Imparting genital hygiene skills to adolescents with intellectual disabilities attending a special education Centre: a quasi-experimental study on effect of short education

Abstract

Objective: The study aimed to evaluate the short-term effects of education given on genital hygiene to female students attending a special education center. Methods: We interviewed 52 girls selected by meeting the inclusion criteria, using a quasi-experimental method, the single group pre-test post-test model in a special education institution located in the Aegean region in Turkey. Results: The results of the programme the genital hygiene knowledge of the participants had significantly improved. Significantly positive changes were observed in genital hygiene knowledge compared to pre-training (p < .001). Conclusion: It is recommended that the program training and practices to be carried out simultaneously be implemented by healthcare professionals for adolescents with intellectual disability and their parents.

Introduction

Adolescents’ bodies begin to change significantly with the onset of puberty (Quint 2016). These changes mark a special period that will determine the health of women and shape lifelong health habits for themselves and future generations (Topuz et al. 2015). The onset of menstruation is considered one of the most important milestones in a woman’s life (Wanjiku 2016) and is seen a symbol of femininity. Menstrual hygiene is the maintenance of hygiene involving dailybath, correct way to use sanitary pad, cleaning perineal area for the period of menstruation to help in reproductive health maintenance and illness prevention (Ahmed et al. 2021, Jeyanthi and Vijayalakshmi 2018). However, in this period Menstrual hygiene is a recognised public health, social and educational issue (Sommer et al. 2016). People with disabilities are likely to experience layers of discrimination when they are menstruating, but little evidence exists (Wilbur et al. 2021).

Adolescents with intellectual disabilities have significant limitations in both their mental and adaptive abilities (American Association on Intellectual and Developmental Disabilities (AAID)) 2013). These limitations often lead to problems in hygiene maintenance with the onset of menstruation (Ariyanti and Royanto 2017). Adolescent face multiple disadvantages due to age, gender, disability, poverty that create inequality in accessing health information, services and supplies to support them through puberty and girls with disabilities have very limited support in case of menstrual management (Jones et al. 2020). Also, they may not be able to clean themselves properly during menstruation. They often need the supervision of caregivers (Joshi and Joshi 2015). When they need help from others for genital cleansing, the risk of exposure to sexual harassment increases (Ariyanti and Royanto 2017). For this reason, it is important to provide customised teaching plans suited to the disability of each adolescent. In this way, it may be easier for the adolescent to understand the education programme and apply what is taught (Ariyanti and Royanto 2017).

The fact that people with disabilities have a reproductive system and do menstruate is commonly forgotten or ignored (Memarian and Mehrpisheh 2015); accordingly, they are not taught about sexuality, reproductive health or menstrual hygiene (Wilbur et al. 2019). Studies conducted so far have centred on the burden placed on caregivers in the family during menstruation, menstrual suppressive medication, or hysterectomy (Márquez-González et al. 2018, Nurkhairulnisa et al. 2018, Thapa and Sivakami 2017) rather than giving teenager with intellectual disabilities more training on personal care, menstruation management and hygiene procedures (Chou and Lu 2012). Article 23 of the United Nations Convention on the Rights of Persons with Disabilities emphasises the right of persons with disabilities to start a family and protect and maintain their fertility (Memarian and Mehrpisheh 2015).

Teenager with intellectual disabilities can learn basic academic and personal care skills (American College of Obstetricians and Gynecologists Committee on Adolescent Health Care (ACOG) 2009, Konuk Sener et al. 2019). However, their recall processes develop more slowly than those of their peers, so they have difficulty remembering information (Konuk Sener et al. 2019). They understand concrete concepts more easily (Wilbur et al. 2021). In a study, Altundağ and Çalbayram (2016) the pad change training given on a doll was found to be effective in girls with intellectual disabilities. Parents often worry about their daughters with disabilities when they reach adolescence. According to a study in Canada, parents who have a child with intellectual disabilities are concerned about issues such as the use of menstrual suppressive medication, hygiene, the parental care burden and menstrual symptoms (Quint 2016). One qualitative study conducted in India have found that most of the mother prefer to keep the issue secret and skip the necessity of menstrual management training as they like to manage this in their own way (Márquez-González et al. 2018).

