While such studies are not sufficient to fully understand a program, and other complementary methods such as in-depth interviewing to capture rich qualitative data on experiences and contextual influences are needed Gambrill ; Lewin, Glenton, and Oxman , high-quality trials are able to minimize the many biases inherent in other designs.

They can estimate the pooled effect of interventions and can identify gaps in current research, methodological weaknesses, and provide guidance for future improvements.

This chapter draws on the findings of a systematic review which aimed to collate and appraise trials of the effectiveness of menstrual health interventions for improving education and psychosocial outcomes in low- and middle-income countries Hennegan and Montgomery The review did not include studies exclusively assessing impacts on reproductive tract infection outcomes as another systematic review had focused on this issue Sumpter and Torondel Study designs eligible for inclusion in the review included randomized and cluster randomized controlled trials, as well as non-randomized controlled trials including more than one intervention and control site.

The review undertook a systematic search of 15 databases, as well as handsearching, grey literature search, 1 checks of reference lists, and contact with experts. Searches were undertaken in January For this chapter, database searches, and citation tracking of papers included in the review were undertaken in December to identify additional eligible studies published between and The original review identified a total of eight eligible trials, with a further four trials published since the initial search.

Thus, this chapter evaluates a total of 12 trials. The subsequent sections of this chapter will summarize menstrual health interventions that have been trialed to date and provide insights into their effectiveness. It will reflect on what we do, and more often do not, know about what works in meeting the menstrual needs of women and girls in low- and middle-income settings.

Menstrual health is multifaceted. Hygienic menstrual practices and positive experiences of menstruation are dependent on the physical and social environment.

Women and girls report needing knowledge and education about menstruation to understand their bodies, inform effective and hygienic practices, and to dispel unhelpful myths or taboos Chothe et al.

They also need clean materials to absorb or catch menses, as well as infrastructure to support safe locations for changing absorbents, and access to water, soap, and locations for washing reusable materials and their bodies Sommer and Sahin Menstruation occurs in a context of social norms that may positively or negatively influence experience and dictate behavior.

Further, the presence or lack of support from key individuals such as parents, teachers, and friends shapes experiences Geertz et al. Menstrual needs are interconnected, and women and girls may face deprivations across several contributing factors.

For the purposes of categorizing interventions, there has been a distinction between the types of interventions that provide a physical resource such as a menstrual absorbent or water, sanitation and hygiene WASH facilities, and programs providing psychosocial intervention which may include education, or efforts to address harmful taboos and stigma Sumpter and Torondel ; Hennegan and Montgomery ; Geertz et al.

The latter aimed at addressing psychosocial deprivations have been termed software interventions, while the former targeted at material deprivations have been termed hardware interventions.

These interventions may include multiple components, and software and hardware interventions may be combined. A lack of menstrual knowledge has been identified across countries as a challenge to positive menstrual experiences Chandra-Mouli and Patel Adolescent girls, particularly around the time of menarche, have been found to lack information on the function and origin of menstruation Crichton et al.

Many girls report being unaware that menstruation would occur, contributing to distress and fear at onset Chandra-Mouli and Patel A lack of understanding of menstruation and strategies for hygienic menstrual practices are likely to perpetuate distress over subsequent menses and may contribute to negative effects on health and education.

Deficits in knowledge are often combined with misinformation evoking further fear. Studies have reported taboos around the disposal of menstrual blood or consequences of others seeing used menstrual materials Sommer et al. At the same time, the stigmatized nature of menstruation across settings results in more implicit behavioral norms such as the expectation to keep menstrual status hidden and secret at all times Jewitt and Ryley This prevents women and girls from discussing menstruation openly and receiving advice, support, or direction to health services where abnormalities are present McMahon et al.

Silence around menstrual issues may also mean that these needs are not prioritized in household budgets and girls are not equipped with the resources to assist the management of menstrual bleeding.

Men and boys similarly lack knowledge and accurate information about menstruation and may perpetuate negative attitudes Mason et al. Software interventions include all interventions designed to address these highlighted psychosocial deprivations.

Five trials of software interventions were included in the systematic review, with a subsequent three trials with an independent software condition published since this time.

Greater detail regarding the design of these studies and risk of bias assessments are available in the original review see Hennegan and Montgomery Software interventions to date have focused on the provision of menstrual education via a range of modalities, including; written materials such as leaflets and posters Mbizvo et al.

An additional trial undertaken in Iran, published in Afsari et al. Limited information was provided in these studies on the contents of the education offered. Most included statements that education included information on the definition and purpose of menstruation, the cyclic nature and timing, and other physical changes associated with puberty.

There was a high risk of bias across these studies, with deficits in reporting, preregistration, and issues with participant attrition dropout and inappropriate treatment of outcome variables.

A more recent cluster-randomized trial provided a pilot evaluation of the Growth and Changes puberty education book in Ethiopia, based on qualitative research in multiple countries Blake et al.

This study identified improvements in knowledge about menstruation and decreases in fear and shame associated with menstruation at four-week follow-up. The trial used a clustered design including 20 schools.

However, intervention and control conditions were assigned at the district, rather than school level. As such, the study only allocated one intervention and one control condition and results should be interpreted with caution.

