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Accepted Manuscript

Dysmenorrhea management and coping among students in Ghana: A qualitative


exploration

Lydia Aziato, PhD, MPhil, FWACN, ONDEC, BA Nursing and Psychology (Hons),
and RN Florence Dedey, BSc, MB.ChB, FWACS Joe Nat A. Clegg-Lamptey,
MB.ChB, FRCSEd, FWACS, FGCS, CBA
PII: S1083-3188(14)00256-3
DOI: 10.1016/j.jpag.2014.07.002
Reference: PEDADO 1738

To appear in: Journal of Pediatric and Adolescent Gynecology

Received Date: 8 April 2014


Revised Date: 29 May 2014
Accepted Date: 11 July 2014

Please cite this article as: Aziato L, Dedey F, Clegg-Lamptey JNA, Dysmenorrhea management
and coping among students in Ghana: A qualitative exploration, Journal of Pediatric and Adolescent
Gynecology (2014), doi: 10.1016/j.jpag.2014.07.002.

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ACCEPTED MANUSCRIPT

Title: Dysmenorrhea management and coping among students in Ghana: A qualitative

exploration.

Authors: Lydia Aziato (PhD, MPhil, FWACN, ONDEC, BA Nursing and Psychology
(Hons), and RN)1
Florence Dedey (BSc, MB.ChB, FWACS)2

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Joe Nat A. Clegg-Lamptey (MB.ChB, FRCSEd, FWACS, FGCS, CBA)2

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Department of Adult Health, School of Nursing, University of Ghana
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Department of Surgery, University of Ghana Medical School, Accra, Ghana.

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Corresponding address: 1School of Nursing, College of Health Sciences, University of
Ghana, P.O. Box LG 43, Legon, Accra, Ghana; email
aziatol@yahoo.com/laziato@ug.edu.gh: Tel. 00233-244719686

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Students dysmenorrhea management and coping

Title: Dysmenorrhea management and coping among students in Ghana: A qualitative

exploration.

Abstract

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Study objective: The study sought to gain an in-depth understanding of primary

dysmenorrhea management and coping strategies for dysmenorrhea among adolescents and

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young adults who were in school.

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Design: The study adopted a qualitative exploratory approach using a descriptive

phenomenology to explore the phenomenon of interest.

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Setting: The study was conducted in two educational institutions in Accra, Ghana (a Senior

High School [SHS] and a University). AN


Participants and data collection: Sixteen participants were purposively recruited (8 SHS and 8
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University students) through snowball sampling. Individual interviews were conducted in
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English, audio-taped, transcribed and analysed using content analysis procedures. Informed
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consent was obtained from all participants and rigor was ensured through prolonged

engagement and member checking.


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Results: Participants employed both pharmacologic (orthodox and herbal) and non-

pharmacologic approaches such as warm compress, exercise, and water and diet therapy for
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their dysmenorrhea. Students dysmenorrhea was managed at the school clinic and the
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hospital. Health professionals demonstrated negative attitudes towards dysmenorrhea

management. Students coped with dysmenorrhea by planning activities before the onset of

pain, receiving social and spiritual support, and developing a mind-set to bear pain.

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Conclusions: Individualized approaches should be employed to enhance dysmenorrhea

management. Health professionals should be educated on dysmenorrhea to improve their

attitude and skills for dysmenorrhea management.

Key words: menstrual pain; phenomenology; pain management; dysmenorrhea; Ghana

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Introduction

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The incidence of menstrual pain or dysmenorrhea among adolescents and young adults

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continues to be high globally. The incidence of dysmenorrhea among adolescents ranges

between 70 and 80% in many countries including Ghana1-3. Adolescents and young adults

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mostly experience dysmenorrhea with no underlying cause (primary dysmenorrhea)4, 5.

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Although a lot has been reported about primary dysmenorrhea, it still remains a problem for

sufferers. The management of secondary dysmenorrhea poses less of a challenge because


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there is an identifiable cause of the pain4 and when this is treated, there is positive and

sustained outcome of the treatment. Primary dysmenorrhea has been managed with several
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approaches over the years including pharmacologic and non-pharmacologic measures.


