Orem-Based Education for Dysmenorrhea Self-Care and Menstrual Hygiene in Adolescents

Introduction Adolescence (10-19 years) is a critical period of physical, biological, psychological, and social change [1]. In girls, menarche generally occurs between 9 and 15 years; initially anovulatory and irregular cycles become ovulatory and regular within approximately two years [2,3]. Adolescents need accurate information and healthy attitudes toward menstruation to maintain reproductive health. However, socially entrenched beliefs that regard menstruation as "dirty," "shameful," or an "illness" may lead to misconceptions and inappropriate menstrual hygiene practices [4]. Inadequate knowledge and insufficient perineal and menstrual hygiene practices may also increase the risk of genital tract infections [5,6].

Dysmenorrhea, one of the most common problems during adolescence, is defined as pelvic pain associated with menstruation and can substantially reduce quality of life [7]. Primary dysmenorrhea occurs in the absence of pelvic pathology, typically begins before or with menstruation, and subsides within 72 hours, whereas secondary dysmenorrhea is associated with underlying pelvic pathologies [8-11]. The worldwide prevalence of primary dysmenorrhea ranges from 20% to 90% [12-14], with rates of 66.2%-98% reported in previous studies [6,15,16]. Primary dysmenorrhea may include nausea, bloating, gastrointestinal symptoms, fatigue, dizziness, headache, low back pain, and irritability [17]. Some symptoms can be alleviated through non-pharmacological methods such as heat application, massage, herbal remedies, and mind-body techniques [18,19]. It may also adversely affect school attendance, social activities, sleep quality, and body image and contribute to depressive symptoms [20-22]. Nevertheless, many adolescents manage dysmenorrhea using their own strategies without adequate support from healthcare professionals [18,23].

Inadequate menstrual hygiene practices are also common among adolescents, including the use and reuse of absorbent cloths and inappropriate genital hygiene practices [24-26]. Such practices may increase the risk of vaginal discharge and urinary and genital tract infections and may be associated with menstrual irregularities and dysmenorrhea [5,6,27]. Therefore, adolescents need to recognize symptoms, manage dysmenorrhea, practice appropriate menstrual hygiene, and strengthen self-care skills. Structured health education may address these needs; however, interventions should extend beyond information provision and be based on a theoretical framework that considers developmental characteristics, self-care capacity, and support needs [28].

Dorothea Orem's Self-Care Theory is one approach to promoting self-care behaviors. Orem classifies self-care requisites as universal, developmental, and health-deviation self-care requisites [29]. Menarche, adaptation to menstruation, coping with dysmenorrhea, and appropriate genital hygiene practices can be considered within developmental and health-deviation self-care requisites. Thus, Orem's theory provides a framework for dysmenorrhea and genital hygiene education. In primary dysmenorrhea management, self-care includes pharmacological and non-pharmacological pain management strategies and appropriate menstrual hygiene practices [30,31]. However, adolescents may have insufficient knowledge and self-care and often rely on family or peers without professional support [32,33]. Although Orem-based educational interventions have been evaluated for various health problems [34-37], no study was identified evaluating an Orem-based educational intervention for primary dysmenorrhea self-care and genital hygiene behaviors among adolescents. Therefore, this cluster-randomized controlled trial aimed to evaluate the effects of an educational intervention based on Orem's Self-Care Theory on primary dysmenorrhea self-care and genital hygiene behaviors among adolescents.

Keywords adolescent; dysmenorrhea; menstrual hygiene; Orem's Self-Care Theory; self-care; nursing education

Hypotheses H0: The educational program based on Orem's Self-Care Theory has no significant effect on adolescent girls' dysmenorrhea self-care or menstrual hygiene behaviors.

H1a: The educational program based on Orem's Self-Care Theory has a significant positive effect on adolescent girls' dysmenorrhea self-care.

H1b: The educational program based on Orem's Self-Care Theory has a significant positive effect on adolescent girls' menstrual hygiene behaviors.

Population and Sample The study was conducted between April and June 2026 in two schools for female students. The study population consisted of 298 ninth-grade female students. The schools had similar sociodemographic profiles, large ninth-grade populations, and sufficient geographical separation to minimize contamination. Each school had approximately four ninth-grade classes, with 30-34 students per class.

The sample size was determined using G*Power 3.1 [38]. Based on dysmenorrhea self-care scores of 108.26 ± 15.91 at pretest and 109.86 ± 15.09 at posttest [39], with a 5% significance level, an effect size of 0.41, and 95% statistical power (1-β = 0.95), the minimum sample size was 80. Allowing for 20% attrition, the target sample was 96 students, with at least 48 participants per group.

The two schools were randomly assigned to the intervention and control groups using computer-assisted randomization. Subsequently, two of the four ninth-grade classes in each school were selected by lottery. A total of 124 students in the selected classes were assessed for eligibility through individual face-to-face interviews. Interviews assessed menstrual history, pain onset and duration, chronic diseases, and hormonal therapy use. Primary dysmenorrhea was identified based on the following criteria: (1) absence of a pathological condition causing pelvic pain during menstruation; (2) onset of pain one day before or on the first day of menstruation; and (3) reduction or resolution of pain within 48-72 hours after menstruation began [8,10,11,40].