Qualitative components of the study triangulated quantitative findings with girls reporting the books reduced shame and confusion and helped to overcome secrecy around menstruation Blake et al. One additional pilot trial in Ghana included in the systematic review Hennegan and Montgomery included both hardware and software conditions, with an education-alone condition allowing for a comparison of the effectiveness to a control.

This study was the only one to assess impacts of education on school attendance rather than knowledge outcomes, however it was a small pilot with one education-alone and one control site Montgomery et al.

The study observed improvements in school attendance at 5-month follow-up. This Ghana pilot was extended to a larger study of eight schools in Uganda, two of which received an education-only intervention Montgomery et al. The larger trial replicated the positive effects on school attendance.

Qualitative follow-up of the trial identified avenues for improvement in the education provided Hennegan et al. This study found that, beyond providing an awareness of menstruation prior to menarche, girls reported the practical information around managing menstrual bleeding to be particularly useful, and that more was desired.

In interviews at the conclusion of the study, girls felt they still lacked information about vaginal discharge, menstrual irregularities, and reproductive tract symptoms.

The study also found that social support, likely resulting from a shared language and education around menstruation, was particularly important and a possible driver of the positive effects identified in the quantitative results.

Taken together, extant trials of software interventions indicate that education interventions improve menstrual knowledge. It is unclear if this translates to impacts on psychosocial outcomes or wellbeing as identified in qualitative research as most studies failed to assess these outcomes.

Of those that did, two identified improvements Blake et al. Less evidence is available to support impacts on school attendance, although one program of work including a pilot and larger study indicates some promising results Montgomery et al. More recent studies highlight the value of including complementary qualitative work alongside trials in the evaluation of menstrual health interventions Montgomery et al.

Hennegan et al. The first, and what appears to have received more attention in trials to date, is to provide girls with information about the basics of menstruation; what it is, why it happens, when it happens, and that this is a healthy and natural process linked to reproduction.

This information helps to dispel fear of illness and shame by emphasizing the healthy nature of menstrual bleeding. The second level of education, which appears less prominently in trials, is more detailed information about menstrual experience and practical guidance.

Such education may be well placed to support effective practice, the identification of abnormalities, and equip girls to feel more informed, confident, and in control of their menstrual care and their bodies.

To effectively and hygienically manage menstruation, women and girls need access to sufficient quantities of clean, safe, comfortable materials fit for the purpose of collecting menses Sommer and Sahin Materials take many forms, from commercial disposable or reusable sanitary pads, tampons, and menstrual cups, to homemade pads or cloth.

Women and girls may use different strategies depending on available resources, needs, and personal and cultural preferences. In low- and middle-income contexts, some women and girls may struggle to access or purchase sufficient materials supporting their preferences.

This may lead to the use of alternatives which are not fit for purpose and are experienced as uncomfortable or ineffective Ellis et al. Beyond materials, women and girls need access to private, safe locations to change menstrual materials, to wash and dry materials if they are reusable, and to wash their body with soap and water Sommer and Sahin As such, supportive infrastructure, and WASH facilities are an essential enabler.

Due to the stigmatized nature of menstruation, women and girls have emphasized the need for a private space where they feel safe and comfortable to undertake menstrual practices such as changing or washing materials Budhathoki et al. Locations for drying reusable absorbents are also needed.

Hygiene guidelines have recommended drying absorbents in the sun to benefit from the antimicrobial properties of UV light, however, the perceived need to conceal menstruation means many girls report drying absorbents under mattresses or in other, hidden locations that are unlikely to facilitate hygiene House et al.

Disposal of single-use menstrual absorbents has been largely overlooked in research and intervention to date.

Few studies have investigated disposal practices, even when implementing single-use product interventions.

In absence of waste management strategies, used products may be thrown into fields and waterways, pit latrines, or sanitation systems where they may cause blockages or health risks Geertz et al. In addition to these environmental impacts, disposal presents a challenge for women and girls.

Cultural taboos around others seeing menstrual blood , or the burning of menstrual blood add strain on finding acceptable disposal options and may contribute to distress and avoidance of social settings during menstruation Sommer et al.

Hardware interventions have been conceptualized as programs providing material resources such as menstrual materials, infrastructure, or disposal facilities.

However, to date, only the provision of menstrual materials has been trialed. Three eligible trials of hardware interventions were identified through systematic review Hennegan and Montgomery , with a further two studies published by the end of Montgomery et al.

Of the total five trials, two focused on the effectiveness of providing menstrual cups, two reusable sanitary pads, and one on disposable sanitary pads. They found no improvement for the girls provided with cups, compared to those who were not, however, school attendance was high for both groups at baseline and its results likely reflect a ceiling effect.

A second study of menstrual cups was undertaken in Kenya and published in Phillips-Howard et al. The largest trial to date, this study included girls from 30 primary schools randomized to one of three conditions; a control, the provision of disposable menstrual pads, or the provision of a menstrual cup.

Education was provided in all conditions. The study did not find any significant difference between conditions on the risk of school dropout over the one year follow-up period and did not report differences in school attendance as this data was collected using calendars given to participants and absences were very rarely reported, thus not analyzed.

