A total of 332 anonymous surveys were completed by learners (241 females, 91 males). A total of 81 learners participated in eight FGDs (63 girls and 18 boys), and 12 parents participated in two FGDS, across three provinces The 10 IDIs included parents, teachers, a social worker, nurse, community leader, member of a School Governing Body, School Principal, and Community Leader (Table 1). The data presented in this manuscript have been consolidated to present a summary of the findings.
Table 1
Details of IDI and FGD participants
| IDIs | FGDs |
N | Type of stakeholders | N | FGD Type |
Total | 10 | Parents, Teachers, Social Worker, Community Leader, Nurse, Member of School Governing Body, Principal, Head of Department (HoD of Education)/Health Promoter | 10 | Female learners (6 groups; n = 63) Male learners (2 groups; n = 18) Parents (2 groups; n = 12) |
Socio-demographics
Participant learner demographic details are outlined in Table 2. The mean age of learners in the survey was 11.8 years (range: 8–17), compared with 11.6 years (range: 9–14) in the FGDs. Over two thirds (72.6%, n = 241) of survey participants were female, similar to the FGD participants, where 77.8% (n = 63) were female. The majority of participants in the survey and FGDs were grade 7 learners.
Table 2
Demographic characteristics of anonymous survey and FGD learner (male and female) participants
Characteristic | Anonymous survey (n = 332)* % (N) | FGD (n = 81) % (N) |
Mean Age (years) Range** | 11.8 8–17 | 11.6 9–14 |
Female Male | 72.5 (241) 27.5 (91) | 77.8 (63) 22.2 (18) |
Education level Grade 4 Grade 5 Grade 6 Grade 7 | 8.1 (27) 9.9 (33) 32.2 (107) 49.7 (165) | 11.1 (9) 14.8 (12) 20.9 (17) 53.1 (43) |
* As the survey was administered anonymously/self-completed there was some missing data.
**Senior primary school learners’ (grade 4 to 7) age is generally 9 to 13 years, but there were a number of learners attending senior primary who fell outside the upper age range.
All parents that participated in the FGDs were female (n = 12). They had a mean age of 44.9 years (range: 22–59). Their highest level of education was Grade 12 (n = 3), with none having completed any tertiary education. All parents had at least one daughter. The most common (n = 6) form of household income reported by the parents was a government grant.
Experiences of menarche
In the survey, female learners were asked about their experience of menstruation. Just under a third (31.5%, n = 76) had reached menarche. The mean age of menarche was 12 years (range: 9–15). A small proportion (5%) were 10 years or younger when they started to menstruate. Over three-quarters (78.9%) of grade seven learners in the survey had started menstruating, compared to 14.5% of those in grade six and few in grade five (2.6%) and grade four (3.9%). Just over two-thirds of female learner survey participants (69.7%, n = 53) experienced the onset of menarche at home, while a quarter (26.3%, n = 20) were at school, the remaining few (3.9%, n = 3) could not remember where they first started.
Just over a third (38.1%, n = 24) of female learner FGD participants had started menstruating before the discussion was held. Mean age of onset of menarche in this group was 11.1 years (range: 10–13). Of the 24 learners who had reached menarche, similar to the survey group, the majority (75%) reported the onset as occurring at home. Two girls experienced onset at school, two could not remember and two did not specify where it occurred.
Knowledge of MHM and menses
Learners participating in the anonymous survey were asked whether they had received lessons in three core areas related to menstruation (Table 3). Fewer than two thirds of learners (61.1%; n = 203) had been educated on their menstrual cycle. Only three-quarters of learners who had started menstruating (76.3%, n = 58) reported they had been given prior information about what would happen when they started to menstruate. Over half of these girls (51.7%, n = 30) had been informed about menstruation by a mother/female guardian, or another relative, followed by those who were informed by an educator in group session (13.8%, n = 8). There were fewer who were informed by an educator in a one-on-one session (3.4%, n = 2) and one was informed by a friend.
Both male and female learners in the survey were asked what passage the menstrual blood passes through before it leaves the body (Table 3). Less than half of both male and non-menstruating female learners knew the correct answer. While many did not know, a small proportion incorrectly mentioned the urinary tract. Although correct knowledge of passage of menstrual blood was higher in menstruating learners, there were still a third of female learners who had started menstruation who did not know which passage the blood passes through. Overall, there was some differences between provinces in the survey (data not shown) however responses were combined to give a more general overview.