Students in the selected classes were assessed for eligibility according to the predefined inclusion and exclusion criteria. Eligible students who provided assent and whose parents provided written informed consent were enrolled in the study. Participant recruitment, allocation, follow-up, and analysis were documented using a CONSORT flow diagram.

Data Collection Instruments Descriptive Information Form The Descriptive Information Form was developed by the researchers based on relevant literature [6,42-45]. It consists of eight questions assessing sociodemographic characteristics, including age, family structure, maternal education, and economic status, as well as menstrual cycle characteristics and previous education on menstruation and genital hygiene.

Menstrual Hygiene Practices Questionnaire The Menstrual Hygiene Practices Questionnaire was developed by the researchers based on relevant literature [46-50]) and consists of eight items assessing adolescents' menstrual hygiene practices. Content validity was evaluated by five faculty members specializing in pediatric nursing (n=3) and women's health nursing (n=2).

Adolescent Dysmenorrhea Self-Care Scale (ADSCS) The ADSCS was developed by Hsieh (2004) based on Orem's Self-Care Deficit Nursing Theory to assess adolescent girls' dysmenorrhea-related self-care experiences [51]. The Turkish validity and reliability study was conducted by Sürücü and Ergün [52], who reported a Cronbach's alpha of .96. The scale consists of 40 items rated on a six-point Likert scale and comprises six subscales: Searching for Knowledge, Expressing Emotions, Seeking Assistance, Control over External Factors, Coping Strategies, and Self-Control. Higher scores indicate greater engagement in self-care behaviors. In the present study, Cronbach's alpha was .90 for the total scale and ranged from .72 to .85 for the subscales.

Data Collection Pretest and Posttest Data Collection At pretest, the Descriptive Information Form, Menstrual Hygiene Practices Questionnaire, and ADSCS were administered to both groups between April 6 and 10, 2026. Data collection took approximately 20 minutes per student. At posttest, the Menstrual Hygiene Practices Questionnaire and ADSCS were administered to both groups between June 8 and 12, 2026, four weeks after completion of the intervention.

Intervention Following ethical and institutional approvals, school administrators were informed about the study, written parental consent was obtained, and eligible students were invited to participate. Written and verbal assent was obtained from the students. Primary dysmenorrhea eligibility was assessed through individual face-to-face interviews covering menstrual and pain characteristics, chronic diseases, and hormonal therapy use.

Intervention Group The intervention group received a four-week educational program based on Dorothea Orem's Self-Care Theory, particularly developmental self-care requisites and the supportive-educative nursing system. The program consisted of six classroom-based sessions, each lasting approximately 40 minutes. Content included female reproductive anatomy and physiology, menstruation and its physical and psychological effects, primary dysmenorrhea and its management, reliable information seeking, emotional awareness and expression, environmental control, evidence-based non-pharmacological pain management, cognitive coping strategies, genital and menstrual hygiene, infection prevention, and menstrual myths and misconceptions [3,18,19,50,53]. Content validity was evaluated by five faculty members specializing in Obstetrics and Gynecological Nursing and Pediatric Nursing, and the program was revised accordingly.

Control Group The control group received no additional education on dysmenorrhea or menstrual hygiene during the study and continued routine school education. After posttest data collection, students in the control group were provided with education on dysmenorrhea management and menstrual hygiene.

Data Analysis Data were analyzed using IBM SPSS Statistics version 22.0 (IBM Corp., Armonk, NY, USA). Normality was assessed using skewness and kurtosis coefficients [54]. Descriptive statistics were presented as numbers, percentages, means, and standard deviations. Between-group comparisons were performed using independent-samples t-tests and appropriate chi-square tests, while within-group changes in menstrual hygiene practices were assessed using the marginal homogeneity test. Two-way mixed ANOVA with Pillai's trace was used to evaluate time, group, and time × group effects on total and subscale scores. Effect sizes were reported as partial eta squared (ηp²), and internal consistency was assessed using Cronbach's alpha. Statistical significance was set at p<.05.

Limitations This study was conducted in only two schools, with schools assigned as clusters to the intervention and control groups, which may limit the generalizability of the findings. Dysmenorrhea self-care and menstrual hygiene behaviors were assessed using self-reported measures and may therefore be subject to social desirability and recall bias. In addition, the follow-up period was limited to four weeks after completion of the intervention; therefore, the study was not designed to evaluate long-term outcomes.

Ethical Considerations Ethical approval was obtained from the Social and Human Sciences Research Ethics Committee of a university (Date: March 2, 2026; No. 704580; Decision No. 01-47), along with institutional permission. Before the study, school administrators were informed, written informed consent was obtained from parents, and written informed assent was obtained from students. Participants were informed that participation was voluntary, that they could withdraw at any time without providing a reason, that the data would be used solely for scientific purposes, and that personal information would remain confidential. The study was conducted in accordance with the Declaration of Helsinki.