The Journal of School Nursing2024, Vol. 40(3) 329–335© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211069601journals.sagepub.com/home/jsn
Menstrual hygiene management (MHM) among female students is a neglected public health issue in the U.S. This study documented period product insecurity, school absenteeism, and use of school resources to obtain period products among highschool students in St. Louis, MO. Female students completed an anonymous, self-administered survey in English (n = 119). Descriptive statistics were used to determine the prevalence of period product need, resources used to obtain period products, and period-related absenteeism. The mean age of participants was 15.78 ± 1.28. Nearly two-thirds (64.4% (95% CI 55.1%-73.0%)) reported period product insecurity. Two-thirds (66.9% (95% CI 57.7%-75.3%)) reported using at least one of the school’s resources to obtain period products. One-third of the participants (33.6% (95% CI 25.0%-43.1%)) reported missing school due to a lack of period products. School nurses need to be cognizant of how MHM affects their students’ attendance at school and what measures they can take to help reduce menstruation-related absenteeism.
Keywordsperiod product insecurity, school absenteeism, high school, school-based clinics
Discussions around menstrual hygiene management (MHM) as a public health issue are growing worldwide. (Sommer et al., 2015; Sommer & Sahin, 2013a) The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) define adequate MHM as women and adolescent girls using a clean, absorbent material to collect menstrual blood that can be changed in privacy as often as necessary for the duration of a menstrual period, using soap and water for washing the body as required and having access to facilities to dispose of used menstrual management materials. (JMP, 2012) Most of the attention regarding MHM issues has been focused on low and middle-income countries. Recently, however, attention has shifted to this issue in more developed countries. (Sebert Kuhlmann et al., 2019) Examples of this increased attention in higher-income countries include Scotland becoming the first country in the world to make period products freely available to those who need them (Diamond, 2020) and New Zealand requiring period products be freely available in all schools. (Triesman, 2021)
Adequate MHM in schools requires the provision of information, period products, adequate supply of water, disposal facilities, support for menstrual pain, and privacy for changing. (Armour et al., 2020; Schmitt et al., 2021; Sommer & Sahin, 2013b) Failure to provide these can affect girls’ well-being, dignity, and health. In addition, it can negatively affect school performance by increasing absenteeism and drop-out rates. (Armour et al., 2020; Davis et al., 2018; Phillips-Howard et al., 2016; Schmitt et al., 2021)
In recognition of the importance of improving MHM for girls, the “MHM in Ten” initiative, developed in 2014, maps out a ten-year plan for MHM in schools around the world. The initiative identifies five priorities to improve MHM by 2024, one of which is to build a robust evidence base around MHM in schools. The initiative’s midway progress update reports overall gains in many of the priority areas. (Sommer et al., 2021) Several governments worldwide have increased their responsibility to support MHM in schools. The report indicates, however, a lack of national policies related to menstruation and MHM in schools. (Sommer et al., 2021) In the U.S., there are currently no national policies that mandate schools provide period products to students for free. To date, only seven states (California, Colorado, Georgia, Illinois, New Hampshire, New York, and Washington) have legislation mandating schools make period products available to students for free. (ACLU & Period Equitt, 2019; Turlington Burns & Weiss-Wolf, 2021) Data documenting the extent of unmet menstrual hygiene needs among students and the relationship to school attendance and performance is imperative to support legislative action. As such, research is one of the “MHM in Ten” initiative’s priorities. (Sommer & Sahin, 2013b)
Despite there being limited studies, most of which are qualitative in nature, from the U.S. regarding MHM among adolescents, there is some evidence of MHM issues among adolescents. (Jackson, 2019; Schmitt et al., 2021; Secor-Turner et al., 2022) A study conducted among working middle-class adolescent girls aged 11-16 from New England (n = 15) reported that participants were not well prepared for menarche, and menstruation impacted them both physically and emotionally. (Jackson, 2019) Similarly, in a qualitative study (n = 12) conducted in a Midwestern city, student participants reported lack of MHM in their school setting impacts their school attendance. (Secor-Turner et al., 2022)
A previous, small quantitative study in St. Louis, Missouri (n = 58) found nearly half of the students reported period product insecurity over the past year, and approximately 17% of students reported missing school due to a lack of period products. Furthermore, 62.1% of the students reported accessing period products through school resources. (Sebert Kuhlmann et al., 2020) While this previous study highlights the important role schools, including nurses’ offices, play in increasing knowledge about MHM and tackling period product insecurities among students, it was conducted during orientation and registration days prior to the start of the school year, and students reported on the previous school year. Here, this current study aims to follow-up on those findings with a larger sample of students reporting on the current school year, thus reducing recall bias and providing further evidence of the relationship between menstrual hygiene needs, school attendance, and the use of school resources to obtain period products among students in an urban high school in St. Louis, Missouri.
