“We carry too many burdens”: Lived experiences of girls’ schooling in Ghana, a critical look at barriers, gender norms, and institutional perspectives

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Although poverty and poor facilities are highlighted by quantitative empirical research, little is known about how girls face these obstacles and how educational institutions respond to them. The lived experiences of girls and the perspectives of coordinators of the School Health Education Program (SHEP) are explored in this study, with particular emphasis on how institutional and sociocultural factors shape attendance and wellbeing. A qualitative descriptive methodology was utilised. Data were collected through forty-three focus group discussions (FGDs) with schoolgirls aged 9-17 years and key informant interviews (KIIs) with SHEP coordinators across six districts in Ghana, purposively sampled to represent northern, middle, and southern zones. Semi-structured guides explored experiences of schooling, menstruation, domestic responsibilities, community norms, and institutional responses. Discussions were conducted in English, transcribed, and thematically analysed using the Dedoose software. Results Four interrelated themes emerged. First, unfriendly school environments limited attendance, as girls reported insufficient WASH facilities, absence of sanitary products, and anxiety regarding potential embarrassment during menstruation. Secondly, gendered domestic labour and time poverty limited participation, as many learners missed school or arrived late due to household chores and caregiving responsibilities. Third, cultural expectations and constrained aspirations, including early marriage, initiation rites, and parental preference for boys’ education, shaped girls’ perceptions of restricted futures. Fourth, classroom experiences during menstruation were characterised by anxiety, discomfort, and reduced participation, with stigma and fear of leakage undermining concentration and engagement. SHEP coordinators acknowledged these challenges but highlighted resource limitations, weak referral systems, and limited training as barriers to effectively supporting girls. Conclusions The lived experiences of girls reveal that educational exclusion extends beyond infrastructure to include stigma, gender norms, and cultural expectations, exacerbated by weak institutional solutions. A multi-sectoral approach that integrates gender-responsive WASH, household sensitisation, community norm transformation, and enhanced school support systems is crucial for creating an environment conducive to girls’ educational success. This study underscores the necessity of integrating social and cultural factors into educational and public health initiatives, prioritising the lived experiences and perspectives of girls. Girls’ education Menstrual hygiene Gender norms Domestic labour School health Qualitative research Ghana Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Globally, significant progress has been achieved in expanding educational access for girls. Yet in many low- and middle-income countries (LMICs), persistent barriers continue to undermine girls’ participation and learning outcomes (1–4). These barriers are increasingly recognised as multidimensional, shaped not only by infrastructural deficits but also by poverty, socio-cultural norms, and gendered expectations that constrain girls’ opportunities within and beyond the classroom (5,6). While enrolment has improved in Ghana, disparities remain in regular attendance, retention, and learning performance, particularly among adolescent girls (7). Studies in Ghana and sub-Saharan Africa have identified inadequate water, sanitation, and hygiene (WASH) facilities, poor menstrual hygiene management (MHM) support, and domestic obligations as major obstacles to girls’ education (8,9). Nonetheless, a significant portion of this evidence has been derived from quantitative surveys or programmatic evaluations that predominantly measure outcomes such as enrolment or attendance. Less attention has been given to the ‘ lived experiences ’ of girls themselves and how they interpret the challenges they face. Understanding these experiences is essential because they capture how material deprivation, cultural expectations, and institutional responses intersect in everyday life, shaping both immediate school participation and longer-term educational aspirations. The perspectives of school stakeholders, including School Health Education Programme (SHEP) coordinators in Ghana, are essential for understanding how institutions recognise and address the difficulties faced by girls in school. SHEP coordinators oversee school health and welfare, encompassing hygiene, safety, and protection matters. Yet, their voices are often absent from research on girls’ education. This largely limits insights into the constraints schools face in providing support. This study addresses these gaps by exploring the lived experiences of girls and the perspectives of SHEP coordinators in Ghana. Specifically, it examines: How girls describe the barriers they face in attending school and achieving positive learning experiences. How SHEP coordinators interpret and respond to these barriers at the institutional level. In combining these perspectives, the study contributes a more holistic understanding of the social, cultural, and institutional dynamics shaping girls’ education. The findings are intended to inform integrated interventions that move beyond infrastructural provision to address stigma, gender norms, and systemic support for girls in schools. Literature review Education for girls in sub-Saharan Africa continues to be limited by a combination of institutional, cultural, and structural constraints. Despite policy reforms like Ghana’s Free Compulsory Universal Basic Education, gender disparities continue, as girls are more prone to dropout due to social expectations and structural disadvantages ( 10 , 11 ). Patriarchal norms impose significant domestic responsibilities on girls and heighten concerns regarding their sexuality and marriage prospects, thereby constraining their educational opportunities( 12 , 13 ). Menstrual hygiene management presents an additional barrier, as insufficient access to sanitary products, stigma, and inadequate WASH facilities negatively impact attendance and participation, especially in rural areas ( 14 , 15 ). School environments frequently reinforce inequality, as teacher attitudes, peer dynamics, and gender-stereotyped curricula hinder girls' aspirations, particularly in STEM fields ( 16 , 17 ). Policies like the Girls’ Education Unit, Capitation Grant, and LEAP cash transfers have increased enrolment; however, their effects are inconsistent, highlighting ongoing implementation gaps ( 18 , 19 ). Feminist and intersectional perspectives highlight that enhancing girls' education necessitates addressing both access and the deep-rooted power dynamics influenced by gender, poverty, geography, and disability ( 20 , 21 ). In summary, girls' education in Ghana is influenced by interconnected and complex web of challenges that transcend the individual level. Theoretical framework This study draws on Bronfenbrenner's Ecological Systems Theory ( 22 – 24 ) to investigate the pathways that connect MHM to learning outcomes and learning. The framework emphasises the multifaceted interactions that influence individual practices across six interrelated levels. The microsystem (immediate contexts such as family, peers, and WASH facilities) and the mesosystem (interactions within home, school, and community networks) surround the individual at the centre. The macrosystem is a reflection of broader socio-cultural norms, beliefs, and gender roles, while the exosystem includes structures that indirectly affect adolescents, such as economic systems, educational institutions, and policies. Finally, the chronosystem emphasises the temporal dimension, which is the way in which past experiences influence current outcomes. This model emphasises the interdependence of biological, psychological, social, organisational, community, and policy factors, providing a comprehensive perspective on the impact of societal structures and environments on the MHM practices of adolescents and their implications for education. Methods Study Design This research utilised a qualitative descriptive design incorporating focus group discussions (FGDs) and key informant interviews (KIIs). Utilising Bronfenbrenner’s Ecological Systems Theory, the analysis examined the interplay of individual, societal, and structural factors in influencing menstrual hygiene management (MHM), school attendance, and educational outcomes ( 22 – 24 ). The framework contextualised girls’ experiences within familial, educational, communal, and wider societal frameworks, guiding the conceptualisation of study variables, selection of respondents, and incorporation of girls’ viewpoints. This methodological approach was selected to document the lived experiences of girls and the institutional perspectives of SHEP coordinators in their own terms, facilitating a more profound comprehension of the socio-cultural circumstances affecting education. Study Setting The study was conducted across six districts in Ghana, purposively selected to represent the country’s three ecological zones: Northern, Middle, and Southern. These districts comprise: Accra Metro, Shai Osudoku District (southern zone), Kumasi Metro and Sekyere South District (middle zone) and Tamale Metro and Nanton District (northern zone). The sampled districts reflect diversity in socio-cultural practices, economic conditions, and educational environments. Schools were sampled in collaboration with the Ghana Education Service (GES), focusing both on rural and urban schools. Participants and Sampling Focus Group Discussions (FGDs) A total of 43 FGDs were conducted with schoolgirls aged 9–17 years, drawn from 24 primary (primary 5 and 6 learners) and 24 junior high schools (JHS 1 and 2 learners). Literature( 25 , 26 ) establishes that menstruation typically commences around the age of 11, contingent upon the child’s physiological development, at which point the child is generally in primary 5 or 6; this rationale underpins the focus on students in these grades. The emphasis at the Junior High level was solely on JHS 1 and 2, as JHS 3 pupils had concluded their Basic Education Certificate Examination (BECE) and were no longer part of the educational system. FGDs were stratified by school level and district to ensure diversity of perspectives. Each group consisted of 6–10 participants, purposively selected to reflect a mix of age, class level and socio-economic background. Key Informant Interviews (KIIs) Among the 43 SHEP coordinators involved, the majority were female (74.4%) and resided in urban areas (67.4%), with equitable representation from the Ashanti (37.2%), Northern (37.2%), and Greater Accra (25.6%) regions. Participants were recruited from six districts, with a near-equal distribution between junior high schools (51.2%) and primary schools (48.8%). This guaranteed varied perspectives across gender, geography, and educational level. Figure 1: Achieved sample Figure 1 figure presents the achieved sample of respondents for the study across all levels. Data Collection Data collection took place between September and October 2022. The FGDs explored girls’ daily schooling experiences, barriers to attendance, menstrual hygiene challenges, domestic responsibilities, community expectations, and perceived support from schools. The KIIs focused on institutional responses, challenges in supporting girls, referral systems, and observations of socio-cultural practices affecting attendance. Interviews and discussions were conducted in English, with the local languages used for emphasis. Trained facilitators led sessions using semi-structured guides. Almost all sessions were audio-recorded with permission, translated into English where necessary, and transcribed verbatim. Data Analysis Data were analysed thematically using Dedoose software. A coding framework was developed both deductively, based on study objectives (e.g., attendance, menstruation, domestic work, cultural norms, institutional responses), and inductively, from emergent themes in the transcripts. Transcripts were double-coded by two researchers to ensure reliability, and discrepancies were resolved through consensus. Themes were synthesised into broader categories that captured recurring experiences and perspectives. Illustrative quotes were selected to highlight participants’ voices. Ethical considerations Ethical approval was obtained from the University of Ghana Ethics Committee for the Humanities (ECH 045/22–23), and school entry authorisation was granted by the Ghana Education Service. Written informed consent was obtained from parents/guardians, and assent was sought from all participating girls. Confidentiality was maintained by anonymising transcripts and using pseudonyms for quotes. Results Analysis of the 43 FGDs with girls and 43 KIIs with SHEP coordinators revealed four interrelated themes shaping girls’ school experiences: (1) unfriendly school environment, (2) gendered domestic labour and time poverty, (3) cultural expectations and constrained aspirations, and (4) girls’ classroom experiences in the context of menstruation. While girls described the direct impact of these barriers on their daily schooling, SHEP coordinators provided insights into institutional constraints and community-level dynamics that reinforced these challenges. Theme 1: Unfriendly school environment The research examined the experiences of adolescent girls regarding the conduciveness of the school environment for menstrual hygiene management. The analysis indicates that the school context is largely unsupportive of menstruating girls. This