Effect of menstruation on girls and their schooling, and facilitators of menstrual hygiene management in schools: surveys in government schools in three states in India, 2015

Abstract

Background:
Lack of menstrual knowledge, poor access to sanitary products and a non-facilitating school environment can make it difficult for girls to attend school. In India, interventions have been developed to reduce the burden of menstruation for school girls by government and non-governmental organizations (NGOs). We sought to identify challenges related to menstruation, and facilitators of menstrual management in schools in three states in India.

Methods:
Surveys were conducted among menstruating school girls in class 8-10 (above 12 years of age) of 43 government schools selected through stratified random sampling in three Indian states (Maharashtra, Chhattisgarh, Tamil Nadu) in 2015. For comparison, ten model schools supported by NGOs or UNICEF with a focussed menstrual hygiene education program were selected purposely in the same states to represent the better-case scenario. We examined awareness about menarche, items used for menstruation, and facilitators on girls' experience of menstruation in regular schools and compared with model schools. Factors associated with school absence during menstruation were explored using multivariate analysis.

Findings:
More girls (mean age 14.1 years) were informed about menstruation before menarche in model schools (56%, n = 492) than in regular schools (36%, n = 2072, P < 0.001). Girls reported menstruation affected school attendance (6% vs 11% in model vs regular schools respectively, P = 0.003) and concentration (40% vs 45%, P = 0.1) and was associated with pain (31% vs 38%, P = 0.004) and fear of stain or smell (11% vs 16%, P = 0.002). About 45% of girls reported using disposable pads in both model and regular schools, but only 55% and 29% of pad-users reported good disposal facilities, respectively (P < 0.001). In multivariate analysis, reported absenteeism during menstruation was significantly lower in Tamil Nadu (adjusted prevalence ratio (APR) 95% confidence interval (CI) = 0.24, 0.14-0.40) and Maharashtra (APR 0.56, CI = 0.40-0.77) compared to Chhattisgarh, and halved in model compared to regular schools (APR 0.50, CI = 0.34-0.73). Pain medication in school (APR 0.71, CI = 0.51-0.97) and use of disposable pads (APR 0.57, CI = 0.42-0.77) were associated with lower absenteeism and inadequate sanitary facilities with higher absenteeism during menstruation.

Conclusions:
Menstrual hygiene education, accessible sanitary products, pain relief, and adequate sanitary facilities at school would improve the schooling-experience of adolescent girls in India.

Full text

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Muthusamy Sivakami1, Anna
Maria van Eijk2, Harshad
Thakur1, Narendra Kakade1,
Chetan Patil1, Sharayu Shin-
de1, Nikita Surani1, Ashley
Bauman2, Garazi Zulaika2,
Yusuf Kabir3, Arun Dobhal3,
Prathiba Singh3, Bharathy Ta-
hiliani3, Linda Mason2, Kelly
T Alexander2, Mamita Bora
Thakkar3, Kayla F Laserson4,
Penelope A Phillips-Howard2
1
School of Health Systems Studies, Tata
Institute of Social Sciences, Mumbai,
India
2 Department of Clinical Sciences,
Liverpool School of Tropical Medicine
(LSTM), Liverpool, UK
3 Water Sanitation and Hygiene Section,
United Nations Children’s Fund, India
4 Centers for Disease Control and
Prevention (CDC) India, Atlanta,
Georgia, USA
Correspondence to:
M. Sivakami
Professor and Chairperson
Centre for Health and Social Sciences
School of Health Systems Studies
Tata Institute of Social Sciences
V N Purav Marg, Deonar
Mumbai-400088
India
sivakami@tiss.edu
Effect of menstruation on girls and their
schooling, and facilitators of menstrual hygiene
management in schools: surveys in government
schools in three states in India, 2015
Background Lack of menstrual knowledge, poor access to sanitary prod-
ucts and a non-facilitating school environment can make it difcult for girls
to attend school. In India, interventions have been developed to reduce
the burden of menstruation for school girls by government and non-gov-
ernmental organizations (NGOs). We sought to identify challenges related
to menstruation, and facilitators of menstrual management in schools in
three states in India.
Methods Surveys were conducted among menstruating school girls in class
8-10 (above 12 years of age) of 43 government schools selected through
stratied random sampling in three Indian states (Maharashtra, Chhattis-
garh, Tamil Nadu) in 2015. For comparison, ten model schools supported
by NGOs or UNICEF with a focussed menstrual hygiene education pro-
gram were selected purposely in the same states to represent the better-case
scenario. We examined awareness about menarche, items used for men-
struation, and facilitators on girls’ experience of menstruation in regular
schools and compared with model schools. Factors associated with school
absence during menstruation were explored using multivariate analysis.
Findings More girls (mean age 14.1 years) were informed about menstru-
ation before menarche in model schools (56%, n = 492) than in regular
schools (36%, n = 2072, P < 0.001). Girls reported menstruation affected
school attendance (6% vs 11% in model vs regular schools respective-
ly, P = 0.003) and concentration (40% vs 45%, P = 0.1) and was associat-
ed with pain (31% vs 38%, P = 0.004) and fear of stain or smell (11% vs
16%, P = 0.002). About 45% of girls reported using disposable pads in both
model and regular schools, but only 55% and 29% of pad-users reported
good disposal facilities, respectively (P < 0.001). In multivariate analysis,
reported absenteeism during menstruation was signicantly lower in Tamil
Nadu (adjusted prevalence ratio (APR) 95% condence interval (CI) = 0.24,
0.14-0.40) and Maharashtra (APR 0.56, CI = 0.40-0.77) compared to Ch-
hattisgarh, and halved in model compared to regular schools (APR 0.50,
CI = 0.34-0.73). Pain medication in school (APR 0.71, CI = 0.51-0.97) and
use of disposable pads (APR 0.57, CI = 0.42-0.77) were associated with
lower absenteeism and inadequate sanitary facilities with higher absentee-
ism during menstruation.
Conclusions Menstrual hygiene education, accessible sanitary products,
pain relief, and adequate sanitary facilities at school would improve the
schooling-experience of adolescent girls in India.
Electronic supplementary material:
The online version of this article contains supplementary material.
journal of
health
global

