Academic Achievement Anxiety and Menstrual Health Outcomes among Female University Students: The Role of Perceived Stress

Academic Achievement Anxiety and Menstrual Health Outcomes among Female University Students: The Role of Perceived Stress | 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 Academic Achievement Anxiety and Menstrual Health Outcomes among Female University Students: The Role of Perceived Stress NAZIRE BAHAR, MELTEM KAYDIRAK, MERVE CİVELEK, İCLAL KARAKAYA This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9392082/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background: Academic achievement anxiety is a common psychosocial stressor among university students and may influence menstrual health outcomes. However, limited research has explored how academic anxiety relates simultaneously to perceived stress, menstrual pain, and menstrual hygiene behaviors in female university populations. Methods: his cross-sectional study included 307 female university students in Turkey (mean age = 20.59 ± 2.02 years). Participants completed online self-report measures assessing academic achievement anxiety, perceived stress, menstrual pain severity, and menstrual hygiene behaviors. Descriptive statistics, Pearson correlations, and regression analyses were conducted to examine associations among the variables. Results: Higher academic achievement anxiety was associated with increased perceived stress (r = 0.32, p < 0.01) and greater menstrual pain severity (r = 0.21, p < 0.01). Anxiety demonstrated a weak but significant negative association with genital hygiene behaviors (r = –0.13, p < 0.05). Regression analyses showed that academic achievement anxiety significantly predicted perceived stress and menstrual pain but had limited predictive value for menstrual hygiene behaviors. Conclusion: Academic achievement anxiety was associated with higher perceived stress, increased menstrual pain and slightly less optimal menstrual hygiene practices among female university students. These findings suggest that academic-related stress may influence key aspects of menstrual health. Supporting stress management and menstrual health awareness within university health services may contribute to improved well‑being in this population. academic achievement anxiety perceived stress menstrual hygiene behaviors menstrual health menstrual pain Introduction Approximately 1.8 billion women worldwide experience regular menstrual cycles ( 1 ). Menstrual health is a holistic concept encompassing physical, psychological, and social well-being throughout the menstrual cycle and has increasingly been recognized as a critical public health priority( 2 ) The maintenance of menstrual health is influenced not only by biological processes but also by psychosocial, environmental, and lifestyle-related factors, including stress ( 3 ). In this context, individuals’ stress levels and psychosocial burdens play a significant role in shaping health-related behaviors( 4 ) Female students in higher education are exposed to a multidimensional stress environment driven by academic performance expectations as well as biological, psychological, and social determinants. Evidence suggests that these cumulative stressors can significantly influence health behaviors ( 3 , 5 ). Academic achievement anxiety, in particular, may elevate perceived stress levels by intensifying psychological pressure and concerns regarding performance outcomes. Increased perceived stress not only affects mental well-being but may also have implications for menstrual health, which is an essential component of reproductive health. Recent population-based evidence also demonstrates that menstrual-related symptoms are associated with reduced school attendance and learning participation among young individuals, highlighting the academic impact of menstrual discomfort ( 6 ). From a physiological perspective, stress activates the hypothalamic–pituitary–adrenal (HPA) axis, leading to hormonal imbalances that can disrupt the menstrual cycle. Such disruptions may manifest as irregular menstruation, dysmenorrhea, or premenstrual syndrome ( 7 , 8 ). Furthermore, elevated stress levels may impair individuals’ ability to maintain adequate menstrual hygiene practices, either through reduced motivation or maladaptive health behaviors. Poor menstrual hygiene practices may increase the risk of infections, thereby posing broader public health concerns. Additionally, limited access to menstrual hygiene products has been shown to increase menstruation-related stress, embarrassment, and absenteeism among students, indicating that menstrual hygiene challenges can further elevate psychosocial burden ( 9 ) Although previous studies have examined the relationship between academic anxiety and stress, as well as the impact of stress on menstrual health separately ( 7 , 8 , 10 ), integrated models addressing these variables simultaneously remain limited. In particular, the mediating role of perceived stress in the relationship between academic achievement anxiety and menstrual hygiene behavior has not been sufficiently explored. This gap highlights an important public health concern, as these factors may influence young women’s health behaviors and long-term reproductive health outcomes. Therefore, this study aims to investigate the effects of academic achievement anxiety on perceived stress levels and menstrual hygiene behavior among female university students. Specifically, the study addresses the following research questions: ( 1 ) What are the levels of academic achievement anxiety, perceived stress, and menstrual hygiene behavior? ( 2 ) Are there significant relationships between academic achievement anxiety and perceived stress, and between perceived stress and menstrual hygiene behavior? ( 3 ) Does perceived stress mediate the relationship between academic achievement anxiety and menstrual hygiene behavior? Materials and methods Study design and setting A descriptive and correlational research design was used in this study, which was conducted with female university students studying in Turkey. Data collection took place between 15 March 2025 and 25 June 2025. According to the Higher Education Council ( 11 ), approximately 3.685.522 female university students are enrolled in Turkish universities. The aim of this study was to investigate the impacts of academic achievement anxiety on perceived stress levels and menstrual hygiene behavior among female university students. As no prior research has specifically addressed this topic in Turkey, this study seeks to fill an important gap in the literature. Assuming a medium effect size of academic anxiety on the specified variables, a power analysis was conducted via G*Power software. The analysis revealed that a minimum sample size of 269 participants was required for a statistical power of 80%, a significance level of 5%, degrees of freedom (df: 10) and a mean effect size of 0.25. Sample and criteria for participants The sample consisted of 307 female university students who met the inclusion criteria and were randomly selected. The inclusion criteria were that the participants were over 18 years of age, were currently enrolled at a university and voluntarily agreed to participate in the study. The exclusion criteria included amenorrhea for any reason (e.g., menopause, pregnancy) and a diagnosed psychiatric disorder. Data collection method The data were collected via an online questionnaire developed by the researchers via the Google Forms platform. The questionnaire was distributed to volunteers via various social media platforms (e.g., Instagram, Facebook, X). Before accessing the survey, the participants were informed in detail about the purpose and scope of the study as well as the voluntary nature of participation. Ethical approval was obtained via a consent form. The participants could not proceed with the survey questions without confirming the statement “I am voluntarily participating in the study”. The questionnaire was structured so that all questions had to be answered and was designed to be completed in approximately 15 minutes. This method aims to improve both participant experience and data integrity ( 12 ) Data collection tools In this study, demographic information, the Genital Hygiene Scale (GHBS), the Visual Analog Scale (VAS) and the Perceived Stress Scale (PSS) were used to collect data. Demographic questionnaire: This form was developed by researchers on the basis of a literature review and consists of twenty questions. It contains questions about the sociodemographic and health-related characteristics of the participants, such as age, year of study, marital status, medical history and menstrual cycle characteristics( 13 , 14 ) Genital hygiene behavior scale (GHBS) This scale was developed by( 15 ) to assess women’s genital hygiene behavior. It consists of 23 items on a five-point Likert scale and includes three subscales: general hygiene behavior (GHB), menstrual hygiene (MH) and awareness of normal findings (ANF). The total score ranges from 23–115, with higher scores indicating healthier hygiene behaviors. In the original study, the coefficients for internal consistency (Cronbach’s alpha) were reported as 0.80 for overall GHBS, 0.70 for GHB, 0.74 for MH and 0.81 for ANF( 15 ) In the present study, the Cronbach’s alpha coefficients were as follows: GHBS: 0.82; GHB: 0.67; MH: 0.66; ANF: 0.72. Visual analog scale (VAS) The VAS is a psychometric instrument in the form of a 10 cm straight line used to measure subjective feelings and experiences. The participants indicated their perceived