situation is primarily associated with the absence of functional WASH infrastructure, inadequate institutional support manifested in unapproachable teachers and inactive or unavailable SHEP, insufficient provision of MHM materials, and the appointment of male SHEP coordinators, which further limits gender-sensitive support mechanisms (Figure 2). “ The school is not friendly for menstruating because there is no water inside the washrooms for us to wash ourselves and change our sanitary pads.” ( FGD JHS girl, Northern Zone) , “When there is no pad, I use cloth, but I feel shy and afraid it will stain my dress. Sometimes I don’t go to school those days.” (FGD, JHS girl, Northern Zone) “The toilets are not good. If you go there during your period, people laugh at you. So some girls prefer to stay at home.” (FGD, Primary girl, Southern Zone) “ There is no changing room in the school, and so if you are menstruating in school and there's the need to wear a pad or change your pad, we just go back home.” (FGD Group 8, Northern Zone). SHEP coordinators confirmed these challenges, noting that inadequate facilities and limited school budgets constrained their ability to provide safe spaces or emergency sanitary supplies. “We try to help when a girl comes with a problem, but we don’t always have pads or even a private room for her. This makes it difficult to keep them in school.” (KII, SHEP Coordinator, Middle Zone) “ The school environment is not friendly for menstruating girls. The school does not have a changing room for menstruating girls. The girls change their pads in the toilet and urinal. The pupils do not receive support from the teachers. They normally receive support from the SHEP coordinator.” (KII, SHEP Coordinator, Northern Zone) Theme 2: Gendered d omestic l abour and t ime p overty Girls described how household responsibilities interfered with schooling. Tasks such as fetching water, cooking, or caring for siblings often led to lateness, absenteeism, and fatigue during lessons (Figure 3). The evidence shows that the drivers of absenteeism extend beyond economic constraints and social events to include entrenched gender norms around domestic responsibilities. Evidence from the field points to girls’ involvement in household chores (e.g., cooking, cleaning, and water collection), caregiving roles (for younger siblings or sick parents), and economic activities (trading, apprenticeships, and nannying). These obligations often occur during school hours or early mornings, resulting in lateness, fatigue, or complete absence from school. The feminisation of domestic labour thus becomes a direct educational barrier. Time poverty, defined as the chronic lack of discretionary time due to competing demands of unpaid and paid work, emerges as a critical dimension of educational inequality. For many girls, school attendance is constrained not only by financial challenges such as lack of feeding or transport money, but also by the temporal costs of labour-intensive tasks like farm work (planting, harvesting) and extended caregiving. Unlike boys, whose labour is more frequently monetised or socially legitimised, girls’ contributions are undervalued yet demand long hours, leaving them with limited time for learning, rest, or leisure. The situation is further compounded by social events: funerals, weddings, outdooring ceremonies, and passing-out celebrations that demand children’s participation, with girls often playing supportive domestic or cultural roles. Peer influence and sickness exacerbate absenteeism, but the underlying burden of domestic responsibilities highlights how deeply time poverty is gendered within households and communities. “Before school, I fetch water and cook. Sometimes I am late, and the teacher punishes me. I feel tired in class.” (FGD, JHS girl, Northern Zone) “On market days, we don’t come to school because we help our mothers to sell. It happens many times in a term.” (FGD, Primary girl, Southern Zone) “ Farming activities and during wedding or naming ceremonies. Also, when your mother is not around and you have to take care of your young siblings.” (FGD, JHS girl, Northern Zone) “ Sometimes we help our parents in the market; most of us take care of our younger siblings as well .” (FGD, Primary Girl, Middle Zone) SHEP coordinators also highlighted this issue, emphasising that the domestic workload for girls was heavier than for boys, with clear consequences for attendance and learning. “You can see that girls are often absent after weekends or farming days. Parents depend on them for household work more than boys.” (KII, SHEP Coordinator, Northern Zone) “ Most parents of students here are single parents, so most girls missing school have to do with pocket money and work-related support to family sometimes. Distance is also another reason, especially when it rains in the morning.” (KII SHEP Coordinator, Middle Zone) The figure (Figure 3) illustrates how girls’ disproportionate involvement in domestic chores, financial challenges, distance to school contributes to time poverty, limiting their frequency of attendance, study time, school participation, and overall learning. Theme 3: Cultural e xpectations and c onstrained a spirations Cultural norms and practices continue to exert a strong influence on girls’ educational trajectories, often constraining their aspirations and shaping parental decisions regarding schooling. From the perspectives of both the girls and the SHEP coordinators, gendered expectations position girls primarily as future wives and mothers, with their value tied to domestic responsibilities and marital prospects rather than educational achievement. Such norms reinforce the perception that investment in girls’ education yields limited returns compared to preparing them for marriage. Qualitative evidence highlights these realities: several girls articulated internalised expectations, conveying scepticism regarding the significance of schooling when prospective responsibilities were contextualised within marriage and domesticity. “Some of my friends stopped school after marriage. Parents said it is better to prepare them for their husband than to waste money on school.” (FGD, JHS girl, Northern Zone) “When you grow and people see you with books, they say you are wasting time. They say the girl must marry.” (FGD, Primary girl, Middle Zone) SHEP coordinators acknowledged the influence of these cultural scripts, noting that while community sensitisation efforts had made progress, many families still prioritised boys’ education. “Parents support education in words, but when resources are scarce, they choose to support the boy. For girls, marriage is still seen as an achievement.” (KII, SHEP Coordinator, Southern Zone) Theme 4: Girls’ Classroom Experiences in the Context of Menstruation The study highlights that menstruation significantly disrupts girls’ learning experiences in school. Focus group discussions revealed that many girls encounter difficulty concentrating during lessons, often due to anxiety about staining their uniforms, discomfort, and the need for constant self-monitoring. These concerns lead to absent-mindedness and reduced classroom participation, with some girls preferring to remain silent even when they know the answers. Additionally, the physical pain and fatigue associated with menstruation, including abdominal cramps, headaches, and loss of appetite, further reduce their capacity to engage fully in classroom activities. Emotional responses such as irritation, withdrawal, and low self-confidence compound these challenges, reinforcing a cycle of reduced attentiveness and academic disengagement (Figure 4). The following quotes speak to this result: “I bleed a lot, and it makes it difficult to concentrate.” (FGD, Primary girl, Northern Zone) “I keep checking myself because I am scared to stain my uniform, and I end up not understanding what is being taught.” (FGD, Primary girl, Middle Zone) “I don’t feel like eating the whole day, and my body becomes weak, and I can’t concentrate when the teacher is teaching.” (FGD, Primary girl, Southern Zone) “I will be quiet in class, and I will not be able to even answer questions when the teacher asks because my concentration will be on the menses.” (FGD, Primary girl, Northern Zone) “Because of the pain associated with menstruation, I sometimes don’t pay attention to what the teacher is teaching.” (FGD, Primary girl, Northern Zone) The SHEP coordinators validated the views expressed by the girls. They identified several learning challenges that girls commonly experience during menstruation. These include difficulty concentrating, fatigue and sleepiness, as well as frustration and heightened discomfort resulting from menstrual pain. “Some of the girls are not able to concentrate; they keep their heads on the table most of the time. They do not participate in class activities fully.” (Female SHEP Coordinator, Southern Zone). “A few of them keep their head on the table because of the pain. They are not able to concentrate because they feel tired or weak. Some do not go for break.” (Female SHEP Coordinator, Southern Zone) “Some of the girls lose concentration in class and do not fully participate in class activities due to the discomfort they feel, but few of them are able to tell us the reason, whether it’s menstruation or other health issues.” (Female SHEP Coordinator, Middle Zone) “They don't participate in class because some of them automatically become sick during this period. They sometimes look tired, and this affects their concentration.” (Male SHEP Coordinator, Northern Zone) “Learning is difficult for some of them, especially those who experience cramps. They are so concentrated on the pain, and they lose concentration during lessons. Their participation in class activities is very low, and some of them even sleep in class.” (Female SHEP Coordinator, Middle Zone). The figure illustrates the key themes that emerged from students’ account of how menstruation affects their learning. Cross- c utting insight: Institutional c onstraints An important insight that emerged across all themes relates to the structural and institutional limitations that undermine the effectiveness of school-based support systems for girls. School SHEP coordinators, who are mandated to provide guidance and support, reported significant barriers in fulfilling their roles. Their interventions are often restricted to basic counselling due to the absence of adequate resources, weak referral pathways, and insufficient training. The lack of dedicated funding and logistics means that coordinators are unable to provide essential materials such as menstrual hygiene products or to implement structured health and life-skills programmes. Moreover, referral systems linking schools to health facilities and social welfare services are poorly developed or non-functional, leaving many girls without the comprehensive support they require when facing menstrual, health, or psychosocial challenges. Capacity gaps further constrain the coordinators’ ability to respond effectively. Many have not received specialised training in gender-responsive pedagogy, psychosocial counselling, or menstrual hygiene management, limiting both their confidence and competence in addressing sensitive issues. In some cases, the appointment of male coordinators without adequate training in gender sensitivity exacerbates girls’ discomfort in seeking support. “We can advise the girls, but we don’t have the power or resources to change their situation. Without community support, our impact is small.” (KII, SHEP Coordinator, Middle Zone) Discussion This study examined the lived experiences of schoolgirls and the perspectives of School Health Education Programme coordinators in Ghana, offering qualitative insights into the socio-cultural and institutional barriers to girls’ schooling. The findings show how unfriendly school environments, gendered domestic responsibilities, cultural expectations, menstruation-related challenges, and institutional weaknesses intersect to constrain girls’ participation and learning. One central finding is that schools are often perceived as unfriendly spaces for menstruating girls, corresponding to the microsystems level of the theory. The absence of functional WASH facilities, limited privacy, and lack of menstrual hygiene products, combined with unsupportive teacher attitudes, create conditions that discourage attendance. Girls frequently reported missing school due to fear of staining, embarrassment, and peer teasing. These results align with evidence from sub-Saharan Africa showing that poor infrastructure and stigma are central drivers of absenteeism and dropout ( 9 , 27 ). Crucially, the school environment is not only an infrastructural issue but also a social one, where stigma and neglect reinforce exclusion. The study further highlights the role of gendered domestic labour in producing time poverty, adding the mesosystem level layer to the discussions. Many girls indicated rising early to fetch water, cook, and care for siblings, often arriving late or missing school entirely. Such unpaid work, culturally framed as natural responsibilities for girls, diminishes study time, creates fatigue, and undermines concentration. These findings resonate with global literature on time poverty, which constrains women’s and girls’ opportunities and perpetuates intergenerational cycles of inequality ( 28 , 29 ). Interventions that ease domestic workloads, such as access to water infrastructure and community childcare, are therefore vital to supporting educational participation. At the macrosystem level, cultural norms and gendered expectations emerged as a key factor in shaping the aspirations and decisions about girls’ educational trajectories. Practices such as early marriage, initiation rites, and mobility restrictions reinforce the framing