The study did not assess psychosocial outcomes but focused on sexually transmitted and reproductive tract infections as secondary outcomes, finding lower risks for those receiving either menstrual product Phillips-Howard et al.

The Ghana pilot study including both hardware and software components provided disposable sanitary pads in hardware conditions and found a moderate improvement in school attendance at three- and five-month follow-ups Montgomery et al.

This was followed by a larger study of reusable sanitary pads in Uganda published in Montgomery et al. This study included four arms: two schools receiving education as noted above, two control schools, two receiving reusable pads alone, and two receiving combined education and product provision.

The larger trial replicated results of the pilot with significant benefits for school attendance identified over the month period, with no differences in the effects of the three different intervention conditions.

The trial included only a small number of clusters and suffered from significant attrition with girls transferring or dropping out of school, with the longest follow-up period of any menstrual health intervention to date.

Attrition levels suggest specific effect estimates of the trial should be interpreted with caution, with imputed analyses suggesting a beneficial effect of the pads or education conditions between 5.

Qualitative follow-up supported the positive quantitative results Hennegan et al. As noted above, social support due to the increased visibility of menstruation in schools may have contributed to intervention effects across schools.

Girls reported largely positive experiences of the reusable pads which they felt were more comfortable and reliable, reducing fears of garment soiling. Another pilot study of homemade reusable sanitary pads in Uganda revealed a moderate, although nonsignificant effect likely due to the small sample size and number of clusters Wilson, Josephine, and Pitt Studies varied in the outcomes assessed, duration, products provided, and design weaknesses making it difficult to draw conclusions.

In comparison to the software interventions, hardware interventions focused more heavily on school attendance outcomes, and often neglected to assess more proximal change such as menstrual experience and distress. This could be facilitated through complementary qualitative research, and mediation and moderation methods undertaken with quantitative data collected as part of trial baseline and follow-up surveys.

Research mapping connections between menstrual management and schooling and refinement of attendance measure techniques may improve outcome assessment in future trials Miiro et al.

Menstrual health programming is rapidly increasing in scale Bobel At the same time, trials of the effectiveness of interventions are limited in number and beset with limitations.

There is some emerging evidence of the effectiveness of education interventions for improving knowledge, and for product provision interventions to encourage greater school attendance. However, methodological weaknesses across the evidence base mean no strong conclusions can be drawn Hennegan and Montgomery More rigorous research is needed to evaluate interventions to improve menstrual health.

Future trials must improve upon the limitations of past work. This includes improved reporting of studies, the use of adequate sample sizes, and strategies to mitigate attrition. Greater breadth is needed in the outcomes included in trials, for example, the assessment of menstrual experience in addition to school attendance.

Across the studies presented in this review, there were limitations to the types of outcomes assessed and the way they were measured. Complementary quantitative and qualitative studies alongside trials may unearth additional understanding of participant experiences and lessons for intervention improvement.

Moreover, as complex interventions within complex settings, understanding how the different aspects of interventions act and interact with the study context is key. This process can be facilitated by explicit theory on the mechanisms at play in interventions, and targeted investigation of these pathways during evaluation Moore et al.

Further, understanding the interaction between mechanisms of impact and the study context is critical for examining whether we would expect intervention effects to replicate in another setting, or at scale.

For example, one currently registered trial lists sexually transmitted infections as primary outcomes in a trial of a menstrual health intervention but has not yet started an explicit framework for testing the pathways through which improved menstrual experiences will impact sexually transmitted infection rates Clinical Trials One mechanism may be through reduced engagement in transactional sex to obtain menstrual materials Phillips-Howard et al.

If this is the case, positive effects identified in the trial are unlikely to replicate in settings where transactional sex is less prevalent.

One series of studies included in the systematic review included both hardware and software conditions. In both the Ghana pilot Montgomery et al. It is unclear if these interventions influenced attendance and menstrual experience through different pathways, and future work is needed to unpack the potential of these interventions in combination.

Careful attention to evaluate different parts of interventions is needed in development, piloting, and trial evaluation Craig et al. This might mean the combination of hardware for example, menstrual product or infrastructure provision and software for example, education or social norm interventions, and also attention to more nuanced details such as education delivery mechanisms for example, group-based, health provider presence , and content must be paid.

More thorough evaluations may be able to identify best practices and suggest minimal or standard intervention packages which could be disseminated more broadly in programming and policy. For example, the identification of core educational components as has been helpful for guidance on the conduct of comprehensive sexuality education UNESCO Similarities to sexual education for menstrual education mean that identifying and core components of education, that can be adapted to local needs, could be valuable in improving effectiveness.

This may also reduce the time needed to invest in development; an important consideration for resource-constrained organizations. Beyond improving methodology in the evaluation of menstrual health interventions, more research and funding for intervention development is needed.

Current education interventions may help dispel myths and stigma around menstruation, however, there have been no trials of interventions designed to target this important barrier to menstrual health.

More research is needed to unpack the potential for interventions targeting menstrual stigma and their influence on hygiene practices, help-seeking, and menstrual experience more broadly. Importantly, education about menstruation alone is unlikely to be sufficient to change social norms Bicchieri Mass media and other community programs to normalize menstruation may have positive influences at a population or community level and provide more supportive environments for women and girls.

