Does menstruation make girls miss school?
YOU CAN DOWNLOAD THIS FAQs AS PDF HERE
WoMena receives many questions from the women and girls we reach out to, from our trainers and from our partners. Therefore, we have created a series titled “WoMena FAQs” where we address these questions and answer them based on the best available scientific literature, consultation with experts, health authority guidelines and manufacturer advice.
Attention to Menstrual Health Management (MHM) has grown rapidly over the last decade. The focus has broadened over that period – from a strict ‘hygiene’ focus on products, water and sanitation (Biran et al. 2012) to a recognition that a broader ‘health’ focus might be needed, including social values (Roeckel 2019). One difficulty is that studies to date are very heterogeneous in design, for example using different metrics to define and measure ‘miss school’ (e.g. missing any days during their period, missing all 4-5 days, missing part-day, or other) and using different methodologies (e.g. reporting by girls or outsider observation), making comparison difficult. It may be that ‘miss school’ is not a reliable indicator until it is better defined. Thus, it is perhaps not surprising that evidence is as yet limited. Researchers are proposing there be a shift from ‘hardware’ oriented design: from a focus on products, water and sanitation to more ‘software’ approach: knowledge, attitudes, feelings (Phillips-Howard et al. 2016, Sommer et al. 2019).
Conclusions for programming therefore remain tentative, and we need to look at many types of ‘evidence’. The ‘evidence’ presented in this review is mostly academic and grey literature, but powerful and consistent testimonials given by girls, their parents, teachers and policy makers that inadequate MHM is a significant problem preventing girls from achieving educational goals also make an impression.
Study strength varies, and we have not attempted to rank them.
Q1. What evidence is there that girls miss school during menstruation? The widely cited claim that ‘One in ten girls in sub-Saharan Africa misses school during their period’ appears to have originated with models by UNICEF, and before that the World Bank in 2005: ‘if a girl misses 4 days of school every 4 weeks due to her period, she will miss 10 to 20 percent of her school days’ (World Bank 2005; Tjon a Ten 2007 quoted in Oster and Thornton 2011). It has been repeatedly questioned, as it is based on modelling rather than empirical data (Tellier 2012, Hennegan et al, 2016, Tellier 2018). However, there is a growing body of literature based on empirical data. This WoMena review identified more than 45 studies, conducted across 18 low- and middle-income countries, of which 25 quantified absenteeism in percentage terms. Three found less than 10 percent excess absenteeism, 12 found between 10-49 percent, and ten studies found more than 50% excess absenteeism during periods. Thus, the slogan may actually be an underestimate – we do not yet know for sure.
For example, one study of several countries found that in Zimbabwe all surveyed girls reported missing school during menstruation, with 62 percent of girls missing school for 1-2 days per month, another 28 percent missing 2-4 days, and 10 percent 4 or more days per month (Tamiru et al. 2014). The same study found that, on average, half of the female students surveyed in Uganda missed 1-3 days of school per month due to menstruation (Tamiru et al. 2014).
The conclusion at this point would seem to be that girls are missing school because of menstruation, and this is widespread across many countries and localities. The levels reported vary greatly. Given that there are no overarching studies to date, and methodologies vary, it is not clear whether variations are due to differences in locales or methodologies – probably both. The programmatic conclusion at this point, to our mind, must be that there is a commanding necessity of finding a common metric and methodology before absenteeism can be considered a reliable indicator, but at this point, the evidence from many different sources indicate that absenteeism is high and constitutes a significant problem for girls and their environments.
Q2. What evidence is there that girls are participating less in school activities during menstruation? Numerous studies have found that, in addition to missing entire or partial school days, girls also participate less in class and experience reduced concentration during menstruation (El-Gilany, Badawi, and El-Fedaway 2005; Grant, Lloyd, and Mensch 2013; Boosey, Prestwich, and Deave 2014; Gultie, Hailu and Workineh 2014; Tegegne and Sisay 2014; Jothy and Kalaiselv 2012; Konapur and Nagaraj 2014; NestBuilders International 2012; Tamiru et al. 2014 and 2015; Wanja 2014; Wong 2011; WaterAid 2009; Caruso et al. 2013).
For example, a study in Uganda found that 64.7 percent of girls avoided standing in class to answer questions during their period, and 51 percent of girls reported having trouble concentrating in class during menstruation (Hennegan et al. 2016). Corroborating this, in Sierra Leone, 26.8 percent of girls “strongly agreed” with the question, “You don’t like to stand up in class when on your period?” (NestBuilders International 2012).
Two studies in Ethiopia found that nearly 41 and nearly 60 percent of girls, respectively, reported that menstruation interfered with their academic performance (Gultie, Hailu and Workineh 2014; Tegegne and Sisay 2014). This was even higher in India, where nearly 70 percent of girls found it difficult to concentrate in class during menstruation (Konapur and Nagaraj 2014).