of girls as future wives and mothers rather than students. Such norms discourage investment in girls’ long-term education and narrow their aspirations, even when they remain enrolled. This finding echo longstanding arguments that patriarchal norms constrain girls’ educational identities ( 5 , 30 ). However, our study also shows the ambivalence of educators, as SHEP coordinators recognised these cultural constraints yet felt ill-equipped to contest them, pointing to a gap between recognition and response. Menstruation itself demonstrates how individual and interpersonal factors intersect with school conditions to undermine learning. Beyond absenteeism, girls described fatigue, pain, and anxiety that reduced their ability to concentrate and participate in class. These accounts expand on previous research ( 31 ) by illustrating that menstruation not only keeps girls out of school but also erodes the quality of learning when they are present. Viewed through the chronosystem lens, such recurring disruptions accumulate over time, gradually undermining educational progress and reinforcing inequalities. Across all themes, institutional constraints weakened the capacity of schools to respond. The exosystem perspective further highlights how institutional weaknesses amplify these challenges. SHEP coordinators pointed to inadequate resources, weak referral systems, and insufficient training in gender-sensitive practices. In some cases, the appointment of unprepared male coordinators heightened girls’ reluctance to seek help. These accounts align with findings from other LMICs, where underfunded school health programmes rely heavily on individual initiative rather than systemic support ( 32 ). Strengthening institutional capacity through training, resources, and enhanced referral systems is, therefore, essential for schools to become both protective and educational spaces. In all, these findings suggest that barriers to girls’ schooling cannot be attributed solely to material deprivation. Instead, they reflect the interplay of ecological influences across multiple levels. Addressing these challenges, therefore, requires multi-sectoral strategies: investments in school infrastructure, policies to reduce girls’ domestic workloads, community-based efforts to challenge harmful gender norms, and stronger institutional support for school health programming. In doing so, interventions would not only reduce absenteeism but also create more enabling environments for girls’ learning and long-term educational attainment. Study limitations While this study provides valuable insights into the lived experiences of girls’ schooling in Ghana, it also acknowledges a number of limitations a number of limitations. First, the findings are based on data from a limited number of districts and schools and may not be generalised to all regions of Ghana or sub-Saharan Africa, given the significant variation in socio-cultural and institutional contexts. Secondly, this qualitative study’s analysis is based on self-reported experiences, which may be affected by recall bias, social desirability, or cultural sensitivities that could restrict openness regarding critical topics such as menstruation and gender norms. Thirdly, the study reflects a particular point in time and may not account for recent policy reforms or changes in community dynamics that shape access and participation in schooling. Finally, the cross-sectional design captures experiences at a single point in time and does not account for recent or ongoing policy reforms that may influence girls’ schooling trajectories. These limitations notwithstanding, the study highlights critical pathways for strengthening policy and practice in support of girls’ education. Conclusion This study shows that girls’ education in Ghana is still affected by structural and socio-cultural hurdles that compromise their right to education. School environments are exclusionary, with inadequate WASH facilities and menstruation stigma which limit attendance and participation. These challenges are compounded by the disproportionate domestic labour girls undertake, which reduces time for learning. Cultural norms that prioritise early marriage and reinforce restrictive gender roles further diminish aspirations and opportunities for girls to remain in school. These findings highlight the urgent need for holistic interventions that extend beyond enrolment to address the conditions that undermine girls’ participation. Gender-responsive education policies must ensure safe and inclusive school environments, strengthen menstrual health support, reduce household labour burdens, and actively engage communities in transforming harmful norms. Such approaches are critical to advancing the global commitments embodied in SDG 4 (Quality Education) and SDG 5 (Gender Equality), while also contributing to improved public health, and social equity. Policy and Practice Implications Policy and practice should prioritise gender-responsive WASH and menstrual hygiene management through investment in safe sanitation, affordable menstrual products, and stigma reduction campaigns to support girls’ attendance and dignity. At the same time, programmes must work to reduce domestic labour burdens by integrating parental sensitisation and providing infrastructure such as water points and childcare schemes to ease girls’ time poverty. Harmful norms require active challenge through multi-sectoral strategies that engage families, traditional leaders, and civil society to reshape perceptions of girls’ roles and aspirations. Institutional capacity also needs strengthening, with SHEP coordinators and teachers receiving resources, gender-sensitive training, and functional referral pathways to deliver effective support. Finally, learning during menstruation should be supported through classroom adaptations and empathetic teaching practices that ensure girls’ presence in school translates into meaningful participation. This study demonstrates that attaining gender equity in education requires interdisciplinary approaches that incorporate health, protection, and education systems by prioritising girls' voices alongside institutional perspectives. In Ghana and similar LMICs, comprehensive interventions that tackle both material conditions and social norms are crucial for ensuring that all girls may not just access education but also excel within it. Abbreviations BECE Basic Education Certificate Examination CCNY Carnegie Corporation of New York ENCAPEH Enhancing Capacity and Postgraduate Education FGDs Focus Group Discussions GES Ghana Education Service JHS Junior High Schools KIIs Informant Interviews LMICs Low- and Middle-Income Countries MHM Menstrual Hygiene Management SDG Sustainable Development Goals SHEP School Health Education Programme WASH Water, Sanitation, and Hygiene Declarations Authors’ Contributions Dr. Jones Agyapong Frimpong : Conceived the study, led data collection, conducted data analysis, and developed the first draft of the manuscript. Prof. Samuel Nii Ardey Codjoe : Contributed to study design, provided critical guidance on interpretation of findings, and revised the manuscript for important intellectual content. Prof. Mumuni Abu : Supervised data analysis, contributed to conceptual framing, and reviewed the manuscript. Dr. Angela Kyerewaa Ayisi-Addo : Provided expertise on qualitative methodology, contributed to interpretation, and revised the manuscript for clarity and scholarly depth. Esther Atujona: Contributed to data analysis and writing the manuscript. All authors read and approved the final version of the manuscript and agree to be accountable for all aspects of the work. Acknowledgements The authors gratefully acknowledge the support of the Ghana Education Service (GES) and the participating schools for granting access and facilitating data collection. We extend our appreciation to the schoolgirls and School Health Education Programme (SHEP) coordinators who generously shared their experiences and perspectives, without which this study would not have been possible. We also thank the field research assistants and translators for their invaluable contributions during data collection, transcription, and translation. This research was supported by the Andrew W. Mellon Foundation through the Enhancing Capacity and Postgraduate Education at the University of Ghana (ENCAPEH) Project , and by the Carnegie Corporation of New York (CCNY) through the BANGA-Africa Project at the University of Ghana . Their support facilitated the fieldwork and data collection processes. Funding This study was partially funded by the Andrew W. Mellon Foundation through the Enhancing Capacity and Postgraduate Education at the University of Ghana (ENCAPEH) Project , and the Carnegie Corporation of New York (CCNY) through the BANGA-Africa Project at the University of Ghana. The funders had no role in study design, data collection and analysis, the decision to publish, or the preparation of the manuscript. Competing Interests The authors declare that they have no competing interests. Ethics Approval and Consent to Participate Ethical approval for this study was obtained from the Ethics Committee for the Humanities (ECH), University of Ghana [ECH 045/ 22-23] . Permission to conduct the study was also granted by the Ghana Education Service (GES) at the national and district levels. Written informed consent was obtained from parents or guardians of all participating schoolgirls, and assent was obtained from the girls themselves prior to participation. Participation was entirely voluntary, and participants could withdraw at any stage without consequence. For key informant interviews with SHEP coordinators and teachers, written informed consent was obtained directly from participants. Confidentiality was assured by anonymising all transcripts and removing identifying information. All methods were carried out in accordance with the Declaration of Helsinki and relevant guidelines and regulations. Consent for Publication Not applicable. The study did not collect identifiable personal data, images, or videos requiring additional publication consent. Availability of data and materials The datasets that were analysed in the current study are available from the corresponding author upon reasonable request. Authors: Author 1: Corresponding Author: Dr. Jones Agyapong Frimpong Bureau for 360 Research and Innovation Limited (BRI360), Accra, Ghana University of Ghana, Regional Institute for Population Studies, Accra, Ghana [email protected] ORCID ID: https://orcid.org/0000-0002-9875-3929 Author 2: Prof. Samuel Nii Ardey Codjoe University of Ghana College of Education, Accra, Ghana Regional Institute for Population Studies, Accra, Ghana [email protected] (0000-0002-6567-0262) https://orcid.org/0000-0002-6567-0262 Author 2: Prof. Mumuni Abu University of Ghana Regional Institute for Population Studies, Accra, Ghana [email protected] 0000-0002-6455-0162 https://orcid.org/0000-0002-6455-0162 Author 2: Dr. Angela Kyerewaa Ayisi-Addo University of Environment and Sustainable Development Department of Sustainable Development and Policy Somanya, Ghana [email protected] 0000-0002-2899-3302 https://orcid.org/0000-0002-2899-3302 Author 3: Esther Atujona University of Ghana Centre for Gender Studies and Advocacy, Accra, Ghana [email protected] https://orcid.org/0000-0003-4544-5321 References Azevedo JPW De, Crawford MF, Nayer R, Rogers FH, Barron Rodriguez MR, Ding EYZ, et al. ENDING LEARNING POVERTY: What will it take? [Internet]. Washington D.C.; 2019 Oct [cited 2025 Sep 17]. Report No.: 142659. Available from: http://document.worldbank.org/curated/en/395151571251399043 Beatty A, Berkhout E, Bima L, Pradhan M, Suryadarma D. Schooling progress, learning reversal: Indonesia’s learning profiles between 2000 and 2014. Vol. 85, International Journal of Educational Development. 2021. Angrist N, Bergman P, Matsheng M. Experimental evidence on learning using low-tech when school is out. Nat Hum Behav. 2022;6(7). UNESCO, World Bank, United Nations Children’s Fund. The state of the global education crisis: a path to recovery [Internet]. UNESCO; 2021. Available from: https://unesdoc.unesco.org/ark:/48223/pf0000380128 Unterhalter E. The Many Meanings of Quality Education: Politics of Targets and Indicators in SDG4. Glob Policy [Internet]. 2019 Jan 1 [cited 2025 Sep 16];10:39–51. Available from: /doi/pdf/10.1111/1758-5899.12591 UNESCO. REPORT ON THE ACTIVITIES OF THE UNESCO INSTITUTE FOR STATISTICS. 2022. Decosas J, Dramaix M, Odei Obeng-Amoako G, Decosas H, Devillé M, Behrendt A, et al. The situation of adolescents in Ghana [Internet]. 2021 [cited 2025 Sep 17]. Available from: http://unicef.org/ghana/media/4101/file/Situation%20Analysis%20-%20Adolescent%20Girl Garn J V., Trinies V, Toubkiss J, Freeman MC. The Role of Adherence on the Impact of a School-Based Water, Sanitation, and Hygiene Intervention in Mali. Am J Trop Med Hyg [Internet]. 2017 [cited 2025 Sep 17];96(4):984. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5392652/ Sommer M, Hirsch JS, Nathanson C, Parker RG. Comfortably, safely, and without shame: Defining menstrual hygiene management as a public health issue. Am J Public Health [Internet]. 2015 Jul 1 [cited 2025 Sep 16];105(7):1302–11. Available from: /doi/pdf/10.2105/AJPH.2014.302525?download=true UNESCO. Global Education Monitoring Report – Gender Report: A new generation: 25 years of efforts for gender equality in education. Global Education Monitoring Report – Gender Report: A new generation: 25 years of efforts for gender equality in education. UNESCO; 2020 Jan. Akyeampong K, Higgins S, Sabates R, Rose P. Understanding complementary basic education in Ghana. sussex.figshare.com [Internet]. 