Abstract
This study explored period product resources and needs in Missouri schools from the perspective of school nurses. We conducted eight focus groups with school nurses (n = 51) across Missouri using purposive sampling. Focus group data were analyzed in Dedoose via multiple coders and achieved strong inter-rater reliability (Cohen’s Kappa = 0.92). Several interconnected themes with associated sub-themes were identified. First, school nurses do not have sufficient resources to help students manage menstruation and minimize menstruation-related absenteeism. Second, schools’ heavy reliance on donations can lead to inconsistencies in supply and a mismatch between what is donated and what is most needed. Third, school nurses desire additional educational resources around menstruation management for students and caregivers. Nurse-identified themes can help inform recommendations for improving schools’ response to students’ menstrual hygiene needs by highlighting priorities for educational content, resources, and product acquisition with a goal of ensuring the suitability and sustainability of MHM in schools.
Keywords
period product insecurity, menstruation, school absenteeism, school health, school nurses, adolescence, reproductive and sexual health, menstrual hygiene
School nurses are fundamental to supporting their students’ health and well-being, including menstrual health and hygiene. Previous research indicates that U.S. students report missing substantial amounts of school due to menstruation – due to pain, cramping, heavy flow, and concerns about odor, but also a lack of period products when needed (Sebert Kuhlmann et al., 2020; Sebert Kuhlmann et al., 2021; Cotropia, 2019). Furthermore, research demonstrates a strong correlation between school attendance and academic performance (National Center for Education Statistics, 2009), suggesting that reducing menstruation-related absenteeism could improve overall performance. Yet, despite this, little is known about menstrual hygiene products, resources, and needs in schools.
Menstrual hygiene management (MHM) refers to “using a clean menstrual management material to absorb or collect blood that can be changed in privacy as often as necessary for the duration of the menstruation period, using soap and water for washing the body as required, and having access to facilities to dispose of used menstrual management materials” (UNICEF, 2019, p. 7). To ensure comprehensive MHM in schools, it is necessary to provide access to information, period products, a sufficient supply of water, appropriate disposal facilities, support for managing menstrual pain, and privacy for changing (Sommer et al., 2021). Failure to provide menstrual hygiene products in schools correlates with increased student absenteeism, early school dropout, and negative impacts on learning ability (Cotropia, 2019).
To improve MHM in schools, it is imperative to understand the perspectives of those providing MHM-related care to students. Menstrual stigma and negative attitudes towards menstruation among school staff can hinder students’ ability to learn, while identifying and addressing these issues can create an environment that fosters learning and wellbeing among all menstruating students (Huseth-Zosel & Secor-Turner, 2021). Previously identified challenges of MHM-related support for students include the relationship between school responsibility and family authority, schoolrelated delivery limitations, and inadequate and disengaging puberty educational content (Schmitt et al., 2022a). While school nurses are trained in reproductive health and menstruation, they may lack professional development opportunities to hone skills for communicating effectively with students about MHM and transgender health (Sweeney et al., 2022). Engaging with school nurses provides a chance to identify professional development opportunities to meet nurses’ unique needs and understand their perspectives on how best to address these issues within their school contexts.
In Missouri, there are no state health education standards around menstrual hygiene education in schools; local districts and individual schools decide whether to provide menstrual hygiene products for students (Sebert Kuhlmann et al., 2022). Therefore, this study aims to understand school nurses’ perspectives on the MHM needs and resources in their schools and to gather recommendations to enhance period product availability and address identified needs.
This study presents the second phase of research conducted in partnership with the Missouri Department of Health and Senior Services (DHSS). In phase one, we electronically surveyed school nurses working in public, charter, private, or parochial schools across Missouri (n = 2,466), with those serving students in 4th grade or higher eligible to participate. A total of 976 school nurses responded (40% response rate) (Sebert Kuhlmann et al., 2023). On the survey, participants indicated if they would be willing to participate in a further focus group discussion.
This second phase utilized focus groups to understand school nurses’ perspectives around period product resources and needs in their schools and to gather recommendations to address these needs. Those who, upon survey completion, indicated an interest and provided their contact information (n= 342) were emailed a sign-up link. Eighty school nurses registered for eight focus groups (10 per group), approximately 23% of those who initially indicated an interest. Fifty-one school nurses then participated in a focus group (64% of those registered).
Focus groups occurred virtually in May 2022 so school nurses statewide could participate. Focus groups were scheduled at various times during the week (i.e., before school, lunchtime, after school); each had one facilitator and a notetaker. A recruitment statement was read aloud at the beginning. If participants decided to continue with the discussion, consent was implied. Everyone decided to participate. All participants also agreed to video and audio recording of the discussion, plus an automated transcription generated via Zoom. Focus groups centered around school nurses’ experience with resources in their schools, supporting menstruating students and those managing period poverty, and recommendations for improving menstrual hygiene management and mitigating the impact of menstruation on their students’ daily lives. Participants were asked about menstrual hygiene products and resources available in their schools, how their schools acquired products, what menstrual health education they offered, and recommendations they had to tackle menstrual needs and inequity in their schools. Focus groups lasted approximately 45 minute participants received a $20 e-gift card upon completion.
