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Cited by 82Menstrual Health and DisordersGender Studies and Social IssuesAdolescent Sexual and Reproductive Health

Physical, social, and political inequities constraining girls’ menstrual management at schools in informal settlements of Nairobi, Kenya.

Open access
Girod, Candace, Ellis, Anna, Andes, Karen L., Freeman, Matthew C., Caruso, Bethany A.·2017·Journal of Urban Health
DOI 10.1007/s11524-017-0189-3PMC PMC5722726
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Abstract

Access to adequate water and sanitation is limited in informal settlements, contributing to girls' challenges managing menstruation at school, especially when they cannot access materials to absorb menstrual blood and appropriate facilities for hygiene. This study documents differences between girls' experience of menstruation at public schools (where the Kenyan government provides menstrual pads) and private schools (where pads are not provided) in two informal settlements of Nairobi, Kenya. Results showed that supply chains to public schools were not reliable, and equitable pad provision was not assured. Girls in private schools struggled to access pads because they were not provided. Sanitation facilities were physically available, but Muslim girls were unable to practice ablution due to the design of toilets in our study schools. Girls experienced fear and anxiety due to harassment from male peers and had incomplete information about menstruation from teachers. Findings suggest that practitioners and policy-makers should acknowledge the diversity of school populations and monitor programs to ensure efforts do not contribute to inequity.

AI snapshot

Written from the paper’s full text.

TL;DR

This qualitative study in six Nairobi informal-settlement primary schools found girls faced inequitable menstrual management by school type and religion: public-school girls had government pad access and better latrine ratios, while private-school girls lacked pads and had worse facilities. Muslim girls could not perform ablution in Fresh Life Toilets, and girls across schools lacked complete menstruation information and feared harassment or assault.

Key findings

  • Public schools were part of Kenya’s Sanitary Towels Programme, but private schools were not; private-school girls more often reported menstrual stains and missed school because they lacked money for pads. Public-school teachers rationed pads, sometimes giving only 4 instead of a full packet, and reported it had been almost a year since the last government disbursement.
  • Girls’ pupil-to-functional-latrine ratio was 27:1 in public schools versus 88:1 in private schools; pupil-to-water-point ratio was reported as 509:1 public versus 232:1 private. None of the private schools in the study met national school WASH standards.
  • Muslim girls could not use Fresh Life Toilets for ablution and called them “Christian toilets”; they instead used older flush toilets with no functional water supply, which were dirtier and rarely had private disposal bins or door locks. At one public school, only 3 of 8 stalls were designated “Muslim toilets” although Muslims were the majority.
  • Girls at all schools lacked complete and accurate menstruation information, and teachers conflated menstruation with pregnancy and rape. Girls at every school expressed fear and stress related to boys; girls in four of six schools asked questions about inappropriate touching or rape, and some disclosed having been raped.

Methods

  • Qualitative study conducted May–August 2015 in Mukuru and Mathare informal settlements, purposively selecting six Sanergy-affiliated primary schools: 3 public and 3 private, 3 Christian-majority and 3 Muslim-majority, and 3 with Fresh Life Toilets and 3 with pit latrines/flush toilets.
  • At each school, researchers conducted one focus group discussion with 6–11 post-menarcheal girls in grades 6–8, one key informant interview with the Head Teacher, one facility observation, and an anonymous question session; tools were adapted from UNICEF’s WASH in Schools menstrual hygiene management assessment tools.
  • Transcripts and typed anonymous questions were analyzed in MAXQDA version 11 using memoing, coding, school case studies, thematic analysis, and MAXMAPS idea webs synthesized into narrative form.

Limitations

  • Stated in the paper: future research should hold focus groups with Muslim girls separately because Muslim girls did not seem completely comfortable sharing opinions when Christian girls were present; only girls in grades 6–8 participated in focus groups, though teachers mentioned some lower-grade girls had reached menarche.
  • Evident from the text: the study relies on a small purposive sample of six schools, limiting generalizability; school administrators selected focus group participants, which may bias the perspectives captured; and no quantitative outcome measures or longitudinal follow-up are reported.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1007/s11524-017-0189-3

Cites

48 of 48 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 61 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Girls had incomplete information about menstruation from teachers.

    “Girls experienced fear and anxiety due to harassment from male peers and had incomplete information about menstruation from teachers.”
    • Also stated in: § Challenges to Managing Menstruation at School for All Girls · plain
      “Girls at all schools experienced challenges accessing complete and accurate information about menstruation.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.
  • Findingown data

    Equitable pad provision was not assured.