Q3. What are the reported reasons menstruation causes missing school or participating less? Menstruation is a natural and healthy process, but it can become a problem where menstruators do not have the means to manage it. Research to date suggests that there are multiple, interrelated factors which contribute to girls either missing school or participating less in school activities during menstruation. These include lack of menstrual hygiene products; inadequate school sanitation facilities; physical pain, lack of education about MHM; discomfort, shame, stigma, and embarrassment; cultural and religious restrictions.
Lack of menstrual hygiene products There are many different types of products that girls use, and usage rates vary based on multiple factors, including where girls live and family income. Some girls use extra pieces of cloth or wear multiple layers of underwear or clothing, while others use reusable or disposable sanitary pads or menstrual cups. Some are homemade, some commercial. Many of these require that girls have knickers (underwear), which is not always the case (Tamiru et al. 2015).
The majority of teachers think the availability of sanitary pads significantly affects girls’ performance in school, with a study in Kenya indicating 71.4 percent believing it does so to a “very great extent” (Njue and Muthaa 2015). Indeed, lack of menstrual hygiene products was reported to be the main barrier to school attendance during menstruation for 73.7 percent of schoolgirls in South Sudan (Tamiru et al. 2014). Girls tend to express dissatisfaction with using pieces of cloth to absorb menstrual blood – as cloth tends to leak and may, if dried improperly, cause irritation (Caruso et al. 2013; Pillitteri, 2012). We refer to WoMena’s FAQ on infection for a more detailed analysis of possible links between MHM products and practices and infection, and what is known about the opinions of different stakeholders (WoMena, 2018). A study in Malawi found that 95 percent of girls used cloth most of the time and in a priority list workshop, girls most frequently requested disposable sanitary pads, water, an incinerator for pads, and soap (Pillitteri 2012).
Pain and discomfort have been repeatedly identified as having a negative effect on both attendance and participation in class (Boosey, Prestwich and Deave 2014; Konapur and Nagaraj 2014; Khan 2012; Miiro et al. 2018; Tamiru et al. 2014; Tegegne and Sisay 2014; Rani, Sharma and Singh 2015; Wanja 2014; WaterAid 2009; Wong 2011; El-Gilany, Badawi, and El-Fedaway 2005; Zegeye, Megabiaw, and Mulu 2009). For example, 71 percent of girls in a study in Uganda said that pain and discomfort were the primary reasons they missed school during menstruation (Crofts 2010). Similarly, Jothy and Kalaiselv (2012) found that 73.3 percent of schoolgirls who missed school during menstruation said they missed school because of pain.
Inadequate water and sanitation facilities figure high in girls’ reported reasons for missing school. Sanitation facilities in schools lacking clean latrines or toilets, lacking privacy for changing menstrual hygiene products (e.g., separate latrines for girls and boys or a lack of locks on the doors), lacking water and/or soap for cleaning, and/or lacking a way to (discreetly) dispose of menstrual hygiene products have all been implicated (Abanyie, Anang and Ampadu 2016; Boosey, Prestwich and Deave 2014; Long et al. 2013; Miiro et al. 2018; Tamiru et al. 2014; WaterAid, 2009). In a multi-country study by SNV Netherlands Development Organisation “the lack of a private place to change” was the primary reason for not going to school during menstruation for 56.6 percent of girls (Tamiru et al. 2014). In sub-Saharan Africa, less than half of upper secondary schools have access to basic hand washing facilities (UN, 2019).
Stigma, shame and embarrassment are implicated in these studies as both contributing and overarching factors to reduced participation in school (Caruso et al. 2013; Long et al. 2013; Khan 2012; Miiro et al. 2018). In India, when asked for reasons for absenteeism during menstruation, 53.4 percent of girls reported shame as a reason (Jothy and Kalaiselv 2012; Tellier and Hyttel 2018). Many of the reasons that girls give for missing school, and explaining why they feel shame – including a lack of privacy for changing and fear of bleeding through clothing – are related to the shame and embarrassment that result from public knowledge of their menstrual status. Both schoolgirls and adults think that girls miss school or participate less in class during menstruation out of a fear of staining clothes (Abanyie, Anang and Ampadu 2016; Boosey, Prestwich and Deave 2014; Long et al. 2013; NestBuilders International 2012; Tegegne and Sisay 2014).
Explicit cultural and religious restrictions are sometimes also a factor in absenteeism. Two studies – one in Nepal and one in India – looked explicitly at absence due to cultural restrictions, and both reported fewer than 6 percent of girls staying out of school during menstruation for cultural or religious reasons (Thakre et al. 2011; WaterAid 2009). Similarly, three studies found that under a third of menstruation-related absences were attributed to cultural practices (Jothy and Kalaiselv 2012; Khan 2012; Udayar, Kruthika and Devi 2016), while other causes of absence, such as pain or a lack of a clean water supply at school, were substantially more common (Jothy and Kalaiselv 2012; Khan 2012).
