Abstract
Educational attainment and achievement are key areas of study for social scientists because they are associated with a wide range of outcomes, including income, careers, marriage, fertility, migration, and longevity. Using unique multimethod, longitudinal data from Nepal, a low-income setting, we explore how the availability of sanitary pads in restrooms is associated with school achievement. We focus on eighth grade students, marking a pivotal time in which many female students begin menstruating. Multilevel modeling estimates reveal that the availability of sanitary pads in school restrooms have a statistically significant positive association with an increase in language test scores for females. The results also show a positive association between the availability of sanitary pads and an increase in math and science test scores, but these associations are not statistically significant. These findings reveal that school hygiene facilities can play an important role in school achievement, which can shape students’ matriculation into the next academic year and potential longer-term consequences including both academic and social outcomes, such as school dropout, income, and marriage timing.
Keywords: Education, Menstruation, Sanitary pads
Introduction
Decades of research reveal that mass education, enrollment in school, and educational achievement together constitute one of the most powerful factors shaping social outcomes. This includes a significant volume of research on educational attainment processes themselves (i.e., Sewell and Hauser (1975)), but it goes far beyond that to link those processes with a tremendous range of social outcomes. For example, evidence of worldwide consequences of mass education is particularly clear regarding the association between school achievement and life outcomes such as employment, earnings, health, and entry and exit from marriage (Thornton et al., 2007). Moreover, these associations are consistent across many different settings, including the United States, Europe, and Asia (Thornton et al., 1995; Yabiku, 2005). For decades, the study of education has focused on access to schools, parental resources and support, and the quality of instruction, educational materials, and educational facilities, such as libraries, labs, or computers (Coleman, 1968; Dornbusch & Ritter, 1988; Epstein, 2010). Only recently has the scientific investigation of the factors promoting greater educational achievement considered the potential influence of school restrooms (Adukia, 2017; Eshun et al., 2014).
School restrooms have the potential to be particularly important in understanding the difference in educational achievement between females and males. Though relatively little research has investigated this association, the work that has been done suggests that restroom facilities for females can be particularly crucial as they navigate both the onset of menstruation and engagement in school (Jasper et al., 2012). A small group of studies indicate that restrooms for female students may play a crucial role in helping them remain in school, but the onset of menarche further complicates the situation for females at school (Adukia, 2017). Recent research found that across currently published literature, there is “moderate evidence showing that education-based interventions can improve menstrual hygiene knowledge and practices among schoolgirls in resource-poor countries”, thus highlighting the importance of the school setting in supporting students during menstruation (Kuhlmann et al., 2017). Particularly in societies where menstruation is a social taboo, the quality of school restrooms may help females stay in school and learn more during their early teens, with long-term, multidimensional, life-course altering consequences.
To date, research on school restrooms focuses primarily on the mere existence of restrooms or the designation of restrooms for females (Kushiyait, 2011; Adukia, 2017; Birdthistle et al., 2011). Though important, focusing on the existence of restrooms for females is primarily limited to the poorest and most remote of all schools, which does not address the more general issue of availability of menstrual hygiene products within female restrooms. We investigate the association between variance in restrooms stocked with menstrual (or sanitary) pads (vs. not stocked) and eighth grade females’ academic success in language skills, math, and science, which are important domains for long-term success. Evidence of an association in this dimension is relevant worldwide, with the potential for a substantial array of long-term consequences across the life course. By focusing on the access to sanitary pads at school, we are able to consider an important aspect of the school experience for females, who face added complexities as they begin menstruating.
Our investigation of this association is possible because of newly created and innovatively linked measures of school facilities (direct observations), student’s academic performance (linked independent test-score records), and student’s personal and family background (standardized survey interviews). The combination of direct observations, student assessment scores, and survey measures provides the data needed to assess this association, while addressing a key set of other school- and family-level measures that also likely shape academic performance in eighth grade. Test scores from both the beginning and the end of the school year of eighth grade enable us to estimate a person-specific change from timepoint one to timepoint two in our model estimation approach. The data comes from Nepal, but from a region where nearly all schools already have separate restrooms for male and female students and the key variation across restrooms is in whether or not those restrooms provide students with menstrual pads. This unique data provides a new insight into the potential of the quality of eighth grade restrooms shaping gender differences in educational achievement, with many long-term consequences.
Theoretical Framework
Given the persistent gender gap in educational achievement and the crucial role of females’ education in later life achievement, health, and well-being not only for themselves but also for their family and community, females’ education has received great attention in both the policy and academic arenas worldwide (Evans & Yuan, 2019; Psaki et al., 2018). Thus, there is a robust literature on females’ schooling that primarily focuses on females’ school enrollment, attendance, and dropout (LeVine, 2006; Bhattarai et al., 2020). However, relatively little is known about factors in the school daily hygiene environment that may be shaping male-female differences in learning achievement. While focused on the home setting, one study in Ethiopia and India notes the gender-specific effects of providing infrastructure improvements can play an important role in reducing gender disparities within psychosocial outcomes during adolescence, further highlighting the distinct role sanitary facilities play across gender (R. Miller et al., 2024). This factor may be particularly important in educational grade-levels when female students begin menstruating and must manage that process in a public space (school), such as in middle school.
Ensuring that female students have the tools for preventing low school achievement that results in class repetition, one of the major reasons for early school dropout, has the potential for a wide range of positive consequences, such as preventing child marriage, providing the skills for healthier and more productive lives, and enabling greater agency especially in making sexual and reproductive decisions (Jain & Kurz, 2007; Klugman et al., 2014; McCleary-Sills et al., 2015; United Nations Children’s Fund, 2001). If, for any other reason, a female student drops out of school, she is more at-risk of an early marriage thus making it difficult to return to school (Bhandari, 2019). Thus, reducing early exits from school is an important priority for improving female life course trajectories. Therefore, advances in understanding the school characteristics that may enable continued female student success and achievement is a high priority topic. Below we ground our framework for studying the impact of providing sanitary pads by first considering how menstruation impacts school outcomes and then defining the role of sanitary pads along this pathway.
