Date on Master's Thesis/Doctoral Dissertation


Document Type

Doctoral Dissertation

Degree Name

Ph. D.


Epidemiology and Population Health

Degree Program

Public Health Sciences with a specialization in Epidemiology, PhD

Committee Chair

Wallis, Anne

Committee Co-Chair (if applicable)

Baumgartner, Rick

Committee Member

Baumgartner, Rick

Committee Member

Harris, Muriel

Committee Member

DuPre, Natalie

Committee Member

Okonofua, Friday

Author's Keywords

adolescent; Nigeria; menstruation; hygiene; school


Menstrual hygiene in lower-middle-income countries (LMICs) is limited and has been linked to many health, educational and social effects. However, the prevalence, details, and impact of menstrual hygiene management have not been well characterized in rural and peri-urban settings across Nigeria. The overall purpose of this research was to investigate menstrual hygiene management (MHM) among adolescent schoolgirls in peri-urban areas of Edo State, Nigeria; and to determine the educational consequences associated with poor MHM. MHM was measured using previously validated questions that were adapted after a formative assessment of MHM within the Edo State community. We used a mixed methods study design to assess the knowledge, practices, and attitudes surrounding menstruation among schoolgirls aged 11-19 years old though in-depth interviews and questionnaires. Firstly, descriptive statistics were used to assess the menstrual characteristics and the major barriers to menstrual hygiene management (Aim 1). Next, the association between menstrual hygiene management (i.e., access to sanitary materials, disposal, changing spaces, and water) and school days missed due to menstruation was examined using multivariable logistic regression (Aim 2). The average age of menarche in our study population was 13 years. The most common reported physical symptoms were stomach pain (73.66%), mood irritability (40.73%), and wet feeling on genitals (37.09%) with no girls reporting no symptoms. Menstruation knowledge was acquired mostly from mothers. The participants correctly answered 76.9% basic questions about menstruation. Almost half of girls (42.63%) felt anxious for their next period, and the girls described cultural myths surrounding menstruation driving them to hide their menstrual products and feel embarrassed to ask for more information or help. Only 27 girls (4.73%) reported complete adequate menstrual hygiene management during their last period. Missing school due to menstruation was associated with inconsistent access to water at school (OR 1.75 95% CI 0.81, 3.78), physical symptoms (headache OR 1.90 95% CI 1.10, 3.28; stomach pains OR 1.43 95% CI 0.71, 2.91; and back pain OR 1.52 95% CI 0.83, 2.75), other symptoms such as mood irritability (OR 1.29 95% CI 0.75, 2.23), stained underwear (OR 1.35 95% CI 0.76, 2.39), never learning about menstruation (OR 2.71 95% CI1.03, 7.14), changing less than 4 times in 24 hours (OR 1.85 95% CI 0.92, 3.73), and a lack of menstruation knowledge (OR 1.18 95% CI0.69, 2.01). This research has shown that improving menstrual hygiene management requires a multi-faceted response that integrates structural changes, social movements, and early access to menstruation knowledge. In addition, this study has shown the clear impact that poor MHM has on a girl’s education, underpinning the need to act. By addressing a root cause like poor MHM, many girls and women will be lifted up and the gender disparities can begin to be dismantled.