Participants were female students enrolled in grades 9 through 12 at a public high school in St. Louis, Missouri, with just over 700 students enrolled. Any student who identified themselves as menstruating was eligible to participate. Data were collected during the students’ lunch periods on a single day in February 2020. Therefore, students who were absent that day or who were taking classes off-campus, e.g., at a local community college through the school’s college-prep partnership program, were excluded. Male students were also excluded. The high school’s student body is over 98% African-American and over 99% eligible for free or reduced lunch. (Missouri Department of Elementary and Secondary Education, n.d.)
A two-page, anonymous, self-administered survey in English was given to female high-school students. The school has 3 consecutive lunch periods of 25 min each. We conducted the survey during all 3 lunch periods on a single day. Announcements were made in the cafeteria while students were eating lunch. Students who approached the table at the side of the cafeteria were provided information about the survey. If they were interested, a research assistant reviewed the verbal consent form with them. If they agreed to participate, they were provided a clipboard with the survey and a pen. They used unoccupied tables in the cafeteria to complete it privately and then returned the surveys anonymously into a single, large, manila envelope. The survey took approximately 10 min to complete. Upon returning the survey, students received a $5 gift card. The Institutional Review Board at Saint Louis University approved this study.
The survey included basic demographic characteristics (age and grade level) plus questions related to menstruation and menstrual hygiene. Survey items were a mix of newly developed questions and ones modified from a previous survey on menstrual hygiene needs among adult women in St. Louis. (Sebert Kuhlmann et al., 2019) Period product insecurity in this study is defined as “not being able to afford period products when needed at least once during the school year.” This variable was measured based on the question “during the current school year, how often have you needed period products but did not have enough money to buy them?” with response options of ‘almost every month,’ ‘some months, but not all,’ ‘only once or twice’ and ‘never.’ This variable was dichotomized with the first three response options grouped as “yes” and ‘never’ as ‘no.’ Students were asked which resources they used to get period products. To assess absenteeism due to menstruation, students were asked, “during the current school year, how often have you missed school due to your periods for the following reasons” with the following reasons presented as ‘pain or cramping with your period,’ ‘heavy bleeding with your periods,’’a bad odor during period’ and ‘not having adequate period products.’ For each reason, response options of ‘more than 1 day each month’, ‘one day each month,’’one day some months but not all,’ and ‘never’ were provided.
Descriptive statistics were used to calculate the prevalence of period product needs, resources used to obtain products, and school absences related to menstruation. Pearson’s chi-square tests assessed the association between period product insecurity and school attendance, including by grade level (9th vs. 10th -12th graders). Since there was a statistically significant difference between 9th and 10-12th graders in the prior study where students reported on the previous school year (likely because 9th graders attended school in a different building the previous year) (Sebert Kuhlmann et al., 2020), we again dichotomized the grade level variable into 9th versus 10-12th graders to test whether this grade level difference was still significant during the current school year when all students were attending school in the same building. The analyses were performed using IBM SPSS v.26 with a statistical significance level of p < 0.05.
One hundred twenty-seven students were approached; five students refused to participate, resulting in a 96% response rate. Of the returned surveys, three were incomplete, leading to 119 participants (94%) included in the analyses. The sample represented nearly one-third of the approximately 350 female students enrolled in the school for the 2019–2020 school year.
The mean age of participants was 15.78 ± 1.28 years. Over one-third of the students (39%) were in 9th grade. Nearly all the participants (91.4%) reported attending school in the same district during the prior school year (2018–2019). Almost half of the participants (43.6%) reported skipping meals or cutting the size of their meals at least once during the current school year (2019–2020) because there was not enough money for food. (Table 1).
The mean age at which participants experienced their first period was 12.11 ± 1.35 years. Nearly two-thirds of students (64.4%% (95% CI: 55.1%-73.0%)) reported period product insecurity during the current school year (2019–2020), i.e., not being able to afford period products when they needed them. Among those who reported period product insecurity, the majority (58.1%) also reported skipping meals or cutting the size of their meals at least once during the current school year. (Table 2) Furthermore, of those who reported period product insecurity, 44.7% experienced this almost every month. Among those who reported period product insecurity, 40% were 9th graders. While most of the participants reported friends and families (79.9%) as resources to obtain period products, the school nurse’s office (61.2%) was the most commonly reported school resource for period products, followed by the in-school health clinic (33.6%) and teachers/school staff members (29.1%). (The ‘in-school’ health clinic is for students enrolled in the district and is physically located within the high school. Any student enrolled in the district may use the clinic’s services at any time.) Overall, two-thirds of participants (66.9% (95% CI: 57.7%-75.3%)) reported using at least one of the school resources (including the in-school health clinic, in the nurse’s offices, or from an individual teacher/staff member) during the current school year to obtain period products. (Table 1) Among those who reported using school resources to obtain period products, 40.3% were 9th graders.