Menstruation, School Restrooms, and Female Academic Performance
Failure to provide clean, safe, private facilities for females at school has the potential to interrupt their education while also putting them at risk of physical and emotional trauma. School restrooms can be high-risk locations for females to experience trauma, due to poor safety if the bathroom doors do not have locks, ridicule from male peers about menstruation, and the risk of assault from authority figures (Abrahams et al., 2006). Female students have stated they avoid schools, in addition to other public sites, during menstruation (Chothe et al., 2014). For students who attend school, they expressed concerns with the challenges in managing menses due to limited affordability of sanitary pads and inadequate facilities in the school (Sommer, 2010). Thus, the quality of school restroom facilities has the potential to provide a critical dimension of school facilities that may shape female academic performance.
Several studies have investigated the relationship between restrooms and their effects on students (Oster & Thornton, 2011; Adukia, 2017). If students are not comfortable using restroom facilities, they risk getting urinary tract infections and experiencing other urinary discomfort (Shoham et al., 2021; Allen & Kane Low, 2022). These experiences, in turn, have high potential to reduce school attendance and engagement. Students may also be distracted due to their discomfort resulting in poor concentration and reduced academic performance. Of course, this general consequence has potential to influence academic performance of both male and female students.
For female students specifically, the need for quality restrooms that are equipped to support menstruation is important. This is reported worldwide (Alhelou et al., 2022; Gruer et al., 2021). In South Asia, for example, one student in a study in India remarked that she was passionate about her schoolwork but failed due to absences from exams that occurred during her menstrual cycle (Adukia, 2017). In Nepal, 41% of females stated that the lack of privacy in restrooms was a major reason they were absent during menstruation (WaterAid, 2009). When female students are absent from school due to inadequate restroom facilities, they risk falling behind their peers, failing exams, and eventually exiting school altogether.
Additionally, for females who are menstruating, menstrual pads can be costly and difficult products to acquire (Crofts & Fisher, 2012; Kirk & Sommer, 2006). By having menstrual hygiene products provided by the school, females may not feel forced to stay at home to care for themselves during their periods given their access to necessary products in school, affecting attendance rates (Fentiman et al., 1999; Oster & Thornton, 2011). More consistent attendance, in turn, has high potential to improve academic performance. Having menstrual products available in school restrooms also prompts discussion among young girls about the changes that occur within one’s body during puberty, with girls raising concerns and questions around menstruation with support figures (e.g., teachers, mothers, aunts) (Hennegan et al., 2017). These discussions may also encourage a healthy relationship with puberty changes, leading to better menstrual management (Hennegan et al., 2017).
Sanitary Pads and Female Academic Performance
Some current literature has explored how providing menstrual hygiene products may affect factors like attendance or the overall experience at school. For example, one recent qualitative study noted the benefits of a menstrual cup, highlighting that not missing class was a major benefit, in addition to the cost savings given purchasing sanitary pads was seen as an economic burden (Pokhrel et al., 2021). However, there is relatively little literature that more explicitly explores the role of sanitary products in shaping female school achievement.
Nevertheless, school attendance and achievement are clearly related and likely to influence each other across time. So, any condition or situation that repeatedly interrupts attendance is also likely to reduce achievement over time. This could be repeated illness, difficult family circumstances, or difficulty physically getting from home to school. High levels of absence reduce both classroom learning and instructions for learning outside the classroom (such as explaining homework assignments). These reductions then produce lower achievement, including lower scores on standardized tests (Aucejo & Romano, 2016; Gottfried, 2010). Crucial to our reasoning, the factors shaping attendance during the school year vary by gender (Skedgell & Kearney, 2018), creating consequences for achievement that also vary by gender in the same way.
In the other direction, school achievement is also a contributor to the decision to enroll in the next year of school, particularly if low achievement includes failing standardized tests required to advance to the next level of school. These year to year obstacles to continuing in school usually only occur once, whereas daily attendance within the school year is a repeated decision (Bhattarai et al., 2020).
The role of sanitary pads in affecting attendance and subsequent school achievement may be important. We hypothesize that providing sanitary pads in school restrooms has the potential to reduce student absence due to menstruation, thus improving school achievement. The established literature, noted earlier, argues that menstruation does impact school attendance (Adukia, 2017; Chothe et al., 2014; Sommer, 2010; WaterAid, 2009). As such, sanitary pads are likely to reduce adverse impacts of menstruation on school attendance. This higher attendance, in turn, is likely to promote higher school achievement.
Investigation of the association between schools providing sanitary pads and the academic success of female students in those schools is a high priority because this is a dimension of the school facility that can be shaped by public policy. Just like a school library or school-based access to computers, local governments can raise the resources to provide specific restroom facilities that increase student school achievement. This makes a test of the hypothesis that restroom facilities can improve female school achievement a high priority, worldwide.
Data and Methods
Study Area
The data for our study come from the Chitwan Valley Family Study (CVFS) area (Axinn, 2015). The setting of our investigation is the western part of the Chitwan Valley in the south central part of Nepal; our study focuses on a multi-ethnic population in this area with similar social, economic, and educational circumstances across the entire population being studied (Axinn, 2015). The study area includes both the urbanized hub of the Chitwan district and settled agricultural area (Rowan et al., 2024), where both include a well-developed transportation and community service infrastructure. This area has living conditions and demographic patterns that are similar in many ways to other parts of South Asia, South East Asia, China, and sub-Saharan Africa that comprise more than half the world’s population. Although our study setting closely resembles the Nepal population, Chitwan is slightly higher in economic indicators (income, education, and the Human Development Index) (Scott et al., 2021).
Nepal has a short history of public education. Until 1939 common people were neither allowed to go to schools opened for the members of the royal family nor were allowed to open schools on their own (Sharma, 1994). However, since 1951 Nepal has taken a series of steps including the decentralization of school education (1954), a free and compulsory primary education (1961), and a teacher’s training and licensing program (Sharma, 1994) to make education more accessible. These efforts greatly increased the number of new schools and consequently the number of students during the 1960s. In 1971, Nepal developed a New Education Plan. One of the objectives of this plan was to provide equal opportunity of education to all by encouraging the public to open a new school if there was not one within a reasonable walking distance (Mathema, 2007; Carney & Bista, 2009).