Note-takers reviewed, edited, and finalized the auto-generated transcripts from their focus group discussions. We developed the focus group guide based on the literature, our previous research, and the preliminary results from a statewide survey of school nurses (Sebert Kuhlmann et al., 2023). We then created an initial codebook with a priori themes based on the focus group guide. We augmented the initial codebook with emergent codes during the analysis process.
Data were analyzed in Dedoose Version 9.0.86 (2023) using thematic content analysis (Kiger & Varpio, 2020). Two co-authors coded the transcripts independently and compared codes for consistency. After initial coding, the coders discussed discrepancies with the PI, refined codes, and finalized the codebook. The coders then individually recoded the transcripts. Once the coded transcripts were finalized, we tested inter-rater reliability in Dedoose. A pooled Cohen’s Kappa statistic of 0.92 indicated strong agreement between coders (McHugh, 2012). All study procedures were approved by Saint Louis University’s Institutional Review Board.
Eighty school nurses registered, and 51 participated across eight focus groups. Participants served schools across the state of Missouri. Figure 1 illustrates the number of participants from each of the nine state regions identified by the Missouri Academy of Science (n.d.). We used these broad geographic regions to protect confidentiality, given that smaller districts may only have one nurse. Over half the participants served schools outside the state’s major metropolitan areas – St. Louis and Kansas City (see Figure 1). All but one participant was female (98%). No other demographic data were collected.
We identified three overarching themes: 1) insufficient access to resources; 2) need for curriculum and educational resources; and 3) experiences with current policies and practices in schools. We present each theme below with supporting quotes and then the nurses’ recommendations and suggestions for how to address the issues presented in that theme.
Theme 1: Insufficient Access to Resources
Nearly all participating school nurses provide a variety of disposable menstrual products, including pads, tampons, and panty liners, to students. While some participants reported that menstrual products were occasionally provided by the school district or included as a line item in the school nurses’ budget, many do not have enough products to help students in need. Most school nurses relied on community groups, parents, family members, and friends to donate period products to their school. Some school nurses would be unable to support menstruating students without product donations. Others felt concerned relying on donations, as donations are not a sustainable long-term solution, can lead to inconsistencies in supply throughout the school year, or may create a mismatch between type of products available and those desired by students.
“I don’t know what would happen, if [organization] ever ceased to exist. Or their resources dried up, I don’t know where we would get [products] from.”
“We’re facing a lot of shortages these days, and I am just deathly afraid that at some point [outside organization] is going to say, sorry we can’t give you anything anymore.”
To supplement supply, many participants purchase period products out-of-pocket. School nurses are committed to supporting the health and well-being of menstruating students, while also finding creative strategies to reduce costs. School nurses recognize, however, that purchasing products out-of-pocket themselves is not a sustainable solution.
“[The schools] go through probably … those great big garbage bags full of pads - I would say probably 2 to 3 of those a year … Sometimes I don’t get enough, and I have to buy them.”
“We had a supply that, when I started here, that’s kind of dwindled down now so I’ve just been replacing it with my own money, and I know I can’t continue to do that.”
“Sometimes my budget gets very tight, so I know I have purchased them out of my own pocket…we just do what we got to do.”
A few nurses reported their schools have sufficient menstrual products for students in need. For others, an inadequate supply of products creates challenges supporting menstruating students during the school day, after school/overnight, over the weekend, and during extended school breaks. Some school nurses ration products to get students through the school day, yet many nurses still try to help students outside of school who otherwise cannot access products.
“But it’s [menstrual products] definitely not enough stock … where we could send it home or anything like that, just more for at school emergencies.”
“I try to get the kids through the day, but there are kids that need … these products for the evenings and the weekends … they need [products] all the time not just at school.”
“We do supply a lot of our kids with their monthly needs for tampons. They’re going home for the weekend, and they’re still on their period. They come … before the end of the Friday, and they get what they need for the weekend because they just don’t have it at home … that’s common with a lot of our families.”
Beyond menstrual products, many participants provide students with auxiliary products, such as underwear, spare clothing, wet wipes, and washcloths, to help manage their menstrual hygiene. Some schools cover auxiliary products in their nurses’ budget, like they do menstrual products, while others again rely on donations from outside sources, other school staff members, or personally purchasing them out-of-pocket. This causes their supply of auxiliary products to be limited or dependent on the timing and contents of donations.
“We do the best we can to have clothing, which is also something we get from [organization] … But otherwise, we don’t have a lot of clothing, but we do the best we can based on donations.”
“Unfortunately, we don’t have any underwear or any wipes or anything … It’s kind of hard to supply those things, and our nursing budget, the little bit we have, it doesn’t cover anything like that. So, we do depend on people to donate clothing, and some of the staff bring in things.”
