Schoolgirls’ experience and appraisal of menstrual absorbents in rural Uganda: a cross-sectional evaluation of reusable sanitary pads

Governments and charity organisations have proposed providing resources, such as reusable pads, to address the barrier that managing menstruation may present to girls’ dignity, health, education, and psychosocial wellbeing. However, studies of sanitary product provision to date have not quantitatively tested girls’ perceptions and experience of such products.

This study describes and compares schoolgirls’ experiences of different menstrual absorbents. The work provides a follow-up to a controlled trial of reusable sanitary pad and puberty education provision which tested improvements in school attendance. By comparing the experiences between girls who received reusable sanitary pads as part of the trial and girls using other existing methods of menstrual absorption (predominantly cloth), this study provides insight into girls’ comfort and preferences. A sample of 205 schoolgirls, from eight schools in rural Uganda were included in the study. 72 girls who were using the reusable pads provided in the intervention study were compared with those using existing improvised methods. A few girls were using disposable sanitary pads, and their results are displayed separately. Results found that girls rated the reusable pads positively. Girls using the reusable pads were more likely to report they were easy to change, and were not disgusting to clean. Those using the reusable pads rated them as more reliable to keep them from soiling during a range of activities. Despite more positive perceptions, there were no differences in girls’ reports of soiling outer garments or experiencing odour during the last menstrual period. Results of the study are important in understanding girls’ preferences and experiences of menstrual absorbents in low income contexts.

Menstruation is a healthy and natural process for women and adolescent girls. The management of menstruation has varied over time and differs with available resources, cultural traditions, and preferences. There is increasing recognition that in low-income contexts, women struggle to manage menstruation in effective and hygienic ways [1]. This has been linked to negative impacts on health, education and wellbeing [2, 3]. A lack of clean and reliable menstrual absorbents has received much of the attention, with interventions focussed on the provision of these products to improve poor menstrual hygiene and associated consequences [4, 5]. There has been a proliferation of programs and organisations providing girls with menstrual absorbents, most frequently reusable or disposable pads [6–8]. A recent systematic review of studies evaluating the effectiveness of such interventions found few rigorous trials had been conducted [5]. The review identified only 3 studies of menstrual product provision, each assessing a different product; menstrual cups, [9] disposable sanitary pads, [10] and home-made reusable pads [11].

Whilst results of these trials seem promising with regard to school attendance, some have criticised menstrual management research for taking for granted the inadequacy of existing local methods [12]. Further, focus on hygiene and education outcomes may have minimised the importance of women and girls’ right to dignity and comfort during menstruation [2, 13]. Trials and observational studies have often overlooked girls’ perceptions of absorbent acceptability, reliability and comfort, as well as absorbents’ impact on self-efficacy. These outcomes are critical for many reasons. Firstly, school absenteeism during menstruation is frequently attributed to soiling or the fear of garment soiling. As a result, trials providing menstrual absorbents may assume that observed improvements to school attendance result from a reduced risk of soiling, but none have reported on this outcome explicitly or tested it as a mediating pathway. Secondly, menstrual management programs typically provide only one type of product, which may be delivered alongside explicit education or proscriptive norms which discourage the use of existing improvised absorbents such as cloth. This could be seen as limiting girls’ choices for menstrual management, particularly in comparison to high-income contexts where women and girls may use a range of different products during menses. This places more pressure on ensuring the acceptability and adequacy of the products provided before interventions are implemented at scale. Further, if trials focus exclusively on school attendance and fail to report on other outcomes which have been neglected to date such as comfort, acceptability, or self-efficacy, sanitary product distribution interventions may be abandoned if education provision alone is found to be equally effective in improving attendance, as has been the case in recent studies [10, 14].

