The Association of Mental Health With Menstrual Health Among Secondary School Students in Uganda: A Longitudinal Cohort Study

Purpose: Poor menstrual health can affect mental health through multiple biopsychosocial pathways. Few studies have examined the associations using multiple dimensions of menstrual health. Methods: We analyzed longitudinal data collected from female secondary school students in Uganda enrolled in a cluster-randomized trial. We administered a baseline survey from March to July 2022 and an endline survey from June to August 2023. We used the Strengths and Difficulties Questionnaire (SDQ) total difficulties score to assess mental health problems. We used mixed-effects linear regression to estimate adjusted mean differences (aMDs) for the effect of baseline menstrual-related exposures on the endline SDQ score. Models were adjusted for the baseline SDQ score and school-level clustering. Results: At baseline, we enrolled 3741 postmenarche participants from 60 schools (mean age 15.6 years, standard deviation = 0.9). Of these, 2829 (75.5%) completed the endline survey. We found evidence for an association between multiple dimensions of poor baseline menstrual health and endline mental health problems, after adjusting for sociodemographic factors and the baseline SDQ score. Dimensions of menstrual health associated with mental health included lack of social support related to menstruation (aMD = 0.74, 95% confidence interval [CI] 0.26–1.21), poorer attitudes to menstruation (aMD = 0.38, 95% CI 0.03–0.73), lower menstrual health self-efficacy (aMD = 0.60, 95% CI 0.15–1.05 for lowest vs. highest tertile) and more unmet menstrual practice needs (aMD = 1.11, 95% CI 0.61–1.60). Discussion: Negative menstrual experiences were associated with subsequent mental health problems among in-school Ugandan adolescents, but effect sizes were small. Interventions would need to achieve large improvements in multiple dimensions of menstrual health to lead to measurable improvements in mental health.