Prevalence and factors associated with school absenteeism during menstruation among higher secondary female students in Kannur district: a school based cross-sectional study

INTRODUCTION

Adolescence is the transition period from childhood to adulthood. Physical, cognitive, psycho-social and emotional changes occur during this period. One such change is the onset of menstruation; i.e. menarche. This in turn affect the health and well-being of an adolescent in many ways, it can affect day to day activities including schooling and academic performance.¹ That will affect the quality of life of an individual- directly or indirectly, thus the society also.

Menstruation or menses is the natural bodily process of releasing blood and associated matter from the uterus through the vagina as part of the menstrual cycle. Those who menstruate have menstrual health and hygiene needs. Good menstrual hygiene is crucial for both physical and mental health, education, and dignity of adolescent schoolgirls.² People who menstruate may miss school or work, or struggle to participate and benefit fully in educational activities, and achievement of gender equality is both affected by and dependent on removing stigma, discrimination and taboos associated with menstruation that often restrict their activities.³

School absenteeism is a significant issue that affects the academic performance and overall well-being of students. In recent years, there has been growing concern about the prevalence of school absenteeism among adolescent girls, particularly in developing countries. Menstrual disorders have been identified as one of the leading causes of school absenteeism among girls.^4-6

World Bank (2005) showed that girls could miss up to 4 consecutive days of school every month because of their periods, meaning that they missed 10-20% of school time, which seriously impacted on their achievement.⁷ But, in India there are only limited studies on the topic, especially in Kerala.

Even though some studies mentioned a significant association between menstrual disorders and school absenteeism as part of studies on menstrual disorders; the factors associated with school absenteeism during menstruation as such is less studied.

So, this study aims to know the prevalence and factors associated with school absenteeism during menstruation. The findings of this study may contribute to the development of effective interventions to address the issue of school absenteeism during menstruation among adolescent girls.

METHODS

A school based cross-sectional study was conducted among 624 higher secondary female students in Kannur district from April 2024 to October 2025 after getting ethical clearance from the institution. Stratified random sampling was done among all higher secondary schools in Kannur district based on their location and management type. Within each substratum, 150 students were collected from randomly selected schools.

Sample size calculation

Calculated by the formula n=Z_α²pq/d²

A study done in 2018, on School absenteeism during menstruation among adolescent girls in Delhi shows 40% school absenteeism during their menstruation.⁴

So, p was taken as 40%, q=(100-p), d=10% relative error, i.e. 10 % of 40. So, sample size=576 which was rounded off to 600. Obtained sample size was 642, with a response rate of 97.2% i.e., 624

Sampling procedure

Stratified random sampling

A List of all the HSS schools of Kannur district was collected from official website-hs-CAP, then they were grouped into urban and rural-All schools situated at municipality or corporation area was considered as urban and those at panchayat were considered as rural.

Flow chart showing sampling technique is given below.

*Special school for speech and hearing, boys only HSS are excluded from the sample. #Bous only is excluded from sample.

Inclusion criteria

All female students who attained menarche were included in the study.

Exclusion criteria

Special school for speech and hearing, students with mental illness/retardation-as it is difficult to get the information and students with any diagnosed genetic disorders like Turner’s syndrome which interferes with menstruation were exclude from the study.

Data was collected using a self-administered pretested semi structured questionnaire and analyzed using SPSS 21. Results were expressed in terms of frequencies, percentages, mean, standard deviation. Chi-square test, Fisher’s exact tests were used to test association.

RESULTS

Baseline characteristics of the population

Among the 624 higher secondary female students enrolled in this study, age ranges between 15-19 years (median±IQR=17±1 years), with the highest proportions at 17 (43.1%) years. All (100%) selected schools were co-educational type. Among the total 624 participants 372 (59.6%) were in plus one and 252 (40.4%) were in Plus two class. Stream-wise distribution of the participants indicates that majority were from science stream, 339 (54%), followed by humanities 184 (30%) and commerce 101 (16%) participants. The highest educational qualifications attained by majority of fathers and mothers were high school certificate 323 (53.5%) and 299 (47.9%), respectively, next to which lies the Intermediate or diploma qualifications, reported among 20.7% fathers and 26.6% mothers. When moving into higher levels of education, proportion of mothers with higher qualifications exceeded that of fathers. Even though educational status of mothers exceeds fathers, 517 (82.9%) were unemployed or unpaid, as they were homemakers. Only a small proportion of mothers were employed (17%), among them 49 (7.9%) were skilled workers followed by 27 (4.3%) engaged in elementary occupation.