Sivakami et al.
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To achieve gender equality, it is important that girls can attend and reach their full potential in schools [1].
Inadequate options for menstrual hygiene recently received attention as a barrier to education for girls in
low and middle income countries [2]. Studies have noted poor sanitation in schools and lack of access to
good quality sanitary products can be associated with lower enrolment in schools, absenteeism, and drop-
out [3-6]. Inadequate menstrual hygiene can potentially have health consequences such as increased risk
of reproductive and urinary tract infections [5,7-11]. The problem of menstrual hygiene is multifaceted;
girls need to be aware about menarche and be able to manage their menstruation in an enabling envi-
ronment with access to hygienic menstrual materials and facilities for changing and disposal of menstru-
al items at home and school [3,12]. National and international concerns about menstrual hygiene have
been spearheaded through water, sanitation, and hygiene (WASH) programs in schools and policy and
programming frameworks to improve knowledge and infrastructure to manage menstrual hygiene [13].
According to 2011 census estimates (the latest available census data), 10% of India’s population were fe-
male adolescents aged 10-19 years, which translates into approximately 120 million girls [14]. Although
menstruation is celebrated in many parts of India, cultural taboos exist which regularly limit girls from
activities during menstruation, including religious restrictions, and freedom to leave the house [3,15].
This contributes to negative attitudes toward menstruation among women, placing a considerable phys-
ical and psychological burden on young girls [3]. A systematic review of Indian studies estimated that
barely half (48%) of adolescent girls in India were aware of menarche before their rst menstruation, and
had inadequate knowledge when attaining menarche. It also documented that the paucity of safe and hy-
gienic disposal systems for menstrual items was worrisome [3].
The government of India has recognized the importance of menstrual hygiene to the health, well-being
and educational achievements of girls and women, and has developed several programs to improve men-
strual hygiene management (MHM) in schools, targeted at improving knowledge, access and disposal of
menstrual waste, and improving sanitation in schools, with support from a number of organisations [16].
Some examples include the production and marketing of low cost sanitary pads [17], government sub-
sidized sanitary pads in rural areas [18], school vending machines for sanitary pads and pad incinerators
[17], and increasing gender separated toilet facilities [19].
In light of these government initiatives, a study was developed to evaluate progress on menstrual man-
agement in schools in India, and to identify facilitators and barriers to menstrual management in Indian
schools in 2015. This paper presents data on cross-sectional surveys conducted among girls in a repre-
sentative sample of government schools in three states in India, and a comparison with “model” schools
receiving additional/intense WASH support in the same states, which allowed us to assess if model schools
achieved improvements with regards to menstrual management.
METHODS
Study population
The study was carried out in the states Chhattisgarh, Maharashtra, and Tamil Nadu, representing the di-
verse cultural and socio-economic spectrum in India (Table S1 in Online Supplementary Document).
Chhattisgarh is a state from central India with a predominantly Tribal population with 2.7 million adoles-
cent girls. Maharashtra is a more developed state in the western part of India with 9.9 million adolescent
girls. Tamil Nadu is a southern state having one of the highest levels of development with 6.1 million ad-
olescent girls. Tamil Nadu has implemented a free sanitary pad scheme since 2011, making pads free of
cost for girls living in rural areas, those in government schools, and new mothers. Girls can receive three
packs of pads once every two months, in addition to iron tablets, and may receive education about men-
struation from an “aganwadi” (female community health) worker [20]. Similar programs in Maharashtra
and Chhattisgarh are less developed.
A total sample size of 1800 adolescent girls (600 girls per state, about 75 girls per school), would be suf-
cient to measure a state-based prevalence of 50% with 95% condence interval and 5% of margin error,
taking clustering into account and using a design effect of 1.5. Multi-level stratied sampling was used
for each state, by rst randomly selecting one district in each of the three states. In each of the select-
ed districts, one block was then randomly selected, and then in each of the selected blocks, a list of all
schools was prepared in collaboration with the state government education department in the respective
districts. In each of these, schools were then randomly selected from all government middle and high

Menstrual hygiene management in schools in India
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schools (regular) after excluding boys’ only schools, solely residential, and private schools (Figure S1 in
Online Supplementary Document). Adolescent girls above 12 years of age in class (called grade in In-
dia) 8-10 (comparable to school year 8-10 in the United States) were selected to maximise the likelihood
they had reached menarche and could provide information on menstrual management and water sani-
tation and hygiene. One class was randomly selected if there was more than one class in grades 8-10. In
Tamil Nadu, more schools were included than in the other states because girls were younger and fewer
girls had reached menarche compared to the other states. In addition to regular schools, schools that re-
ceived support on menstrual hygiene from external sources (“better practice” or model schools) to rep-
resent the best case scenario in MHM were purposively chosen with the help of the UNICEF team in the
respective state to assess if this resulted in signicantly better menstrual management practices. In the
model schools, external experts (from UNICEF or other NGOs) regularly provided information sessions
on puberty, menstrual hygiene and on how to use menstrual pads.
Schools were visited, and meetings were held with the head teachers. Parental consent forms were then
distributed by study staff with the help of school staff. Meetings with target girls who had parental con-
sent were conducted to discuss the study and respond to questions before girls assented. Pre-tested struc-
tured self-administered questionnaires in the local languages of each state were used to elicit information
on the sanitation status of the school, knowledge about menstruation, pre-menarche, menstrual practices
and beliefs, and the effect of menstruation on school life. The data collection was carried out from June
to December 2015. Three senior research ofcers supervised the eld data collection team who received
intensive one-week training before the start of the study.
Analysis
For this analysis, only girls who reported they had started menstruating were included. We tabulated
results for model and regular schools by state for the following themes: awareness about menarche and
source of information, menstruation-related restrictions, menstrual absorbents, effect of menstruation on
the school experience, and barriers and facilitators of menstrual management at the school level. Missing
data was included as a separate category of the variables of interest. Signicant differences were explored
at the state level and model vs regular schools overall and within states (χ2 test). To assess factors associ-
ated with school absence during menstruation, we used generalized linear regression with a log link and
binomial distribution for multivariate analyses. Poisson regression with a robust variance estimator was
used for models which did not converge (Stata v14.2, StataCorp LLC, College Station, USA). The follow-
ing factors were explored in univariate analysis: age, state, model vs regular school, menstrual item used,
education or program on menstrual hygiene in school and factors related to sanitary situation in school.
Factors with a P-value <0.1 in the univariate model and model vs regular schools as a focus of interest
were included in the multivariate model, whereby factors with a P-value >0.05 were removed from the
multivariate model using backward elimination. Univariate and multivariate models were adjusted for
clustering at the school level, and interactions between signicant variables were examined.
Ethical considerations
The study was approved by the Tata Institute of Social Sciences, Mumbai, and the Liverpool School of
Tropical Medicine, UK, after fullling all the ethical requirements. Participant information sheets, describ-
ing the study and the activities involved for study participants were prepared. Written informed consent
from the parents and assent from the girls was obtained before the study, in compliance with national
and international ethical committee requirements. The survey questionnaire had ID numbers and had no
names on it. Consent forms and questionnaires were translated into local languages of the states involved.
RESULTS
Characteristics of schools and participating girls
Of the 3617 girls who participated, 2564 (70.9%) reported they had begun menstruating and were in-
cluded in this analysis. These menstruating girls attended 43 randomly selected regular schools (N = 2072)
and 10 model schools (N = 492) in the 3 states (Table 1). Over half of schools were co-educational (58%),
a third (31%) were girls’ only, and the remaining had some girls and some mixed classes. Girls’ average
age was 14.1 years (standard deviation (SD) = 1.1), with girls from Tamil Nadu slightly younger than oth-
er states, and girls in model schools slightly older (14.2 vs. 14.0 years, P < 0.01). Most girls were in grade