Table 3
Knowledge/understanding of menses and experience of MHM product use (anonymous survey data)
Knowledge/understanding of menses | Total |
Received education on menstrual related topics (Male and female learners) | n = 332 % (N) |
Education on: Puberty Reproductive anatomy/reproduction Menstrual cycle | 77.4 (257) 80.1 (266) 61.1 (203) |
Information given prior to first menstrual cycle (All female learners) | n = 76 |
Yes No | 76.3 (58) 23.7 (18) |
Who gave information prior to first menstrual cycle (Menstruating female learners) | n = 58 |
Mother/female guardian Sister Grandmother Aunt Friend Educator in a group session Educator in one-on-one session | 51.7 (30) 17.2 (10) 13.8 (8) 10.3 (6) 3.4 (2) 1.7 (1) 1.7 (1) |
Knowledge of passage of menstrual blood (Male and female learners) |
Menstruating female learners | n = 74* |
Vagina Urinary tract Don’t know | 63.5 (47) 6.8 (5) 30.1 (22) |
Non-menstruating female learners | n = 164* |
Vagina Urinary tract Don’t know | 32.3 (53) 7.9 (13) 59.8 (98) |
Male learners | n = 89** |
Vagina Urinary tract Don’t know | 49.4 (44) 11.2 (10) 39.3 (35) |
Experience of product use (Menstruating female learners) |
Supply of menstrual product available at first menses? | n = 76 |
Yes No | 55.2 (42) 44.8 (34) |
If yes, who supplied product | n = 42 |
Mother/female guardian Sister Grandmother Father/male guardian Educator in school | 76.2 (32) 9.5 (4) 2.4 (1) 2.4 (1) 7.1 (3) |
If no, what was used | n = 34 |
Toilet paper Cloth Not specified | 79.4 (27) 20.6 (7) 5.9 (2) |
Product currently used*** | n = 76 |
Sanitary towel (disposable) Sanitary towel (reusable) Panty liners Cloth Toilet paper Tampons | 61.8 (47) 2.6 (2) 17.1 (13) 10.5 (8) 9.2 (7) 2.6 (2) |
*Three female learners did not respond to this question
**Two male learners did not respond to this question
***Multiple responses allowed
In the qualitative data, knowledge of menstruation and MHM was markedly different between male and female learners. Females who had reached menarche appeared to be better educated and informed compared to those who had not yet menstruated. Although males of all ages appeared to have little knowledge of menstruation and/or were hesitant to discuss it, a few did have some knowledge about “menses” or “periods”.
P04: It’s when blood comes from underneath. […]
P01: The girl starts to change and enters puberty. (Gauteng Province, Learners-boys, FGD10)
Schools and female family members were also described as the most important source of information on menses and MHM for females.
F: [W]here do you learn most about periods, do you learn here at school or at home? […]
P03: [A]t home […]
P04: I learned at school [….]
P07: I learned at home and at school (Gauteng Province, Learners-girls, FGD09)
Male learners reportedly received some education on menstruation from school and fragmented information from media sources, peers and overheard conversations.
F: So those who know them [about sanitary pads], where have they seen them before?
P06: At school […]
P04: And TV (Television). (Gauteng Province, Learners-boys, FGD10)
Male, female learners, and stakeholders all reported that young males were not commonly educated about menstruation at home. Many respondents did not believe young males should receive such education as they felt menses was a female issue, and that males would have no use for this knowledge.
P09: when I think about why they [young males] don't get educated, because they, boys don't usually go to this situation [get periods], because if you tell a parent, the parent will say “no these are girls' situations”. (Eastern Cape, Learners-girls, FGD05)
Some educators expressed the opinion that female learners were not provided with MHM education at home and that they were obligated to educate the girls on how to be clean and hygienic while menstruating. This was reiterated by some female learners.
TS02: First of all, it sometimes happens that it [referring to menstruation] starts here at school, and you find that she [the girl] does not know what to do. […] You find that she [the girl] is just sitting but can feel there is something wet […] Then during break time when she needs to stand up, then you’re like “Haw so much damage has happened”. […] Then you take her to talk to her and say “Do you know this? Did they teach you at home?” One would say yes, one would say they don’t know. Then we explain and say “Here’s a pad take it and go to the toilet to put it, when you see that sekonakele [there’s damage] change it and put another one”. (KwaZulu-Natal, Teacher, IDI02)
F: You feel that you have enough knowledge?
