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South African Journal of Child Health

On-line version ISSN 1999-7671
Print version ISSN 1994-3032

S. Afr. j. child health vol.16 n.1 Pretoria Apr. 2022 



The relationship between menstrual hygiene management, practices, and school absenteeism among adolescent girls in Johannesburg, South Africa



N KhamisaI; N NanjiII; N TshumaIII; J KaguraIV

IPhD; Division of Health and Society, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
IIBPH (Hons); School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
IIIPhD; The Best Health Solutions, Johannesburg, South Africa
IVPhD; Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa





BACKGROUND. Factors associated with menstrual hygiene management (MHM) and practices affect school absenteeism, with up to 7 million girls missing 25% of their given school year each month in South Africa (SA).
OBJECTIVE. To identify the most significant factors associated with MHM and practices affecting school absenteeism among adolescents in Johannesburg, SA.
METHODS. A secondary data analyses of a cross sectional study among 489 adolescent girls from 30 schools in Johannesburg, SA was conducted. Data was collected using a self-administered questionnaire. Logistical regression analysis was conducted for all variables affecting school absenteeism using STATA version 14.
RESULTS. Female adolescents who had pre-menarcheal training were more likely to attend school (odds ratio (OR) 1.96; 95% confidence interval (CI) 1.04 - 3.73; p= 0.038). Those who disposed of their absorbent materials by burning, throwing them by the roadside or on farmland were almost 2x more likely to be absent from school (OR 2.07; 95% CI 1.05 - 4.08; p= 0.038). Dysmenorrhea (painful menstruation) was associated with higher likelihood of being absent from school (OR 2.6; 95% CI 1.29 - 5.29; p=0.008).
CONCLUSION. This present study reveals that MHM and practices related to school absenteeism extend beyond the availability of sanitary materials. These findings can be used to create dialogue between various stakeholders about best practices for reducing school absenteeism related to MHM.



Menstrual hygiene management (MHM) and practices include the use of clean menstrual management materials for the absorption or collection of blood, the necessary changing of these materials in private for the duration of the menstrual cycle, the required use of soap and clean water for body washing, access to safe and convenient facilities for disposal of used materials, adequate knowledge about the menstrual cycle as well as the management thereof with dignity and absence of fear or discomfort.[1]

In developing countries, MHM is particularly challenging due to inadequate knowledge as well as lack of access to sanitary materials and hygiene facilities, thereby impacting education and health outcomes.[2] Sub-Saharan Africa (SSA) has one of the fastest growing populations of adolescent girls in the world, with poor MHM and practices being a prominent issue in this region.[3] Poor MHM and practices is documented in several studies, with some studies showing that up to 87% of girls use old clothes and rags as absorbent materials and these materials are not properly washed before re-using.[4] This as well as lack of clean, functional, private and gender-specific facilities, fear of leakage and poor access to sanitary materials are commonly reported to be associated with abseentism at school.[2]

School absenteeism among adolescent girls is a known effect, with some SSA studies estimating between 1.6 - 2.1 days of school are missed every month by 50 - 70% of menstruating girls.[3] In South Africa (SA), 7 million girls are reported to be absent from school each month due to lack of sanitary pads, which results in them missing 25% of learning during the school year.[5] Embarrassment, fear of being ridiculed together with menstrual pain (dysmenorrhea) and lack of sanitary materials contributed to school absenteeism among girls in Uganda.[6] Interestingly, an Ethiopian^ study showed that 56% of girls who received re-usable sanitary pads were absent from school. Pre-menarcheal training is associated with school absenteeism through knowledge of MHM and practices, and predictors of this include age and living with both parents.[8]

School absenteeism is associated with several factors including access to sanitary materials, hygiene facilities, pre-menarcheal training, painful menstrual symptoms as well as age and living conditions. Noteworthy is that these factors often work together in influencing school absenteeism, with studies showing that despite pre-menarcheal training, a lack of adequate disposal facilities negatively affects school absenteeism.[7] This not only impacts the psychosocial wellbeing of girls by negatively affecting their confidence and dignity, but also their academic experience through participation and performance at school.[4] Reports further indicate that these issues are exacerbated in SSA, where 47% of schools have limited or no sanitation facilities and 21% have basic hygiene services equipped with soap and water.[9] In SA specifically, 7.1 million people (including women and children) and 4 500 schools do not have access to basic sanitation facilities.[10] This as well as a lack of research that could potentially inform policy and practice in the country justifies the need for the present study. The present study seeks to identify the most significant MHM factors and practices affecting school absenteeism among adolescents in Johannesburg, SA.