“In general, I have a $1,000 budget for all of my schools - any supply I need for the entire school year… any underwear, shorts, leggings, anything over and above a pad I buy out of my own pocket, including literature and things for the girls to feel clean.”
Many participants identified challenges in providing underwear for menstruating students. Given the wide range of ages many school nurses serve, they do not have appropriately sized underwear to support all students. Furthermore, underwear can be costly; new pairs must be purchased frequently. To address these barriers, school nurses developed strategies to obtain underwear for menstruating students. For example, participants reported looking for sales, purchasing items on clearance, or encouraging those who donate items to buy larger quantities at a lower cost. Another participant, who has access to a washer and dryer at school, cleans and reuses the underwear she purchases to cut down on costs. To replenish her supply, she purchases underwear that students do not want to keep and will be more inclined to return.
“I purchase underwear myself or spread the word by friends and our Parent Teacher Organization to purchase underwear when they find it ‘on sale.’”
“One of my staff members, her mother goes to Walmart, and whenever she sees clearance items, she buys them all for me all the time. So, I get those dollar pairs of pants and shirt[s] … It’s a community effort here.”
“I’m lucky enough to have a washer and dryer … I’ll wash them with bleach, and if they look clean, then I reuse them again. But most of the time the underwear doesn’t come back … I learned to buy ‘granny panties’ because if you have cute little bikinis, you’ll have the same girls coming in all the time wanting … another one.”
When students have menstrual accidents, most school nurses allow them either to call their parents or caregivers to bring spare clothing to school or to go home to wash up and change in privacy. Several school nurses are concerned, however, that this practice burdens parents or caregivers, especially when they must leave work.
“I hate it when kids have to call home and request their parents bring clothes up for them, but sometimes … the only option is for the parents to either leave work or… leave home to get a pair of pants up to their kid at the school.”
“That’s kind of frustrating when [a menstrual accident] happens, because [students] end up having to go home or get picked up. And then they have a parent that’s leaving work just to take care of their needs.”
Many participants recommended more resources so they could have more products accessible in school and create baskets for students to take supplies home. To expand their supply, most participants suggested increasing funding to allow them to purchase more period products. Other suggestions include working with the state government to purchase period products at a discounted cost and identifying multiple community groups to donate instead of relying on a single organization.
“I agree with funding, because … I have the ability to get the supplies, to go get them and disperse them. And I have a fabulous team. But having the money to buy them, and to keep up with the demand, I think that’s what’s huge.”
“I have made little purse/backpack packs that include a couple pads and a change of underwear in a discrete little zippered pouch, but again, it gets expensive, so I absolutely agree that funding is absolutely necessary.”
“If there was some kind of … state warehouse or something where they bought bulk, and we could get it even way cheaper…”
Some participants were also interested in providing reusable period products, such as menstrual cups, period underwear, and washable, reusable cloth pads, to students in need, as this could help with both the school’s supply of products, and student attendance at school.
“… you have menstrual cups, and you have other options where we wouldn’t have to keep … hand[ing] out of box the tampons where it would be reusable… it would be pretty cool to be able to offer a supply like that where we wouldn’t have to blow through all of our money, buying pads every single day.”
“It’d be great to get ahold of some period panties. Generally, if a young lady has a personal hygiene accident or a menstrual accident, that’s basically a[n] automatic ticket home unless the parents … bring this stuff up, but generally for a lot of the young ladies they need to come home because they need to bathe, shower, to get cleaned up […] but they generally don’t come back to school. But for the minor stuff when it just starts, it’d be great to have period panties …”
Other participants recommend students bring a spare set of auxiliary products (e.g., pants, underwear) to school in case they have a menstrual accident, and the school does not have spare clothing available. Some suggested that this could help mitigate menstruation-related absences, as well as parents or caregivers having to leave work to bring spare clothing to their child.
“I know our principal has recommended … to parents at the beginning of the school year - but most don’t do it - that every student have a spare change of clothes … because you never know who’s going to fall in the mud or get their clothes soiled…”
“[Students] don’t have any idea about when [their period’s] going to come back … they’re just not prepared.”
Theme 2: Needs for Curriculum and Educational Resources
The majority of school nurses use a puberty education curriculum provided by a for-profit company that manufactures period products to teach students about menstrual health and hygiene. While school nurses have mixed opinions about the content and the curriculum’s overall effectiveness, most initially began using it due to the supplemental resources and sample products provided to schools, including disposable menstrual products, deodorant, and informational pamphlets. However, the company no longer provides these items to schools. The lack of sample products supplied by the company has further exacerbated the insufficient supply of products in schools. Because schools are no longer getting resources through the company, some school nurses have begun looking into other curriculum programs or partnering with outside agencies, such as a local health department, for their puberty education.
“We use [company program] for … our fifth grader … I don’t love it, it’s a little cheesy, but that’s what we use.”
“So, in 2021, I got some free products … deodorants for boys, girls, and some pads, but then that’s no longer … You can’t get the booklets … which is a bummer because … there was something for the mom, you always had coupons, … a little twosided thing for the mom, and … $2 or $3 or $4, worth of coupons, which was great.”