Over two-thirds of participants (68.9% (95% CI:59.8%- 77.1%)) reported missing school at least one day each month for reasons related to their periods. The most common reason for missing school at least once during the school year related to their periods was pain or cramping (78.7%), followed by heavy bleeding (71.8%) and bad odor (41%). Approximately one-third of the participants (33.6% (95% CI 25.0%-43.1%)) reported missing school due to a lack of period products, with 16.8% (95% CI 10.4%-25.0%) reporting missing one or more days each month due to not having an adequate supply of period products. (Table 1) Ninth graders accounted for 44.7% of the students who reported missing school at least once due to lack of period products, but there was no statistically significant difference between 9th and 10-12th graders. (p = 0.368) Furthermore, 26.7% of students reported receiving discipline at their school (e.g., being penalized for failing to change into gym attire, being late to class) for something related to their period.
When asked about their main source of information regarding MHM, most participants indicated family members or friends (75.2%), with only 6% mentioning school as their main source. Almost half of the participants (49.2%) reported wanting more information/education on managing their periods and caring for personal hygiene during menstruation.
We aimed to assess the relationship between menstrual hygiene needs, school attendance, and utilization of school resources to obtain period products. A very high percentage of participants reported period product insecurity. Furthermore, most of the participants reported using school resources to obtain period products. Despite the high percentage of students who utilized school resources to obtain period products, a substantial percentage of students still reported missing school due to a lack of period products. A small but significant proportion of students also reported receiving discipline at school for some reason related to their periods. In addition, very few students reported receiving information about menstrual hygiene from school.
Period product insecurity among school-age girls is a neglected issue in the U.S. (Sommer et al., 2019) This study highlights the magnitude of the problem, with almost two-thirds of the students reporting period product insecurity, even within a school that provides several options for students to access period products. The high-level of period product insecurity documented here is consistent with an earlier study conducted in the same area with a smaller sample, in which nearly 70% of participants reported not being able to afford period products when they needed them. (Sebert Kuhlmann et al., 2020) Even though there are few previous quantitative studies regarding period product insecurity among school-age females in the U.S., a study conducted among adult women in St. Louis, Missouri, reported a similar percentage of women experiencing period product insecurity (64%). (Sebert Kuhlmann et al., 2019) The findings across studies suggest that schools may offer a huge opportunity to tackle period product insecurity among adolescents by making period products freely available at school.
Furthermore, half of the respondents reported they would like more information on menstruation and caring for their personal hygiene during menstruation. However, only a few students reported receiving this type of information from school. Similarly, in a qualitative study among adolescent females from three cities in the US (New York City, Los Angeles, and Chicago), students labeled the information they are receiving regarding MHM as insufficient. Yet, in the same study, school personnel mentioned most parents expect their female children to get information related to menstruation from schools, and there is no need for them to discuss it with their children. (Schmitt et al., 2021) These examples illustrate how female students often do not get necessary information about menstruation and MHM. Schools have a huge potential to fill this gap, however, by providing education on menstruation and MHM to their students.
Here, one-third of the participants reported missing school during the current school year due to a lack of period products. This is higher than the percentage of students who missed school due to lack of access to period products (12.7%) in a study conducted by Cortopia among 623 young women aged 18-25 from the U.S. about their experiences regarding their period and missing school when they were in high school. (Cotropia, 2019) The lower percentage of missing school in Cortopia’s study could be due to recall bias as women were asked to report their experiences when they were in high school. The other reason for the discrepancy between the two study findings might be explained by the difference in study population. Our sample was selected from a school population with 98% African American students and 99% eligible for free or reduced lunch, whereas the sample in the study conducted by Cortopia was 73.5% white. This underlines the extent of period product insecurity among students in our study.
On a positive note, numerous students reported utilizing the school resources available to obtain period products, highlighting the importance of making these products freely available in schools through a variety of sources. Among our respondents, missing school due to a lack of period products accounted for only a small proportion of reported absences due to menstruation. In Cortopia’s study, 92.4% of students reported needing period products while at school to manage their period, but less than half attended schools that provide them, again highlighting the importance of making these resources available through schools. (Cotropia, 2019).