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Pharmacologic agents for primary dysmenorrhea include analgesics such as paracetamol,

piroxicam, ibuprofen, diclofenac and mefenamic acid6, combined oral contraceptive agents
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and herbal preparations4, 7. Primary dysmenorrhea management is challenging because these

agents have different efficacy for different individuals7 8 and some sufferers resort to trial and
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error9. Primary dysmenorrhea sufferers usually resort to self-medication to control pain10.


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Other sufferers are prescribed medications apart from analgesia (vitamins, sedatives and haematenics)

for associated symptoms4. The lack of knowledge on analgesic also limits the use of analgesics

for dysmenorrhea9. Menstrual pain is seen as a normal female phenomenon in certain

cultures; so, some sufferers may not take analgesics8, 11, 12. Also, patients may not report pain

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because of the effect of socialization about pain perception and expression, thus hindering

dysmenorrhea management13, 14.

Non-pharmacologic approaches have been used with some degree of efficacy for

dysmenorrhea management. The use of exercise, warm compress, massage and rest7, 11; and

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red bean pillow15 have been reported. Music has also been found to reduce pain16 and could

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be useful. Transcutaneous electrical nerve stimulation, acupuncture, and acupressure have

also been reported4, 17.

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The non-pharmacologic measures have varying effectiveness for dysmenorrhea sufferers.

This further highlights the difficult nature of primary dysmenorrhea management. It is

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therefore necessary for on-going research on dysmenorrhea to derive an effective approach
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for pain relief. Physical, social, psychological, and spiritual support may also be necessary for

students with severe dysmenorrhea as pain is a multidimensional phenomenon and


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individuals respond to pain differently18.
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Individuals with moderate to severe dysmenorrhea whose pain management is inadequate


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have to cope with the pain every month. There is paucity of research on in-depth qualitative

explorations of coping strategies adopted by students with dysmenorrhea especially in Ghana.


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Female students with severe dysmenorrhea sometimes absent themselves from school and are

unable to cope with activities of daily living1, 6, 10, 12, 19, 20. It is important for females to attend
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school so that they can have better quality of life and be empowered to contribute effectively
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during adulthood. In view of this, the study sought to explore the pain management

approaches and the coping strategies adopted by students for dysmenorrhea. The study

formed part of an initial exploration on dysmenorrhea among students towards development

and implementation of a multi-method intervention for pain management.

Methods

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The study adopted a descriptive phenomenology to understand the participants world. The

methodology allowed in-depth exploration of the phenomenon under investigation.

Descriptive phenomenology allows the lived experiences of participants to emerge without an

influence from the researcher or existing literature. In this instance, dysmenorrhea is a

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subjective personal phenomenon and the study approach allows an exploration of this largely

personal phenomenon21.

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The study was conducted in two educational institutions in Accra, Ghana a Senior High

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School (SHS) and a University. Snowball sampling was adopted to recruit participants where

an initial participant helps to identify another participant(s) with dysmenorrhea for

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recruitment22. The inclusion criteria were students with no underlying pathology, and those

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who consented to be part of the study. Participants confirmed that they were not diagnosed of

any other pelvic disease and were not on any special treatment as a result of their
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dysmenorrhea. This personal confirmation was used to classify participants as having primary

dysmenorrhea in this study. No confirmatory diagnostic evaluations were done before


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participants were recruited. The exclusion criteria were those with underlying disease
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(secondary dysmenorrhea) and those who did not consent to participate in the study.
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Data was collected through individual in-depth interviews in English using a semi-structured

interview guide. Participants shared their dysmenorrhea management and coping experiences
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and these were probed until full-understanding of emerging themes were derived. For
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example: Please tell me how you manage your menstrual pain; Share with me the effect of

the approach you use to manage your pain; How do you cope with your pain?. The first

author conducted all the interviews at a time when the participants were not in pain.

Interviews were conducted at a place and time convenient for participants and were audio-

taped with their consent. These were later transcribed verbatim and analysed concurrently.

Interviews lasted for 45 minutes to one hour.

