on combined psychosocial outcomes, Roy\u0026rsquo;s Largest Root test suggested a significant impact on at least one subscale. Specifically, the Conduct Problems subscale showed a statistically significant difference, indicating that menstrual pain may be associated with increased conduct-related behaviors. This finding is consistent with literature suggesting that chronic pain conditions can influence behavioral responses in adolescents [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This finding has important implications for both clinical practice and educational settings. It suggests that menstrual pain may influence behavioral responses such as irritability or rule-breaking, highlighting the need for healthcare providers and educators to consider menstrual health as a potential underlying factor when addressing conduct issues in adolescents. As such, integrating menstrual health education and pain management strategies into school health programs and behavioral interventions could help reduce the impact of pain on conduct, ultimately supporting better psychosocial outcomes for adolescent girls.\u003c/p\u003e\u003cp\u003eAlthough not reaching conventional levels of statistical significance, the near-threshold p-values for Prosocial Behavior (p\u0026thinsp;=\u0026thinsp;0.0683) and Hyperactivity (p\u0026thinsp;=\u0026thinsp;0.0530) suggest possible emerging patterns worth further exploration. These trends hint that menstrual pain may subtly influence adolescents\u0026rsquo; capacity for social engagement and behavioral regulation. Specifically, the slight reduction in prosocial scores among those reporting higher levels of menstrual pain could indicate that physical discomfort interferes with empathic behavior, cooperation, and willingness to help others, traits central to prosocial functioning. This corroborates with findings from prior studies, where adolescent girls experiencing dysmenorrhea reported social withdrawal, irritability, and reduced participation in peer activities during menstruation [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Pain and fatigue may lower the emotional and cognitive resources available for outward-focused behaviors like helping peers or resolving conflict peacefully.\u003c/p\u003e\u003cp\u003eIn terms of hyperactivity, the observed trend toward higher scores among girls with more severe menstrual pain may reflect increased restlessness, concentration difficulties, or behavioral dysregulation. These manifestations could result from the discomfort itself or from secondary factors such as sleep disruption and anxiety commonly associated with dysmenorrhea [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Though the hyperactivity scores did not differ significantly across pain levels in this dataset, the p-value approaching significance suggests a potentially meaningful relationship that may be better captured with larger sample sizes or repeated measures designs.\u003c/p\u003e\u003cp\u003eCollectively, these near-significant findings reinforce the notion that even in the absence of clinically elevated scores or statistically robust differences, menstrual pain may exert subtle but important influences on adolescents\u0026rsquo; psychosocial behavior. Future studies employing longitudinal or mixed-methods approaches could clarify these associations and help determine whether these behavioral shifts have longer-term developmental implications.\u003c/p\u003e\u003cp\u003eThe lack of significant differences in Emotional Symptoms and Peer Problems subscales suggests that menstrual pain may not strongly influence these dimensions. However, it is important to consider that emotional responses to pain can be complex and influenced by various factors, including individual coping mechanisms and social support systems [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe relatively high standard deviation in total difficulties scores points to significant variability in psychosocial wellbeing within the group. This variation reinforces the importance of tailored support systems within schools to address the diverse needs of students experiencing menstrual pain.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and Limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA key strength of this study is its multidimensional approach to adolescent wellbeing, incorporating both physical and psychosocial health. Using MANOVA allowed for a comprehensive view of how menstrual pain might impact various aspects of psychological functioning. However, the cross-sectional nature of the data limits causal interpretation. Additionally, the reliance on self-reported measures may introduce reporting bias, particularly given the sensitivity of both menstrual health and psychological issues in adolescent populations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOverall, this study suggests that menstrual pain is not just a physical health issue, it can intersect with psychosocial wellbeing, particularly in the form of increased conduct problems. These findings call for more integrated approaches in schools and health services