Increasing Menstrual Hygiene Awareness to Reduce School Dropout among Adolescent Girls in Madagascar

Julieta Vera
Duncan Webb
Fieldwork by:
2,380 school girls in 140 primary and secondary schools
Target group:
  • Primary schools
  • Secondary schools
  • Students
  • Women and girls
Outcome of interest:
  • Dropout and graduation
  • Enrollment and attendance
  • Mental health
Intervention type:
  • Information
  • Training
Research papers:

Social stigmas surrounding menstruation and lack of knowledge of menstrual hygiene practices can be significant barriers to girls’ education. Researchers are evaluating the impact of raising awareness about menstrual hygiene on girls’ school absenteeism in Madagascar.

Policy issue

School absenteeism can predict eventual school dropout and longer-term life challenges for adolescents and hamper efforts to break the poverty cycle.1 A large body of evidence has documented how issues around menstruation can create obstacles to girls’ education, due to a wide range of physical factors, such as the lack of adequate hygienic products and facilities at schools, compounded by cultural attitudes that create taboos around menstruation.2 Improved awareness and knowledge about menstrual hygiene practices can help reduce stigma and physical consequences of menstruation for school girls.3 However, little is known about how to most effectively convey such information. Can supporting young community leaders to foster open communication about menstrual hygiene improve social norms and reduce girls’ school absenteeism?

Context of the evaluation

Stigma surrounding menstruation and a lack of adequate sanitary infrastructure or support systems in schools can be important obstacles to girls’ education.4 Menstruation-related issues are a potential driving factor behind adolescent girls’ absenteeism and dropout.

The Jeunes Filles Leaders program (“Young Girl Leaders” or YGL) aims to improve the level of knowledge and awareness of menstrual hygiene among young girls (starting Grade 4) by leveraging the presence of “positive social deviants” within school communities to diffuse information about menstrual hygiene practices. Positive deviance relies on the notion that a few individuals within a given community may adopt beneficial strategies in response to a challenge, leading to better outcomes than fellow community members.5 In the context of this evaluation, these individuals are young girls inclined to break the norm of silence to foster open discussions about menstrual hygiene as well as reduce stigma and change social norms around the topic.

Young girls in the classroom
Photo: CARE Madagascar

Details of the intervention

Researchers are partnering with the NGO CARE to assess the effectiveness of the YGL program in reducing school absenteeism among adolescent girls. The Young Girl Leaders receive communication training from CARE to improve their information delivery skills, as well as information regarding different Water, Sanitation and Hygiene (WASH) practices (e.g., using a sanitary napkin).

The intervention is built on top of a set of water, sanitation and hygiene (WASH) infrastructure improvements and related support activities consisting of three components:

  • Infrastructure: construction and rehabilitation of latrines and water-access points, and training in-school WASH committees in the management of infrastructure maintenance
  • School support: training of teachers on WASH practices, setting up and training in-school WASH committees, training of school girls on the use of cloth menstrual pads and focus groups to share experiences on their use.
  • Community support: training of local seamstresses in the production of washable cloth menstrual pads (to be promoted through vouchers to school girls), and diffusion of information regarding WASH practices through a local newspaper.

To capture the relative effectiveness of varying information diffusion strategies, researchers randomly assign 140 schools to one of the four groups below:

  1. WASH + Formal YGL: 35 schools receive the YGL program, along with the standard WASH package offered by the NGO. Information about menstrual hygiene practices is transmitted during formal structured sessions organized and run by the girl leaders at the school. These sessions are run regularly, with support and feedback from CARE’s local partners. Young Girl Leaders in these schools are first identified by school teachers based on their level of social deviance (i.e., their willingness to go against social norms and speak on topics related to menstrual hygiene) and their participation is purely voluntary.
  2. WASH + Informal YGL: 35 schools receive the YGL program, along with the standard WASH activities offered by the NGO. Information is delivered using an informal diffusion mechanism, whereby the girl leaders are encouraged to discuss menstrual hygiene behaviors in informal conversations, outside the classroom. Just as in the other modality, Young Girl Leaders in these schools are first identified by school teachers based on their level of social deviance (i.e., their willingness to go against social norms and speak on topics related to menstrual hygiene) and their participation is purely voluntary.
  3. WASH: In the first two years of program implementation, 35 schools receive only the basic WASH activities. These schools will receive the YGL program after the endline for the evaluation, starting March 2023.
  4. Comparison: 35 schools receive no intervention during the evaluation period and will serve as the comparison group.

Researchers collected school registry and baseline survey data at the household level, interviewing girls as well as their female tutor and a brother of similar age (if available). Midline and endline surveys will be conducted to measure the program’s impact on schooling outcomes, attitudes and behaviors around menstrual hygiene and general sanitation, psychosocial well-being, and physical health indicators.

Ethical Considerations

Due to the stigma surrounding menstruation, the target population might feel uncomfortable or be reluctant to partake in the program. Given that the target population are young girls, the opinion of their parents regarding the program is also relevant. To address these concerns, in addition to standard consent and assent procedures, the following measures are put in place:

  • Potential rejection of the program by parents will be addressed through the sensitization campaigns conducted by CARE in the targeted villages, along with the WASH committees organized at the school level.
  • After the voucher distribution of reusable sanitary pads, CARE is planning to hold mother-daughter focus groups to discuss their experiences of using the pads.

Results and policy lessons

Study ongoing; results forthcoming.


Gubbels, Jean, Claudia E. van der Put, and Mark Assink. 2019. “Risk Factors for School Absenteeism and Dropout: a Meta-Analytic Review.” Journal of Youth and Adolescence 48(9): 1637-1667.

Benshaul-Tolonen, Anja, Garazi Zulaika, Marni Sommer, and Penelope A. Phillips-Howard. 2020. "Measuring Menstruation-Related Absenteeism Among Adolescents in Low-Income Countries." The Palgrave Handbook of Critical Menstruation Studies: 705-723.
Jyoti, Kamal, Mohan Lal, Sanjeev Mahajan, and Tejbir Singh. 2020. "Assessing the impact of information, education and communication activities regarding menstrual hygiene practices among adolescent girls 13-17 years in the rural area of Amritsar." International Journal of Community Medicine and Public Health 7(4): 1470-1474.
UNESCO. 2014. "Puberty Education & Menstrual Hygiene Management." Good Policy and Practice in Health Education, Booklet 9.
Marsh, David R., Dirk G. Schroeder, Kirk A. Dearden, Jerry Sternin, and Monique Sternin. 2004. "The power of positive deviance." Bmj 329, no. 7475: 1177-1179.