2018 [cited 2025 Sep 21]; Available from: https://sussex.figshare.com/articles/report/Understanding_complementary_basic_education_in_Ghana/23474684/1/files/41183804.pdf Dunne M, Leach F, Chilisa B, Maundeni T. Gendered school experiences: The impact on retention and achievement in Botswana and Ghana [Internet]. 2005 [cited 2025 Sep 21].Availablefrom:https://www.academia.edu/download/50142520/genschoolbotsghanaedpaper56.pdf Hunt F. Dropping Out from School: A Cross Country Review of the Literature. Create Pathways to Access. Research Monograph, No. 16. [Internet]. 2008 [cited 2025 Sep 21]. Available from: https://eric.ed.gov/?id=ED504047 Sommer M, Sutherland C, Chandra-Mouli V. Putting menarche and girls into the global population health agenda. Reprod Health. 2015 Mar 20;12(1). Montgomery P, Ryus CR, Dolan CS, Dopson S, Scott LM. Sanitary Pad Interventions for Girls’ Education in Ghana: A Pilot Study. PLoS One [Internet]. 2012 Oct 31 [cited 2025 Sep 21];7(10):e48274. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0048274 Parkes J, Heslop J, Oando S, … SS. Conceptualising gender and violence in research: Insights from studies in schools and communities in Kenya, Ghana and Mozambique. Elsevier [Internet]. 2013 [cited 2025 Sep 21]; Available from: https://www.sciencedirect.com/science/article/pii/S0738059313000035 FAWE. Gender-Responsive Pedagogy in Early Childhood Education: A toolkit for teachers and school leaders [Internet]. 2019 [cited 2025 Sep 21]. Available from: https://fawe.org/wp-content/uploads/2019/03/GRP-in-ECE-Toolkit_low_res_72dpi_English.pdf Darvas P, Balwanz D. Basic education beyond the millennium development goals in Ghana: How equity in service delivery affects educational and learning outcomes [Internet]. 2013 [cited 2025 Sep 21]. Available from: https://books.google.com/books?hl=en&lr=&id=zAg4AgAAQBAJ&oi=fnd&pg=PP2&dq=Darvas,+Peter%3B+Balwanz,+David.+2014.+Basic+Education+beyond+the+Millennium+Development+Goals+in+Ghana&ots=2alxSqRpBf&sig=FBqCl3Iq6iryLgVHUfvMuyIXUrU Osei R, Owusu A, Asem F, Lawrence Afutu-Kotey R. Effects of Capitation Grant on Education Outcomes in Ghana Millennium Challenge Ghana Compact View project YOUTH LIVELIHOODS AND ENTREPRENEURSHIP IN THE MOBILE TELEPHONY SECTOR IN THE GREATER ACCRA METROPOLITAN AREA View project. 2009 [cited 2025 Sep 22]; Available from: https://www.researchgate.net/publication/228871302 Stromquist NP. Women in higher education today. Journal of Educational Planning and Administration [Internet]. 2015 Jul 15 [cited 2025 Sep 21];XXIX(3):287–306. Available from: https://niepa.ac.in/download/Publications/JEPA_(15%20years)/JEPA%202015_Vol-29%20(1-4)/JEPA_JUL-2015-VOL29_3%20Final.pdf#page=67 Morley L, Lussier K. Intersecting poverty and participation in higher education in ghana and tanzania. International Studies in Sociology of Education. 2009 Jun;19(2):71–85. Bronfenbrenner U. Recent Advances in Research on the Ecology of Human Development. Development as Action in Context [Internet]. 1986 [cited 2025 Sep 17];287–309. Available from: https://link.springer.com/chapter/10.1007/978-3-662-02475-1_15 Fatusi AO, Blum RW. Predictors of early sexual initiation among a nationally representative sample of Nigerian adolescents. BMC Public Health. 2008;8. Mmari K, Sabherwal S. A Review of Risk and Protective Factors for Adolescent Sexual and Reproductive Health in Developing Countries: An Update. Journal of Adolescent Health [Internet]. 2013 Nov 1 [cited 2025 Sep 16];53(5):562–72. Available from: https://www.sciencedirect.com/science/article/abs/pii/S1054139X13003832 Ghana Education Service. Ghana Education Service-Implementation Model for WASH in Schools Ghana [Internet]. 2014 [cited 2025 Sep 17]. Available from: www.washghana.net/sites/default/files/Ghana+Education+Service+WASH+in+Schools+National+Implementation+Model.pdf Morgan C, Bowling M, Bartram J, Lyn Kayser G. Water, sanitation, and hygiene in schools: Status and implications of low coverage in Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and Zambia. Int J Hyg Environ Health. 2017;220(6). Hennegan J, Montgomery P. 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 [Internet]. 2016 Feb 1 [cited 2025 Sep 16];11(2):e0146985.Availablefrom:https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0146985 Antonopoulos R, Hirway I. Unpaid Work and the Economy. Unpaid Work and the Economy [Internet]. 2010 [cited 2025 Sep 16];1–21. Available from: https://link.springer.com/chapter/10.1057/9780230250550_1 Evans DK, Yuan F. What We Learn about Girls’ Education from Interventions That Do Not Focus on Girls. World Bank Economic Review [Internet]. 2022 May 19 [cited 2025 Sep17];36(1):244–67. Availablefrom:http://documents.worldbank.org/curated/en/09972721208232158 Eloundou-Enyegue PM, Stokes CS. Teen fertility and gender inequality in education: A contextual hypothesis. Demogr Res. 2004 Dec 8;11:305–34. Phillips-Howard PA, Nyothach E, Ter Kuile FO, Omoto J, Wang D, Zeh C, et al. Menstrual cups and sanitary pads to reduce school attrition, and sexually transmitted and reproductive tract infections: a cluster randomised controlled feasibility study. BMJ Open [Internet]. 2016 [cited 2025 Sep 16];e013229. Available from: https://bmjopen.bmj.com/content/6/11/e013229.short Gelli A, Aurino E, Folson G, Arhinful D, Adamba C, Osei-Akoto I, et al. A school meals program implemented at scale in Ghana increases height-for-age during midchildhood in girls and in children from poor households: A cluster randomized trial. Journal of Nutrition. 2019 Aug 1;149(8):1434–42. Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1FGDGuidewithstudents.docx English version of the FGD Guide with students is attached as Supplementary File 1. SupplementaryFile2IDIGuidewithSHEPCoordinators.docx English version of the IDI Guide with SHEP Coordinators is attached as Supplementary File 2. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 25 Nov, 2025 Reviewers agreed at journal 11 Nov, 2025 Reviewers invited by journal 31 Oct, 2025 Editor assigned by journal 28 Oct, 2025 Editor invited by journal 06 Oct, 2025 Submission checks completed at journal 03 Oct, 2025 First submitted to journal 03 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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1","display":"","copyAsset":false,"role":"figure","size":48650,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAchieved sample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 1 figure presents the achieved sample of respondents for the study across all levels.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7712315/v1/6ef2f28fd78488a25f61be2a.png"},{"id":95680306,"identity":"bb2a84cb-a05a-4f87-8ce3-8e168a981be9","added_by":"auto","created_at":"2025-11-11 20:03:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":103726,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThemes on school environment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe figure highlights key barriers within the school setting that negatively affect girls’ participation and comfort.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7712315/v1/49b715026acb662c7519e1a9.png"},{"id":95798066,"identity":"87adca43-c33d-48c5-8471-6158707dd0a6","added_by":"auto","created_at":"2025-11-13 08:15:12","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":92470,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThemes on gendered domestic labour and time poverty\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe figure (Figure 3) illustrates how girls’ disproportionate involvement in domestic chores, financial challenges, distance to school contributes to time poverty, limiting their frequency of attendance, study time, school participation, and overall learning.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7712315/v1/82079aff25faaebfa3deccc6.png"},{"id":95680307,"identity":"5c5e8933-94ea-4834-8442-e7bd185a1adb","added_by":"auto","created_at":"2025-11-11 20:03:34","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":69553,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThemes on learning experiences during menstruation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe figure illustrates the key themes that emerged from students’ account of how menstruation affects their learning.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7712315/v1/2f0f877d08538da9a865603b.png"},{"id":95804718,"identity":"6845f642-8e04-4251-8eff-aa21cd4b4c1e","added_by":"auto","created_at":"2025-11-13 08:39:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1185847,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7712315/v1/d400a538-6906-418e-a2c1-97f79a75df0b.pdf"},{"id":95680312,"identity":"c074348e-0075-449e-a286-e8a5dc6b8a85","added_by":"auto","created_at":"2025-11-11 20:03:34","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":81246,"visible":true,"origin":"","legend":"\u003cp\u003eEnglish version of the FGD Guide with students is attached as Supplementary File 1.\u003c/p\u003e","description":"","filename":"SupplementaryFile1FGDGuidewithstudents.docx","url":"https://assets-eu.researchsquare.com/files/rs-7712315/v1/f5516448dfdb7c30bc7562d2.docx"},{"id":95799083,"identity":"01711f84-b1b0-4442-970a-bb0fe1fde04d","added_by":"auto","created_at":"2025-11-13 08:18:43","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":64350,"visible":true,"origin":"","legend":"\u003cp\u003eEnglish version of the IDI Guide with SHEP Coordinators is attached as Supplementary File 2.\u003c/p\u003e","description":"","filename":"SupplementaryFile2IDIGuidewithSHEPCoordinators.docx","url":"https://assets-eu.researchsquare.com/files/rs-7712315/v1/8ec47cb0947696a0c351c62b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003e“We carry too many burdens”: Lived experiences of girls’ schooling in Ghana, a critical look at barriers, gender norms, and institutional perspectives\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGlobally, significant progress has been achieved in expanding educational access for girls. Yet in many low- and middle-income countries (LMICs), persistent barriers continue to undermine girls’ participation and learning outcomes\u0026nbsp;(1–4).\u0026nbsp;These barriers are increasingly recognised as multidimensional, shaped not only by infrastructural deficits but also by poverty, socio-cultural norms, and gendered expectations that constrain girls’ opportunities within and beyond the classroom (5,6). While enrolment has improved in Ghana, disparities remain in regular attendance, retention, and learning performance, particularly among adolescent girls (7).\u003c/p\u003e\n\u003cp\u003eStudies in Ghana and sub-Saharan Africa have identified inadequate water, sanitation, and hygiene (WASH) facilities, poor menstrual hygiene management (MHM) support, and domestic obligations as major obstacles to girls’ education (8,9). Nonetheless, a significant portion of this evidence has been derived from quantitative surveys or programmatic evaluations that predominantly measure outcomes such as enrolment or attendance. Less attention has been given to the ‘\u003cem\u003elived experiences\u003c/em\u003e\u003cem\u003e’\u003c/em\u003e of girls themselves and how they interpret the\u0026nbsp;challenges\u0026nbsp;they face. Understanding these experiences is essential because they capture how material deprivation, cultural expectations, and institutional responses intersect in everyday life, shaping both immediate school participation and longer-term educational aspirations.\u003c/p\u003e\n\u003cp\u003eThe perspectives of school stakeholders, including School Health Education Programme (SHEP) coordinators in Ghana, are essential for understanding how institutions recognise and address the difficulties faced by girls in school. SHEP coordinators oversee school health and welfare, encompassing hygiene, safety, and protection matters. Yet, their voices are often absent from research on girls’ education. This largely limits insights into the constraints schools face in providing support. This study addresses these gaps by exploring the lived experiences of girls and the perspectives of SHEP coordinators in Ghana. Specifically, it examines:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eHow girls describe the barriers they face in attending school and achieving positive learning experiences.\u003c/li\u003e\n \u003cli\u003eHow SHEP coordinators interpret and respond to these barriers at the institutional level.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eIn combining these perspectives, the study contributes a more holistic understanding of the social, cultural, and institutional dynamics shaping girls’ education. The findings are intended to inform integrated interventions that move beyond infrastructural provision to address stigma, gender norms, and systemic support for girls in schools.\u003c/p\u003e"},{"header":"Literature review","content":"\u003cp\u003eEducation for girls in sub-Saharan Africa continues to be limited by a combination of institutional, cultural, and structural constraints. Despite policy reforms like Ghana\u0026rsquo;s Free Compulsory Universal Basic Education, gender disparities continue, as girls are more prone to dropout due to social expectations and structural disadvantages (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePatriarchal norms impose significant domestic responsibilities on girls and heighten concerns regarding their sexuality and marriage prospects, thereby constraining their educational opportunities(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMenstrual hygiene management presents an additional barrier, as insufficient access to sanitary products, stigma, and inadequate WASH facilities negatively impact attendance and participation, especially in rural areas (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). School environments frequently reinforce inequality, as teacher attitudes, peer dynamics, and gender-stereotyped curricula hinder girls' aspirations, particularly in STEM fields (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Policies like the Girls\u0026rsquo; Education Unit, Capitation Grant, and LEAP cash transfers have increased enrolment; however, their effects are inconsistent, highlighting ongoing implementation gaps (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Feminist and intersectional perspectives highlight that enhancing girls' education necessitates addressing both access and the deep-rooted power dynamics influenced by gender, poverty, geography, and disability (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In summary, girls' education in Ghana is influenced by interconnected and complex web of challenges that transcend the individual level.