PID unknown: Because the teachers at school have taught us
PID unknown: They teach us that when we start menstruating, what we need to do in order for use to get help. What we need to buy. (KwaZulu-Natal, Learners-girls, FGD01)
Most learners suggested they were given information about menstruation in school. Respondents described that educators from Life Orientation/Life Skills and Natural Sciences classes provided education on menstruation and related topics. They described that Learner Support Assistants were available to assist with menses related queries. In some instances, external NGOs provided education on menstruation in the schools.
SP08: It’s LO [Life Orientation] teacher, learner liaising agent our LSA [Learner Support Assistant] which is [Name of teacher], [NGO name] coordinators, which is Miss [name of teacher] and Miss [name of teacher]. (Eastern Cape, School Principal, IDI08)
Respondents noted that the grade(s) in which education on menstruation was provided ranged from grades 4 or 5 to grade 7 (ages 10–14 years), and that education was provided to male and female learners. Some learners noted that the content was elaborated on each year, in order to be age appropriate.
P02: [T]hey are different, at grade 5 they teach you a little, and when you get to grade 6, they will give you more, and grade seven more. (GP, Learners-girls, FGD09)
Misinformation and misconceptions about MHM and menses
Misinformation, myths and misconceptions occurred amongst all age groups of learners in the FGDs, and existed alongside accurate knowledge and often intertwined with this.
P09: I don’t understand how pads help when you are on your periods [….]
P07: I feel that I have enough knowledge [about menstruation]. […] That… when you start having your periods, you need to start wearing pads. (KwaZulu-Natal, Learners-girls, FGD01)
F: [S]o is there information that says if you are next to a person who is menstruating you will also get it? […]
P10: It is something that is really happening. […] Because you are already menstruating but, when you are done, but this person will simply re-infect you and so you should not be close to them. […]
P08: I would say that there is no such thing, you cannot infect/pass it on to another person if they have not started. (Eastern Cape, Learners-girls, FGD05)
Discussions on MHM included misunderstandings and beliefs around boys and pregnancy, especially with advice on how to behave when a girl reaches menarche. Close physical association with the opposite sex was discouraged.
P10: Sorry miss if you are being teased, or you are sitting next to a boy, or you are being teased by a boy, too much blood comes out. (Eastern Cape, Learners-girls, FGD05)
P05: Some people say when a girl has started menstruation, she starts to like boys. (KwaZulu-Natal, Learners-boys, FGD02)
MHM product use
Experience of MHM product use by menstruating learners who participated in the anonymous survey is shown in Table 3. Almost half of participants (44.8%; n = 34) did not have any menstrual product available at first menses, and most of these used toilet paper instead (79.4%; n = 27). Mothers or close family members supplied their first product in almost all cases. Over three-quarters of all girls (78.9%, n = 60) currently used either disposable sanitary pads or panty liners, while three girls mentioned they used both. More than 10% (n = 8) reported that they used cloth for MHM.
Participants in the FGDs had more knowledge about pads/sanitary towels for menstrual management than other MHM products. Disposable pads/sanitary towels were reportedly the most widely used menstrual management products in their communities, generally because they were most affordable and widely available of the commercially available products Various brands of sanitary towels were used, depending on personal preferences, comfort and affordability.
SGB03: It is because they prefer pads, they like them and because pads are mostly and easily available [… ] Even if you go to the shops you will just find pads. (KwaZulu-Natal, School Governing Body, IDI03)
SP08: Yes they are affordable [referring to sanitary towels], you’ll buy pads that will be suitable for your pocket [meaning not too expensive]. (Eastern Cape, School Principal, IDI08)
Most participants had not heard about reusable pads/panty pads. Although one male learner reported that he had seen these from his grandmother, one parent expressed concern about washing a reusable pad.
F: So where did you hear about them?
P06: I saw them [….] [f]rom my grandmother from Cape Town
F: Okay, did grandmother explain to you how long they last and things like that?
P06: I never asked her.
F: Okay, you just saw them and you know what type of pads they are.