levels of pain or stress on a continuum ranging from "none" to "very severe". In this study, the VAS was used to assess the level of academic achievement anxiety and menstrual pain in female university students ( 16 ) Perceived stress scale (PSS) The scale was adapted into Turkish by (Yerlikaya & İnanç, 2007).It consists of 14 items that assess a person’s level of stress experienced in the previous month. Four items (items 4, 5, 7, and 8) are reverse coded. The total score reflects the level of perceived stress, with higher scores indicating a higher perceived level of stress. The PSS is widely used in academic research and has demonstrated adequate validity and reliability. The internal consistency coefficient was 0.72 in the current study. Data cleaning and reliability check After data collection, the dataset was carefully checked before being analyzed, and unreliable responses were removed. In particular, responses that were completed in an unusually short time (e.g., 2–3 minutes) were excluded. In addition, response patterns such as selecting the same response for all items (straight-lining), internally inconsistent responses and data with poor response validity were also excluded. This adjustment process served to ensure the validity of the data and the accuracy of the analyses. The internal consistency of the scale values was also assessed in preliminary analyses via Cronbach’s alpha coefficients. Such procedures are generally recommended in research on the basis of online surveys ( 12 ) Data analysis In this study, the statistical analyses were performed with Statistical Package for the Social Sciences ( IBM SPSS) version 22.0. Prior to the main analyses, the distribution of the data was checked for normality by examining the values for skewness and kurtosis. The results revealed that all the variables met the acceptable criteria for a normal distribution (± 1.5), allowing the use of parametric statistical tests ( 12 ) Descriptive statistics, including frequencies (percentages), means and standard deviations, were calculated to provide an overview of participants' sociodemographic characteristics and scale scores. Pearson's correlation coefficients were calculated to examine the relationships between the primary study variables academic achievement anxiety, perceived stress and menstrual hygiene behavior. In addition, simple and multiple linear regression analyses were conducted to determine the predictive impacts of academic achievement anxiety on perceived stress and menstrual hygiene behavior. All the statistical analyses were performed with a significance level of p < 0.05. Results The mean age of the participating female students was 20.59 ± 2.02 years, the mean age at menarche was 12.90 ± 1.47 years, and the average duration of menstruation was 4.71 ± 3.79 days. More than half of the students (62.2%) had a moderate income, and more than half (63.2%) lived with their family. Only 59.6% of the participants reported having regular menstrual cycles, 64.2% stated that they sometimes had difficulty attending school during their menstrual periods, and 12.4% reported having difficulty affording menstrual hygiene products (Table 1 ). Table 1 Information on the socio-demographic and menstrual characteristics of the female students (N = 307 ) Variable Mean ± SD Min – max Variable n % Age (min- max) 20.59 ± 2.02 18–30 Regularity of menstruation Age at menarche 12.90 ± 1.47 10–19 Regular 183 59.6 Duration of menstruation (days) 5.79 ± 1.46 3–15 Irregular 38 12.4 Number of pads used per day 4.71 ± 3.79 0–10 Partly regular 86 28.0 Family type N % Type of menstrual hygiene product used Nuclear 240 78.2 Sanitary Pad 304 99.0 Extended 51 16.6 Cloth Pad 8 2.6 Broken 16 5.2 Tampon 9 2.9 Income level Ability to buy menstrual products Low 66 21.5 Easy 269 87.6 Medium 191 62.2 Difficult 38 12.4 High 50 16.3 Difficulty attending school during menstruation Place of residence Always 58 18.9 With family 194 63.2 Sometimes 197 64.2 Dormitory, own house 113 36.8 Never 52 16.9 Employment status Faculty Working 48 15.6 Health Sciences* 167 54.4 Not Working 259 84.4 Other Disciplines ** 140 45.6 *Health sciences: students enrolled in degree programmes in medicine, dentistry, pharmacy, nursing and midwifery **Other disciplines: students enrolled in degree programmes in the fields of education, engineering, law, communication, science and literature, art and design and social sciences Table 2 Correlation between academic achievement anxiety, perceived stress, menstrual hygiene behaviour and menstrual pain and the total scale scores (N = 307) Academic Achievement Anxiety Level, VAS PSS GHBS GHB MH ANF Menstrual pain 0.32** -0.13 * -0.16 ** -0.04 -0.10 0.21** Perceived Stress Scale 1 -0.12 * -0.15 ** -0.04 0.08 0.15 ** Scales and Subscale Mean ± SD Min – maks Academic Achievement Anxiety Level, VAS 6.35 ± 2.47 0–10 Perceived Stress Scale 29.94 ± 6.88 3–53 Genital Hygiene Behaviors Scale 93.87 ± 9.92 56–113 General Hygiene Behaviors Subscale 48.95 ± 5.58 26–60 Menstrual Hygiene Subscale 33.12 ± 4.48 19–40 Awareness of Normal Findings Subscale 11.79 ± 2.38 3–15 Menstrual pain, VAS 5.95 ± 2.74 0–10 *Correlation is significant at the 0.05 level (2-tailed). **Correlation is significant at the 0.01 level (2-tailed); VAS: Visual Analogue Scale Table 3 Assessment of the Basic Regression Assumptions for Each Scale Model Independent variable B Std. Error β (Beta) t p R² 1 Academic achievement Anxiety 0.891 0.151 0.320 5.899 0.000* 0.102 2 -0.547 0.228 -0.136 -2.405 0.017 0.019 3 -0.364 0.128 -0.161 -2.849 0.005 0.026 4 0.238 0.062 0.214 3.831 0.000* 0.046 Model 1: PSS; Model 2: GHBS; Model 3: GHB, Model 4: Menstrual Pain *p < 0,0001 VAS: Visual Analogue Scale; PSS: Perceived Stress Scale; GHBS: Genital Hygiene Behaviors Scale; GHB: General Hygiene Behaviors; MH: Menstrual Hygiene; ANF: Awareness of Normal Findings. Table 4 Evaluation of multiple linear regression assumptions for academic achievement anxiety Variable B Std. Error Beta (β) t Sig. (p) (Constant) 5.29 1.46 3.60 0.00 PSS 0.09 0.02 0.27 4.97 0,00 GHBS 0.00 0.03 0.01 0.10 0.91 GHB -0.05 0.05 -0.11 -0.92 0.35 ANF -0.06 0.07 -0.05 -0.83 0.40 Menstrual Pain,VAS 0.15 0.05 0.17 3.16 0.002 Dependent Variable: Academic Achievement Anxiety VAS: Visual Analogue Scale; PSS: Perceived Stress Scale; GHBS: Genital Hygiene Behaviors Scale; GHB:General Hygiene Behaviors; MH: Menstrual Hygiene; ANF: Awareness of Normal Findings. The correlations between academic achievement anxiety, perceived stress, menstrual hygiene behaviors, and menstrual pain were examined. A moderate positive correlation was found between academic achievement anxiety levels and perceived stress (r = 0.32, p < 0.01). Similarly, a positive correlation was observed between academic achievement anxiety and menstrual pain levels (r = 0.21, p < 0.01). In contrast, academic achievement anxiety was negatively correlated with genital hygiene behaviors (r = -0.13, p < 0.05) and general hygiene behaviors (r = -0.16, p 0.05). Perceived stress was also found to be negatively correlated with genital hygiene behaviors (r = -0.12, p < 0.05) and general hygiene behaviors (r = -0.15, p < 0.05). Moreover, a positive correlation was observed between perceived stress and menstrual pain (r = 0.15, p < 0.01). The mean scores of the participants on the relevant scales were as follows: Academic Achievement Anxiety Level: 6.35 ± 2.47 (range: 0–10), PPS: 29.94 ± 6.88 (range: 3–53), GHBS: 93.87 ± 9.92 (range: 56–113), GHBS: 48.95 ± 5.58 (range: 26–60), MHS: 33.12 ± 4.48 (range: 19–40), ANFS: 11.79 ± 2.38 (range: 3–15), and Menstrual Pain Scale (VAS): 5.95 ± 2.74 (range: 0–10). These findings indicate that higher levels of academic anxiety and perceived stress are associated with increased menstrual pain and poorer hygiene-related behaviors. According to Model 1, the effect of academic achievement anxiety on perceived stress level was found to be statistically significant (B = 0.891; β = 0.320; t = 5.899; p < 0.001) . Academic achievement anxiety was also found to have a significant and negative effect on women's general genital hygiene behaviors (B = − 0.547; β = − 0.136; t = − 2.405; p = 0.017) . In Model 3, a significant and negative relationship was identified between academic achievement anxiety and one of the subdimensions of genital hygiene—hygiene behaviors (B = − 0.364; β = − 0.161; t = − 2.849; p = 0.005) . Model 4 examined the effect of academic achievement anxiety on menstrual pain. The results indicated that the model was statistically significant (B = 0.238; β = 0.214; t = 3.831; p < 0.001) . In this study, a positive correlation was found between academic achievement anxiety and both perceived stress level (r = 0.32) and menstrual pain intensity (r = 0.21), whereas a significant negative correlation was observed between academic achievement anxiety and genital hygiene behaviors (r = − 0.12). Simple linear regression analyses revealed that academic achievement anxiety had a significant effect on perceived stress level (β = 0.891; β = 0.320; t = 5.899; p < 0.001), a significant negative effect on general genital hygiene behaviors (β = − 0.547; β = − 0.136; t = − 2.405; p = 0.017), a significant negative effect on hygiene behaviors (β = − 0.364; β = − 0.161; t = − 2.849; p = 0.005), and a significant effect on menstrual pain (β = 0.238; β = 0.214; t = 3.831; p < 0.001). Furthermore, multiple linear regression analysis confirmed the overall model’s significance (F(5, 301) = 10.352, p < 0.001), explaining 14.7% of the variance in academic achievement anxiety (R² = 0.147). Discussion In this study, which