Background: Menstrual health is fundamental to adolescent well being, educational engagement, and gender equity. Despite policy attention, schoolgirls in many low  and middle income settings continue to lack accurate information, hygienic menstrual materials, and supportive school environments. Evidence from rigorously evaluated, curriculum linked interventions in government schools remains limited. Materials and Methods: We conducted a cluster controlled, quasi experimental study across eight government secondary schools (grades 6–10) in rural catchment areas served by the Department of Community Medicine, Kamineni Academy of Medical Sciences and Research Centre. Four schools received a multifaceted health education package (interactive sessions, peer champions, audiovisual modules, teacher training, and low cost pad distribution support); four comparison schools continued routine curricula. Menstruating students aged 10–17 years who had attained menarche were enrolled (N=384; Intervention=192; Control=192). Baseline (pre intervention) and 6 month post intervention surveys captured knowledge (0–20 scale), attitudes (0–50 scale), practices, school absence, and a composite “adequate MHM” indicator (hygienic absorbent, ≥3 changes/day, privacy, safe disposal). Analyses used cluster adjusted tests and difference in differences estimates. Results: Follow up response was 96.1% (Intervention n=184; Control n=185). Mean knowledge improved from 6.2±2.8 to 15.4±2.5 in the intervention arm versus 6.0±2.9 to 8.2±3.1 in controls (Diff in Diff +7.4; p<0.001). Adequate MHM rose from 23.4% to 71.2% in the intervention arm and from 22.9% to 30.3% in controls (Risk Ratio 2.35; 95% CI 1.82–3.02; p<0.001). Menstrual related school absence (≥1 day/last period) fell from 45.8% to 18.5% in the intervention arm versus 43.8% to 41.1% in controls (p<0.001 between arms at endline). Conclusion: A low cost, school integrated health education package substantially improved menstrual knowledge, hygienic practices, and school participation. Scaling participatory, teacher supported models could accelerate progress toward adolescent health and education goals.

Study Design and Setting

We conducted a cluster controlled, quasi experimental pre post study in eight government run co educational secondary schools (grades 6–10) located in rural service areas linked to the Department of Community Medicine, Kamineni Academy of Medical Sciences and Research Centre, Hyderabad, India. The study was conducted from May 2024 to April 2025. Clusters (schools) were purposively selected in consultation with district education authorities to represent comparable enrollment size, infrastructure tier, and catchment socioeconomic profile. Four schools were allocated to receive the intervention package; four served as comparison sites and continued routine health instruction.

Study Population

Eligible participants were enrolled female students aged 10–17 years who had attained menarche, were present during baseline data collection (April–June 2024), and provided written assent with parental consent. Exclusion criteria: reported chronic gynecologic conditions interfering with menstruation, cognitive impairment precluding survey comprehension, or planned school transfer within six months. A total of 384 girls consented (Intervention=192; Control=192).

Sample Size Justification

We powered the study to detect a ≥20 percentage point absolute increase in the proportion of girls achieving “adequate MHM” in the intervention arm compared with a ≤5 point change in controls, assuming a baseline prevalence ~23%, intracluster correlation coefficient (ICC) 0.02 (school level), α=0.05 (two sided), 90% power, and equal cluster sizes. The required effective sample was 172 per arm; inflating by 10% for attrition yielded a target of 190 per arm, which we met.

Intervention Components

The multifaceted package (July–August 2024) comprised: (1) two interactive, age segmented classroom sessions (biology, cycle tracking, hygienic absorbent use, changing frequency, pain self care, myth busting); (2) participatory small group demonstrations using low cost disposable and reusable products; (3) training of two peer “MHM champions” per class; (4) teacher orientation toolkit with flipcharts and Q&A guide; (5) audiovisual module in local language; (6) facilitation linkage to subsidized sanitary pad supply through the district health program; and (7) establishment of private, lockable changing corners where feasible using low cost partitions and bins. Comparison schools received routine health syllabus only; after endline, they were offered the package.

Data Collection and Measures

Structured, pretested questionnaires were administered at baseline (pre intervention) and 6 month follow up (February–March 2025) by trained female field investigators blinded to allocation during data entry. Knowledge (20 items; correct=1) and attitude (Likert 0–4 across 10 items; range 0–50) scales were summed. Practice indicators captured last cycle behaviors: (a) use of hygienic absorbent (commercial pad, menstrual cup, new clean cloth with soap wash & sun dry); (b) changing frequency (≥3/day vs <3); (c) access to private facility at school; (d) safe disposal (burn/bury in pit, incinerator, or wrapped in closed bin). A composite “adequate MHM” required all four domains. Menstrual related school absence was self reported days missed (continuous) and dichotomized ≥1 day.