According to modified BG Prasad SES scale 2025, the largest group, 28% (175) belonged to class IV (Lower middle). Least number of participants belonged to classes-I and V,10.7% and 9.9% respectively. Majority (68%) of the participants lived in nuclear families, followed by three generation families (17.3%) and joint families (14.6%). Most participants were following Islam and Hinduism, accounting for 323 (51.8%) and 269 (43.1%), followed by Christianity 31 (5%). A very small proportion, 1 (0.2%), reported not following any religion. Most of the participants,392 (62.8%) resided in rural areas, while 232 (37.2%) were urban residents. Total number of family members ranged from 2 to 16, with a median of 5±2 members. Majority of the participants, 450 (72.1%) belonged to families with 2 to 5 members followed by 159 (25.5%) with 6 to 10 family members.

Prevalence of school absenteeism

Among the 624 study participants, Prevalence of school absenteeism during menstruation was 59.8% (373). Among absentees (373), 288 (77.2%) missed school for 2 to 3 days per menstruation, followed by 4-7 days (10.4%). Six (1.6%) students missed classes for more than 7 days per cycle also. A majority of 253 (67.8%) missed ≤6 days of classes for past 6 months during menstruation, while 111 (29.8%) missed between 6 to 12 days and 9 (2.4%) missed more than 12 days of classes. The median no. of days absent during menstruation was 4±4 (IQR) (Mean=4.37±4.07) days. Predominant reason for absenteeism during menstruation reported in the study was pain during menstruation, which accounts for about 91% among absentees, followed by tiredness (52%), discomfort (45%), fear of leakage of menstrual blood (27%), lack of sick room (20%), excessive bleeding (16%), lack of medicines for combating pain at school (11%), lack of proper disposal system for menstrual products (3.5%) and customs (2.7%) being the least.

Menstrual characteristics

Median age at menarche was 13±1 (Mean=12.72±1.106) years, which ranges from 6 to 16 years. Normal age at menarche (11-15 years) was reported among most (93%) of the participants, while few reported early menarche (10 years or less) (2%) and late menarche (15 years or above) (5%). 18% (115) reported feeling embarrassed during menstruation, majority did not. 66% (414) reported regular cycles, while 34% (210) irregular cycles. Average duration of menstrual cycle was normal in majority 508 (81%) of the participants, while 81 (13%) and 35 (6%) students reported oligomenorrhea and polymenorrhea respectively. Duration of bleeding during each menstruation was ≤7 days in majority 597 (96%), while 27 (4%) reported bleeding duration of more than 7 days. Of the total 624 participants in the study, 567 (≈91%) reported one or more menstrual abnormalities. Out of which, the most frequent abnormality was dysmenorrhea, reported in 537 participants (95%), followed by heavy menstrual bleeding in 175 participants (31%). A total of 57 (10%) participants did not report any of the menstrual abnormalities. Of those reporting pain (537), 50% described mild pain, 28.7% moderate and 21% severe. 87 students did not experience any pain.

School absenteeism during menstruation varied significantly by school category (p=0.016), academic stream (p=0.015) and age group (p=0.021). Students in the rural private and rural government schools reported higher absenteeism compared to those schools situated in urban areas. Similarly, commerce and humanities streams reported higher absenteeism compared to those in the science stream.

Likewise, younger students (≤16 years) had significantly higher absenteeism than older students (>16 years). Other variables such as parental education, occupation, religion, type of family, and socioeconomic class were not significantly associated with school absenteeism. However, students residing in rural areas had a significantly higher rate of absenteeism compared to their urban counterparts (p=0.032) (Table 1).

Among menstrual factors, early age at menarche (p=0.012) and menorrhagia (heavy menstrual bleeding) (p=0.015) were significantly associated with school absenteeism. Participants with an early onset of menarche and those who experienced heavy menstrual bleeding had higher absenteeism rates. Other variables, such as cycle regularity, duration of cycle, and embarrassment during menstruation showed no significant association (Table 2).

*χ² test, ^#Fisher’s exact test

*χ2 test

DISCUSSION

Socio demographic profile of the study population

The present study was conducted among 624 participants in the higher secondary coeducation schools situated in urban and rural areas of Kannur district in northern Kerala.