Q4: Can interventions make a difference? Two studies – one in Kenya and one in Nepal – on the impact of providing menstrual cups to girls found no statistically significant improvement in school attendance (Oster and Thornton 2010; Philips-Howard et al. 2016). In both cases, there was very low reported absenteeism due to menstruation prior to the intervention, leaving little possibility that an intervention might improve attendance. However, there is growing evidence on what works.
Providing reusable sanitary pads has been found to be associated with at least a short-term increase in attendance (Wilson, Reeve, and Pitt 2014; Mucherah and Thomas 2017), as has provision of both reusable pads and puberty education (Appollis 2014; Scott et al. 2009; Montgomery et al. 2012). One study provided reusable pads, education, or both, and compared this to a control group which received nothing. In this particular population, while attendance declined across all study arms over a two-year follow-up period, the control group (which received nothing) experienced a 17 percent greater drop in attendance than the intervention arms (Montgomery et al. 2016).
Education alone, or in concert with MHM product provision of pads, has been shown, over time, to lead to similar declines in absenteeism as just provision of sanitary pads (Scott et al. 2009; Montgomery 2012). The researchers theorized that opening up “discussion of this taboo subject” may have “fostered improved peer and other relations making the school environment more supportive” allowing education to be as effective as pads and education (Montgomery et al. 2012). For this reason, education alone may be as effective as providing MHM products.
Qualitative research by Mason et al. (2015) examining provision of commercially-produced, disposable sanitary pads or menstrual cups against a control group found that girls using cloth expressed more concerns than girls using pads or menstrual cups about leaking and being teased by others; they also reported staying away from school during menstruation. Both girls and parents reported that girls who had received pads or menstrual cups had improvements in school attendance, and girls reported having greater concentration in class (Mason et al. 2015). In addition, one study found an association between WASH interventions and increased attendance for girls (Freeman et al. 2012).
Interventions that provide menstrual hygiene products and/or education may also change perceptions of stigma and feelings of shame surrounding menstruation, but evidence of this to date is mixed. While a pilot study by Montgomery et al. (2012) found that provision of reusable pads was associated with decreased feelings of shame and insecurity, no such significant difference was replicated in the expanded trial (Montgomery et al. 2016).
Q5: How does WoMena’s work address the linkage between menstruation and education? WoMena’s approach has been broad (an ‘ecological model’ as described by Dahlberg and Krug, 2002; Roenitzsch 2015)., addressing the above range of reasons. It includes providing menstrual products (cups/reusable pads and addressing the local water and sanitation/disposal situation in collaboration with with the local community. Beyond product distribution, education and engagement of girls is central, including the issue of pain management (e.g. providing hot water bottles). Recognising the damaging effects of shame, WoMena works to develop a supportive environment, e.g. training local volunteers who can support and mentorship in a sustainable manner, in particular including males – both school children and men (e.g. being named ‘male ambassadors’; and interacting with public institutions, such as Ministries of Education or Health, as well as international organisations.
Some results include: high continued use of products, diminished shame (one study in Uganda indicated that the percentage of girls reporting having discussed MHM with their families went from being ‘taboo’ (no-one discussed) to 94 percent. Strikingly, before the intervention girls repeatedly often mention that they feel ‘fearful’ about MHM; six months later they report going about their lives, including bicycling to school, ‘freely’ (e.g. Refstrup, 2015; Zabell, 2016). Girls who participated in a recent Ruby Cup trial with WoMena reported increased feelings of agency – the cup provided them with greater mobility and freedom of movement, as well as increased confidence (CARE International & WoMena Uganda, 2018).
WoMena studies aim at seeing the feasibility of approaches which are preconditions for school attendance, as well as purposes in themselves. This needs more investment than merely distributing products, but also has wider possible positive implications.
For example, education about MHM can be an entry point for broader reproductive health education (Abbott et al 2012, Tellier et al., 2018, CARE International & WoMena Uganda, 2018). Studies to date indicate that broader reproductive and sexuality education in turn contributes to later sexual debut and fewer sexual partners, improving the odds of higher educational attainment (UNESCO, 2018). There is also much literature indicating that girls’ education and age at first sex are key drivers of fertility decrease – that is, completing secondary school has a major effect on reducing fertility levels (Ariho & Nzabona, 2019).
References
Abanyie, S., Anang, R., Ampadu, B., 2016. Menstrual Health Management in Some Selected Basic Schools in Ghana.
Abbott, C.L., Bailey, B., Louis, D., Mcnab, S., Patel, D., López, C.P., Rani, R.S. and Vaval, S.L., 2011. Evaluation of UNFPA’s Provision of Dignity Kits in Humanitarian and Post-Crisis Settings Client: United Nations Populations Fund.
