title: Menstruation and the Cycle of Poverty: A Cluster Quasi-Randomised Control Trial of Sanitary Pad and Puberty Education Provision in Uganda.
abstract: BACKGROUND
  Poor menstrual knowledge and access to sanitary products have been proposed as barriers to menstrual health and school attendance. In response, interventions targeting these needs have seen increasing implementation in public and private sectors. However, there has been limited assessment of their effectiveness.
  
  
  OBJECTIVE
  Assess the impact of providing reusable sanitary pads and puberty education on girls' school attendance and psychosocial wellbeing outcomes.
  
  
  METHODS
  A cluster quasi-randomised controlled trial was conducted across 8 schools, including 1124 girls, in rural Uganda. Schools were allocated to one of four conditions: the provision of puberty education alone; reusable sanitary pads alone; puberty education and reusable sanitary pads; and a control (no intervention). The primary outcome was school attendance. Secondary outcomes reflected psychosocial wellbeing.
  
  
  RESULTS
  At follow-up, school attendance had worsened for girls across all conditions. Per-protocol analysis revealed that this decline was significantly greater for those in the control condition d = 0.52 (95%CI 0.26-0.77), with those in control schools having a 17.1% (95%CI: 8.7-25.5) greater drop in attendance than those in any intervention school. There were no differences between the intervention conditions. High rates of school drop-out and transfer meant the trial suffered from substantial participant drop-out. Intention-to-treat analyses using two different imputation strategies were consistent with the main results, with mean differences of 5.2% attendance in best-case and 24.5% in worst-case imputations. Results were robust to adjustments for clustering. There was no impact of the interventions on girls' self-reported shame or insecurity during menstruation.
  
  
  CONCLUSIONS
  Results of the trial support the hypothesised positive impact of providing sanitary pads or puberty education for girls' school attendance in a developing country context. Findings must be interpreted with caution in light of poor participant retention, intervention fidelity, and the attendance measures used.
  
  
  BACKGROUND
  Pan African Clinical Trials Registry PACTR201503001044408.
authors.affiliation: Centre for Evidence-Based Intervention, University of Oxford, Oxford, United Kingdom.
authors.forename: Paul
authors.initials: P
authors.lastname: Montgomery
authors.affiliation: Centre for Evidence-Based Intervention, University of Oxford, Oxford, United Kingdom.
authors.forename: Julie
authors.initials: J
authors.lastname: Hennegan
authors.affiliation: SOAS, University of London, London, United Kingdom.
authors.forename: Catherine
authors.initials: C
authors.lastname: Dolan
authors.affiliation: Applied Technologies for Learning in the Arts and Sciences, University of Illinois, Urbana-Champaign, Illinois, United States of America.
authors.forename: Maryalice
authors.initials: M
authors.lastname: Wu
authors.affiliation: Bentley University, Waltham, MA, United States of America.
authors.forename: Laurel
authors.initials: L
authors.lastname: Steinfield
authors.affiliation: Said Business School, University of Oxford, Oxford United Kingdom.
authors.forename: Linda
authors.initials: L
authors.lastname: Scott
mesh_terms: D000293:Adolescent; D002648:Child; D016000:Cluster Analysis; D005260:Female; D006266:Health Education; D006801:Humans; D052576:Menstrual Hygiene Products / Q000600:supply & distribution*; D008598:Menstruation / Q000523:psychology*; D011203:Poverty / Q000706:statistics & numerical data; D000297:Psychology, Adolescent; D011627:Puberty / Q000523:psychology*; D012424:Rural Population; D057566:Self Report; D013332:Student Dropouts / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D014454:Uganda