Study setting and design

Johannesburg is the biggest city in SA, with a population of ~4.4 million people. It is situated in Gauteng Province (GP), the most populous and highly urbanised province in the country. The city is comprised of 1 434 856 households with an average household size of 2.8 people per household. Of these households, 64.7% have access to piped water and 26.9% have water in their premises.[11] The Department of Water and Sanitation recently announced a plan to provide water to over 3 126 schools nationwide. To facilitate this and ensure installation of water tanks in schools, the department has partnered with Rand Water and Department of Education with the aim of having up to 1 320 tanks installed at schools across the provinces.[12] GP has ~2 606 schools and Johannesburg has 269 schools.[13]

Participants and sampling

This study is a secondary analysis of quantitative data obtained from a cross-sectional study among female adolescents aged between 12 and 19 years (grades 8 - 12) from 30 schools in the inner city of Johannesburg. Sample size calculation was done using 95% confidence interval, 0.05 precision and prevalence rate as well as the Leslie Fischer formula («=Z2PQ/d2), which revealed a sample size of 489.

The primary study used a multistage sampling technique to identify the schools as well as participants. Proportionate stratified random sampling method was used in the identification of schools from each sub-district. The Department of Education quintile classification formed the strata from which public schools were randomly selected using a lottery method. The number of schools were selected using a sampling fraction in each of the strata that was proportional to that of the total sub-district population. Stratified systematic sampling method was used in the identification of participants in the selected schools. The grade levels formed the strata from which participants were systematically selected, with class registers constituting the sampling frame. In cases where a respondent declined to participate in the study, a successive participant was selected.

The inclusion criteria were female adolescents who were in grades 8 - 12 and between the ages of 12 -19 years. Male and female adolescents below or above the ages of 12 - 19 who were not in grades 8 - 12 were excluded.

Data collection

A self-administered questionnaire with close-ended questions was administered to consenting participants during the primary study. An electronic data system was used to record responses using electronic tablets. The questionnaire consisted of questions related to demographics, pre-menarcheal training, MHM, menarche and menstrual cycle. Inter-rater reliability was achieved confirming the consistency of the questionnaire. Data quality was affirmed through an automated data entry spreadsheet, which underwent systematic checking.

Ethical considerations

Ethics approval was obtained for the secondary study from Monash University Human Research Ethics Committee (ref. no. 9690). Informed consent was provided by parents of participants prior to participation in the primary study. Data were password protected and stored in a safe place, with participant information were only available to the researchers. The participants were able to withdraw from the study at any time and referred for counselling if they experienced distress or discomfort.

Data analysis

The outcome variable was school absenteeism (measured as absent or not absent) and exposure variables included age, age at menarche, weight, height, body mass index (BMI) and duration of menstrual cycle, among others. Variables such as parents' education, pre-menarcheal training, disposal of absorbent materials, and dysmenorrhea were further categorised. Each completed questionnaire was coded using a pre-existing coding sheet to reduce errors. Data were cleaned and analysed using STATA, version 14.0 (STATACorp, USA)

Descriptive analysis was used to determine sample characteristics. A χ2and Fisher's exact tests were performed on the categorical variables while student's i-test was performed for continuous variables. A stepwise logistic analysis using backward selection was used to identify the MHM factors and practices most significantly associated with school absenteeism after adjusting for confounding variables (these were significant at 20% in the bivariate analyses). Thereafter, the variables that were significant at 20% were retained and other variables of interest were refitted in the model. The model was refitted until the model with a good fit was achieved. This was confirmed using the goodness of fit test. Finally, interactions between some variables were checked by fitting their interaction terms into the model. This was followed by a likelihood ratio test, which was conducted after each interaction term was fitted in the model to determine if it improved the fit of the model.



The average age of the study participant was 16 years, age at menarche was 12 years, weight was 58 kg, height was 1.7 m, BMI was 20, and length of menstrual cycle was 27 days (Table 1).



As indicated in Table 2, mothers' education (χ2= 6.8), type of absorbent material used (χ2 = 4.15), disposal of the absorbent material (χ2= 7.95), experience at first menstruation (χ2= 10.18), attitude towards menstruation (χ2= 10.7), and dysmenorrhea (χ2= 11.4) were significantly associated with school absenteeism (p<0.05).



A unit increase in age at menarche showed a 28% increased odds of school absenteeism. Use of tissue paper or cloth as an absorbent material meant 105% increased odds of being absent from school. Disposal of absorbent material in another way (burning or on the roadside), compared with the reference of disposal in bins showed a 122% more likelihood of being absent from school. Being expectant of the girls' first menstruation was statistically significant with school absenteeism but being expectant as compared with undesirable (reference) was associated with 75% less likelihood of being absent from school. A satisfied attitude was associated with an 86% less likelihood of being absent from school. Having a painful menstruation was associated with a 200% more likelihood of being absent from school (Table 3).



Table 4 shows multivariate analyses, whereby age at menarche and pre-menarcheal training were marginally associated with school absenteeism, with an additional year being associated with 14% increased odds of missing school due to menstruation. On the other hand, pre-menarcheal training was associated with 87% increased odds of missing school. Modes of disposal of absorbent material was one of the most significant predictor of school absenteeism related to menstruation, with any other form such as burning, roadside or on farmland as compared with bins (reference) being significantly associated with a 2-fold increase in school absenteeism. Dysmenorrhea was significantly associated with 3-fold increased odds of school absenteeism. Interestingly, there was a significant association between experience of first menstruation and school absenteeism; adolescents who were expectant of the first menstruation were notably less likely to miss school due to menstruation compared with those who were confused about menarche. There was an interaction between pre-menarcheal training and the experience at first menstruation (odds ratio (OR) 0.22; 95% confidence interval (CI) 0.06 - 0.84; p=0.026).




