Provision of menstrual products lowers school absenteeism in adolescent girls in coastal Kenya: findings from a quasi experimental study.

Introduction
Despite global recognition of menstrual health as a public health priority, challenges in menstrual hygiene management (MHM) continue to affect adolescent girls' education in low- and middle-income countries. This study investigated knowledge, and perceptions on menstrual issues and the association of MHM product provision on school absenteeism among adolescent girls in Kilifi South Sub-County, in coastal Kenya.Methods
A mixed-methods design was implemented among 300 high school girls aged between 14 and 18 years in five secondary schools. A cross-sectional survey was conducted to assess MHM knowledge, menstrual practices, and school absenteeism. Focus group discussions were employed to explore perceptions regarding menstruation, product preferences, and challenges encountered during menses. Schools were randomly assigned to one of five study arms: a control group, non-reusable pads, reusable pads, menstrual cups, or all products with a choice option. Binary logistic regression with backward stepwise elimination method was used to determine factors associated with MHM knowledge. Kruskal-Wallis for inter-arm comparisons and Wilcoxon Signed Rank Test for within-arm comparisons were used to evaluate changes in absenteeism. Qualitative data were analyzed thematically using ATLAS.ti software.Results
In all schools, most of the participants demonstrated good MHM knowledge. Most of the participants use disposable sanitary pads, but financial constraints limit consistent access. Perceptions of menstruation were deeply influenced by cultural taboos and misinformation, contributing to stigma and influencing choice of menstrual product. Participants expressed a strong preference for disposable pads due to their ease of use and comfort, although financial constraints often necessitated the use of cheaper alternative products. Our intervention demonstrated significant reductions in menstruation-related absenteeism across all study groups. At baseline, the median menses-related school absenteeism score for all groups was 1 (IQR: 0-2), significantly decreasing to 0 (IQR: 0-1) (p < 0.001) at endline. Within study arms, significant declines in absenteeism were observed in the control group (median 1 to 0; p = 0.012), menstrual cup group (median 1 to 0; p = 0.041), disposable pads group (median 1 to 0; p < 0.001), and reusable cloth group (median 1 to 0; p < 0.001).Conclusion
The findings indicate that effective menstrual health management significantly improves school attendance among adolescent girls. Beyond product provision, addressing knowledge gaps, pain management, psychological support, and enhanced WASH infrastructure is essential. Increased awareness and open discussions about menstruation can also lead to positive outcomes. We recommend integrating comprehensive menstrual education into school curriculum, establishing sustainable menstrual product programs with complementary resources, and upgrading school WASH facilities to support female students.