examined the effects of academic achievement anxiety on perceived stress levels and menstrual hygiene behaviors among female university students, the mean age of the participants was 20.59 ± 2.02 years. Although definitive national statistics on the average age of female university students in Turkey are limited, available data indicate that this population typically falls between 18 and 24 years of age( 18 ). Therefore, the mean age observed in the present sample is consistent with national demographic patterns. The mean age at menarche (12.90 ± 1.47) also aligns with findings from previous research conducted in Turkey ( 19 , 20 ). While the literature indicates that menarche is influenced by biological, socioeconomic, nutritional and environmental factors ( 21 – 23 ), the values obtained in this study support the representativeness of the sample. In this study, 59.6% of participants reported having regular menstrual cycles, similar to findings from comparable age groups ( 24 , 25 ). However, a considerable proportion experienced irregular cycles. Previous studies suggest that menstrual irregularities may be associated with stress, lifestyle factors and sleep disturbances ( 26 – 28 ). Most students reported using disposable pads as their primary menstrual product, and the low rates of cloth and tampon use observed in this study are consistent with earlier findings among university samples in Turkey ( 29 ). Additionally, 12.4% of the participants reported difficulty accessing menstrual hygiene products. Similar financial and structural barriers have been noted in previous research ( 29 , 30 ). Limited access, combined with menstrual discomfort, may reduce school or campus attendance. Earlier studies have shown that menstrual cramps, fear of leakage and inadequate hygiene facilities may contribute to absenteeism or early departure from school(Proff et al., 2023; Suleman et al., 2024). These findings suggest that menstrual hygiene challenges are not only individual health concerns but also broader institutional and societal issues. Proper genital hygiene behavior is essential for maintaining reproductive health and preventing infections. The GHBS scores obtained in the present study are similar to those reported in previous research among university students ( 13 , 33 , 34 ). Unlike earlier studies, which mainly included students from health-related departments, the current study involved participants from diverse academic fields, indicating that genital and menstrual hygiene behaviors may exhibit similar trends across different educational backgrounds. These results emphasize the need for broader university-based menstrual health education rather than interventions focused on specific academic disciplines. Academic achievement anxiety was found to increase perceived stress levels, which may negatively affect menstrual symptoms and hygiene behaviors. Prior studies have shown that academic stress is associated with menstrual cycle irregularities, increased symptom severity and challenges in menstrual management ( 14 , 26 , 35 ) Additional evidence suggests that individuals with higher stress levels experience dysmenorrhea, fatigue and mood changes more frequently( 36 , 37 ) The findings of the present study are consistent with these results, demonstrating significant associations between academic achievement anxiety and perceived stress (r = 0.32, p < 0.01), and between perceived stress and menstrual pain intensity (r = 0.15, p < 0.01). These findings underscore the multidimensional effects of stress on both psychological well-being and menstrual health. The regression models tested in this study further clarify the mechanisms linking academic achievement anxiety to menstrual outcomes. In Model 1, academic achievement anxiety significantly predicted perceived stress (B = 0.891; β = 0.320; p < 0.001). In Model 2, academic achievement anxiety had a significant but modest negative effect on menstrual hygiene behavior (B = − 0.547; β = − 0.136; p = 0.017). Although the explanatory power of this model was low (R² = 0.019), this suggests that menstrual hygiene behavior is influenced by multiple factors beyond academic anxiety alone, including personal, environmental and cultural variables. These findings align with earlier evidence showing that psychological stress can reduce adherence to hygiene routines ( 3 , 38 , 39 ) Finally, academic achievement anxiety was found to have a significant effect on menstrual pain (B = 0.238; β = 0.214; p < 0.001). This finding is consistent with literature demonstrating that psychological stress can intensify menstrual pain and increase the likelihood of dysmenorrhea ( 7 , 40 ) Taken together, the results of this study support the view that academic stress contributes to both physiological menstrual symptoms and menstrual hygiene behaviors among female university students. Conclusion This study demonstrates that academic achievement anxiety is an important psychosocial factor influencing menstrual health among female university students. Higher levels of academic anxiety were associated with increased perceived stress, greater menstrual pain intensity, and less favorable menstrual hygiene behaviors. Although the predictive effect on hygiene behaviors was modest, the findings indicate that academic stress interacts with both physiological and behavioral aspects of menstrual health. These results highlight the need for increased attention to academic-related stressors in university settings, as addressing such factors may support improvements in students’ psychological well-being and menstrual health. Future research should explore additional individual, environmental and structural determinants that may shape menstrual hygiene behaviors and menstrual experiences more broadly. Abbreviations Hypothalamic–Pituitary–Adrenal: HPA Genital Hygiene Scale: GHBS, Visual Analog Scale: VAS Perceived Stress Scale: PSS General Hygiene Behavior: GHB, Menstrual Hygiene: MH Awareness Of Normal Findings: ANF Statistical Package for the Social Sciences: IBM SPSS Declarations Ethical considerations Ethical approval was obtained from the Ethics Committee of Istanbul Medipol University Non-Interventional Research Ethics Committee (Date: 06.03.2025, Approval No: E-10840098-202.3.02-1940/273). The study complied with the principles of the Declaration of Helsinki. The survey form was completely anonymous, and no personally identifiable information (such as name, email address, IP address, etc.) was collected. The data were stored in a secure digital environment for research purposes only and were not shared with third parties. Participation in the survey was completely voluntary, and no pressure or coercion was exerted on the participants . All participants provided informed consent prior to participation. Acknowledgments We would like to express our gratitude to all the students who voluntarily participated in this study; their valuable contributions were essential to the successful completion of this research. Disclosure statement No potential conflicts of interest have been declared by the authors. Funding This research received no external funding. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Consent for publication Not applicable Authors' Contributions NB, MC, İK, and MMK jointly contributed to the conceptualization, methodology development, and data curation of the study. Data analysis was performed by NB and MMK. MMK was responsible for software development, validation, formal analysis, and project administration. Visualization was carried out by NB. Funding acquisition was conducted by MC and İK. 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Perceptions of barriers and facilitators to menstrual hygiene management programs for Pakistani girls. Front Public Health. 2023;11. doi:10.3389/fpubh.2023.1083688 Suleman A, Krishna S, Krishnakumar D, Nemoto K, Nguyễn MLT, Mehta SD. A pilot survey of students’ menstrual attitudes, experiences, and needs on an urban university campus. Women’s Health. 2024;20. doi:10.1177/17455057241254713 Tiryaki S, Gezginci E, Göktaş S. Determining the genital hygiene behaviors of health sciences faculty students. İnönü Üniversitesi Sağlık Hizmetleri Meslek Yüksek Okulu Dergisi. 2021;9(2):510–22. doi:10.33715/inonusaglik.843789 Hadımlı A, Akan A, Kardeş G, Akkurt B, Saydam BK. Determination of menstrual hygiene management and genital hygiene behaviors of students: A university example from Turkey. Revista da Escola de Enfermagem da USP. 2024;58. doi:10.1590/1980-220x-reeusp-2024-0113en Jones LI, Simbaña A, Lozada Velasteguí DA, Pérez Sánchez AS, Harris N, Wiseman N, et al. An exploration into the menstrual health of ecuadorian university students: A mixed-methods study. Women’s Reproductive Health. 2025;1–17. doi:10.1080/23293691.2025.2524375 Govind GK, Devi G. Academic stress on menstrual cycle among adolescents. . International Journal of Indian Psychology. 2023;11(3):2635–43. Kaya B, Demirtaş H. The relationship between perceived stress level and menstrual symptoms among university students. Journal of Women’s Health Nursing. 2024;10(1):51–4. Matsuura Y, Tran NH, Nguyen BT, Phan QN, Nguyen KT, Yasui T. Menstruation-related symptoms and associated factors among female university students in Vietnam. Youth. 2024;4(1):344–56. doi:10.3390/youth4010024 Munro AK, Hunter EC, Hossain SZ, Keep M. A systematic review of the menstrual experiences of university students and the impacts on their education: A global perspective. PLoS One. 2021;16(9):e0257333. doi:10.1371/journal.pone.0257333 Naw J Jacquelyn, Dr. Anjana Sinha. Menstrual pain, depression, anxiety and stress among women. International Journal of Indian Psychology. 