By Dani Stoilova

Although significant strides have been made in evaluating the consequences of inadequate menstrual hygiene management on educational outcomes, existing literature has discounted less observable outcomes and shown a distinct preference for material interventions. As a result, non-material menstruation-related constraints have been broadly overlooked alongside educational outcomes beyond absenteeism. 

In “Biological, material, and socio-cultural constraints to effective menstrual hygiene management among secondary school students in Tanzania”, we extend our research to develop a method of cross-sectional analysis that quantifies the relative importance of four distinct mechanisms (material, biological, socio-cultural, and informational constraints) on a variety of schooling outcomes (absenteeism, early departure, concentration, and participation). Overall, we find and argue that a holistic approach, addressing multiple constraint types, is necessary to improve schooling experiences and ultimately educational outcomes. 

For the study, we collected survey data from four co-educational secondary schools in Northern Tanzania with a final sample size of 524 female students. The survey contained a knowledge assessment, questions about menstruation-related experiences, attitudes, information sources and teasing behaviors. The paper’s strength is its unique quantitative data on reasons for absenteeism and other behaviors as well as its ability to gain insight into the relative prevalence of different educational barriers. 

We find that information is the least binding constraint, with 90-95% of girls in the sample reporting that they received information about menstruation and how to manage it. This is in contrast to some prior qualitative research in developing countries. Girls generally received information from an average of 4.5 sources ranging from friends and relatives to school and health officials. While these results are generally optimistic, we find that a small cohort of girls who have received below-average levels of information, indicating that there is still room for improvement in educating young women about menstruation. 

On the other hand, we find socio-cultural constraints, such as those resulting in shame and fear, to be prevalent and binding. With shame and fear consistently being two of the most common reasons for reduced participation and concentration in the classroom. Moreover, girls in the sample appear to be subject to socio-cultural constraints related to menstruation in their interactions with teachers and family members – 26% report teachers being unhelpful or not understanding if they knew a student was post-menarche and 38% report that menstruating women are restricted from certain daily activities in their homes. 

Biological constraints are similarly hindering as we find cramps, pain, and irregular periods to be some of the most reported reasons for absenteeism, early departure, and inability to concentrate in class. Further supported by the statistical analysis completed in the paper.  In addition, we find that 49% of girls in the sample use painkillers during menstruation emphasizing how debilitating symptoms of premenstrual syndrome can be while introducing an additional cost factor. Girls also report feeling unequipped to understand their menstrual cycles with 66% indicating that it is difficult to know when their next period will occur. We conclude that biological constraints, cycle-tracking, and pain management techniques including, but not limited to, the provision of painkillers should be considered further in MHM interventions. 

Finally, we explore material constraints which include access to and availability of MHM absorbents. Overall, we do uncover some disparity between girls’ preferred absorbent and their most used absorbent which we argue is due to accessibility and affordability barriers. We also find that having adequate WASH facilities is a similarly important factor, with a large portion of the sample reporting that they have left school early during their last period because they had no place to wash or change. However, while we find that material constraints have a direct impact on concentration, we do not find a statistically significant link between our material constraint measure and absenteeism – similar to findings from menstrual absorbent interventions. As a result, we propose further research on the improvement of WASH facilities for MHM interventions. 

While prior literature has made it evident that there is a link between menstruation and educational outcomes, there is still a considerable amount to be done beyond informational and material interventions. Our results have a series of implications for future research. First, interventions should consider participation and concentration as main educational outcomes, in addition to absenteeism, to fully understand young women’s experiences. Second, biological and socio-cultural constraints should be further evaluated in trials as our paper finds them to be significant drivers of menstruation-related absenteeism. Finally, we propose a holistic approach toward interventions including analgesic use, alternative pain-management techniques, menstrual cycle tracking technologies, and social programming in future trials. 

Read the full paper here:

Stoilova, D., Cai, R., Aguilar-Gomez, S., Batzer, N. H., Nyanza, E. C., & Benshaul-Tolonen, A. (2022). Biological, material and socio-cultural constraints to effective menstrual hygiene management among secondary school students in Tanzania. PLOS Global Public Health, 2(3), e0000110.