Statistical Analysis

Analyses used Stata 18 with cluster robust standard errors at school level. Baseline comparability was assessed by design adjusted χ² tests for categorical variables and t tests for continuous scores. Primary analysis estimated difference in differences (DiD) in mean knowledge/attitude scores and risk differences in binary outcomes. We also computed post intervention risk ratios (RR) with 95% confidence intervals. Multivariable mixed effects logistic regression identified predictors of adequate MHM at endline, including study arm and covariates (mother’s education, socioeconomic status, knowledge score, facility availability, age at menarche). Missing follow up data (4.2% intervention; 3.6% control) were handled by inverse probability weighting; complete case results are shown in tables. Statistical significance: p<0.05.

Ethical Considerations

Approval was taken from the Institutional Ethics Committee. Permissions were obtained from the District Education Officer and school heads. Written parental consent and student assent were secured. Confidentiality was maintained; surveys used unique codes only. Post study, comparison schools received the full educational package.

Participant Flow and Retention

Of 412 eligible menstruating students screened, 384 (93.2%) consented and completed baseline. Follow‑up at 6 months achieved 184/192 (95.8%) in intervention schools and 185/192 (96.4%) in control schools; losses were due to transfers or prolonged absence.

Table 1. Baseline Sociodemographic and Menstrual Characteristics by Study Arm

           †Cluster‑adjusted χ².

Table 2. Knowledge and Attitude Scores: Pre‑ and Post‑Intervention

Table 3. Menstrual Hygiene Practice Indicators: Pre‑ and Post‑Intervention

Table 4. Key Post‑Intervention Outcomes

Table 5. Multivariable Predictors of Adequate MHM at Endline (mixed‑effects logistic regression, n=369)

Baseline characteristics were well balanced between study arms (all p>0.05), with mean participant age concentrated in the 13–14 year band and roughly two‑fifths of mothers reporting no schooling beyond primary level (Table 1). Baseline adequate knowledge and adequate MHM were low in both groups (≈23%).

At 6 months, intervention schools demonstrated markedly higher mean knowledge (15.4 vs 8.2) and attitude scores (36.7 vs 24.2) than controls. Difference‑in‑differences estimates indicated net improvements of +7.0 and +12.2 points, respectively (both p<0.001) (Table 2).

Substantial gains were observed across all practice indicators in the intervention arm (Table 3). Hygienic absorbent use increased by 45.3 percentage points (42.7% to 88.0%), compared with a 12.4‑point rise in controls (40.6% to 53.0%). Similar magnitude changes occurred for changing frequency (28.1% to 80.4%), private facility access (20.8% to 68.5%), and safe disposal (13.5% to 72.8%), each significantly greater than control changes (all p<0.001). Menstrual‑related absenteeism fell 27.3 points in intervention schools (45.8% to 18.5%) versus a 2.7‑point decline in controls (43.8% to 41.1%).

Consequently, the composite adequate MHM indicator reached 71.2% in the intervention arm compared with 30.3% in controls (RR 2.35; 95% CI 1.82–3.02; p<0.001). Adequate knowledge similarly favored intervention schools (89.1% vs 38.9%; RR 2.29; p<0.001) (Table 4). In multivariable models, intervention exposure remained strongly associated with adequate MHM (AOR 6.05). Maternal education, higher SES, higher knowledge score, and access to a private school facility independently predicted better outcomes; age at menarche was not significant (Table 5).

Collectively, findings support the effectiveness of a comprehensive, participatory school‑based health education approach in improving multi‑domain menstrual hygiene outcomes and reducing school absence within six months.

School aged girls require timely information, supportive norms, and enabling school environments to manage menstruation with dignity. Our cluster controlled evaluation demonstrates that a low cost, participatory health education package substantially improved menstrual knowledge, key hygiene behaviors, and composite MHM status among rural government schoolgirls over six months, with concomitant reductions in menstrual related absenteeism. These findings align with emerging global consensus that integrated educational and environmental strategies are essential for menstrual health. [1,2]

The magnitude of knowledge gain we observed (mean +9.2 points; adequate knowledge 89.1%) is comparable to or exceeds improvements reported in recent South Asian school interventions. A true experimental study from Nepal reported increases in adequate knowledge from 10% to 67% and good practice from 22.5% to 67% after a targeted health education program. [5] An educational intervention in rural Belagavi District, Karnataka, demonstrated an 88.8% improvement in knowledge scores and significant gains in practice indicators following a multimedia session plus booklet distribution. [6] Peer educator models (PRAGATI) implemented in Rajasthan similarly improved adequate knowledge from 20.5% to 56.4% and shifted practice behaviors. [8]

Our multi component approach—interactive instruction, peer champions, teacher enablement, and modest facility enhancements—may explain the larger practice shifts observed relative to some information only programs. Systematic reviews highlight that combining educational content with material or environmental support produces more robust behavior change than education alone. [9,10] Evidence from East Africa indicates that puberty education and provision of menstrual materials can mitigate declines in school attendance, though effects vary by context and implementation fidelity. [7,12]

Baseline estimates of hygienic absorbent use (~41–43%) and sociocultural constraints mirror rural Indian patterns derived from NFHS 5 secondary analyses and district level studies. [3,4,11] Our observed post intervention hygienic absorbent uptake (88%) approximates the upper range reported in targeted distribution or subsidy programs when paired with education. [4,6]

Clinical and Public Health Implications

Improving menstrual hygiene may reduce risks of reproductive or urogenital infections, skin irritation, and psychosocial distress, with downstream benefits for participation in school and community life. [4,9,10] Embedding participatory menstrual health modules within the existing school health platform offers a scalable avenue to advance adolescent health, gender equity, and educational attainment.