“[W]e had been using [company program], but the last year for it was this year, we’re actually transitioning to something else … because I’m having to buy the product out of my budget anyway … and the district would prefer to have something that’s not branded.”
Most school nurses reported providing puberty education in 4th or 5th grade. Several participants noted limitations, however, with the current curriculum age range. Since some students reach menarche before 4th or 5th grade, the timing of the education is not as beneficial.
“We’ve honestly found that a lot of our [students] are starting earlier and earlier. [Curriculum delivery] in 5th grade might actually be too late for many of them. So, we’re not really sure … how to start that conversation early …”
“I cannot tell you how many times I am the first person to have discussion regarding the menstrual cycle… it’s happened throughout my school nursing career, and to have a hysterical young lady is really upsetting because she’s never been told, and she thinks she’s bleeding to death … We actually need to probably start having those conversations sooner because … they’re maturing faster, which means their periods are showing up much earlier …”
Moreover, school nurses reported that they also do not have educational resources for older students who may begin their periods at a later age or who experience changes in their menstrual cycle over time, such as heavy or irregular bleeding, as well as pain or cramping.
“We have nothing we give out for later, for kids that start later… It’s given out … when it’s first talked about and that’s pretty much what they get.”
“Our students at the high school need more info as their cycle changes from middle school and ‘activity’ changes as well.”
Most school nurses reported separating students by sex during puberty education. Some noted that students are taught by teachers of the same sex, regardless of subject expertise.
“We do a boy video and a girl video, and then the next day it switches … it’s not quite the same program, but they find out. But they’re never together to do it. The PE department presents our program, and then I’m in there, if they have any questions, not with the boys, but with the girls. We have one male … PE teacher and he … and our music teacher do that, the boy section together, but I’m always with the girls.”
“[W]e have a male fifth grade teacher that shows it to the boys … so we divide them up, and the male teacher and the principal show the boys and then myself, the nurse, and the female teachers show the girls, and then they get to ask questions, and we do this on a Friday afternoon.”
Several participants reported that their schools provide puberty education on a Friday afternoon, oftentimes before an extended weekend holiday or spring break. School nurses hope this approach encourages students to go home, speak with a caregiver, and ask questions about what they learned. The COVID-19 pandemic forced schools to adapt, however, due to school closures and limits placed on student gatherings. Many school nurses started sending links directly to parents, hoping they would watch with their students.
“So, we honestly try to do [puberty education] on … a Friday. Maybe in the afternoon, so they can go home and talk to mom or grandma, or aunt, or whoever.”
“The past couple of years from the pandemic onward, we’ve just been providing parents with the link themselves to review, and this year we had a snow day. We typically do it the Friday before spring break, so … they’re just done for a week … the Friday before spring break this year, we had snow days, so we weren’t able to do that. So, we sent the link home to the parents to watch with the kids … up until the pandemic, we had some really good discussions.”
“[F]or the last 2 years, because of COVID, we haven’t even done … the in-class sessions, we just sent out links for the parents to go over it with the students … so a lot of girls are probably missing out on getting that information.”
Most participants want improved and expanded curriculum plus tailored educational resources for different grades, sexes and genders, and in multiple languages. School nurses would like educational materials tailored to students in younger grades to provide them with this information prior to menarche, while also having materials for older students who start later.
“I really like the idea of having some just good resources to back up for education. And different levels. Definitely different levels because you’re not going to talk to a 5th grader about what you would talk to an 8th grader about who might be sexually active or considering to be.”
“I think information to send home with them either paper or electronically, and the opportunity to do more of an education with these girls … They don’t know how to count the days; they don’t know how to anticipate when it should happen again … so a little education on that and … just add that into the basic hygiene of it all.”
“I’ve noticed a lot of the girls right around 14 or 15 …[t]hey don’t know what a normal period is, that you shouldn’t have to change a tampon every 30 minutes … I don’t think they’re getting that kind of education on what’s abnormal, just what to do when …you start.”
School nurses also want educational resources to be modernized, culturally competent, and inclusive of all students, including male students, transgender students, and students with limited English proficiency. In addition, several school nurses wanted more education for themselves and resources on how they could better support their students.
“More education for boys, that would not be a bad thing.”
“I thought it was great just to hear about transgender female or, transgender males, that are getting a period still, because … I would have to think differently. And the way I described what was happening to their body….”
“And then, of course, there’s the communication gap with language barriers.”
Furthermore, several school nurses want informational materials developed specifically for parents and caregivers. Participants indicated a need for literature to distribute to parents and caregivers on how they can speak with their children about menstrual health and hygiene that includes websites for more information. Like with student-tailored resources, school nurses want information for parents and caregivers to be available in multiple languages.
