Adolescent girls' descriptions of dysmenorrhea and barriers to dysmenorrhea management in Moshi, Tanzania: A qualitative study.

Dysmenorrhea, defined as abdominal cramping and pain associated with menstruation, is a significant public health concern for adolescent girls around the world [ 1 , 2 ]. In Sub-Saharan Africa (SSA), between 61%-84% of adolescent girls experience dysmenorrhea, with severe pain occurring among 33%-56% of girls [ 3 – 8 ]. In two studies from the Tanzania (the location of the current study), 75% of adolescent girls reported dysmenorrhea and 42% of girls reported very strong pain [ 7 , 8 ]. In both SSA generally and in Tanzania specifically, dysmenorrhea has been shown to disrupt participation in school and social events, with dysmenorrhea linked to difficulty paying attention in class, school absenteeism, decreased school performance, difficulties engaging in physical activity, and an inability to socialize with friends [ 7 – 14 ]. Despite the high prevalence of dysmenorrhea in SSA, most adolescent girls do not receive first-line treatments for menstrual pain [ 7 , 13 , 15 , 16 ]. Thus, understanding factors that influence the management of dysmenorrhea is critical to improving both sexual and reproductive health (SRH) and overall well-being among girls in SSA. First-line treatments for primary dysmenorrhea include non-steroidal anti-inflammatory medications (NSAIDs) and hormonal contraceptive pills [ 2 ]. NSAIDs show especially high efficacy for primary dysmenorrhea because they are prostaglandin synthetase inhibitors [ 17 , 18 ], and menstrual pain occurs in part due to the release of prostaglandins [ 1 , 2 ]. Testing for gynecological and hormonal conditions is recommended among girls whose pain does not respond to NSAIDs and hormonal contraceptives [ 2 ]. However, these first-line treatments are not universally available or acceptable across settings [ 19 ]. In research from SSA, the proportion of women and girls seeking medical care for menstrual disorders ranges from 9%-16%, and many women and girls report “putting up with” pain [ 13 , 15 , 16 ]. Dysmenorrhea management strategies reported by girls in SSA have included resting, medication, herbal treatments, dietary changes, heat applied to the abdomen, exercise, and increased water intake [ 10 , 11 , 15 ]. Across five studies, the use of medications such as analgesics ranged from 43% to 64%, with 55% of girls in Tanzania with dysmenorrhea taking medications for menstrual pain [ 6 , 7 , 11 , 13 , 15 ]. In many cases, the non-NSAID analgesic paracetamol (i.e., acetaminophen), was the most common drug used, which is not a first-line treatment [ 6 , 7 , 11 , 13 , 15 ]. Few girls in SSA report using hormonal contraceptives to manage menstrual pain [ 7 , 13 , 15 ]. There is evidence that sociocultural factors may serve as barriers to accessing medications: in Uganda, adolescent girls reported limited access to pain medications and beliefs that medications can be harmful to the body [ 12 ]. Although prior research has described girls’ use of pain management strategies in SSA [ 10 , 11 , 15 ], there is still little insight into the psychosocial and cultural factors driving the management of dysmenorrhea in Tanzania. In Tanzania, difficulties managing dysmenorrhea may be heightened because menstruation is often stigmatized and girls can lack access to menstrual education, menstrual supplies, reproductive healthcare, and social support [ 7 , 8 , 20 – 27 ]. A health barrier is any factor that makes it more difficult for an individual to use health services (including prevention, diagnosis, or treatment) or improve their health in any other way [ 28 ]. To be more effective, interventions for dysmenorrhea should be culturally tailored to address barriers that impact girls’ ability to access menstrual care and manage dysmenorrhea. Therefore, this research analyzed qualitative interviews with adolescent girls and adult experts who work with adolescent girls (e.g., teachers, medical providers, parents, and non-governmental organization (NGO) staff) in Tanzania to describe 1) girls’ experiences of dysmenorrhea, 2) sociocultural factors impacting girls’ ability to manage dysmenorrhea, and 3) barriers to dysmenorrhea management.