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The study was approved by the Institutional Review Board of the Noguchi Memorial Institute

for Medical Research at the University of Ghana. Permission was obtained from the

appropriate educational authority before data was collected. Individual informed consent was

obtained from all participants. Teachers at the Senior High School also gave consent before

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students below 18 years in their School were interviewed. There were no parents at the

School at the time of data collection to give consent. Confidentiality and anonymity were

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ensured by removing all identifiable information and assigning identification codes to

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participants. The right to withdraw from the study was stressed. The principle of anonymity

and confidentiality was explained to the research assistant. Identification codes SD and UD

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were used to represent SHS and University students respectively and numbers 1, 2, 3 to 16

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were added to these codes as participants were recruited chronologically. For example SD8

represented the 8th interview and the participant was from the SHS.
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Transcripts were read several times to make ensure that the true meanings of their

experiences were captured. Themes and sub-themes were generated from the data and
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transported to the NVivo software version 9. Data was coded and similar codes were grouped
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into sub-themes and themes as the analysis progressed. Data that were most suitable to

describe the theme were used to present findings. The team discussed themes and sub-themes
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with the view of representing the true experiences of participants and where there was

disparity during the analysis; consensus was reached after a review of the themes and sub-
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themes as necessary.
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Rigor was achieved through prolonged engagement which ensured that in-depth

understanding was achieved. The process of member-checking was employed during

interviews to follow-up on initial themes generated during data collection. Concurrent

analysis ensured that participants experiences were followed among participants until themes

were fully developed. Also, participants accounts were summarized and they confirmed the

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accuracy of their experiences during the interviews. Detailed fieldnotes were written. Context

and participants were described to enable transferability and application of findings to similar

context. Verbatim quotes were used to report findings and this ensured that participants

experiences were vividly represented.

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Results

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Demographic Characteristics: The participants were 16; made up of 8 SHS and 8

University students. Two of the University students were married and one had two children.

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One was a doctoral student and the others were undergraduates. The SHS students were in the

first and second years of their programs and all were not married. One participant was a

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Muslim and the others were all Christians. Participants were aged between 16 to 38 years.
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Themes and sub-themes that emanated from the study were pain management strategies such
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as pharmacologic (orthodox analgesics and herbal medicine); and non-pharmacologic

interventions (warm compress, exercise, and water and diet therapy); place of care (care at
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School Clinic school policies and Hospital care - personnel attitude); coping (planning,
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support, and mind-set).

Pain management strategies: Dysmenorrhea was managed with both pharmacologic and
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non-pharmacologic approaches such as exercise, warm compress, and water and diet therapy.

The pharmacologic management included both orthodox analgesics and herbal medicine. The
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subthemes that emerged were pharmacologic management and herbal medicine; non-
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pharmacologic interventions warm compress, exercise, and water and diet therapy.

Orthodox analgesics: Participants took various forms of analgesic such as paracetamol,

diclofenac, buscopan (Hyoscine butylbromide), Efpac (An aspirin-Parcetamol compound),

ibuprofen, and mefenamic acid to manage their menstrual pain. The effectiveness of the pain

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relief differed among the participants and some individuals did not get adequate pain relief.

The analgesics were in the form of tablets, suppositories, and injections. In addition to the

analgesics, some participants took sleeping tablets when in pain. For example:

I just took paracetamol and I was Ok (UD2);

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I took paracetamol but paracetamol did not work for me; I inserted the diclofenac and
it was Ok because I felt no pain afterwards. I was sometimes taking diclofenac or
paracetamol but they were not helping me at all (UD1).

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Sometimes I take sleeping tablets (SD11);

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I take buscopan or mefenamic acid (UD5);
I always take Efpac before it starts (SD7).
Some participants did not like taking analgesics and rather bore the pain until it became

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unbearable. For example: I take paracetamol when I know that is the last alternative; I dont
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like taking medicine, I try to bear the pain (UD3). Others did not take analgesics because

they reacted to the medications.


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I started reacting to Diclofenac, Brufen and Buscopan because my eyes got swollen.
So I stopped taking them. I was asked to start taking paracetamol but the pain will not
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subside so I stopped taking medication (UD16). Paracetamol makes me bleed more


(SD7). Diclofenac cuts my menses, it does not flow as it used to (UD16)
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Some participants stopped taking medications because their mothers of possible side

effects; I stopped using my inserting medicine because my mother said it might give me
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some side effects (SD14). Others stopped because of fear of addiction.