“[S]omething for the parents, … how to start the conversation. … Some people are tech savvy, then some people need paper, but at least either way you’ve got access … but also access to other languages…”
“What I have found is that it’s … taboo … you’ve got to break the cycle. So maybe you have a pamphlet for the kids, but [also] a pamphlet for how to talk to your daughter about personal hygiene, how to talk about the menstrual cycle, …because some of [the parents] … don’t have the right information either.”
“It would be great to have an online resource that could just be emailed out to parents so they could use [it] at their convenience whenever. Because, of course, everybody is on completely different schedules, and we’re going over stuff in 4th or 5th grade, but some girls are not starting until 8th grade … something just to send to parents.”
Theme 3: Experiences with Current Policies and Practices in Schools
Most school nurses report having menstrual products and other auxiliary supplies available in their office/clinic for students in need. Often, these products are kept inside a closet, a bathroom in the nurse’s office, or in a care cart kept in/near the office for students to access as needed. While many school nurses encourage students to utilize their office/clinic to access supplies, some want menstrual products offered elsewhere in the school to limit exposures to ill students in the nurses’ office. Some participants also want to change the perception around menstruation so that it is not seen as a ‘sickness’ that requires a visit to the nurses’ office.
“I keep a basket of feminine supplies in a couple of bathrooms at the high school, or they come to our offices and ask. We let them get what they need.”
“In the nurse’s office, we always have a variety of different kinds of pads and tampons, and…we have an area in our waiting room of our office. It has a box with tampons and a big bin of pads, different kind of pads, and then panty liners. And, if the kids want, they can take whatever they’d like, and we also have them in our clinic restrooms and that way they don’t havetoaskus… We have a little sign that says, ‘take whatever you need’”
“We try to avoid the students, unless they absolutely need to come into the clinics to get those supplies simply because of the risk for exposure to [COVID, etc.]. And also, it’s not an illness, right? So, we want to change what that perception is.”
Many participants discussed offering period products in school bathrooms. There were tensions, however, between the benefits and concrete examples of misuse of these limited resources when placed in restrooms. While a significant advantage to having products located in restrooms includes easy accessibility for all students without them having to ask, drawbacks include products being used up quickly, utilized to vandalize the restroom (e.g., stuck to the wall, plugged the toilet), and disposed of inappropriately. This can be a tremendous cost to the school, in terms of products wasted and janitorial resources for clean-up, as well as physical damage to facilities. Table 1 highlights nurses’ positive and negative experiences offering menstrual products in school restrooms.
School nurses are committed to supporting their menstruating students and developing various strategies to do so. For example, some participants mentioned they provide menstrual products to teachers and other staff to distribute to students in case school nurses are unavailable.
“[A]t the beginning of the year, I give teachers the little first aid kit, and a lot of times I put some in there, but I also have teachers that come in and ask, … and they will get them and have them as well.”
“We also have [products] at the front desk, so in case [students] can’t get in to me. Then our guidance office has some [products].”
Several school nurses also provide one-on-one education to students outside of the curriculum. School nurses will meet individually with students to talk about their hygiene, menstrual cycle, the importance of being prepared for their period, and how to track it, especially when referred by a teacher.
“A lot of times the teachers will call me, …‘can you address hygiene with this student?’”
“[Students] don’t know how to count, they don’t have any idea about when [their period is] going to come back … they’re just not prepared. I always tell my girls, what happens if you’re not at school, honey? Because a lot of restrooms are not carrying feminine hygiene products, and there’s no guarantee when you get there that there are feminine hygiene products.”
Many school nurses allow students to rest in their office if they are experiencing menstrual pain and provide resources to help alleviate symptoms. In most schools, with the permission of a student’s parent/caregiver or a doctor’s note, the school nurse can dispense over-the-counter pain medication. School nurses often provide students heating pads or hot packs to help relieve menstrual pain. When school nurses note persistent concerns from students, such as painful or heavy periods, they oftentimes contact the parent/caregiver to discuss the symptoms and potentially refer the student for further medical evaluation. For schools that do not allow the dispensing of over-the-counter medication, nurses may allow students to call their parents/caregivers to bring pain medication to school.
“We have the heating pads and stuff for them if they need it … or get Ibuprofen or Tylenol if they need to.”
“I have Tylenol and Ibuprofen for cramping. But I also … purchased the disposable heat packs that you pop a little thing in the middle, in that way girls, if they’re having really bad cramps, they last 15 minutes … and they can use those.”
“Then there’s those kids that seem to have really painful periods every month, and that’s whenever I talk to the parents about possible referral to a doctor …‘this isn’t normal to have this painful of cramping.’”
“We don’t have any stock medication in our district except for epi [epinephrine injection] and albuterol, so for Tylenol and Ibuprofen, it’s nothing we can even offer to the kids … see if they want to call home to have a parent bring something up if they’re in that much pain.”
Overall, participants want to improve their current practices to better support their menstruating students. Regarding product location, some participants who reported that menstrual products were not available in their school restrooms want them more accessible in these spaces. Many school nurses, however, noted significant concerns with providing menstrual products in restrooms, so understanding student needs and the school environment is necessary when deciding on product location. One school nurse suggested posting flyers in the student restrooms that included websites or QR codes that could refer them to more information about caring for their menstrual health and hygiene.