    “Results showed that supply chains to public schools were not reliable, and equitable pad provision was not assured.”
    • Also stated in: § Challenges Posed by Policy, School Infrastructure, and Social Norms · plain
      “Girls had inequitable access to pads even in public schools where they were provided by the government because not all girls felt comfortable requesting them.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.
  • Findingown data

    Muslim girls were unable to practice ablution due to the design of toilets in the study schools.

    “Sanitation facilities were physically available, but Muslim girls were unable to practice ablution due to the design of toilets in our study schools.”
    • Also stated in: § Challenges Posed by Policy, School Infrastructure, and Social Norms · plain
      “Participants referred to the FLTs as the “Christian toilets” because Muslim students were unable to use them. FLT urine containers were too small and girls were not allowed to perform ablution in them.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.
  • Findingown data

    Girls in private schools struggled to access pads because they were not provided.

    “Girls in private schools struggled to access pads because they were not provided.”
    • Also stated in: § Challenges Posed by Policy, School Infrastructure, and Social Norms · plain
      “At private schools, where the program did not apply, girls more frequently reported menstrual stains and missed school than girls in public schools because they lacked money to purchase menstrual pads.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.
  • Findingown data

    Supply chains to public schools were not reliable.

    “Results showed that supply chains to public schools were not reliable, and equitable pad provision was not assured.”
    • Also stated in: § Challenges Posed by Policy, School Infrastructure, and Social Norms · plain
      “They reported that it had been almost a year since the last pad disbursement, and they were not sure when or if the government would distribute more pads.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Teachers’ accounts of pad rationing and supply are accurate.
  • May combine two claims. 58
  • Classified as probably not a substantial claim. 10
  • The quote only partly states this claim. 1

  • May combine two claims.

    Findingown data

    Teachers reported that it had been almost a year since the last pad disbursement, and they were not sure when or if the government would distribute more pads.

    “They reported that it had been almost a year since the last pad disbursement, and they were not sure when or if the government would distribute more pads.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Teachers’ accounts of pad rationing and supply are accurate.

  • May combine two claims.

    Findingown data

    At private schools, girls more frequently reported menstrual stains and missed school than girls in public schools because they lacked money to purchase menstrual pads.

    “At private schools, where the program did not apply, girls more frequently reported menstrual stains and missed school than girls in public schools because they lacked money to purchase menstrual pads.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • May combine two claims.

    Findingown data

    Non-governmental organizations sometimes donated pads, but the timing was unpredictable, and the quantity was only sufficient for 1 month or less.

    “Participants said that non-governmental organizations sometimes donated pads, but the timing was unpredictable, and the quantity was only sufficient for 1 month or less.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • May combine two claims.

    Findingown data

    All public schools had pour flush toilets, and two public schools had Fresh Life Toilets in addition to their pour flush toilets.

    “All of the public schools had pour flush toilets, and two of the public schools had Fresh Life Toilets in addition to their pour flush toilets.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Teachers did not have an objective way to identify needy students, so they distributed based on their knowledge, potentially overlooking some girls in need.

    “They did not have an objective way to identify needy students, so they distributed based on their knowledge, potentially overlooking some girls in need.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Teachers’ accounts of pad rationing and supply are accurate.

  • May combine two claims.

    Findingown data

    The pupil to water point ratio was 509:1 in public schools and 232:1 in private schools.

    “however, the pupil to water point ratio was over twice the ratio in private schools compared to public schools (509:1 public, 232:1 private).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Girls in every school felt rushed using the facilities to some degree; girls in public school, where the latrine ratio was lower, were less concerned than private school girls.

    “Girls in every school felt rushed using the facilities to some degree; however, girls in public school, where the latrine ratio was lower, were less concerned than private school girls.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • May combine two claims.

    Findingown data

    The pupil to water point ratio contributed to long lines for handwashing, and participants in one public school reported bullying from older girls in line.

    “The pupil to water point ratio contributed to long lines for handwashing, and participants in one public school reported bullying from older girls in line.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Almost all of the Muslim students in this study attended public schools.

    “Almost all of the Muslim students in this study attended public schools.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Public schools were larger than private schools with fairly even numbers of girls and boys.

    “Public schools were larger than private schools with fairly even numbers of girls and boys (See Table 1).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    Private schools were located within the informal settlements and served students from that community, while public schools were located 2 km or less from informal settlements and served students who lived in informal settlements as well as those who did not.

