Systematic Review of Educational Interventions to Improve the Menstrual Health of Young Adolescent Girls

"Multicomponent interventions that speak to different actors and include hardware and software provision alongside menstrual education may make menstrual health more attainable."

Globally, young adolescent girls tend to be ill-prepared for menarche and menstruation. Discussing menstruation is almost universally a taboo, making it difficult for girls to learn about it and know what is normal or when to seek help. This systematic review sought to describe and evaluate the impact of menstrual education interventions intended to equip young adolescent girls with the knowledge and skills to promote menstrual health.

This review draws on papers published in English from January 2014 until May 2020. Twenty-four papers met the inclusion criteria. They included: 12 randomised controlled trials (RCTs); five quantitative descriptive studies; one quantitative non-random study; five mixed methods studies; and one qualitative study. Studies were undertaken in Iran (six), Turkey, Indonesia (two), Ethiopia, India (four), Bangladesh, Uganda (four), the United States, Nepal, Kenya (two), and China. The methodological quality of study designs was mixed: 11 were rated as high quality and 13 as moderate to low. Those considered to be of the highest quality were RCTs.

The interventions were designed to improve the menstrual health of the recipients by addressing one or more elements of menstrual knowledge, attitude, or practices (KAP). Most of the interventions were delivered in the school setting, although only two embedded the education into the school curriculum. Eight of the interventions employed didactic teaching, sometimes supplemented with posters, flip-charts, and question-and-answer (Q&A) sessions. Two interventions employed a more formal lecture presentation; two used stories and video presentations; and two distributed puberty books. Three interventions facilitated learning through peer education, and seven focused on menstrual hygiene management (MHM) training (e.g., demonstrating pad usage using a doll).

All 24 included studies that evaluated some form of menstrual education intervention reported that there was a measurable improvement in the menstrual KAP of young adolescent girls. A meta-analysis was conducted on 11 qualitative studies, which measured a change in menstrual knowledge following an intervention. A visual inspection of forest plots showed that all studies found a significant improvement in menstrual knowledge.

Qualitative results around knowledge and attitudes showed that interventions that included group and peer teaching were most impactful at standard deviation (SD) 5.337 and 10.044, respectively, when compared to other communication interventions. The effect size of interventions that distributed pamphlets and books was lowest at 0.33, followed by those that showed videos (1.40) and then lectures with Q&A sessions (2.13 and 4.81, respectively). That is, a larger effect was gained with the more interactive interventions, which "relates to the higher degree of participation, and concurs with current educational philosophy about the importance of active learning....Discussing menstruation gives the girls agency to determine what it is that they need to know for themselves."

Guided by logic models developed for school-based interventions, the researchers worked backwards from the higher order aim of good menstrual health to propose a chain of causal events, as captured by the below model:

The aim of good menstrual health is the distal outcome to the intervention. It is characterised by girls feeling empowered and having agency to make choices about their own bodies and lives. They can choose a suitable menstrual product to meet their individual needs. They track their menstrual cycle to be well prepared so they are not caught out at school and have to go home, and they engage as necessary with reproductive health services without shame or stigma. Girls with agency are able to control their menstruation and not the other way around. They can focus on their school work and reach their potential.

The results of the review provide evidence that menstrual education improves the menstrual KAP of young adolescent girls. It is suggested that increasing the menstrual KAP of girls boosts their confidence to seek further knowledge and skills in a positive feedback loop. Menstrual education is viewed as underpinning the logic model and is the first step to achieving menstrual health.

The researchers indicate that "[m]ulticomponent interventions may be more successful than single components in achieving the distal outcome of menstrual health and well-being. Girls need an enabling environment as well as knowledge....[I]nterventions that seek to improve the menstrual literacy of the whole community and reduce menstrual stigma may be more effective in achieving the macrodistal outcomes of girl empowerment and gender equality."

The review also highlights the fact that menstrual education needs to be delivered by trained personnel who are confident to lead discussion. Especially but not exclusively in low- and middle-income countries (LMICs), where resources are limited, "it would be prudent to ensure that menstrual education is embedded into the school curriculum and that teachers receive specialist training." In addition, "programme and policy-makers need to address the menstrual literacy of the wider population."