Sivakami et al.
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10 (51%), while 35% were in grade 9, and 13% in grade 8. Participating girls were mostly Hindu (93%),
with 3% Muslims, and 2% other religions.
Girls’ awareness and knowledge about menstruation
Nearly all (93%) menstruating girls had received some information about menstruation (Table 2). Par-
ents or guardians were the major source (68%), with friends the next most reported source. There were
striking differences by state and type of school; approximately 1 in 10 girls said teachers were a common
source, the highest proportion were in model schools in Tamil Nadu (51%), and lowest in regular schools
in Maharashtra (3%). Half (48%) of girls did not hear about menstruation until their rst period began;
the proportion of girls who were informed before menarche was signicantly higher in model schools
compared to regular schools (56% vs 36%, P < 0.001).
Cultural taboos and restrictions during menstruation
Religious restrictions (not going to temple, etc.) were common, affecting 88% of girls overall, and nearly
all (91%) girls in regular schools (Figure 1, and Table S2 in Online Supplementary Document); girls
reported less restrictions in the model schools in Maharashtra (64%) and Tamil Nadu (76%) compared
to the regular schools (94% and 93%, respectively, P < 0.001). Restrictions during exercise were prevalent
(83% overall); again this was signicantly lower in model schools in Maharashtra (89% vs 50%, P < 0.001)
and Tamil Nadu (92% vs 69%, P < 0.001) but not in Chhattisgarh (78% vs 84%, P = 0.205). Other re-
ported restrictions due to cultural traditions were less common (Figure 1); thus one in ve reported dif-
Table 1. Characteristics of participating schools and girls by state and school type, India 2015
Maharashtra Chhattisgarh taMil Nadu all 3 states
Regular
school,
n (%)
Model
school,
n (%)
Regular
school,
n (%)
Model
school,
n (%)
Regular
school,
n (%)
Model
school,
n (%)
Total,
n (%)
Characteristics of schools:
Number of schools 12 412 419 253
Type of school:
-Co-education 10 310 018 041
-Girls only 2 1 2 4 1 2 12
Participants:
-Not menstruating 169 (19.9) 119 (40.6) 143 (16.9) 56 (18.9) 480 (40.1) 50 (37.6) 1017 (28.1)
-Menstruating 664 (78.2) 173 (59.0) 691 (81.5) 236 (79.7) 717 (59.9) 83 (62.4) 2564 (70.9)
-No answer 16 (1.9) 1 (0.3) 14 (1.7) 4 (1.4) 1 (0.1) 036 (1.0)
Median number of menstruating
participants per school, range 48, 16-109 45, 22-61 50, 14-149 58, 8-112 24, 15-113 42, 24-59 45, 8-149
Characteristics of school girls (only menstruating girls included):
Total number of participants 664 173 691 236 717 83 2564
Average age of participant (SD)* 14.4 (1.0)
n = 645
14.2 (0.9)
n = 169
14.3 (1.0)
n = 685
14.4 (1.1)
n = 236
13.5 (0.9)
n = 715
13.6 (0.8)
n = 83
14.1 (1.1)
n = 2533
Grades of participants:†
-8 97 (14.6) 31 (17.9) 66 (9.6) 27 (11.4) 104 (14.5) 9 (10.8) 334 (13.0)
-9 230 (34.6) 65 (37.6) 225 (32.6) 92 (39.0) 246 (34.3) 26 (31.3) 884 (34.5)
-10 327 (49.3) 73 (42.2) 389 (56.3) 113 (47.9) 366 (51.1) 48 (57.8) 1316 (51.3)
-Missing 10 (1.5) 4 (2.3) 11 (1.6) 4 (1.7) 1 (0.1) 0 (0.0) 30 (1.2)
Religion:‡
-Hindu 619 (93.2) 128 (74.0) 686 (99.3) 232 (98.3) 641 (89.4) 79 (95.2) 2385 (93.0)
-Muslim 33 (5.0) 11 (6.4) 1 (0.1) 4 (1.7) 31 (4.3) 0 (0.0) 80 (3.1)
-Other§ 12 (1.8) 33 (19.1) 0 (0.0) 0 (0.0) 44 (6.1) 4 (4.8) 93 (3.6)
- No answer 0 (0.0) 1 (0.6) 4 (0.6) 0 (0.0) 1 (0.1) 0 (0.0) 6 (0.2)
SD – standard deviation
*P < 0.01 for comparison by state (Tamil Nadu vs schools in the other states) and model schools (mean 14.2, SD = 1.1) vs regular schools (mean 14.0,
SD = 1.0, P = 0.005, t test).
†P < 0.05 comparing schools in Chhattisgarh vs schools in the other states, no difference by model schools vs regular schools (χ2 test).
‡P < 0.001 comparing schools by states and model schools vs regular schools (χ2 test).
§Other: Christian, Buddhist, Jain etc.