Studies of the influence of mass-media campaigns have been undertaken for other health and hygiene challenges, such as water and sanitation products, diarrheal disease, immunization, nutrition, mother-to-child transmission of HIV, and reproductive health, and could inform studies of these approaches to menstrual health Naugle and Hornik ; Evans et al.

Interventions that target parental or male attitudes to menstruation have received little attention. One upcoming cluster RCT with multiple intervention arms will include a condition providing both school level and community level education Sol et al.

No studies have trialed improvements to WASH or other infrastructure to support menstrual management. These infrastructure challenges are relevant in home, school, and work environments and interventions have the potential to be integrated into other campaigns such as those aiming to improve sanitation coverage Hennegan et al.

New intervention approaches to address menstrual health are varied. They range from more detailed and comprehensive education on menstrual health and body literacy, to reducing stigma and taboo at all levels, and infrastructure and WASH facilities to support menstrual activities, as well as integrated packages of these components.

Moreover, menstrual pain and disorders have been largely neglected in trials and cross-sectional studies and populations such as those in humanitarian settings, those living with disabilities, girls outside of schools, and adult women at home and in the workplace have received inadequate attention Sommer, Chandraratna, et al.

To support the development and evaluation of such interventions an improved evidence base is needed. This would inform intervention design as well as outcome assessment in trials. Greater integration of NGO, multinational programming, and academic research efforts would be of great value.

NGO programs often only include case-study assessments of effectiveness but have often described more integrated approaches to intervention development Sommer, Sahin, et al. Sufficient funding must be allocated to evaluation, to ensure that policies and programs are evidence-based and effective prior to large-scale dissemination.

In the absence of evidence for the effectiveness of interventions, implementing organizations and advocates should proceed with caution. Integrated monitoring strategies should pay special attention to unintended harms. Handsearching refers to manual searches of the table of contents of relevant journals or conference proceedings.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4. The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material.

If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Turn recording back on. National Library of Medicine Rockville Pike Bethesda, MD Web Policies FOIA HHS Vulnerability Disclosure.

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Show details Bobel C, Winkler IT, Fahs B, et al. Singapore: Palgrave Macmillan ; Search term. Chapter 47 Interventions to Improve Menstrual Health in Low- and Middle-Income Countries: Do We Know What Works?

Julie Hennegan. Author Information and Affiliations Authors Julie Hennegan 1. Affiliations 1 Baltimore, MD, USA Email: ude. aibmuloc relkniw. Corresponding author. Menstruation Matters Menstrual health interventions have been motivated by growing recognition of the difficulties women face during menstruation, and the consequences of unmet menstrual needs.

How Do We Know What Works? Interventions Menstrual health is multifaceted. Software Interventions A lack of menstrual knowledge has been identified across countries as a challenge to positive menstrual experiences Chandra-Mouli and Patel Hardware Interventions To effectively and hygienically manage menstruation, women and girls need access to sufficient quantities of clean, safe, comfortable materials fit for the purpose of collecting menses Sommer and Sahin Do We Know What Works?

Note 1. References Abedian, Zahra, Maryam Kabirian, Seyed Reza Mazlom, and Behroz Mahram. Afsari, Atousa, Mojgan Mirghafourvand, Sousan Valizadeh, Massomeh Abbasnezhadeh, Mina Galshi, and Samira Fatahi. This includes gender-separated facilities with door locks, lighting, disposal bins, and handwashing stations with soap and water.

Behavior changes and hygiene promotion campaigns incorporating MHH will be undertaken, targeting students, teachers, parents and the larger community. Under the project, sanitation facilities were constructed at more than schools across the Greater Accra Metropolitan Area.

The facilities all include separate toilets and changing rooms for girls, with locks on doors, handwashing facilities, and hygienic and safe spaces for disposal of used sanitary products. The project aims to address low attendance of adolescent girls in schools by ensuring that school sanitation facilities provide functional single-sex toilets with a reliable supply of water and soap.

Educational materials on hygiene and MHM will also be provided and dispersed. Few schools have adequate sanitation facilities, and those that do are poorly maintained and unsuitable for MHH.

The Urban Sanitation Project is responding with a sanitation marketing and hygiene promotion campaign emphasizing the improvement of menstrual hygiene for girls and women. It is financing construction of 78 sanitation facilities in schools and market places in two project cities.

Standard designs include handwashing facilities, accessibility for people with disabilities, and MHH amenities. MHH and hygiene promotion activities, including training for teachers and pupils, will be conducted in the schools.

These approaches will inform future interventions in schools across the country. The Enabling Environment for Menstrual Health and Hygiene: Case Study - Kenya. Menstrual Health and Hygiene Resource Package: Tools and Resources for Task Teams PDF.

Providing Sustainable Sanitation Services for All in WASH Interventions through a Menstrual Hygiene Management Approach PDF. Improving toilet hygiene and handwashing practices during and post-COVID pandemic in Indonesian schools. The Rising Tide : A New Look at Water and Gender. A Holistic Approach to Better Menstrual Health and Hygiene: Entrepreneurs in Action.

ItsTimeForAction: Investing in Menstrual Hygiene Management is to Invest in Human Capital. Menstrual Hygiene Management Enables Women and Girls to Reach Their Full Potential.