Imparting genital hygiene behaviours to women and changing incorrect practices is an important step in preventing infections (Demirağ et al. 2019). For these reasons, it is important to effectively improve self-care knowledge and skills to prevent short- and long-term genital problems during menstruation (Ariyanti and Royanto 2017).

Issues related to genital health and hygiene are considered to be shameful and are taboo in many societies; they are not discussed enough and incorrect practices can prevail. Since menstrual bleeding is seen as ‘dirty’ in some societies, it has been shown that menstrual mismanagement and lack of hygiene practices are related to social taboos (Rheinländer et al. 2019, Steward et al. 2018). This can lead to serious reproductive health problems, one of the most common of which is genital infections. These infections follow from practices such as lack of handwashing, use of inappropriate underwear or failing to pay adequate attention to hygiene during menstruation (Taşkın 2020).

The main responsibility of teaching individuals about genital hygiene behaviours falls on the shoulders of nurses. Nurses can help individuals to prevent urogenital infections and to improve reproductive health by using both educational and counselling roles (Taşkın 2020). Particularly for adolescents with intellectual disabilities, who have difficulty in taking care of themselves, the situation is critically important. Thus, people with intellectual impairments may be able to understand information about the menstrual cycle, if it is tailored to their level of understanding and repeated regularly (Wilbur et al. 2021).

Although self -menstrual care is important area of self-care skills but there is limited practice related to this area. Usually mothers don’t get any information or training from school and manage by applying their own knowledge (Akter 2021). Nurse practitioners should partner with girls with ID and their caregivers to support open communication and optimal gynecologic health.

The literature is limited research into improving the genital hygiene skills of teenager with intellectual disabilities. Studies have instead focused on pad use during menstruation with a limited number of subjects. To be accepted by society in our daily social life, individuals need to be able to perform some life and personal care skills. This is necessary not only for individuals with normal development but also for those with intellectual disabilities. As there is no interventional research in Turkey on adolescents with intellectual disabilities aiming to develop genital hygiene skills, the present study aims to examine the effects of training on genital hygiene skills and to evaluate the effect of education given on genital hygiene to female students attending a special education centre.

Aim

The study aimed to evaluate the effect of education given on genital hygiene to female students attending a special education cente.

Study hypothesis

Hypothesis 1. Genital hygiene education given in the form of repeated sessions increases the genital hygiene and menstrual care skills of trainable female adolescents with intellectual disability.

Methods

Study design

This study used a pre-posttest quasi-experimental design and follow-up stages.

Participants

The study population consisted of adolescents attending a special education who studied in the Aegean region in Turkey (N = 58). Although it was aimed to reach the entire population, a sample calculation was made for the study reliability. There is just one special education institution at the secondary level in the province. The study sample was determined as 52 students with a 95% confidence interval, 0.05 error level, and 0.95 representation power by power analysis (Faul et al. 2007). Accordingly, 52 adolescents who met the study’s inclusion criteria were recruited for the study between March and June 2018. Parents or legal guardians of participants were asked to provide their informed consent and to talking study participation with their child beforehand. The female students attending the school between March and June and meeting the inclusion criteria were all included in the study. There were 58 female students enrolled in the school during this education period. However, six students who had attendance problems during the study period did not participate in the study.

The inclusion criteria included being female, being aged between 12 and 24, having started to menstruate, being an adolescent who has intellectual disabilities and attends a special education center, not needing assistance in the toilet, being able to follow simple orders, having no serious motor problems, being able to manage self-care, especially during menstruation, and not using any medical procedure or medical treatment aimed at stopping menstruation during data collection.