2023. doi:10.25215/1102.148 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 18 May, 2026 Reviewers agreed at journal 16 May, 2026 Reviews received at journal 06 May, 2026 Reviewers agreed at journal 05 May, 2026 Reviewers agreed at journal 02 May, 2026 Reviews received at journal 27 Apr, 2026 Reviewers agreed at journal 27 Apr, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviewers invited by journal 21 Apr, 2026 Editor assigned by journal 21 Apr, 2026 Editor invited by journal 20 Apr, 2026 Submission checks completed at journal 18 Apr, 2026 First submitted to journal 18 Apr, 2026 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. 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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-9392082","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":631293326,"identity":"7e2a74e1-982a-4771-9036-282b2dd031a5","order_by":0,"name":"NAZIRE BAHAR","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYJCCAyCCj70BSBpYkKCFjQdEGUiQYBWbRAKIIkKLOfvxh4crKurk2CSfX93wo0CCgb+9OwGvFsuehISDZ84cNmaTzim72QN0mMSZsxvwajE4kHDgYGPbgcQ26Zy0GzxALQYSuQS0nH/YcLDxX119m+SZtJt/iNJyI5nhYGMDcwKbBPux28TZcuMZw8GGY4cN23hy2G7LGEjwEPbL+fTHHxtq6uT52Y8/u/nmj40cf3svfi1IgMcATBKrHATYH5CiehSMglEwCkYQAAD5yEkcIMiiVwAAAABJRU5ErkJggg==","orcid":"","institution":"Istanbul Medipol University: Istanbul Medipol Universitesi","correspondingAuthor":true,"prefix":"","firstName":"NAZIRE","middleName":"","lastName":"BAHAR","suffix":""},{"id":631293327,"identity":"34912dbb-32a5-458d-b57e-e006de1ef141","order_by":1,"name":"MELTEM KAYDIRAK","email":"","orcid":"","institution":"Istanbul University Cerrahpaşa","correspondingAuthor":false,"prefix":"","firstName":"MELTEM","middleName":"","lastName":"KAYDIRAK","suffix":""},{"id":631293328,"identity":"3e44622e-fb52-47df-be84-a2c693ece412","order_by":2,"name":"MERVE CİVELEK","email":"","orcid":"","institution":"Istanbul Medipol University: Istanbul Medipol Universitesi","correspondingAuthor":false,"prefix":"","firstName":"MERVE","middleName":"","lastName":"CİVELEK","suffix":""},{"id":631293329,"identity":"a9c290ff-92fa-4265-9a15-cab6f535c492","order_by":3,"name":"İCLAL KARAKAYA","email":"","orcid":"","institution":"Istanbul Medipol University: Istanbul Medipol Universitesi","correspondingAuthor":false,"prefix":"","firstName":"İCLAL","middleName":"","lastName":"KARAKAYA","suffix":""}],"badges":[],"createdAt":"2026-04-12 06:38:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9392082/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9392082/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108092015,"identity":"eeac30fd-39ec-4794-a8f7-03bb6804a15d","added_by":"auto","created_at":"2026-04-29 09:26:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":354493,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9392082/v1/4fb2787a-8083-40b0-8233-f211ebee5ea8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Academic Achievement Anxiety and Menstrual Health Outcomes among Female University Students: The Role of Perceived Stress","fulltext":[{"header":"Introduction","content":"\u003cp\u003eApproximately 1.8\u0026nbsp;billion women worldwide experience regular menstrual cycles (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Menstrual health is a holistic concept encompassing physical, psychological, and social well-being throughout the menstrual cycle and has increasingly been recognized as a critical public health priority(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) The maintenance of menstrual health is influenced not only by biological processes but also by psychosocial, environmental, and lifestyle-related factors, including stress (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In this context, individuals\u0026rsquo; stress levels and psychosocial burdens play a significant role in shaping health-related behaviors(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eFemale students in higher education are exposed to a multidimensional stress environment driven by academic performance expectations as well as biological, psychological, and social determinants. Evidence suggests that these cumulative stressors can significantly influence health behaviors (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Academic achievement anxiety, in particular, may elevate perceived stress levels by intensifying psychological pressure and concerns regarding performance outcomes. Increased perceived stress not only affects mental well-being but may also have implications for menstrual health, which is an essential component of reproductive health. Recent population-based evidence also demonstrates that menstrual-related symptoms are associated with reduced school attendance and learning participation among young individuals, highlighting the academic impact of menstrual discomfort (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFrom a physiological perspective, stress activates the hypothalamic\u0026ndash;pituitary\u0026ndash;adrenal (HPA) axis, leading to hormonal imbalances that can disrupt the menstrual cycle. Such disruptions may manifest as irregular menstruation, dysmenorrhea, or premenstrual syndrome (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Furthermore, elevated stress levels may impair individuals\u0026rsquo; ability to maintain adequate menstrual hygiene practices, either through reduced motivation or maladaptive health behaviors. Poor menstrual hygiene practices may increase the risk of infections, thereby posing broader public health concerns. Additionally, limited access to menstrual hygiene products has been shown to increase menstruation-related stress, embarrassment, and absenteeism among students, indicating that menstrual hygiene challenges can further elevate psychosocial burden (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAlthough previous studies have examined the relationship between academic anxiety and stress, as well as the impact of stress on menstrual health separately (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), integrated models addressing these variables simultaneously remain limited. In particular, the mediating role of perceived stress in the relationship between academic achievement anxiety and menstrual hygiene behavior has not been sufficiently explored. This gap highlights an important public health concern, as these factors may influence young women\u0026rsquo;s health behaviors and long-term reproductive health outcomes.\u003c/p\u003e \u003cp\u003eTherefore, this study aims to investigate the effects of academic achievement anxiety on perceived stress levels and menstrual hygiene behavior among female university students. Specifically, the study addresses the following research questions:\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) What are the levels of academic achievement anxiety, perceived stress, and menstrual hygiene behavior?\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Are there significant relationships between academic achievement anxiety and perceived stress, and between perceived stress and menstrual hygiene behavior?\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Does perceived stress mediate the relationship between academic achievement anxiety and menstrual hygiene behavior?\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eA descriptive and correlational research design was used in this study, which was conducted with female university students studying in Turkey. Data collection took place between 15 March 2025 and 25 June 2025. According to the Higher Education Council (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), approximately 3.685.522 female university students are enrolled in Turkish universities. The aim of this study was to investigate the impacts of academic achievement anxiety on perceived stress levels and menstrual hygiene behavior among female university students. As no prior research has specifically addressed this topic in Turkey, this study seeks to fill an important gap in the literature.\u003c/p\u003e \u003cp\u003eAssuming a medium effect size of academic anxiety on the specified variables, a power analysis was conducted via G*Power software. The analysis revealed that a minimum sample size of 269 participants was required for a statistical power of 80%, a significance level of 5%, degrees of freedom (df: 10) and a mean effect size of 0.25.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSample and criteria for participants\u003c/h3\u003e\n\u003cp\u003eThe sample consisted of 307 female university students who met the inclusion criteria and were randomly selected. The inclusion criteria were that the participants were over 18 years of age, were currently enrolled at a university and voluntarily agreed to participate in the study. The exclusion criteria included amenorrhea for any reason (e.g., menopause, pregnancy) and a diagnosed psychiatric disorder.\u003c/p\u003e\n\u003ch3\u003eData collection method\u003c/h3\u003e\n\u003cp\u003eThe data were collected via an online questionnaire developed by the researchers via the Google Forms platform. The questionnaire was distributed to volunteers via various social media platforms (e.g., Instagram, Facebook, X). Before accessing the survey, the participants were informed in detail about the purpose and scope of the study as well as the voluntary nature of participation. Ethical approval was obtained via a consent form. The participants could not proceed with the survey questions without confirming the statement \u0026ldquo;I am voluntarily participating in the study\u0026rdquo;. The questionnaire was structured so that all questions had to be answered and was designed to be completed in approximately 15 minutes. This method aims to improve both participant experience and data integrity (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e\n\u003ch3\u003eData collection tools\u003c/h3\u003e\n\u003cp\u003eIn this study, demographic information, the Genital Hygiene Scale (GHBS), the Visual Analog Scale (VAS) and the Perceived Stress Scale (PSS) were used to collect data.