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ferent sleeping arrangements, 16% reduced social
interactions within the home, 12% reduced social
interactions outside the home, and 7% had restrict-
ed food choices.
Items used for menstrual hygiene
management by girls
Overall, 45% of girls used disposable sanitary pads,
28% used cloths, and 21% reusable pads. Menstrual
cups and tampons were reported by 1% each, 2%
of girls said they did not use anything, and 3% did
not respond. There were considerable differences by
state and school (Figure 2 and Table S3 in Online
Supplementary Document). The majority of girls
in Chhattisgarh used cloths (61%), whereas the ma-
jority of girls in Maharashtra and Tamil Nadu used
disposable pads (47% and 66%, respectively). Re-
usable pads were mainly used in Maharashtra (37%)
and Tamil Nadu (21%). Only in Chhattisgarh signif-
icant differences were present between model and
regular schools; cloths were used less frequently in
model schools where disposable pads were more
common.
Effect of menstruation on school experience
The majority of girls reported going to school during their menstruation (87%, Table 3), and this was
higher among model schools (92% vs 86% in regular schools, P = 0.003). One out of ve girls in regular
schools in Chhattisgarh reported missing school during their period. The majority (65%) of girls reporting
Table 2. Girls’ awareness of menarche and source of information by state and school type, India 2015
Maharashtra Chhattisgarh taMil Nadu all 3 states
Regular
school, n (%)
Model
school, n (%)
Regular
school, N (%)
Model
school, n (%)
Regular
school, n (%)
Model
school, n (%) Total
N = 664 N = 173 N = 691 N = 236 N = 717 N = 83 N = 2564
Who informed you about menstruation?*
Mother, father, caretaker† 598 (90.1) 87 (50.3) 347 (50.2) 128 (54.2) 517 (72.1) 65 (78.3) 1742 (67.9)
Other relative‡ 13 (2.0) 2 (1.2) 78 (11.3) 32 (13.6) 55 (7.7) 9 (10.8) 189 (7.4)
Friends§ 79 (11.9) 40 (23.1) 233 (33.7) 76 (32.2) 73 (10.2) 32 (38.6) 533 (20.8)
School teacher (lesson/private)20 (3.0) 38 (22.0) 22 (3.2) 18 (7.6) 89 (12.4) 42 (50.6) 229 (8.9)
Other (eg, doctor, warden)‡ 10 (1.5) 3 (1.7) 5 (0.7) 4 (1.7) 0 (0.0) 0 (0.0) 22 (0.9)
No one¶ 22 (3.1) 4 (2.3) 22 (3.2) 6 (2.5) 35 (4.9) 0 (0.0) 89 (3.5)
No response 6 (0.9) 7 (4.1) 73 (10.6) 0 (0.0) 0 (0.0) 0 (0.0) 86 (3.4)
When did you learn about
menstruation?§,** N = 636 N = 162 N = 596 N = 230 N = 682 N = 83 N = 2389
Before start 242 (38.1) 99 (61.1) 257 (43.1) 119 (51.7) 204 (29.9) 50 (60.2) 971 (40.6)
When 1st period 352 (55.4) 52 (32.1) 244 (40.9) 84 (36.5) 393 (57.6) 29 (34.9) 1154 (48.3)
After 1st period 17 (2.7) 6 (3.7) 46 (7.7) 15 (6.5) 51 (7.5) 3 (3.6) 138 (5.8)
No answer 25 (3.9) 5 (3.1) 49 (8.2) 12 (5.2) 34 (5.0) 1 (1.2) 126 (5.3)
*More than one option was allowed.
†P < 0.05 for comparison by state, model schools vs regular schools, and in Maharashtra model vs regular school.
‡P < 0.05 for comparison by state.
§P < 0.05 for comparison by state, model schools vs regular schools, and in Maharashtra and Tamil Nadu model vs regular school.
P < 0.05 for comparison by state, model schools vs regular schools, and within states model vs regular school.
¶P < 0.05 for comparison in Tamil Nadu model vs regular school.
**Among girls who were informed by persons mentioned above about menstruation (so excluding girls who reported to have not been informed about
menstruation and girls with no response to the question).
Figure 1. Restrictions (%) during menstruation among school girls in
three states in India, 2015. Religious restrictions: P < 0.05 comparing
model schools vs regular schools, and in Maharashtra and Tamil Nadu
model vs regular school. Sleeping arrangements: P < 0.05 comparing by
state, model vs regular schools, and in Chhattisgarh and Tamil Nadu
model vs regular school. Behave different inside house: P < 0.05 compar-
ing by state, and in Maharashtra model vs regular school. Behave differ-
ent outside house: P < 0.05 comparing by state, model vs regular school,
and in Maharashtra model vs regular school. Eating/exercise: P < 0.05
comparing by state, model schools vs regular schools, and in Maharash-
tra and Tamil Nadu model vs regular school.