Procedures

Assessment tools: Genital hygiene was evaluated using the Adolescent Genital Hygiene Questionnaire for adolescents with intellectual disabilities. The questionnaire consists of two parts. The first section consists of three questions about students (age, grade and menstrual period). The second part is composed of 20 items with questions about genital hygiene behaviours. The forms were created by the researchers after conducting a literature review (Altundağ and Çalbayram 2016, Taşkın 2020, Quint 2016). To confirm the validity of the questionnaire forms, the content validity and face validity of the forms were examined. Five professors working on pediatric nursing were consulted as experts in carrying out the content validity of the questionnaire forms. The experts rated each question using one of the following options: 1 = much change needed (with recommendation), 2 = slight change needed (with recommendation), 3 = appropriate, 4 = highly appropriate. From the content validity index used in the evaluation of the expert opinions, it was determined that the item-level content validity index ranged between 0.90 and 1.00 and that the scale-level content validity index was 0.96. Acceptable content validity index values are reported to be above 0.80 for both the item and scale level (Davis 1992). A pilot study was administered to six students who had attendance problems and did not want to participate in the study continually. It took approximately 5 to 10 min for the girls to answer all the survey questions. After the pilot study, the adolescents did not make any suggestions, and no revisions were made to the survey questions.

The support of the participants’ parents was considered important to ensure the study was continued in the natural environment. For this reason, a ‘Menstrual Care Skill Application Parents’ Opinion Form’ was used. The form is related to genital hygiene before and after education, the menstrual cycle, care skills, hand hygiene and showering during the menstrual period.

The implementation of the study was carried out in the following sequence. First, the participants and their families were informed about the study and their opinions were collected. The researcher and a teacher from the school’s guidance service interviewed the students and filled in the Adolescent Genital Hygiene Questionnaire.

Then, the training and practice/skill stages were carried out and evaluated. The training programme was explained to the groups before they started the session, and an appropriate training atmosphere was created. A total of eleven groups were formed. Except for three group of four students, the others were all five students. The training was implemented in the training hall of the school, which had the necessary equipment and lighting facilities so that the presentations and educational materials could be seen and read by the group. The training was given by researcher who is an associate professor in the field of paediatric health and diseases, has three years of clinical and 17 years of academic experience and has studies in intellectual disability field.

The training content included information on menstruation and the menstrual cycle, genital hygiene (a), whether the pad actually needs to be changing, how and whether to bathe during the menstrual period, hand hygiene and selecting healthy underwear and knowing how often it should be changed (b). The appropriateness and sufficiency of the educational topics were examined by relevant experts (professors working on pediatric nursing, seven experts in all). The content validity index regarding educational content was found to be 0.95, suggesting high agreement among experts with this conclusion being higher than 0.80. The training was given under two main themes at different hours in the timetable (a and b). A projector was used in the training sessions. The presentations used in the training had a maximum of three lines of text in 18px Arial font. A large picture describing the menstrual cycle was also used and maintenance skills in menstruation were explained with pictures. Due to her personal characteristics, the training period was short. The presenter spoke in a loud, clear voice. Each presentation lasted 10 min, and each training session (a and b) lasted between 30 and 40 min in total (due to interactions such as demonstrations, animations, narration and question–answer sessions).

Interactive education methods, such as demonstrations, role-plays, narration and question-answer sessions, which ensure the participation of adolescents, were also used in the training. Demonstrations were held during the training sessions. During the training, the adolescents were asked to give basic education to a person who had just entered her period through the role-play method. Each training theme was addressed once with the trainer and then dramatized by the participants themselves. The girls were able to provide training on subjects such as the frequency of pad change, bathing and cleaning of the genital area. The students were given one training session and one application in each theme (a and b), in a total of four interventions.

While one group received education, the other groups continued their school lessons. The groups were distributed as recommended by the school guidance service according to their menstrual cycles because, for the post-test, the aim was for each participant to have had one menstrual period and applied what she had learnt. Bringing the students to the training hall, accompanying them during the training and making sure the coding was done by the teacher in charge of the guidance service.

To ensure the success and sustainability of the practices, the same training was also given to the mothers of the children participating in the study. The aim was to ensure that the training undertaken was generalised to and continued in the natural environment. Afterwards, the parental opinion form concerning ‘application of menstrual care skills’ was filled in. The mother training programme did not involve the children. This programme also involved presentations, question-answer sessions and demonstration methods.