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people say that you get addicted to the pain killer and I did not want that to happen;
I was also afraid of the side-effects. I wanted to have my menses without taking any
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pain killer. The month I dont take the pain killer, I feel I have done well (UD5).
The analgesics were either recommended by a health professional, a family member, or self-

medicated. I went to the hospital and the doctor said I should start taking paracetamol

(UD4); my aunt gave me the insertion medicine (SD10). I started taking Efpac after

watching the advert on TV (SD7). Some participants abused the analgesics when they were

in pain. A participant who was a student nurse narrated:

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I tend to abuse the medicine a lot since I have them at home and I use it all because
of the pain. I inject myself with the diclofenac and I wait for a short time then I give
myself another one (UD16).
Herbal medicine: Some participants took herbal preparations. The herbal preparations

were not prescribed by specialist herbalists and some of the herbs were prepared by the

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participants themselves. For example, Shea nut leaves were boiled and taken as tea.

Shea nut leaves are good for pain relief; the leaves are dried so you just boil it and

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drink it. You drink it three days then you go off it or you can take it as a tea. You can
take it before your menstrual period or during menstruation so you dont experience

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any cramps (UD1)

Some participants did not know the name of the herbal preparation they took: My mother

prepared it for me and it reduced the pain somehow (SD10); My elder sister gave me some

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herbal preparation. She said I should use some as enema (UD16).
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Some participants did not have any relief when they used the herbal preparation: I used to

take boiled mahogany; it is bitter. I used to take it but I did not see any changes; it was still
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the same (SD8). Others also neither took any herbal medicine nor wished to take it: I have
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never tried herbal medication and I dont want it (SD12); I did not take the herbal
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preparation my father gave me because I knew it will not bring the pain down UD16).

Non-pharmacologic interventions: Dysmenorrhea was also managed with non-drug


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approaches such as use of warm compress, exercise and water and diet therapy.

Warm compress: The warm compress was applied in the form of hot water bottle or
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traditional application of warm material soaked in warm water. Teachers, mothers and peers
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encouraged the use of warm compresses. My physical education teacher told me about the

use of warm water (SD10). My mother asked me to put some warm compresses there

(UD2). I have the hot water bottle at home and I used it as my friend directed (UD4);

Some participants believed that the warm compress diverted their attention from the pain

rather than relieved pain directly

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When the hot water bottle is on your lower abdomen you only think about the heat it is
providing, but when it is taken off, and the place cools off, then your mind goes back to
the pain. That is how it works for me (UD6).

Other participants did not use warm compresses: I dont use warm water or hot water bottle;

I have never used it; I dont know much about it (SD11). Others did not use warm

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compresses because they did not have the energy to boil water and some did not have access

to warm water in School (Senior High). When I am in pain I do not even have the energy to

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go boil the water. It is too much work for me (UD5). I cannot get warm water in the School;

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we are not allowed to boil water (SD10).

Exercise: Some participants employed exercise such as swimming, and jogging to manage

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dysmenorrhea.
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It needs exercise. The more you lay on your bed, the more you feel the pain;
swimming does help (UD3). My mothers friend who is a nurse told me to exercise
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and when I do, the pain reduces (UD4). I jog around and the pain would go away
(UD5).

Deep breathing and leg exercises also helped to some extent.


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I deep breathe and pretend I am dead; I lie on the floor and raise my legs up and I
breath in and out; my legs will be up and I breathe in but when I am exhaling, then I
drop my legs. It helped somehow (UD1).
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Water and diet therapy: Some participants drank a lot of water to help urinate frequently.

The frequent urination helped to reduce pain. I take a lot of water and tend to urinate; if I
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urinate thrice, the pain reduces (UD3). A participant took water to enable her vomit because
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the vomiting reduced her pain. Sometimes I try to take a lot of water to enable me vomit so

the pain will reduce (UD15). Another participant took water because she could not eat and a

doctor told her the water pushes the blood and reduced pain.

I take in a lot of water as a doctor told me to do. So mostly I supplement the taking of
water to eating food. He said the water pushes the blood and I do not really feel the

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pain like I used to. when I do not take in a lot of water the pain is very bad, I become
hot and it is unbearable (SD8).

A few participants modified their diet to manage dysmenorrhea. Some avoided sugar. I

heard that when you take sugar it makes the pain worse; so, I just restrict sugar. When I

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take the sugar, I cannot bear the pain (UD2). Others also avoided rice and oil. It is rice and

oil that affect me so I do not take when I am having my menses (SD7).