“We don’t stock the bathrooms with period products, which it would be nice if it was just something that automatically happened, so a kid doesn’t have to ask to come to see the nurse to get a pad, if it was just automatically in the bathrooms, especially where the older kids use the restrooms.”
“I think a lot of [products] could be … set out in locker rooms in middle and high school … I think it might reach a larger group in the locker room.”
“I would like to see more product availability and opportunities for students to see links or QR codes in the bathroom to gain more info.”
Participants also desire additional strategies they can employ to help students manage their menstruation. For example, one school nurse thought having a supply of daily planners to distribute to students could help her teach them how to track their periods.
“But for my girls … their issue is they don’t know when the next month, when they’recomingonaperiod… I really would like to have the small daily planners with calendars because a lot of girls don’t have phones. Some of our girls have phones where they download the period tracker app … but a lot of girls don’t know when they’re coming on … Andsojusttryingtofigure out …”
School nurses shared their own successful strategies with each other. Participants were eager both to learn from their colleagues’ actions and to share what worked in their own schools.
“… in our high school bathrooms … we have a shelf where we put that product, but in our middle school bathrooms, they’re just stalls connected to each other with no shelving unit. So, two of our middle school teachers actually made this thing that hangs over the dividers between the bathrooms … like a cloth saddle bag, and then she puts those pads in, so it’s available on both sides of that stall. Either side … they’re already in the bathroom, nobody’s going see them grab it.”
“I just thought this was really enlightening … to see what other districts do and what other resources other people have and get ideas. I need to find a place to put a basket [for menstrual products].”
Overall, this study provides an in-depth understanding of menstruation-related resources and identified recommendations on how to improve practices in schools. These findings illustrate the schools’ reliance on donations for both period and auxiliary products. While initial survey results with Missouri school nurses also indicated dependence on donations (Sebert Kuhlmann et al., 2023), focus group participants provided further explanation, describing how relying on donations can create inconsistencies in supply throughout the school year and a mismatch in supplies needed versus what is donated. Schools being unable to provide menstrual hygiene products significantly affects attendance at school, students’ ability to learn, and overall health of menstruating students (Cotropia, 2019). Several participants suggested more funding for menstrual products in order to have a more consistent supply for students in need.
Most school nurses also provide auxiliary products to students having menstrual accidents and pain management resources to students experiencing menstrual pain. When students leak through their clothing or experience severe cramps, it disrupts the school day; students may have to rest in the nurse’soffice and miss class or may need to leave school altogether. Parents/caregivers may also need to leave work to bring resources to school or take their child home. School nurses are aware of students who have been absent from school or who have left school early or arrived late due to their period (Sebert Kuhlmann et al., 2023). Furthermore, substantial proportions of students report missing school because of their period (Sebert Kuhlmann et al., 2020; Sebert Kuhlmann et al., 2021). Attendance at school, however, is critical to student success (National Center for Education Statistics, 2009). It is imperative to support menstruating students so they can both attend and fully participate in school.
Additionally, school nurses largely reported utilizing [company] for their menstruation-related curriculum and providing this education during fourth or fifth grade. Consistent with studies of both elementary school nurses (Sweeney et al., 2022) and students (Schmitt et al., 2021), receiving period education at this age may occur postmenarche, however. Given that puberty first occurs in girls between 8 and 13 years old (National Institute of Child Health and Human Development, 2021), providing puberty education at a younger age may help students feel more prepared to manage their menstruation prior to menarche.
Participants also desire tailored educational resources for older students, especially for those who reach menarche later or who start experiencing more severe symptoms, such as heavy or painful periods. Periods are often irregular during the first two years of menstruation (Nemours Teen Health, 2018). As menstruation progresses, having resources so students can identify abnormal symptoms is necessary for their overall health. Moreover, school nurses also want resources for parents/caregivers so they feel more prepared to speak with their children about menstruation. Previous studies found that parents/caregivers often do not discuss menstruation with their students due to discomfort around the topic or reliance on schools to teach the information (Schmitt et al., 2021; Schmitt et al., 2022a). Providing educational websites or information in multiple languages could also help better inform parents/caregivers so they feel more comfortable speaking with their children.
School nurses’ recommendations around educational resources mirror students’ desire for additional menstrual hygiene education (Sebert Kuhlmann et al., 2020; Sebert Kuhlmann et al., 2021; Schmitt et al., 2022a; Secor-Turner & Huseth-Zosel, 2022). Very few states, however, include menstruation management in their health education standards (Sebert Kuhlmann et al., 2022), resulting in significant variation in menstruation-related education for students, even within the same district or school. Developing menstruationrelated education standards could ensure students receive a similar curriculum across and within schools.