The practice/skill stages: At this stage, two applications were carried out with each group for each training theme. Menstrual cycle, noticing the start of menstruation, genital hygiene, genital area hair cleaning (a), pad use and decision to change, menstrual period bathing and dressing technique, choosing healthy underwear and deciding that the laundry is dirty-change, hand hygiene practices (b) was performed on the baby doll by each participant. A pad, underwear, red paint and a velcro fastener were used to simulate the applications on the baby doll. The use of menstrual pads, choice of healthy underwear, decision to change clothes, cleaning the genital area, deciding that the hair in the genital area has grown and practice of cleaning the hair were carried out by each student once in two separate lessons, once accompanied by an instructor (a and b practice) and once alone (a and b practice). The skills were marked as done/not done on the evaluation form by the counsellor.

Evaluation: After the training, each participant was expected to have a menstrual period. A post-menstrual test was carried out, during which commands related to the training topics were given to the participants by the researcher. The researcher and a teacher from the school’s guidance service interviewed the students and filled in the Adolescent Genital Hygiene Questionnaire. The skills were observed and marked ‘correct’ (1 point) and ‘wrong’ (0 points) on the Adolescent Genital Hygiene Questionnaire Form by the assigned teacher. In order to transfer the training given to real life, information about the natural environment was obtained orally three months after the parents.

Statistical analysis

Data were analysed using SPSS version (SPSS 20.0 SPSS, Chicago, IL). Numbers and percentage values were used to evaluate the data collected in accordance with the purpose of the research. Mc Nemar chi-square test was used to compare variables before and after the training. Statistical significance was accepted as p < .05.

Ethics statement

All procedures performed in the study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. We obtained an institutional approval from the Ethics Committee of Pamukkale University (60116787-020/25170/10/04/2018) and the written and verbal consents of the families after explaining the purpose of the study to them. Before starting the study, in line with the principle of ‘Respect for Autonomy’, the participants were informed that they were free to participate in the study and stop any time. Additionally, in line with the principle of ‘Confidentiality and the Protection of Confidentiality’, the participants were informed that their information would be kept confidential. Those who were willing to participate in the study were included in the study. Since individual rights must be protected in the research, the Human Rights Declaration of Helsinki was adhered to during the study.

Results

Out of 58 teenagers with intellectual disabilities contacted, 52 participated in the study. The mean age of the participants in the study was 17.83 (min.: 14.00-max.: 23.00). Of those participating in the study, 26 had regular periods (28-35 days). Other students were found to have periods with 40-day cycles or longer. The teenager participating in the study were found to have had periods for 3.19 (min: 1-max: 9) years.

Table 1 shows the information status of girls about genital cleaning before and after the study. The level of those who did not use soap for cleaning the genital area after training was determined to increase, and the difference was statistically significant (p < .05). After the training, there was an increase in monthly unwanted hair removal and the difference was statistically significant (p < .05).

Table 1.

The pre-and post-study status information of the adolescents about genital cleaning.

		Pre-training				Post-training
		Yes		No		Yes		No
		n	%	n	%	n	%	n	%	p b
I use soap when cleaning my genital area.		19	36.5	33a	63.5	6	11.5	46a	88.5	0.004
Frequency of cleaning unwanted hair
	Once in a month	35a	67.3	17	32.7	50a	96.2	2	3.8	<.001
I get help when cleaning unwanted hair		26	50.0	26	50.0	22	42.3	30	57.7	0.388
Method used to remove unwanted hair
	Wax	18	34.6	34	65.4	26	50.0	26	50	0.008
	Razor blade	22	42.3	30	57.7	16	30.8	36	69.2	0.070
	Depilatory	15	28.8	37	71.2	11	21.2	41	78.2	0.125

^a It is the correct answer.

^b McNemar's test was done.

The information status of the adolescents about the use of underwear before and after the study is given in Table 2. Cotton underwear use increased after training (pre-training = 78.8; post-training = 82.7). Similarly, changing underwear every day increased after training (pre-training = 48.1; post-training = 55.8). However, the difference was not determined to be statistically significant (p > .05).