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Place of Care: Management of dysmenorrhea at the school clinic and hospital were seen as

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inadequate. Health professionals were perceived to have negative attitudes towards

dysmenorrhea management. Also, strict school policies were considered unfavourable for

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effective dysmenorrhea management. Sub-themes described were care at school clinic;

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school policies; hospital care; and personnel attitude

Care at School Clinic: Participants described the care at the SHS school clinic. Some
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participants did not like going to the school clinic because they handled dysmenorrhea on

their own and they did not see it as serious. Those going there vomit and I didnt vomit. I
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never went to the school clinic with dysmenorrhea because I handled it myself and I saw it to
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be normal (UD2). Some participants did not go to the school clinic because of the poor

attitude of the school nurse The way the school nurse treats those of us with menstrual pain
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is not good because she thinks it is a normal thing. She shouts on us so some of us dont feel

like going there (SD10). The school clinic did not have variety of analgesics for pain
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management so some participants were taken to the hospital during severe dysmenorrhea.
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The school nurse will not give me Efpac; she tells me she does not have or it is
finished. when I am having my menses I go to the sick bay and sometimes she sends
me to the hospital when very severe (SD7).

Others went to the school clinic because they had no choice. In SHS, you do not have a

choice; you have to be in the sick bay or school clinic if the pain is very severe (UD5).

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School Policies: Participants senior high schools had different policies for students

during dysmenorrhea. Some schools did not allow students to stay in the dormitory during

dysmenorrhea. When they lock the dormitory, I just go and sit by a food vendor; they didnt

allow us to stay there and I didnt like the sick bay (UD2). However, other schools allowed

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students to stay in the dormitory. I will be in the dormitory for 5 days (UD16). There were

no policies to help students with severe dysmenorrhea that missed lectures.

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Mostly my friends give me the notes but I do not get what really went on in class and I
cannot go to all the teachers to let them explain. So if I miss a class, that is it; I have to

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read over and over. I do not do well in exams when in pain (UD15).

Hospital care: Some participants went to the hospital on account of dysmenorrhea. They

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went to the hospital from home or school. They were given medication and intravenous
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fluids. When I go home and it is severe, I go to my clinic and they give me an infusion and

injections and I feel better; sometimes the school nurse sends me to the hospital (SD10).
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Some participants did not have any relief from the hospital treatment. We went to the

hospital and the doctor gave me some pills but it does not work, and anytime I go to the
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hospital they keep changing the pill and it still does not do anything (SD8). One participant
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reported that after having two children she removed her uterus because of severe

dysmenorrhea. I decided to take my womb off after my two girls so I will not go through any
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menstrual pain again (UD1). Some participants went to the hospital regularly due to severe

dysmenorrhea and associated symptoms such as vomiting.


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I was most of the time detained so that I could be given some IV fluids to sustain me
and sometimes the vomiting becomes so severe the first day and I will have to be rushed
to the emergency room and be detained (UD16).
Personnel attitude: Participants lamented poor attitude of health professionals. Health

professionals believed that dysmenorrhea was normal Why should I make noise about

menses? Its not a disease (SD8). Health professionals did not attend to participants with the

urgency they expected. When you go and you are in pain, they rush to you but as soon as

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they realize it is dysmenorrhea, they relax. They say this thing will not kill you so they leave

you on the bed and you see them attend to other people (UD15); sometimes I only go to the

hospital when I am vomiting or running or I am very weak else, nobody takes me serious

(UD5)..

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Some health professionals shouted at participants and it resulted in negative thoughts about

the health professionals. The nurses and doctors will be shouting at me but they do not know

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what I am feeling within. So I will be saying in my head that they are wicked. So because of

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that, I do not go there (SD10).

Some participants felt angry when health professionals did not treat them as they expected.

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I get angry and I feel like talking back but since they are not in me, they do not know
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what I am going through; so, it better to keep quiet and at the end they will give me the
pills and I will leave. I will not be with them forever (SD8).
Some health professionals did not exhibit the right attitude because they thought
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dysmenorrhea was caused by taking too many sweets. They did not treat me well the first
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time because they thought I was taking too much sweets (SD9).
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Coping: Participants coped with dysmenorrhea through planning activities and routines

before the onset of pain. They also obtained support from friends and family and tuned their
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minds to accept dysmenorrhea

Planning: Participants planned and carried out their activities such as learning and
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washing of clothes before the onset of menstruation. Participants learned ahead and wrote
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assignments ahead of the day of submission if it coincided with menstruation.

