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Nghiên cứu tình trạng rối loạn kinh nguyệt và một số yếu tố liên quan ở sinh viên nữ Trường Đại học Y Hà Nội

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Bài viết trình bày rối loạn kinh nguyệt ảnh hưởng đáng kể đến sức khỏe và chất lượng cuộc sống của phụ nữ, đặc biệt là nữ sinh viên trường y. Nghiên cứu này nhằm đánh giá tình trạng rối loạn kinh nguyệt và một số yếu tố liên quan ở sinh viên nữ Trường Đại học Y Hà Nội. Nghiên cứu mô tả cắt ngang được thực hiện trên 312 sinh viên nữ từ tháng 8 năm 2023 đến tháng 1 năm 2024.

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Nội dung Text: Nghiên cứu tình trạng rối loạn kinh nguyệt và một số yếu tố liên quan ở sinh viên nữ Trường Đại học Y Hà Nội

  1. TNU Journal of Science and Technology 230(01): 209 - 216 A STUDY OF MENSTRUAL DISORDERS AND SOME ASSOCIATED FACTORS IN FEMALE STUDENTS AT HANOI MEDICAL UNIVERSITY Do Thanh Tung1*, Lo Ba Cuong1, Tran Minh Duc1, Pham Hong Ha1, Nguyen Phuong Tu1, Nguyen Hai Phuong2 1Hanoi Medical University, 2National Hospital of Obstetrics and Gynecology ARTICLE INFO ABSTRACT Received: 19/8/2024 Menstrual disorders can have a significant impact on women's health and quality of life, especially among medical university students. Our Revised: 17/10/2024 study aimed to assess menstrual disorders and some associated factors Published: 18/10/2024 in female students at Hanoi Medical University. The descriptive cross-sectional study was conducted on 312 female students from KEYWORDS August 2023 to January 2024. The results showed over half (55.45%) of the students reported menstrual irregularities. The most common Menstrual disorders issues were oligomenorrhea (46.15%) and menorrhagia (8.33%). Associated factors Notably, 95.83% experienced premenstrual symptoms; dysmenorrhea were the most prevalent during menstruation (93.91%). Menstrual Medical students disorders were significantly associated with BMI, family history of BMI menstrual disorders, and place of residence before university Family history admission. Our study’s results provided a better understanding of the factors associated with menstrual disorders, thus having potential applications in the prevention and control of the disease. NGHIÊN CỨU TÌNH TRẠNG RỐI LOẠN KINH NGUYỆT VÀ MỘT SỐ YẾU TỐ LIÊN QUAN Ở SINH VIÊN NỮ TRƯỜNG ĐẠI HỌC Y HÀ NỘI Đỗ Thanh Tùng1*, Lỗ Bá Cương1, Trần Minh Đức1, Phạm Hồng Hà1, Nguyễn Phương Tú1, Nguyễn Hải Phương2 1Trường Đại học Y Hà Nội, 2Bệnh viện Phụ sản Trung ương THÔNG TIN BÀI BÁO TÓM TẮT Ngày nhận bài: 19/8/2024 Rối loạn kinh nguyệt ảnh hưởng đáng kể đến sức khỏe và chất lượng cuộc sống của phụ nữ, đặc biệt là nữ sinh viên trường y. Nghiên cứu Ngày hoàn thiện: 17/10/2024 này nhằm đánh giá tình trạng rối loạn kinh nguyệt và một số yếu tố Ngày đăng: 18/10/2024 liên quan ở sinh viên nữ Trường Đại học Y Hà Nội. Nghiên cứu mô tả cắt ngang được thực hiện trên 312 sinh viên nữ từ tháng 8 năm TỪ KHÓA 2023 đến tháng 1 năm 2024. Kết quả cho thấy hơn một nửa (55,45%) số sinh viên bị rối loạn kinh nguyệt. Các vấn đề phổ biến nhất là kinh Rối loạn kinh nguyệt thưa (46,15%) và rong kinh (8,33%). Đáng chú ý, 95,83% có triệu Yếu tố liên quan chứng tiền kinh nguyệt; đau bụng kinh là triệu chứng phổ biến nhất Sinh viên y trong khi hành kinh (93,91%). Rối loạn kinh nguyệt liên quan có ý nghĩa thống kê đến BMI, tiền sử gia đình về rối loạn kinh nguyệt và BMI nơi sống trước khi vào đại học. Kết quả nghiên cứu của chúng tôi Tiền sử gia đình cung cấp hiểu biết tốt hơn về các yếu tố liên quan đến rối loạn kinh nguyệt, do đó có tiềm năng ứng dụng trong phòng ngừa và kiểm soát bệnh tật. DOI: https://doi.org/10.34238/tnu-jst.10975 * Corresponding author. Email: tungoct404@gmail.com http://jst.tnu.edu.vn 209 Email: jst@tnu.edu.vn