Table 2.

The pre-and post-study information status of the adolescents about the use of underwear.

		Pre-training				Post-training
		Yes		No		Yes		No
		n	%	n	%	n	%	n	%	p b
Type of underwear (panties) used
	Cotton	41a	78.8	11	21.2	43a	82.7	9	17.3	0.815
	Nylon	11	21.2	41	78.8	10	19.2	42	80.8	1.000
Frequency of changing underwear (panties)
	Everyday	25a	48.1	27	51.9	29a	55.8	23	44.2	0.481
	Two to three times a week	14	26.9	38	73.1	11	21.2	41	78.8	0.629
	Once a week	3	5.8	49	94.2	5	9.6	47	90.4	0.688
	When it's dirty	10	19.2	42	8.8	7	13.5	45	86.5	0.543

^a It is the correct answer.

^b McNemar's test was done.

The pad replacement status of the adolescents before and after the training is given in Table 3. Following the training, the frequency of pad replacement was found to increase to a frequency of every three to four hours and the difference was statistically significant (p < .05). After the training, the level of adolescents’ twice-a-day-pad replacement was observed to decrease and the difference was statistically significant (p < .05). The handwashing levels of the participants after changing pads during the menstrual period were found to increase after the training and the difference was statistically significant (p < .05). Handwashing levels before and after pad changing were also determined to increase after the training and the difference was statistically significant (p < .05).

Table 3.

The pre-and post-study information status of the adolescents about the pad replacement.

		Pre-training				Post-training
		Yes		No		Yes		No
		n	%	n	%	n	%	n	%	p b
Pet change status during menstrual period
	Six to eight times a day	12a	23.1	40	76.9	31a	59.5	21	40.4	<.001
	Twice a day	15	28.8	37a	71.2	4	7.7	48a	92.3	0.007
	Once a day	1	1.9	51	98.1	3	5.8	49	94.2	0.625
	Three to four times a day	23	44.2	29	55.8	15	28.8	37	71.2	0.096
Relationship between pad changing and hand washing
	After replacing the pad	37a	71.2	15	28.8	48a	92.3	4	7.7	0.007
	Before and after pad replacement	13a	25.0	39	75.0	49a	94.2	3	5.8	<.001
	Neither	2	3.8	50	96.2	1	1.9	51	98.1	1.000
Type of pad used
	Disposable pad	49a	94.2	3	5.8	46	88.5a	6	11.5	0.453
	Washable cloth	1	1.9	51	98.1	1	1.9	51	98.1	1.000
	Cotton	2	3.8	50	96.2	6	11.5	46	88.5	0.219
	Daily pad	26	50.0	26	50.0	29	55.8	23	44.2	0.664
	Daily perfumed pad	15	28.8	37a	71.2	10	19.2	42a	80.8	0.267

^aIt is the correct answer.

^bMcNemar's test was done.

The information status of the adolescents about bathroom and toilet uses before and after the study is given in Table 4. After the training, participants’ level of having a standing shower during the menstrual period was found to increase and the difference was statistically significant (p < 0.05). Also, after the training, participants’ level of handwashing before going to the toilet increased and the difference was statistically significant (p < .05).

Table 4.

The pre-and post-study information status of the adolescents about the bathroom and toilet hygiene.

		Pre-training					Post-training
		Yes			No		Yes		No
		n	%	n	%	n	%	n	%	p b
I take a bath during the menstrual period		36a	69.2	16	30.8	47a	90.4	5	9.6	0.003
I make my bathroom standing		33a	63.5	19	36.5	45a	86.5	7	13.5	0.004
I wash my hands before toilet		24a	46.2	29	53.8	39a	75.0	13	25.0	0.003
I wash my hands after toilet		51a	98.1	1	1.9	46	88.5	6	11.5	0.063
I wash my genital area after toilet		43a	82.7	9	17.3	45	86.5	7	13.5	0.727
How to wash the genital area after toilet
	From front to back	34a	65.4	18	34.6	45a	86.5	7	13.5	0.013
	From back to front	12	23.1	40	76.9	5	9.6	47	90.4	0.065
	I don't pay attention	6	11.5	46	88.5	2	3.8	50	96.2	0.219

^a It is the correct answer.