\u003c/p\u003e \u003cp\u003eDemographic questionnaire: This form was developed by researchers on the basis of a literature review and consists of twenty questions. It contains questions about the sociodemographic and health-related characteristics of the participants, such as age, year of study, marital status, medical history and menstrual cycle characteristics(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e\n\u003ch3\u003eGenital hygiene behavior scale (GHBS)\u003c/h3\u003e\n\u003cp\u003eThis scale was developed by(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) to assess women\u0026rsquo;s genital hygiene behavior. It consists of 23 items on a five-point Likert scale and includes three subscales: general hygiene behavior (GHB), menstrual hygiene (MH) and awareness of normal findings (ANF). The total score ranges from 23\u0026ndash;115, with higher scores indicating healthier hygiene behaviors. In the original study, the coefficients for internal consistency (Cronbach\u0026rsquo;s alpha) were reported as 0.80 for overall GHBS, 0.70 for GHB, 0.74 for MH and 0.81 for ANF(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) In the present study, the Cronbach\u0026rsquo;s alpha coefficients were as follows: GHBS: 0.82; GHB: 0.67; MH: 0.66; ANF: 0.72.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eVisual analog scale (VAS)\u003c/h2\u003e \u003cp\u003eThe VAS is a psychometric instrument in the form of a 10 cm straight line used to measure subjective feelings and experiences. The participants indicated their perceived levels of pain or stress on a continuum ranging from \"none\" to \"very severe\". In this study, the VAS was used to assess the level of academic achievement anxiety and menstrual pain in female university students (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePerceived stress scale (PSS)\u003c/h3\u003e\n\u003cp\u003eThe scale was adapted into Turkish by (Yerlikaya \u0026amp; İnan\u0026ccedil;, 2007).It consists of 14 items that assess a person\u0026rsquo;s level of stress experienced in the previous month. Four items (items 4, 5, 7, and 8) are reverse coded. The total score reflects the level of perceived stress, with higher scores indicating a higher perceived level of stress. The PSS is widely used in academic research and has demonstrated adequate validity and reliability. The internal consistency coefficient was 0.72 in the current study.\u003c/p\u003e\n\u003ch3\u003eData cleaning and reliability check\u003c/h3\u003e\n\u003cp\u003eAfter data collection, the dataset was carefully checked before being analyzed, and unreliable responses were removed. In particular, responses that were completed in an unusually short time (e.g., 2\u0026ndash;3 minutes) were excluded. In addition, response patterns such as selecting the same response for all items (straight-lining), internally inconsistent responses and data with poor response validity were also excluded. This adjustment process served to ensure the validity of the data and the accuracy of the analyses.\u003c/p\u003e \u003cp\u003eThe internal consistency of the scale values was also assessed in preliminary analyses via Cronbach\u0026rsquo;s alpha coefficients. Such procedures are generally recommended in research on the basis of online surveys (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eIn this study, the statistical analyses were performed with Statistical Package for the Social Sciences \u003cb\u003e(\u003c/b\u003eIBM SPSS) version 22.0. Prior to the main analyses, the distribution of the data was checked for normality by examining the values for skewness and kurtosis. The results revealed that all the variables met the acceptable criteria for a normal distribution (\u0026plusmn;\u0026thinsp;1.5), allowing the use of parametric statistical tests (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eDescriptive statistics, including frequencies (percentages), means and standard deviations, were calculated to provide an overview of participants' sociodemographic characteristics and scale scores. Pearson's correlation coefficients were calculated to examine the relationships between the primary study variables academic achievement anxiety, perceived stress and menstrual hygiene behavior. In addition, simple and multiple linear regression analyses were conducted to determine the predictive impacts of academic achievement anxiety on perceived stress and menstrual hygiene behavior. All the statistical analyses were performed with a significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe mean age of the participating female students was 20.59\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02 years, the mean age at menarche was 12.90\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47 years, and the average duration of menstruation was 4.71\u0026thinsp;\u0026plusmn;\u0026thinsp;3.79 days. More than half of the students (62.2%) had a moderate income, and more than half (63.2%) lived with their family. Only 59.6% of the participants reported having regular menstrual cycles, 64.2% stated that they sometimes had difficulty attending school during their menstrual periods, and 12.4% reported having difficulty affording menstrual hygiene products (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eInformation on the socio-demographic and menstrual characteristics of the female students (N\u0026thinsp;=\u0026thinsp;307\u003c/b\u003e)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMin \u0026ndash; max\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (min- max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.59\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;2.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eRegularity of menstruation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at menarche\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.90\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRegular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e59.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of menstruation (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.79\u0026thinsp;\u0026plusmn;\u0026thinsp;1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIrregular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of pads used per day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.71\u0026thinsp;\u0026plusmn;\u0026thinsp;3.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePartly regular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eType of menstrual hygiene product used\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNuclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSanitary Pad\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e304\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e99.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtended\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCloth Pad\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBroken\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTampon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIncome level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eAbility to buy menstrual products\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEasy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e269\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e87.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDifficult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eDifficulty attending school during menstruation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlace of residence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e197\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e64.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDormitory, own house\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eFaculty\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHealth Sciences*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e54.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot Working\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e259\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOther Disciplines **\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e45.