In 1986, Nepal adopted the privatization of the school system as its national educational policy for the first time. The introduction of this policy has led to the emergence of numerous English medium based private boarding schools (K. Khanal, 1996, 2000). Similar to other developing countries, the pace of privatization of schools was slow during the 1990s (Baum et al., 2014; Pradhan, 2018) but spiked with restoration of the multiparty democratic system that adopted economic liberalization as its economic policy (Caddell, 2007; Pigg, 1992; Skinner & Holland, 1996; Pradhan, 2018). As a result, the number of private schools increased from 3,137 in 2004 to 6,687 in 2019 (Evans & Yuan, 2019).
However, despite significant progress in school accessibility, close to universal and gender parity in primary school enrollment (S. Khanal, 2018), as well as school retention, particularly amongst females in higher grades, are persistent challenges. Females also tend to be more disadvantaged in basic literacy, especially at primary grade levels, and drop out of school at higher rates than males (Psaki et al., 2018).
Data
This study uses multiple datasets collected through a mixed methods approach (Axinn & Pearce, 2006). This includes 1) three independent tests at the beginning and end of school year designed by a subject matter specialist from the Education Review Office of the Ministry of Education, 2) archival records from the Bharatpur Municipality Education Office, and district coordination office 3) structured interviews with all eighth grade students (45-min) and one parent of each student (60-min), 4) surveys administered to the school’s head teacher, SMC chair, PTA chair, and all eighth grade teachers, and 5) classroom observations across three-days for 6th – 8th grade classrooms and one day visits to gather overall school data (e.g., staffing, resources, facilities), and school history calendar methods, collected during 2019–2020 (pre-COVID-19 pandemic) (Rowan et al., 2024).
These datasets provide us with 1) measures of the key outcome of student achievement (endline and baseline test scores), 2) measures of key predictors (school observations of sanitary pads), and 3) measures of controls that could create associations between these two (school observations of other facilities and parental family survey responses). Parental and family level data was measured with a confidential, in-person survey interview collected by professional interviewers (Rowan et al., 2024).
Of the 113 schools in the study area offering eighth grade instruction, 56 are private and 57 are public schools, although 53 private schools are used for this analysis scattered throughout the Western Chitwan Valley (Rowan et al., 2024).1,2 We investigate private schools to study how sanitary pads would affect female student test scores. Within Nepal, the privatization of schooling starting in the 1980s has resulted in about a quarter of students attending private schools nationwide (Rowan et al., 2024). Amongst the children measured in our study within western Chitwan, 45% of them attend private schools. Because all the private schools did have restrooms, we are able to focus our analysis on the providing of pads in restrooms rather than whether or not a school has a restroom. Private schools, particularly those within this area of Nepal, tend to have the same level of instructional resources (Rowan et al., 2024), but this wealth-based self-selection allows analysis to focus on the impact of sanitary pads.
Measures
1). Measures of the Key Outcome of Student Achievement
The measures of student achievement come from the endline and baseline assessments, which were conducted in the same manner at both the beginning and end of the school year. The answer sheet for the baseline and endline assessments were scored by a team of trained examiners. These trained examiners scored answers following a standard protocol developed by the subject expert. Five percent of the baseline assessments were randomly selected and scored twice by two different examiners independently. An inter-rater reliability test resulted in a 0.90 Kapa. The same team of examiners scored the endline assessment at the end of the school year following the same protocol as in the baseline assessment at the beginning of the school year, with the same consistent outcome. Our measures of student achievement – baseline and endline assessment – are thus the obtained scores out of full marks of 47 for Nepali (language), out of 50 for math, and out of 48 for science.3
While the endline test score is the key outcome we’re measuring, baseline test scores for Nepali, math, and science are always included in the regression models for the respective endline test scores given baseline test scores help us understand improvement in student test scores. We ran t-tests separated by schools with and without sanitary pads across each subject to confirm statistically significant differences in means (table available upon request).
The student achievement assessment was designed to assess learning outcomes of eighth grade students by Nepal’s National Assessment of Student Achievement (NASA) team (subject teachers, subject matter expert) led by the director of the Education Review Office, the Ministry of Education, Science and Technology (Rowan et al., 2024). The final set of assessments for Nepali, math, and science were administered twice, at the beginning of the school year (baseline) and the end of the school year (endline). It was a written assessment, administered face-to-face through paper-pencil tests. Both the baseline and endline assessments were administered to all eighth grade students who were present on the test day in all 53 private schools used in the analysis.
Although attendance is an important metric to consider when assessing academic engagement, test scores are an important measure of academic success. In many settings, these scores determine whether students matriculate into the next year or risk failing out, thus deterring the continuation of academic studies. Test scores also provide standardized assessments of the individual-level variance in the trajectory of learning across time. Test scores by subject matter provide insight into the individual-level attainment of specific skills and knowledge (Metsämuuronen & Raj Kafle, 2013; Poudel & Bhattarai, 2018).
Students were dropped from analysis if there was missing data. Given exams for each subject were administered on different days, each subject and set of students used in analysis was examined independently of each other. For Nepali, 254 total students were dropped as they were missing Nepali test scores and/or control variables, resulting in 766 students used for analysis. For math, 235 total students were dropped as they were missing math test scores and /or control variables, resulting in 785 students used in the analysis. For science, 244 total students were dropped as they were missing science test scores and/or control variables, resulting in 776 students used in analysis. While some students were dropped due to data availability, we still maintain a large sample size across subjects for analysis.
Please see Tables 1–3 for the observed range, mean, and standard errors of Nepali, math, and science test scores.