P06: Yes. (KwaZulu-Natal, Learners-boys, FGD02)
PA04: Aw, I prefer the ones that are disposable ones. […] [Laughter] Ai, I’d have to go back and wash, ai. (KwaZulu-Natal, Parent, IDI04)
Products requiring insertion – such as menstrual cups and tampons – were not widely known or available. When asked specifically about tampons, the majority of female learners had no knowledge about tampons. Some parents also had limited to no knowledge about tampons. Similarly, knowledge about the menstrual cup was poor to non-existent. Where knowledge was evident, their use was not widely supported. Specifically, there were concerns about fear of inserting products, as well as concerns about the impact of product insertion on virginity.
P04: No, I haven’t seen them [referring to tampons]
P03: We have never seen them […]
P?: We see them from the shops, but they, it’s rare because we don’t buy them […]
P01: We don’t even know how they are done [meaning don’t know how they are used] [….] Yes, I have never bought them myself. (Eastern Cape, Parents, FGD07)
P05: Because tampons Miss, I would be scared of inserting it [laughing] […]
P08: I would be scared of using it. [….]
P10: Because Miss, maybe it might happen, I don't know Miss, maybe it happens to go deep inside or maybe it would break you [referring to virginity]. (Eastern Cape, Learners-girls, FGD05)
P04: It is because… as parents we encourage that virginity stay intact in our children. […] We, we do not promote that the one that must be inserted is used by children. Especially a child that is in maybe grade 6, grade 7. Even if they are that side at (name of a High School), we do not promote that a child uses something that is inserted, because the thing that is inserted causes damage to the child. We promote that they use disposable pads, if you do not have a pad, use a cloth, a towel cloth and use that. We also promote that when a person is bathing, they must not put their hand [because of the belief that this interferes with virginity]. As parents, that is what we promote. (KwaZulu-Natal, Parents, FGD04)
Some stakeholders made reference to a programme that introduced the menstrual cup into high schools- which they did not believe was well supported.
SW01: Menstrual Cups. So the learners were not comfortable with them. [….] But it…there was also Spoornet that was supplying with the cups. […], but according to the learners they were not comfortable to use it. [….] Especially those who are virgins they were afraid to use the cups. (KwaZulu-Natal, Social Worker, IDI01)
There were some reports of the use of cloths and other products (such as tissue/toilet paper and newspaper) for menstrual management. The use of these products was often reportedly related to shortage or lack of affordability of sanitary towels and in many instances resulted in school absenteeism.
PA07: The problem is that you may find that the pads may not be enough and also to find that there is not enough money to buy them. With this situation, children then decides to wear cloth, others toilet paper but these products are not safe to use so others then decide to be absent and stays home. (Eastern Cape, Parent, IDI07)
P05: I would roll a lot of tissue, roll it, roll it [….] and put it underneath. (KwaZulu-Natal, Learners-girls, FGD03)
Impact of menses on school attendance
Half of female learners participating in the anonymous survey (50%, n = 38) who had started menstruating reported they had “ever missed school” for a reason relating to their menstrual cycle (Table 4). The mean number of days absent was 5.3 days in the last school term. The main reasons for missing school were pain (stomach/headaches) related to their cycle (86.1%, n = 31), with a third (30.6%, n = 11) reporting insufficient or no available MHM products. A small number (11.1%, n = 4) reported they did not like going to school on heavy bleeding days.
Learners were also asked about missing in school activities, for example sports and drama, due to MHM reasons and almost all (35/38) of those who reported missing school also said they had missed in-school activities. The range of activities missed in the last term was 1–23 times. No learner reported missing activities but not missing school.
Table 4
Experience of school absenteeism by menstruating female learners in the anonymous survey
Absenteeism (Menstruating female learners) | Total n = 76 % (n) |
Ever missed school* | 50 (38) |
Mean number of days missed in last term Range | 5.3 1–24 |
Reasons for missing school** Pain Not enough sanitary protection Not wanting to attend school on heavy bleeding days No reason given | 86.1 (31) 30.6 (11) 11.1 (4) 5.2 (1) |
Ever missed in-school activities in last term | 46.1 (35) |
Mean number of times missed in-school activities (sport/drama) in last term Range | 4.6 1–23 |
*Four learners were not sure if they had missed school
** Multiple responses allowed
FGD and IDI discussions by many learners, parents and stakeholders highlighted that school absenteeism due to menses is a problem in their communities.
