The effect of an audio-recorded intervention program on the knowledge and self-reported practices of menstruation and hygiene among visually impaired young girls in Rwanda: a mixed method study

Abstract

Background

Menstrual hygiene practices among visually impaired young girls are a significant public health concern in Rwanda. Limited knowledge about menstruation leads to inadequate hygiene practices, increasing the risk of cervical cancer, urinary tract infections, and reduced quality of life. The menstrual hygiene needs of visually impaired girls who depend on daily assistance for personal hygiene have not been adequately addressed in previous studies.

Objectives

To assess the effect of an audio-recorded program on the knowledge and self-reported practices of menstruation hygiene among visually impaired young girls in Rwanda.

Methodology

A pre-post mixed intervention study was conducted involving 93 visually impaired young girls from four specialized educational institutions. After obtaining consent and assent, baseline data were collected following an audio-recorded intervention. A pretested tool was used to measure participants’ knowledge and practices about menstruation and menstrual hygiene. Post-interventional data was collected, and paired t-tests were used to analyze changes in knowledge and practice scores. Qualitatively, focus group discussions were used to evaluate the perceived effect of the audio-recorded program. Qualitative data were organized by Dodoose software and analyzed using thematic analysis.

Results

The majority of participants (67.7%) were enrolled in secondary education level and lived in rural areas (76.3%), with the largest proportion (43%) being between the ages of 16 and 20 years. There was a significant increase in the knowledge of young visually impaired girls (p < 0.001) after the audio-recorded intervention program. There was a significant increase in the overall menstrual hygiene practice after the implementation of the audio-recorded program (p < 0.001). Qualitatively, four themes emerged from the study, including improved knowledge and abilities, boosted confidence, the convenience of audio, and the perceived need to increase audio effectiveness.

Conclusion

The study revealed a significant association between the audio-recorded interventions and improved menstrual hygiene knowledge and practices among visually impaired young girls. However, since the study utilized a pretest-posttest design, a randomized controlled trial is recommended for robust evidence.

Background

Globally, menstruation is a monthly challenge for billions of women and girls. Around 52% of the female population (26% of the global population) are of reproductive age, and on any given day, more than 800 million girls and women between the ages of 15 and 49 (25% of the female population) are menstruating [1, 2]. In Africa, the practice of menstrual hygiene management is still low and the issue is underestimated [3]. Due to low menstrual hygiene practices, young girls are particularly prone to reproductive tract infection, school absenteeism, and increased school dropout [4]. Studies reveal that young girls lack appropriate knowledge and practices about menstruation and menstrual hygiene [5,6,7]. Particularly, girls with vision impairments do not receive appropriate attention to the menstrual hygiene issue [8, 9]. According to global estimates from the World Health Organization (WHO), at least 2.2 billion individuals worldwide suffer from vision impairment; of these 36 million are blind, for whom 19.8 million are women [10]. Yet, 90% of visually impaired people worldwide live in low-income environments [10].​.

Although the exact number of visually impaired girls in Rwanda is unknown, estimates indicated that approximately 400,000 people mainly young individuals have visual impairments [11]. A retrospective study analyzing patient records of individuals under the age of 18 years at a tertiary referral centre at Kabgayi Eye Unit found that 10.9% out of 3,939 had visual impairments [12]. According to the Rwandan Ministry of Education, in 2022, visual impairment was reported among 2,709 males and 2,334 female students aged 6 to 17 years [13].

Visually impaired girls often face greater challenges in maintaining regular personal hygiene. However, with extended periods of practice and assistance, they eventually learn to manage their daily routines and personal hygiene activities [5]. Despite experiencing doubts and uncertainties, they navigate the menstrual cycle, with menstrual hygiene management being particularly crucial in this context [14]. Therefore, visually impaired young girls need adequate education and suitable assistance to use sanitary materials, especially for menstrual hygiene management.

According to the WHO and UNICEF Joint Monitoring Program, menstrual hygiene management involves young girls and women utilizing clean materials to absorb menstrual blood, changing them privately as needed during their menstrual cycle, washing the body with clean water and soap as necessary, and having access to safe and convenient facilities for disposing of used menstrual materials [15]. Additionally, girls and women possess an understanding of the fundamental aspects of the menstrual cycle and know how to manage it with dignity, free from discomfort or fear [15]. Visually impaired girls, in particular, need assistance in identification, placing menses materials, washing the menses clothing and disposal of used menstrual materials appropriately [16, 17]. It is documented that lack of information, knowledge and skills on personal and menstrual hygiene are the key challenges reported by visually impaired girls [18]. Thus, to help visually impaired young girls, there is need to elaborate on the interventions that increase their knowledge and menstrual practices.