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Health sciences: students enrolled in degree programmes in medicine, dentistry, pharmacy, nursing and midwifery\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e**Other disciplines: students enrolled in degree programmes in the fields of education, engineering, law, communication, science and literature, art and design and social sciences\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation between academic achievement anxiety, perceived stress, menstrual hygiene behaviour and menstrual pain and the total scale scores (N\u0026thinsp;=\u0026thinsp;307)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAcademic Achievement Anxiety Level, VAS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePSS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eGHBS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGHB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMH\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eANF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMenstrual pain\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.32**\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e-0.13\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.16\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.04\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.10\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.21**\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived Stress Scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e-0.12\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.15\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.15\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eScales and Subscale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c8\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMin \u0026ndash; maks\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcademic Achievement Anxiety Level, VAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e6.35\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;2.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c8\" namest=\"c4\"\u003e \u003cp\u003e0\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived Stress Scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e29.94\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;6.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c8\" namest=\"c4\"\u003e \u003cp\u003e3\u0026ndash;53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGenital Hygiene Behaviors Scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e93.87\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;9.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c8\" namest=\"c4\"\u003e \u003cp\u003e56\u0026ndash;113\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral Hygiene Behaviors Subscale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e48.95\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;5.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c8\" namest=\"c4\"\u003e \u003cp\u003e26\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenstrual Hygiene Subscale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e33.12\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;4.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c8\" namest=\"c4\"\u003e \u003cp\u003e19\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAwareness of Normal Findings Subscale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e11.79\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;2.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c8\" namest=\"c4\"\u003e \u003cp\u003e3\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenstrual pain, VAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e5.95\u0026thinsp;\u0026plusmn;\u0026thinsp;2.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c8\" namest=\"c4\"\u003e \u003cp\u003e0\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e*Correlation is significant at the 0.05 level (2-tailed). **Correlation is significant at the 0.01 level (2-tailed); VAS: Visual Analogue Scale\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssessment of the Basic Regression Assumptions for Each Scale\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndependent variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStd. Error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eβ (Beta)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eR\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eAcademic achievement Anxiety\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.891\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.899\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.000*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.547\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.228\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.405\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.017\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.364\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.849\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.238\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.062\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.831\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.000*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eModel 1: PSS; Model 2: GHBS; Model 3: GHB, Model 4: Menstrual Pain *p\u0026thinsp;\u0026lt;\u0026thinsp;0,0001\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eVAS: Visual Analogue Scale; PSS: Perceived Stress Scale; GHBS: Genital Hygiene Behaviors Scale; GHB: General Hygiene Behaviors; MH: Menstrual Hygiene; ANF: Awareness of Normal Findings.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEvaluation of multiple linear regression assumptions for academic achievement anxiety\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStd. Error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBeta (β)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSig. (p)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Constant)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0,00\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGHBS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGHB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eANF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenstrual Pain,VAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eDependent Variable: Academic Achievement Anxiety\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eVAS: Visual Analogue Scale; PSS: Perceived Stress Scale; GHBS: Genital Hygiene Behaviors Scale; GHB:General Hygiene Behaviors; MH: Menstrual Hygiene; ANF: Awareness of Normal Findings.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe correlations between academic achievement anxiety, perceived stress, menstrual hygiene behaviors, and menstrual pain were examined. A moderate positive correlation was found between academic achievement anxiety levels and perceived stress (r\u0026thinsp;=\u0026thinsp;0.32, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Similarly, a positive correlation was observed between academic achievement anxiety and menstrual pain levels (r\u0026thinsp;=\u0026thinsp;0.21, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). In contrast, academic achievement anxiety was negatively correlated with genital hygiene behaviors (r = -0.13, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and general hygiene behaviors (r = -0.16, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No significant correlations were found between academic achievement anxiety and menstrual hygiene behaviors or awareness of normal findings (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Perceived stress was also found to be negatively correlated with genital hygiene behaviors (r = -0.12, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and general hygiene behaviors (r = -0.15, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Moreover, a positive correlation was observed between perceived stress and menstrual pain (r\u0026thinsp;=\u0026thinsp;0.15, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The mean scores of the participants on the relevant scales were as follows: Academic Achievement Anxiety Level: 6.35\u0026thinsp;\u0026plusmn;\u0026thinsp;2.47 (range: 0\u0026ndash;10), PPS: 29.94\u0026thinsp;\u0026plusmn;\u0026thinsp;6.88 (range: 3\u0026ndash;53), GHBS: 93.87\u0026thinsp;\u0026plusmn;\u0026thinsp;9.92 (range: 56\u0026ndash;113), GHBS: 48.95\u0026thinsp;\u0026plusmn;\u0026thinsp;5.58 (range: 26\u0026ndash;60), MHS: 33.12\u0026thinsp;\u0026plusmn;\u0026thinsp;4.48 (range: 19\u0026ndash;40), ANFS: 11.79\u0026thinsp;\u0026plusmn;\u0026thinsp;2.38 (range: 3\u0026ndash;15), and Menstrual Pain Scale (VAS): 5.95\u0026thinsp;\u0026plusmn;\u0026thinsp;2.74 (range: 0\u0026ndash;10). These findings indicate that higher levels of academic anxiety and perceived stress are associated with increased menstrual pain and poorer hygiene-related behaviors.\u003c/p\u003e \u003cp\u003eAccording to Model 1, the effect of academic achievement anxiety on perceived stress level was found to be statistically significant \u003cem\u003e(B\u0026thinsp;=\u0026thinsp;0.891; β\u0026thinsp;=\u0026thinsp;0.320; t\u0026thinsp;=\u0026thinsp;5.899; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eAcademic achievement anxiety was also found to have a significant and negative effect on women's general genital hygiene behaviors \u003cem\u003e(B = \u0026minus;\u0026thinsp;0.547; β = \u0026minus;\u0026thinsp;0.136; t = \u0026minus;\u0026thinsp;2.405; p\u0026thinsp;=\u0026thinsp;0.017)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eIn Model 3, a significant and negative relationship was identified between academic achievement anxiety and one of the subdimensions of genital hygiene\u0026mdash;hygiene behaviors \u003cem\u003e(B = \u0026minus;\u0026thinsp;0.364; β = \u0026minus;\u0026thinsp;0.161; t = \u0026minus;\u0026thinsp;2.849; p\u0026thinsp;=\u0026thinsp;0.005)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eModel 4 examined the effect of academic achievement anxiety on menstrual pain. The results indicated that the model was statistically significant \u003cem\u003e(B\u0026thinsp;=\u0026thinsp;0.238; β\u0026thinsp;=\u0026thinsp;0.214; t\u0026thinsp;=\u0026thinsp;3.831; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/em\u003e. In this study, a positive correlation was found between