Table 1:
Descriptive statistics of student-level measures for Nepali for female students in private schools.
| N | Min | Max | Mean | SE | |
|---|---|---|---|---|---|
| Endline Nepali Score | 766 | 1 | 40 | 21.79 | 0.26 |
| Baseline Nepali Score | 766 | 3 | 40 | 21.94 | 0.26 |
| Attendance | 766 | 52 | 245 | 212.15 | 0.60 |
| Student Age | 766 | 13 | 17 | 14.44 | 0.03 |
| Household Measures | |||||
| Ethnicity1 | |||||
| Brahmin\Chhetri | 766 | 0 | 1 | 0.61 | 0.02 |
| Hill Janajati | 766 | 0 | 1 | 0.21 | 0.01 |
| Dalit | 766 | 0 | 1 | 0.04 | 0.01 |
| Newar & Other Ethnicities | 766 | 0 | 1 | 0.06 | 0.01 |
| Terai Janajati | 766 | 0 | 1 | 0.07 | 0.01 |
| Father’s Education Level | |||||
| 0 years | 766 | 0 | 1 | 0.01 | 0.00 |
| 1 – 5 years | 766 | 0 | 1 | 0.06 | 0.01 |
| 6 – 10 years | 766 | 0 | 1 | 0.41 | 0.02 |
| 11+ years | 766 | 0 | 1 | 0.52 | 0.02 |
| Mother’s Education Level | |||||
| 0 years | 766 | 0 | 1 | 0.04 | 0.01 |
| 1 – 5 years | 766 | 0 | 1 | 0.12 | 0.01 |
| 6 – 10 years | 766 | 0 | 1 | 0.45 | 0.02 |
| 11+ years | 766 | 0 | 1 | 0.39 | 0.02 |
| Income (₹) | |||||
| Less than 100,000 | 766 | 0 | 1 | 0.05 | 0.01 |
| 100,000 – 250,000 | 766 | 0 | 1 | 0.18 | 0.01 |
| 250,000 – 500,000 | 766 | 0 | 1 | 0.32 | 0.02 |
| More than 500,000 | 766 | 0 | 1 | 0.45 | 0.02 |
| Savings in a Financial Institution | 766 | 0 | 1 | 0.80 | 0.01 |
| Money or Assets Set Aside for the Child to Attend College or Future Schooling | 766 | 0 | 1 | 0.17 | 0.01 |
| Household Size | 766 | 3 | 17 | 5.16 | 0.06 |
N/A values are coded to “Other Ethnicities”
Table 3:
Descriptive statistics of student-level measures for science for female students in private schools.
| N | Min | Max | Mean | SE | |
|---|---|---|---|---|---|
| Endline Science Score | 776 | 3 | 43 | 21.68 | 0.29 |
| Baseline Science Score | 776 | 1 | 40 | 17.00 | 0.25 |
| Attendance | 776 | 128 | 245 | 212.62 | 0.55 |
| Student Age | 776 | 12 | 20 | 14.44 | 0.03 |
| Household Measures | |||||
| Ethnicity1 | |||||
| Brahmin\Chhetri | 776 | 0 | 1 | 0.60 | 0.02 |
| Hill Janajati | 776 | 0 | 1 | 0.22 | 0.01 |
| Dalit | 776 | 0 | 1 | 0.05 | 0.01 |
| Newar & Other Ethnicities | 776 | 0 | 1 | 0.06 | 0.01 |
| Terai Janajati | 776 | 0 | 1 | 0.06 | 0.01 |
| Father’s Education Level | |||||
| 0 years | 776 | 0 | 1 | 0.01 | 0.00 |
| 1 – 5 years | 776 | 0 | 1 | 0.06 | 0.01 |
| 6 – 10 years | 776 | 0 | 1 | 0.41 | 0.02 |
| 11+ years | 776 | 0 | 1 | 0.52 | 0.02 |
| Mother’s Education Level | |||||
| 0 years | 776 | 0 | 1 | 0.05 | 0.01 |
| 1 – 5 years | 776 | 0 | 1 | 0.12 | 0.01 |
| 6 – 10 years | 776 | 0 | 1 | 0.45 | 0.02 |
| 11+ years | 776 | 0 | 1 | 0.38 | 0.02 |
| Income (₹) | |||||
| Less than 100,000 | 776 | 0 | 1 | 0.06 | 0.01 |
| 100,000 – 250,000 | 776 | 0 | 1 | 0.17 | 0.01 |
| 250,000 – 500,000 | 776 | 0 | 1 | 0.31 | 0.02 |
| More than 500,000 | 776 | 0 | 1 | 0.46 | 0.02 |
| Savings in a Financial Institution | 776 | 0 | 1 | 0.80 | 0.01 |
| Money or Assets Set Aside for the Child to Attend College or Future Schooling | 776 | 0 | 1 | 0.18 | 0.01 |
| Household Size | 776 | 3 | 17 | 5.16 | 0.06 |
N/A values are coded to “Other Ethnicities”
2). Measure of Key Predictor: School Observation of Sanitary Pads
In contrast to the individual-level test scores, the providing of sanitary pads is measured at the school-level (n=53). This measure came from direct observation of restrooms by the research staff and coded as 1 if the research staff saw a sanitary pad in the restroom and 0 otherwise.
Because all schools in our sample had restrooms, our analysis focused on whether the restroom was equipped with sanitary pads. Descriptive statistics for the providing of sanitary pads and other school-level measures across the three subjects are shown in Table 4.
Table 4:
Descriptive statistics of school-level measures (n = 53)
| % of Schools | SE | |
|---|---|---|
| Sanitary Pads | - | 0.05 |
| Yes | 18.87% | - |
| No | 81.13% | - |
| Library | - | 0.06 |
| Yes | 69.81% | - |
| No | 30.19% | - |
| Laboratory | - | 0.07 |
| Yes | 62.26% | - |
| No | 37.74% | - |
| Computer Room | - | 0.04 |
| Yes | 88.68% | - |
| No | 11.32% | - |
In addition to the providing of pads mentioned above, there were a number of other questions asked about restroom quality. These include whether there were separate facilities for students and faculty, separate restrooms for females and males, and the general condition of the restroom as a whole. However, there was not enough variation in these measures to include them in the analysis. We also explored a question asking about whether handwashing stations were provided in the restroom as another dimension to measure restroom quality given there was variation, but this measure was not a statistically significant predictor of change in test scores and is included in the supplementary tables (Table S.2).