^b McNemar's test was done.

Three months after the training, parents opinions forms were received. In general, the main themes of the views from the parents were determined as follows. Before the education, the parents had difficulty in convincing the children to clean the unwanted hair and they had odor problems; they stated that they had difficulties in changing dirty laundry, they did not want to change their menstrual pads themselves, and they did not change pads at school. After the training, they stated that cooperation and harmony regarding genital hygiene practices in their children increased, the odor decreased and the self-confidence of the children increased. In addition, they stated that they could decide more easily for the change of laundry, that they changed the pads more often, and that their hand hygiene increased.

Discussion

In this study, the adolescents with intellectual disabilities, who started getting periods, were trained on genital hygiene, and the effectiveness of training before and after the training was evaluated. There were made improvements in students’ the genital hygiene practices and our training yielded positive results.

Gaining the right knowledge and attitudes about the menstruation period is important in terms of establishing the desired behaviors in the protection and development of health. Health education is useful in solving problems specific to this period of adolescence (Kırbaş et al. 2020). Misperceptions about menstruation and genital hygiene will lead to incorrect menstrual practices. Hygiene practices such as the use of hygienic pads and adequate washing of the genital area are necessary during the menstrual period and learning about genital hygiene during menstruation is a vital aspect of health education for adolescent girls (Jyothi and Hurakadli 2019).

Acquisition of good menstruation and genital hygiene habits can be difficult for an adolescent who is physically or developmentally disabled, as well as her caregivers. However, girls with intellectual disabilities want to be able to manage their menstrual periods by themselves. Most adolescents who can use the toilet without help can learn to use pads or tampons properly (Memarian and Mehrpisheh 2015). In a study, teeanger with intellectual disabilities were determined to be able to manage themselves after the education given in accordance with their education levels, and an increase in their care behaviours was determined (Ariyanti and Royanto 2017). One of the training modules provided in special education centres affiliated to the Ministry of National Education in Turkey is the ‘self-care skills module’, which involves ‘personal care and cleaning’ (Ministry of Education 2015).

Training programmes for teenager with intellectual disabilities should comply with their intellectual levels (Memarian and Mehrpisheh 2015, Wilbur et al. 2021). The study, an increase in genital hygiene skills of adolescents with intellectual disabilities was determined as a result of the training and role-play methods appropriate to the level of students attending special educational institutions and simultaneous training sessions with their mothers. With respect to our study hypothesis, adolescents with ID showed a more positive changes in genital hygiene knowledge compared to pretraining. This shows the importance of the applied training that is implemented with visually interesting training materials and methods. This result was sup-ported by a study done by Altundag and Çalbayram (Altundağ and Çalbayram 2016). Mothers can also assist their daughters in menstruation training (Joshi and Joshi 2015). For these reasons, families were also given the same training as their children in the study. Giving similar training to the mothers may also have increased their retention of knowledge by allowing language unity with their children and continuity of the training in the home environment. We learned from the mothers' feedback that adolescent girls were more independent in skills and practices and were able to generalize the education given in the home environment.

In cases of genital hygiene deficiency, vaginal discharge can be a source of infection (Taşkın 2020). Cultural practices affect genital hygiene. The use of soap or chemical products in the genital area disturbs the vagina flora. For this reason, they are not recommended for genital hygiene (Bilgiç et al. 2019). It is sufficent to clean with water and then to dry (Taşkın 2020). In this study, the levels of not using soap in the genital area were found to increase, and the difference was statistically significant (p < .05). Atress et al. (2018), found that around two thirds of the mentally retarded female students dried the genital area each time they used bathroom during menstruation. This application alone is not a preparatory condition for genital infection. However, it is a health behaviour that should be developed and applied in terms of adolescent health.