  2. TNU Journal of Science and Technology 230(01): 209 - 216 1. Introduction Menstruation is the periodic shedding of the uterine lining, leading to vaginal bleeding. Menstrual disorders involve changes in the frequency, regularity, duration, or amount of menstrual bleeding compared to a normal cycle [1]. These irregularities can cause a range of health problems including anemia, vaginitis, endometrioma, ovarian inflammation, and fertility problems. Additionally, they can significantly impact a woman's daily activities, mental, and sexual health. Menstrual disorders are a significant global health concern. A study in Hue city identified that up to 73.6% of women experience such issues before menopause [2]. Multiple studies have reported high rates of menstrual disorders among university students: 55% had menstrual irregularities at Al Neelain University, 80.7% among Lebanese nursing students; especially, 97.8% at Makerere University College had at least one type of menstrual disorder [3]-[5]. Previous research has indicated that students experiencing menstrual disorders reported a lower quality of life [5], [6]. Furthermore, Enguday Demeke et al. (2023) showed a decrease of 0.19 points on a 4.0 scale in the average academic grades of students with irregular menstruation compared to those with regular menstruation [7]. Therefore, measures should be implemented to mitigate the prevalence of menstrual disorders among students, particularly medical students, since they experience heightened stress levels and potentially lower quality of life compared to students in other disciplines [8], [9]. Understanding the underlying causes and contributing factors of menstrual disorders is crucial for developing targeted interventions, managing reproductive health issues, and ultimately enhancing menstrual health outcomes. While some research in Vietnam has explored characteristics and types of menstrual disorders, studies investigating the factors associated with these issues in students, particularly those facing a demanding academic environment, are lacking. For these reasons, we conducted a study titled "A Study of Menstrual Disorders and Some Associated Factors in Female Students at Hanoi Medical University" to assess the prevalence and patterns of menstrual disorders, and identify factors associated with menstrual disorders among female students at Hanoi Medical University. 2. Materials and methods 2.1. Study population Inclusion criteria: Female students of Hanoi Medical University who volunteered to participate in the study. Exclusion criteria: Female students who were pregnant, one year postpartum and breastfeeding, seriously ill, or did not agree to participate in the research. 2.2. Place and time This study was conducted at Hanoi Medical University, Hanoi, Vietnam from August 2023 to January 2024. 2.3. Study design Descriptive cross-sectional study. 2.4. Variables The variables of this study included: (1) socio-demographic characteristics; (2) anthropometric characteristics; (3) menstrual characteristics, (4) lifestyle characteristics, and (5) family history of menstrual disorders. 2.5. Sample size and sampling methods The formula for estimating sample size is given by (1). http://jst.tnu.edu.vn 210 Email: jst@tnu.edu.vn
  3. TNU Journal of Science and Technology 230(01): 209 - 216 2 𝑍1−𝛼/2 × 𝑝(1 − 𝑝) 𝑛= (1) 𝑑2 With α = 0.05, Z(1–α/2) = 1.96, d = 0.05, p: estimated proportion of menstrual disorders is 80.7% [4]. The needed sample size is 240. A total of 312 subjects were finally enrolled in our study through the convenience sampling method. 2.6. Data collection and statistical analysis A pre-designed online questionnaire was used to collect data, with data being captured using the REDCap software. Data was analyzed in Stata 14 using descriptive statistics such as percentages, frequencies, means, and standard deviations. Inferential statistics were used to determine significant differences, with p < 0.05 considered statistically significant. 2.7. Ethical issues Informed consent was obtained from all participants. Data sets were stored securely and used for research purposes only. 3. Results and Discussion 3.1. General characteristics and menstrual characteristics of the research subjects Table 1. Socio-demographic and anthropometric characteristics of the study participants Variable Categories Frequency (n) Percent (%) < 20 years old 114 36.54 Age 20 - 22 years old 154 49.36 > 22 years old 44 14.10 Kinh 275 88.14 Ethnicity Others 37 11.86 Residence before Urban 102 32.69 university admission Rural 210 67.31 Dormitory 70 22.44 Current residence Lodging 186 59.62 Staying with family 56 17.95 First year 62 19.87 Second year 62 19.87 Third year 76 24.36 School year Fourth year 49 15.71 Fifth year 26 8.33 Sixth year 37 11.86 General medicine 99 31.73 Odonto-Stomatology 33 10.58 Traditional medicine 25 8.01 Preventive medicine 16 5.13 Nursing 72 23.08 Majors Nutrition 19 6.09 Medical testing techniques 10 3.20 Rehabilitation techniques 2 0.64 Optometry 17 5.45 Public health 19 6.09 Underweight (
