Menstrual hygiene management amongst schoolgirls in the Rukungiri district of Uganda and the impact on their education: a cross-sectional study

Introduction An increasing number of studies have found that girls in low-income settings miss or struggle at school during menstruation if they are unable to manage their menstrual hygiene effectively. This study explores the menstrual hygiene practices and knowledge of girls at rural government primary schools in the Rukungiri district in Uganda and assesses the extent to which poor menstrual hygiene management (MHM) affects their education. Methods A self-administered questionnaire was completed by schoolgirls in six government-run primary schools in the Rukungiri district. Focus groups were held with girls from each school and semi-structured interviews were conducted with headteachers and female teachers from the participating schools. A toilet assessment was also conducted in each school. Results One hundred and forty schoolgirls completed the questionnaire. The girls reported a lack of access to adequate resources, facilities and accurate information to manage their menstrual hygiene effectively at school. They reported that, as a result, during menstruation they often struggle at school or miss school. Eighty-six girls (61.7%) reported missing school each month for menstrual-related reasons (mean 1.64, range 0-10, SD. 1.84). Conclusion It is common for girls who attend government-run primary schools in the Rukungiri district to miss school or struggle in lessons during menstruation because they do not have access to the resources, facilities, or information they need to manage for effective MHM. This is likely to have detrimental effects on their education and future prospects. A large-scale study is needed to explore the extent of this issue.


Introduction
School dropout for girls in low-income settings increases when they reach puberty [1][2][3]. Previously overlooked menstrual-related concerns are increasingly recognised as factors that contribute to this [4][5][6][7][8]. However, research into the impact of unmet menstrual needs on girls' education remains scarce. The dearth of studies about menstrual hygiene management (MHM) and the impact of unmet menstrual needs is particularly striking given the relevance of the topic to numerous fields, such as WASH (water, sanitation and hygiene), humanitarian relief, and human rights.
Menarche is an important milestone in a girl's transition to womanhood. However, menstruation can place significant obstacles in the way of girls' access to health, education and future prospects if they are not equipped for effective MHM. Good MHM requires access to necessary resources (e.g. menstrual materials to absorb or collect menstrual blood, soap and water), facilities (e,g. private place to wash, change and dry re-usable menstrual materials, in addition to an adequate disposal system for menstrual materials), and education about MHM [9].

MHM amongst girls in rural government-run primary schools in
Uganda is an under-examined area of research. Girls in this setting are unlikely to have access to what they need to manage their menstrual flow and are thus more at risk of absenteeism from school [10][11][12][13][14]. Girls have a human right to education and educating girls is a wise investment for development, producing 'high and long-lasting returns' for families, societies and subsequent generations [15]. Therefore, research into the impact of poor MHM on girls' education is vital.
This study aims to assess and explore the extent to which schoolgirls in a low-income setting in south-west Uganda are able to manage their menstrual hygiene effectively and if this impacts on their education. We aim to contribute to the emerging literature on