This study sought to identify MHM factors and practices that most significantly affect school absenteeism among female adolescents in Johannesburg, SA. The results confirmed that age at menarche, pre-menarcheal training, disposal method, experience of first menstruation, and dysmenorrhea were significantly associated with school absenteeism.

Female adolescents exposed to pre-menarcheal training were more likely to attend school. This is aligned with several studies showing that lack of knowledge about MHM and practices negatively affect school attendance in developing countries.[14] A Ugandan[15] study showed that poor rates of school attendance were mitigated by 17% when pre-menarcheal training was involved. Studies have reported specific gaps in knowledge related to the reason for menstruation and origin thereof, which was attributed to the limited role of schools in providing pre-menarcheal training.[16] Pre-menarcheal training offers knowledge about adequate MHM and practices, thereby improving preparedness and encouraging healthy management of menstruation. Female adolescents possessing adequate knowledge about how to manage their menstrual cycles are more likely to have positive feelings about it and are less likely to experience fear, secrecy and vulnerability associated with missing school.[14]

In the multivariate analyses, disposal method of the absorbent material was shown to be significantly associated with school absenteeism. Female adolescents who disposed of absorbent materials by burning and throwing them by the roadside or farmland were notably more likely to be absent from school. Previous studies have attributed this to a lack of adequate disposal facilities such as bins, with one study reporting that only 1.1% of female adolescents were able to access these in Ugandan schools. [6] Consistent with a study conducted in Zambia,[17] where the majority of female adolescents disposed absorbent materials in toilets, it was explained that this was due to a lack of dustbins in the school toilets. This was also a preferred method of disposal due to fear of not wanting their used pads to be seen by others.[17] Lack of adequate disposal facilities in schools prevents the frequent changing of absorbent materials, which leads to leaking on outer garments and makes it difficult for girls to attend school due to fear of shame and embarrassment.[6

The results of the present study confirm that female adolescents who were expectant of the first menstruation were less likely to miss scho ol compared with those who were confused about first menstruation. Significant statistical interaction between pre-menarcheal training and experience of menarche also confirms that preparation for menarche in terms of training has a positive impact on adolescents' psychosocial wellbeing, while improving school attendance through creating a positive perception about menstruation.[18]

Dysmenorrhea was also shown to be significantly associated with school absenteeism. Female adolescents who had dysmenorrhea showed 3-fold increased odds of being absent from school. These findings are confirmed by previous studies suggesting that those experiencing dysmenorrhea were 4.4x more likely to be absent from school.[19] A similar study in Egypt[20] showed that school absenteeism was the only factor among other daily activities that was significantly associated with dysmenorrhea. Dysmenorrhea is also considered to be the most prevalent menstrual problem among females and is reported to be the most common factor contributing to school absenteeism in Ethiopia.[21] Evidently, the pain experienced by menstruating females is accompanied by a number of other symptoms including nausea, vomiting and fatigue, which affects the ability to attend school, sit in class and concentrate for an extended period of time.[20,21]

Study limitations

Limitations of the present study include the small sample size, which reduces generalisability of the findings. Cross-sectional design of the study makes it difficult to establish causality and the use of a self-administered questionnaire makes it difficult to verify the accuracy of responses. School absenteeism in this sample was 11%, which is far lower than in other countries and might have affected the effect size. It is recommended that future studies should explore the effect of specific MHM practices on school absenteeism among female adolescents from a number of schools across SA.



This study provides empirical evidence for the direct association between pre-menarcheal training and school absenteeism in Johannesburg, SA, while adding new knowledge about the effect of disposal methods on school absenteeism. Understanding the impact of various menstrual symptoms, including dysmenorrhea, is important in this context and it is recommended that the findings of the present study be used to create dialogue between various stakeholders including schools, government, parents, teachers, and learners about best practices for reducing school absenteeism related to MHM and practices. Existing policies should incorporate improved MHM practices including compulsory pre-menarcheal training and access to adequate disposal facilities to increase attendance at school. Dispensing of pain medication by a qualified health professional should also be a consideration for pain management among menstruating adolescents attending school.

Declaration. None.

Acknowledgements. We would like to acknowledge and thank the participants of the study as well as CARe for collecting and sharing the data used in this study. Sincere appreciation is extended to Munachimso Dim, who refined the statistical approach in this manuscript.

Author contributions. NK, NN, JK and NT conceptualised this study. NT developed the protocol for this research study, planned the research, undertook data collection (with the assistance of trained research assistants). NN and JK analysed the data and NK, NN and JK interpreted the data. NK wrote the draft of the manuscript. NK and JK provided input at all stages of the study. All authors approved the final version of the manuscript for publication.

Funding. CARe provided funding for costs related to data collection.

Conflicts of interest. None.



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N Khamisa

Accepted 17 March 2021

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