P08: Some are not able to come [to school] because it it becomes painful to others […]
P10: Some, they cannot come because it is probably bleeding a lot, the blood is coming out too much […]
P01: Some people cannot come to school because they do not have pad […]
P05: Some Miss, they do not go to school because maybe someone does not have pads and you know if you go to school you have a leakage, maybe others would go because at school there are separate pads [from a school sanitary distribution programme]. [….]
P06: I was going to say Miss, some cannot go to school because it would be their first time, and they would be scared of going to school […]
P07: I was going to say do not come because they do not know whether the blood would just come out in front of the class (Eastern Cape, Learners-Girls, FGD05)
However, some respondents, mostly stakeholders from the Department of Education and some parents, believed that menses-related school absenteeism was no longer a problem in their communities, some attributing this to school MHM sanitary supply programmes.
Do girls miss school in your district or even in this school because of their menstrual cycle?
ST10: No […] We don’t have such cases. (Gauteng Province, School Teacher, IDI10)
Do girls miss school here because of their menstrual cycle?
TS02: As I’m saying, arrival of the supply of product helped us, they use to be absent from school a lot back in the days. You’d find that a person would be scared to come to school because they don’t have things to help them [sanitary products], but now since they have been receiving it, they no longer miss school. (KwaZulu-Natal, Teacher, IDI02)
Furthermore, some female learners did not think that menstruation was an excuse to miss school.
P09: No Miss, because […] even if you are [having your menses], nobody will be looking around for you. You need to learn here at school, you can’t just be absent. (KwaZulu-Natal, Learners-girls, FGD01)
Discussions by learners, parents and stakeholders highlighted that factors such as lack of sanitary products, menstrual pain, social discomfort and fear of stigma were the main factors that impacted school attendance.
Lack of sanitary products
The supply of sanitary products was often inconsistent or lacking for learners in these communities. In instances where learners could not afford sanitary products and school sanitary supply programmes fell short of demand, lack of sanitary pads was a key factor in girls feeling unable to attend school. The use of alternative sanitary protection (like toilet paper or cloths) was considered too risky or otherwise inappropriate for school attendance by learners and other stakeholders.
P04: Some do not come because they would be short of what they use, like pads, some would come but wear a cloth but […]
P04: Some would come wearing a cloth but they would be scared, the heart is saying that maybe this could slip out and spill […]
P01: Some come, some do not because maybe kids might see that, “hawu mfethu [brotherly/sisterly words] what is it, have you been poured with a goat blood or chicken blood or what or they poured you with beetroot?” (KwaZulu-Natal, Learners-girls, FGD03)
Social discomfort and fear of stigmatisation
Fear of being identified as menstruating and especially of being the object of public shame, ridicule, or disgust were commonly stated reasons for not wanting “to be seen by others” and therefore missing school. (This was often linked to not having the appropriate sanitary products as described above). Many female learners expressed their discomfort with being at school while menstruating – focused on their fears of being laughed at, of being stigmatised and of feeling lonely and left out because they did not feel able to play with others.
P09: I am not comfortable a lot, being on periods at school because really I know that there would be people who would talk about me, gossip, and become a joke in the class, that I have got my periods in class, dirtying, she is smelling and that and that, you see all those stuffs
P10: I am not comfortable because you feel lonely if you are on your periods, sit alone and find out that some kids are playing, you are scared of playing. (KwaZulu-Natal, Learners-girls, FGD03)
It was highlighted that younger girls in particular were often uncomfortable with attending school while menstruating.
P01: But they some are not comfortable [going to school] because they are still very young, some won’t be able to play with their friends because they are worried about what is underneath her [meaning in their underwear]. (Eastern Cape, Parents, FGD07)
Pain and feeling “unwell”
In the FGDs and IDIs, pain associated with menstruation was commonly cited as a reason for school absenteeism, even when sanitary products were available. General feelings of being “unwell” and fatigue were also described in girls’ experiences of menses.
P01: I sometimes do not come [to school] because I would be feeling pains, feeling period pains, I would just have it even during the periods, but I would have it […] I would be feeling pain, like my intestines are coming out [laughter] in the stomach. (KwaZulu-Natal, Learners-girls, FGD03)
Overall, learners in the FGDs noted that teachers and other school staff were supportive regarding menstruation. Girls described that they were allowed to absent themselves from school if necessary, to change clothes, or if suffering from menstrual pain. Respondents reported that in these circumstances pads were often provided by educators, but that they were seldom, if ever, given analgesics. The majority of schools did not provide pain relief medication to learners, and therefore they had to rely on nearby clinics to assist girls suffering with menstrual related pain. Learners were reportedly accompanied by a teacher if family were unavailable.
