Abstract
BackgroundAdolescent girls’ risk of school dropout and reproductive health (RH) challenges may be exacerbated by girls’ attitudes toward their bodies and inability to manage their menstruation. We assessed effects of sanitary pad distribution and RH education on girls in primary grade 7 in Kilifi, Kenya.MethodsA cluster randomized controlled trial design was used. Eligible clusters were all non-boarding schools in three sub-counties in Kilifi County that had a minimum of 25 girls enrolled in primary grade 7. 140 primary schools, 35 per arm, were randomly assigned to one of four study arms: (1) control; (2) sanitary pad distribution; (3) RH education; or (4) both sanitary pad distribution and RH education. Outcomes were school attendance, school engagement, RH knowledge and attitudes, gender norms, and self-efficacy. For outcomes measured both at baseline and endline, difference-in-differences (DID) models were estimated and for outcomes without baseline data available, analysis of covariance models were used.ResultsThe study enrolled 3489 randomly selected girls in primary grade 7, with a mean age of 14.4 (SD 1.5). Girls in arms 2 and 4 received on average 17.6 out of 20 packets of sanitary pads and girls in arms 3 and 4 participated on average in 21 out of 25 RH sessions. Ninety-four percent of the baseline sample was interviewed at the end of the intervention with no differential attrition by arm. There was no evidence of an effect on primary school attendance on arm 2 (coefficient [coef] 0.37, 95% CI − 0.73, 1.46), arm 3 (coef 0.14, 95% CI − 0.99, 1.26) or arm 4 (coef 0.58, 95% CI − .37, 1.52). There was increased positive RH attitudes for girls in arm 3 (DID coef. 0.63, 95% CI 0.40–0.86) and arm 4 (DID coef. 0.85, 95% CI 0.64, − 1.07). There was also an increase in RH knowledge, gender norms and self-efficacy in arms 3 and 4.ConclusionsThe findings suggest that neither sanitary pad distribution nor RH education, on their own or together, were sufficient to improve primary school attendance. However, as the RH education intervention improved RH outcomes, the evidence suggests that sanitary pad distribution and RH education can be positioned in broader RH programming for girls.Trial registration: ISRCTN, ISRCTN10894523. Registered 22 August 2017—Retrospectively registered, http://www.isrctn.com/ISRCTN10894523
Highlights
Adolescent girls’ risk of school dropout and reproductive health (RH) challenges may be exacerbated by girls’ attitudes toward their bodies and inability to manage their menstruation
The study results show that addressing girls’ menstrual health challenges are important, but are better positioned as part of comprehensive sexuality education programs addressing stigma and shame associated with menstruation, access to menstrual products, inequitable gender norms and sexual and reproductive health knowledge gaps, as opposed to a girls education intervention
An analysis of school attendance data from this study showed a positive impact on attendance due to sanitary pad distribution, that effect washed out in models that accounted for absence due to school transfer [13]
Summary
Adolescent girls’ risk of school dropout and reproductive health (RH) challenges may be exacerbated by girls’ attitudes toward their bodies and inability to manage their menstruation. According to several qualitative studies in Africa, these vulnerabilities are exacerbated by girls’ lack of knowledge of their bodies and rights, and their inability to safely and comfortably manage their menstruation [2,3,4,5]. Qualitative studies conducted in Kenya, and other countries in sub-Saharan Africa, have identified several challenges girls face in managing their menstruation, including lack of access to menstrual products and lack of accurate information about menstruation. Girls expressed that they missed school during their menses due to lack of menstrual products, fear of leaking blood on their uniforms and pain from menstrual cramps [3, 5, 8]. The literature on the challenges linked to a lack of menstrual hygiene products and knowledge has been largely qualitative
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