School nurses’ desire for more resources to discuss menstruation with students were sentiments also expressed in the survey (Sebert Kuhlmann et al., 2023). These findings align with a survey of elementary school nurses who desire more professional development on discussing menstruation with students (Sweeney et al., 2022). Similarly, in a study among teachers in the U.K., a majority reported that training would help improve menstruation education (Brown et al., 2022). Importantly, school nurses in Missouri explicitly cited the need for more resources to talk to transgender students experiencing menstruation.
Regarding product placement within schools, most nurses provide menstrual products in their office, yet there were tensions around product availability in restrooms. While some school nurses noted having products available in restrooms allowed students to obtain them discreetly at their leisure, others described negative experiences, including wasted products and vandalized restrooms. Importantly, however, some of the schools’ negative experiences providing products for free in restrooms, such as hoarding, may actually demonstrate a significant need for menstrual products among students, i.e., they cannot afford a basic necessity, so they take several when available. Furthermore, in a study with adolescent girls, many participants noted how the school restrooms’ environment negatively affected their menstrual experiences due to a lack of privacy, challenges disposing their products, and overall restroom uncleanliness (Schmitt et al., 2022b).
As of May 2023, 23 states and Washington, D.C., had legislation supporting free access to menstrual products in schools for students (Alliance for Period Supplies, 2023). At least 17 states require products to be freely available in school restrooms to some capacity (e.g., in all restrooms, in at least half the restrooms, etc.). While there are no laws pertaining to period products in school or statewide funding mandates in Missouri, the state budget for the 2022–2023 school year earmarked $1 million dollars to support period products in schools (MOST Policy Initiative, 2022; Missouri House of Representatives, 2022). The funding was renewed for 2023–2024. While policies dictating the location of products may be well-intentioned, consideration should be given to allowing schools flexibility in implementation.
Like all studies, there are limitations to note. First, this study used a cross-sectional design, so temporality or causality cannot be established. Additionally, participants were identified from school nurses who previously completed a survey about period product resources and needs in Missouri schools and who indicated an interest in participating in a future focus group (Sebert Kuhlmann et al., 2023). Therefore, those who participated may have been more interested and invested in this topic than others. Furthermore, while 80 school nurses signed up to participate in the focus groups, 51 attended. Focus group attendance was heavily influenced by a resurgence of COVID-19 infections among students and school staff, as well as end-of-year demands on school nurses. Finally, the only participant characteristics we collected were the geographic location of the school(s) served and gender. Despite these limitations, this study is one of the first to gather in-depth professional perspectives from school nurses in both urban and rural communities regarding menstrual health and hygiene needs in their schools.
School nurses serving Missouri’s schools provided important insights into period product resources and needs in their schools and recommendations on how to improve support for menstruating students. They emphasized the need for a consistent supply of menstrual products, improving menstruation-related education, and refining policies and practices to ensure menstruating students can stay at and participate fully in the school day. Importantly, themes were noted from school nurses across the state; there were no differences between urban versus rural districts. Continued advocacy for policies to provide free or subsidized menstrual products in schools, as well as standardized menstruation education is needed. Any policies, however, should allow schools flexibility to work within their context at the local level. Future research should consider developing and evaluating informational resources for both students and parents/caregivers, as well as analyzing the effect of state policies around the distribution of menstrual products in schools.
The authors would like to thank the School Health Program in Missouri’s Department of Health & Senior Services for their support in the initial recruitment for the study.
All authors contributed to the conceptualization of the study and data collection. ASK, KP, and CA led the data analysis and manuscript writing. All authors contributed to critically revising the manuscript and approved the final version for submission.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Approved by Saint Louis University’s Institutional Review Board (#32711).
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Internal faculty grant from Saint Louis University awarded to Anne K. Sebert Kuhlmann. Saint Louis University, (grant number internal faculty award).
Anne K. Sebert Kuhlmann https://orcid.org/0000-0001-7350-0186
Mintesnot T. Teni https://orcid.org/0000-0002-8300-1281
Alliance for Period Supplies. (2023). Period Products in Schools. https://allianceforperiodsupplies.org/period-products-in-schools/.
Brown, N., Williams, R., Bruinvels, G., et al. (2022). Teachers’ perceptions and experiences of menstrual cycle education and support in UK schools. Frontiers in Global Women’s Health, 3, 827365. https://doi.org/10.3389/fgwh.2022.827365
Cotropia, C. A. (2019). Menstruation management in United States schools and implications for attendance, academic performance, and health. Women’s Reproductive Health, 6(4), 289–305. https://doi.org/10.1080/23293691.2019.1653575
Dedoose Version 9.0.86. (2023). Cloud application for managing, analyzing, and presenting qualitative and mixed method research data. Socio Cultural Research Consultants, LLC. www.dedoose.com.