In the current study, more than a quarter of the students reported receiving disciplinary action (e.g., being penalized for failing to change into gym attire, being late to class) at school because of their period. This finding, coupled with previous studies which have reported adolescent girls’ feelings of embarrassment about menstruation (Schmitt et al., 2021; Secor-Turner et al., 2022), suggests the need to educate teachers and school staff about students’ menstrual hygiene needs. Such training and education for school staff have been called for elsewhere as well. (Sommer et al., 2017).
Furthermore, here, there was no statistically significant difference between 9th and 10-12th graders in missing school due to a lack of period products. This finding contrasts with Sebert Kuhlmann et al.’s previous study in the same study area, which found 9th graders were more likely to report missing school due to lack of period products. (Sebert Kuhlmann et al., 2020) The previous study was conducted before the start of the school year during orientation and inquired about the prior school year when the incoming 9th graders attended the junior high school, while the current study was conducted during the school year in which all participants were in the same building attending the senior high school. By the middle of the school year, the 9th graders in the current study may have become familiar with the resources for period products available to them in the high school. This might have contributed to 9th graders missing school due to their periods at a rate similar to those students in 10th -12th grades during the current school year.
Like all studies, this study has some important limitations. First, the participants were recruited using convenience sampling during lunch periods on a single school day in February 2020. This led to excluding students who missed school on the day of data collection, including those who may have been absent that day due to their periods. Second, data on absenteeism were collected via self-report, which may have resulted in recall bias. While the school administration tracks student absences, they do not document whether absences are related to menstruation. Third, there is a lack of standardized measures for menstrual hygiene needs and school attendance in more developed countries. Our survey modeled questions of period product insecurity based on validated measures for food insecurity and some of the few prior studies that have been conducted on period product need in the U.S. Still, further studies are required to develop standardized measurements for menstrual hygiene needs in the U.S., especially among adolescents. Finally, the only sociodemographic characteristics we collected were age and grade-level due to space/time constraints. There are likely other important socio-demographic characteristics that influence the relationship between access to period products and school attendance that should be investigated in future studies. (Davis et al., 2018) Identifying such factors that may predict period product insecurity and school absenteeism will be important for developing tailored interventions and policies to tackle this issue.
In conclusion, this study highlights the magnitude of period product insecurity among students in a school where nearly all are eligible for free or reduced lunch. It also highlights students’ resourcefulness, however, in utilizing the school resources available to them in order to obtain period products when needed. Schools being able to provide and promote this type of environment for their students has the potential to decrease school absenteeism due to periods among students. Schools should consider where and how many places within the building students can access products and other aspects of MHM, such as pain management and safe places to change clothes. Given that only seven U.S. states currently require schools to provide period products to students, more states may consider legislation requiring menstrual hygiene education and the provision of free period products within schools. Any such legislation must include funding support for schools to provide these products and services.
School nurses can play an important role in tackling MHM issues among students. The current study demonstrates the importance of providing period products through various sources within the school, such as the nurse’soffice, especially in schools that serve students with a high level of unmet basic needs. In addition to providing period products, school nurses could play a significant role in increasing MHM knowledge among their students, helping students manage menstrual pain and cramping, and increasing students’ awareness of the menstruation-related resources available to them. As shown in the current study, nearly half of the students desire additional information around managing personal hygiene during menstruation at school. School nurses could help provide this information for students. Furthermore, school nurses can advocate for an environment where students receive all the necessary education and have access to adequate facilities to manage their menstruation. As many states look to CDC’s Whole School Whole Community Whole Child framework as guidance for their school health standards, guidelines for adequate MHM supplies and facilities in school could be incorporated into this framework. (CDC, n.d.) A comprehensive effort by schools and school nurses, supported by legislation, should help reduce menstruation-related absences in schools.
This research was funded by a grant from Incarnate Word Foundation (St. Louis, MO, USA) to Saint Louis University (A. Sebert Kuhlmann, PI).
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Incarnate Word Foundation.
Mintesnot T. Teni https://orcid.org/0000-0002-8300-1281
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Anne Sebert Kuhlmann, PhD, MPH is an Associate Professor in the College for Public Health and Social Justice at Saint Louis University.
Mintesnot T. Teni, MSc is a doctoral student in the College for Public Health and Social Justice at Saint Louis University.
Rhonda Key, PhD was the Principal of Jennings Senior High School in Missouri at the time of the study.
Cryslynn Billingsley, PhD is the Assistant Principal of Jennings Senior High School in Missouri.
1 College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri, USA
2 Jennings School District, Jennings, Missouri, USA
Corresponding Author:Anne Sebert Kuhlmann, PhD, 3545 Lafayette Avenue, Salus Center #309, St. Louis, MO 63104.Email: anne.sebertkuhlmann@slu.edu