In this study, age of the participants ranged from 15 to 19 years, with median age (IQR) of 17 (1) years, which is comparable with the study done in Uganda where median age of 16 (IQR=15,16) years was reported, but is more when compared to the study by Alenur et al in Telangana, where median age (IQR) was 14 (15-14) years. This might be due to the inclusion of only late adolescents studying in HSS in the present study.^8,9

The highest educational qualifications attained by majority of fathers and mothers were high school certificate 323 (53.5%) and 299 (47.9%) respectively, next to which lies the Intermediate/diploma qualifications, reported among 20.7% fathers and 26.6% mothers. When moving into higher levels of education, proportion of mothers with higher qualifications exceeded that of fathers. Parental education, especially mothers’ education in other studies in India and other countries like Ghana reported a lower proportion of literate mothers comparing to the present study.^6,10,11

Even though educational status of mothers exceeds fathers in the present study, 82.9% mothers were unemployed or unpaid, as they were homemakers. Only a small proportion of mothers were employed (17%), which coincides with the majority (69.7%) of mothers as housewives in a cross sectional study conducted by Kumbeni et al in rural northern Ghana, where 49.7% of the mothers had primary education or lesser education.⁶

According to modified BG Prasad SES scale, the largest group (28%) belonged to class IV (Lower middle) in this study. It is similar to the study done among adolescent girls in resettlement colonies of Delhi, where majority (33.9%) belonged to class IV, with less no. of participants belonged to classes I, 10.7% and 4.7% in Kannur and Delhi respectively.¹²

Family structure in today’s world is mostly nuclear, which corroborates with the evidence from this study and various other studies. Majority (68%) of students lived in nuclear families in the present study, followed by three generation families (17.3%) and joint families (14.6%) in the present study. Similarly, 60.0% participants reported a nuclear family structure in a study by Gupta et al in urban slums of India, and Garg et al in Delhi where nuclear family comprised of 84.4%.^11,12

School absenteeism

Prevalence of school absenteeism during menstruation for the past 6 months in the present study accounted for 59.8% (373), which is greater when compared to the available Indian studies, ranged from 13.9% to 53%.^4,8,10-21 When considering the international studies, school absenteeism varies widely from 14% to 70.7%.^5-7,22–25

The reasons for school absenteeism during menstruation reported were similar in most of the studies discussed here, where the predominant reason stated was pain during menstruation (dysmenorrhea). Other reasons in this study includes tiredness, discomfort, fear of leakage of menstrual blood and staining of clothes, lack of sick room/no place to manage periods at school, excessive bleeding, lack of medicines for pain at school, lack of proper disposal system for menstrual products at school and customs forbidding students to stay out of school. Apart from above mentioned reasons; due to shame, lack of toilet facility and water supply, lack of pads and premenstrual symptoms cited in other studies.^4,8,12-14-31

In the present study, among absentees majority (77.2%) missed up to 2 to 3 days per menstruation, which is higher comparing to other studies where most of them took only one or two days of leave.^{4,5,10,12,14,17,18,27} Some (2.2%) students even remained out of school for more than 5 days every month in a study in Jalandhar, while in this study 1.6% remained out of school for more than 7 days.¹⁷ Even though it is a small proportion, it raises concern for addressing the issues related with.

When considering total number of days of menstrual absenteeism during past 6 months (n=373), majority 67.8% missed ≤6 days of classes, while 29.8% missed between 6 to 12 days and 2.4% missed more than 12 days of classes. The median (±IQR) no. of days absent during menstruation was 4±4 (Mean±SD=4.37±4.07) days. Considering an average of 100 to 120 working days over 6 months in higher secondary schools in Kerala state, this absenteeism accounts for roughly 5% to 10% of working school days, which is an alarming concern and should be addressed appropriately, since higher secondary education is a crucial phase that builds foundation for future education and career paths.