Menstrual health and hygiene empowers women and girls: How to ensure we get it right. In times of COVID, the future of education depends on the provision of water, sanitation, and hygiene services. Reflections from a mother on Menstrual Hygiene Day. The SDGs, surveys, and the need for additional evidence on Menstrual Hygiene Management.

Globally, periods are causing girls to be absent from school. This site uses cookies to optimize functionality and give you the best possible experience.

If you continue to navigate this website beyond this page, cookies will be placed on your browser. To learn more about cookies, click here. Understanding Poverty Topics Water. BRIEF May 12, Share more close. Context Priority Areas Country Examples Resources.

These moves are supported by a UNICEF report, which calls for the early start to menstrual education age 5—8 and the education of boys By creating an environment that is conducive for girls to manage their menses as they need, schools are investing in their academic success. School-based menstrual health education is key, as it exposes girls to methods of management that parents may not be familiar with.

As such, school-based menstrual health education as a form of formal sensitization is a tool for empowerment, ultimately enabling girls to effectively manage their own menstrual cycle.

The Kenyan government recently approved Menstrual Hygiene Management education as a part of their government approved educational curriculum that addresses the menstrual needs of girls using a three-topic approach — Breaking the Silence, Safe and Hygienic Management and Safe Disposal Informal education fostered by the school is as critical to menstrual health education as formal education is.

Teachers saw the impact of the study among girls who were not enrolled in addition to those that were. Girls were taught the tools they had learned to help them better manage their own menses by their classmates. Mason et al. Through peer support, girls were able to help sensitize their fellow classmates, thereby expanding the effects of the intervention 3.

Peer support groups, as an entity within the school, present an educational opportunity for girls to transmit educational information to each other. Recognizing this pathway is crucial as we look to develop further school-based interventions.

While this issue was not prioritized in discussions in FGDs, some teachers noted that the washrooms in their school did not afford girls the privacy they needed, resulting in them going home to change their menstrual products. While certain facilities were equipped with full washrooms for the girls, others were not.

The nature of the MS study was that each school was chosen based on different levels of adherence with WASH protocols, so the noted differences between facilities is in line with the study design.

Information obtained in focus groups conducted with girls in the MS Study suggests otherwise. Oduor et al. In order to build an MHH-supportive environment, both the adequacy of the facilities in addition to sensitization must be considered to have a significant and sustainable impact.

As we examine next steps for improving MHH championing schools, it is crucial to recognize the individual, culturally tied experience of menses that girls experience. Incorporating this understanding of menstruation in schools through sensitization of teachers, puberty education, and infrastructural changes will only further empower girls to manage it as best fits in their own cultural context.

A key limitation of the study is that not all teachers participated in the three FGDs for their school, with some only participating in one or two. However, while this prevented some teachers from commenting critically on students before, during, and after the interventions, many who were new to the focus groups were able to draw upon their previous experience which informed their opinions.

While we have knowledge of the fact that both male and female teachers participated in each of the FDGs, gender was not recorded in the transcripts to maintain the confidentiality of the participants, thus we do not have a ratio of the male to female teacher participation per FGD and were unable to conduct further analysis on differences in opinion by gender.

While gendered language was sometimes used in the FDGs, allowing some conclusions to be made about how students approached teachers, the lack of availability of this information makes it difficult to make wider assessments of gendered expectations of teachers in addressing menstruation in schools.

In addition, this analysis is based on results from the MS study in the year following intervention. There is no information on whether this study had a longer-term impact on teachers or the effect on school culture around menstruation.

Study findings and study researchers helped to inform limited progress over the past decade in guidelines for teachers as well as establishing MHH strategies and policies, including the Ministry of Health Menstrual Hygiene Management strategy and Menstrual Hygiene Management in Schools: A Handbook for Teachers 21 , Additionally, a program that supplied sanitary products to some of the most vulnerable girls in Kenya was developed and implemented in by the State Department for Gender and Affirmative Action, although this program was not informed by the study findings.

While these changes are important, they are limited in scope and impact. Thus, the analysis presented here remains significant despite the years that have passed since the research team collected the data used in this analysis.

This study illustrates the important role that teachers play in MHH. The results of this study build on existing MHH research that recognizes the necessity of building an MHH-supportive environment in schools. Through its approach of incorporating teacher views, it offers a new perspective in the understanding of MHH interventions at the school level.

Teacher knowledge, existing opinions of MHH, and thoughts on the types of interventions present an opportunity to incorporate their understanding of the barriers to MHH and cultural attitudes at the school as a whole that would benefit future MHH interventions, and aid in adapting the theoretical concept of the MHH-supportive environment into practice at their schools.

The datasets presented in this article are not readily available because this study was conducted with approval from the Kenya Medical Research Institute KEMRI Scientific and Ethics Review Unit SERU which requires that data should be released from any KEMRI-based Kenyan study including deidentified data only after written approval for additional analyzes.

In accordance, data for this study will be available upon request, after obtaining written approval for the proposed analysis from the KEMRI SERU. Requests to access the datasets should be directed to KEMRI SERU, seru kemri. The studies involving human participants were reviewed and approved by Kenya Medical Research Institute KEMRI Scientific and Ethics Review Unit SERU.