  4. TNU Journal of Science and Technology 230(01): 209 - 216 The general characteristics details are provided in Table 1. The mean age of study participants was 20.24 ± 1.75 years. A significant portion of the students (67.31%) came from rural areas before attending university and did not live with their families during university (82.05%). The average BMI of the participants was 19.96 ± 2.52. Table 2. Menstrual characteristics of the study participants Variable Categories Frequency (n) Percent (%) 2 times every 1 month 5 1.60 1 time every 1 month (normal) 257 82.37 Frequency of menstrual cycle 1 time every 2 months 36 11.54 1 time every 3 months 9 2.88 1 time every 6 months 5 1.60 15 9 2.88 < 21 days 11 3.53 Menstrual cycle length 21 - 35 days (normal) 148 47.44 > 35 days 153 49.04 Do menstruation come on the Yes (normal) 137 43.91 same day or around the same day? No 175 56.09 < 3 days 15 4.81 3 - 7 days (normal) 271 86.86 Duration of menstrual flow 7 - 10 days 23 7.37 > 10 days 3 0.96 Figure 1. Prevalence of menstrual disorders among participants Table 2 provides information on the menstrual characteristics of the study subjects. Most of the participants have a normal age of menarche (96.15%), highlighting that menstrual disorders are not solely limited to individuals with early or late menarche, even those with a normal age of menarche can be at risk. Nearly half had menstrual cycles > 35 days, and over half had periods that did not start on the same day or around the same day each month. The majority of participants have a normal frequency of menstrual cycle and bleeding duration. There is a small subset of participants (8.33%, n=26) experiencing menstrual flow exceeding 7 days. For those with extended menstrual flow, we recommend further evaluation through ultrasound and blood tests to assess potential underlying causes, such as anemia or ovarian tumors. Figure 1 shows that 55.45% of participants (n=173) identified as having menstrual disorders based on their reported menstrual characteristics. This finding aligns with a study at Al Neelain University with a rate of 55.0% [3]. These results suggest that medical students might be a population particularly susceptible to menstrual disorders, potentially due to the stress associated with their demanding academic environment [8], [9]. Further research is needed to investigate whether medical school specifically, compared to non-medical programs, increases susceptibility to menstrual disorders. Elucidating the underlying causes of this potential association would be http://jst.tnu.edu.vn 212 Email: jst@tnu.edu.vn
  5. TNU Journal of Science and Technology 230(01): 209 - 216 crucial for developing targeted interventions to improve menstrual health in this population. However, the prevalence observed in this study is higher compared to studies conducted in Ethiopia with 32.6% and 33.4% [1], [10]. This variation across studies might be due to factors like living conditions, racial/ethnic backgrounds, lifestyle choices, and nutritional deficiencies across countries. Additionally, variations in how studies define and diagnose menstrual disorders can also influence reported prevalence. Table 3. Distribution and prevalence of menstrual disorders, premenstrual symptoms, and dysmenorrhea Variable Frequency (n) Percent (%) Oligomenorrhea 144 46.15 Polymenorrhea 11 3.53 Amenorrhea 9 2.88 Menorrhagia 26 8.33 Hypomenorrhea 15 4.81 Premenstrual symptoms 299 95.83 Dysmenorrhea 293 93.91 Distribution and prevalence of menstrual disorders, premenstrual symptoms, and dysmenorrhea are provided in Table 3. Oligomenorrhea was the most prevalent menstrual disorder, affecting 46.15% of participants. This is in line with another study in Vietnam with 38.1% oligomenorrhea [11]. Meanwhile, some