With the onset of adolescence, genital pubescence begins. Although there are cultural differences, the removal of hair may have a protective effect against diseases (Bilgiç et al. 2019). Different methods can be used. In this study, the participants were determined to mostly use a razor blade before the training in their genital cleaning (42.3%), whereas they were found to use wax (50.0%) after the training. Also, the frequency of unwanted hair removal was determined to become monthly after the training and the difference was found to be statistically significant (p < .05). In studies with non-disabled individuals, similar cleaning methods were observed to be used (Bilgiç et al. 2019). In this study with adolescents with intellectual disabilities, teenagers were found to have difficulties in performing complex tasks such as bathing and removing unwanted body hair (Surekha et al. 2017). The study reported that mothers helped remove the hair in the genital area, but that adolescent reminded their parents to do it once a month.

Underwear choice is an important issue for genital hygiene. Synthetic underwear causes the area to remain wet and moist. For this reason, using cotton underwear should be preferred for the prevention of genital infections (Bilgiç et al. 2019). In the present study, cotton underwear uses by participants with intellectual disabilities increased after training (pre-training = 78.8; post-training = 82.7). The results of the research conducted with non-disabled university students were similar to our study finding (Bilgiç et al. 2019). However, underwear preferences may vary according to cultural factors.

Changing underwear every day is important for genital and perineum hygiene. In studies conducted in Turkey, there has been a rise in the rate of changing underwear every day, but it is not yet at the desired level (Bilgiç et al. 2019, Topuz et al. 2015). In addition, there is an inverse relationship between the frequency of changing underwear and vaginal infections (Taşkın 2020). In this study, the status of everyday underwear changes in adolescents with intellectual disabilities was found to increase after the training. In studies conducted on non-disabled teenager, frequent daily underwear changes were found to be low (Bilgiç et al. 2019, Topuz et al. 2015). Change underwear every day is important for genital hygiene.

In the literature, studies related to menstruation and girl with intellectual disabilities are somewhat limited. Inadequate hygiene during menstruation is an important cause of reproductive system infections. For this reason, it is important for young girls to apply the necessary health behaviours during the menstrual cycles starting from menarche (Taşkın 2020). In this study, handwashing levels of participants after the pad change during the menstrual period were found to increase and the difference was statistically significant (p < .05). Also, handwashing levels increased before and after pad changing after training and the difference was statistically significant (p < .05). Bilgiç et al. (2019), determined that almost half of students (41.8%) did not wash their hands before entering the toilet. Demirağ et al. (2019), found that 3.1% of students did not wash their hands before changing pads, but that 92.8% of them washed their hands after changing pads. Washing hands before using the toilet reduces the risk of urogenital infections and even prevents infections. For this reason, hands should be washed both before and after changing the pad, especially during the menstrual period.

Genital hygiene practices during the menstrual period affect genital health (Bilgiç et al. 2019). For this reason, healthcare professionals and rehabilitation staff should be knowledgeable and competent to meet the gynaecological needs of girls with disabilities. Girls of reproductive age should have access to clean and soft, absorbent, healthy products that protect them from various infections in the long term (Joshi and Joshi 2015). During their menstrual period, the use of disposable, absorbent sanitary pads that are changed every three to four hours is recommended (Taşkın 2020). Training should also be provided for pad use at the menstrual stage. They should be trained to change pads in special places (Joshi and Joshi 2015). In this study, the girls with intellectual disabilities were determined to often use disposable pads. The frequency of pad replacement every three or four hours was found to increase after the training and the difference was found to be statistically significant (p < .05). In parallel with the study data, the opinions taken from the parents after the education showed that, in general, the adolescents' menstrual period pad changes were done more frequently and more often by themselves. It can be said that the education given the adolescents with intellectual disabilities makes a significant contribution to their care skills. After the video-based training of individuals with disabilities, there was an increase in the level of knowledge (28.5% before the intervention; 100% after the intervention programme) and the individuals were able to perform self-care skills in the post-training menstrual period (Ariyanti and Royanto 2017). In a study conducted with girls with intellectual disabilities, 14.9% of the adolescents were able to use pads without any problems (Öncü et al. 2019). Atress et al. (2018), found that depicted that, around two fifths of the mentally retarded female students changed pads two times daily. In a study the adolescents with intellectual disabilities, Kırbaş et al. (2020), reported improvements in students' hygiene skills practices. Ahmed et al. (2021), in their studies, knowledge and practices related to menstruation were lacking before the application of audio drama nursing intervention using peer education sessions. In addition, after providing the audio drama nursing intervention using peer education, there was an improvement and statistically significant differences in the total scores of visually impaired adolescent girls' knowledge and practices regarding menstruation. The similarity between the findings may be related to the similarity of characteristics of the sample in the studies.