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eTheoretical framework\u003c/h2\u003e\u003cp\u003eThis study draws on Bronfenbrenner's Ecological Systems Theory (\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) to investigate the pathways that connect MHM to learning outcomes and learning. The framework emphasises the multifaceted interactions that influence individual practices across six interrelated levels. The microsystem (immediate contexts such as family, peers, and WASH facilities) and the mesosystem (interactions within home, school, and community networks) surround the individual at the centre. The macrosystem is a reflection of broader socio-cultural norms, beliefs, and gender roles, while the exosystem includes structures that indirectly affect adolescents, such as economic systems, educational institutions, and policies. Finally, the chronosystem emphasises the temporal dimension, which is the way in which past experiences influence current outcomes. This model emphasises the interdependence of biological, psychological, social, organisational, community, and policy factors, providing a comprehensive perspective on the impact of societal structures and environments on the MHM practices of adolescents and their implications for education.\u003c/p\u003e\u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy Design\u003c/h2\u003e\n \u003cp\u003eThis research utilised a qualitative descriptive design incorporating focus group discussions (FGDs) and key informant interviews (KIIs). Utilising Bronfenbrenner\u0026rsquo;s Ecological Systems Theory, the analysis examined the interplay of individual, societal, and structural factors in influencing menstrual hygiene management (MHM), school attendance, and educational outcomes (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e). The framework contextualised girls\u0026rsquo; experiences within familial, educational, communal, and wider societal frameworks, guiding the conceptualisation of study variables, selection of respondents, and incorporation of girls\u0026rsquo; viewpoints. This methodological approach was selected to document the lived experiences of girls and the institutional perspectives of SHEP coordinators in their own terms, facilitating a more profound comprehension of the socio-cultural circumstances affecting education.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eStudy Setting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted across six districts in Ghana, purposively selected to represent the country\u0026rsquo;s three ecological zones: Northern, Middle, and Southern. These districts comprise: Accra Metro, Shai Osudoku District (southern zone), Kumasi Metro and Sekyere South District (middle zone) and Tamale Metro and Nanton District (northern zone). The sampled districts reflect diversity in socio-cultural practices, economic conditions, and educational environments. Schools were sampled in collaboration with the Ghana Education Service (GES), focusing both on rural and urban schools.\u003c/p\u003e\n\u003ch3\u003eParticipants and Sampling\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eFocus Group Discussions (FGDs)\u003c/h2\u003e\n \u003cp\u003eA total of 43 FGDs were conducted with schoolgirls aged 9\u0026ndash;17 years, drawn from 24 primary (primary 5 and 6 learners) and 24 junior high schools (JHS 1 and 2 learners). Literature(\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e) establishes that menstruation typically commences around the age of 11, contingent upon the child\u0026rsquo;s physiological development, at which point the child is generally in primary 5 or 6; this rationale underpins the focus on students in these grades. The emphasis at the Junior High level was solely on JHS 1 and 2, as JHS 3 pupils had concluded their Basic Education Certificate Examination (BECE) and were no longer part of the educational system. FGDs were stratified by school level and district to ensure diversity of perspectives. Each group consisted of 6\u0026ndash;10 participants, purposively selected to reflect a mix of age, class level and socio-economic background.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eKey Informant Interviews (KIIs)\u003c/h3\u003e\n\u003cp\u003eAmong the 43 SHEP coordinators involved, the majority were female (74.4%) and resided in urban areas (67.4%), with equitable representation from the Ashanti (37.2%), Northern (37.2%), and Greater Accra (25.6%) regions. Participants were recruited from six districts, with a near-equal distribution between junior high schools (51.2%) and primary schools (48.8%). This guaranteed varied perspectives across gender, geography, and educational level.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1: Achieved sample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 1 figure presents the achieved sample of respondents for the study across all levels.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData collection took place between September and October 2022. The FGDs explored girls\u0026rsquo; daily schooling experiences, barriers to attendance, menstrual hygiene challenges, domestic responsibilities, community expectations, and perceived support from schools. The KIIs focused on institutional responses, challenges in supporting girls, referral systems, and observations of socio-cultural practices affecting attendance. Interviews and discussions were conducted in English, with the local languages used for emphasis. Trained facilitators led sessions using semi-structured guides. Almost all sessions were audio-recorded with permission, translated into English where necessary, and transcribed verbatim.\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eData Analysis\u003c/h2\u003e\n \u003cp\u003eData were analysed thematically using Dedoose software. A coding framework was developed both deductively, based on study objectives (e.g., attendance, menstruation, domestic work, cultural norms, institutional responses), and inductively, from emergent themes in the transcripts. Transcripts were double-coded by two researchers to ensure reliability, and discrepancies were resolved through consensus. Themes were synthesised into broader categories that captured recurring experiences and perspectives. Illustrative quotes were selected to highlight participants\u0026rsquo; voices.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eEthical considerations\u003c/h2\u003e\n \u003cp\u003eEthical approval was obtained from the University of Ghana Ethics Committee for the Humanities (ECH 045/22\u0026ndash;23), and school entry authorisation was granted by the Ghana Education Service. Written informed consent was obtained from parents/guardians, and assent was sought from all participating girls. Confidentiality was maintained by anonymising transcripts and using pseudonyms for quotes.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAnalysis of the 43 FGDs with girls and 43 KIIs with SHEP coordinators revealed four interrelated themes shaping girls\u0026rsquo; school experiences: (1) unfriendly school environment, (2) gendered domestic labour and time poverty, (3) cultural\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eexpectations and constrained aspirations, and (4) girls\u0026rsquo; classroom experiences in the context of menstruation. While girls described the direct impact of these barriers on their daily schooling, SHEP coordinators provided insights into institutional constraints and community-level dynamics that reinforced these challenges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eUnfriendly school environment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research examined the experiences of adolescent girls regarding the conduciveness of the school environment for menstrual hygiene management. The analysis indicates that the school context is largely unsupportive of menstruating girls. This situation is primarily associated with the absence of functional WASH infrastructure, inadequate institutional support manifested in unapproachable teachers and inactive or unavailable SHEP, insufficient provision of MHM materials, and the appointment of male SHEP coordinators, which further limits gender-sensitive support mechanisms (Figure 2).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eThe school is not friendly for menstruating because there is no water inside the washrooms for us to wash ourselves and change our sanitary pads.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003e(\u003c/em\u003e\u003cem\u003eFGD\u0026nbsp;\u003c/em\u003e\u003cem\u003eJHS girl, Northern Zone)\u003c/em\u003e\u003cem\u003e,\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When there is no pad, I use cloth, but I feel shy and afraid it will stain my dress. Sometimes I don\u0026rsquo;t go to school those days.\u0026rdquo;\u003c/em\u003e (FGD, JHS girl, Northern Zone)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The toilets are not good. If you go there during your period, people laugh at you. So some girls prefer to stay at home.\u0026rdquo;\u003c/em\u003e (FGD, Primary girl, Southern Zone)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eThere is no changing room in the school, and so if you are menstruating in school and there\u0026apos;s the need to wear a pad or change your pad, we just go back home.\u0026rdquo;\u003c/em\u003e (FGD Group 8, Northern Zone).\u003c/p\u003e\n\u003cp\u003eSHEP coordinators confirmed these challenges, noting that inadequate facilities and limited school budgets constrained their ability to provide safe spaces or emergency sanitary supplies.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We try to help when a girl comes with a problem, but we don\u0026rsquo;t always have pads or even a private room for her. This makes it difficult to keep them in school.\u0026rdquo;\u003c/em\u003e (KII, SHEP Coordinator, Middle Zone)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eThe school environment is not friendly for menstruating girls. The school does not have a changing room for menstruating girls. The girls change their pads in the toilet and urinal. The pupils do not receive support from the teachers. They normally receive support from the SHEP coordinator.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(KII, SHEP Coordinator, Northern Zone)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2: Gendered\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ed\u003c/strong\u003e\u003cstrong\u003eomestic\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003el\u003c/strong\u003e\u003cstrong\u003eabour and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003et\u003c/strong\u003e\u003cstrong\u003eime\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003cstrong\u003eoverty\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGirls described how household responsibilities interfered with schooling. Tasks such as fetching water, cooking, or caring for siblings often led to lateness, absenteeism, and fatigue during lessons (Figure 3).\u0026nbsp;The evidence shows that the drivers of absenteeism extend beyond economic constraints and social events to include entrenched gender norms around domestic responsibilities. Evidence from the field points to girls\u0026rsquo; involvement in household chores (e.g., cooking, cleaning, and water collection), caregiving roles (for younger siblings or sick parents), and economic activities (trading, apprenticeships, and nannying). These obligations often occur during school hours or early mornings, resulting in lateness, fatigue, or complete absence from school. The feminisation of domestic labour thus becomes a direct educational barrier.\u003c/p\u003e\n\u003cp\u003eTime poverty, defined as the chronic lack of discretionary time due to competing demands of unpaid and paid work, emerges as a critical dimension of educational inequality. For many girls, school attendance is constrained not only by financial challenges such as lack of feeding or transport money, but also by the temporal costs of labour-intensive tasks like farm work (planting, harvesting) and extended caregiving. Unlike boys, whose labour is more frequently monetised or socially legitimised, girls\u0026rsquo; contributions are undervalued yet demand long hours, leaving them with limited time for learning, rest, or leisure.\u003c/p\u003e\n\u003cp\u003eThe situation is further compounded by social events: funerals, weddings, outdooring ceremonies, and passing-out celebrations that demand children\u0026rsquo;s participation, with girls often playing supportive domestic or cultural roles. Peer influence and sickness exacerbate absenteeism, but the underlying burden of domestic responsibilities highlights how deeply time poverty is gendered within households and communities.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Before school, I fetch water and cook. Sometimes I am late, and the teacher punishes me. I feel tired in class.\u0026rdquo;\u003c/em\u003e (FGD, JHS girl, Northern Zone)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;On market days, we don\u0026rsquo;t come to school because we help our mothers to sell. It happens many times in a term.