studies conducted outside Vietnam reported menorrhagia and polymenorrhea as the most common irregularities [1], [10]. The differences across studies might be attributed to differences in sample size, and lifestyle factors. Notably, a large majority of participants reported experiencing premenstrual symptoms (95.83%) and dysmenorrhea (93.91%). These findings are particularly concerning, especially in light of previous studies on university students in Turkey, which reported similarly high rates (Dysmenorrhea: 90.1%, PMS: 71.3%) [6]. Dysmenorrhea is a significant public health issue, as it can severely impact a woman's quality of life and daily activities. Studies estimate that one in ten women experiences dysmenorrhea so severe that it disrupts their daily routine for one to three days per menstrual cycle [12]. Dysmenorrhea is also believed to be the most common menstrual problem that causes girls to miss school, seek pain relief, seek medical treatment, or even take long-term absences from school [13]. PMS is characterized by changes in mood, behavior, and physical symptoms that occur during the premenstrual period and can go away right before menstruation begins [14]. Although the precise mechanisms underlying PMS are not fully understood, a potential contributing factor is the impact of progesterone on neurotransmitter function [14]. Additionally, sympathetic activity may also be activated, resulting in dysmenorrhea by intensifying uterine contractions [14]. Arshia Syed and Smitha B. Rao reported, however, lower prevalence rates of dysmenorrhea and PMS, with 45% and 68% respectively [15]. The differences can likely be attributed to a variety of factors, including BMI, sleep quality, and stress levels [16]. Regardless of the specific PMS symptoms experienced, both PMS and dysmenorrhea can significantly impact a woman's quality of life, personal health, and ability to function in daily activities and social settings. 3.2. Factors associated with menstrual disorders Table 4. Factors associated with menstrual disorders Menstrual Variable Categories disorders OR (95% CI) p-value No Yes Residence before Rural 83 127 1.8628 (1.1228 - 3.0923) 0.0104* university admission Urban 56 46 Reference Underweight/ BMI 42 77 1.8524 (1.1286 - 3.0525) 0.0098* Overweight http://jst.tnu.edu.vn 213 Email: jst@tnu.edu.vn
  6. TNU Journal of Science and Technology 230(01): 209 - 216 Menstrual Variable Categories disorders OR (95% CI) p-value No Yes Normal 97 96 Reference Have you ever had Yes 29 37 1.0319 (0.5767 - 1.8572) 0.9103 sexual intercourse? No 110 136 Reference Family history of Yes 27 54 1.8824 (1.0770 - 3.3318) 0.0182* menstrual disorders? No 112 119 Reference ≤ 5 hours/day 12 20 1.5152 (0.4292 - 5.3233) 0.4646 Sleeping hours 6-8 hours/day 117 142 1.1033 (0.4044 - 2.9728) 0.8286 > 8 hours/day 10 11 Reference After 2 AM 10 10 0.8421 (0.2435 - 2.9138) 0.7594 Sleeping time After 12 AM 113 143 1.0657 (0.4882 - 2.2969) 0.8605 Before 11 PM 16 19 Reference Note: * p < 0.05 Table 4 shows the factors associated with menstrual disorders. Three factors were significantly associated with menstrual disorders: BMI, family history of menstrual disorders, and residence before university (p < 0.05). First, students who were overweight or underweight (outside the normal BMI range) were 1.85 times more likely to experience menstrual disorders compared to those with a normal BMI (95% CI [1.13 - 3.05], p < 0.05). This finding is in line with previous research [1], [10], [17]. Maintaining a healthy weight is crucial for regular menstrual cycles and ovulation. Underweight individuals may lack the energy reserves needed for ovulation, while overweight individuals may have hormonal imbalances like elevated testosterone and lower sex hormone binding globulin, disrupting menstrual regularity and potentially lengthening cycles [18], [19]. According to WHO, obesity has increased over the years: worldwide adult obesity has more than doubled since 1990; in 2022, almost half of the adult population (43%) were overweight, and of that number, 16% were classified as obese [20]. This highlights the potential impact of weight management on menstrual health in young women. The study also