Appollis, T., 2014. Keeping Girls in School through Better Menstrual Hygiene Management: An Outcome Evaluation of the Always Keeping Girls in School Programme. University of Cape Town, Cape Town, South Africa.
Ariho, P. and Nzabona, A., 2019. Determinants of Change in Fertility among Women in Rural Areas of Uganda. Journal of Pregnancy, 2019
Biran, A., Curtis, V., Gautam, O.P., Greenland, K., Islam, S., Schmidt, W.P., Sijbesma, C., Sumpter, C. and Torondel, B., 2012. Background Paper on Measuring WASH and Food Hygiene Practices–Definition of Goals to be Tackled Post 2015 by the Joint Monitoring Programme. London Sch Hyg Trop Med, 2012, p.81.
Boosey, R., Prestwich, G., Deave, T., 2014. Menstrual hygiene management amongst schoolgirls in the Rukungiri district of Uganda and the impact on their education: a cross-sectional study. Pan African Medical Journal.
CARE International and WoMena Uganda, 2018. Ruby Cups: Girls in Imvepi Refugee Settlement Taking Control. CARE International in Uganda, Kampala. https://womena.dk/wp-content/uploads/2018/12/Ruby-Cups-Girls-in-Imvepi-Refugee-Settlement-Taking-Control-03.12.18-Final-report.pdf
Caruso, B., Fehr, A., Inden, K., Sahin, M., Ellis, A., Andes, K.L., Freeman, M.C., 2013. WASH in Schools Empowers Girls’ Education in Freetown, Sierra Leone: An Assessment of Menstrual Hygiene Management in Schools. UNICEF, New York.
Chandra-Mouli, V., Patel, S.V., 2017. Mapping the knowledge and understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low- and middle-income countries. Reprod Health 14, 30. https://doi.org/10.1186/s12978-017-0293-6
Chinyama, J., Chipungu, J., Rudd, C., Mwale, M., Verstraete, L., Sikamo, C., Mutale, W., Chilengi, R., Sharma, A., 2019. Menstrual hygiene management in rural schools of Zambia: a descriptive study of knowledge, experiences and challenges faced by schoolgirls. BMC Public Health 19, 16. https://doi.org/10.1186/s12889-018-6360-2
Coswosk, É.D., Neves-Silva, P., Modena, C.M., Heller, L., 2019. Having a toilet is not enough: the limitations in fulfilling the human rights to water and sanitation in a municipal school in Bahia, Brazil. BMC Public Health 19, 137. https://doi.org/10.1186/s12889-019-6469-y
Crofts, T., 2010. An Investigation into schoolgirls use of low cost sanitary pads in Uganda. Loughborough University, (Unpublished), pp. 1-109.
Crofts, T., Fisher, J., 2012. Menstrual hygiene in Ugandan schools: an investigation of low-cost sanitary pads. Journal of Water Sanitation and Hygiene for Development 2, 50–58. https://doi.org/10.2166/washdev.2012.067
Dahlberg LL, Krug EG: Violence: A Global Public Health Problem. In World Report on Violence and Health. Edited by Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. Geneva: World Health Organization; 2002:1–21.
El-Gilany, A.-H., Badawi, K., El-Fedaway, S., 2005. Epidemiology of dysmenorrhoea among adolescent students in Mansoura, Egypt. – PubMed – NCBI. Eastern Mediterranean Health Journal 11, 155–163.
Freeman, M.C., Greene, L.E., Dreibelbis, R., Saboori, S., Muga, R., Brumback, B., Rheingans, R., 2012. Assessing the impact of a school-based water treatment, hygiene and sanitation programme on pupil absence in Nyanza Province, Kenya: a cluster-randomized trial. Tropical Medicine & International Health 17, 380–391. https://doi.org/10.1111/j.1365-3156.2011.02927.x
Grant, M., Lloyd, C.B., Mensch, B., 2013. Menstruation and school absenteeism: Evidence from rural Malawi. Comparative Education Review 57, 260–284.
Gultie, T., Hailu, D., Workineh, Y., 2014. Age of Menarche and Knowledge about Menstrual Hygiene Management among Adolescent School Girls in Amhara Province, Ethiopia: Implication to Health Care Workers & School Teachers. PLOS ONE 9, e108644. https://doi.org/10.1371/journal.pone.0108644
Guya, E., Mayo, A.W., Kimwaga, R., 2014. Menstrual Hygiene Management in Secondary schools in Tanzania. International Journal of Science and Technology 3, 27–40.
