Cross-sectional study exploring knowledge, attitude, and barriers toward menstruation among pharmacists in Ajman, UAE

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1 Research Article Cross-sectional study exploring knowledge, attitude, and barriers toward menstruation among pharmacists in Ajman, UAE Ghader Ayman Koujan 1, Ammar Abdulrahman Jairoun 2 * ABSTRACT Objective: The aim of this study is to assess pharmacists knowledge and attitude about menstruation and barriers that prevent them from providing menstruation counseling/services in Ajman, United Arab Emirates (UAE). Materials and Methods: A cross-sectional study was planned to approach potential respondents for the study. A self-administered questionnaire was delivered to pharmacists in public or private pharmacies (n = 50) practising in Ajman, UAE. Results: This study showed that 58% of the pharmacists had shown a good level of knowledge toward menstruation; however, confusion between the types of dysmenorrhea was observed among respondent pharmacists and 70% of them had not participated in menstrual disorder educational program. About 94% of pharmacists responded that they would like more education on menstrual disorders. The present study illustrated also that lack of time of the patients (76%) and patient health beliefs (76%) were the most common barriers that impact the pharmacist ability to provide menstrual counseling services. Conclusion: There is an essential need for educational interventions among the pharmacists to improve and update their knowledge about menstrual disorder. KEY WORDS: Attitude, Menstruation knowledge, Health-care providers INTRODUCTION Menstruation is considered a natural phenomenon in the reproductive life of every female. Referred to as menstrual period, it marks the start of a woman s reproductive life. Although it is a normal physiological process, it is something that is not openly discussed in rural areas. It is even considered an inconvenience and sometimes embarrassing even in developed countries. [1] A normal menstrual cycle depends on hormones released from hypothalamuspituitary and ovaries. Its reaction from each other and effect on the endometrium dictates a normal or abnormal flow. Menstrual disorder is common among adolescents and young adults. It affects their quality of life, especially those who suffer from dysmenorrhea and heavy menstruation. There are several menstrual disorders that are experienced by women during this period. The most common are excessive uterine bleeding, dysmenorrhea, Access this article online Website: jprsolutions.info ISSN: and premenstrual syndrome. [2] Improper behavior toward menstruation is one of the markers of poor knowledge. Several studies evaluating knowledge about menstruation among adolescent girls worldwide in different countries obtained varied results. One study assessed knowledge and beliefs toward menstruation among 400 female nursing students in Saudi Arabia revealed that a high percentage lacked knowledge and correct beliefs regarding menstruation. [3] This finding was reasonably similar to a study conducted in the urban area of Nigeria, which reflected a general lack of information about menstrual issues. [4] Another study assessed knowledge and practices related to menstruation among 200 girls in the age group of years at tribal (Gujjar) reported a lack of conceptual clarity about the process of menstruation before the start of menstruation. [5] This is consistent with the results revealed by another study in which 43.8% of Saudi girls in Taif were below the standard level of menstrual knowledge. [6] Moreover, several studies showed that there is a gap in the level of awareness about menstruation among female when they first experienced it. [7-9] 1 Department of Clinical Pharmacy, Ajman University, Ajman, UAE, 2 Department of Public Health and Safety, Consumer Product Safety Section, Dubai Municipality, UAE *Corresponding author: Ammar Abdulrahman Jairoun, Department of Public Health and Safety, Consumer Product Safety Section, Dubai Municipality, UAE. dr_ammar_91_@hotmail.com Received on: ; Revised on: ; Accepted on: Journal of Pharmacy Research Vol 11 Issue

2 In another study, Lawan et al., on menstruation and menstrual hygiene among adolescent school girls in Kano, Nigeria, reported poor knowledge about the physiological aspects and psychology of menstruation. [10] However, a cross-sectional survey in the nursing college of Kufa university among 87 female students identified acceptable and fair level of awareness toward menstruation. [11] Similar response was observed by other studies in which an average level of awareness regarding menstrual aspects was reported. [12,13] Findings and reports from other studies also showed a good knowledge about menstrual disorders and management among adolescent students. [14-17] Menstrual education and preparation of adolescent girls before the start of menstruation is considered one of the most important factors promoting and advancing their behavior in dealing with menstruation. Thus, the findings of several studies revealed that the majority of the participants learned of menses before its onset. [5,18-20] On the other hand, these findings are in contrast to the results reported by Reddy et al. who revealed that only one in seven of the adolescent girls had knowledge of menses before its