Limitations

Non random cluster allocation may introduce selection bias, though baseline comparability was good. Self reported practices and absenteeism are subject to recall and desirability biases; we attempted mitigation via anonymous surveys. Short (6 month) follow up limits assessment of durability. Facility upgrades were modest and heterogeneous across schools. Finally, results may not generalize to urban private schools or out of school adolescents.

Longer term randomized trials comparing education only, materials only, and combined packages; cost effectiveness analyses; and implementation research on sustaining school WASH improvements are warranted. Inclusion of psychosocial and infection outcomes would strengthen causal pathways. [1,2,7,9]

In a cluster controlled evaluation across rural government schools, a participatory, curriculum linked health education intervention produced substantial and rapid improvements in menstrual knowledge, hygienic behaviors, and a composite adequate MHM indicator among adolescent girls. Gains translated into reduced menstrual related school absence within six months. Effects persisted after adjusting for socioeconomic and maternal education factors, highlighting the added value of structured school engagement beyond household determinants. Integrating interactive menstrual health modules, peer support, and basic facility enhancements into routine school health programming is a pragmatic strategy to advance adolescent well being, educational participation, and gender equity. Wider scale up should be accompanied by monitoring of quality, sustainability of WASH improvements, and periodic refresher sessions to maintain behavior change. Our findings support policy commitments to universal menstrual health literacy in schools and underscore the feasibility of impact through existing community medicine and school health platforms.

1. Hennegan J, Winkler IT, Bobel C, Keiser D, Hampton J, Larsson G, et al. Menstrual health: a definition for policy, practice, and research. Sex Reprod Health Matters. 2021;29(1):1911618.
2. United Nations Children’s Fund (UNICEF). Guidance on Menstrual Health and Hygiene. New York: UNICEF; 2019.
3. International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS 5), 2019–21: India. Mumbai: IIPS; 2021.
4. Singh A, Chakrabarty M, Singh S, Chandra R, Chowdhury S, et al. Menstrual hygiene practices among adolescent women in rural India: a cross sectional study. BMC Public Health. 2022;22:2126.
5. Ghimire S, Gahatraj NR, Shrestha N, Manandhar S, Dhital SR. Effects of health education intervention on menstrual hygiene knowledge and practices among the adolescent girls of Pokhara Metropolitan, Nepal. PLoS One. 2024;19(9):e0291884.
6. Khan N, Mahishale A. An educational intervention on situational awareness and understanding of menstrual hygiene, knowledge, taboo, and its practices among school going adolescent girls in rural areas of Belagavi, Karnataka. Arch Med Health Sci. 2024;12(2):214 22.
7. Montgomery P, Hennegan J, Dolan C, Wu M, Steinfield L, Scott L. Menstruation and the cycle of poverty: a cluster quasi randomised control trial of sanitary pad and puberty education provision in Uganda. PLoS One. 2016;11(12):e0166122.
8. Dwivedi R, Sharma C, Bhardwaj P, Singh K, Joshi N, Sharma PP. Effect of peer educator PRAGATI on knowledge, attitude, and practice of menstrual hygiene in adolescent school girls. J Family Med Prim Care. 2020;9(7):3593 9.
9. Sumpter C, Torondel B. A systematic review of the health and social effects of menstrual hygiene management. PLoS One. 2013;8(4):e62004.
10. Kuhlmann AS, Henry K, Wall LL. Menstrual hygiene management in resource poor countries. Obstet Gynecol Surv. 2017;72(6):356 76.
11. Belayneh Z, Mekuriaw B. Knowledge and menstrual hygiene practice among adolescent school girls in southern Ethiopia: a cross sectional study. BMC Public Health. 2019;19:1595.
12. Austrian K, Kangwana B, Soler-Hampejsek E, Maddox N, Wado YD, et al. Adolescent girls initiative—Kenya: impact evaluation of provision of sanitary pads and reproductive health education on school participation. Reprod Health. 2021;18:179.
13. Singh A, et al. (NFHS 5 sub analysis rural India menstrual hygiene differentials). BMC Public Health. 2022;22:2126. [Duplicate analytic reference to highlight rural gradients; cite in text as supportive secondary analysis.]
14. Dasgupta A, Sarkar M. Menstrual hygiene: how hygienic is the adolescent girl? Indian J Community Med. 2008;33(2):77 80.