Methods
This cross-sectional study adopts a mixed methods approach, combining four sources of data [16]: self-administered questionnaires, focus group discussions (FGDs), semi-structured interviews with key informants and a toilet assessment. The study was conducted in six rural, government-run primary schools in the Rukungiri District of south-west Uganda between March-April 2013.
The schools were recruited through the headteacher of a local private school. This headteacher, who was the organisation's main contact in the education sector in the locality, supported the researchers in identifying the closest government-run primary schools to the central research facilities in Kisiizi hospital. Six schools were identified and agreed to participate. Girls aged 13-16 years who had started menstruation were invited to take part. The girls who participated were old enough to attend secondary school, yet remained in the upper end of primary school because they were behind with their studies. One hundred and seventy-three girls in total participated in the self-administred questionnaire. Prior to the research we informed the schools of the selection criteria that respondents had to meet to participate. However, when analysing the results we discovered that thirty-three girls had still participated who did not meet this criteria. Their questionnaires were consequently excluded from the final results.
Data collection took place in a private classroom, a private outdoor location in the school compound, and the school toilets. Participants gave written consent before participating and confidentiality and anonymity were emphasised at every stage. The girls sat a seat apart from each other when completing the questionnaire and could not converse amongst themselves so that they would not influence each other's answers. Participation was voluntary and girls were allowed to withdraw from the research at any stage if they wished to, without having to give a reason. Due to the sensitive nature of menstruation, the researchers and translator were female. There were no male pupils or teachers present during the questionnaire completion, FDGs or interviews with female teachers. The FGDs and interviews were audio-recorded and then transcribed verbatim for analysis. Before conducting the research, the field researchers received formal training from Irise International by staff members who have experience of working in this area.
The anonymous, self-administered questionnaire had been piloted in Kenya [14], reviewed by the local translator in Uganda and Page number not for citation purposes 3 amended before use to make it accessible for respondents. It included sections on general absenteeism, knowledge about menstruation, menstrual practices, menstrual-related absenteeism and income level. The questionnaires were used to collect quantitative data on the girls' experiences of menstruation as they have been found to increase respondents' willingness to share sensitive information on health issues [17]. Participants are also less likely to under or over-estimate sensitive health problems [18] and less likely to have acquiescence 'yes-saying' response bias compared to when they participated in interviews or focus groups [19].
The questionnaire was written in English, but was translated into Rukiga by a local translator. The girls could ask questions in Rukiga whilst completing the questionnaire and answer questions in Rukiga to ensure that language was not a barrier. Their answers were then translated into English to be analysed.
Once the questionnaires had been completed, we conducted FGDs with six to nine girls in each school. Senior female teachers selected the girls, choosing the eldest post-menarche girls who had completed the questionnaire as they were the most willing to take part. We employed participatory methods, which are research activities designed to engage participants in the research process as equal partners and to draw out their 'voiced experiences' [20].
These methods were used because they have been found to empower research participants and facilitate interaction between them. Given the power dynamics of the research process and the taboo nature of menstruation, this is important [5,21]. Moreover, it is essential to consult girls affected by poor MHM to gain an accurate understanding of the problem and find effective solutions [5,22].
Semi-structured in-depth interviews were conducted with the headteachers from each of the six schools (all of whom were male), senior female teachers from five schools, and a female teacher in one school because the senior female teacher was absent. We interviewed the head teachers to gain their perspective on the MHM of the schoolgirls, because they are the highest school authority and the senior women teachers because they are responsible for the girls' welfare, reproductive education and for supporting the girls during menstruation. The interview with the female teacher provided an additional perspective from another important female figure in the girls' lives.
We drew on the girls' toilet assessment criteria from Pillitteri [12] and WaterAid MHM toolkits [23] to develop a toilet assessment survey. The survey asked about the toilets' design, construction, operation, maintenance, privacy, access for girls with disabilities, water supply, and disposal system for sanitary products. In each school a researcher assessed the toilets for girls using this survey.
To ensure that the toilets were observed in their normal state, the researcher asked permission to visit them once the girls had completed the questionnaires and FDGs, rather than asking in advance. This prevented the school from tidying up the toilets to present them in a better condition than usual for the research.
We employed SPSS 19 TM to enter and analyse the data. Descriptive statistics and frequencies were used to examine the characteristics of the study population. Interviews and FGDs were analysed by thematic content analysis [24]. The transcripts were coded and classified by both field researchers (Robyn Boosey and Georgina Prestwich) and then recurrent themes that emerged were discussed.
We obtained ethical approval from the Management Committee of Church of Uganda Kisiizi Hospital and the University of Bristol.

Questionnaire
One hundred and seventy-three girls completed the questionnaire, of whom 33 (19.1%) did not match the selection criteria for the following reasons: 8 (4.6%) were not the right age, 23 (13.3%) had not started menstruation, and 2 (1.2%) did not state whether or not they had started their period. The final sample size was 140. The mean age for the girls in the study population was 14.45 (SD 0.908). Table 1 presents the respondents' socio-economic characteristics.
Page number not for citation purposes 4 When asked if there were additional reasons for menstrual-related absenteeism not listed in the questionnaire, one girl stated that she was afraid of her menstrual cloth falling out if she was beaten at school. Figure 2 shows the different products that girls use to absorb menstrual blood. Even though girls report using mixed methods, the most common product used to absorb menstrual blood is cloth (n=122, 87.1%) (Figure 2). Whilst 50 (37%) girls had bought disposable sanitary pads in the last 6 months, 122 (87.8%) had been prevented from buying disposable sanitary pads on at least one occasion because they could not afford them (61.6%) or because disposable pads were not available in local shops (34.6%) ( Table 1).

Toilet assessment
None of the girls' school toilets assessed in any of the schools were adequate for good MHM ( Table 2) due to their lack of cleanliness, light, access for girls with disabilities and soap and water, in addition to the poor ratio of toilets for the number of girls. The definitions used for the assessment of the toilets such as 'sufficient', 'accessible', and 'clean' are based on UNICEF's school WASH guidelines [7,25]. 'Sufficient light' is understood to mean enough light to see what you are doing and if the facilities are clean when the cubicle door is closed. 'Separate' means that the girls' toilets are in different blocks or designated areas separated from boys' and teachers' toilets by distance and/or some physical barrier like a wall.

Focus group discussions (FGDs)
There were three main themes that were discussed about menstruation in the FGDs: the taboo nature of menstruation, the challenges facing schoolgirls and their recommendations for solutions to these challenges. These are described below. Head teachers and female teachers interviewed reported that girls missed school during menstruation to avoid the shame and embarrassment of menstrual accidents, whether this be due to menstrual blood leaking and staining their uniform or a menstrual cloth falling out. A senior woman teacher said that female teachers also sometimes miss school for menstrual-related reasons, for example when their menstrual materials do not absorb the blood sufficiently. Girls' fear of dropping their menstrual cloth if they are beaten at school (a concern also expressed by the girls in the FGDs) Senior female teachers reported that male headteachers rarely allocate sufficient funding for resources and facilities to help girls to manage their menstrual hygiene because they are not aware and/or not interested in girls' menstrual needs. This is sometimes influenced by views in the wider community. One senior woman teacher reported an occasion when a headteacher had wanted to purchase sanitary products for schoolgirls but had been prevented from doing so as the local community did not think this was a suitable way for school money to be spent.