onset. [21] Regarding the health effects and symptoms associated with menstruation, 50% of adolescent females recognized that menstruation is usually associated with pain while 22.5% of them said that it is usually associated with weight gain. [22] Moreover, pain in the lower abdomen and backache were the most common symptoms identified by the adolescent females. [12] In addition, 51% of adolescent girls consider that dizziness was the highest health effect associated with menstruation. [16] In another study by Dhingra et al., stomach ache was the most common identified complication faced by the adolescent during the menstruation. [5] This was in accordance with the study of Kumar et al. which showed that 80% of the females reported pain in the abdomen as the most common complaint. [14] However, no known studies have examined the knowledge and beliefs of pharmacists regarding menstruation. Therefore, the purpose of this research study was to assess the knowledge and attitude about menstruation among pharmacists who worked at public and private pharmacies and health-care centers and to identify the barriers that prevent them from providing menstruation counseling/services. MATERIALS AND METHODS Study Design and Study Setting This study was cross-sectional questionnaire-based survey carried out in public or private pharmacies and medical centers in Ajman/United Arab Emirates (UAE) between January and May The study aimed to assess knowledge and attitude and to explore the impact of pharmacist intervention in the management of menstrual disorder. Study Participants 50 pharmacists of different age groups and nationalities were randomly recruited from several public, private pharmacies, and health centers in Ajman, UAE. Inclusion/Exclusion Criteria Pharmacists and assistant pharmacists who were worked at public and private hospitals and clinics and healthcare centers in Ajman/UAE were invited to complete a self-administered questionnaire. Pharmacists working in other Emirates were excluded from the study. Data Collection (Study Tool) Self-administered questionnaire was used to collect the data from the participants. The questionnaire was designed to assess: (1) The knowledge, attitude of the pharmacists toward menstruation, and their role in the management of menstrual disorders and (2) the barriers that the pharmacist may encounter when providing menstruation counseling or services. A total of 50 questionnaires were distributed by trained pharmacy students to pharmacists in Ajman city. The questionnaire was composed of six sections: Section one consisted of 6 questions in total which include demographic data (gender, age group, experience year, position in pharmacy, pharmacy location, and participation in health education program related to menstrual disorder). The second section of the questionnaire was designed with the aim to assess the pharmacists knowledge regarding menstruation and consisted of 22 questions. Each question response was scored as yes, no, or do not know. Correct option scored 1 while incorrect response scored zero. A total score of 22 was obtained. A score of 70% and above was judged to be good, 50-69% fair, and <50% poor. The third section consisted of 5 questions to measure the pharmacist view and attitude on menstruation. The fourth section contains 6 questions to explore the barriers that impact the pharmacist ability to provide specific menstruation counseling or services. The fifth section contains 3 questions to estimate the prevalence of treatments and medications used for menstrual pain management. Ethical Principles The participation in this study was voluntary, and confidentiality of the participants was maintained at all time. Before the administration of questionnaires, the background of the survey was explained and written informed consent forms were signed before data collection. Validation and Pre-testing of Questionnaire Before the study, the validity of the questionnaires for their content and relevance was assured by subject 938 Journal of Pharmacy Research Vol 11 Issue

3 experts consisting of faculty at the college of Pharmacy at Ajman University. Then, they were translated into Arabic language and validated for the readability by distributing them on a pilot sample of 10 pharmacists to clarify any ambiguities. Statistical Analysis On the receipt of completed survey forms, the data were analyzed using the statistical package for Social Sciences version 20. Descriptive analysis was employed, and the results were expressed in frequency, percentage, bar chart, and pie chart. RESULTS Sociodemographic Characteristics of the Pharmacists Table 1 showed the sociodemographic characteristics of the participants. 