Three to four days before my menses, I plan my things very well. If I have things I
really have to do on the day of menstrual pain, I try my best to do it before then. For
instance, if I have an assignment that will be due during my menses, or I have some
clothes to wash, I try to do them before my menstrual period. I also learn ahead of time
because I know I cannot learn with menstrual pain (UD5).

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Participants learnt ahead because they did not want to perform poorly academically due to

dysmenorrhea. I try to ask for the topics for the term so when I am not in school I do my

studies at home in advance so that I do not lag behind (SD9). Others sought help from other

people to help them cover what they miss during dysmenorrhea. I look for someone to teach

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me areas I miss or teach me before the topic is treated and when I am not in pain, I sit up and

catch up with the lost lessons (UD16).

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Support: Participants had support from their colleagues. Some roommates washed

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for participants when in pain and cleaned their vomitus. I had a mate who washed for me.

When I vomit on the floor she cleans and even washes my panties for me when I have severe

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pain (UD16). Friends also offered emotional support through communication and touch

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when participants were in pain. Sometimes the way they talk to me you will be fine. Just a

touch and I feel ok; the person understands what I am going through (UD3).
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Participants also received support from their teachers through extra teaching and visits. Some
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of my tutors help me catch up with the class after my menstruation. Some also visit me,
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reassure me and these help me relax because I have the support of my teachers (SD16).

Some participants received prayer support with the hope that the pain will subside after the
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prayers. I always prayed and even went to an all-night and a deliverance prayer meeting

hoping that it will subside (UD16). However, some reported no improvement in pain after
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prayers. after the prayers there was no real change because it kept on happening (SD9).
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Some prayed because they thought dysmenorrhea was caused by evil spirits.

mostly when I start feeling the pain I start praying, initially I was told that some evil
spirits cause dysmenorrhea so when I take my medication I start praying that God
should take my pain away (UD15).
Mind-set: Participants coped with dysmenorrhea by conditioning their mind that it was

temporary. I have prepared my mind that the pain will come and go; so when it comes I

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prepare for it and then it goes on its own (UD16). Others accepted the pain as part of their

life because they had a family history of dysmenorrhea. I have realized the pain is part of me

and I accept that it is inevitable because my mother also went through it (UD5). Some

conditioned themselves to perform some activities during pain. little things that I have to

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do during dysmenorrhea such as washing or cooking; I just have to psyche myself up that

very soon I can go back to sleep (UD5). Some do not show any facial expressions because of

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their mind set about dysmenorrhea. I will be feeling the pain but because I have made up my

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mind about it, I will not express it for people to see. I will not show it (UD4). Others made

up their mind to bear the pain without showing signs of pain because the significant others

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may feel sad that they are suffering. Sometimes I do not want anybody to see me in pain; not

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even my husband because I feel I make them sad with my dysmenorrhea (UD15).

Discussion
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The findings draw attention to aspects of dysmenorrhea management congruent with previous
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4, 6, 19
research. For example the use of different analgesics has been widely reported .
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Analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) have been found to be

frequently used for dysmenorrhea management due to its effect on prostaglandin action and

production23, 24
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and NSAIDs are considered the primary drug of choice for dysmenorrhea

management25. Unavailability of different types of analgesics in school clinics was a


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challenge in this study. This means that students with dysmenorrhea did not get specific
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analgesics that are effective for them. The analgesics were not used appropriately because

some used insufficient doses while others abused the analgesics. The findings indicate that

students with dysmenorrhea did not have adequate knowledge on the use of analgesics and its

effects and this is consistent with the existing literature8. Herbal medicine has been used to

control pain over the years26-28. Findings indicated that most students did not prefer the herbal

medication and few used it at home on recommendation from their family.

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The involvement of the family members in the management of dysmenorrhea indicates that

education on effective management should include the family and the general population.

Family members either encouraged or discouraged the use of analgesics and herbal

preparations for pain management. Literature suggests that the family forms an integral part

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of healthcare decision making and contributes to direct care of patients29, 30. It is necessary to

acknowledge this in dysmenorrhea management and actively involve the family of students

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with dysmenorrhea to achieve better care outcomes.