    “Private schools were located within the informal settlements and served students from that community, while public schools were located 2 km or less from informal settlements and served students who lived in informal settlements as well as those who did not.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The pupil to functional latrine ratio for girls was 27:1 in public schools and 88:1 in private schools.

    “High pupil to latrine ratios at private schools were an obstacle for girls (27:1 public, 88:1 private).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Girls had inequitable access to pads even in public schools where they were provided by the government because not all girls felt comfortable requesting them.

    “Girls had inequitable access to pads even in public schools where they were provided by the government because not all girls felt comfortable requesting them.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • May combine two claims.

    Findingown data

    Harassment and assault from boys as well as the threat of rape from classmates and community members hindered the level of safety girls felt in their school.

    “Harassment and assault from boys as well as the threat of rape from classmates and community members hindered the level of safety girls felt in their school.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • May combine two claims.

    Findingown data

    Girls in private school said they felt rushed to finish changing their pads, and they sometimes waited until they could go home.

    “Girls in private school said they felt rushed to finish changing their pads, and they sometimes waited until they could go home.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    Muslim girls used older flush toilets with no functional water supply because FLT urine containers were too small and they were not allowed to perform ablution in them.

    “Instead, Muslim girls used older flush toilets with no functional water supply.”
    • Also stated in: § Challenges Posed by Policy, School Infrastructure, and Social Norms · plain
      “FLT urine containers were too small and girls were not allowed to perform ablution in them.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Girls believed that "splash back" could cause urinary tract infections, gonorrhea, or infertility-regardless of menstrual status.

    “They worried about negative health outcomes due to poor menstrual management, and they believed that “splash back” (urine splattering onto the vulva) could cause urinary tract infections, gonorrhea, or infertility—regardless of menstrual status.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • May combine two claims.

    Findingown data

    Some girls said that they go home when the toilets are too dirty because they do not feel comfortable changing their pads or they feel too rushed to clean a stain from their skirt due to long lines for toilet use.

    “Some girls said that they go home when the toilets are too dirty because they do not feel comfortable changing their pads or they feel too rushed to clean a stain from their skirt due to long lines for toilet use.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Sometimes girls threw their used pads on the floor if they could not wait for a stall with a disposal bin, scaring younger children who would urinate or defecate on the floor to avoid going near the used pad.

    “Sometimes girls threw their used pads on the floor if they could not wait for a stall with a disposal bin, scaring younger children who would urinate or defecate on the floor to avoid going near the used pad.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • May combine two claims.

    Findingown data

    Muslim girls had to compromise their religious beliefs or use older, dirtier toilets when the new toilets did not accommodate ablution.

    “Muslim girls had to compromise their religious beliefs or use older, dirtier toilets when the new toilets did not accommodate ablution.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given

    The schools in this study had toilets available and a large number of pupils used them.

    “The schools in this study had toilets available and a large number of pupils used them.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    At one school, the janitor refused to clean the toilets when girls threw their pads on the floor; his frustration caused fear and stress for girls.

    “At one school, the janitor refused to clean the toilets when girls threw their pads on the floor; his frustration caused fear and stress for girls.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • May combine two claims.

    Findingown data

    A janitor flushed the Muslim girls' toilets two or three times per day, so they were far dirtier and rarely had private disposal bins or locks on doors.

    “A janitor flushed the toilets two or three times per day, so they were far dirtier and rarely had private disposal bins or locks on doors.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • May combine two claims.

    Findingown data

    Muslim girls in public schools described frustration with access to water points, and lines were often very long.

    “Muslim girls in public schools (which had higher pupil to water point ratios in our sample) described frustration with access to water points. They said that lines were often very long.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • May combine two claims.

    Findingown data

    Public schools in this study benefitted greatly from policies including the Sanitary Towels Programme and WASH guidelines, but problems with implementation and access persisted.

    “Public schools in this study benefitted greatly from policies including the Sanitary Towels Programme and WASH guidelines; however problems with implementation and access persisted.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The designated Muslim toilets had more feces and urine on the ground, creating further inequity.

    “Those toilets had more feces and urine on the ground, creating further inequity.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Three stalls out of eight at one public school were designated as "Muslim toilets," although Muslims made up the majority of the student body.

    “Three stalls out of eight at one public school were designated as “Muslim toilets,” although Muslims made up the majority of the student body.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Girls reported that teachers explained how to wear a sanitary pad and how to clean their bodies during menstruation, coupled with warnings about not getting pregnant and/or not getting raped.