Girls’ dignity must be kept at the forefront of primary research and intervention studies of menstrual management. Assessment of reliability, comfort, and satisfaction with activities such as changing and washing absorbents put girls’ agency and preferences at the centre of program evaluation. The present study is the first to do this quantitatively, providing a cross-sectional follow-up to the Menstruation and the Cycle of Poverty trial [14] and evaluates reusable pads as an alternative to existing improvised methods. Reusable pads are assessed in terms of girls’ experiences, preferences and self-reported leaking, odour, and avoidance of daily activities during menses. The study compares ratings between those using reusable pads provided as part of the trial, and those using existing improvised menstrual absorbents (including cloth, toilet paper, and underwear alone). A small group of girls reported using commercially produced sanitary pads and their ratings are displayed separately.

Past trials of menstrual product provision have addressed some of these questions with qualitative reports or field observations of product acceptability and uptake [9, 11, 15]. The Menstruation and the Cycle of Poverty trial [14] assessed here, conducted a pilot assessment of menstrual products. Prior to trial implementation girls in a different region provided feedback on proposed absorbents for intervention compared to each other and existing methods such as cloth or underwear alone (see [16]). While reported reusable pad acceptability was high, only 44% of the sample reported they would switch from their existing methods (possibly due to a high baseline rate of disposable sanitary pad use). Other studies have found qualitative evidence of acceptability of menstrual cups, but it is unclear if these would be preferred to other methods if offered [17]. A recent study of women in a high income context, where other products such as pads and tampons are available, found only 55% reported they would continue using a menstrual cup after an acceptability study [18]. Whilst some positive endorsement is evidenced here, findings indicate individual differences in preferences, and that acceptability and experience measures must be taken into account in trials of product provision interventions beyond preliminary qualitative studies. Quantitatively reported outcomes would allow comparison between different products trialled. While some have suggested that large trials of multiple products may be needed to best maximise outcomes for women and girls, [4, 17] quantitative reports across studies of girls’ experiences would also allow for comparisons and help identify products which have a demonstrated benefit for health and education outcomes, as well as girls’ comfort. This evaluation is needed to provide agents in the field and policy makers with the breadth of information necessary for large-scale dissemination of programs to be considered.

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.

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.

The present study was the most comprehensive quantitative assessment to date comparing girls’ experiences of different menstrual absorbents in a low income context. Specifically, comparing reusable sanitary pads to existing improvised methods, predominantly cloth, in rural Uganda. The reusable pads tested here, AFRIpads, received favourable ratings. They were reported to be quicker to change, less of a problem to change at school, and less disgusting to wash than other absorbents. Although these pads took longer to dry, girls were less likely to report wearing them damp. This may be a true difference as a result of the accompanying instruction not to wear them damp, or may represent social desirability bias in reporting, as girls knew they were not supposed to wear the pads damp.

Girls reported that they felt the reusable pads were more reliable to keep them from soiling in a variety of settings. Perceptions of reliability across ranged from 68 to 90% for those using reusable pads compared to 29–54% for those using existing improvised methods. Interestingly, among the highest ratings of 90 and 54% reliability were for protection from soiling when going to school. This is highly suggestive of girls providing biased, desired responses. Girls reported the lowest reliability of absorbents when sitting for a long time (68 and 36% for pads and existing improvised methods, respectively), one of the main school activities. Similarly, girls rated reliability when they needed to be gone from home for a long time as 76 and 41% for reusable pads and improvised methods, another aspect of the school day which did not corroborate girls’ ratings of absorbent reliability when at school. As AFRIpads were the only product provided in the intervention, this study was unable to test if girls would have rated other provided products more highly (e.g., other types of reusable pad, reusable menstrual underwear, tampons). Only a very small group used disposable sanitary pads, which may have been favoured and showed high ratings. No girls reported using inserted methods. Girls reported liking the reusable pads, although half reported that they would not be able to afford them. Girls stated they would be likely to spend money on these products if they had the funds available but they were not asked if they would favour other types of products; an important consideration for future research.