A concept map of themes related to dysmenorrhea is presented in Fig 1 . Ten adolescent girls and ten adult experts were enrolled. Adolescent participants were between the ages of 14–19 ( Table 2 ). Experts included adults between 30–60 years old, including three NGO staff members (e.g., shelter staff, educators), two teachers, a faith community leader, a pharmacist, two medical doctors, and a mother who had raised adolescent girls. Three local experts were male, including an NGO staff member, teacher, and healthcare provider. Nine adolescent girls reported experiencing menstrual pain. This included six girls who named dysmenorrhea as a primary challenge in response to open-ended questions about stressors during puberty and three girls who confirmed they had experienced menstrual pain in response to probing from interviewers (e.g., “ Do you experience physical problems before or during your period ?”). One girl did not personally experience menstrual pain. Interviewer: What are the bad things or the good things that you went through in the process of growing up ? Participant: To start with the bad things , I normally go through severe abdominal cramps . I get sick , and sometimes I don’t go to school , and I have to stay at home until I get well . Much blood gets out . It causes me a lot of discomfort , and it is something that really annoys me –Adolescent E (17, urban setting, in school) Five girls had severe dysmenorrhea, which can be defined as a high level of pain that 1) causes functional impairment (e.g., being unable to attend school), 2) is not relieved by medications, and/or 3) is accompanied by symptoms such as headaches, fainting, diarrhea, vomiting, or heavy bleeding [ 33 ]. Pain severity varied between menstrual periods, across days within a single menstrual period, and within the course of a day. Dysmenorrhea and co-occurring symptoms had a negative impact on girls’ mental health and quality of life. Girls reported having to miss school, daily chores, work, physical activity, and social events due to pain. Dysmenorrhea was linked to difficulties concentrating and feelings of annoyance, irritability, anger, fatigue, and sadness. For example, girls reported missing enjoyable activities such as playing with friends, which led to feelings of sadness. Another challenge is that I get so much pain that makes me unable to carry on with my work .–Adolescent J (17, urban area, out of school) I feel so bad that I fail to concentrate , and my mind cannot function to do anything .–Adolescent G (17, rural area, in school) Adolescent girls reported increased irritability and anger due to menstrual pain, which was also observed by adult experts. Interviewer: Does it [pain] affect your feelings in any way ? Participant: Yes . I get angry easily and I cannot hang with someone for more than two minutes because the person irritates me , and I can even hit them .–Adolescent E (17, urban, in school) They usually have mood swings , which can make it difficult to cope with others .–Adult Expert (NGO Staff, Male) Pain management strategies reported by girls included pharmacological strategies (including medications and herbs) and behavioral strategies (see Table 3 ). Behavioral strategies were reported more often than pharmacological strategies. Girls typically combined multiple pain treatments. Note . 1 Did not personally experience menstrual pain, but had been instructed to exercise to manage pain. 2 Adolescent was unaware of medication’s name. Medications provided by a doctor or available at a pharmacy were labeled as “hospital medications,” whereas herbal treatments, such as teas, were described as “traditional medicine.” Traditional medicines reported by girls included teas, plants, herbs, and honey. It is some kind of herbal medicine which is ground into powder form , mixed with honey , and I was told to lick it .–Adolescent E (17, urban area, in school) Hospital medications taken by girls included the non-NSAID analgesic paracetamol ( n = 4), the NSAID ibuprofen ( n = 1), and an unknown medication (adolescent could not recall the name) ( n = 1). No girls reported taking hormonal contraceptives. Five adult experts in our study recommended medication to treat menstrual pain, including hyoscine butylbromide (i.e., Buscopan, an anticholinergic medication that serves as a gastrointestinal antispasmodic), paracetamol/acetaminophen (a non-NSAID analgesic and antipyretic), NSAIDs, and tramadol (an opioid analgesic). No adolescent participants, however, reported using Buscopan or tramadol. Healthcare providers reported that they preferred Buscopan over other medications, including NSAIDs. The first thing we give them are muscle relaxants , as the pain is caused by the muscle contractions .–Adult Expert D (Medical Doctor, Woman) The best medicine which I can give a girl , which reduces pain quickly is Buscopan . Buscopan is better than ibuprofen and paracetamol because it does work very quick to reduce menstrual period pain .–Adult Expert J (Pharmacist, Woman) Behavioral strategies used by girls included resting (including lying down and sleeping); increasing fluid intake and drinking hot water; physical activity; and placing hot water on the abdomen. I take hot water and put it into a container , and I use it to massage my stomach , and as I do this the pain subsides .–Adolescent E (17, urban setting, in school) Girls were able to rest by getting permission from parents or teachers to miss school or by getting help with chores. Specific physical activities reported by girls included heavy chores (e.g., farming), playing, jumping rope, and other general exercise. Despite the use of physical activity among some girls, other girls had to decrease physical activity during menstruation because of physical symptoms (pain, fatigue, nausea) or worries about leaks due to a lack of menstrual supplies, such as absorbent materials and underwear. I find my fellow girls are playing a very good game , but I cannot join in because I am in my period and because they are jumping around , and I cannot do that . It makes me sad , and I hate it .