Huseth-Zosel, A. L., & Secor-Turner, M. (2021). Teacher perceptions of and experiences with student menstruation in the school setting. Journal of School Health, 92(2), 194–204. https://doi.org/10.1111/josh.13120
Kiger, M. E., & Varpio, L. (2020). Thematic analysis of qualitative data: AMEE guide No. 131. Medical Teacher, 42(8), 846–854. https://doi.org/10.1080/0142159X.2020.1755030
McHugh, M. L. (2012). Interrater reliability: The kappa statistic. Biochemia Medica, 22(3), 276–282. https://doi.org/10.11613/BM.2012.031
Missouri Academy of Science. (n.d.). Regions. https://www.moacademysci.org/junior-academy/regions/
Missouri House of Representatives. (2022). HB 3002. https://house.mo.gov/Bill.aspx?bill=HB3002&year=2022&code=R
MOST Policy Initiative. (2022). No-cost period products in school: Implementation. https://mostpolicyinitiative.org/wp-content/uploads/2022/04/No-Cost-Period-Products-in-Schools_-Implementation.pdf
National Center for Education Statistics. (2009, February). Every school day counts: The Forum guide to collection and using attendance data. https://nces.ed.gov/pubs2009/attendancedata/chapter1a.asp
National Institute of Child Health and Human Development. (2021, June 21). Puberty and precocious puberty. https://www.nichd.nih.gov/health/topics/puberty
NEMOURS Teen Health. (2018, December). Irregular periods. https://kidshealth.org/en/teens/irregular-periods.html
Schmitt, M. L., Gruer, C., Hagstrom, C., et al. (2022a). It always gets pushed aside: Qualitative perspectives on puberty and menstruation education in U.S.A Schools. Frontiers and Reproductive Health, 4, 1018217. https://doi.org/10.3389/frph.2022.1018217
Schmitt, M. L., Hagstrom, C., Gruer, C., et al. (2022b). Girls may bleed through pads because of demerits: Adolescent girls’ experiences with menstruation and school bathrooms in the U.S.A. Journal of Adolescent Research, 39(2), 511–536. https://doi.org/10.1177/07435584221139342
Schmitt, M. L., Hagstrom, C., Nowara, A., et al. (2021). The intersection of menstruation, school, and family: Experiences of girls growing up in urban cities in the U.S.A. International Journal of Adolescence and Youth, 26(1), 94–109. https://doi.org/10.1080/02673843.2020.1867207
Sebert Kuhlmann, A., Hunter, E., Wall, L. L., et al. (2022). State standards for menstrual hygiene education in U.S. Schools. Journal of School Health, 92(4), 418–420. https://doi.org/10.1111/josh.13135
Sebert Kuhlmann, A., Key, R., Billingsley, C., et al. (2020). Students’ menstrual hygiene needs and school attendance in an urban St. Louis, Missouri, District. Journal of Adolescent Health, 67(3), 444–446. https://doi.org/10.1016/j.jadohealth.2020.05.040
Sebert Kuhlmann, A., Palovick, K. A., Teni, M. T., et al. (2023). Period product resources and needs in schools: A statewide survey of Missouri’s school nurses. Journal of School Health, 93(7), 557–564. https://doi.org/10.1111/josh.13326
Sebert Kuhlmann, A., Teni, M. T., Key, R., et al. (2021). Period product insecurity, school absenteeism, and use of school resources to obtain period products among high school students in St. Louis, Missouri. Journal of School Nursing, 1059840 52110696. https://doi.org/10.1177/10598405211069601
Secor-Turner, M., & Huseth-Zosel, A. (2022). Menstruation experiences of middle and high school students in the midwest: A pilot study. The Journal of School Nursing, 38(6), 504–510. https://doi.org/10.1177/1059840520974234
Sommer, M., Caruso, B. A., Torondel, B., et al. (2021). Menstrual hygiene management in schools: Midway progress update on the “MHM in ten” 2014–2024 global agenda. Health Research Policy and Systems, 19(1), 1–4. https://doi.org/10.1186/s12961-020-00669-8
Sweeney, E. N., Fisher, C. M., & Adkins, M. M. (2022). Elementary school nurses’ perceptions regarding menstruation education: An exploratory study. The Journal of School Nursing, 40(3), 336–341. https://doi.org/10.1177/10598405221082682
UNICEF. (2019, May). Guide to menstrual hygiene materials. https://www.unicef.org/media/91346/file/UNICEF-Guidemenstrual-hygiene-materials-2019.pdf
Anne K. Sebert Kuhlmann, PhD, MPH is an Associate Professor of Behavioral Sciences & Health Equity in the College for Public Health & Social Justice at Saint Louis University.
Kirstin A. Palovick, MA is a PhD student in Public Health Sciences at Saint Louis University.
Casey Allen, MPH was a MPH student at Saint Louis University.
Mintesnot T. Teni, PhD, was a PhD students in Public Health Sciences at Saint Louis University.
Cheleia Marshall, MPH was a MPH student at Saint Louis University.
1 College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, USA
Corresponding Author: Anne K. Sebert Kuhlmann, College for Public Health and Social Justice, Saint Louis University, 3545 Lafayette Ave., Room 309, Salus Center, St. Louis, MO 63104, USA. Email: anne.sebertkuhlmann@slu.edu