\u0026rdquo;\u003c/em\u003e (FGD, Primary girl, Southern Zone)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eFarming activities and during wedding or naming ceremonies. Also, when your mother is not around and you have to take care of your young siblings.\u0026rdquo;\u003c/em\u003e (FGD, JHS girl, Northern Zone)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eSometimes we help our parents in the market; most of us take care of our younger siblings\u003c/em\u003e\u003cem\u003e\u0026nbsp;as well\u003c/em\u003e\u003cem\u003e.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(FGD, Primary Girl, Middle Zone)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSHEP coordinators also highlighted this issue, emphasising that the domestic workload for girls was heavier than for boys, with clear consequences for attendance and learning.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You can see that girls are often absent after weekends or farming days. Parents depend on them for household work more than boys.\u0026rdquo;\u003c/em\u003e (KII, SHEP Coordinator, Northern Zone)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eMost parents of students here are single parents, so most girls missing school have to do with pocket money and work-related support to family sometimes. Distance is also another reason, especially when it rains in the morning.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(KII SHEP Coordinator, Middle Zone)\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe figure (Figure 3) illustrates how girls\u0026rsquo; disproportionate involvement in domestic chores, financial challenges, distance to school contributes to time poverty, limiting their frequency of attendance, study time, school participation, and overall learning.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 3: Cultural\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ee\u003c/strong\u003e\u003cstrong\u003expectations and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ec\u003c/strong\u003e\u003cstrong\u003eonstrained\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ea\u003c/strong\u003e\u003cstrong\u003espirations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCultural norms and practices continue to exert a strong influence on girls\u0026rsquo; educational trajectories, often constraining their aspirations and shaping parental decisions regarding schooling. From the perspectives of both the girls and the SHEP coordinators, gendered expectations position girls primarily as future wives and mothers, with their value tied to domestic responsibilities and marital prospects rather than educational achievement. Such norms reinforce the perception that investment in girls\u0026rsquo; education yields limited returns compared to preparing them for marriage. Qualitative evidence highlights these realities: several girls articulated internalised expectations, conveying scepticism regarding the significance of schooling when prospective responsibilities were contextualised within marriage and domesticity.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some of my friends stopped school after marriage. Parents said it is better to prepare them for their husband than to waste money on school.\u0026rdquo;\u003c/em\u003e (FGD, JHS girl, Northern Zone)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When you grow and people see you with books, they say you are wasting time. They say the girl must marry.\u0026rdquo;\u003c/em\u003e (FGD, Primary girl, Middle Zone)\u003c/p\u003e\n\u003cp\u003eSHEP coordinators acknowledged the influence of these cultural scripts, noting that while community sensitisation efforts had made progress, many families still prioritised boys\u0026rsquo; education.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Parents support education in words, but when resources are scarce, they choose to support the boy. For girls, marriage is still seen as an achievement.\u0026rdquo;\u003c/em\u003e (KII, SHEP Coordinator, Southern Zone)\u003c/p\u003e\n\u003ch2 id=\"_Toc148534896\"\u003e\u003cstrong\u003eTheme 4:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eGirls\u0026rsquo; Classroom Experiences in the Context of Menstruation\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe study highlights that menstruation significantly disrupts girls\u0026rsquo; learning experiences in school. Focus group discussions revealed that many girls encounter difficulty concentrating during lessons, often due to anxiety about staining their uniforms, discomfort, and the need for constant self-monitoring. These concerns lead to absent-mindedness and reduced classroom participation, with some girls preferring to remain silent even when they know the answers.\u003c/p\u003e\n\u003cp\u003eAdditionally, the physical pain and fatigue associated with menstruation, including abdominal cramps, headaches, and loss of appetite, further reduce their capacity to engage fully in classroom activities. Emotional responses such as irritation, withdrawal, and low self-confidence compound these challenges, reinforcing a cycle of reduced attentiveness and academic disengagement (Figure 4). The following quotes speak to this result:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I bleed a lot, and it makes it difficult to concentrate.\u0026rdquo; (FGD, Primary girl, Northern Zone)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I keep checking myself because I am scared to stain my uniform, and I end up not understanding what is being taught.\u0026rdquo; (FGD, Primary girl, Middle Zone)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t feel like eating the whole day, and my body becomes weak, and I can\u0026rsquo;t concentrate when the teacher is teaching.\u0026rdquo; (FGD, Primary girl, Southern Zone)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I will be quiet in class, and I will not be able to even answer questions when the teacher asks because my concentration will be on the menses.\u0026rdquo; (FGD, Primary girl, Northern Zone)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Because of the pain associated with menstruation, I sometimes don\u0026rsquo;t pay attention to what the teacher is teaching.\u0026rdquo; (FGD, Primary girl, Northern Zone)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe SHEP coordinators validated the views expressed by the girls. They identified several learning challenges that girls commonly experience during menstruation. These include difficulty concentrating, fatigue and sleepiness, as well as frustration and heightened discomfort resulting from menstrual pain.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some of the girls are not able to concentrate; they keep their heads on the table most of the time. They do not participate in class activities fully.\u0026rdquo;\u003c/em\u003e (Female SHEP Coordinator, Southern Zone).\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A few of them keep their head on the table because of the pain. They are not able to concentrate because they feel tired or weak. Some do not go for break.\u0026rdquo;\u003c/em\u003e (Female SHEP Coordinator, Southern Zone)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some of the girls lose concentration in class and do not fully participate in class activities due to the discomfort they feel, but few of them are able to tell us the reason, whether it\u0026rsquo;s menstruation or other health issues.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Female SHEP Coordinator, Middle Zone)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They don\u0026apos;t participate in class because some of them automatically become sick during this period. They sometimes look tired, and this affects their concentration.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Male SHEP Coordinator, Northern Zone)\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Learning is difficult for some of them, especially those who experience cramps. They are so concentrated on the pain, and they lose concentration during lessons. Their participation in class activities is very low, and some of them even sleep in class.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Female SHEP Coordinator, Middle Zone).\u003c/p\u003e\n\u003cp\u003eThe figure illustrates the key themes that emerged from students\u0026rsquo; account of how menstruation affects their learning.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCross-\u003c/strong\u003e\u003cstrong\u003ec\u003c/strong\u003e\u003cstrong\u003eutting insight: Institutional\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ec\u003c/strong\u003e\u003cstrong\u003eonstraints\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn important insight that emerged across all themes relates to the structural and institutional limitations that undermine the effectiveness of school-based support systems for girls. School SHEP coordinators, who are mandated to provide guidance and support, reported significant barriers in fulfilling their roles. Their interventions are often restricted to basic counselling due to the absence of adequate resources, weak referral pathways, and insufficient training.\u003c/p\u003e\n\u003cp\u003eThe lack of dedicated funding and logistics means that coordinators are unable to provide essential materials such as menstrual hygiene products or to implement structured health and life-skills programmes. Moreover, referral systems linking schools to health facilities and social welfare services are poorly developed or non-functional, leaving many girls without the comprehensive support they require when facing menstrual, health, or psychosocial challenges.\u003c/p\u003e\n\u003cp\u003eCapacity gaps further constrain the coordinators\u0026rsquo; ability to respond effectively. Many have not received specialised training in gender-responsive pedagogy, psychosocial counselling, or menstrual hygiene management, limiting both their confidence and competence in addressing sensitive issues. In some cases, the appointment of male coordinators without adequate training in gender sensitivity exacerbates girls\u0026rsquo; discomfort in seeking support.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We can advise the girls, but we don\u0026rsquo;t have the power or resources to change their situation. Without community support, our impact is small.\u0026rdquo;\u003c/em\u003e (KII, SHEP Coordinator, Middle Zone)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the lived experiences of schoolgirls and the perspectives of School Health Education Programme coordinators in Ghana, offering qualitative insights into the socio-cultural and institutional barriers to girls\u0026rsquo; schooling. The findings show how unfriendly school environments, gendered domestic responsibilities, cultural expectations, menstruation-related challenges, and institutional weaknesses intersect to constrain girls\u0026rsquo; participation and learning.\u003c/p\u003e\u003cp\u003eOne central finding is that schools are often perceived as unfriendly spaces for menstruating girls, corresponding to the microsystems level of the theory. The absence of functional WASH facilities, limited privacy, and lack of menstrual hygiene products, combined with unsupportive teacher attitudes, create conditions that discourage attendance. Girls frequently reported missing school due to fear of staining, embarrassment, and peer teasing. These results align with evidence from sub-Saharan Africa showing that poor infrastructure and stigma are central drivers of absenteeism and dropout (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Crucially, the school environment is not only an infrastructural issue but also a social one, where stigma and neglect reinforce exclusion.\u003c/p\u003e\u003cp\u003eThe study further highlights the role of gendered domestic labour in producing time poverty, adding the mesosystem level layer to the discussions. Many girls indicated rising early to fetch water, cook, and care for siblings, often arriving late or missing school entirely. Such unpaid work, culturally framed as natural responsibilities for girls, diminishes study time, creates fatigue, and undermines concentration. These findings resonate with global literature on time poverty, which constrains women\u0026rsquo;s and girls\u0026rsquo; opportunities and perpetuates intergenerational cycles of inequality (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Interventions that ease domestic workloads, such as access to water infrastructure and community childcare, are therefore vital to supporting educational participation.\u003c/p\u003e\u003cp\u003eAt the macrosystem level, cultural norms and gendered expectations emerged as a key factor in shaping the aspirations and decisions about girls\u0026rsquo; educational trajectories. Practices such as early marriage, initiation rites, and mobility restrictions reinforce the framing of girls as future wives and mothers rather than students. Such norms discourage investment in girls\u0026rsquo; long-term education and narrow their aspirations, even when they remain enrolled. This finding echo longstanding arguments that patriarchal norms constrain girls\u0026rsquo; educational identities (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). However, our study also shows the ambivalence of educators, as SHEP coordinators recognised these cultural constraints yet felt ill-equipped to contest them, pointing to a gap between recognition and response.\u003c/p\u003e\u003cp\u003eMenstruation itself demonstrates how individual and interpersonal factors intersect with school conditions to undermine learning. Beyond absenteeism, girls described fatigue, pain, and anxiety that reduced their ability to concentrate and participate in class. These accounts expand on previous research (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) by illustrating that menstruation not only keeps girls out of school but also erodes the quality of learning when they are present. Viewed through the chronosystem lens, such recurring disruptions accumulate over time, gradually undermining educational progress and reinforcing inequalities.