PP-H, LM, and KA conceived and designed the study. LM, EN, KO, and PP-H performed the experiment. JS and LN performed the qualitative analysis. JS wrote the first draft of the manuscript. All authors contributed to the article and approved the submitted version.

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors thank the Head Teachers and school staff, parents, and children in schools in Gem sub-County for their enthusiasm to participate in this study. Field and office staff are thanked for their hard work and diligence.

The Director of KEMRI has approved this manuscript. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers.

Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Uncovering the challenges to menstrual hygiene management in schools in Mali. Tegegne, TK, and Sisay, MM. Menstrual hygiene management and school absenteeism among female adolescent students in Northeast Ethiopia.

Sommer, M, Figueroa, C, Kwauk, C, Jones, M, and Fyles, N. Attention to menstrual hygiene management in schools: an analysis of education policy documents in low-and middle-income countries. Silence around menstrual issues may also mean that these needs are not prioritized in household budgets and girls are not equipped with the resources to assist the management of menstrual bleeding.

Men and boys similarly lack knowledge and accurate information about menstruation and may perpetuate negative attitudes Mason et al. Software interventions include all interventions designed to address these highlighted psychosocial deprivations.

Five trials of software interventions were included in the systematic review, with a subsequent three trials with an independent software condition published since this time. Greater detail regarding the design of these studies and risk of bias assessments are available in the original review see Hennegan and Montgomery Software interventions to date have focused on the provision of menstrual education via a range of modalities, including; written materials such as leaflets and posters Mbizvo et al.

An additional trial undertaken in Iran, published in Afsari et al. Limited information was provided in these studies on the contents of the education offered. Most included statements that education included information on the definition and purpose of menstruation, the cyclic nature and timing, and other physical changes associated with puberty.

There was a high risk of bias across these studies, with deficits in reporting, preregistration, and issues with participant attrition dropout and inappropriate treatment of outcome variables.

A more recent cluster-randomized trial provided a pilot evaluation of the Growth and Changes puberty education book in Ethiopia, based on qualitative research in multiple countries Blake et al. This study identified improvements in knowledge about menstruation and decreases in fear and shame associated with menstruation at four-week follow-up.

The trial used a clustered design including 20 schools. However, intervention and control conditions were assigned at the district, rather than school level. As such, the study only allocated one intervention and one control condition and results should be interpreted with caution.

Qualitative components of the study triangulated quantitative findings with girls reporting the books reduced shame and confusion and helped to overcome secrecy around menstruation Blake et al. One additional pilot trial in Ghana included in the systematic review Hennegan and Montgomery included both hardware and software conditions, with an education-alone condition allowing for a comparison of the effectiveness to a control.

This study was the only one to assess impacts of education on school attendance rather than knowledge outcomes, however it was a small pilot with one education-alone and one control site Montgomery et al. The study observed improvements in school attendance at 5-month follow-up.

This Ghana pilot was extended to a larger study of eight schools in Uganda, two of which received an education-only intervention Montgomery et al.

The larger trial replicated the positive effects on school attendance. Qualitative follow-up of the trial identified avenues for improvement in the education provided Hennegan et al. This study found that, beyond providing an awareness of menstruation prior to menarche, girls reported the practical information around managing menstrual bleeding to be particularly useful, and that more was desired.

In interviews at the conclusion of the study, girls felt they still lacked information about vaginal discharge, menstrual irregularities, and reproductive tract symptoms. The study also found that social support, likely resulting from a shared language and education around menstruation, was particularly important and a possible driver of the positive effects identified in the quantitative results.

Taken together, extant trials of software interventions indicate that education interventions improve menstrual knowledge. It is unclear if this translates to impacts on psychosocial outcomes or wellbeing as identified in qualitative research as most studies failed to assess these outcomes.

Of those that did, two identified improvements Blake et al. Less evidence is available to support impacts on school attendance, although one program of work including a pilot and larger study indicates some promising results Montgomery et al.

More recent studies highlight the value of including complementary qualitative work alongside trials in the evaluation of menstrual health interventions Montgomery et al. Hennegan et al. The first, and what appears to have received more attention in trials to date, is to provide girls with information about the basics of menstruation; what it is, why it happens, when it happens, and that this is a healthy and natural process linked to reproduction.

This information helps to dispel fear of illness and shame by emphasizing the healthy nature of menstrual bleeding. The second level of education, which appears less prominently in trials, is more detailed information about menstrual experience and practical guidance.

Such education may be well placed to support effective practice, the identification of abnormalities, and equip girls to feel more informed, confident, and in control of their menstrual care and their bodies. To effectively and hygienically manage menstruation, women and girls need access to sufficient quantities of clean, safe, comfortable materials fit for the purpose of collecting menses Sommer and Sahin Materials take many forms, from commercial disposable or reusable sanitary pads, tampons, and menstrual cups, to homemade pads or cloth.

Women and girls may use different strategies depending on available resources, needs, and personal and cultural preferences. In low- and middle-income contexts, some women and girls may struggle to access or purchase sufficient materials supporting their preferences.

This may lead to the use of alternatives which are not fit for purpose and are experienced as uncomfortable or ineffective Ellis et al.

