Effects of sanitary pad distribution and reproductive health education on upper primary school attendance and reproductive health knowledge and attitudes in Kenya: a cluster randomized controlled trial

Abstract

Background 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. We assessed effects of sanitary pad distribution and RH education on girls in primary grade 7 in Kilifi, Kenya. Methods A 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. Results The 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. Conclusions The 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

Improving Menstrual Health Literacy Through Life-Skills Programming in Rural Ethiopia

“…(2) knowledge of biological facts about menstruation (which are important, for example, in shaping knowledge and practices to prevent adolescent pregnancies) (24,59); (3) knowledge about MHM (which is important in supporting girls' broader health and access to education) (47,60); and (4) the ability to apply this new knowledge to local realities (including through efforts to provide local supplies and infrastructure that are supportive of MHM) (38,51).…”

“…Although RCTs are less common, a cRCT in Kenya explored the impact on knowledge and attitudes of participating in reproductive health education classes over 25 sessions, delivered by trained facilitators during girls-only health clubs. The authors find that girls who participated felt more positively about menstruation, knew more about sexual and reproductive health, had more equitable gender norms, and were more self-confident by the end of the classes than those who did not Austrian et al (59). However, the intervention did not engage with the wider community to address drivers of poor knowledge or discriminatory gender norms.…”

The More You Know, the Less You Stress: Menstrual Health Literacy in Schools Reduces Menstruation-Related Stress and Increases Self-Efficacy for Very Young Adolescent Girls in Mexico

“…Previous studies have examined psychosocial outcomes and MHH as a way to measure effectiveness of MHH programming ( 62 , 63 ), in particular measuring self-efficacy using existing self-efficacy scales ( 33 , 47 , 64 ). Results from our study support the hypothesis that increasing MHH literacy significantly improves girls' menstruation-related stress and self-efficacy, though not school engagement ( Figure 1 ).…”

“…Studies evaluating the impacts of MHH education on school attendance have yielded mixed results ( 33 – 38 ), with different countries and programs demonstrating varying levels of absenteeism ( 39 – 41 ) and coping strategies among menstruating girls ( 42 ). Alternatively, in qualitative studies, girls consistently elaborate on the struggles of managing their periods at school.…”

Menstrual health for all requires wider high level commitment

“…11 Some studies have shown, however, that provision of products is not enough to significantly improve school attendance among girls. 12 13 Furthermore, although these policies represent an important step in support of gender equality, such policies are usually limited to the provision of period pads, with no menstrual education for girls or boys, often because of deeply rooted myths and taboos that code menstruation as bad, unclean, and to be hidden. 14 A further dimension for education and policy involves environmental waste, which will increase with greater access to disposable pads.…”