\u003c/p\u003e\u003cp\u003eAcross all themes, institutional constraints weakened the capacity of schools to respond. The exosystem perspective further highlights how institutional weaknesses amplify these challenges. SHEP coordinators pointed to inadequate resources, weak referral systems, and insufficient training in gender-sensitive practices. In some cases, the appointment of unprepared male coordinators heightened girls\u0026rsquo; reluctance to seek help. These accounts align with findings from other LMICs, where underfunded school health programmes rely heavily on individual initiative rather than systemic support (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Strengthening institutional capacity through training, resources, and enhanced referral systems is, therefore, essential for schools to become both protective and educational spaces.\u003c/p\u003e\u003cp\u003eIn all, these findings suggest that barriers to girls\u0026rsquo; schooling cannot be attributed solely to material deprivation. Instead, they reflect the interplay of ecological influences across multiple levels. Addressing these challenges, therefore, requires multi-sectoral strategies: investments in school infrastructure, policies to reduce girls\u0026rsquo; domestic workloads, community-based efforts to challenge harmful gender norms, and stronger institutional support for school health programming. In doing so, interventions would not only reduce absenteeism but also create more enabling environments for girls\u0026rsquo; learning and long-term educational attainment.\u003c/p\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eStudy limitations\u003c/h2\u003e\u003cp\u003eWhile this study provides valuable insights into the lived experiences of girls\u0026rsquo; schooling in Ghana, it also acknowledges a number of limitations a number of limitations. First, the findings are based on data from a limited number of districts and schools and may not be generalised to all regions of Ghana or sub-Saharan Africa, given the significant variation in socio-cultural and institutional contexts. Secondly, this qualitative study\u0026rsquo;s analysis is based on self-reported experiences, which may be affected by recall bias, social desirability, or cultural sensitivities that could restrict openness regarding critical topics such as menstruation and gender norms. Thirdly, the study reflects a particular point in time and may not account for recent policy reforms or changes in community dynamics that shape access and participation in schooling. Finally, the cross-sectional design captures experiences at a single point in time and does not account for recent or ongoing policy reforms that may influence girls\u0026rsquo; schooling trajectories. These limitations notwithstanding, the study highlights critical pathways for strengthening policy and practice in support of girls\u0026rsquo; education.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study shows that girls\u0026rsquo; education in Ghana is still affected by structural and socio-cultural hurdles that compromise their right to education. School environments are exclusionary, with inadequate WASH facilities and menstruation stigma which limit attendance and participation.\u003c/p\u003e\u003cp\u003eThese challenges are compounded by the disproportionate domestic labour girls undertake, which reduces time for learning. Cultural norms that prioritise early marriage and reinforce restrictive gender roles further diminish aspirations and opportunities for girls to remain in school. These findings highlight the urgent need for holistic interventions that extend beyond enrolment to address the conditions that undermine girls\u0026rsquo; participation. Gender-responsive education policies must ensure safe and inclusive school environments, strengthen menstrual health support, reduce household labour burdens, and actively engage communities in transforming harmful norms. Such approaches are critical to advancing the global commitments embodied in SDG 4 (Quality Education) and SDG 5 (Gender Equality), while also contributing to improved public health, and social equity.\u003c/p\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003ePolicy and Practice Implications\u003c/h2\u003e\u003cp\u003ePolicy and practice should prioritise gender-responsive WASH and menstrual hygiene management through investment in safe sanitation, affordable menstrual products, and stigma reduction campaigns to support girls\u0026rsquo; attendance and dignity. At the same time, programmes must work to reduce domestic labour burdens by integrating parental sensitisation and providing infrastructure such as water points and childcare schemes to ease girls\u0026rsquo; time poverty. Harmful norms require active challenge through multi-sectoral strategies that engage families, traditional leaders, and civil society to reshape perceptions of girls\u0026rsquo; roles and aspirations. Institutional capacity also needs strengthening, with SHEP coordinators and teachers receiving resources, gender-sensitive training, and functional referral pathways to deliver effective support. Finally, learning during menstruation should be supported through classroom adaptations and empathetic teaching practices that ensure girls\u0026rsquo; presence in school translates into meaningful participation.\u003c/p\u003e\u003cp\u003eThis study demonstrates that attaining gender equity in education requires interdisciplinary approaches that incorporate health, protection, and education systems by prioritising girls' voices alongside institutional perspectives. In Ghana and similar LMICs, comprehensive interventions that tackle both material conditions and social norms are crucial for ensuring that all girls may not just access education but also excel within it.\u003c/p\u003e\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003col\u003e\n \u003cli\u003eBECE \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Basic Education Certificate Examination\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCCNY \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Carnegie Corporation of New York \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eENCAPEH \u0026nbsp; \u0026nbsp; \u0026nbsp;Enhancing Capacity and Postgraduate Education\u003c/li\u003e\n \u003cli\u003eFGDs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Focus Group Discussions\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGES \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Ghana Education Service\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eJHS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Junior High Schools\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKIIs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Informant Interviews\u003c/li\u003e\n \u003cli\u003eLMICs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp;Low- and Middle-Income Countries\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMHM \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Menstrual Hygiene Management\u003c/li\u003e\n \u003cli\u003eSDG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Sustainable Development Goals\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSHEP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;School Health Education Programme\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWASH \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp;Water, Sanitation, and Hygiene\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eDr. Jones Agyapong Frimpong\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Conceived the study, led data collection, conducted data analysis, and developed the first draft of the manuscript.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eProf. Samuel Nii Ardey Codjoe\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Contributed to study design, provided critical guidance on interpretation of findings, and revised the manuscript for important intellectual content.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eProf. Mumuni Abu\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Supervised data analysis, contributed to conceptual framing, and reviewed the manuscript.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDr. Angela Kyerewaa Ayisi-Addo\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Provided expertise on qualitative methodology, contributed to interpretation, and revised the manuscript for clarity and scholarly depth.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEsther Atujona:\u003c/strong\u003e Contributed to data analysis and writing the manuscript.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll authors read and approved the final version of the manuscript and agree to be accountable for all aspects of the work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors gratefully acknowledge the support of the Ghana Education Service (GES) and the participating schools for granting access and facilitating data collection. We extend our appreciation to the schoolgirls and School Health Education Programme (SHEP) coordinators who generously shared their experiences and perspectives, without which this study would not have been possible.\u003c/p\u003e\n\u003cp\u003eWe also thank the field research assistants and translators for their invaluable contributions during data collection, transcription, and translation.\u003c/p\u003e\n\u003cp\u003eThis research was supported by the Andrew W. Mellon Foundation through the \u003cem\u003eEnhancing Capacity and Postgraduate Education\u003c/em\u003e\u003cem\u003e\u0026nbsp;at the University of Ghana (ENCAPEH) Project\u003c/em\u003e, and by the Carnegie Corporation of New York (CCNY) through the \u003cem\u003eBANGA-Africa Project at the University of Ghana\u003c/em\u003e. Their support facilitated the fieldwork and data collection processes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was partially funded by the Andrew W. Mellon Foundation through the \u003cem\u003eEnhancing Capacity and Postgraduate Education at the University of Ghana (ENCAPEH) Project\u003c/em\u003e, and the Carnegie Corporation of New York (CCNY) through the \u003cem\u003eBANGA-Africa Project\u003c/em\u003e at the University of Ghana. The funders had no role in study design, data collection and analysis, the decision to publish, or the preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Ethics Committee for the Humanities (ECH), University of Ghana \u003cstrong\u003e[ECH 045/ 22-23]\u003c/strong\u003e. Permission to conduct the study was also granted by the Ghana Education Service (GES) at the national and district levels.\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from parents or guardians of all participating schoolgirls, and assent was obtained from the girls themselves prior to participation. Participation was entirely voluntary, and participants could withdraw at any stage without consequence. For key informant interviews with SHEP coordinators and teachers, written informed consent was obtained directly from participants.\u003c/p\u003e\n\u003cp\u003eConfidentiality was assured by anonymising all transcripts and removing identifying information. All methods were carried out in accordance with the Declaration of Helsinki and relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. The study did not collect identifiable personal data, images, or videos requiring additional publication consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets that were analysed in the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor 1: Corresponding Author:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDr. Jones Agyapong Frimpong\u003c/strong\u003e\u003cbr\u003eBureau for 360 Research and Innovation Limited (BRI360), Accra, Ghana\u003c/p\u003e\n\u003cp\u003eUniversity of Ghana, Regional Institute for Population Studies, Accra, Ghana\u003cbr\[email protected]\u003cbr\u003eORCID ID: \u003cstrong\u003ehttps://orcid.org/0000-0002-9875-3929\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor 2:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProf. Samuel Nii Ardey Codjoe\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUniversity of Ghana\u003c/p\u003e\n\u003cp\u003eCollege of Education, Accra, Ghana\u003c/p\u003e\n\u003cp\u003eRegional Institute for Population Studies, Accra, Ghana\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003ch3\u003e\u003cu\u003e(0000-0002-6567-0262)\u003c/u\u003e\u003c/h3\u003e\n\u003cp\u003ehttps://orcid.org/0000-0002-6567-0262\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor 2:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProf. Mumuni Abu\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUniversity of Ghana\u003c/p\u003e\n\u003cp\u003eRegional Institute for Population Studies, Accra, Ghana\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003e0000-0002-6455-0162\u003c/p\u003e\n\u003cp\u003ehttps://orcid.org/0000-0002-6455-0162\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor 2:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDr. Angela Kyerewaa Ayisi-Addo\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUniversity of Environment and Sustainable Development\u003c/p\u003e\n\u003cp\u003eDepartment of Sustainable Development and Policy\u003c/p\u003e\n\u003cp\u003eSomanya, Ghana\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003e0000-0002-2899-3302\u003c/p\u003e\n\u003cp\u003ehttps://orcid.org/0000-0002-2899-3302\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor 3:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEsther Atujona\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUniversity of Ghana\u003c/p\u003e\n\u003cp\u003eCentre for Gender Studies and Advocacy, Accra, Ghana\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003ehttps://orcid.org/0000-0003-4544-5321\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAzevedo JPW De, Crawford MF, Nayer R, Rogers FH, Barron Rodriguez MR, Ding EYZ, et al. ENDING LEARNING POVERTY: What will it take? [Internet]. Washington D.C.; 2019 Oct [cited 2025 Sep 17]. Report No.: 142659. Available from: http://document.worldbank.org/curated/en/395151571251399043\u003c/li\u003e\n \u003cli\u003eBeatty A, Berkhout E, Bima L, Pradhan M, Suryadarma D. Schooling progress, learning reversal: Indonesia\u0026rsquo;s learning profiles between 2000 and 2014. Vol. 85, International Journal of Educational Development. 