to address menstrual health as part of broader adolescent mental health interventions. Future research should adopt longitudinal designs and consider biological, emotional, and environmental mediators to better understand the pathways through which menstrual pain affects psychosocial outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset is available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge the support of the school health education program coordinators for their assistance during data collection, and are grateful for the assistance of school authorities in obtaining permission and consent to conduct the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of Population and Behavioral Sciences, Fred N. Binka School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eDepartment of Epidemiology and Biostatistics, Fred N. Binka School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eDepartment of Family and Community Health, Fred N. Binka School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: SG, IW; Data curation: IW; Formal analysis: IW; Investigation: IW, PK, SG; Methodology: IW, SG; Project administration: PK; Supervision: SG, FA; Writing\u0026mdash;original draft: IW, Writing\u0026mdash;reviews and editing: all authors. +\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was conducted in accordance of the Helsinki declaration. Ethical approval was issued by the University of Health and Allied Sciences\u0026rsquo; Research Ethics Committee [UHAS-REC A.6 l2l23-24]. Written informed assent and consent was obtained from all participants and their local guardians involved in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interest\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFern\u0026aacute;ndez-Mart\u0026iacute;nez E, Onieva-Zafra MD, Parra-Fern\u0026aacute;ndez ML. The Impact of Dysmenorrhea on Quality of Life Among Spanish Female University Students. Int J Environ Res Public Health. 2019;16:713. \u003c/li\u003e\n\u003cli\u003eSahin N, Kasap B, Kirli U, Yeniceri N, Topal Y. Assessment of anxiety-depression levels and perceptions of quality of life in adolescents with dysmenorrhea. Reprod Health. 2018;15:13. \u003c/li\u003e\n\u003cli\u003eAburshaid FA, Ahmad SG, Ashmauey AA, Mohammad HG. Effect of Planned Health Educational Program on Menstrual Knowledge and Practices among Adolescent Saudi Girls. J Nurs Health [Internet]. 2017 [cited 2024 Sep 27]; Available from: https://www.semanticscholar.org/paper/Effect-of-Planned-Health-Educational-Program-on-and-Aburshaid-Ahmad/59e2b76a87c91bd3d0ce4ccf5ec3b4b2bc03a27b\u003c/li\u003e\n\u003cli\u003eKhalil S, Alsaleem S, Siddiqui A, Alshaikh A, Althabet M. Menstrual disorders and its effect on life activities of secondary school students in Abha, Saudi Arabia. 2020. \u003c/li\u003e\n\u003cli\u003eHennegan J, Shannon AK, Rubli J, Schwab KJ, Melendez-Torres GJ. Women\u0026rsquo;s and girls\u0026rsquo; experiences of menstruation in low- and middle-income countries: A systematic review and qualitative metasynthesis. PLOS Med. 2019;16:e1002803. \u003c/li\u003e\n\u003cli\u003eHolmes K, Curry C, Sherry null, Ferfolja T, Parry K, Smith C, et al. Adolescent Menstrual Health Literacy in Low, Middle and High-Income Countries: A Narrative Review. Int J Environ Res Public Health. 2021;18:2260. \u003c/li\u003e\n\u003cli\u003eGberbie MK. Effects of cultural diversity on employee relationships and performance in multinational companies in Western region, Ghana [Internet] [Thesis]. University of Cape Coast; 2012 [cited 2024 Sep 27]. Available from: http://ir.ucc.edu.gh/jspui/handle/123456789/2702\u003c/li\u003e\n\u003cli\u003eAFS-USA. Ghana: Exploring Ghana Culture and Customs [Internet]. AFS-USA. [cited 2024 Sep 27]. Available from: https://www.afsusa.org/countries/ghana/\u003c/li\u003e\n\u003cli\u003eGbogbo S, Wuresah I, Addo P, Klomegah S, Gbogbo E, Axame W, et al. Promoting menstrual health and hygiene\u0026mdash;insights from the 2023 World Menstrual Hygiene Day celebration events in the Hohoe municipality in Ghana. Front Public Health [Internet]. 2024 [cited 2024 Sep 27];12. Available from: https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2024.1406665/full\u003c/li\u003e\n\u003cli\u003eKapadi R, Elander J. Pain coping, pain acceptance and analgesic use as predictors of health-related quality of life among women with primary dysmenorrhea. Eur J Obstet Gynecol Reprod Biol. 2020;246:40\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eRajkumari R, Keithellakpam S, Thiyam J, Devi M. Relationship between psychosocial stress and menstrual function-related abnormalities among the female undergraduate medical students. J Evol Med Dent Sci. 2017;6:3103\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eMohamed Elsawy M, Mohamed Ahmed Ayed M, Mohamed Al Sherbeny E, Rabie Kamel Goma L, Yousef Abdelwahed A. Effect of Progressive Muscle Relaxation Technique on Menstrual Cramps among Adolescent students. Egypt J Health Care. 2023;14:571\u0026ndash;89. \u003c/li\u003e\n\u003cli\u003eIacovides S, Avidon I, Baker FC. What we know about primary dysmenorrhea today: a critical review. Hum Reprod Update. 