Hennegan, J., Dolan, C., Wu, M., Scott, L., Montgomery, M., 2016. Measuring the prevalence and impact of poor menstrual hygiene management: a quantitative survey of schoolgirls in rural Uganda. BMJ Open 6, e0125976. https://bmjopen.bmj.com/content/6/12/e012596
Hennegan, J., Montgomery, P., 2016. Do Menstrual Hygiene Management Interventions Improve Education and Psychosocial Outcomes for Women and Girls in Low and Middle Income Countries? A Systematic Review. PLoS ONE 11, e0146985. https://doi.org/10.1371/journal.pone.0146985
Hyttel, M., Faldt Thomsen, C., Luff, B., Storrusten, H., Nyakato, V.N., Tellier, M., 2017. Drivers and Challenges to Use of Menstrual Cups Among Schoolgirls in Rural Uganda: A Qualitative Study. Waterlines, Practical Action Publishing 36, 16.
Jasper, C., Le, T.-T., Bartram, J., 2012. Water and Sanitation in Schools: A Systematic Review of the Health and Educational Outcomes. Int J Environ Res Public Health 9, 2772–2787. https://doi.org/10.3390/ijerph9082772
Joshi, D., Buit, G., González-Botero, D., 2015. Menstrual hygiene management: education and empowerment for girls? Waterlines 34, 51–67. https://doi.org/10.3362/1756-3488.2015.006
Jothy, K., Kalaiselvi, S., 2012. Is menstrual hygiene management an issue for the rural adolescent school girls? Elixir Social Science 44, 7223–7228.
Khan, A., 2012. Perceptions and Practices about Menstrual Hygiene among Adolescent Girls in a Rural Area – A Cross-Sectional Study. IJHSR 2, 29–34.
Konapur, K., Nagaraj, C., 2014. Dysmenorrhoea and Premenstrual Syndrome: Frequency and effect on daily activities of adolescent girls in rural areas of Bangalore. International Journal of Medical Science and Public Health 3, 1225. https://doi.org/10.5455/ijmsph.2014.090720143
Lahiri-Dutt, K., 2015. Medicalising menstruation: a feminist critique of the political economy of menstrual hygiene management in South Asia. Gender, Place & Culture 22, 1158–1176. https://doi.org/10.1080/0966369X.2014.939156
Long, J., Caruso, B.A., Lopez, D., Vancraeynest, K., Sahin, M., Andes, K.L., Freeman, M.C., 2013. WASH in Schools: Empower Girls’ Education in Rural Cochabamba, Bolivia: An Assessment of Menstrual Hygiene Management in Schools. United Nations Children’s Fund, New York, NY.
Mason, L., Laserson, K., Oruko, K., Nyothach, E., Alexander, K., Odhiambo, F., Eleveld, A., Isiye, E., Ngere, I., Omoto, J., Mohammed, A., Vulule, J., Phillips-Howard, P., 2015. Adolescent schoolgirls’ experiences of menstrual cups and pads in rural western Kenya: a qualitative study. Waterlines 34, 15–30. https://doi.org/10.3362/1756-3488.2015.003
Miiro, G., Rutakumwa, R., Nakiyingi-Miiro, J., Nakuya, K., Musoke, S., Namakula, J., Francis, S., Torondel, B., Gibson, L.J., Ross, D.A., Weiss, H.A., 2018. Menstrual health and school absenteeism among adolescent girls in Uganda (MENISCUS): a feasibility study. BMC Womens Health 18. https://doi.org/10.1186/s12905-017-0502-z
Montgomery, P., Hennegan, J., Dolan, C., Wu, M., Steinfield, L., Scott, L., 2016. Menstruation and the Cycle of Poverty: A Cluster Quasi-Randomised Control Trial of Sanitary Pad and Puberty Education Provision in Uganda. PLOS ONE 11, e0166122. https://doi.org/10.1371/journal.pone.0166122
Montgomery, P., Ryus, C.R., Dolan, C.S., Dopson, S., Scott, L.M., 2012. Sanitary Pad Interventions for Girls’ Education in Ghana: A Pilot Study. PLoS One 7. https://doi.org/10.1371/journal.pone.0048274
Mucherah, W., Thomas, K., 2017. Reducing barriers to primary school education for girls in rural Kenya: reusable pads’ intervention. Journal of Adolescent Medicine and Health. https://doi.org/10.1515/ijamh-2017-0005
Mwangolo, S.B., 2015. Influence of kenya government interventions on girl child dropout in public primary schools in Malindi Subcounty, Kilifi County, Kenya (Thesis). University of Nairobi.
NestBuilders International, 2012. Rural WASH in Schools Programme Sierre Leone Baseline Study Report. Nestbuilders International for UNICEF Sierra Leone, Sierra Leone.
Njue, E.K., Muthaa, G.M., 2015. Influence of Availability of Sanitary Facilities on the Participation of the Girl-Child in Public Primary Schools in Garissa County, Kenya. Open Journal of Social Sciences 3, 162–169. https://doi.org/10.4236/jss.2015.38018
Oster, E., Thornton, R., 2011. Menstruation, Sanitary Products and School Attendance: Evidence from a Randomized Evaluation. American Economic Journal: Applied Economics.