–Adolescent G (17, rural setting, in school) Some of them cannot afford the sanitary pads , and so they use pieces of cloth , and when you use pieces of cloth it is easy for the blood to leak .–Adolescent E (17, urban setting, in school) Six girls positively reframed menstrual cramps as a useful sign that menstruation is about to start. This allowed them to prepare by having menstrual supplies available. Reports of treatment efficacy were mixed for hospital medications, herbal treatments, and behavioral strategies, with efficacy for each method ranging from no pain relief to full pain relief. One medical doctor noted that the effectiveness of pain treatments depends on the severity of the pain, and stronger medical treatments are needed for girls who have gynecological disorders such as endometriosis. I just put up with the pain . Some of the medicines do not help you to feel better .–Adolescent B (18, urban setting, finished school) There is honey medicine that was made for me , and I was told to use it . I used it for about three months during which I never felt any abdominal cramps… I mean I had no pain at all– Adolescent E (17, urban setting, in school) They [medications] usually help . It’s very rare that they fail . Mostly it’s with the endometriosis cases , where they need an injection first , because painkillers do not work with them .–Adult Expert D (Medical Doctor, Woman) Girls reported receiving herbal treatments from family members or growing medicinal plants at their houses. Adult experts and adolescent girls both agreed that medications are available from healthcare providers and pharmacists at clinics, hospitals, and pharmacies. One of the pharmacists reported that girls must get permission from a parent to get hormonal contraceptives, and the pharmacist would only dispense hormonal contraceptives for pregnancy prevention. If she [a girl] is still at home , she must get a permission from her parent [to get hormonal contraceptives] , because if by any chance a parent realizes she is using family planning without permission it is not right , and if she is asking for family planning medicine for another use , as a pharmacist I will not allow that . It is only for pregnancy prevention .–Adult Expert J (Pharmacist, Woman) Adult experts also reported that medication accessibility was limited by costs. When a girl is going through severe pain the family cannot afford to take her to the hospital for treatments .–Adult Expert C (Pastor, Woman). In government hospitals , they usually announce that they [contraceptive pills] are given out for free , but it’s not true , because you have to pay for consultation fee , so if you do not have money , you still won’t be able to access them .–Adult Expert I (Medical Doctor, Male) To manage financial costs, one medical provider said some patients had enrolled in a local microinsurance initiative (insurance with low premiums and limited coverage often designed for low-income families) that paid for women’s health visits. Girls did not describe costs related to medications, although they were not specifically asked about financial costs. However, girls did mention that costs were a barrier to accessing menstrual management supplies generally, and when asked what support should be provided to girls during puberty, one adolescent noted that girls should be provided with pads and medicine: The first thing is to get the sanitary pads so that they can take care of themselves . The second is that , to those who get a lot of pain during their period , they should get medicine that will be able to relieve abdominal cramps completely .–Adolescent Girl E (17, urban setting, in school) Girls reported selecting pain management strategies based on advice from medical providers and pharmacists ( n = 6), aunts ( n = 3), mothers ( n = 2), sisters ( n = 1), television/advertisements ( n = 1), books ( n = 1), and teachers ( n = 1). It should be noted that “aunt” can sometimes refer to any female adult in the community. One adolescent noted that a doctor came to her house to provide menstrual education: Interviewer: What else did the doctor talk about concerning things like the pain ? Participant: That the pain will increase , and I should do exercises , play , and jump the rope . And also to drink hot water . He said that whenever I am in this condition , I shouldn’t run to lie down because the pain would disappear . — Adolescent G (17, rural area, in school) Two adult experts suggested girls should be educated that menstrual pain is normal; one noted this should be in addition to providing pain treatments. They should get painkillers or take a rest , and they should be told that this is normal and temporary until when they give birth .–Adult Expert E (Mother) Two adult experts indicated that parents are typically not aware that hormonal contraceptive pills can be used to manage menstruation, as contraceptives are only known for preventing pregnancy. No girls reported taking hormonal contraceptives, but they were not specifically asked about their knowledge of contraceptives for menstrual management. One medical doctor reported that medical providers receive limited training regarding dysmenorrhea in college or medical school, and continuing education is rarely available. Interviewer: Do doctors and nurses receive training in dysmenorrhea ? Participant: Honestly , it ends when they are taught in college . After that , no one bothers about that anymore . Having someone come teach continuing medical education is very rare .