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absence stated it was for 1 day, 22% said 2-3 days
and 13% responded that it was throughout men-
struation. Concentration problems at school during
menstruation were common (45%), with differenc-
es noted by state (Table 3). Other frequently men-
tioned problems in school included pain (stomach,
head, hips and limbs, 36%), fear of staining or smell
or losing the cloth or pad in school (15%), feeling
unwell, tired, dizzy, and weak (11%). A few (5%)
reported reduced mobility and comfort resulting
in problems with sitting, walking, bicycling, and
reaching school. Girls who used disposable pads
were signicantly more likely to report attending
school during menstruation (95%), and less fre-
quently reported concentration or other problems
during menstruation (39%, and 47%, respectively)
than girls who used cloths (81%, 53%, and 68%,
respectively, P < 0.001 for all comparisons, Figure
S2 and S2 in Online Supplementary Document).
Facilitation of schools of menstrual hygiene management
Toilet and wash facilities reported by girls
About half of girls thought there were enough toilets in the school to deal with their menstruation, with
the lowest proportion in the regular schools in Maharashtra (33%), and the highest in model schools
in Tamil Nadu (99%; Table 4). Only 37% of girls stated their school had toilets exclusively for them,
with the highest proportion in Tamil Nadu (60%). Access to toilets differed by state, with 48% of girls in
Chhattisgarh stating they could use them any time, while the majority of girls in other states were only
Figure 2. Items (%) used to deal with menstruation in three states in In-
dia, 2015. Disposable pads: P < 0.05 by state, and in Chhattisgarh model
vs regular schools. Reusable pads: P < 0.05 by state, and in Chhattisgarh
model vs regular schools. Cloth/rag: P < 0.05 by state, and in Chhattis-
garh model vs regular schools. Tampon: no differences. Cup: P < 0.05 by
state, and in Chhattisgarh model vs regular schools.
Table 3. Effect of menstruation on school experience
Maharashtra Chhattisgarh taMil Nadu all 3 states
Regular
school, n (%)
Model
school, n (%)
Regular
school, n (%)
Model
school, n (%)
Regular school
n (%)
Model school
n (%)
Total
N = 664 N = 173 N = 691 N = 236 N = 717 N = 83 N = 2564
Go to school during period:*
Yes 587 (88.4) 162 (93.6) 520 (75.3) 206 (87.3) 684 (95.4) 82 (98.8) 2241 (87.4)
No 67 (10.1) 7 (4.1) 143 (20.7) 23 (9.8) 25 (3.5) 0265 (10.3)
No response 10 (1.5) 4 (2.3) 28 (4.1) 7 (3.0) 8 (1.1) 1 (1.2) 58 (2.3)
Concentration problems at school during menstruation:†
Yes 336 (50.6) 68 (39.3) 343 (49.6) 107 (45.3) 263 (36.7) 24 (28.9) 1141 (44.5)
No 316 (47.6) 97 (56.1) 333 (48.2) 125 (53.0) 445 (62.1) 59 (71.1) 1374 (53.6)
No response 12 (1.8) 8 (4.6) 15 (2.2) 4 (1.7) 9 (1.3) 0 (0.0) 48 (1.9)
Do you have other problems when attending school during menstruation?‡
Yes 439 (66.1) 119 (68.8) 477 (69.0) 109 (46.2) 279 (38.9) 15 (18.1) 1438 (56.1)
No 217 (32.7) 40 (23.1) 176 (25.5) 107 (45.3) 431 (60.1) 68 (81.9) 1039 (40.5)
No response 8 (1.2) 14 (8.1) 38 (5.5) 20 (8.5) 7 (1.0) 0 (0.0) 87 (3.4)
Specication of some problems when attending school during menstruation:
Pain during menstruation§ 242 (36.5) 69 (40.0) 209 (44.7) 69 (29.2) 228 (31.8) 13 (15.7) 930 (36.3)
Fear of stains, smell, loss of item152 (23.0) 25 (14.5) 125 (18.1) 25 (10.6) 60 (8.4) 2 (2.4) 389 (15.2)
Feeling tired, dizzy, weak, unwell¶ 127 (19.1) 38 (22.0) 57 (8.3) 18 (7.6) 46 (6.4) 7 (8.4) 293 (11.4)
Discomfort when moving or sitting¶ 24 (3.6) 3 (1.7) 54 (7.8) 23 (9.8) 18 (2.5) 2 (2.4) 124 (4.8)
*P < 0.05 comparing by state, model schools vs regular schools, and in Maharashtra and Chhattisgarh model vs regular school.
†P < 0.05 comparing by state, and in Maharashtra model vs regular school.
‡P < 0.05 comparing by state, model schools vs regular schools, and within states model schools vs regular schools.
§P < 0.05 comparing by state, model schools vs regular schools, and in Chhattisgarh and Tamil Nadu model vs regular school.
P < 0.05 comparing by state, model schools vs regular schools, and in Maharashtra and Chhattisgarh model vs regular school.
¶P < 0.05 comparing by state.

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allowed during break-time. For accidental leaking
of blood during lessons, a higher proportion of girls
in model schools stated they were allowed to leave
the class (63% in regular vs 76% in model schools,
P < 0.001). Most girls thought there was enough
time for changing their menstrual item during
break (55% in regular and 73% in model schools,
P < 0.001). Washing facilities in schools were insuf-
cient, with overall just 51% of girls reporting wash-
ing was always possible.
Disposal facilities as reported by girls
Only 27% of girls reported that their schools had
good disposal facilities for menstrual waste, and op-
tions varied widely across states and schools (Figure
3, and Table S4 in Online Supplementary Docu-
ment). The most frequently mentioned option for
disposal was taking the soiled item home (21%),
with 41% of girls in regular schools in Maharashtra
saying this. Burn pits (20%), rubbish pits (17%),
or bins (16%) were the next most common, with
a low proportion (7%) reporting an incinerator for
waste. Incinerators were more common in model
schools; for example 2% of girls in Tamil Nadu reg-
ular schools reported incinerators, whereas this was
64% in model schools (P < 0.001). In Tamil Nadu,
19% of girls reported throwing menstrual waste
down the toilets, compared with <5% in the other
two states where free napkins were less available.
When limiting analysis specically to the 1153 girls
using disposable pads, 37% reported disposal in
burning or rubbish pits, 17% in buckets, 9% in an
incinerator, 11% in toilets, and 19% reported taking
the used pad home.
Additional facilitation (pain relief, pad
provision, point person for menstrual hygiene
management)
Overall, 21% of girls reported they could get pain
relievers for menstrual cramps in the school when
needed, with a signicantly higher proportion in
model (39%) compared with regular schools (17%)
in all states (P < 0.001, Figure 4, and Table S4 in
Online Supplementary Document). Overall, 37%
of girls said absorbents were made available to them
in school. This was almost exclusively due to pad
provision in Tamil Nadu, with 81% of girls saying
they were regularly given pads. Pad distributions
were signicantly more common in model schools
than in regular schools (overall 46% vs 35%, P < 0.001), and, within states, in Maharashtra (47% vs 9%,
respectively, P < 0.001) and Chhattisgarh (30% vs 13%, respectively, P < 0.001). Overall, 51% of girls re-
ported they knew a point person in the school they could approach for problems with menstrual hygiene
management, mostly (75%) this was a female teacher (Table S4 in Online Supplementary Document).
Education in schools on menstruation and menstrual hygiene
Overall, 34% of girls reported to have received education about menstrual hygiene in school; the propor-
tion differed signicantly by state, type of school and within states (Table S5 in Online Supplementary
Figure 3. Disposal options (%) of menstrual items in schools in three
states in India, 2015. *Excluding participants who used reusable pads or
cups. Pit: P < 0.05 for comparison by state, and for Maharashtra and Ch-
hattisgarh model vs regular school. Bucket/dustbin: P < 0.05 for compar-
ison by state and model vs regular school, and in Tamil Nadu model vs
regular school. Take back home: P < 0.05 for comparison by state, model
vs regular school, and in Maharashtra and Tamil Nadu model vs regu-
lar school. Rubbish pit for burning: P < 0.05 by state and in Maharash-
tra, Chhattisgarh, and Tamil Nadu comparing model vs regular schools.
In toilet/latrine: P < 0.05 by state and type of school. School incinerator:
P < 0.05 by state, type of school, and in Maharashtra, Chhattisgarh and
Tamil Nadu model vs regular school.
Figure 4. Facilitators of menstrual hygiene (%) in schools in three states in
India. Good disposal facilities: P < 0.05 for comparison by state, model vs
regular school overall and within states. Providing pain relief: P < 0.05 for
comparison by state, model vs regular school overall and within states.
Regularly given pads: P < 0.05 for comparison by state, model vs regu-
lar school overall and within states. Teaching about menstrual hygiene:
P < 0.05 for comparison by state, model vs regular school overall and
within states.