identified a link between family history and menstrual disorders. Students with mothers or sisters who had menstrual disorders were 1.88 times more likely to experience them themselves (95% CI [1.08 - 3.33], p < 0.05). This finding is consistent with a study on 2,650 female students at the Faculty of Education and Nursing of a university [21]. There are two potential explanations for this association. First, some recessive genetic conditions or blood clotting disorders, such as hemophilia, Von Willebrand disease, or idiopathic thrombocytopenic purpura, can affect menstruation and may only become apparent during reproductive years. Second, daughters often learn about menstrual hygiene practices from their mothers and sisters, which can potentially shape a young woman's own experiences and behaviors related to menstruation [22]. Further research is needed to identify the specific genes involved in menstrual disorders to improve our understanding of the underlying causes of menstrual disorders and potentially develop more effective treatment options. Living environment also emerged as a factor influencing menstrual health. Students from rural backgrounds were 1.86 times more likely to experience menstrual disorders compared to their urban counterparts (95% CI [1.12 - 3.09], p < 0.05). This finding is consistent with a study in Ethiopia in 2021 [10]. This disparity could be due to several factors. Rural areas may lack access to proper menstrual hygiene facilities and education, negatively impacting menstrual health. Nutritional differences between rural and urban areas might also play a role. Additionally, the transition from a rural to an urban environment can be stressful, potentially leading to elevated cortisol levels that disrupt sex hormones and contribute to menstrual irregularities. Beyond the factors already discussed, numerous studies suggest that other aspects of a woman's life can influence her menstrual cycle, including stress, lack of exercise, smoking, http://jst.tnu.edu.vn 214 Email: jst@tnu.edu.vn
  7. TNU Journal of Science and Technology 230(01): 209 - 216 coffee, unhealthy diet, etc [17]. The female reproductive system is particularly sensitive to both physical and emotional stressors. While short-term stress might not cause noticeable changes, sustained or severe stress can have a significant negative impact on a woman's health and well- being. This is because stress triggers the activation of the corticotropin-releasing hormone system, which can lead to menstrual irregularities or even temporary cessation of menstruation (amenorrhea). 4. Conclusions In this study, more than half of the participants experience menstrual disorders, with oligomenorrhea and menorrhagia being the most common types. Our research also identified several risk factors, including having a BMI outside the normal range, a family history of menstrual disorders, and living in a rural area before university admission. Future research should use more accurate methods to quantify menstrual blood volume, as it could be a valuable tool in assessing blood loss, overall health, and well-being. Additionally, further studies and support systems are needed to address menstrual disorders and their impact on women's well-being. Acknowledgments The authors are deeply grateful to the class leaders at Hanoi Medical University for their support in facilitating our data collection and research. REFERENCES [1] A. B. Zeru, E. D. Gebeyaw, and E. T. Ayele, “Magnitude and associated factors of menstrual irregularity among undergraduate students of Debre Berhan University, Ethiopia,” Reprod Health, vol. 18, no. 1, p. 101, May 2021. [2] D. P. T. Nguyen, V. Q. H. Nguyen, and N. T. Cao, “Dysfunctional symptoms in postmenopausal women in Hue city,” (in Vietnamese), Vietnamese Journal of Obstetrics and Gynecology, vol. 10, no. 4, pp. 15-22, Nov. 2012. [3] A. Ali, H. Khalafala, and H. Fadlalmola, “Menstrual Disorders Among Nursing Students at Al Neelain University, Khartoum State,” Sudan Journal of Medical Sciences (SJMS), vol. 15, no. 2, pp. 199-214, Jun. 2020. [4] N. Karout, S. M. Hawai, and S. Altuwaijri, “Prevalence and pattern of menstrual disorders among Lebanese nursing students,” East