Associations of menstrual health with school absenteeism and educational performance among Ugandan secondary school students: A longitudinal study

Background Relatively few studies have quantified the amount of school missed due to poor menstrual health, or the impact of menstrual health on educational performance.

We analysed baseline and longitudinal data from participants in a cluster-randomised trial of a menstrual health intervention in 60 Ugandan secondary schools. We measured school absenteeism as the self-reported number of days absent due to menstruation per month and assessed educational performance using examination results, at baseline and endline. We estimated adjusted incidence rate ratios (aIRR) for associations with school absenteeism, using negative binomial regression adjusted for school-level clustering. We estimated adjusted standardised mean differences (aSMD) in examination scores using mixed-effects linear regression.

At baseline, 3312 participants reported menstruating in the past 6 months (mean age 15.6 years). Of these, 323 (9.8%) participants reported missing at least one day of school per month due to menstruation and 1286 (38.8%) missed at least one day per month for any reason. Of the 1192 participants in the control arm seen at endline, 135 (11.3%) missed at least one day due to menstruation (mean days missed=0.30 per month (95%CI 0.27-0.34)). Menstrual-related absenteeism and poorer examination performance at endline were both associated with multiple dimensions of menstrual health (use of inadequate menstrual materials, negative menstrual attitudes, unmet menstrual practice needs, and experience of menstrual teasing). In addition, absenteeism (due to menstruation and overall) was associated with menstrual pain.

Among Ugandan students, multiple dimensions of menstrual health are associated with school absenteeism and educational performance. Competing Interest Statement The authors have declared no competing interest. Clinical Trial ISRCTN45461276 Clinical Protocols https://doi.org/10.1186/s13063-022-06672-4 Funding Statement Yes Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval for MENISCUS protocol, the informed consent forms and draft CRFs were obtained from the Uganda Virus Research Institute Research & Ethics Committee (UVRI-REC) (reference GC/127/819) and the Uganda National Council of Science and Technology (UNCST) (reference HS1525ES) and the LSHTM Research Ethics Committee (reference 22952-2). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability The data are held in a public repository here: LSHTM Data Compass Weiss, H, Nelson, K, Mugenyi, L, Batuusa, L, Thomas, K and Baleke, C (2024). MENISCUS Trial. [Project]. London School of Hygiene & Tropical Medicine, London, United Kingdom. https://doi.org/10.17037/DATA.00003822. Abbreviations - MH - Menstrual health - LMP - Last menstrual period - CI - Confidence interval - LRT - Likelihood ratio test - SMD - Standardized mean difference - IRR - Incidence rate - MENISCUS - Menstrual health interventions, schooling, and mental health problems among Ugandan students - MHM - Menstrual hygiene management - SES - Socio-economic status - WASH - Water, sanitation and hygiene - SAMNS - Self-efficacy in Addressing Menstrual Needs Scale - MHPM - Menstrual Hygiene Preparation and Maintenance sub-scale - MPM - Menstrual Pain Management sub-scale - EST - Executing Stigmatized Tasks sub-scale