Phillips-Howard, P.A., Caruso, B., Torondel, B., Zulaika, G., Sahin, M. and Sommer, M., 2016. Menstrual hygiene management among adolescent schoolgirls in low-and middle-income countries: research priorities. Global health action, 9(1), p.33032.
Phillips-Howard, P.A., Nyothach, E., Kuile, F.O. ter, Omoto, J., Wang, D., Zeh, C., Onyango, C., Mason, L., Alexander, K.T., Odhiambo, F.O., Eleveld, A., Mohammed, A., Eijk, A.M. van, Edwards, R.T., Vulule, J., Faragher, B., Laserson, K.F., 2016. Menstrual cups and sanitary pads to reduce school attrition, and sexually transmitted and reproductive tract infections: a cluster randomised controlled feasibility study in rural Western Kenya. BMJ Open 6, e013229. https://doi.org/10.1136/bmjopen-2016-013229
Pillitteri, S.P., 2012. School menstrual hygiene management in Malawi: More than Toilets (Briefing note summarizing a Master of Science thesis project for Cranfield University, UK). Cranfield University.
Rani, A., Sharma, M.K., Singh, A., 2015. Practices and perceptions of adolescent girls regarding the impact of dysmenorrhea on their routine life: a comparative study in the urban, rural, and slum areas of Chandigarh. International Journal of Adolescent Medicine and Health 0. https://doi.org/10.1515/ijamh-2014-0063
Refstrup Skov S., 2015. ‘When I insert it there is no problem, I am free’ – Master’s thesis; Department of Public Health, Faculty of Health and Medical Sciences. https://womena.dk/mhm-student-research/
Scott, L., Dopson, S., Montgomery, P., Dolan, C., Ryus, C., 2009. Impact of Providing Sanitary Pads to Poor Girls in Africa. University of Oxford.
Sommer, M., Zulaika, G., Schmitt, M., Gruer, C. (Eds.).,2019. Monitoring Menstrual Health and Hygiene: Measuring Progress for Girls on Menstruation; Meeting Report. New York & Geneva: Columbia University and WSSCC.
Sumpter, C., Torondel, B., 2013. A Systematic Review of the Health and Social Effects of Menstrual Hygiene Management. PLOS ONE 8, e62004. https://doi.org/10.1371/journal.pone.0062004
Tamiru, S., Acidria, P., Ali, C.S., Ndebele, L., Mamo, K., Mushi, R., Brar, B., Greenfield, N., 2014. Girls in Control: Compiled Findings from Studies on Menstrual Hygiene Management of Schoolgirls. [WWW Document]. SNV.org. URL http://www.snv.org/public/cms/sites/default/files/explore/download/snv_girls_in_control_baseline_report.pdf (accessed 2.2.16).
Tamiru, S., Mamo, K., Acidria, P., Mushi, R., Satya Ali, C., Ndebele, L., 2015. Towards a sustainable solution for school menstrual hygiene management: cases of Ethiopia, Uganda, South-Sudan, Tanzania, and Zimbabwe. Waterlines 34, 92–102. https://doi.org/10.3362/1756-3488.2015.009
Tegegne, T.K., Sisay, M.M., 2014. Menstrual hygiene management and school absenteeism among female adolescent students in Northeast Ethiopia. BMC Public Health 14. https://doi.org/10.1186/1471-2458-14-1118
Tellier, S; Hyttel, M (WoMena). 2018. Menstrual Health Management in East and Southern Africa: A Review Paper. Johannesburg: UNFPA. https://womena.dk/wp-content/uploads/2018/06/UNFPA-Review-Menstrual-Health-Management-Final-04-June-2018.pdf
Thakre, Subhash, Thakre, Sushama, Reddy, M., Pathak, K., Ughade, S., 2011. Menstrual Hygiene: Knowledge and Practice among Adolescent School Girls of Saoner, Nagpur District. Journal of Clinical and Diagnostic Research 5, 1027–1033.
Udayar, S.E., K, K., Devi, P.V., 2016. Menstrual Hygiene Practices among Adolescent Girls Residing in Tribal and Social Welfare Hostel in Andhra Pradesh: A Community Based Study -. National Journal of Community Medicine 7, 681–685.
United Nations, 2019. The Sustainable Development Goal Report 2019. United Nations New York, 2019. https://unstats.un.org/sdgs/report/2019/
UN Commission on the Status of Women, Sixty-third session, 2019. Follow-up to the Fourth World Conference on Women and to the twenty-third special session of the General Assembly, entitled “Women 2000: gender equality, development and peace for the twenty-first century.” Social protection systems, access to public services and sustainable infrastructure for gender equality and the empowerment of women and girls . Agreed conclusions (No. Agenda item 3(a)(i)). United Nations Economic and Social Council, New York.
UNESCO, 2014. Puberty Education and Menstrual Hygiene Management (No. Booklet 9), Good Policy and Practice in Health Education. UNESCO.