Mediterr Health J, vol. 18, no. 4, pp. 346-352, Apr. 2012. [5] E. Odongo, J. Byamugisha, J. Ajeani, and J. Mukisa, “Prevalence and effects of menstrual disorders on quality of life of female undergraduate students in Makerere University College of health sciences, a cross sectional survey,” BMC Womens Health, vol. 23, no. 1, p. 152, Mar. 2023. [6] E. Bilir, Ş. Yıldız, K. Yakın, and B. Ata, “The impact of dysmenorrhea and premenstrual syndrome on academic performance of college students, and their willingness to seek help,” Turk J Obstet Gynecol, vol. 17, no. 3, pp. 196-201, Sep. 2020. [7] E. Demeke, A. B. Zeru, E. Tesfahun, and W. B. Mohammed, “Effect of menstrual irregularity on academic performance of undergraduate students of Debre Berhan University: A comparative cross sectional study,” PLOS ONE, vol. 18, no. 1, p. e0280356, Jan. 2023. [8] H. B. M. S. Paro et al., “Health-related quality of life of medical students,” Med Educ, vol. 44, no. 3, pp. 227-235, Mar. 2010. [9] M. C. Rosal, I. S. Ockene, J. K. Ockene, S. V. Barrett, Y. Ma, and J. R. Hebert, “A longitudinal study of students’ depression at one medical school,” Acad Med, vol. 72, no. 6, pp. 542-546, Jun. 1997. [10] Y. M. Mittiku, H. Mekonen, G. Wogie, M. A. Tizazu, and G. E. Wake, “Menstrual irregularity and its associated factors among college students in Ethiopia, 2021,” Frontiers in Global Women’s Health, vol. 3, 2022. [Online]. Available: https://www.frontiersin.org/articles/10.3389/fgwh.2022.917643. [Accessed Feb. 14, 2024]. [11] T. Vi et al., “Medical Student’s Menstrual Cycle: The Unknown Unknowns,” CTUMP, vol. 8, no. 4, pp. 29-35, Oct. 2022. http://jst.tnu.edu.vn 215 Email: jst@tnu.edu.vn
  8. TNU Journal of Science and Technology 230(01): 209 - 216 [12] “Overview: Period pain,” in InformedHealth.org [Internet], Institute for Quality and Efficiency in Health Care (IQWiG), 2023. [Online]. Available: https://www.ncbi.nlm.nih.gov/books/NBK279324/. [Accessed Jul. 11, 2024]. [13] T. Joshi, M. Kural, D. Agrawal, N. Noor, and A. Patil, “Primary dysmenorrhea and its effect on quality of life in young girls,” Int J Med Sci Public Health, vol. 4, no. 3, p. 381, 2015. [14] P. R. Gudipally and G. K. Sharma, “Premenstrual Syndrome,” in StatPearls, Treasure Island (FL): StatPearls Publishing, 2024. [Online]. Available: http://www.ncbi.nlm.nih.gov/books/NBK560698/. [Accessed Jul. 11, 2024]. [15] A. Syed and S. B. Rao, “Prevalence of premenstrual syndrome and dysmenorrhea among medical students and its impact on their college absenteeism.,” International Journal of Reproduction, Contraception, Obstetrics and Gynecology, vol. 9, no. 4, pp. 1377-1382, Apr. 2020. [16] R. Mitsuhashi, A. Sawai, K. Kiyohara, H. Shiraki, and Y. Nakata, “Factors Associated with the Prevalence and Severity of Menstrual-Related Symptoms: A Systematic Review and Meta-Analysis,” Int J Environ Res Public Health, vol. 20, no. 1, p. 569, Dec. 2022. [17] S. Maity et al., “Academic and Social Impact of Menstrual Disturbances in Female Medical Students: A Systematic Review and Meta-Analysis,” Front Med (Lausanne), vol. 9, p. 821908, 2022. [18] R. E. Frisch and J. W. McArthur, “Menstrual cycles: fatness as a determinant of minimum weight for height necessary for their maintenance or onset,” Science, vol. 185, no. 4155, pp. 949-951, Sep. 1974. [19] K. Itriyeva, “The effects of obesity on the menstrual cycle,” Current Problems in Pediatric and Adolescent Health Care, vol. 52, no. 8, p. 101241, Aug. 2022. [20] “Obesity and overweight”. [Online]. Available: https://www.who.int/news-room/fact- sheets/detail/obesity-and-overweight. [Accessed Jul. 11, 2024]. [21] D. Ş. Küçükkelepçe, S. Hazar, S. Aytop, and S. T. Taşhan, “The Correlation Between the Menstrual Irregularity and Eating Attitude and Social Appearance Anxiety among University Students,” MÜSBİD, vol. 10, no. 2, Dec. 2021. [22] M. S. Neupane, K. Sharma, A. P. Bista, S. Subedi, and S. Lamichhane, “Knowledge on menstruation and menstrual hygiene practices among adolescent girls of selected schools, Chitwan,” Journal of Chitwan Medical College, vol. 10, no. 1, Mar. 2020. http://jst.tnu.edu.vn 216 Email: jst@tnu.edu.vn
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