The experience of puberty in Iranian adolescent girls: a qualitative content analysis

The current study is a qualitative content analysis. Participants who met the inclusion criteria were girls 12–20 years old from the city of Sari who had experienced at least 3 menstrual cycles. They were enrolled using a subjective sampling method (appropriate for qualitative studies) that continued until the point of data saturation (a total of 38 participants). Initially, purposeful and snowball sampling methods were used for data collection.

Data were collected by semi-structured interviews. Once the participants were informed of the objective of the study and consent to participate was obtained, they engaged in a focus group discussion (FGD) and individual in-depth interviews that took place in venues convenient for them (schools, universities or their homes). Initially, six focus groups were conducted. Five girls participated in each FGD. In addition to the FGDs, individual in-depth interviews were conducted with eight girls who were too embarrassed to participate in a focus group. They preferred to explore their experiences in a private session. All FGDs and individual interviews were conducted confidentially. Finally, researchers extracted a number of themes and categories by analyzing qualitative data.

The credibility of the research was checked. The following were performed to ensure rigor and trustworthiness in this qualitative inquiry. First, a member check procedure was used, and primary codes were considered for the participants’ responses. The research team members (internal check) evaluated the interviews, codes and derived categories to assess the accuracy of the coding process and to determine whether they applied similar codes. The transcripts were reviewed by the participants. In this step, the interviewer’s relationship with the participants further developed, with more interview sessions conducted to assure data accuracy. Methods such as prolonging engagement, devoting enough time and developing a good relationship were used. Additionally, a peer debriefing method (external check) was used in which the transcripts and findings from the data were given to experts for their comments, non-correlated occasions were omitted, and comments were added to confirm the results obtained. In this step, the experts' comparison of the study analysis with correlated studies and receipt of their feedback increased the quality and precision of the analysis [14].

The ethics committee of Mazandaran University of Medical Sciences (code number: 89-10-29-89150) approved the protocol of the study. All participants were informed of the purpose and methods of the research. In line with ethical considerations pertaining to qualitative studies, the researchers assured confidentiality and anonymity, preserved the participants’ right to withdraw at any time during the study and obtained informed consent from participants and their parents. Participants were initially asked for demographic information including age, age at menarche, amount of income, level of education and parents’ occupation. Participants were then asked to provide their opinions about the experience of puberty. To assist with the interview process, general interpretive questions with open answers were designed to create a semi-structured interview, with the answer to each question leading to the next question. Questions discussed in focus groups and in-depth interviews included the following:

All interviews were recorded, transcribed verbatim and analyzed. The duration of FGDs was between 1 and 3 h, with individual interviews averaging 60–90 min. The interviews continued until the point of data saturation.

Data analysis was conducted to extract codes, categories and themes by qualitative content analysis. Qualitative Content analysis is defined as the process of organizing qualitative data regard to emerging categories, concepts, and themes.

In current study qualitative content analysis was conducted as follow:

The number of participants by age group was as follows: 13 years old (13), 17 years old (11), 18 years old (4), 19 years old (4) and 20 years old (6), for a total of 38 girls. Thirteen participants were guidance (lower secondary) school students, 1 was a high school student, 4 were college students and 10 were university students. Age at menarche ranged from 10 to 15 years, with a mean of 12.6 years.

Seven main themes were extracted from the interviews: menarche as the most unpleasant event in puberty, nervousness and shame regarding bodily changes, psychological changes, and discord with parents, sexual orientation and the need for education on this issue, scholastic dysfunction and religious considerations.

The point of view held by adolescent girls is of great importance in understanding and assessing their needs in puberty. Most participants in this study did not have a pleasant puberty experience. They regarded it as a troublesome time, consistent with results of other studies conducted both inside and outside Iran [5, 10].

Anxiety and shame about physical appearance and psychological changes during puberty was a cause of concern for this study’s participants. Many adolescent girls are preoccupied with their appearance and may spend most of their time concerned with makeup and beauty. Embarrassment about sexual bodily changes exists in most cultures [9]. A study in Oman showed that only half of 1,675 guidance school girls were aware of bodily and sexual changes they undergo at puberty [15]. These changes may be a potential source of confusion and pressure for adolescents [1].

Similar to previous studies, this study showed that adolescent girls often do not receive accurate information about menstrual health because of culturally specific practices that lead to incorrect and unhealthy behaviors. However, educational interventions, such as the health promotion project in this study, can be quite effective in promoting menstrual health. [16, 17].

One of the most annoying experiences reported by participants in this study was discord with parents. We assume this could be the result of a generation gap [18]. As extracted from the participants’ statements, lack of compliance with parental advice is a cause of discord. Findings in this study showed that adolescents tend to resist their parents’ commands. They prefer to consult their parents rather than taking advice or orders from them. Adolescents will talk about themselves with their parents provided they perceive some parental enthusiasm for their ideas [18].

Menarche in the majority of girls was unexpected and worrisome, which depicts girls’ paucity of knowledge in this area. A previous study in Iran reported that only 17.4% of the students were knowledgeable enough to embrace puberty [2]. That study also reported that 69% of the girls divulged their first menarche experience to their mother.