academic achievement anxiety and both perceived stress level (r\u0026thinsp;=\u0026thinsp;0.32) and menstrual pain intensity (r\u0026thinsp;=\u0026thinsp;0.21), whereas a significant negative correlation was observed between academic achievement anxiety and genital hygiene behaviors (r = \u0026minus;\u0026thinsp;0.12). Simple linear regression analyses revealed that academic achievement anxiety had a significant effect on perceived stress level (β\u0026thinsp;=\u0026thinsp;0.891; β\u0026thinsp;=\u0026thinsp;0.320; t\u0026thinsp;=\u0026thinsp;5.899; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a significant negative effect on general genital hygiene behaviors (β = \u0026minus;\u0026thinsp;0.547; β = \u0026minus;\u0026thinsp;0.136; t = \u0026minus;\u0026thinsp;2.405; p\u0026thinsp;=\u0026thinsp;0.017), a significant negative effect on hygiene behaviors (β = \u0026minus;\u0026thinsp;0.364; β = \u0026minus;\u0026thinsp;0.161; t = \u0026minus;\u0026thinsp;2.849; p\u0026thinsp;=\u0026thinsp;0.005), and a significant effect on menstrual pain (β\u0026thinsp;=\u0026thinsp;0.238; β\u0026thinsp;=\u0026thinsp;0.214; t\u0026thinsp;=\u0026thinsp;3.831; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Furthermore, multiple linear regression analysis confirmed the overall model\u0026rsquo;s significance (F(5, 301)\u0026thinsp;=\u0026thinsp;10.352, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), explaining 14.7% of the variance in academic achievement anxiety (R\u0026sup2; = 0.147).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, which examined the effects of academic achievement anxiety on perceived stress levels and menstrual hygiene behaviors among female university students, the mean age of the participants was 20.59\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02 years. Although definitive national statistics on the average age of female university students in Turkey are limited, available data indicate that this population typically falls between 18 and 24 years of age(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTherefore, the mean age observed in the present sample is consistent with national demographic patterns. The mean age at menarche (12.90\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47) also aligns with findings from previous research conducted in Turkey (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). While the literature indicates that menarche is influenced by biological, socioeconomic, nutritional and environmental factors (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), the values obtained in this study support the representativeness of the sample.\u003c/p\u003e \u003cp\u003eIn this study, 59.6% of participants reported having regular menstrual cycles, similar to findings from comparable age groups (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). However, a considerable proportion experienced irregular cycles. Previous studies suggest that menstrual irregularities may be associated with stress, lifestyle factors and sleep disturbances (\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Most students reported using disposable pads as their primary menstrual product, and the low rates of cloth and tampon use observed in this study are consistent with earlier findings among university samples in Turkey (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdditionally, 12.4% of the participants reported difficulty accessing menstrual hygiene products. Similar financial and structural barriers have been noted in previous research (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Limited access, combined with menstrual discomfort, may reduce school or campus attendance. Earlier studies have shown that menstrual cramps, fear of leakage and inadequate hygiene facilities may contribute to absenteeism or early departure from school(Proff et al., 2023; Suleman et al., 2024). These findings suggest that menstrual hygiene challenges are not only individual health concerns but also broader institutional and societal issues.\u003c/p\u003e \u003cp\u003eProper genital hygiene behavior is essential for maintaining reproductive health and preventing infections. The GHBS scores obtained in the present study are similar to those reported in previous research among university students (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Unlike earlier studies, which mainly included students from health-related departments, the current study involved participants from diverse academic fields, indicating that genital and menstrual hygiene behaviors may exhibit similar trends across different educational backgrounds. These results emphasize the need for broader university-based menstrual health education rather than interventions focused on specific academic disciplines.\u003c/p\u003e \u003cp\u003eAcademic achievement anxiety was found to increase perceived stress levels, which may negatively affect menstrual symptoms and hygiene behaviors. Prior studies have shown that academic stress is associated with menstrual cycle irregularities, increased symptom severity and challenges in menstrual management (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) Additional evidence suggests that individuals with higher stress levels experience dysmenorrhea, fatigue and mood changes more frequently(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) The findings of the present study are consistent with these results, demonstrating significant associations between academic achievement anxiety and perceived stress (r\u0026thinsp;=\u0026thinsp;0.32, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and between perceived stress and menstrual pain intensity (r\u0026thinsp;=\u0026thinsp;0.15, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). These findings underscore the multidimensional effects of stress on both psychological well-being and menstrual health.\u003c/p\u003e \u003cp\u003eThe regression models tested in this study further clarify the mechanisms linking academic achievement anxiety to menstrual outcomes. In Model 1, academic achievement anxiety significantly predicted perceived stress (B\u0026thinsp;=\u0026thinsp;0.891; β\u0026thinsp;=\u0026thinsp;0.320; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In Model 2, academic achievement anxiety had a significant but modest negative effect on menstrual hygiene behavior (B = \u0026minus;\u0026thinsp;0.547; β = \u0026minus;\u0026thinsp;0.136; p\u0026thinsp;=\u0026thinsp;0.017). Although the explanatory power of this model was low (R\u0026sup2; = 0.019), this suggests that menstrual hygiene behavior is influenced by multiple factors beyond academic anxiety alone, including personal, environmental and cultural variables. These findings align with earlier evidence showing that psychological stress can reduce adherence to hygiene routines (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eFinally, academic achievement anxiety was found to have a significant effect on menstrual pain (B\u0026thinsp;=\u0026thinsp;0.238; β\u0026thinsp;=\u0026thinsp;0.214; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This finding is consistent with literature demonstrating that psychological stress can intensify menstrual pain and increase the likelihood of dysmenorrhea (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) Taken together, the results of this study support the view that academic stress contributes to both physiological menstrual symptoms and menstrual hygiene behaviors among female university students.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates that academic achievement anxiety is an important psychosocial factor influencing menstrual health among female university students. Higher levels of academic anxiety were associated with increased perceived stress, greater menstrual pain intensity, and less favorable menstrual hygiene behaviors. Although the predictive effect on hygiene behaviors was modest, the findings indicate that academic stress interacts with both physiological and behavioral aspects of menstrual health. These results highlight the need for increased attention to academic-related stressors in university settings, as addressing such factors may support improvements in students\u0026rsquo; psychological well-being and menstrual health. Future research should explore additional individual, environmental and structural determinants that may shape menstrual hygiene behaviors and menstrual experiences more broadly.