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Table 4. Facilitators by schools of menstrual hygiene management
Maharashtra Chhattisgarh taMil Nadu all 3 states
Regular school,
n (%)
Model school,
n (%)
Regular
school, N (%)
Model
school, n (%)
Regular
school n (%)
Model
school n (%) Total
N = 664 N = 173 N = 691 N = 236 N = 717 N = 83 N = 2564
Are there enough toilets to deal with menstruation in the school?‡
Yes 220 (33.1) 104 (60.1) 268 (38.8) 94 (39.8) 494 (68.9) 82 (98.8) 1262 (49.2)
No 399 (60.1) 54 (31.2) 376 (54.4) 128 (54.2) 214 (29.9) 1 (1.2) 1172 (45.7)
No answer 45 (6.8) 15 (8.7) 47 (6.8) 14 (5.9) 9 (1.3) 0130 (5.1)
Toilets for girls:§
For female staff & girls 166 (25.0) 34 (19.7) 79 (11.4) 95 (40.3) 195 (27.2) 29 (34.9) 598 (23.2)
For girls only 123 (18.5) 47 (27.2) 183 (26.5) 90 (38.1) 441 (61.5) 50 (60.2) 934 (36.5)
For boys and girls 188 (28.3) 61 (35.3) 242 (35.0) 5 (2.1) 62 (8.7) 4 (4.8) 562 (21.9)
For all staff & students 154 (23.2) 15 (9.7) 108 (15.6) 35 (14.8) 11 (1.5) 0323 (12.6)
No response 33 (5.0) 16 (9.3) 79 (11.4) 11 (4.7) 8 (1.1) 0147 (5.7)
When can you use the toilet?‖
Any time 215 (32.4) 41 (23.7) 323 (46.7) 125 (53.0) 175 (24.4) 22 (26.5) 901 (35.1)
Only during breaks 395 (59.5) 115 (66.5) 213 (30.8) 75 (31.8) 527 (73.5) 60 (72.3) 1385 (54.0)
Other responses* 30 (4.5) 2 (1.2) 38 (5.5) 4 (1.7) 11 (1.5) 1 (1.2) 86 (3.4)
No response 24 (3.6) 15 (8.7) 117 (16.9) 32 (13.6) 4 (0.6) 0192 (7.5)
Is there enough time in breaks for change of menstrual item?
Yes 307 (46.2) 132 (76.3) 301 (43.6) 147 (62.3) 532 (74.2) 80 (96.4) 1499 (58.5)
No 343 (51.7) 30 (17.3) 342 (49.5) 84 (35.6) 175 (24.4) 3 (3.6) 977 (38.1)
No response 14 (2.1) 11 (6.4) 48 (6.9) 5 (2.1) 10 (1.4) 089 (3.4)
Are you allowed to leave class if leaking?¶
Yes 354 (53.3) 133 (76.9) 367 (53.1) 162 (68.6) 593 (82.7) 77 (92.8) 1686 (65.8)
No 295 (44.4) 34 (19.7) 266 (38.5) 64 (27.1) 114 (15.9) 6 (7.2) 779 (30.4)
No response 15 (2.3) 6 (3.5) 58 (8.4) 10 (4.2) 10 (1.4) 099 (3.9)
Can you wash yourself in school when leaking?
Can always wash in school 230 (34.6) 131 (75.7) 317 (45.9) 114 (48.3) 443 (61.8) 72 (86.8) 1307 (51.0)
Can sometimes wash 47 (7.1) 12 (6.9) 113 (16.4) 50 (21.2) 209 (29.2) 11 (13.3) 442 (17.2)
Can never wash in school 375 (56.5) 18 (10.4) 219 (31.7) 60 (25.4) 48 (6.7) 0720 (28.1)
No response 12 (1.8) 12 (6.9) 42 (6.1) 12 (5.1) 17 (2.4) 095 (3.7)
*Other included responses such as queuing before toilet, toilet unusable, no toilet present, go home for change
‡P < 0.05 for comparison by state, model vs regular school, and Maharashtra and Tamil Nadu model vs regular school.
§P < 0.05 for comparison by state, model vs regular school, and Maharashtra and Chhattisgarh model vs regular school.
P < 0.05 for comparison by state, model vs regular school, and Maharashtra model vs regular school.
¶P < 0.05 for comparison by state, model vs regular school overall and within states.
Document). The majority of girls heard about it in a hygiene lesson (58%), during lessons separate from
boys (82%). Written materials about menstruation were infrequently available (19%) and mainly present
in model schools. Of the 1742 girls who heard about menstrual hygiene from their parents or guardians,
586 (34%) had lessons at school as well.
Factors associated with missing school during menstruation
Numerous factors were associated with missing school during menstruation in univariate analysis (Ta-
ble 5); however, six remained in the multivariate model. State and type of school affected absence rates,
and were signicantly lower in Tamil Nadu (adjusted prevalence ratio (APR) = 0.24, 95% condence
interval (CI) = 0.14-0.40) and Maharashtra (APR = 0.56,95% CI = 0.40-0.77) compared to Chhattisgarh,
and halved in model compared to regular schools (APR = 0.50, 95% CI = 0.34-0.73) The use of dispos-
able pads, the availability of pain medication, and a space to wash in school were all associated with
less absenteeism during menstruation. Dysfunctional toilets or long queues for toilets were associated
with increased absenteeism. In a separate multivariate analysis including only variables related to san-
itary facilities at school, “clean toilets”, “toilet breaks”, and “can wash in school” remained signicant;
however, “gender-separate toilets” was not signicant in the multivariate analysis (Table S6 in Online
Supplementary Document).