50 questionnaires were collected from Ajman, UAE pharmacists who were working in different pharmacies and hospitals. Knowledge of Pharmacist toward Menstruation It can be seen from the Table 2 that the overall percentage of correct answers was from 30% to 100%. The highest percentage of participants were aware that imbalance in the level of body hormones can cause menstrual disorders. However, only 30% of responding participants correctly identified that primary dysmenorrhea occurs when there is no identifiable underlying pelvic pathology. Assessment of Menstrual Knowledge A 21-item questions package was used to assess pharmacists knowledge toward menstruation and its management. A correct response was rated 1 while incorrect option was scored zero. A total score of 21 Table 1: Sociodemographic Sociodemographic (n=50) Frequency (%) Gender Male 15 (30) Female 35 (70) Age group (92) (8) Years of experience 1 5 years 40 (80) 6 10 years 7 (14) years 3 (6) Position in the pharmacy Senior pharmacist 14 (28) Pharmacist 36 (72) Pharmacy location Hospital pharmacy 11 (22) Medical center 9 (18) Community pharmacy 30 (60) Participation in menstrual disorder education program Yes 15 (30) No 35 (70) was obtainable. A score of 70% and above was judged to be good, 50-69% fair, and <50% poor. For study participants, the overall mean of knowledge score was with ± standard deviation of In all, 58% of the respondents had good knowledge toward menstruation, and 38% of the studied subjects had fair knowledge while 4% had poor knowledge (Figure 1). Attitude of Pharmacists toward Menstruation It can be observed from Table 3 that there was a positive attitude toward menstruation where 94% of pharmacists prefer to get more knowledge regarding the menstrual disorders and 90% of them believed that there are a misunderstanding and lack of attention to the issue of menstruation. Furthermore, 96% of the pharmacists agreed that a course on menstrual disorder management should be established at the university level. Response of Pharmacists to Barriers Questions It can be seen from Table 4 that lack of the time by the pharmacist, patient health beliefs, and language barriers were the most barriers that impact the pharmacist ability to provide specific menstruation counseling or services. Menstrual Disorder s Managements Figures 2-4 showed that 64% of respondent pharmacists reported that the most common menstrual disorder was Dysmenorrhea, and the commonly used OTC medication to relief dysmenorrhea was mefenamic acid. Moreover, most of pharmacists (60%) responded that hormonal contraception is preferred when nonsteroidal anti-inflammatory drugs (NSAIDs) fail to relieve pain or contraindicated. DISCUSSION To the best of our knowledge, this is the first study to evaluate pharmacists knowledge and attitude Figure 1: Distribution of knowledge category among pharmacists Journal of Pharmacy Research Vol 11 Issue

4 Table 2: Knowledge of pharmacists toward menstruation Knowledge correct response Total n (%) n=50 Senior pharmacist n (%) n=14 Pharmacist n (%) n=36 Menstruation is a bloody discharge from the uterus to the 47 (94) 14 (100) 33 (91.7) vagina? (Yes) Heavy menstrual flow is an example of menstrual 43 (86) 13 (92.9) 30 (83.3) disorders? (Yes) Imbalance in the level of body hormones can cause menstrual 50 (100) 14 (100) 36 (100) Disorders? (Yes) Stress can predispose to menstrual disorders? (Yes) 45 (90) 12 (85.7) 33 (91.7) Women who have never given birth have a higher 30 (60) 9 (64.3) 21 (58.3) risk of experiencing severe, frequent cramping during menstruation? (Yes) Consumption of adequate diet could help alleviate some 43 (86) 12 (85.7) 31 (86.1) menstrual disorders? (Yes) Menstrual disorders may be associated with infertility? (Yes) 36 (72) 10 (71.4) 26 (72.2) Restriction of food intake for the fear of gaining weight can 38 (76) 8 (57.1) 30 (83.3) cause some menstrual problems (Yes) Self initiated vomiting after overeating can cause menstrual 22 (44) 7 (50) 15 (41.7) problems? (Yes) Menstrual disorder is common among younger age 36 (72) 11 (78.6) 25 (69.4) women? (Yes) Being excessively overweight or underweight can increase the 42 (84) 12 (85.7) 30 (83.3) risk for some menstrual disorders? (Yes) Some diseases of the reproductive organs can predispose to 42 (84) 13 (92.9) 29 (80.6) menstrual disorders? (Yes) Some menstrual disorders might signify a form of abnormality 45 (90) 14 (100) 31 (86.1) in the reproductive system that need medical attention (Yes) Menstruation can occur in other parts of the body other than 22 (44) 8 (57.1) 14 (38.9) the uterus? (Yes) Engaging in exercise can help to relieve some discomforts 40 (80) 12 (85.7) 28 (77.8) associated with menstruation? (Yes) Applying heating pad to the abdomen can help control pain as 45 (90) 13 (92.9) 32 (88.9) a result of menstruation? (Yes) Contraceptives can help to relieve pain associated with 30 (60) 12 (85.7) 18 (50.0) menstruation? (Yes) Regulating the intake of sugary foods can help control some 31 (62) 9 (64.3) 22 (61.1) menstrual problems? (Yes) Iron supplements can help control menstrual pain? (No) 38 (76) 11 (78.6) 27 (75) Self medication may be harmful for management of menstrual 38 (76) 12 (85.7) 26 (72.2) disorders (Yes) Primary dysmenorrhea occurs when there is identifiable 15 (30) 2 (14.3) 13 (36.1) underlying pelvic pathology? (No) Primary dysmenorrhea may be effectively managed with OTC (Yes) 37 (74) 9 (64.3) 28 (77.8) Table 3: Attitude of pharmacists toward menstruation Attitude Total n (%) n=50 Menstruation is associated with some discomforts which may affect women s health and academic activities of students? (Yes) Do you think that there are a misunderstanding and lack of attention to the issue of menstruation? (Yes) Dysmenorrhea is the most gynecological symptoms reported by women? (Yes) Do you think it is necessary to get more information about menstrual disorder? (Yes) Is it necessary to establish the course Menstrual disorder management at the university level? (Yes) Senior pharmacist n (%) n=14 Pharmacist n (%) n=36 44 (88) 13 (92.9) 31 (86.1) 45 (90) 12 (85.7) 33 (91.7) 39 (78) 9 (64.3) 30 (83.3) 47 (94) 12 (85.7) 35 (97.2) 48 (96) 13 (92.9) 35 (97.2) about menstruation and barriers that prevent them from providing menstruation counseling/services in the Arab and Gulf region. Due to the busy health systems such that in United Arab Emirates (UAE), pharmacists as part of this therapeutic network should be thoroughly involved in care, cooperate with other 940 Journal of Pharmacy Research Vol 11 Issue