3). Measures of Controls: School-Level Observations & Parental Family Survey Responses
School-Level Observations.
Our models also include several school characteristics that are likely to influence student achievement and the association between sanitary pads and student achievement.
Library, Laboratory, Computer Room.
These school quality measures include the presence of a library, laboratory, and computer room. Each of these characteristics are a separate control measure. If a school has a library, it received a value of 1 and 0 if not. The laboratory and computer room measures also follow the same coding scheme, receiving a value of 1 if the school has the facility and a 0 otherwise. Descriptive statistics for these school-level measures across the three subjects can also be seen in Table 4.
Instructional Quality.
We use a Nepal-specific version of the TRIPOD survey measure of instructional quality, assessing seven dimensions of quality, as explained in Rowan et al. (Rowan et al., 2024).
Student-Level Measures.
Additional student-level measures we controlled for include age (measured in years), ethnicity, attendance, father’s education, mother’s education, household income, household size, and household wealth. These measures all come from parental family survey interviews. One mechanism is that some households may be more affluent where they may be able to provide sanitary pads, potentially modifying the effects. Because of this, we control for household assets and income to assess the independent association between access to school sanitary pads and school achievement.
Age.
First, because the onset of menstruation varies by age, we include a measure of individual age. Although the age range of the sample is large, 92% of the students in the Nepali sample, 92% of the students in the math sample, and 91% of the students in the science sample are 15 years or under. In rural Nepal, it is not unusual for students as old as 15 years to attend eighth grade because of both high rates of repeating a grade due to previous exam failures and high rates of interruption to school that prevent children completing the grade within the school year they start the grade.
Ethnicity.
We include a measure of individual ethnicity: Brahman/Chhetri, Hill Janajati, Dalit, Terai Janajati, Newar and other ethnicities. Within the models, Brahman/Chhetri is used as the reference category. Because of the role that caste hierarchy plays in Nepal, ethnicity is strongly associated with these inequalities.
Parental Education.
Following previously published research on parental education effects on their children from Nepal (Axinn et al., 2024), maternal and paternal education levels are also included across four categories, coded 1 through 4: zero years of formal education, 1 – 5 years of formal education, 6 – 10 years of formal education, and more than 10 years of formal education. Parental education level may affect a student’s perspective on the importance of education, impacting academic outcomes.
Household Income.
Household income, which plays a role in the resources a student has access to, was also included. We divided income across four categories, coded 1 through 4: less than 100,000 rupees, 100,000 – 250,000 rupees, 250,000 – 500,000 rupees, and more than 500,000 rupees.4
Household Wealth.
We also use two key measures of household wealth particularly likely to shape the ability of parents to spend to support their children’s educations: whether or not (1,0) the household maintains any savings in a financial institution (bank or similar) and whether or not (1,0) the household has set aside a special set of savings to support their children’s educations.
Household Size.
Household size is the number of members of the household, which may play a role in the allocation of resources for education given the need to support other members of a household.
Attendance.
Lastly, given the role that attendance may play in student achievement, we also include it as a control, measured by the number of days in a school year the student attended school.
Analytic Strategy
Models treat the endline Nepali, math, and science assessment raw score as the dependent variable while controlling for the baseline Nepali, math, and science score. As explained above, the same assessment was administered twice, first at the beginning of the school year (baseline) and second at the end of the school year (endline), thus a positive change between the baseline and endline assessment score is treated as student learning achievement during the school year. To account for students being ‘nested’ within schools, we utilize a multilevel model approach clustered by schools using random effects, with Ordinary Least Squared (OLS) regression given the dependent variable is expressed as a raw score. We conducted data cleaning in R Version 4.4.1 and conducted all analysis in Stata 19.5 using the “mixed” command, specifying that standard errors are clustered by school using “cluster.”
Our measures of whether restrooms are equipped with pads and controls come from multiple surveys of students and parents, school archival records, and unannounced school observations. Thus, to estimate the association between student achievement and the quality of school restroom facilities, we estimate multivariate models of student achievement by subject, controlling for school-level characteristics, student background, and parent and household socioeconomic characteristics.
New measures allow us to measure person specific change from timepoint one to timepoint two within our modeling strategy by assessing factors associated with a change in academic performance across the eighth grade. Specifically, we estimate the effects of pads on change in test scores. Treatment groups would be those that had pads provided at schools compared to the control group who are those that do not. Measurements of academic success were taken at the start of the school year (baseline test scores) and at the end of the school year (endline test scores). We assume that students would be exposed to pads in restrooms over the course of the academic year, after the baseline test is administered and scored. In Nepal, baseline tests were administered at the start of the academic year, a timeframe in which students would not be “exposed” to pads to have any meaningful effect on baseline scores.
Results
Table 5 presents the results for the linear regression analysis for endline Nepali, math, and science scores, again controlling for the baseline test scores.
Table 5:
Linear regression multilevel model results for endline Nepali, math, and science scores of female students in private schools.
