This study was conducted and reported according to best practice guidelines in the Strengthening the Reporting of Observational studies in Epidemiology statement [20]. The checklist for cross-sectional studies is reported in Additional file 1.
Participants
Girls attending the trial schools at baseline were recruited into the Menstruation and the Cycle of Poverty trial. In addition, girls who transferred into the study schools during the trial were included in intervention delivery (of reusable pads and education) and in the final survey as not to stigmatise trial girls or discriminate against non-trial girls in resource provision. Similarly, non-menstruating girls were surveyed as not to identify menstruating girls. While those who transferred to the study schools could not be included in the intention-to-treat analyses of primary trial outcomes, they were incorporated in the final survey data set for secondary analyses.
Across the eight schools, 435 girls completed the final follow-up survey of the Menstruation and The Cycle of Poverty trial. Of these, 205 had reached menarche at the time of survey and were included in the present study.
In the present study, 145 girls (70.7%) were attending the trial schools at baseline and a part of the Menstruating and the Cycle of Poverty trial intention-to-treat sample. Of these, 67 (46.2%) received the reusable pads. A further 60 girls who had not been attending the study schools at baseline, but transferred into these schools during the trial are also included in the present study. Of these girls, 20 (33.3%) had received reusable sanitary pads.
Materials
Reusable pads were provided to girls in four of the eight trial schools (for the reusable pads alone, and reusable pads and puberty education conditions). These were provided in October 2012, and March 2014. Girls were given a single pack of AFRIpads, underwear, and a small quantity of omo soap (1 sachet, 45 g). AFRIpads are a reusable cloth pad produced locally in Uganda. Packs provided included soil-resistant ‘base’ pads that fastened to underwear, 3 winged pads, and 3 straight pads, along with 2 bags for transporting pads (see http://www.afripads.com/). This was considered the ‘deluxe menstrual kit’ by AFRIpads at the time of delivery (see Fig. 1). Instructions on using and cleaning the reusable pads were provided by trained local research assistants alongside delivery.
Measures
The follow-up survey was administered in November 2014. English surveys were loaded on iPads (using an offline app for SurveyGizmo) and delivered verbally in the local language (Lusoga), with trained research assistants from the partner NGO inputting responses in English. Research assistants were local young women, and visited the study schools in teams. For the survey, girls were taken aside to a private space and interviewed individually. If girls were absent on the day of interview, additional school sweeps were undertaken to survey all girls. Survey items required a response before progressing, or interviewers could indicate a ‘don’t know/no answer’ response if girls’ did not provide an answer. Survey interviews lasted approximately 30–40 min for menstruating girls.
The survey was developed by the research team in consultation with stakeholders and the partner NGO. Core items had been piloted in Ghana [10, 15]. Qualitative feasibility and acceptability work was undertaken prior to trial implementation, both in the local area, and similar regions (see [16]). This further shaped question development, as did existing menstrual hygiene literature. For transparency all survey items are reported in full in Additional file 2.
Participant characteristics. Girls self-reported their age, school grade, and how long it took them to get to school each day.
Menstrual absorbent use. Menstrual absorbent use was captured through the item: “What do you usually use to catch/absorb your MP (menstrual period)?” and girls provided a free response and resulted in the following responses: AFRIpad, cloth, sanitary pad or other items including toilet paper, underwear alone, mattress, or sponge. Follow-up items asked girls who provided their menstrual absorbent as a free response, responses included: the girls’ mother, another family member, or herself. Girls were asked where absorbents were obtained which was used to code if new or old cloth was being used. The menstrual absorbent categories are the same as reported in an additional secondary analysis paper on menstrual hygiene practices [21].
Girls provided number responses to questions: “how many pieces of cloth do you have?” and “how many pieces of cloth do you use a day?”. They were also asked to report (Yes/No) if they shared cloth with anyone in their household. Girls provided yes/no responses to indicate whether or not they had underwear, and if they wore underwear with their menstrual absorbent.
Cleaning and changing absorbents. Girls provided a numbered response to the question: “How many minutes does it take for you to change your sanitary protection?”. They were asked if they were able to “go for a full day without changing protection” with response options “no, never”, “yes, on some days” and “yes, always”. Girls were asked to rate on a 3-point Likert scale if changing their absorbent at school was “not a problem at all”, “a little bit of a problem” or “a big problem”. Girls provided yes/no responses to items asking if they washed their absorbents, used soap, used clean water for washing, and if water was hot or cold. Girls also provided a yes/no response to the item “Did you feel disgusted by washing the pad/cloth?”. Absorbent drying time was reported as the number of hours the pad or cloth took to dry, and girls reported if they wore their absorbent damp “never”, “sometimes”, or “often”.
Absorbent reliability. Girls were asked: “Do you feel you can rely on this method [most frequently used absorbent] to keep you from soiling when you have to…” followed by the list of activities reported in results tables. They reported that leaking when using their absorbent was “not at all a problem”, “a little bit of a problem” or “a big problem”. Girls reported if they worried about odour: “never”, “rarely”, “sometimes”, “often” or “all of the time”. This was followed by a question asking girls to report on the situations in which they worried about odour. Girls provided yes/no responses to if they had experienced a list of events during their last menstrual period, including odour, and outside garment soiling.
Restrictions due to menstruation. Girls were asked if their menstruation ever causes them to miss or avoid certain activities. Interviewers read a list of activities such as such as physical exercise or being around males and girls reported if their menstruation caused them to miss or avoid this activity. Similarly, girls provided a yes/no response to the item: “are there any activities or settings that you avoid while on your menstrual period?”. For those who indicated that there were, girls were asked to list them. Girls were also asked: “do the boys you know tease girls about their MP (menstrual period)”, and provided yes/no responses.
Reusable pad ratings. For girls who reported that they had received reusable pads, items captured how much they liked them (from “dislike very much” to “like it very much” on a 4-points scale). Girls were asked how likely they would be to purchase such pads if they had the resources to do so (from “not at all likely” to “extremely likely” on a 5-point scale, with mid-point of “moderately likely”).
Analyses
Analyses were conducted with Stata 14.0 [22]. Descriptive statistics captured participant characteristics and schoolgirls’ satisfaction with reusable pads. Description of girls’ experiences and reliability ratings are presented for each type of absorbent (reusable pads, new or old cloth, disposable sanitary pads, or other which included toilet paper, mattress, and underwear alone). However, there was insufficient power to compare differences in experience and reliability across the 5 absorbent types. It was not deemed appropriate to group commercial sanitary pads, as a purpose-built menstrual absorbent, with other improvised methods such as cloth. Thus, the existing improvised absorbents (new or old cloth, or other absorbents including toilet paper, mattress, and underwear alone) were compared with girls using the reusable pads received as part of the Menstruating and the Cycle of Poverty trial. Additional sensitivity analyses (available from corresponding author on request) included girls using disposable sanitary pads in the comparison group as a treatment-as-usual comparison and found no difference in the pattern of observed effects. Experiences of girls using disposable sanitary pads are retained in tables but there was insufficient power to test statistically significant differences for this group. Girls using reusable pads were compared to those using improvised methods using binary logistic regressions for dichotomous outcomes, and t-tests for continuous outcomes. Reference categories for logistic regressions were selected to favour positive odds ratios for more intuitive interpretation for readers.