    “Girls reported that teachers explained how to wear a sanitary pad and how to clean their bodies during menstruation, coupled with warnings about not getting pregnant and/or not getting raped.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Some teachers would say that the classroom did not have bottles, although the bottle was in sight.

    “Girls noted that some teachers would say that the classroom did not have bottles, although the bottle was in sight.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • May combine two claims.

    Findingown data

    Girls could find a teacher to ask the janitor to unlock the door, but this was particularly problematic for girls who were too shy to talk to their teachers.

    “Alternatively, girls could find a teacher to ask the janitor to unlock the door; however, this was particularly problematic for girls who were too shy to talk to their teachers.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • May combine two claims.

    Findingown data

    Girls in FLT schools (2 public, 1 private) were satisfied with disposal because FLTs have disposal bins within the stall.

    “FLTs have disposal bins within the stall, so girls in FLT schools (2 public, 1 private) were satisfied.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

  • May combine two claims.

    Findingown data

    Teachers were unsure of when they would receive more pads from the government and had not received a supply in almost a year.

    “Teachers were also unsure of when they would receive more pads from the government and had not received a supply in almost a year.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Teachers in this study discussed menstruation, sexuality, and pregnancy together, but they did not present concrete information that could help girls understand their changing bodies and how these topics are related.

    “Teachers in this study discussed menstruation, sexuality, and pregnancy together, but they did not present concrete information that could help girls understand their changing bodies and how these topics are related.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Girls in every school faced harassment from their male peers, and many experienced sexual assault.

    “Girls in every school faced harassment from their male peers, and many experienced sexual assault.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Some participants disclosed that they had been raped, and they did not feel safe in their communities, while others were anxious about being raped.

    “Some participants disclosed that they had been raped, and they did not feel safe in their communities, while others were anxious about being raped.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Teachers told girls that they needed to be wary of boys and men once they reached menarche and that family members could be dangerous because they might misconstrue friendliness as a sexual advance.

    “Teachers told girls that they needed to be wary of boys and men once they reached menarche and that family members could be dangerous because they might misconstrue friendliness as a sexual advance.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    When girls can manage menstruation at school in supportive environments, they are less likely to be absent and can concentrate better in class, potentially improving their educational experience.

    “When girls can manage menstruation at school in supportive environments, they report that they are less likely to be absent and can concentrate better in class, potentially improving their educational experience [1–4].”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [1] Montgomery P, Ryus CR, Dolan CS, Dopson S, Scott LM. Sanitary pad interventions for girls’ education in Ghana: a pilot study. PloS One. 2012;7(10):e48274. source

      Not checked in the free run.

    • cites [2] Mason L, Laserson K, Oruko K, et al. Adolescent schoolgirls’ experiences of menstrual cups and pads in rural western Kenya: a qualitative study. Waterlines. 2015;34(1):15–30. source

      Not checked in the free run.

    • cites [3] McMahon SA, Winch PJ, Caruso BA, et al. ‘The girl with her period is the one to hang her head’Reflections on menstrual management among schoolgirls in rural Kenya. BMC international health and human rights. 2011;11(1):7. source

      Not checked in the free run.

    • cites [4] Trinies V, Caruso B, Sogoré A, Toubkiss J, Freeman M. Uncovering the challenges to menstrual hygiene management in schools in Mali. Waterlines. 2015;34(1):31–40. source

      Not checked in the free run.

  • May combine two claims.

    Premiseown data

    In public schools in Kenya, the government provides menstrual pads, while private schools do not.

    “This study documents differences between girls’ experience of menstruation at public schools (where the Kenyan government provides menstrual pads) and private schools (where pads are not provided) in two informal settlements of Nairobi, Kenya.”
    • Also stated in: § Challenges Posed by Policy, School Infrastructure, and Social Norms · plain
      “Public schools were part of the Sanitary Towels Programme sponsored by the Kenyan government.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [24] Sharif S, Godia G, Wamae A, Migiro S, Muriithi A, Kabaka S. National school health strategy implementation plan 2010–2015. Nairobi, Kenya: Ministry of Public Health and Sanitation & Ministry of Education; 2010.

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Girls are often uninformed and unsure about what is happening to their bodies when they reach menarche, causing fear and confusion.

    “Girls are often uninformed and unsure about what is happening to their bodies when they reach menarche, causing fear and confusion [8, 9].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [8] Fatusi AO, Hindin MJ. Adolescents and youth in developing countries: health and development issues in context. J Adolesc. 2010;33(4):499–508. source

      Not checked in the free run.