2015;21:762\u0026ndash;78. \u003c/li\u003e\n\u003cli\u003eCochran WG. Sampling Techniques, 3rd Edition | Wiley [Internet]. Wiley.com. 1996 [cited 2024 Sep 27]. Available from: https://www.wiley.com/en-us/Sampling+Techniques%2C+3rd+Edition-p-9780471162407\u003c/li\u003e\n\u003cli\u003eGSS. Population by Regions: Volta [Internet]. 2021 [cited 2024 Jan 18]. Available from: https://www.statsghana.gov.gh/regionalpopulation.php?population=MTUzMDcwMjM4MS44Mzc=\u0026amp;\u0026amp;Volta\u0026amp;regid=10\u003c/li\u003e\n\u003cli\u003eDeighton J, Croudace T, Fonagy P, Brown J, Patalay P, Wolpert M. Measuring mental health and wellbeing outcomes for children and adolescents to inform practice and policy: a review of child self-report measures. Child Adolesc Psychiatry Ment Health. 2014;8:14. \u003c/li\u003e\n\u003cli\u003eHoosen N, Davids EL, De Vries PJ, Shung-King M. The Strengths and Difficulties Questionnaire (SDQ) in Africa: a scoping review of its application and validation. Child Adolesc Psychiatry Ment Health. 2018;12:6. \u003c/li\u003e\n\u003cli\u003eKansiime C, Hytti L, Nalugya R, Nakuya K, Namirembe P, Nakalema S, et al. Menstrual health intervention and school attendance in Uganda (MENISCUS-2): a pilot intervention study. BMJ Open. 2020;10:e031182. \u003c/li\u003e\n\u003cli\u003eZiba FA, Adams Y, Dapare PPM, Nanoa EY-O, Ayalbire MA, Baba EM. Dysmenorrhea and Associated Risk Factors among Adolescent Girls in Junior High School of Upper East Region, Ghana. Int J Res Rep Gynaecol. 2019;13\u0026ndash;24. \u003c/li\u003e\n\u003cli\u003eAmeade EPK, Garti HA. Relationship between Female University Students\u0026rsquo; Knowledge on Menstruation and Their Menstrual Hygiene Practices: A Study in Tamale, Ghana. Adv Prev Med. 2016;2016:1056235. \u003c/li\u003e\n\u003cli\u003eHasford KE, Amponsah SK, Yawson AE. Dysmenorrhea Among University of Ghana Medical and Dental Students: Prevalence and Management Options. Postgrad Med J Ghana. 2023;12:2\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eAziato L, Dedey F, Clegg-Lamptey JNA. The experience of dysmenorrhoea among Ghanaian senior high and university students: pain characteristics and effects. Reprod Health. 2014;11:58. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Menstrual health, mental health, dysmenorrhea, adolescent health","lastPublishedDoi":"10.21203/rs.3.rs-7075276/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7075276/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMenstrual pain, or dysmenorrhea, is a prevalent issue among adolescent girls, affecting their psychosocial well-being. In Ghana, where cultural stigmas and limited healthcare access persist, the psychosocial impact of menstrual pain remains underexplored. This study investigated the effect of menstrual pain on psychosocial well-being among adolescent girls in Hohoe, Ghana. This cross-sectional study was conducted in a basic school in Hohoe, involving 98 adolescent girls aged 10–19 (mean = 13.4, SD = 1.4). The participants were selected through random sampling, and data were collected using the Strengths and Difficulties Questionnaire (SDQ), which assessed their emotional, social, and behavioral difficulties. Descriptive statistics and MANOVA were performed. Half of the participants (50%) reported severe menstrual pains and 23.5% and 9.2% reported moderate and mild pain respectively. Overall, 20.4% reported high psychosocial difficulties, with higher difficulties were reported in emotional challenges (25.5%), conduct problems (21.4%). Menstrual pain had significant effect on psychosocial wellbeing, with those reporting severe pain reporting higher difficulties in conduct problems. This study found that while many teenage girls showed normal prosocial behavior, some also faced emotional and behavioral challenges, with menstrual pain linked to conduct issues. The study stresses the need for holistic support, addressing both physical and mental health in schools.\u003c/p\u003e","manuscriptTitle":"Menstrual pain and psychosocial wellbeing among adolescent girls in Hohoe, Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-08 10:36:09","doi":"10.21203/rs.3.rs-7075276/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-08-30T18:23:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296460471489546433602844390178649294530","date":"2025-08-30T16:55:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-28T15:00:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-24T10:34:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-24T10:32:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-23T11:05:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2025-07-23T11:01:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8b520dbd-402b-4e4c-9a25-72bd571a7de0","owner":[],"postedDate":"September 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-08T10:36:09+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-08 10:36:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7075276","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7075276","identity":"rs-7075276","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}