| Model 5A: Nepali | Model 5B: Math | Model 5C: Science | |
|---|---|---|---|
| Pads Provided | 1.37* (0.53) |
1.14 (1.17) |
0.37 (0.71) |
| Covariates: | |||
| Library | 0.20 (0.64) |
1.67 (1.18) |
1.59 (1.11) |
| Laboratory | 0.51 (0.75) |
0.22 (1.00) |
0.66 (0.92) |
| Computer Room | −1.92* (0.79) |
−1.25 (1.40) |
0.88 (0.83) |
| Instructional Quality | −1.55* (0.76) |
−0.19 (1.66) |
0.16 (1.33) |
| Attendance | 0.01 (0.01) |
0.03 (0.03) |
0.02 (0.02) |
| Student Age | −0.18 (0.24) |
−0.39 (0.31) |
−0.44 (0.24) |
| Ethnicity1 (ref: Brahmin\Chhetri) | |||
| Hill Janajati | −0.33 (0.53) |
−0.54 (0.60) |
−0.31 (0.45) |
| Dalit | 0.27 (0.89) |
1.07 (1.63) |
2.54*** (0.74) |
| Newar & Other Ethnicities | 0.20 (0.72) |
−0.35 (0.88) |
0.42 (0.88) |
| Terai Janajati | −0.07 (0.59) |
1.62* (0.76) |
0.15 (0.84) |
| Father’s Ed. Level (ref: 0 years) | |||
| 1 – 5 years | 0.94 (1.13) |
−1.56 (1.52) |
2.80 (1.45) |
| 6 – 10 years | 0.58 (0.98) |
0.66 (1.59) |
2.66* (1.14) |
| 11+ years | 1.35 (0.91) |
0.89 (1.79) |
3.56** (1.17) |
| Mother’s Ed. Level (ref: 0 years) | |||
| 1 – 5 years | −2.32** (0.84) |
1.75 (1.47) |
0.04 (1.36) |
| 6 – 10 years | −2.07** (0.74) |
1.98 (1.36) |
0.13 (1.45) |
| 11+ years | −2.00** (0.75) |
1.82 (1.35) |
0.37 (1.47) |
| Income Groups (Ref: less than 100,000) | |||
| 100,000 – 250,000 | 0.87 (0.82) |
1.14 (1.30) |
0.74 (1.08) |
| 250,000 – 500,000 | 1.13 (0.83) |
1.77 (1.32) |
0.22 (0.99) |
| More than 500,000 | 0.39 (0.76) |
1.88 (1.30) |
0.62 (1.00) |
| Savings in a Financial Institution | −0.18 (0.44) |
0.32 (0.50) |
0.30 (0.42) |
| Money or Assets Set Aside for the Child to Attend College or Future Schooling | −0.26 (0.45) |
−0.47 (0.57) |
−0.88 (0.54) |
| Household Size | 0.12 (0.09) |
−0.24* (0.12) |
−0.08 (0.11) |
| Baseline Score of Subject | 0.77*** (0.03) |
0.95*** (0.03) |
0.86*** (0.03) |
| Intercept | 10.46* (4.78) |
4.51 (9.50) |
3.73 (5.84) |
| Number of Observations | 766 | 785 | 776 |
| Number of Clusters | 53 | 53 | 53 |
Statistical significance of z-test:
P ≤ 0.05;
P ≤ 0.01;
P ≤ 0.001
N/A values are coded to “Other Ethnicities”
Nepali
In Model 5A, the association between endline Nepali scores and the providing of pads is positive and statistically significant. This means that for female eighth grade students, the improvement in scores on standardized tests between the baseline test and the endline test is significantly higher in schools that provide menstrual pads in female bathrooms. Moreover, this result is from a multilevel, multivariable model that includes multiple measures of other school facilities expected to improve test scores and multiple dimensions of the parental household with potential to shape both school quality and individual test scores. This unusually thorough investigation of our key hypothesis yields support for the conclusion menstrual hygiene products have potential to improve female school achievement in eighth grade.
In this model, we also find that providing of a computer room has a negative, statistically significant association. The measure of computer rooms is included as a potential mechanism of school quality. In this case, the observed association is in the opposite direction relative to the prediction, but it may be that computer rooms are less likely to affect Nepali language test scores. Mother’s education has a negatively significant association with change in test scores. In this setting, that means children in 8th grade who grew up with mothers with less than 6 years of education benefit more from being in school than children who grew up with mothers who have 6 or more years of education. While Nepali is the official and most-widely spoken language of Nepal, mothers with lower levels of education are more likely to come from ethnic minority groups, where a language other than Nepali is used at home. Therefore, children raised by mothers with lower levels of education are likely to improve more in grade 8 from any instruction at all and from fellow students, given they may be more sensitive to interventions, with potential for greater room for growth. Household income has a positive but insignificant association with the change in Nepali test scores.
Math
We also explored math tests scores providing an additional and contrasting academic subject. In Model 5B, we find that results are also positive but are not statistically significant. Similar to the Nepali models, we do find positive associations with the availability of sanitary pads, with the coefficient increasing in magnitude as models control for school and household characteristics. Although none of these associations are statistically significant in our sample of 53 schools, note that the magnitude of the estimated associations is similar across both Nepali and math test scores.
Science
Lastly, we explored science test scores. In Model 5C, we find that similar to math results, science results are positive but not statistically significant. Similar to the Nepali model, income remains positive but statistically insignificant.
Additional Analysis
We conducted additional analysis for male students in private schools with results in Table S.1. While across all three subjects there are modest, positive associations with having menstrual pads in female bathrooms, they remain statistically insignificant. This is expected given the providing of sanitary pads is unlikely to directly benefit male students.
Additionally, we explored the dimension of handwashing/soap station further as a means of measuring restroom quality for all three subjects using the same approach as the main models, controlling for both school and household-level characteristics in Table S.2. While these results were positive, they were not statistically significant and of relatively smaller magnitude compared to the results for sanitary pads.
We also explored the impact if either pads or a handwashing station is provided using the same methodology in Table S.3. For Nepali, this resulted in positive, statistically significant results, but given that providing handwashing stations only was not statistically significant, they do not predict improvements in test scores as strongly as pads do. Similar to the results shown in Table 5, for math and science, results were positive and not statistically significant.5
Discussion
Worldwide, there is increasing awareness that more thorough public distribution of sanitary products for menstruation has the potential to significantly improve females’ health and overall quality of life (Hernandez, 2021; Tumin, 2022; Treisman, 2021). However, studies on how the provision of sanitary products may help young females move ahead in their lives remain quite rare. Such studies are important first to narrow, if not eliminate, the prevailing gender gap in achievement (education, employment, or earnings), particularly in low-middle income settings where these gender gaps are most obvious. Indeed, most of the gender gaps begin early in the life, including within education. This research is a high priority because it can help target resources for improving access to menstrual products to the specific locations and situations where those resources can have the greatest total impact on the population while further closing the gender gap.