Factors associated with school absenteeism during menstruation

Sociodemographic factors

School absenteeism during menstruation varied significantly by school category (p=0.016), academic stream (p=0.015) and age group (p=0.021) in the present study, where students in the rural private and rural schools reported higher absenteeism compared to those schools situated in urban areas. Similarly, commerce and humanities streams reported higher absenteeism compared to those in the science stream. Likewise, younger students (≤16 years) had significantly higher absenteeism than older students (>16 years) in the present study. In contrast to this, a study done in Luang Prabang Province, Lao People’s Democratic Republic by Inthaphatha et al, noted age 16 years or older as a factor associated with school absence due to menstruation. But schools outside the city were significantly less associated with school absence. A logistic regression analysis was performed which identified higher age (age>16 years old) (Adjusted OR (AOR)=1.79, 95% CI=1.37-2.34, p<0.001) and higher allowance (>200,000 LAK per week) (AOR=2.38, 95% CI=1.16-4.87, p<0.05) were significantly associated with school absence. Living with relatives (AOR=0.64, 95% CI=0.43 67 0.95, p<0.05) and studying at schools outside the city (AOR=0.59, 95% CI=0.38-0.90, p<0.05) were significantly less associated with school absence due to menstruation than living with their parents and schools in the city respectively.³²

Age and type of school were not statistically significant in some studies, but the socio-demographic characteristics like age, education, religion, socioeconomic status, residential area were not significantly associated with school absenteeism in a study by Garg et al.^12,31 Multivariable logistic regression in another study showed that, among girls, missing ≥5 days of school in the past month was independently associated with older age (aOR=2.53, 95% CI 1.08, 5.96 for those aged 15-17 vs 12-14), religion (aOR=0.35, 95% CI=0.13, 0.99 for Muslim vs Catholic).³⁰All these findings were in contrast with the present study, where younger age group has more absenteeism which is statistically significant.

Multivariable logistic regression in a study in Uganda by Miiro et al showed that, among girls, missing ≥5 days of school in the past month was independently associated with lower socio economic status (aOR=2.34, 95% CI 1.34, 4.11), while in the present study socio economic status was not statistically significant.³⁰ Other variables such as parental education, occupation, religion, type of family, were not significantly associated with absenteeism in the present study.

However, students residing in rural areas had a significantly higher rate of absenteeism compared to their urban counterparts (p=0.032), with a similar higher likelihood of absenteeism associated with girls living in rural areas of Bangladesh, with a coefficient of -5.6 (CI: - 10.06, -1.14, p<0.01).³¹

Mother’s education and privacy in school were only significant at the univariate level in a study by Kumbeni et al while mothers education was not significant in the present study.⁶

Menstrual characteristics

Among menstrual factors, early age at menarche (≤10 years) (p=0.012) and menorrhagia (heavy menstrual bleeding) (p=0.015) were significantly associated with absenteeism. Participants with an early onset of menarche and those who experienced heavy menstrual bleeding had higher absenteeism rates. Students who reported no menstrual abnormalities had significantly lower absenteeism (p<0.001). Other variables, such as cycle regularity, duration of cycle, and embarrassment during menstruation, showed no significant association in the present study. Similarly, menorrhagia was identified as a significant predictor of academic absenteeism in a multivariate logistic regression analysis in a study conducted among high school students in Norway. The OR for academic absenteeism was 1.55 for participants with menorrhagia, with a statistical significance of p=0.012.⁹

A prospective cohort analysis found that adolescents reporting heavy or prolonged bleeding had significantly more time off school, missing an average of 1.7 additional days of school per year (a 16.58% increase). Heavy or prolonged bleeding was also associated with 48% higher odds of persistent absence (missing 10% or more of school time).³³ In another study conducted in Myanmar, heavy bleeding was associated with increased odds of absenteeism in multivariable comparisons aOR=3.33, 95% CI 1.51-7.34, p=0.003).³⁴ Pain, fear of leakage and excessive bleeding was cited as a major reasons for absence in India and noted statistically significant association between school absenteeism and excessive bleeding (ꭓ²=20.923, p=0.00).¹⁷ Which was comparable with the present study.

CONCLUSION

The prevalence of school absenteeism during menstruation is 59.8%. Predominant reason for absenteeism during menstruation reported in the study was pain during menstruation, which accounts for about 91% among absentees, followed by tiredness (52%), discomfort (45%), fear of leakage of menstrual blood (27%), lack of sickroom (20%), excessive bleeding (16%), lack of medicines for combating pain at school (11%), lack of proper disposal system for menstrual products (3.5%) and customs (2.7%) being the least. Significant factors associated were school category, academic stream, age group, residence, age at menarche, presence of menorrhagia.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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