Investigating the Impact of a Menstrual Hygiene Program on School Absenteeism of Rural Ugandan Girls: A Delayed Cluster Randomised Control Trial

Abstract

Background: Observational studies have described how inadequate Menstrual Hygiene Management (MHM) impacts negatively on girls' engagement in school but are yet to confirm if MHM interventions can have an impact. We hypothesise that provision of menstrual health education and re-usable sanitary pads can improve girls' school attendance. Methods: We conducted a non-blinded delayed control cluster-randomised trial in 40 government primary schools in former Greater Bushenyi District, Western Uganda. A group of 30 girls aged 12-18 from each school was randomly assigned to intervention (menstrual health education and reusable sanitary pads) or control (receiving the intervention at the end of the study) groups. The primary outcome was the mean number of days of school missed per month. Findings: We randomised 1,170 girls from 20 intervention (582 girls) and 20 control (588 girls) schools. At follow-up, 499 girls from 20 intervention (259 girls) and 19 control (240 girls) were included in the primary analysis. School attendance according to register data was similar in the intervention group compared to the control (-0.22 days, 95% CI: -0.204, 0.644 days, p-value: 0.300). High rates of missing register data and school drop-out meant the trial suffered from substantial missing data. There was a positive non-statistically significant effect on girls' knowledge of menstruation, daily activities during menstruation and self-esteem. No adverse effects were reported. Interpretation: An MHM intervention consisting of pad distribution and education may not result in sustainable improvements in girls' school engagement. Future work should consider interventions that include behaviour change components . Results should be interpreted in light of issues with the volume of missing data. Work is needed to develop reliable and replicable methods of measuring the impact of MHM interventions on girls' school engagement. Trial Registration Number: The trial is registered with ClinicalTrials.gov, study ID: NCT02243488. Funding Statement: The Leverhulme Trust Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: Ethics for this study has been granted by The University of Sheffield’s School of Health and Related Research (Ethics reference number: 0677/KW). Ethics approval has been obtained locally from Makerere University School of Public Health and the trial will be registered with The Ugandan National Council for Science and Technology (UNCST). The trial has also been registered with Clinicaltrials.gov and the protocol will be published online on the White Rose Consortium.