2021.\u003c/li\u003e\n \u003cli\u003eAngrist N, Bergman P, Matsheng M. Experimental evidence on learning using low-tech when school is out. Nat Hum Behav. 2022;6(7).\u003c/li\u003e\n \u003cli\u003eUNESCO, World Bank, United Nations Children\u0026rsquo;s Fund. The state of the global education crisis: a path to recovery [Internet]. UNESCO; 2021. Available from: https://unesdoc.unesco.org/ark:/48223/pf0000380128\u003c/li\u003e\n \u003cli\u003eUnterhalter E. The Many Meanings of Quality Education: Politics of Targets and Indicators in SDG4. Glob Policy [Internet]. 2019 Jan 1 [cited 2025 Sep 16];10:39\u0026ndash;51. Available from: /doi/pdf/10.1111/1758-5899.12591\u003c/li\u003e\n \u003cli\u003eUNESCO. REPORT ON THE ACTIVITIES OF THE UNESCO INSTITUTE FOR STATISTICS. 2022.\u003c/li\u003e\n \u003cli\u003eDecosas J, Dramaix M, Odei Obeng-Amoako G, Decosas H, Devill\u0026eacute; M, Behrendt A, et al. The situation of adolescents in Ghana [Internet]. 2021 [cited 2025 Sep 17]. Available from: http://unicef.org/ghana/media/4101/file/Situation%20Analysis%20-%20Adolescent%20Girl\u003c/li\u003e\n \u003cli\u003eGarn J V., Trinies V, Toubkiss J, Freeman MC. The Role of Adherence on the Impact of a School-Based Water, Sanitation, and Hygiene Intervention in Mali. Am J Trop Med Hyg [Internet]. 2017 [cited 2025 Sep 17];96(4):984. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5392652/\u003c/li\u003e\n \u003cli\u003eSommer M, Hirsch JS, Nathanson C, Parker RG. Comfortably, safely, and without shame: Defining menstrual hygiene management as a public health issue. Am J Public Health [Internet]. 2015 Jul 1 [cited 2025 Sep 16];105(7):1302\u0026ndash;11. Available from: /doi/pdf/10.2105/AJPH.2014.302525?download=true\u003c/li\u003e\n \u003cli\u003eUNESCO. Global Education Monitoring Report \u0026ndash; Gender Report: A new generation: 25 years of efforts for gender equality in education. Global Education Monitoring Report \u0026ndash; Gender Report: A new generation: 25 years of efforts for gender equality in education. UNESCO; 2020 Jan.\u003c/li\u003e\n \u003cli\u003eAkyeampong K, Higgins S, Sabates R, Rose P. Understanding complementary basic education in Ghana. sussex.figshare.com [Internet]. 2018 [cited 2025 Sep 21]; Available from: https://sussex.figshare.com/articles/report/Understanding_complementary_basic_education_in_Ghana/23474684/1/files/41183804.pdf\u003c/li\u003e\n \u003cli\u003eDunne M, Leach F, Chilisa B, Maundeni T. Gendered school experiences: The impact on retention and achievement in Botswana and Ghana [Internet]. 2005 [cited 2025 Sep 21].Availablefrom:https://www.academia.edu/download/50142520/genschoolbotsghanaedpaper56.pdf\u003c/li\u003e\n \u003cli\u003eHunt F. Dropping Out from School: A Cross Country Review of the Literature. Create Pathways to Access. Research Monograph, No. 16. [Internet]. 2008 [cited 2025 Sep 21]. Available from: https://eric.ed.gov/?id=ED504047\u003c/li\u003e\n \u003cli\u003eSommer M, Sutherland C, Chandra-Mouli V. Putting menarche and girls into the global population health agenda. Reprod Health. 2015 Mar 20;12(1).\u003c/li\u003e\n \u003cli\u003eMontgomery P, Ryus CR, Dolan CS, Dopson S, Scott LM. Sanitary Pad Interventions for Girls\u0026rsquo; Education in Ghana: A Pilot Study. PLoS One [Internet]. 2012 Oct 31 [cited 2025 Sep 21];7(10):e48274. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0048274\u003c/li\u003e\n \u003cli\u003eParkes J, Heslop J, Oando S, \u0026hellip; SS. Conceptualising gender and violence in research: Insights from studies in schools and communities in Kenya, Ghana and Mozambique. Elsevier [Internet]. 2013 [cited 2025 Sep 21]; Available from: https://www.sciencedirect.com/science/article/pii/S0738059313000035\u003c/li\u003e\n \u003cli\u003eFAWE. Gender-Responsive Pedagogy in Early Childhood Education: A toolkit for teachers and school leaders [Internet]. 2019 [cited 2025 Sep 21]. Available from: https://fawe.org/wp-content/uploads/2019/03/GRP-in-ECE-Toolkit_low_res_72dpi_English.pdf\u003c/li\u003e\n \u003cli\u003eDarvas P, Balwanz D. Basic education beyond the millennium development goals in Ghana: How equity in service delivery affects educational and learning outcomes [Internet]. 2013 [cited 2025 Sep 21]. Available from: https://books.google.com/books?hl=en\u0026amp;lr=\u0026amp;id=zAg4AgAAQBAJ\u0026amp;oi=fnd\u0026amp;pg=PP2\u0026amp;dq=Darvas,+Peter%3B+Balwanz,+David.+2014.+Basic+Education+beyond+the+Millennium+Development+Goals+in+Ghana\u0026amp;ots=2alxSqRpBf\u0026amp;sig=FBqCl3Iq6iryLgVHUfvMuyIXUrU\u003c/li\u003e\n \u003cli\u003eOsei R, Owusu A, Asem F, Lawrence Afutu-Kotey R. Effects of Capitation Grant on Education Outcomes in Ghana Millennium Challenge Ghana Compact View project YOUTH LIVELIHOODS AND ENTREPRENEURSHIP IN THE MOBILE TELEPHONY SECTOR IN THE GREATER ACCRA METROPOLITAN AREA View project. 2009 [cited 2025 Sep 22]; Available from: https://www.researchgate.net/publication/228871302\u003c/li\u003e\n \u003cli\u003eStromquist NP. Women in higher education today. Journal of Educational Planning and Administration [Internet]. 2015 Jul 15 [cited 2025 Sep 21];XXIX(3):287\u0026ndash;306. Available from: https://niepa.ac.in/download/Publications/JEPA_(15%20years)/JEPA%202015_Vol-29%20(1-4)/JEPA_JUL-2015-VOL29_3%20Final.pdf#page=67\u003c/li\u003e\n \u003cli\u003eMorley L, Lussier K. Intersecting poverty and participation in higher education in ghana and tanzania. International Studies in Sociology of Education. 2009 Jun;19(2):71\u0026ndash;85.\u003c/li\u003e\n \u003cli\u003eBronfenbrenner U. Recent Advances in Research on the Ecology of Human Development. Development as Action in Context [Internet]. 1986 [cited 2025 Sep 17];287\u0026ndash;309. Available from: https://link.springer.com/chapter/10.1007/978-3-662-02475-1_15\u003c/li\u003e\n \u003cli\u003eFatusi AO, Blum RW. Predictors of early sexual initiation among a nationally representative sample of Nigerian adolescents. BMC Public Health. 2008;8.\u003c/li\u003e\n \u003cli\u003eMmari K, Sabherwal S. A Review of Risk and Protective Factors for Adolescent Sexual and Reproductive Health in Developing Countries: An Update. Journal of Adolescent Health [Internet]. 2013 Nov 1 [cited 2025 Sep 16];53(5):562\u0026ndash;72. Available from: https://www.sciencedirect.com/science/article/abs/pii/S1054139X13003832\u003c/li\u003e\n \u003cli\u003eGhana Education Service. Ghana Education Service-Implementation Model for WASH in Schools Ghana [Internet]. 2014 [cited 2025 Sep 17]. Available from: www.washghana.net/sites/default/files/Ghana+Education+Service+WASH+in+Schools+National+Implementation+Model.pdf\u003c/li\u003e\n \u003cli\u003eMorgan C, Bowling M, Bartram J, Lyn Kayser G. Water, sanitation, and hygiene in schools: Status and implications of low coverage in Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and Zambia. Int J Hyg Environ Health. 2017;220(6).\u003c/li\u003e\n \u003cli\u003eHennegan J, Montgomery P. 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 [Internet]. 2016 Feb 1 [cited 2025 Sep 16];11(2):e0146985.Availablefrom:https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0146985\u003c/li\u003e\n \u003cli\u003eAntonopoulos R, Hirway I. Unpaid Work and the Economy. Unpaid Work and the Economy [Internet]. 2010 [cited 2025 Sep 16];1\u0026ndash;21. Available from: https://link.springer.com/chapter/10.1057/9780230250550_1\u003c/li\u003e\n \u003cli\u003eEvans DK, Yuan F. What We Learn about Girls\u0026rsquo; Education from Interventions That Do Not Focus on Girls. World Bank Economic Review [Internet]. 2022 May 19 [cited 2025 Sep17];36(1):244\u0026ndash;67. Availablefrom:http://documents.worldbank.org/curated/en/09972721208232158\u003c/li\u003e\n \u003cli\u003eEloundou-Enyegue PM, Stokes CS. Teen fertility and gender inequality in education: A contextual hypothesis. Demogr Res. 2004 Dec 8;11:305\u0026ndash;34.\u003c/li\u003e\n \u003cli\u003ePhillips-Howard PA, Nyothach E, Ter Kuile FO, Omoto J, Wang D, Zeh C, et al. Menstrual cups and sanitary pads to reduce school attrition, and sexually transmitted and reproductive tract infections: a cluster randomised controlled feasibility study. BMJ Open [Internet]. 2016 [cited 2025 Sep 16];e013229. Available from: https://bmjopen.bmj.com/content/6/11/e013229.short\u003c/li\u003e\n \u003cli\u003eGelli A, Aurino E, Folson G, Arhinful D, Adamba C, Osei-Akoto I, et al. A school meals program implemented at scale in Ghana increases height-for-age during midchildhood in girls and in children from poor households: A cluster randomized trial. Journal of Nutrition. 2019 Aug 1;149(8):1434\u0026ndash;42.\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Girls’ education, Menstrual hygiene, Gender norms, Domestic labour, School health, Qualitative research, Ghana","lastPublishedDoi":"10.21203/rs.3.rs-7712315/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7712315/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003cbr\u003e\nGirls continue to face barriers to sustained school participation and learning, despite Ghana's steady progress in school enrolment across basic education. Although poverty and poor facilities are highlighted by quantitative empirical research, little is known about how girls face these obstacles and how educational institutions respond to them. The lived experiences of girls and the perspectives of coordinators of the School Health Education Program (SHEP) are explored in this study, with particular emphasis on how institutional and sociocultural factors shape attendance and wellbeing.\u003c/p\u003e\n\u003cp\u003eA qualitative descriptive methodology was utilised. Data were collected through forty-three focus group discussions (FGDs) with schoolgirls aged 9-17 years and key informant interviews (KIIs) with SHEP coordinators across six districts in Ghana, purposively sampled to represent northern, middle, and southern zones. Semi-structured guides explored experiences of schooling, menstruation, domestic responsibilities, community norms, and institutional responses. Discussions were conducted in English, transcribed, and thematically analysed using the Dedoose software.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\n Four interrelated themes emerged. First, unfriendly school environments limited attendance, as girls reported insufficient WASH facilities, absence of sanitary products, and anxiety regarding potential embarrassment during menstruation. Secondly, gendered domestic labour and time poverty limited participation, as many learners missed school or arrived late due to household chores and caregiving responsibilities. Third, cultural expectations and constrained aspirations, including early marriage, initiation rites, and parental preference for boys’ education, shaped girls’ perceptions of restricted futures. Fourth, classroom experiences during menstruation were characterised by anxiety, discomfort, and reduced participation, with stigma and fear of leakage undermining concentration and engagement. SHEP coordinators acknowledged these challenges but highlighted resource limitations, weak referral systems, and limited training as barriers to effectively supporting girls.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003cbr\u003e\nThe lived experiences of girls reveal that educational exclusion extends beyond infrastructure to include stigma, gender norms, and cultural expectations, exacerbated by weak institutional solutions. A multi-sectoral approach that integrates gender-responsive WASH, household sensitisation, community norm transformation, and enhanced school support systems is crucial for creating an environment conducive to girls’ educational success. This study underscores the necessity of integrating social and cultural factors into educational and public health initiatives, prioritising the lived experiences and perspectives of girls.\u003c/p\u003e","manuscriptTitle":"“We carry too many burdens”: Lived experiences of girls’ schooling in Ghana, a critical look at barriers, gender norms, and institutional perspectives","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-11 20:03:29","doi":"10.21203/rs.3.rs-7712315/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-11-25T14:22:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59009492490193566303223459809667572441","date":"2025-11-12T00:39:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-31T04:49:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-28T09:34:07+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-06T10:24:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-03T12:17:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-10-03T12:14:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"183c0a1a-9d19-4910-9acf-3eb82c4c11f3","owner":[],"postedDate":"November 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-11T20:03:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-11 20:03:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7712315","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7712315","identity":"rs-7712315","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}