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Table 5. Factors associated with missing school during menstruation by adolescent girls, 3 states in India, 2015
FaCtor
uNivariate aNalysis Multivariate aNalysis
Missing school:
n/N (%)
Prevalence ratio,
95% CI*
P-value Prevalence ratio,
95% CI*
P-value
Age (years):
13 and below 47/665 (7.1) Reference NS
14 97/981 (9.9) 1.43, 0.97, 2.10 0.068
15 and above 118/832 (14.2) 2.03, 1.44-2.85 <0.001
State:
Chhattisgarh 166/892 (18.6) Reference Reference
Maharashtra 74/823 (9.0) 0.48, 0.31-0.75 0.001 0.56, 0.40-0.77 <0.001
Tamil Nadu 25/791 (3.2) 0.17, 0.10-0.28 <0.001 0.24, 0.14-0.40 <0.001
Model school
Yes 30/480 (6.3) 0.54, 0.26-1.13 0.104 0.50, 0.34-0.73 <0.001
No 235/2026 (11.6) Reference
Menstrual item used:
Nothing or NR 15/94 (16.0) 0.84, 0.49-1.44 0.523 1.19, 0.73-1.95 0.490
Cloth 131/688 (19.0) Reference Reference
Reusable pads 48/525 (9.1) 0.48, 0.32-0.72 <0.001 0.98, 0.74-1.31 0.893
Disposable pads 58/1140 (5.1) 0.27, 0.19-0.39 <0.001 0.57, 0.42-0.77 <0.001
Insertables† 13/59 (22.0) 1.16, 0.70-1.91 0.569 2.51, 1.54-4.07 <0.001
Pain medication in school:
Yes 25/528 (4.7) 0.39, 0.26-0.59 <0.001 0.71, 0.51-0.97 0.031
No or not reported 240/1978 (12.1) Reference Reference
Pads given in school:
Yes 50/943 (5.3) Reference NS
No 181/1329 (13.6) 2.57, 1.74-3.80 <0.001
Don’t know 17/153 (11.1) 2.10, 1.11-3.95 0.022
Not reported 17/81 (21.0) 3.96, 2.40-6.54 <0.001
Education MH in school:
Yes 47/824 (5.7) Reference NS
No 197/1432 (13.8) 2.41, 1.65-3.53 <0.001
Don’t know 11/188 (5.9) 1.03, 0.57-1.86 0.935
Not reported 10/62 (16.1) 2.83, 1.43-5.60 0.003
MH program in school:
Yes 522 (20.4) Reference
No 1565 (61.0) 3.01, 1.77-5.12 <0.001 NS
Don’t know 363 (14.2) 1.51, 0.75-3.02 0.246
Not reported 114 (4.5) 3.30, 1.54-7.06 <0.001
Enough toilets in school:
Yes 93/1240 (7.5) 0.55, 0.39-0.78 0.001 NS
No 156/1153 (13.5) Reference
Not reported 16/113 (14.2) 1.05, 0.52-2.09 0.898
When can you use the toilet?:
Any time 100/887 (11.3) Reference Reference
Only during breaks 106/1365 (7.8) 0.69, 0.49-0.96 0.029 0.95, 0.71-1.27 0.744
Other responses§ 21/85 (24.7) 3.18, 1.70-5.95 <0.001 1.61, 0.98-2.66 0.062
No response 38/169 (22.5) 2.90, 1.91-4.38 <0.001 1.42, 1.01-1.99 0.045
Toilets clean:
Always clean 73 (1128 (6.5) Reference NS
Sometimes clean 122/978 (12.5) 1.93, 1.32-2.80 0.001
Never clean or NR 70/396 (17.7) 2.73, 1.74-4.29 <0.001
Toilets for girls:
For female staff & girls 60/582 (10.3) 1.40, 0.94-2.07 0.096 NS
For girls only 68/921 (7.4) Reference

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FaCtor
uNivariate aNalysis Multivariate aNalysis
Missing school:
n/N (%)
Prevalence ratio,
95% CI*
P-value Prevalence ratio,
95% CI*
P-value
For boys and girls 79/549 (14.4) 1.95, 1.07-3.55 0.029
For all staff & students 38/320 (11.9) 1.61, 0.96-2.71 0.073
No response 20/134 (14.9) 2.02, 1.10-3.72 0.024
Can wash in school:
Can always wash 95/1287 (7.4) Reference Reference
Can sometimes wash 47/437 (10.8) 1.46, 1.07-1.98 0.017 1.44, 1.07-1.92 0.015
Can never wash or NR 123/778 (15.8) 2.14, 1.56-2.94 <0.001 1.49, 1.13-1.95 0.004
Disposal options at school:
In pits 92/927 (9.9) 3.07, 0.96-9.85 0.059 NS
In buckets 44/389 (11.3) 3.47, 1l06-11.36 0.040
Take home 65/515 (12.6) 3.96, 1.23-12.72 0.021
Throw in toilet 17/202 (8.4) 2.60, 0.78-8.60 0.119
Incinerator 6/186 (3.2) Reference
Other or no answer 38/259 (14.7) 4.50, 1.29-15.72 0.019
CI – condence interval, MH – menstrual hygiene, NR – not reported, NS – not signicant
*All analyses adjusted for school as cluster. Factors explored but not signicant included class, time of transport to school, and
means of transport to school. No interactions of interest were noted between signicant variables.
†Tampons or menstrual cups.
§Other included responses such as queuing before toilet, toilet unusable, no toilet present, go home for change.
Table 5. Continued
DISCUSSION
This study explored the current progress of both government and external agencies to reduce the barriers
menstruation causes for schoolgirls in India, and identied where actions can be taken to improve this
further. Menstruation was not only shown to impact absenteeism (among 10% of girls) but also affected
the quality of school time, with close to half of the girls complaining of an inability to concentrate when
in school, and about a third complaining of pain (36%); other worries included fear of staining, smell,
or feeling unwell, and discomfort with movement and sitting. These problems were affected by the type
of menstrual item used, eg, they were more common among users of cloth (used by 28% of girls) com-
pared to disposable pad users (used by 45%). The status of sanitary facilities was reported to be often
inadequate, compromising girls’ ability to manage their menstruation in school. Model schools had half
the reported menstrual-related absence, and compared to Chhattisgarh absence was 75% lower in Tam-
il Nadu where sanitary napkin schemes predominate. Simply providing sanitary pads would clearly not
resolve girls’ menstrual issues, however. Comparison of regular against `model’ schools highlighted that
additional activities reach girls and improved their knowledge, and ability to cope with menstruation in
school. Variations between states displayed a need to tailor interventions to address differing cultural and
socio-geographical challenges; eg, in regions where cloths are routinely used, girls would need information
on how to hygienically clean and dry them. This study also demonstrated the ongoing need for improving
sanitary and disposal facilities at the schools (eg, one in ve girls using disposable pads had to take the
used napkin home for disposal), and encouraging (development and) use of biodegradable pads. Gains
can be achieved from simple measures such as pain relief in school or relaxation of school-break rules.
Most girls were not aware of menarche and faced barriers and restrictions when menstruating, consistent
with past studies across India [3,6]. While health education is a common thread across the Government
of India schemes, our study found no evidence of menstrual education offered systematically in regular
schools. Model schools’ focused programmes signicantly improved girls’ awareness of menstrual hygiene
suggesting this provides a template to reframe girls’ understanding that menstruation is a normal phys-
iological process [21,22]. However, parents were the main source of information about menstruation,
and efforts to equip families with information to prepare daughters on menarche and menstrual hygiene