Some people do not have a bath during the menstruation period due to religious and cultural reasons. However, bathing during this period reduces the risk of infection as well as increasing physical and psychological comfort (Demirağ et al. 2019). In this study, the participants were determined to have a standing shower more often after the training and the difference was statistically significant (p < .05). In their study with university students, Demirağ et al. (2019), found that genital hygiene habits and menstrual hygiene habits were inadequate. However, it was determined that a large proportion of the participants had a bath during their menstrual period (71.1%).

Insufficient genital hygiene is the most important cause of genital infections. It is possible to prevent genital infections by taking some simple steps (Bilgiç et al. 2019). Hand washing is the most important step that prevents infection (Demirağ et al. 2019). In this study, the level of adolescents’ handwashing before using the toilet increased and the difference was statistically significant (p < .05).

Proper genital hygiene practices are important in the prevention of urinary and genital infections. Women’s anatomical structure causes the risk of infection to be higher than in men. For this reason, it is important to clean with water from front to back after urinating and defecating and then to dry (Taşkın 2020). In this study, the adolescents with intellectual disabilities were found to wash their genital area after the toilet mostly from front to back after the training and the difference was found to be statistically significant (p < .05). Studies in the literature determined that more than half of the participants had the habit of cleaning the perineum from front to back (Bilgiç et al. 2019, Demirağ et al. 2019). It to clean with water from back to front after urinating and defecating increases the risk of both urinary tract infections and vaginal infections.

Adolescent girls are a special group that should be taken into consideration because they have high rates in the population, they frequently experience reproductive health problems and they are the least likely to be beneficiaries of reproductive health services. Raising the awareness of adolescent girls about proper hygiene practices is one of the most important responsibilities of nurses working directly with society (Yılmaz and Kahraman 2019). While this is already a troublesome process for individuals without disabilities, for adolescents with intellectual disabilities, it is an even more challenging process to cope with. The result of the study was found to be positive. For the continuity of these desired hygienic practices, it is thought that it would be beneficial to organise individual-specific training programmes for girls and their families run by school nurses in the institutions and rehabilitation centres where adolescents with intellectual disabilities are trained.

Study limitations

The present study is limited to the mothers of adolescents with ID who attend special education and rehabilitation centres. There is just one special education institution at the secondary level in the province. Therefore, there is no control group. This study addressed genital hygiene habits of teenagers with intellectual disabilities and can qualify as good evidence for the efficacy of interventions regarding these habits. However, this study was limited to genital hygiene training activities given to teenagers with mild adolescents with intellectual disabilities and their parents. Therefore, the outcomes cannot be generalized for all teenagers with intellectual disabilities and their families.

Conclusion

Adolescents must gain effective self-care skills through education in these periods. It is very important for healthcare professionals to impart girls with intellectual disabilities the cleaning habits for menstrual periods and to increase their acceptance in society. However, the number of studies focusing on this topic is limited. Due to the increase of various educational institutions and state support, the attendance of these girls to special educational institutions is growing, and these adolescents are socializing. For this reason, the role of education is very important for girls with intellectual disabilities to adopt genital hygiene habits. According to the results of our study, training to be given to teeangers with intellectual disabilities should include visual and interesting materials, and the training should be sustainable. Besides, training and practices can be recommended to be carried out simultaneously.

Disclosure statement

No potential conflict of interest was reported by the author.