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Health professionals also demonstrated varying attitudes towards pain management. Negative

attitudes reported in this study is consistent with previous findings from the context of the

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study indicating nurses inadequate analgesic administration for post-operative pain31. Also,

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health professionals have been found to have inadequate knowledge on pain management32, 33

and this could translate to negative attitudes on dysmenorrhea. Also, some health
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professionals perceived dysmenorrhea as a normal phenomenon and did not give participants

care as was expected. This finding is consistent with previous reports suggesting that health
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professionals in Ghana have poor attitudes towards pain management31, 34. The severity of
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dysmenorrhea determines the involvement of health professionals either at the school clinic

or the hospital. In mild and moderate cases, the students applied self-care measures as
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reported from other contexts3, 12.


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Non-pharmacologic approaches employed by participants (warm compress, diet, rest and


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sleep, and exercise) were consistent with previous reports4. Non-pharmacological approaches

are considered adjuvant or additional pain management strategies and should not substitute

the use of appropriate analgesics35. Non-pharmacological approaches have varying

effectiveness for dysmenorrhea7, 15


. Thus, participants acknowledged that some of the

approaches such as the warm compress or hot water bottle were not effective for them.

Participants perceived that the hot water bottle served as diversion for the pain. However,

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Students dysmenorrhea management and coping

students at the SHS did not have access to hot water for pain relief. The school policy did not

permit the use of water heaters. Perhaps such a policy could prevent any fire incidence. The

house mistress or school nurse could provide students with the hot water bottle to manage

pain. Also, majority of the participants claimed that exercise is a good remedy for

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dysmenorrhea management and should be encouraged.

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Students coped with dysmenorrhea by employing measures such as planning, support and

mind-set. Planning and carrying out activities before the onset of pain helps to minimize the

SC
negative effect of dysmenorrhea. However, students do have control of all school activities

such as examinations especially quizzes. Also, the menstrual cycles vary and even if a

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lecturer/teacher would postpone an exam because of a dysmenorrhea, another students pain

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may coincide with the new date. Therefore, the authors suggest that there should be policies

to enable the student affected by severe dysmenorrhea to write such internal exams after the
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pain has subsided. Prayer, emotional and physical support enhances coping during pain36-38.

Prayer did not control pain anticipated and the belief that dysmenorrhea was caused by spirits
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calls for intensified education on the pathophysiology of dysmenorrhea. It was believed that
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conditioning the mind to go through the cyclical pain helped participants to cope. They stated

that dysmenorrhea did not last forever and that gave them anticipatory hope.
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Implications of Findings
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There should be increased education on various strategies for dysmenorrhea management and
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ways of coping to minimize the debilitating effect on students. Drug abuse and fear of

addiction should be discussed in-depth to enhance proper use of analgesics for dysmenorrhea

management. Education and coping strategies should be extended to mothers of sufferers and

young girls. The educational institutions should have policies that would enable remedial

classes for those who are unable to attend lectures during severe dysmenorrhea. Also, health

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Students dysmenorrhea management and coping

professionals should change their negative attitudes towards those with dysmenorrhea so that

appropriate and timely intervention can be given to sufferers. Students could form a support

group so that they can give each other support as necessary and share ideas on coping

strategies. The school clinic should be provided with adequate resources such as various

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types of analgesics and hot water bottles to improve dysmenorrhea management.

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Conclusion

The management of dysmenorrhea should be considered from multi-faceted perspectives

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since a single approach may not be effective for all sufferers. Those with severe

dysmenorrhea should be given adequate care to help them cope with pain. Continued research

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is necessary to identify effective interventions for primary dysmenorrhea. Knowledge and
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attitudes of health professionals should be assessed in future studies to identify gaps so that

appropriate training can be instituted to enhance dysmenorrhea management. Also, the


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impact of inadequate dysmenorrhea management on education and work can be assessed
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systematically to inform policies. Efficacy of different analgesics for dysmenorrhea can be


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assessed in future studies. Quantitative designs can be used in the future to draw correlations

between aspects of dysmenorrhea such as severity, chronicity, treatment and perceptions of


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participants.

Conflict of Interest: The authors declare no conflict of interest in the conduct of this study.
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Acknowledgement: We thank Miss Daniela Korletey for transcribing our interviews


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