Beyond materials, women and girls need access to private, safe locations to change menstrual materials, to wash and dry materials if they are reusable, and to wash their body with soap and water Sommer and Sahin As such, supportive infrastructure, and WASH facilities are an essential enabler.

Due to the stigmatized nature of menstruation, women and girls have emphasized the need for a private space where they feel safe and comfortable to undertake menstrual practices such as changing or washing materials Budhathoki et al. Locations for drying reusable absorbents are also needed.

Hygiene guidelines have recommended drying absorbents in the sun to benefit from the antimicrobial properties of UV light, however, the perceived need to conceal menstruation means many girls report drying absorbents under mattresses or in other, hidden locations that are unlikely to facilitate hygiene House et al.

Disposal of single-use menstrual absorbents has been largely overlooked in research and intervention to date. Few studies have investigated disposal practices, even when implementing single-use product interventions. In absence of waste management strategies, used products may be thrown into fields and waterways, pit latrines, or sanitation systems where they may cause blockages or health risks Geertz et al.

In addition to these environmental impacts, disposal presents a challenge for women and girls. Cultural taboos around others seeing menstrual blood , or the burning of menstrual blood add strain on finding acceptable disposal options and may contribute to distress and avoidance of social settings during menstruation Sommer et al.

Hardware interventions have been conceptualized as programs providing material resources such as menstrual materials, infrastructure, or disposal facilities.

However, to date, only the provision of menstrual materials has been trialed. Three eligible trials of hardware interventions were identified through systematic review Hennegan and Montgomery , with a further two studies published by the end of Montgomery et al.

Of the total five trials, two focused on the effectiveness of providing menstrual cups, two reusable sanitary pads, and one on disposable sanitary pads. They found no improvement for the girls provided with cups, compared to those who were not, however, school attendance was high for both groups at baseline and its results likely reflect a ceiling effect.

A second study of menstrual cups was undertaken in Kenya and published in Phillips-Howard et al. The largest trial to date, this study included girls from 30 primary schools randomized to one of three conditions; a control, the provision of disposable menstrual pads, or the provision of a menstrual cup.

Education was provided in all conditions. The study did not find any significant difference between conditions on the risk of school dropout over the one year follow-up period and did not report differences in school attendance as this data was collected using calendars given to participants and absences were very rarely reported, thus not analyzed.

The study did not assess psychosocial outcomes but focused on sexually transmitted and reproductive tract infections as secondary outcomes, finding lower risks for those receiving either menstrual product Phillips-Howard et al.

The Ghana pilot study including both hardware and software components provided disposable sanitary pads in hardware conditions and found a moderate improvement in school attendance at three- and five-month follow-ups Montgomery et al.

This was followed by a larger study of reusable sanitary pads in Uganda published in Montgomery et al. This study included four arms: two schools receiving education as noted above, two control schools, two receiving reusable pads alone, and two receiving combined education and product provision.

The larger trial replicated results of the pilot with significant benefits for school attendance identified over the month period, with no differences in the effects of the three different intervention conditions.

The trial included only a small number of clusters and suffered from significant attrition with girls transferring or dropping out of school, with the longest follow-up period of any menstrual health intervention to date.

Attrition levels suggest specific effect estimates of the trial should be interpreted with caution, with imputed analyses suggesting a beneficial effect of the pads or education conditions between 5.

Qualitative follow-up supported the positive quantitative results Hennegan et al. As noted above, social support due to the increased visibility of menstruation in schools may have contributed to intervention effects across schools.

Girls reported largely positive experiences of the reusable pads which they felt were more comfortable and reliable, reducing fears of garment soiling. Another pilot study of homemade reusable sanitary pads in Uganda revealed a moderate, although nonsignificant effect likely due to the small sample size and number of clusters Wilson, Josephine, and Pitt Studies varied in the outcomes assessed, duration, products provided, and design weaknesses making it difficult to draw conclusions.

In comparison to the software interventions, hardware interventions focused more heavily on school attendance outcomes, and often neglected to assess more proximal change such as menstrual experience and distress. This could be facilitated through complementary qualitative research, and mediation and moderation methods undertaken with quantitative data collected as part of trial baseline and follow-up surveys.

Research mapping connections between menstrual management and schooling and refinement of attendance measure techniques may improve outcome assessment in future trials Miiro et al.

Menstrual health programming is rapidly increasing in scale Bobel At the same time, trials of the effectiveness of interventions are limited in number and beset with limitations. There is some emerging evidence of the effectiveness of education interventions for improving knowledge, and for product provision interventions to encourage greater school attendance.

However, methodological weaknesses across the evidence base mean no strong conclusions can be drawn Hennegan and Montgomery More rigorous research is needed to evaluate interventions to improve menstrual health. Future trials must improve upon the limitations of past work.

This includes improved reporting of studies, the use of adequate sample sizes, and strategies to mitigate attrition. Greater breadth is needed in the outcomes included in trials, for example, the assessment of menstrual experience in addition to school attendance.

Across the studies presented in this review, there were limitations to the types of outcomes assessed and the way they were measured. Complementary quantitative and qualitative studies alongside trials may unearth additional understanding of participant experiences and lessons for intervention improvement.

Moreover, as complex interventions within complex settings, understanding how the different aspects of interventions act and interact with the study context is key.