UNESCO, 2018. International technical guidance on sexuality education: an evidence-informed
Approach. Revised edition. France.UNESCO.https://unesdoc.unesco.org/ark:/48223/pf0000260770
Water and Sanitation Collaborative Council, UN Women, 2015. Menstrual Hygiene Management: Behaviour and Practices in Kye-Ossi and Bamoungoum, Cameroon. WSSCC and UN Women.
Water and Sanitation Collaborative Council, UN Women, 2014. Menstrual Hygiene Management: Behaviour and Practices in the Louga Region, Senegal. WSSCC and UN Women.
WaterAid, 2009. Is menstrual hygiene and management an issue for adolescent school girls? A comparative study of four schools in different settings of Nepal. WaterAid.
Wilson, E., Reeve, J., Pitt, A., 2014. Education. Period. Developing an acceptable and replicable menstrual hygiene intervention. Development in Practice 24, 63–80. https://doi.org/10.1080/09614524.2014.867305
WoMena, 2018: FAQ-is there any connection between menstrual cups and infections? https://womena.dk/is-there-any-connection-between-menstrual-cups-and-infections/
Wong, L.P., 2011. Attitudes towards dysmenorrhoea, impact and treatment seeking among adolescent girls: A rural school-based survey. Australian Journal of Rural Health 19, 218–223. https://doi.org/10.1111/j.1440-1584.2011.01213.x
Zabell M.,2016. ”I FEEL JUST FREE” – A mixed methods study on the perceptions and experiences of the menstrual cup among adolescent girls in rural Uganda. https://womena.dk/mhm-student-research/
Zegeye, D.T., Megabiaw, B., Mulu, A., 2009. Age at menarche and the menstrual pattern of secondary school adolescents in northwest Ethiopia. BMC Women’s Health 9, 29. https://doi.org/10.1186/1472-6874-9-29
Mucherah, W., Thomas, K., 2017. Reducing barriers to primary school education for girls in rural Kenya: reusable pads’ intervention. Journal of Adolescent Medicine and Health. https://doi.org/10.1515/ijamh-2017-0005
Mwangolo, S.B., 2015. Influence of Kenya government interventions on girl child dropout in public primary schools in Malindi Subcounty, Kilifi County, Kenya (Thesis). The University of Nairobi.
NestBuilders International, 2012. Rural WASH in Schools Programme Sierre Leone Baseline Study Report. Nestbuilders International for UNICEF Sierra Leone, Sierra Leone.
Njue, E.K., Muthaa, G.M., 2015. Influence of Availability of Sanitary Facilities on the Participation of the Girl-Child in Public Primary Schools in Garissa County, Kenya. Open Journal of Social Sciences 3, 162–169. https://doi.org/10.4236/jss.2015.38018
Oster, E., Thornton, R., 2011. Menstruation, Sanitary Products, and School Attendance: Evidence from a Randomized Evaluation. American Economic Journal: Applied Economics.
Phillips-Howard, P.A., Caruso, B., Torondel, B., Zulaika, G., Sahin, M. and Sommer, M., 2016. Menstrual hygiene management among adolescent schoolgirls in low-and middle-income countries: research priorities. Global health action, 9(1), p.33032.
Phillips-Howard, P.A., Nyothach, E., Kuile, F.O. ter, Omoto, J., Wang, D., Zeh, C., Onyango, C., Mason, L., Alexander, K.T., Odhiambo, F.O., Eleveld, A., Mohammed, A., Eijk, A.M. van, Edwards, R.T., Vulule, J., Faragher, B., Laserson, K.F., 2016. Menstrual cups and sanitary pads to reduce school attrition, and sexually transmitted and reproductive tract infections: a cluster-randomized controlled feasibility study in rural Western Kenya. BMJ Open 6, e013229. https://doi.org/10.1136/bmjopen-2016-013229
Pillitteri, S.P., 2012. School menstrual hygiene management in Malawi: More than Toilets (Briefing note summarizing a Master of Science thesis project for Cranfield University, UK). Cranfield University.
Rani, A., Sharma, M.K., Singh, A., 2015. Practices and perceptions of adolescent girls regarding the impact of dysmenorrhea on their routine life: a comparative study in the urban, rural, and slum areas of Chandigarh. International Journal of Adolescent Medicine and Health 0. https://doi.org/10.1515/ijamh-2014-0063
Refstrup Skov S., 2015. ‘When I insert it there is no problem, I am free’ – Master’s thesis; Department of Public Health, Faculty of Health and Medical Sciences. https://womena.dk/mhm-student-research/
Scott, L., Dopson, S., Montgomery, P., Dolan, C., Ryus, C., 2009. Impact of Providing Sanitary Pads to Poor Girls in Africa. The University of Oxford.
