Abstract
Menstrual hygiene management is an important determinant for girls' educational outcomes. We develop a method of cross-sectional analysis that quantifies the relative importance of four distinct mechanisms: material, biological, social and informational constraints and consider four main schooling outcomes: absenteeism, early departure, concentration and participation. We use survey data from 524 female students enrolled in four co-educational secondary schools in Northern Tanzania. Average age at first period is 14.2 years (standard deviation = 1.1, range 9-19). Information is the least binding constraint: 90-95% of girls report they received information about menstruation and how to manage it. In contrast, biological constraints are hindering: (i) the distribution of menstrual cramps and pain is bifurcated: most girls report very light or very strong pain (rather than moderate) with considerable educational impacts for girls in the latter group, (ii) irregular cycles (62%) and difficulty predicting the cycle (60%) lead to stress and uncertainty. Socio-cultural constraints are binding as 84% would feel shame if male peers knew their menstrual status, and 58% fear being teased over periods. Material constraints include prohibitive costs: girls spending between 12-70% of the daily national poverty line (6,247 TSH per day) on pads during their period. However, we discern no statistically significant relationship between access to pads and absenteeism. In contrast, biological and socio-cultural constraints as well as lack of sanitary infrastructure have significant effects on absenteeism. The results have several implications. First, sanitary pad interventions should consider participation and concentration as main outcomes, in addition to absenteeism. Second, biological (menstrual cramps and pain) and socio-cultural (fear, stigma) constraints are drivers of menstruation-related absenteeism and participation in the classroom and need to be evaluated in trials. We suggest exploring analgesic use, alternative pain-management techniques, menstrual cycle tracking technologies, and social programming in future trials.
Highlights
Menstrual hygiene management is an important determinant for girls’ educational outcomes in low and middle-income countries
We acknowledge that each constraint type does not exist independent from the others, we develop a methodology that combines and considers the impact of each constraint on educational outcomes
In the fully identified model, girls who report a material constraint index score of 1 were 14.9% less likely to miss school (45.7% of the sample mean) and 24.8% more likely to concentrate less in class (75.2% of the sample mean). These results indicate that material constraints may have a greater impact on educational outcomes like participating and concentrating in class than previously anticipated
Summary
Menstrual hygiene management is an important determinant for girls’ educational outcomes in low and middle-income countries. Our study lightly follows in the footsteps of research conducted in Uttar Pradesh by Malhotra et al (2016) [26] which investigates a variety of factors that may constrain girls’ ability to manage their menstruation, including knowledge and attitudes. The aforementioned study comes to similar conclusions: a majority of girls report being constrained in the management of their menstruation and socio-cultural constraints are common, with many girls feeling isolated or impure during menstruation. The extant literature emphasizes the effect of menstruation on girls’ educational outcomes, but the bulk of previous impact evaluation research focuses solely on absenteeism and enrollment rates. In addition to absenteeism, research from Sub-Saharan Africa [14, 27, 28] has found that girls self-report worsened school performance, decreased mobility, and difficulty concentrating during their period. We investigate three gaps in the measurement of educational outcomes
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