Statement of principal findings
This study found that menstrual-related challenges pose a significant problem for girls' education in rural government-run primary schools in the Rukungiri district of Uganda. We found that the majority of girls surveyed were at risk of menstrual-related absenteeism. This was supported by the findings of the FGDs and interviews.

Strengths and weaknesses of this study
This study recognises the girls who took part as the experts of their own MHM experiences, asking them to identify the menstrualrelated challenges they faced and to devise the solutions they would recommend to address these challenges. All questions in the questionnaire had a high response rate, therefore the results are highly representative of the respondents. The girls' voiced experiences of MHM were recorded through a range of participatory methods in the FGDs.
We chose to collect self-reported data in this study in order to capture the voice of the girls whose menstrual hygiene practices we were exploring. However, self-reported data is limited due to the possibilities of recall bias and under-reporting [26,27].

Strengths and weaknesses in relation to other studies
Although studies into the impact of menstruation on girls' absenteeism often focus on secondary schools, and sometimes private schools, because they are more educated and articulate, this study focused on 13-16 year old girls at government-run primary schools in a rural, low-income setting. We chose this target population because, even though they are particularly at risk of poor Whilst many studies about girls' menstrual hygiene practices either employ qualitative or quantitative methods, this study combines qualitative methods with quantitative methods to provide a more detailed picture of the girls' situation [16]. The interviews and FGDs provide a boarder context for the questionnaire responses. They also complement each other and therefore add robustness to the findings, thus offsetting the disadvantages of these methods when they are employed separately.
A limitation to this study in relation to other studies is that it potentially overlooks girls who may have been absent from school when we conducted the research or who had already dropped out of school for menstrual-related reasons. A further limitation is the study population size, which was smaller than some studies [28].
The additional reasons for girls missing school during menstruation that girls reported (fear of staining clothes, menstrual pain and a lack of sanitary pads) have also been documented in other studies about menstrual-related absenteeism [12,13,[33][34][35]. This demonstrates that they are common obstacles to girls' school attendance and should form the focus of future interventions. The link between corporal punishment and menstrual-related absenteeism that girls mentioned in the FGDs has been absent from previous studies. This may be because girls participating in other MHM studies may not have considered this a reason for menstrualrelated absenteeism or felt safe enough to share this information.
Alternatively, previously, they may not have been given the opportunity to share additional reasons for menstrual-related absenteeism.
These findings highlight the harmful effects of poor menstrual hygiene management on girls' education. It causes girls to miss sections of the school syllabus, which are difficult to catch up due to the small amount of academic support available and to risk missing important exams [11,30]. This puts them at a further disadvantage to boys and may increase the likelihood that they will drop out of school. This can have detrimental effects to their future prospects because pupils need to pass their Primary Leaving Exam (PLE) to secure a place at a free secondary school [36].
Female teachers sometimes also missed school because they struggled to manage their menstrual hygiene in the school environment and this highlights the fact that menstrual-related absenteeism is not just a risk for female pupils. The risk of female teachers having to miss school when they menstruate if they are not equipped for MHM has been highlighted previously [37,38]. The menstrual-related absence of female teachers has damaging consequences for all pupils who risk missing out on several hours of education on a regular basis. In the context of the current global teacher shortage, this is a waste of valuable resources [39].
This study found that even if girls manage to attend school during menstruation, the fear of staining their clothes and being ridiculed reduces their concentration and makes them reluctant to participate in class. This concern has also been raised in other studies [13,38].
The girls surveyed had poor knowledge of and incorrect beliefs about menstruation, which has also been found in studies in Tanzania, India and Malawi [20,40] This point has been overlooked in other studies.

Meaning of the study
This study highlights the existence and damaging effect of poor MHM on girls' education in the Rukungiri District of Uganda. It supports the findings of other studies into the MHM of girls in lowincome settings, whilst introducing unexplored nuances to the discussion. These findings are highly significant because girls have human rights to education, health and water and sanitation.
Furthermore, educating girls has broad benefits for a country, including its economic development and the population's overall health [44,45].

Unanswered questions and future research
Small-scale, local projects have estimated the extent of poor MHM and its impact on girls' education in low-income settings. A largerscale study would capture this more accurately, specifically with regards to dropout rates and reduction in qualifications.

Conclusion
In many low and middle-income countries, girls lack accurate information about and resources and facilities for effective Menstrual Hygiene Management. Consequently, they are likely to miss school or to struggle to concentrate and participate in lessons when they are menstruating. Girls who are unable to manage their menstrual hygiene at school risk missing a substantial proportion of their education and falling behind, which could lead to them dropping out of school altogether. This has negative consequences, for the girls and others, because educating a girl has significant benefits for her family, community, and country [15]. A large-scale study would be able to quantify the extent and impact of poor Menstrual Hygiene Management on girls' education and suggest feasible solutions to ensure poor MHM does not prevent girls from reaching their potential at school.