The above ratings indicate positive perceptions of reliability of the reusable pads, and may indicate better performance. However, they also highlight issues with current outcome assessment in menstrual management research and discrepancies between girls’ perceptions of absorbents and their lived experience [13, 21]. While girls using reusable pads had 8.44 times higher odds of reporting leaking was not a problem and reported higher perceptions of reliability, there were no differences in reported outer garment soiling during the last menses (44% for both those using reusable pads and those using improvised methods). These high proportions suggest that the provision of better absorbents may not be sufficient to protect against embarrassment. More research is needed on the frequency of soiling and contributing factors (e.g., wearing pads for too long, underwear quality, inadequate absorbents, being unprepared for menstruation and soiling when menstruation commences). It is also difficult to determine from these results if the reusable pads were more reliable absorbents, or only perceived to be so. Future work which collects objective measures of absorbency and fluid retention may answer these questions with regard to product development. Improved outcome measures may capture the time and causes of soiling which may also distinguish between absorbent failure and behavioural predictors of soiling. Similar rates of odour and concern about odour were reported for reusable pads and other absorbents. This could reflect other aspects of menstrual hygiene management such as washing and drying, which were not improved by pad provision [21]. Differences between perceptions of reliability and actual soiling and odour also highlight the value of quantiative and mixed-methods approaches to assessing absorbents as such discrepancies may not have been identified in qualitative studies.

Girls reported missing activities due to menstruation. Differences in responses to items ‘does your menstruation ever cause you to miss/avoid…’ where the list of items was read aloud, and ‘are there activities you avoid while menstruating…’ with volunteered responses, further demonstrates the need for more careful and validated outcome assessment in this field. Validity and reliability studies are needed, with lessons from fields with more research such as sexual and reproductive health which also ask for sensitive information about personal experience and practices, with known social desirability. Across a range of domains there is a need for measure development. Further, mixed-methods research may assist in attaining the nuanced measurement of proposed outcomes. Despite issues of outcome assessment, comparison between reusable pads and existing methods revealed fewer differences than expected in daily activities. When girls were asked if their menstruation ever caused them to miss certain activities there were no differences in reports. When asked to volunteer settings avoided while menstruating there were large differences between pads and existing methods on selected items. This may indicate differences in volunteered responses, or being asked if they avoided activities, in contrast to asking if menstruation caused them to miss activities. Girls using existing methods had 5.00 times higher odds of avoiding physical sports and exercise, and were more likely to report avoiding fetching water, cooking or working in the field or garden.

Together study findings reveal the importance of considering the full story of menstrual management when assessing interventions. Primary trial outcomes reporting the same improvements in school attendance following reusable pad provision as puberty education, [14] do not reveal improvements to girls’ confidence in absorbents, disgust in washing, difficulties changing absorbents, or participation in other activities. Findings also suggest that the provision of pads alone may not be sufficient to reduce garment soiling and that more detailed work is needed.

Although not statistically significant, there was an almost 10% higher report of teasing amongst those using the trial-provided reusable pads. No trials to date have assessed potential harms of menstrual management interventions in low income contexts, [5] this finding cautions that the provision of sanitary products in schools may leave girls vulnerable to teasing about menstruation if interventions draw attention to, or ‘outs’, menstruating girls.

Results of this study suggest reusable pads are perceived to be more reliable and convenient to manage than girls’ existing improvised menstrual absorbents (predominantly cloth) in rural Uganda. Whilst the primary outcomes of the trial found no difference between reusable pads and puberty education in improving school attendance, this follow-up work reveals other important benefits of pad provision. Findings suggest that to fully appraise programs providing sanitary products to girls, a wide range of outcomes must be considered. Girls’ comfort and dignity must be kept in the forefront of evaluation and consideration by policy makers when interpreting the results of existing studies. Potential harms from outing girls’ menstrual status, or reductions to their choice of menstrual absorbents by restricting them to only one advised product should also be considered. Ideally schoolgirls may be provided with a choice of products, and willingness and ability to pay studies may provide further details on preferences and practices.