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHypothalamic\u0026ndash;Pituitary\u0026ndash;Adrenal: HPA\u003c/p\u003e\n\u003cp\u003eGenital Hygiene Scale: GHBS, \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVisual Analog Scale: VAS\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePerceived Stress Scale: PSS\u003c/p\u003e\n\u003cp\u003eGeneral Hygiene Behavior: GHB,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMenstrual Hygiene: MH \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAwareness Of Normal Findings: ANF\u003c/p\u003e\n\u003cp\u003eStatistical Package for the Social Sciences: IBM SPSS\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Ethics Committee of \u0026nbsp;Istanbul Medipol University Non-Interventional Research Ethics Committee (Date: 06.03.2025, Approval No: E-10840098-202.3.02-1940/273). The study complied with the principles of the Declaration of Helsinki. The survey form was completely anonymous, and no personally identifiable information (such as name, email address, IP address, etc.) was collected. The data were stored in a secure digital environment for research purposes only and were not shared with third parties. Participation in the survey was completely voluntary, and no pressure or coercion was exerted on the participants\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eAll participants provided informed consent prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our gratitude to all the students who voluntarily participated in this study; their valuable contributions were essential to the successful completion of this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo potential conflicts of interest have been declared by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\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\u003eAuthors\u0026apos; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNB, MC, İK, and MMK jointly contributed to the conceptualization, methodology development, and data curation of the study. Data analysis was performed by NB and MMK. MMK was responsible for software development, validation, formal analysis, and project administration. Visualization was carried out by NB. Funding acquisition was conducted by MC and İK. Resources were provided by MC and İK. The original draft was written collaboratively by NB, MC, İK, and MMK, while review and editing were completed by NB and MMK.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization (WHO). WHO statement on menstr\u0026uuml;el health and rights [Internet]. 2022 [cited 2025 May 15]. Available from: https://www.who.int/news/item/22-06-2022-who-statement-on-menstr\u0026uuml;el-health-and-rights\u003c/li\u003e\n\u003cli\u003eKansiime C, Hytti L, Nelson KA, Torondel B, Francis SC, Tanton C, et al. Menstrual health interventions, schooling, and mental health problems among Ugandan students (MENISCUS): study protocol for a school-based cluster-randomised trial. 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The decreasing age of menarche in Turkey: global warming, socioeconomic development, and environmental factors. 2023.\u003c/li\u003e\n\u003cli\u003eKarakaş S, Dikici A, Oyardı G. Determining coping methods for premenstrual syndrome among university students. . Journal of Health Sciences of Istanbul Rumeli University, . 2023;1(2):42\u0026ndash;58.\u003c/li\u003e\n\u003cli\u003eWang Z, Asokan G, Onnela JP, Baird DD, Jukic AMZ, Wilcox AJ, et al. Menarche and time to cycle regularity among individuals born between 1950 and 2005 in the US. JAMA Netw Open. 2024;7(5):e2412854. doi:10.1001/jamanetworkopen.2024.12854\u003c/li\u003e\n\u003cli\u003eChristanti S, Syafiq A, Fikawati S. Eating habits and age at \u0026ouml;enarche in junior high school female students in DKI Jakarta province in 2023. Amerta Nutrition. 2024;8(2):190\u0026ndash;8. doi:10.20473/amnt.v8i2.2024.190-198\u003c/li\u003e\n\u003cli\u003eG\u0026uuml;ran T, Helvacıoğlu D, G\u0026uuml;rpınar Tosun B, Yavaş Abalı Z, Alır F, Arslan YT, et al. Decline in the age of menarche in Istanbul schoolgirls over the Last 12 Years. J Clin Res Pediatr Endocrinol. 2023;15(2):154\u0026ndash;9. doi:10.4274/jcrpe.galenos.2023.2022-11-16\u003c/li\u003e\n\u003cli\u003eKarak\u0026uuml;\u0026ccedil;\u0026uuml;k S, S\u0026ouml;nmez M, Ken\u0026ccedil; İ. Determining the frequency of premenstrual syndrome symptoms and coping methods using a PMS diary among university students. . Journal of Adnan Menderes University Health Sciences Faculty. 2022;6(3):419\u0026ndash;30.\u003c/li\u003e\n\u003cli\u003eErbaş N, Altunbaş N. According to some variables in girls a high school determining the premenstrual syndrome violence and perceped stress level. 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An exploration into the menstrual health of ecuadorian university students: A mixed-methods study. Women\u0026rsquo;s Reproductive Health. 2025;1\u0026ndash;17. doi:10.1080/23293691.2025.2524375\u003c/li\u003e\n\u003cli\u003eGovind GK, Devi G. Academic stress on menstrual cycle among adolescents. . International Journal of Indian Psychology. 2023;11(3):2635\u0026ndash;43.\u003c/li\u003e\n\u003cli\u003eKaya B, Demirtaş H. The relationship between perceived stress level and menstrual symptoms among university students. Journal of Women\u0026rsquo;s Health Nursing. 2024;10(1):51\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eMatsuura Y, Tran NH, Nguyen BT, Phan QN, Nguyen KT, Yasui T. Menstruation-related symptoms and associated factors among female university students in Vietnam. Youth. 2024;4(1):344\u0026ndash;56. doi:10.3390/youth4010024\u003c/li\u003e\n\u003cli\u003eMunro AK, Hunter EC, Hossain SZ, Keep M. A systematic review of the menstrual experiences of university students and the impacts on their education: A global perspective. PLoS One. 2021;16(9):e0257333. doi:10.1371/journal.pone.0257333\u003c/li\u003e\n\u003cli\u003eNaw J Jacquelyn, Dr. Anjana Sinha. Menstrual pain, depression, anxiety and stress among women. International Journal of Indian Psychology. 2023. doi:10.25215/1102.148\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-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"academic achievement anxiety, perceived stress, menstrual hygiene behaviors, menstrual health, menstrual pain","lastPublishedDoi":"10.21203/rs.3.rs-9392082/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9392082/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eAcademic achievement anxiety is a common psychosocial stressor among university students and may influence menstrual health outcomes. However, limited research has explored how academic anxiety relates simultaneously to perceived stress, menstrual pain, and menstrual hygiene behaviors in female university populations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e his cross-sectional study included 307 female university students in Turkey (mean age = 20.59 ± 2.02 years). Participants completed online self-report measures assessing academic achievement anxiety, perceived stress, menstrual pain severity, and menstrual hygiene behaviors. Descriptive statistics, Pearson correlations, and regression analyses were conducted to examine associations among the variables.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Higher academic achievement anxiety was associated with increased perceived stress (r = 0.32, p \u0026lt; 0.01) and greater menstrual pain severity (r = 0.21, p \u0026lt; 0.01). Anxiety demonstrated a weak but significant negative association with genital hygiene behaviors (r = –0.13, p \u0026lt; 0.05). Regression analyses showed that academic achievement anxiety significantly predicted perceived stress and menstrual pain but had limited predictive value for menstrual hygiene behaviors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Academic achievement anxiety was associated with higher perceived stress, increased menstrual pain and slightly less optimal menstrual hygiene practices among female university students. These findings suggest that academic-related stress may influence key aspects of menstrual health. Supporting stress management and menstrual health awareness within university health services may contribute to improved well‑being in this population.\u003c/p\u003e","manuscriptTitle":"Academic Achievement Anxiety and Menstrual Health Outcomes among Female University Students: The Role of Perceived Stress","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-29 09:25:59","doi":"10.21203/rs.3.rs-9392082/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"223910166484991782749235036689532265301","date":"2026-05-18T10:50:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"266657267325458262308380510543672718838","date":"2026-05-16T17:42:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-06T14:19:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"274086999805665214354445169597592214045","date":"2026-05-05T21:09:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296759133793628639736627019573384454495","date":"2026-05-02T18:55:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-27T14:40:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79930049046362121756186148835739455048","date":"2026-04-27T07:22:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"205194911827974749796635467835843471565","date":"2026-04-22T12:40:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-21T06:54:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-21T06:51:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-20T06:33:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-18T13:16:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-04-18T13:12:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bd877106-a5a4-4620-b7c7-1e0829823d69","owner":[],"postedDate":"April 29th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"223910166484991782749235036689532265301","date":"2026-05-18T10:50:24+00:00","index":83,"fulltext":""},{"type":"reviewerAgreed","content":"266657267325458262308380510543672718838","date":"2026-05-16T17:42:38+00:00","index":82,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-06T14:19:25+00:00","index":62,"fulltext":""},{"type":"reviewerAgreed","content":"274086999805665214354445169597592214045","date":"2026-05-05T21:09:47+00:00","index":61,"fulltext":""},{"type":"reviewerAgreed","content":"296759133793628639736627019573384454495","date":"2026-05-02T18:55:46+00:00","index":57,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-29T09:25:59+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-29 09:25:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9392082","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9392082","identity":"rs-9392082","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}