–Adult Expert D (Medical Doctor, Woman) Multiple girls and adult experts either held personal negative beliefs about hospital medicine (e.g., painkillers, hormonal contraceptives) or knew other people, including friends, family members, and teachers, who held such beliefs. This included beliefs that hospital medications are harmful to organs, that medications cause unwanted changes in menstrual patterns, that painkillers lead to harmful levels of tolerance, and that hormonal contraceptives cause infertility. Two adolescents were told by their aunts that medicines are harmful, but they were not given an explanation as to why. One adolescent believed hormonal contraceptives were only appropriate for married women who already had children. Another adolescent’s teacher discouraged the use of medication before first trying physical exercises to reduce menstrual pain. No participants discussed potential negative side effects from herbal treatments. Painkillers during your period are not good , because they can bring some harm such as repetitive periods .–Adolescent H (15, rural setting, in school) The body will get used to the painkillers , and it will reach a point where they won’t be of help anymore even if they will be prescribed for another disease . The painkillers are not so good for the kidney due to the chemicals they contain .–Adult Expert C (Pastor, Woman) The teacher answered that medicine is not good in the body , because it becomes poison , and the abdominal cramps that they get do not require treatment with medicine .–Adolescent D (15, urban setting, in school) The drugs may prevent you from ever getting children again . …One of my aunts told me that it is not good to use medicine , but she didn’t explain to me why it is not good , so I decided that it wasn’t a good thing . Because it is just a temporary thing that is passing , I just put up with the pain .–Adolescent I (15, rural setting, out of school) Of the sociocultural factors impacting dysmenorrhea management, several can be defined as barriers because they may make it more difficult for girls to manage dysmenorrhea. This includes 1) beliefs that medications are harmful; 2) lack of knowledge among caregivers about the benefits of hormonal contraceptives for dysmenorrhea management; 3) needing caregiver permission to receive hormonal contraceptives; 4) lack of continuing education for medical providers; 5) costs of medical visits and medications; and 6) lack of access to menstrual supplies such as pads, which makes it difficult to exercise for pain management.

Dysmenorrhea negatively impacts the physical and psychological well-being of girls in Tanzania. Menstrual pain also hinders girls’ ability to participate in school and work. Although first-line treatments have been developed, these medications and other behavioral pain coping strategies may not be culturally relevant due to local beliefs that medications are harmful, limited knowledge of the benefits of hormonal contraceptives for dysmenorrhea, and a lack of access to resources, such as accurate information about medications, money for medications and medical visits, and menstrual management supplies. To improve SRH disparities among girls in SSA, it is necessary to understand the causes of dysmenorrhea and increase access to effective dysmenorrhea treatments that are acceptable to girls and their caregivers across cultural contexts.

From August 2018 to November 2018, qualitative semi-structured interviews were conducted as part of a larger study among adolescent girls in the Kilimanjaro region of Tanzania, which includes the municipality of Moshi. The larger study sought to characterize the types of stressors girls experience related to menstruation and puberty, how girls cope with stressors, and how stress and coping impact mental health and reproductive health. As interviews progressed, it became apparent that dysmenorrhea was a major stressor for girls, and additional questions were added to gain a deeper understanding of dysmenorrhea and menstrual pain management. The current analysis presents findings specific to dysmenorrhea. The research team consisted of a principal investigator from the United States (EMC) who has a background in clinical health psychology, as well as research assistants and co-investigators from Tanzania and the United States. Paid research assistants from Tanzania (two young adult women) who had experience working with adolescent girls conducted all study activities with participants in Swahili. Coding was completed by the first author (EMC) and two undergraduate research assistants, and themes were discussed with research assistants in Tanzania. To acknowledge and reduce sources of bias, the team held ongoing discussions about reflexivity, bias, and positionality. We employed a community-engaged approach to increase the relevancy of research questions, improve the validity of findings, enhance inclusivity in global research, and gain a better understanding of the cultural factors impacting girls’ experiences during puberty. As such, this study was implemented in partnership with Femme International, a local NGO that conducts menstrual needs assessments and provides menstrual education and supplies to adolescent girls, and Kilimanjaro Christian Medical University College, a regional research hospital. Partner organizations, members of the local community (e.g., staff at multiple NGOs, medical providers, religious leaders, community leaders), and a community advisory board of men and women hosted by Kilimanjaro Christian Medical University College were consulted prior to study design and throughout implementation. They provided input on research aims, methods, interpretation of