This process can be facilitated by explicit theory on the mechanisms at play in interventions, and targeted investigation of these pathways during evaluation Moore et al.

Further, understanding the interaction between mechanisms of impact and the study context is critical for examining whether we would expect intervention effects to replicate in another setting, or at scale. For example, one currently registered trial lists sexually transmitted infections as primary outcomes in a trial of a menstrual health intervention but has not yet started an explicit framework for testing the pathways through which improved menstrual experiences will impact sexually transmitted infection rates Clinical Trials One mechanism may be through reduced engagement in transactional sex to obtain menstrual materials Phillips-Howard et al.

If this is the case, positive effects identified in the trial are unlikely to replicate in settings where transactional sex is less prevalent. One series of studies included in the systematic review included both hardware and software conditions.

In both the Ghana pilot Montgomery et al. It is unclear if these interventions influenced attendance and menstrual experience through different pathways, and future work is needed to unpack the potential of these interventions in combination.

Careful attention to evaluate different parts of interventions is needed in development, piloting, and trial evaluation Craig et al. This might mean the combination of hardware for example, menstrual product or infrastructure provision and software for example, education or social norm interventions, and also attention to more nuanced details such as education delivery mechanisms for example, group-based, health provider presence , and content must be paid.

More thorough evaluations may be able to identify best practices and suggest minimal or standard intervention packages which could be disseminated more broadly in programming and policy. For example, the identification of core educational components as has been helpful for guidance on the conduct of comprehensive sexuality education UNESCO Similarities to sexual education for menstrual education mean that identifying and core components of education, that can be adapted to local needs, could be valuable in improving effectiveness.

This may also reduce the time needed to invest in development; an important consideration for resource-constrained organizations.

Beyond improving methodology in the evaluation of menstrual health interventions, more research and funding for intervention development is needed. Current education interventions may help dispel myths and stigma around menstruation, however, there have been no trials of interventions designed to target this important barrier to menstrual health.

More research is needed to unpack the potential for interventions targeting menstrual stigma and their influence on hygiene practices, help-seeking, and menstrual experience more broadly.

Importantly, education about menstruation alone is unlikely to be sufficient to change social norms Bicchieri Mass media and other community programs to normalize menstruation may have positive influences at a population or community level and provide more supportive environments for women and girls.

Studies of the influence of mass-media campaigns have been undertaken for other health and hygiene challenges, such as water and sanitation products, diarrheal disease, immunization, nutrition, mother-to-child transmission of HIV, and reproductive health, and could inform studies of these approaches to menstrual health Naugle and Hornik ; Evans et al.

Interventions that target parental or male attitudes to menstruation have received little attention. One upcoming cluster RCT with multiple intervention arms will include a condition providing both school level and community level education Sol et al. No studies have trialed improvements to WASH or other infrastructure to support menstrual management.

These infrastructure challenges are relevant in home, school, and work environments and interventions have the potential to be integrated into other campaigns such as those aiming to improve sanitation coverage Hennegan et al. New intervention approaches to address menstrual health are varied.

They range from more detailed and comprehensive education on menstrual health and body literacy, to reducing stigma and taboo at all levels, and infrastructure and WASH facilities to support menstrual activities, as well as integrated packages of these components.

Moreover, menstrual pain and disorders have been largely neglected in trials and cross-sectional studies and populations such as those in humanitarian settings, those living with disabilities, girls outside of schools, and adult women at home and in the workplace have received inadequate attention Sommer, Chandraratna, et al.

To support the development and evaluation of such interventions an improved evidence base is needed. This would inform intervention design as well as outcome assessment in trials. Greater integration of NGO, multinational programming, and academic research efforts would be of great value.

NGO programs often only include case-study assessments of effectiveness but have often described more integrated approaches to intervention development Sommer, Sahin, et al. Sufficient funding must be allocated to evaluation, to ensure that policies and programs are evidence-based and effective prior to large-scale dissemination.

In the absence of evidence for the effectiveness of interventions, implementing organizations and advocates should proceed with caution. Menstrual Hygiene Is Key in Promoting Good Health These hygiene practices can help you stay healthy and comfortable during your period: Wear lightweight, breathable clothing such as cotton underwear.

Tight fabrics can trap moisture and heat, allowing germs to thrive. Change your menstrual products regularly. Trapped moisture provides a breeding ground for bacteria and fungi. Wearing a pad or period underwear for too long can lead to a rash or an infection.

Keep your genital area clean. Wash the outside of your vagina vulva and bottom every day. When you go to the bathroom, wipe from the front of your body toward the back, not the other way. Use only water to rinse your vulva.

The vagina is a self-cleaning organ. Changing the natural pH balance of your vagina by washing or using chemicals to cleanse out the vagina can be harmful and may result in a yeast infection or bacterial vaginosis.

Use unscented toilet paper, tampons, or pads. Scented hygiene products can irritate the skin and impact your natural pH balance. Drink enough liquids. This can help wash out your urinary tract and help prevent infections, like vaginal candidiasis.

Track and monitor your period. Your menstrual cycle is a valuable marker for your overall health. Irregular periods can be a sign of conditions like diabetes, thyroid dysfunction, and celiac disease.