    • cites [9] Ali TS, Rizvi SN. Menstrual knowledge and practices of female adolescents in urban Karachi, Pakistan. J Adolesc. 2010;33(4):531–41. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    A greater proportion of informal settlement households need to get water from public taps (20%) or purchase their water from private companies (11%) compared to 14 and 3% of Nairobi residents, respectively.

    “A greater proportion of informal settlement households need to get water from public taps (20%) or purchase their water from private companies (11%) compared to 14 and 3% of Nairobi residents, respectively [32].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [32] APHRC. Population and health dynamics in Nairobi ’ s informal settlements: report of the Nairobi cross-sectional slums survey 2012. Nairobi, Kenya: African Population and Health Research Center; 2014.

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The Kenyan government initiated a school health strategy that includes distributing sanitary pads for girls to administrators in public primary schools, improving the pupil to toilet ratio, and creating disposal mechanisms for pads at public primary and secondary schools.

    “In an attempt to cater to girls’ needs, the Kenyan government initiated a school health strategy, which includes distributing sanitary pads for girls to administrators in public primary schools, improving the pupil to toilet ratio, and creating disposal mechanisms for pads at public primary and secondary schools [24].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [24] Sharif S, Godia G, Wamae A, Migiro S, Muriithi A, Kabaka S. National school health strategy implementation plan 2010–2015. Nairobi, Kenya: Ministry of Public Health and Sanitation & Ministry of Education; 2010.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Women's education is associated with improvements in economic productivity, decision-making ability, contraception use, age at first birth, family size, maternal mortality and morbidity, and educational attainment among their children.

    “Evidence suggests that women’s education is associated with improvements in economic productivity, decision-making ability, contraception use, age at first birth, family size, maternal mortality and morbidity, and educational attainment among their children [13–18].”
    Quote in the paperNot a substantial claim0 of 6 sources checked
    • cites [13] Ainsworth M, Beegle K, Nyamete A. The impact of women’s schooling on fertility and contraceptive use: a study of fourteen sub-Saharan African countries. The World Bank Economic Review. 1996;10(1):85–122. source

      Not checked in the free run.

    • cites [14] Martin TC. Women’s education and fertility: results from 26 demographic and health surveys. Stud Fam Plan. 1995:187–202. source

      Not checked in the free run.

    • cites [15] McAlister C, Baskett TF. Female education and maternal mortality: a worldwide survey. J Obstet Gynaecol Can. 2006;28(11):983–90. source

      Not checked in the free run.

    • cites [16] Hatt LE, Waters HR. Determinants of child morbidity in Latin America: a pooled analysis of interactions between parental education and economic status. Soc Sci Med. 2006;62(2):375–86. source

      Not checked in the free run.

    • cites [17] UNFPA. Empowering women, developing society: Female Education in the Middle East and North Africa: Population Reference Bureau. Available at: http://www.prb.org/Publications/Reports/2003/EmpoweringWomenDevelopingSocietyFemaleEducationintheMiddleEastandNorthAfrica.aspx ." Date Accessed: August 24, 2017.

      Not checked in the free run.

    • cites [18] Roudi-Fahimi F, Moghadam V. Empowering women, developing society: Female Education in the Middle East and North Africa. Washington, DC: Population Reference Bureau; 2003. p. 1-8.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    In 2003, the Kenyan government instituted Free Primary School Education, which increased school enrollment by 13% within the first year.

    “In 2003, the Kenyan government instituted Free Primary School Education, which increased school enrollment by 13% within the first year, [19, 20]”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [19] Njue EK, Muthaa GM. Influence of availability of sanitary facilities on the participation of the girl-child in public primary schools in Garissa County, Kenya. Open Journal of Social Sciences. 2015;3(08):162. source

      Not checked in the free run.

    • cites [20] Elimu Yetu Coalition. Monitoring of the free primary education and establishing the unit cost of primary education in Kenya. Nairobi, Kenya; 2004.

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Ninety-four percent of informal settlement residents have access to a toilet, but as many as 83% rely on paid public toilets, which forces many residents to use flying toilets or open defecation.

    “Ninety four percent of informal settlement residents have access to a toilet, but as many as 83% rely on paid public toilets, which forces many residents to use flying toilets (when one defecates into a plastic bag and throws it away) or open defecation [28, 31, 32].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [28] Corburn J, Hildebrand C. Slum sanitation and the social determinants of women’s health in Nairobi, Kenya. J Environ Public Health. 2015;2015:6. source

      Not checked in the free run.