outcomes, and dissemination of results. Findings were presented directly to the aforementioned community members and community advisory board, who agreed with the results. An a priori sample of 10 adolescent girls and 10 adult experts was selected based on prior research [ 29 ]. Based on the reoccurrence of similar themes, the study team determined that saturation had likely been reached by the end of recruitment. Adolescent girls were eligible if they were 14–19 years old and had reached menarche. We used non-random purposive sampling to recruit girls who varied in age, years in school, pregnancy history, marriage status, socioeconomic status, rural/urban region, and religion. Adult experts were defined as adults who worked or lived with adolescent girls. We aimed to recruit at least one teacher, healthcare provider, NGO staff member, local government leader, faith community leader, mother, and father. Tanzanian research assistants recruited participants through presentations and face-to-face recruitment in settings where adolescent girls are likely to be found. This included public markets, NGOs, schools, and churches/mosques. Adult experts were contacted via phone and in person based on employment settings (for example, pharmacies, schools, and shelters). Ethical approval for human subjects research was obtained from the Duke University and Kilimanjaro Christian Medical University College Institutional Review Boards and the National Institutes of Medical Research in Tanzania. The Tanzania Commission for Science and Technology granted permission for the principal investigator to conduct this research. The Moshi Municipal Council provided permission to recruit in schools. Consent forms were translated into Swahili and reviewed by local NGO staff to ensure they were understandable to girls. All participants provided written and signed informed consent. A waiver of parental consent was requested for girls under 18 and granted by the regulatory agencies to protect girls’ privacy by allowing girls to participate without having to disclose their menstrual status to caregivers. This was essential because discussing menstruation with men is considered taboo, and having to disclose menstrual status to male caregivers could prevent girls from being represented in this research [ 20 ]. Interviews consisted of a single session lasting between 30 minutes and an hour. Interviewers took part in supervision after each interview and received training on interpersonal strategies to enhance the girls’ comfort. The larger theory of interest for the study was the transactional model of stress and coping, which sought to understand the link between stress, coping, and mental health among girls [ 30 ]. Semi-structured interview guides were designed to gather information on three main themes: (1) what are the challenges or stressors girls face relating to puberty and menstruation, (2) how are girls coping with or managing these challenges, and (3) how and why do stress and coping impact mental health? To avoid biasing the interviews to be overly focused on stressors, questions were also asked about positive experiences during menstruation and puberty. As interviews progressed, it became apparent that dysmenorrhea was a significant stressor for girls, and additional questions were added to probe more deeply on characteristics of dysmenorrhea (e.g., pain location and severity), treatments used for dysmenorrhea, reasons for using specific treatments, and the effectiveness of treatments. Interviews with adult experts included additional questions on resources available to girls to manage dysmenorrhea and the role of adults (e.g., parents, teachers, medical providers, and community leaders) in helping girls manage menstrual stressors. Table 1 presents examples of actual questions asked by interviewers. Interviewers led with open-ended questions and followed up with probes to gather more detail on menstrual pain, confirm our understanding of participants’ responses, and address any participant confusion. Interviews were transcribed by research assistants in Tanzania, who also completed quality assurance checks on each other’s transcriptions. Transcripts were translated into English twice (once by a research assistant and once by a professional translator) to confirm the accuracy of the translations. Due to having a priori theories of interest for a larger study on stress and coping, the qualitative theoretical framework for the overall study was thematic content analysis. Methods from a grounded theory approach, such as line-by-line coding of entire transcripts, were also used to capture any emergent themes and reduce bias; thus, a grounded theory approach was used to describe emergent themes regarding dysmenorrhea, and no a priori theoretical stance regarding dysmenorrhea was applied to our analysis [ 31 ]. Three researchers (EMC and two research assistants) coded adolescent interviews and adult expert interviews separately using NVivo Version 12 [ 32 ]. The code list was developed through an iterative, collaborative process. All interviews were double-coded using a line-by-line descriptive coding strategy. Attention was paid to repeated themes, negative cases, and minor themes. Discrepancies were discussed early in the coding process when the initial code list was being developed (first cycle coding) and again towards the end of the coding process. When examining the subset of codes pertaining to stress and coping, there was initial disagreement in coding for 2.8% of the coded sections for the adolescent interviews and 6% of the coded sections for the adult expert interviews. Discrepancies were resolved using group discussion among the research team. Themes were discussed with Tanzanian research assistants to confirm accuracy.