Gender differences in educational achievement are among the most highly studied topics in the social sciences, but those investigations rarely attend to the potential role of sanitary pads in producing these gender differences. Considering that current academic success can play a role in continuing education and impact the subsequent life outcomes shaped by education, it is important to consider factors that may hinder that success (Lamichhane & Okubo, 2014). Given that schools can more easily keep restrooms stocked with menstrual hygiene supplies than address family and societal differences, well-stocked restrooms may play an important role in providing females with the support they need to succeed in school, especially as they begin menstruation. Motivated by this potential, our investigation focuses on the association between sanitary pads and school achievement in eighth grade. Our approach uses a setting of high variance in restroom quality overall. In this setting, we harness a special combination of new measures of individual-level academic change across the year, observation of school facilities, and the individual and family background of each individual student.
Our results are compelling. They indicate that there is an association between the providing of pads and improvement in female students’ achievement. These results are important because test scores play an important role in determining student progression and overall academic success. The role of restrooms for middle-school-aged students is complex, given the circumstances of puberty, particularly menstruation, and the resulting societal and personal implications. These findings fall in line with our initial hypothesis that there is a relationship between schools providing pads and academic success. Of course, other dimensions of restroom quality are relevant and should be considered further, but in our investigation, they do not predict improvements in test scores as strongly as sanitary pads do.
Our findings also contribute to a complex, contradicting literature. A previous study in Nepal, nearby the population we study, examined how the provision of menstrual cups affected attendance and found that the attendance gap due to menstruation is relatively small, and the providing of menstrual cups does not close this gap (Oster and Thornton, 2011). However, this contrasting finding is likely a result of the substantial design differences between these two studies of female students in Nepal. Oster and Thornton’s result come from a small-scale, randomized trial providing novel menstrual cups to Nepalese females. It required females and their mother to consent in advance, attend a training in use of the cups, and take these cups with them after the training. The study we report reduces selection bias associated with agreement to participate, attendance at the training, or use of a novel device. Rather, the design we use compares change in test scores for females, not attendance, at schools that provide menstrual pads in bathrooms compared to schools that do not, amongst a general population in which these pads are commonly available and used throughout the population. It is also important to note that our population representation is much larger. The Oster and Thornton study was limited to four schools and 198 female students, whereas our study included 53 schools and more than 750 female students. It is likely that the larger sample size of female students, lower selection bias into the study, and our focus on schools providing sanitary pads directly to students rather than the more unusual menstrual cups delivered outside of school, each contribute to the stronger results we document here.
These results are important because of the potential for the provision of menstrual hygiene products to improve female academic success. Across settings, continuing in school not only increases educational attainment but also generally slows entry into marriage and subsequent child birth and may allow for increased household wealth (Aryal, 2007; L. C. Miller et al., 2017). Attendance is a key mechanism that may affect educational attainment, with attendance days potentially being affected by menstruation. Specifically, the timing of menstruation related absence relative to class content or assignments is outside of the individuals control. This menstruation induced absence may have different consequences than a more general count of any absence. However, it is important to note that this study measures general absence rather than menstrual-related absence specifically, which may inform why attendance does not emerge as a key mediating variable within this analysis.
The total benefits of interventions that aim to provide better access to adequate menstrual hygiene care may well go beyond educational enrollment, attainment, and the benefits of educational achievement. Our study may also underestimate the impact of sanitary pads given our estimates are within the private school setting where students tend to come from more affluent backgrounds and may already have reliable access to menstrual products. For students in public schools, this suggests that the association may be larger given financial barriers to accessing menstrual products may be more prevalent. These findings can lay the foundation for further study to understand the unique role that menstruation, and broadly women’s healthcare, can play in academic success and family formation processes, which can shape the life trajectory, opportunities, and autonomy of females.
Limitations
Although this study has many strengths, it also has important weaknesses that should be addressed in subsequent research. This study was focused solely on students in private schools in Chitwan, Nepal whose experiences may vary from students in other populations. Additional studies from a broader range of settings are a high priority. Even within this setting, additional data to enable analysis of the extent to which the observed effect is concentrated within students from disadvantaged backgrounds would be an important next step.
Other limitations of this specific study can also be addressed in important ways in future research. First, observation in a single school year do not allow us to account for availability of sanitary pads in prior years. Second, additional measures of prior academic ability (e.g., cumulative GPA, seventh grade performance) would strengthen the study, potentially providing more comprehensive measures of academic ability than individual subject performance on tests. Third, this is also an observational study and not a randomized trial, and as such we cannot eliminate the possibility that unobserved differences may be associated with observed changes. The findings we document provide motivation to create this important blend of measures across a broader range of school settings and schooling circumstances.
We also acknowledge that we do not find statistical significance across all subjects. This may be because for subjects like math and science, other factors such as fathers’ education and household ethnicity are more influential in academic success (as shown for science scores, see Table 5). But this may also be because of the relatively small sample of schools (n = 53) so that a statistical test with more power might reveal the observed positive associations are statistically significant. These possibilities require additional research – research we argue is a high scientific and public policy priority.
Finally, this study focuses specifically on the school setting. Other study settings outside of school, including both home and outside the home, may prove valuable. Settings of work, recreation, religious observance, and other nonfamily activities may provide meaningful insight into which locations for hygiene supplies are the most strongly associated with key outcomes for females. Variation in study setting will also mean that broader outcomes besides educational achievement can be studied. Additional measures of achievement have potential to reveal different associations with the availability of pads. This may include outcomes linked to occupational achievement, but it may also include outcomes such as personal self-evaluations of confidence or comfort around experiences with menstruation. Broader studies of this association also have the potential to improve our understanding of the likely mechanisms producing this association and the likely consequences of individual variation in prior circumstances. For example, the interaction between gender identity and restroom quality is likely complex. The unique experiences of marginalized identities with menstruation and restrooms may lead to different outcomes.
Conclusion
Overall, our findings indicate that there is promising evidence that schools can proactively provide pads in restrooms to improve female school achievement. Of course, it is important to note that this evidence is a first step and context-specific. More research on these topics is needed. A precise understanding of the links between restroom quality overall, and as measured through the providing of menstruation products, and achievement will provide better approaches to efficiently and effectively use this approach to improve life trajectories. Additionally, analysis into how sanitary pads affect students within public schools would be a valuable next step – this will need to account for differences amongst students within public schools compared to private schools (Rowan et al., 2024).