    • cites [31] Corburn J, Karanja I. Informal settlements and a relational view of health in Nairobi, Kenya: sanitation, gender and dignity. Health Promotion International. 2014;31(2):258-269. source

      Not checked in the free run.

    • cites [32] APHRC. Population and health dynamics in Nairobi ’ s informal settlements: report of the Nairobi cross-sectional slums survey 2012. Nairobi, Kenya: African Population and Health Research Center; 2014.

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Access to pads and WASH facilities largely determined whether girls stayed in school all day during menstruation and how comfortable they felt managing menstruation at school.

    “Access largely determined whether girls stayed in school all day during menstruation and how comfortable they felt managing menstruation at school.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Only 28% of informal settlement households have water piped into their residence compared to 78% of residents in Nairobi collectively.

    “Only 28% of informal settlement households have water piped into their residence compared to 78% of residents in Nairobi collectively.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [32] APHRC. Population and health dynamics in Nairobi ’ s informal settlements: report of the Nairobi cross-sectional slums survey 2012. Nairobi, Kenya: African Population and Health Research Center; 2014.

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Using public toilets costs 3-7% of a family's income, they tend to be over 50 m away from homes, and every time women walk to the toilet, they risk sexual violence by community members.

    “Using these public toilets costs 3–7% of a family’s income, they tend to be over 50 m away from their homes, and every time they walk to the toilet, women risk sexual violence by community members [31].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [31] Corburn J, Karanja I. Informal settlements and a relational view of health in Nairobi, Kenya: sanitation, gender and dignity. Health Promotion International. 2014;31(2):258-269. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Inadequate menstrual hygiene management in school may jeopardize girls' ability to stay in school and achieve better life outcomes for themselves and their future families.

    “Inadequate menstrual hygiene management (MHM) in school may jeopardize girls’ ability to stay in school and achieve better life outcomes for themselves and their future families.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    The technical guidelines for national school WASH specify that each toilet block should have ablution facilities, disposal facilities, at least one water point, the girl-pupil to toilet ratio should be 1:25, and boys' and girls' toilets should be separated.

    “The technical guidelines for national school WASH specify that each toilet block should have ablution facilities, disposal facilities, at least one water point, the girl-pupil to toilet ratio should be 1:25, and boys’ and girls’ toilets should be separated [25].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [25] Kenya Ministry of Education M. Primary school design. Nairobi, Kenya: School Infrasturcture Management Unit, SIMU; 2010.

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Schools in informal settlements of Nairobi have poor sanitation, impeding girls' school attendance because they are unable to manage menstruation adequately.

    “Recent research found that schools in these communities have poor sanitation, impeding girls’ school attendance because they are unable to manage menstruation adequately [28].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [28] Corburn J, Hildebrand C. Slum sanitation and the social determinants of women’s health in Nairobi, Kenya. J Environ Public Health. 2015;2015:6. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    While educational opportunities for girls have improved, school systems have not achieved gender parity, and girls have a higher risk of being unenrolled.

    “While educational opportunities for girls have improved, school systems have not achieved gender parity, and girls have a higher risk of being unenrolled [22, 23].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [22] UNESCO. UNESCO global partnership for girls’ and women’s education-one year on: Kenya. Available at: http://www.unesco.org/eri/cp/factsheets_ed/KE_EDFactSheet.pdf . Date Accessed: August 24, 2017.

      Not checked in the free run.

    • cites [23] King N, Dewey C, Borish D. Determinants of primary school non-enrollment and absenteeism: results from a retrospective, convergent mixed methods, cohort study in rural western Kenya. PLoS One. 2015;10(9):e0138362. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    This discourse may lead girls to believe that they are at fault when they are harassed or sexually assaulted, which is harmful to their mental health, and may be a factor influencing girls' lower belief in a just world compared to boys.

    “This discourse may lead girls to believe that they are at fault when they are harassed or sexually assaulted, which is harmful to their mental health, and may be a factor influencing girls’ lower belief in a just world compared to boys [51, 55].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [51] Ruto SJ. Sexual abuse of school age children: evidence from Kenya. J Int Coop Educ. 2009;12:177–92.

      Not checked in the free run.

    • cites [55] Tavrow P, Withers M, Obbuyi A, Omollo V, Wu E. Rape myth attitudes in rural Kenya: toward the development of a culturally relevant attitude scale and “blame index”. Journal of interpersonal violence. 2013;0886260512471086 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    Private schools increase access to education for some students, but they are not equal to public schools, putting children who reside in informal settlements at a greater disadvantage compared to the average Nairobi child.