P07: Yes, here at school, it was said, they should be giving us [pain killers] but now they cannot give us because they not doctors, they cannot give us the pills because they do not know them and they not doctors, they did not study to give pills, and you do not know what it will do. (KwaZulu-Natal, Learners-girls, FGD03)
However, there were a few schools that reportedly did provide analgesics to female learners.
P10: [T]hey do not allow you [to go home if you have period pains], for example if maybe [other participant] has headache, maybe they will give her pills, they do not believe that you have to go home. (Gauteng Province, Learners-girls, FGD09)
Missing in-school activities
Lack of sanitary products was thought by female learners, parents and stakeholders to impact participation in in-school physical activities such as sports and playing with friends.
SGB03: Yes, because, because they will not be able to play if… they do not have something [referring to menstrual management products] to help them. (KwaZulu-Natal, School Governing Body Representative, IDI03)
School sanitary towel programmes were deemed to have had a positive impact on menstruating girls’ participation in activities such as sports, dancing, drama or playing with friends. Despite this, internalised fears of leaking blood or public recognition of menstruation were cited as reasons for not participating, or not participating fully, in these activities.
F: You are not afraid; you are not afraid that something will happen as you play?
P02: […] I will not be comfortable, because people will see the pads and go to show each other about me. (Eastern Cape, Learners-girls, FGD05)
However, some respondents (mostly stakeholders within the school system and boy learners) did not believe that menstruation influenced girls’ decisions on whether or not to participate in physical activities.
I: Okay, eh do children ever miss playing, eh let’s say there’s a sport day and children are playing, eh only to find that the child is menstruating and cannot play with other children. Have such situation ever happened? […]
SP08: No […] It never happened. (Eastern Cape, School Principal, IDI08)
A few girl learners felt they were able to participate in sports and other activities even when they were menstruating. They did not feel restricted by, or were able to adapt to, their menses in order to continue with everyday activities. One group of girls stated it was better to keep active whilst menstruating.
P05: When you are on your periods you should not sleep, you must exercise […]
P08: Ma’m when you have period pain, you must exercise because the more you sleep you get more pain [….]
P07: When you are on your periods and you want to play, maybe you want to play, you should put on something tight. (Gauteng Province, Learners-girls, FGD09)
School sanitary towel programmes
Respondents (learners and stakeholders across the regions) were supportive of Sanitary Towel Programmes in the schools. They felt that access to the products would enable girls, especially those from lower socio-economic groups, to continue attending school throughout menses.
However, qualitative data demonstrated that the availability of sanitary towels was inconsistent across schools. Some schools had programmes for providing sanitary towels – although the source of the products varied (Government or NGO) according to school and region. In addition, the regularity of supply varied according to school and provider.
ST09: Sometimes they comes from the clinics, like eh last week I receive a box [of pads] from one of the nurses. (Gauteng Province, School Teacher, IDI09)
ST10: I used to see the sanitary towel, it about 3 years back here at school, now of yet we haven’t seen anything. (Gauteng Province, School Teacher, IDI10)
P01: They are not given everyday but you do get them when you need them […]
P06: They are available all the time because they know when you’ll get your menses […]
P04: Uhm, they are available at anytime because they do not know exactly what day you are going to get your periods. Like here at school they gave us even before some of us started having their period. (KwaZulu-Natal, Learners-girls, FGD01)
Results of the school sanitation survey demonstrated that condition and type of toilet facilities varied considerably between provinces, with urban schools having flush toilets while rural schools were often restricted to ventilated improved pit (VIP) toilets. However, regardless of toilet type, the condition of the toilets varied between schools in each province, with some observed blockages of flush toilets and overflowing pit toilets while others were found to be in excellent condition. All schools had cold water available for hand washing, either inside or outside the toilet facilities. Soap and toilet paper were usually not available. Few schools across all three provinces had sealed sanitary bins. The school free sanitary pad distribution programme was also implemented in different ways and often supply was inconsistent as was also reported in the group discussions.