The work we report here uses a rare combination of standardized test scores from the beginning and ending of eighth grade and direct observation of the availability of menstrual pads in school restrooms to assess the association between pad availability and improvements in test scores. The models we use also incorporate parental family background and other school facilities to address potential spuriousness of associations with menstrual pads. We find a statistically significant improvement in languages test scores, and insignificant improvements in math and science scores. These important results leave many opportunities for subsequent studies to continue to advance this area of research. As that work continues, these results indicate it is possible that this small and relatively inexpensive change – providing menstrual pads in female bathrooms – has potential to improve female school achievement. And more broadly, success in school encourages young women to continue with their studies, with the potential to shape many other dimensions of the life course.
Supplementary Material
Table 2:
Descriptive statistics of student-level measures for math for female students in private schools.
| N | Min | Max | Mean | SE | |
|---|---|---|---|---|---|
| Endline Math Score | 785 | 0 | 48 | 27.08 | 0.38 |
| Baseline Math Score | 785 | 1 | 44 | 19.73 | 0.31 |
| Attendance | 785 | 128 | 245 | 212.50 | 0.55 |
| Student Age | 785 | 12 | 20 | 14.44 | 0.03 |
| Household Measures | |||||
| Ethnicity1 | |||||
| Brahmin\Chhetri | 785 | 0 | 1 | 0.61 | 0.02 |
| Hill Janajati | 785 | 0 | 1 | 0.22 | 0.01 |
| Dalit | 785 | 0 | 1 | 0.05 | 0.01 |
| Newar & Other Ethnicities | 785 | 0 | 1 | 0.07 | 0.01 |
| Terai Janajati | 785 | 0 | 1 | 0.07 | 0.01 |
| Father’s Education Level | |||||
| 0 years | 785 | 0 | 1 | 0.01 | 0.00 |
| 1 – 5 years | 785 | 0 | 1 | 0.06 | 0.01 |
| 6 – 10 years | 785 | 0 | 1 | 0.42 | 0.02 |
| 11+ years | 785 | 0 | 1 | 0.51 | 0.02 |
| Mother’s Education Level | |||||
| 0 years | 785 | 0 | 1 | 0.05 | 0.01 |
| 1 – 5 years | 785 | 0 | 1 | 0.12 | 0.01 |
| 6 – 10 years | 785 | 0 | 1 | 0.45 | 0.02 |
| 11+ years | 785 | 0 | 1 | 0.39 | 0.02 |
| Income (₹) | |||||
| Less than 100,000 | 785 | 0 | 1 | 0.06 | 0.01 |
| 100,000 – 250,000 | 785 | 0 | 1 | 0.17 | 0.01 |
| 250,000 – 500,000 | 785 | 0 | 1 | 0.31 | 0.02 |
| More than 500,000 | 785 | 0 | 1 | 0.46 | 0.02 |
| Savings in a Financial Institution | 785 | 0 | 1 | 0.80 | 0.01 |
| Money or Assets Set Aside for the Child to Attend College or Future Schooling | 785 | 0 | 1 | 0.17 | 0.01 |
| Household Size | 785 | 3 | 17 | 5.17 | 0.06 |
N/A values are coded to “Other Ethnicities”
Highlights.
This study links sanitary pad availability in schools & female school achievement.
Female language scores increased with access to sanitary pads in school restrooms.
Hygiene in schools can play a key role in females’ academic success.
Hygiene in schools could promote greater gender equality in academic success.
School hygiene support could foster positive life outcomes shaped by education.
Acknowledgements:
The authors gratefully acknowledge and thank, first and foremost, the students; their parents, teachers, and principals; the professionals of the school management committee/school board; and the parent teacher association of the Western Chitwan Valley. We also thank the survey staff at the Institute for Social and Environmental Research–Nepal for their outstanding fieldwork in collecting the data reported here. Finally, we greatly thank Kada Durakovic, Jennifer Mamer, and Claudia Minetti for their exceptional assistance with the preparation of this manuscript and Paul Schulz for his valuable assistance with construction of the data and measures we analyze. The authors alone remain responsible for any errors and omissions in this manuscript.
Funding Information:
This research was supported by a grant (ES/P005551/1) from the Department for International Development – Economic and Social Research Council (DFID-ESRC) and by an NICHD center grant to the Population Studies Center at the University of Michigan (P2CHD041028).
Glossary
- Menarche
First menstrual period in female adolescence
- Nepali
Official language of Nepal
- National Assessment of Student Achievement (NASA)
Communicates the status of the learning achievement of students
- Baseline assessment
Assessment administered at the start of the academic year by subject
- Endline assessment
Assessment administered at the end of the academic year by subject
- Inter-rater reliability test
Representation to the extent to which data collected in a study represents variables measured; this can be measured through the extent to which data collectors (raters) assign the same score to a variable
- Ordinary Least Squared (OLS) regression
Analysis that fits a model between one or more explanatory variables and a continuous or at least interval outcome variable
Footnotes
Declaration of Interest: Dr. Ghimire is also the Director of the Institute for Social and Environmental Research–Nepal (ISER-N) that collected the data for the research reported here. Ghimire’s conflict of interest management plan is approved and monitored by the Regents of the University of Michigan.
Declaration of Generative AI and AI-Assisted Technologies in the Manuscript Preparation Process
During the preparation of this work, the authors used ChatGPT to supplement the results of our literature review. After using the tool/service, the authors thoroughly reviewed the results and take full responsibility for the content of the published article.
In Nepal, private schools that were created as businesses, rather than created by local, district, or national governments are referred to as “institutional” schools. To remain consistent with the literature we use the term private school.
Three private schools did not have complete data available to support the analysis.
Students without both an endline and baseline test score for a subject were not included in the analysis.
At the time of interview, US $1 was approximately 130 Nepali rupees.
Results for math and science remain consistent when we remove insignificant controls.
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