    “private schools increase access to education for some students, but they are not equal to public schools, putting children who reside in informal settlements at a greater disadvantage compared to the average Nairobi child [38].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [38] Edwards DB, Klees SJ, Wildish J. Dynamics of low-fee private schools in Kenya: governmental legitimation, school-community dependence, and resource uncertainty: Philadelphia, PA: Drexel University; 2015.

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    National WASH guidelines require ablution facilities in schools, but establishing national guidelines did not ensure equity.

    “National WASH guidelines require ablution facilities in schools, but these findings show that establishing national guidelines did not ensure equity.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    Teachers absolved boys of their behavior toward girls, saying girls should not be 'mixing up' with boys, solidifying the idea that boys are not accountable for their actions.

    “Teachers absolved boys of their behavior toward girls, saying girls should not be “mixing up” with boys, solidifying the idea that boys are not accountable for their actions [51, 52].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [51] Ruto SJ. Sexual abuse of school age children: evidence from Kenya. J Int Coop Educ. 2009;12:177–92.

      Not checked in the free run.

    • cites [52] Jewitt S, Ryley H. It’s a girl thing: menstruation, school attendance, spatial mobility and wider gender inequalities in Kenya. Geoforum. 2014;56:137–47. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    The lower frequency of menstrual accidents, staining, and going home among public school girls was because their teachers supplied them with sanitary pads and they had better access to toilets.

    “because their teachers supplied them with sanitary pads and they had better access to toilets”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Few other options exist for collecting data in informal settlements, and policy-makers rarely have what they need to make informed decisions.

    “Few other options exist for collecting data in informal settlements, and policy-makers rarely have what they need to make informed decisions [58].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [58] Elsey H, Thomson DR, Lin R, Maharjan U, Agarwal S, Newell J. Addressing inequities in urban health: do decision-makers have the data they need? Report from the urban health data special session at international conference on urban health Dhaka 2015. Journal of Urban Health. 2016;93(3):526–37. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The JMP has medium/long-term plans to include informal settlements in its data collection, but there is no clear indication of when that may be.

    “The JMP has medium/long-term plans to include informal settlements in its data collection, but there is no clear indication of when that may be [46].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [46] JMP. WASH post-2015 proposed indicators for drinking water, sanitation and hygiene. http://www.who.int/water_sanitation_health/monitoring/coverage/wash-post-2015-rev.pdf?ua=1/: World Health Organization, UNICEF, Joint Monitoring Program; 2015. Date Accessed: August 24, 2017.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Provision of menstrual materials reduces incidence of sexually transmitted infections, purportedly by reducing girls' needs to engage in transactional sex in exchange for menstrual products.

    “Studies show that provision of menstrual materials reduces incidence of sexually transmitted infections, purportedly by reducing girls’ needs to engage in transactional sex in exchange for menstrual products [64].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [64] Phillips-Howard PA, Nyothach E, ter Kuile FO, et al. Menstrual cups and sanitary pads to reduce school attrition, and sexually transmitted and reproductive tract infections: a cluster randomised controlled feasibility study in rural western Kenya. BMJ Open. 2016;6(11):e013229. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Only girls in grades 6-8 participated in focus groups, but teachers mentioned that some girls in lower grades had reached menarche.

    “Only girls in grades 6–8 participated in focus groups, but teachers mentioned that some girls in lower grades had reached menarche.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Study design and conductreasoning

    Our focus on informal settlements and girls from both public and private schools with different types of facilities, and from a variety of economic and religious backgrounds is a strength of this work.

    “Our focus on informal settlements and girls from both public and private schools with different types of facilities, and from a variety of economic and religious backgrounds is a strength of this work.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Providing concrete information about sex, pregnancy, and menstruation can help girls to have more self-confidence and improve their ability to navigate sexual relationships.

    “Providing concrete information about sex, pregnancy, and menstruation can help girls to have more self-confidence and improve their ability to navigate sexual relationships [62].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [62] Sommer M, Sutherland C, Chandra-Mouli V. Putting menarche and girls into the global population health agenda. Reprod Health. 2015;12(1):24. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Provision of menstrual cups specifically has been shown to reduce the incidence of bacterial vaginosis.

    “Provision of menstrual cups specifically has been shown to reduce the incidence of bacterial vaginosis [64].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [64] Phillips-Howard PA, Nyothach E, ter Kuile FO, et al. Menstrual cups and sanitary pads to reduce school attrition, and sexually transmitted and reproductive tract infections: a cluster randomised controlled feasibility study in rural western Kenya. BMJ Open. 2016;6(11):e013229. source

      Not checked in the free run.