Sommer, M., Zulaika, G., Schmitt, M., Gruer, C. (Eds.).,2019. Monitoring Menstrual Health and Hygiene: Measuring Progress for Girls on Menstruation; Meeting Report. New York & Geneva: Columbia University and WSSCC.
Sumpter, C., Torondel, B., 2013. A Systematic Review of the Health and Social Effects of Menstrual Hygiene Management. PLOS ONE 8, e62004. https://doi.org/10.1371/journal.pone.0062004
Tamiru, S., Acidria, P., Ali, C.S., Ndebele, L., Mamo, K., Mushi, R., Brar, B., Greenfield, N., 2014. Girls in Control: Compiled Findings from Studies on Menstrual Hygiene Management of Schoolgirls. [WWW Document]. SNV.org. URL http://www.snv.org/public/cms/sites/default/files/explore/download/snv_girls_in_control_baseline_report.pdf (accessed 2.2.16).
Tamiru, S., Mamo, K., Acidria, P., Mushi, R., Satya Ali, C., Ndebele, L., 2015. Towards a sustainable solution for school menstrual hygiene management: cases of Ethiopia, Uganda, South-Sudan, Tanzania, and Zimbabwe. Waterlines 34, 92–102. https://doi.org/10.3362/1756-3488.2015.009
Tegegne, T.K., Sisay, M.M., 2014. Menstrual hygiene management and school absenteeism among female adolescent students in Northeast Ethiopia. BMC Public Health 14. https://doi.org/10.1186/1471-2458-14-1118
Tellier, S; Hyttel, M (WoMena). 2018. Menstrual Health Management in East and Southern Africa: A Review Paper. Johannesburg: UNFPA. https://womena.dk/wp-content/uploads/2018/06/UNFPA-Review-Menstrual-Health-Management-Final-04-June-2018.pdf
Thakre, Subhash, Thakre, Sushama, Reddy, M., Pathak, K., Ughade, S., 2011. Menstrual Hygiene: Knowledge and Practice among Adolescent School Girls of Saoner, Nagpur District. Journal of Clinical and Diagnostic Research 5, 1027–1033.
Udayar, S.E., K, K., Devi, P.V., 2016. Menstrual Hygiene Practices among Adolescent Girls Residing in Tribal and Social Welfare Hostel in Andhra Pradesh: A Community Based Study -. National Journal of Community Medicine 7, 681–685.
United Nations, 2019. The Sustainable Development Goal Report 2019. United Nations New York, 2019. https://unstats.un.org/sdgs/report/2019/
UN Commission on the Status of Women, Sixty-third session, 2019. The follow-up to the Fourth World Conference on Women and to the twenty-third special session of the General Assembly, entitled “Women 2000: gender equality, development, and peace for the twenty-first century.” Social protection systems, access to public services and sustainable infrastructure for gender equality and the empowerment of women and girls. Agreed conclusions (No. Agenda item 3(a)(i)). United Nations Economic and Social Council, New York.
UNESCO, 2014. Puberty Education and Menstrual Hygiene Management (No. Booklet 9), Good Policy and Practice in Health Education. UNESCO.
UNESCO, 2018. International technical guidance on sexuality education: an evidence-informed
Approach. Revised edition. France.UNESCO.https://unesdoc.unesco.org/ark:/48223/pf0000260770
Water and Sanitation Collaborative Council, UN Women, 2015. Menstrual Hygiene Management: Behaviour and Practices in Kye-Ossi and Bamoungoum, Cameroon. WSSCC and UN Women.
Water and Sanitation Collaborative Council, UN Women, 2014. Menstrual Hygiene Management: Behaviour and Practices in the Louga Region, Senegal. WSSCC and UN Women.
WaterAid, 2009. Is menstrual hygiene and management an issue for adolescent school girls? A comparative study of four schools in different settings in Nepal. WaterAid.
Wilson, E., Reeve, J., Pitt, A., 2014. Education. Period. Developing an acceptable and replicable menstrual hygiene intervention. Development in Practice 24, 63–80. https://doi.org/10.1080/09614524.2014.867305
WoMena, 2018: FAQ-is there any connection between menstrual cups and infections? https://womena.dk/is-there-any-connection-between-menstrual-cups-and-infections/
Wong, L.P., 2011. Attitudes towards dysmenorrhoea, impact, and treatment-seeking among adolescent girls: A rural school-based survey. Australian Journal of Rural Health 19, 218–223. https://doi.org/10.1111/j.1440-1584.2011.01213.x
Zabell M.,2016. ”I FEEL JUST FREE” – A mixed-methods study on the perceptions and experiences of the menstrual cup among adolescent girls in rural Uganda. https://womena.dk/mhm-student-research/
Zegeye, D.T., Megabiaw, B., Mulu, A., 2009. Age at menarche and the menstrual pattern of secondary school adolescents in northwest Ethiopia. BMC Women’s Health 9, 29. https://doi.org/10.1186/1472-6874-9-29