Menstruation and the cycle of poverty: a cluster quasi-randomised control trial of sanitary pad and puberty education provision in Uganda

Paul Montgomery, J. M. Hennegan, C. Dolan, M. Wu, L. Scott

Research output: Contribution to journalAbstractpeer-review


The management of menstruation has been posited as a significant barrier to girls’ educational attainment in low income contexts. Interventions providing sanitary products and information about menstruation have been proposed as simple and efficient strategies for improving girls’ attendance and gender parity in education. Despite increasing implementation of such interventions, there have been limited high quality assessments of the effectiveness of proposed interventions to date.

This trial aimed to assess the impact of providing sanitary pads and puberty education on school attendance and psychosocial outcomes for girls in rural Uganda.

A cluster quasi-randomised controlled trial was conducted across 8 schools, including 1124 girls, in rural Uganda. The trial included four conditions: the provision of puberty education alone; reusable sanitary pads alone; puberty education and reusable sanitary pads; and a control receiving no intervention. The primary outcome was school attendance measured at baseline and 18-month follow up. Change scores were compared across conditions. Secondary outcomes reflected psychosocial wellbeing including shame and insecurity during menstruation and were measured at the end of the follow-up period (24-months after intervention) through surveys administered verbally in the local language.

After 18-months, school attendance worsened for girls across all conditions. Per-protocol analysis revealed that this decline was significantly greater for those in the control condition d = 0.52 (95% CI 0.26–0.77), with those in control schools having 17% greater drop in attendance than those in any intervention school. There was no difference between the intervention conditions. High rates of school-drop out, school-transfer, and girls moving away meant the trial suffered from substantial participant drop-out. However, intention-to-treat analyses using different imputation strategies revealed the same pattern of attendance retention in intervention conditions compared to the control. There were no differences between any of the conditions on girls’ self-reported feelings of shame and insecurity experienced during menstruation.

This trial is the largest to date demonstrating a positive impact of providing sanitary pads or puberty education for girls’ school attendance in a developing context. The study revealed no difference in the effectiveness of sanitary pad provision compared to education.
Original languageEnglish
Article numberOP47
Pages (from-to)A29
JournalJournal of Epidemiology and Community Health
Issue numberSuppl 1
Early online date13 Sept 2016
Publication statusPublished - Sept 2016


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