63 of 63

  • The paper relies on this without support.

    The six purposively selected Sanergy-affiliated schools are representative of public and private schools in Nairobi informal settlements.

    “We purposively selected six Sanergy-affiliated primary schools (grades K-8), based on dominant religion, toilet type, and public or private status.”

  • The paper relies on this without support.

    Girls’ self-reports in focus groups and anonymous question sessions accurately reflect their experiences and school conditions.

    “The FGDs, which included 6–11 post-menarcheal girls in grades 6–8, used participatory activities to explore girls’ challenges at school related to menstruation and to identify girls’ perceptions of important toilet characteristics for menstruating girls.”

  • The paper relies on this without support.

    Teachers’ accounts of pad rationing and supply are accurate.

    “Public school teachers described rationing the pads by only giving girls half of the number they might typically need because they did not have enough to give to each girl for the duration of her period.”

  • The paper relies on this without support.

    No other studies about this topic compare public and private schools.

    “No other studies about this topic compare public and private schools.”

  • The paper relies on this without support.

    Prior research has not investigated equity in access or differences in experience for Muslim and Christian girls in the same WASH setting.

    “Prior research has not investigated equity in access or differences in experience for Muslim and Christian girls in the same WASH setting.”

  • The paper relies on this without support.

    Under current Joint Monitoring Program (JMP) data collection procedures, informal settlements are not considered to be official data collection sites.

    “under current Joint Monitoring Program (JMP) data collection procedures, informal settlements are not considered to be official data collection sites.”
6 of 6

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Cites

Flagged first, then by citations

1 of the 49 references couldn’t be matched to a known paper.

Research works printed but not linked: 4

  1. Caruso BA, Long JL, Yerian SE, et al. WASH in schools empowers girls’ education: tools for assessing menstrual hygiene management in schools. New York: UNICEF; 2013.
  2. Paulino S, Thinguri R. Critical analysis of the effectiveness of the government policy on provision of sanitary pads to the needy girls in public primary schools in Kenya. Researchjournali’s Journal of Education. 2015;3(6):1-8.
  3. Haver J, Caruso BA, Ellis A, et al. WASH in schools empowers Girls’ education in Masbate province and metro manila, Philippines. New York, New York: UNICEF; 2012.
  4. Long J, Caruso BA, Lopez D, et al. WASH in schools empowers girls’ education in rural Cochabamba, Bolivia. New York, New York: UNICEF; 2013. p. 1–56.

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Related

Authors
Girod, C., Ellis, A., Andes, K. L., Freeman, M. C., & Caruso, B. A.
Affiliations
Emory University (US)
Corresponding author
Caruso, Bethany A.
ORCID
Venue
Journal of Urban Health
Publisher
Springer Science and Business Media LLC
Published
2017-09-05
Volume
94
Issue
6
Pages
835-846
ISSN
  • 0028-7091 (ISSN-L)
  • 1099-3460
  • 1468-2869
DOI
10.1007/s11524-017-0189-3
PMC
PMC5722726
OpenAlex
W2753024337
Semantic Scholar
c923324737f6980a82ec80e9b373d824a34ef3de
Cited by
79
References
49
Citations by year
2026: 7 · 2025: 8 · 2024: 9 · 2023: 9 · 2022: 18 · 2021: 16 · 2020: 7 · 2019: 2 · 2018: 3
FWCI
3.08
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Urban Health (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Funders
  • Bill and Melinda Gates Foundation (OPP104072)
  • Rollins School of Public Health
  • Oak Ridge Associated Universities
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Menstrual Health and Disorders
  • Social Sciences › Gender Studies › Gender Studies and Social Issues
  • Health Sciences › Health Professions › General Health Professions › Adolescent Sexual and Reproductive Health
Keywords
menstrual management, female students, informal settlements, menstrual pads, public and private schools, sanitation facilities, ablution, Muslim girls, peer harassment, menstrual health education, water and sanitation access, gender inequity, Nairobi
MeSH terms
Adolescent Health, Adolescent, Child, Female, Humans, Kenya, Health Knowledge, Attitudes, Practice, Menstruation, Poverty Areas, Sanitation, School Health Services, Schools, Socioeconomic Factors, Adolescent Health Services, Menstrual Hygiene Products

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-08.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-08.

Statistics and arithmetic are recomputed, not judged.

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