Beyond the Cycle: Investigating the Relationship Between Menstrual Hygiene Factors, Family Economic Stability, and Depression Among Adolescent Girls in Uganda—A 24 Month Mixed-Effects Regression Analysis of the Suubi4Her Trial

Flavia Namuwonge,1 Phionah Namatovu,1 Samuel Kizito,2 Vicent Ssentumbwe,2 Nhial T Tutlam,2 Proscovia Nabunya,2 Mary M McKay,3 Fred M Ssewamala2 1International Center for Child Health and Development, Masaka Field Office, Masaka, Uganda; 2Brown School, International Center for Child Health and Development, Washington University in St. Louis, St. Louis, MO, 63130, USA; 3Office of the Provost, Washington University in St. Louis, St. Louis, MO, 63130, USACorrespondence: Flavia Namuwonge, International Center for Child Health and Development, Masaka Field Office, P.O. Box 1988, Masaka, Uganda, Email [email protected]: Menstrual hygiene management (MHM) is essential for adolescent well-being, yet many girls lack adequate menstrual products. While MHM factors are linked to depression, little is known about these associations in Uganda. Because financial insecurity and family context can intensify or buffer menstrual challenges, we examined the relationships between menstrual knowledge, pain, affordability barriers, supply type, restrictions, and depression in the context of an intervention targeting economic and family support.Methods: We analyzed data from a three-arm cluster randomized controlled trial (Suubi4Her) with a 24 month follow up (2018 to 2022). A total of 1260 adolescent girls aged 14 to 17 from 47 secondary schools in Uganda were randomized into three study arms: Control (n=16 schools, n=408); Economic Empowerment using Youth Development Accounts (YDA) (n=16 schools, n=471), matched savings accounts promoting financial literacy and economic stability; and YDA plus Family Strengthening Intervention using Multiple Family Group (MFG) meetings (n=15 schools, n=381), structured caregiver-adolescent sessions to improve family communication, support, and problem solving. Depression was assessed using the Beck Depression Inventory (BDI). Mixed effects regression models examined associations, adjusting for school and individual clustering.Results: Age (β= -0.98, 95% CI: -1.32, -0.64, p < 0.001) was significantly associated with lower depression. Menstrual knowledge (β=0.83, 95% CI: 0.61, 1.06, p < 0.001), menstrual pain (β=0.73, 95% CI: 0.51, 0.95, p < 0.001), affordability barriers (β=3.55, 95% CI: 2.41, 4.30, p < 0.001), and menstrual restrictions (β=1.22, 95% CI: 0.16, 2.28, p= 0.024) were also associated with increased depression. Hygienic products weakened the psychological impact of menstrual pain (β=-0.40, 95% CI: -0.63, -0.16, p= 0.001). Intervention participants had lower depression (YDA: β= -1.88, 95% CI: -3.09, -0.68, p = 0.002; YDA+MFG: β= -1.89, 95% CI: -3.21, -0.56, p= 0.005). Taken together, these results suggest that menstrual hygiene challenges increase the risk of depression, while age, access to hygienic products, and participation in supportive interventions can mitigate these negative effects.Conclusion: Findings point to a need for comprehensive MHM programs integrating family economic support, pain management, and mental health. Addressing affordability barriers and menstrual stigma enhances adolescent girls’ well-being.Plain Language Summary: Many adolescent girls in Uganda face challenges managing their periods. Some cannot afford menstrual products like pads. Others experience physical discomfort, such as pain, and are often limited in what they can do during their period, including attending school or participating in daily activities.This study looked at whether these menstrual hygiene challenges are linked to symptoms of depression. It included 1260 girls between the ages of 14 and 17 from 47 secondary schools in Uganda. The girls were part of a larger study testing two programs: one offered support through savings accounts and financial education, and the other added family group meetings to support better communication and care within families.The researchers found that girls who had more menstrual pain, could not afford pads, or had restrictions on their activities during menstruation were more likely to report feeling depressed. Those who participated in the savings and family support programs also had better mental health compared to those who received only basic school support.These results suggest that improving access to menstrual products and offering support through savings and family programs can help reduce depression in adolescent girls. Addressing menstrual health needs is important for supporting girls’ mental well-being.Keywords: affordability constraints, adolescent mental health, adolescent girls, economic empowerment