A related qualitative study in the US used in-depth interviews with 22 girls of different ethnic backgrounds who were between 14–18 years of age. Findings showed that those who had previously been educated to be prepared for pubertal changes coped better with them [19].

Although similar results were found in the present study, many participants were too embarrassed to get more information on these issues from their mothers. Instead, they kept some distance from their mothers to avoid puberty-related discussions. We argue that girls are often not intimate enough with their mothers to comfortably discuss their problems with them. During one study, researchers asked 157 girls in 9th grade to give their opinions on how best to prepare girls for menarche. Of them, 35% stated that adolescents need emotional support and reassurance that menstruation is a natural phenomenon and not a calamity that causes fear, anxiety and shame. Mothers can reassure their daughters that their experiences are quite normal and give them more accurate information about menstruation. The best time for such counseling sessions between parents and girls is before the onset of menarche [20].

It is possible, to some extent, to correct existing misinformation about menstruation. For example, we could include anatomy lessons in the school curriculum to eliminate adolescents’ common misunderstandings [21]. A study in Iran stipulated that the most efficient strategy to convey the necessary information to girls is by involvement of families, and mothers in particular [22].

A tendency towards independence in adolescence is another cause for discord between parents and children. It is part of adolescents’ nature to oppose any dominant source of power within their social circle, including parents. Parents and adolescents may have contradictory ideas about various issues that at times may result in discord. Parents tend to regard handing responsibilities over to their teenaged children as a risk, and thus they try not to lose control over their teenagers’ decision making or problem solving process. Adolescents may ask “What kind of independence am I getting when everybody is telling me what or what not to do?” Parents may find striking a balance between exercising their authority and respecting their children’s freedom quite a challenge [23].

As mentioned, adolescents prefer to socialize with their peers rather than their families, which may be the reason they are less likely to be critical or assertive around friends. Previous studies have shown that protective parents who fail to establish an intimate relationship with their teenaged children tend to harbor a negative opinion about their children’s best friends, which may be a source of mistrust and distance between parents and children. Teenagers who have good interaction with each other enjoy a higher level of integrity and do better at school. Parents should encourage their adolescent children to have social gatherings at their own homes so they can meet their friends [24].

It is quite common for adolescents to experience a dip in their school performance, attributable to new activities in the teenage years [24]. Most of the adolescents who participated in this study experienced a loss of motivation for studying. Parents who make comparisons between their adolescent and other adolescents contribute to possible emotional problems in their child that may lead to educational frustration. Rather than comparing their adolescent with peers, parents should encourage their child to make friends with other adolescents, or according to one participant, they should compare each teenager to his or her own past rather than other adolescents [24].

Sexual drive and adolescents’ lack of proper information in this regard was one of the highest ranking concerns reported by most participants. The majority wanted to know more about topics such as STDs, naive and high risk sexual practices and reproduction. A previous study showed that Tehrani adolescent girls’ priorities in sexual education included pubertal health and healthy psychological maturity [25].

Despite adolescent girls’ need and desire to learn more about sexual issues, their mothers may expect them to remain naïve and unaware of these “shameful” topics [5]. It should be reiterated that addressing the needs of girls is an investment in the future of a country. According to previously conducted studies in Iran, the number of adolescents who date the opposite sex is 3 times more than in the past. Their relationships have progressed beyond friendship to having sex, and the number of adolescents with multiple sexual partners is increasing. This trend, rooted in the adolescent sexual and psychological revolution, is introducing a host of pathologies in adolescence. Islam has by no means made sex taboo or prohibited education regarding sexual issues. Islamic literature contains modules on sexual education. In fact, it is a must for Muslims to learn appropriate sexual practices [26], with failure to address such educational needs invariably associated with problems such as unwanted pregnancies and STDs [9].

A qualitative study in Iran concluded that in view of the Iranian cultural and religious background, families and religious beliefs play a pivotal role in reducing high risk sexual behaviors in Iranian adolescents [27]. Nonetheless, the importance of the teachers’ role in maintaining ethical values can never be overestimated [26].

Most adolescents in this study reported that they knew very little about the implications of Islamic and Sharia rules on ritual washing, praying and fasting after puberty and during menstruation. However, after their first experience of menstruation they felt they needed to know more about them. A previous study in Mazandaran, Iran showed that although almost 76% of students knew the correct answers to questions about menstruation and Sharia practices, only 56% knew the correct method of ablution during the menstrual period [5]. A study in Isfahan, Iran reported that implications of Sharia rules with regard to pubertal changes comprise an important entity [28].

Finally, the importance of collaboration between adolescents, their families and society to broaden insights on puberty and its essential needs should be reiterated.

Findings from the current study show that for the majority of the participants, puberty was an unpleasant experience. Most of them were in need of education regarding how to address issues surrounding puberty. The society, families and of course the adolescents themselves are responsible for working together to create an atmosphere in which correct information on puberty and the associated issues is readily accessible.

ZH, NAHG, and MF designed the study, NAHG, ZH, and LH collected and analyzed data. NAHG and ZH wrote the first draft of the manuscript, which has been commented on by the other authors. Both authors contributed to and approved the final version of the manuscript.