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would add value to school-based initiatives, and are included in government guidelines [6,23]. While
differences exist across states, it was an interesting and encouraging observation that some restrictions re-
lated to menstruation were less in model schools (with more attention to menstrual hygiene) compared
to regular schools. The education of girls might have a wider effect on family and society. As our study is
cross-sectional, it is not possible to clarify this.
Approximately half of girls reported using disposable pads. The high use in Tamil Nadu reects the imple-
mentation of the free sanitary pads scheme in this state [20]; it is notable that about 20% of girls choose
to use reusable pads in Tamil Nadu, which may be because of the disposal issues for disposable pads. A
preference for reusable pads has also been reported among women living in slums in Hyderabad [24].
The wider reported experience of differing menstrual products suggests other products, currently deemed
to be unacceptable due to the many taboos, may indeed be welcomed by girls and women in India. Al-
though girls clearly seem to benet from a scheme as implemented in Tamil Nadu and envisioned for
the rural areas in India [20], inadequate disposal hinders success. Incinerators have been promoted as an
option, but there are concerns about the environmental impact [25]. According to solid waste manage-
ment rules of the Government of India, sanitary pad manufacturers must provide a wrapper with each
pad, and must be deposited in landlls as non-biodegradable waste [26,27]. For the environment, the
reusable options for menstruation may be preferable; biodegradable menstrual pads, now being tested in
India, may be another option. It is unclear if girls are aware of all the options available to deal with men-
struation, and very likely that their access to some of them will be limited (eg, reusable pads, menstrual
cup, or tampons). Lack of adequate toilet facilities emerges as one of the major reasons for girls’ absen-
teeism which has been demonstrated by others [3]. While government systems suggest that all schools
have enough gender specic toilets [28], girls’ responses do not corroborate this with 46% of girls saying
there were not enough toilets, and only 37% saying they were for girls only. Even when toilets were pres-
ent, the functionality could be doubted when girls responded the toilets were unusable so they preferred
to go outside or stay home. In addition, only 35% of the girls reported they could use the toilets anytime
(not only during breaks) and only 51% reported they could always wash themselves in school (51%). The
time during break was too short for a change of the menstrual item for one third of the girls (38%), and
thirty percent responded they could not leave the class when leaking. A more exible approach of school
rules with allowance of toilet visits during lessons may better facilitate girls’ menstrual hygiene and reduce
absenteeism. About one third of girls had some form of pain during menstruation; it is encouraging that
the ability of provision of pain relief in school may assist in keeping girls in school during their period.
India is a country of contrasts with strong gender-related disparities; a strength of this study is that we
adopted the same methodology across three geographical locations. We are aware that this still would not
allow us to generalize the ndings to government schools in other States of India, or to private schools.
Nonetheless, it gives an opportunity to understand menstrual management in-depth with a large sample
size across the country. Some girls in the study did not respond to questions, especially in Chhattisgarh;
for example, 10% of girls in the overall sample and 20% in Chhattisgarh did not give any response about
disposal of menstrual waste in the school. Great care was taken with the use of local words, and question-
naires were pre-tested to get accurate information. Despite our efforts, there is a possibility that some girls
had difculty in understanding some questions, and self-reported responses may suffer from “desirability
bias”. Model schools were selected so they may have been prone to bias; however they may illustrate the
“best case scenario”. Researchers were not aware of the type of interventions which had occurred in the
model schools or regular schools involved. Studies were cross-sectional, so causality cannot be inferred.
In conclusion, our study further strengthens the case for national investment in menstrual hygiene man-
agement by schools. Focused national policies and budget support for menstrual hygiene would facilitate
schools to improve this in a continuous and sustainable way. Ensuring sufcient gender specic private
toilet facilities with water for changing and washing, and provision of sanitary materials would help re-
duce girls’ absenteeism in schools during menstruation. Providing pain relief, and adapting school rules
(to facilitate toilet visits) may further help to facilitate menstrual care in schools. Broader policy impli-
cations include the responsiveness of the education sector to enhance girls’ reproductive health and life
skills, and modify social norms to diminish menstrual restrictions. International investment in the devel-
opment of environmentally-friendly materials and disposal systems is also called for.

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Acknowledgements: We thank all the school girls, head teachers and teachers who provided the information.
We also thank eld staff who collected data, UNICEF ofcials from Chhattisgarh, Maharashtra and Tamil Nadu
for facilitating the study in the respective states.
Disclaimer: The ndings and conclusions in this report are those of the authors and do not necessarily repre-
sent the views of the Centers for Disease Control and Prevention.
Ethical approval: The study protocol, consent forms and data collection instruments were reviewed and ap-
proved by the Tata Institute of Social Sciences, Mumbai, India, and the Liverpool School of Tropical Medicine, UK.
Funding: This study was funded by the Department of Foreign Affairs, Trade and Development (DFAD), Gov-
ernment of Canada through a grant to UNICEF. MS, AMvE and PAP-H had full access to all data and had nal
responsibility for the decision to submit for publication.
Authorship declaration: PAP-H is the LSTM PI; and MS, HT, NK were Indian Institutional CO-PIs of the origi-
nal eld work study from which this paper is derived; they all contributed to the conceptualization and develop-
ment of the research study and its implementation. MS, NK, CP, SS, NS, GZ, and AB supervised data collection
for the study. MS and AMvE analysed and interpreted the data. MS and AMvE wrote the rst draft of the paper.
PAP-H, HT, NK, MBT, YK, AD, PS, BT, LM, KA, GZ and KFL critically revised subsequent drafts of the paper.
All authors approved the nal version.
Competing interests: The authors have completed the Unied Competing Interest form at www.icmje.org/
coi_disclosure.pdf (available on request from the corresponding author) and declare no competing interests.
Additional Material
Online Supplementary Document
1 United Nations Development Programme. Sustainable Development Goals: Goal 5 Gender Equality Targets. 2017. Avail-
able: http://www.un.org/sustainabledevelopment/gender-equality/. Accessed: 27 February 2017.
2 Sommer M, Caruso BA, Sahin M, Calderon T, Cavill S, Mahon T, et al. A Time for Global Action: Addressing Girls’ Men-
strual Hygiene Management Needs in Schools. PLoS Med. 2016;13:e1001962. Medline:26908274 doi:10.1371/jour-
nal.pmed.1001962
3 van Eijk AM, Sivakami M, Thakkar MB, Bauman A, Laserson KF, Coates S, et al. Menstrual hygiene management
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