5 Table 4: Response of pharmacists to barriers questions Barriers Total n (%) n=50 Senior pharmacist n (%) n=14 Pharmacist n (%) n=36 Lack of time by the pharmacist (Yes) 30 (60) 8 (57.1) 22 (61.1) Lack of time by the patients (Yes) 38 (76) 10 (71.4) 28 (77.8) Pharmacist perception that it is not their role (Yes) 19 (38) 4 (28.6) 15 (41.7) Language barriers (Yes) 36 (72) 8 (57.1) 28 (77.8) Patient health beliefs (Yes) 38 (76) 10 (71.4) 28 (77.8) Conflict between professional and commercial interests 27 (54) 10 (71.4) 17 (47.2) Figure 2: Distribution of menstrual disorder according to pharmacists Figure 3: Distribution of common OTC according to pharmacists health staff, and perform pharmaceutical services to deliver safe and adequate counseling about diseases and medications. The present study also addressed the importance of raising awareness of pharmacists role in the management of menstrual disorders. 50 questionnaires were collected from pharmacists who were working in different pharmacies and hospitals in Ajman, UAE. It can be seen that the majority of the participant pharmacists (92%) were in the age group of years. Males constituted 30% of sample and 70% of respondents were female. Regarding their experience, more than three quarters (80%) of the studied sample had 1-5 years of experience. According to participant s position in the pharmacy, the majority Figure 4: Distribution of hormonal contraception according to pharmacists of them (72%) were general pharmacists, and 28% were pharmacists in charge senior pharmacists. The majority of the studied group (60%) worked in community pharmacy, 22% in hospital pharmacy, and 18% in medical center. About 70% of those pharmacists had not participated in menstrual disorder educational program before. The present study revealed that 58% of the pharmacists had shown a good level of knowledge toward menstruation and associated risk factors, whereas 38% had acceptable knowledge and 4% had poor knowledge. However, the positive knowledge response was not assuring enough when the results were traced down to specific questions. Interestingly, about three quarters of the study participants (70%) wrongly identified that primary dysmenorrhea occurs when there is identifiable underlying pathology. Such wrong perception might be related to their confusion between the types of dysmenorrhea. Moreover, only 44% of the participant pharmacists knew that menstruation can occur in other parts of the body other than the uterus. The attitude of the participant pharmacists with regard to menstruation was found to be positive. 90% of them agreed that there is misunderstanding and lack of attention to the issue of menstruation, and 88% of them believed that menstruation is associated with some discomforts which may affect women s health and the academic activities of students. In our study, pharmacists recognized the importance of menstruation and the majority responded that they would like more education on menstrual Journal of Pharmacy Research Vol 11 Issue

6 disorders (94%). In addition, 96% of them believed in the importance of establishing menstrual disorder management course at the university level. Nowadays, pharmacy practice became more patient centred which provides optimal drug therapy to improve patient outcomes. Efforts to better understand the barriers that impact the pharmacist ability to provide menstrual counseling services was outlined and explored in the present study. It was found that lack of time by the patients (76%) and patient health beliefs (76%) were the most common barriers identified by the pharmacists. Other barriers have been found include language barriers (72%), lack of time by the pharmacist (60%), conflict between professional and commercial interests (54%), and pharmacist perception that it is not their role (38%). Regarding the treatments and medications used for menstrual pain management, about 64% of respondent pharmacists said that the most menstrual disorder appeared and faced in their working place was dysmenorrhea, and the most OTC medication used to relieve dysmenorrhea was mefenamic acid. Moreover, most of pharmacists (60%) thought that hormonal contraception is preferred when NSAIDs fail to relieve pain or contraindicated with female. Limitations The limitations in the present study were that a selfadministered questionnaire was used, instead of the face-to-face interviews and it was conducted only in one emirate. CONCLUSION The results of the study emphasized the importance of introducing an educational interventions among the pharmacists to improve and update their knowledge about menstrual disorder. ACKNOWLEDGMENTS Authors would like to thank Prof. Dr. Abdelazim Ahmed Al and Dr. Nihal Abdalla for their precious help and for their assistance and valuable remarks. REFERENCES 1. 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