Visually impaired young girls are regarded as vulnerable groups. However, they may benefit from listening to an audio intervention to increase their understanding and menstrual hygiene practices. The audio- recorded program is useful for saving time and can be used repeatedly to help vision-impaired girls obtain the desired results [19]. For young girls who are visually impaired, information transmission through audio media is essential by giving people with visual disability autonomy, equity, and social inclusion [20, 21]. Some quantitative studies, though not conducted in East African countries including Rwanda, have provided some evidence suggesting the effectiveness of audio-based educational sessions, in improving knowledge and hygiene practice among visually impaired girls [22,23,24]. However, there is a notable gap to include qualitative research that explores the perspectives and experiences of visually impaired girls regarding these interventions. Thus, there was a need for in-depth qualitative studies to assess their views on the perceived effect, relevance, and necessity of audio-recorded educational materials. Such mixed research would provide valuable insights to complement each other, ensuring a more comprehensive understanding of how these interventions address the educational and informational needs of visually impaired girls. Therefore, a mixed pretest-posttest intervention was carried out to assess the effect of an audio-recorded program on the knowledge and practices towards menstrual hygiene among visually impaired young girls in Rwanda as well as to explore their perspectives and experiences on the program.

Methods

Study design

A pretest - posttest mixed method design was used. The audio-recorded intervention program’s potential to improve visually impaired young girls’ knowledge and practices around menstrual hygiene was evaluated using quantitative research methods. Moreover, a qualitative approach was conducted to explore the perceptions and experiences of visually impaired young girls on the audio-recorded program.

Study setting

Within the attractive landscapes of Rwanda, a nation known for its rich cultural tapestry, the study was conducted in specialized educational schools for visually impaired students. Currently, there are only four schools for young people with visual impairments. They are owned by religious organizations, which follow official curriculum developed by Rwanda’s Ministry of Education. Among these schools are Home de la Vierge des Pauvre Gatagara in Rwamagana district and Blessing school in Musanze district, both located in urban area, as well as Kibeho School in Nyaruguru district and Groupe Scolaire Gahini in Kayonza district from rural settings. The schools provide to individuals with visual impairments, offering education up to the secondary level of education along with essential study materials.

Study population and recruitment

This study focused on all visually impaired young girls aged 10 to 24 years who were enrolled in schools specialized in visual impairments. This group age was selected based on the definition of WHO, where young people covers the range of 10 to 24 years [25]. The study included all visually impaired young girls enrolled in the four specialized schools for visual impairments. However, individuals who were unavailable for both the pretest and posttest assessments, along with those with mental disorders, deafness, or a lack of willingness to participate, were excluded from the study. During the pretest data collection period, a total of 101 visually impaired young girls were included in the study, after considering the exclusion criteria. However, during posttest data collection, 93 were considered where 3 went home due to sickness and the remaining 5 were not able to be located despite contacted during the follow-up phone calls with their guardians. At each school, the visually impaired girls had one guardian who supervise and providing further care. Regarding to qualitative approach, four focus group discussions (FGDs) were used and each group was composed of six participants. They were purposively selected based on level of study. Two institutions, Home de la Vierge des Pauvre Gatagara and Kibeho School, had senior one to three levels (Grade 7 to 9), and two participants were selected from each level. However, Blessing and Gahini School, had senior one to six levels (Grade 7 and 12), and one participant was selected, resulting in a total of six participants in each group.

Description of the intervention

The research team members who are specialized in reproductive health and midwifery developed a 30-minute audio-recorded program. The program was structured based on relevant literature related to reproductive health, menstrual hygiene, and menstruation management. The script of the program was translated into a local language (Kinyarwanda), and then a translation expert from University of Rwanda-School of Education back translated into English to ensure content consistency. Overall, the audio-recorded program intervention combined both educational and practical components to improve the menstrual hygiene knowledge and practices of visually impaired young girls. The program covered several key components:

• Reproductive health and menstruation (e.g., anatomy of the reproductive system, ovulation timing, characteristics of menstruation, menopause).

• Problems and causes of menstrual pain, along with strategies to alleviate pain.

• Hygiene practices during menstruation (practical component), including washing hands with clean water and soap, using only clean water when cleaning the genital areas, washing underwear with water and soap and dry them under the sun, types of pads, changing frequency, personal hygiene etc.

• Addressing common myths associated with menstruation.

Before administering the audio-recorded program, a structured questionnaire was used to assess their baseline knowledge and practice of menstrual hygiene in March 2023. Additionally, researchers conducted a 20-minute brief introduction and instruction about menstruation and reproductive health as well as how to use the audio program. Then, they were provided with the 30-minute audio program to listen to. They were instructed to play and listen to the program daily for the first month to help them become more familiar with content of the program. While in the second and third month, they were instructed at their convenience or based on their needs. However, to ensure consistency, phone calls were made twice a month with their guardians to remind them to listen or play the audio recordings. This consistent exposure was aimed at reinforcing their understanding of menstrual hygiene concepts. After three months of audio program exposure, a posttest questionnaire was administered in July 2023. This questionnaire assessed whether the audio program intervention has effectively enhanced the participants’ knowledge and practice of menstrual hygiene.

Data collection instruments

The quantitative research instrument was developed by the research team, guided by the literature process of similar studies [6, 22, 26]. All these studies showed good internal consistency with Cronbach alpha of greater than 0.7. The developed data collection tool was composed of key demographic characteristics of the study participants, knowledge towards menstruation and menstrual hygiene as well as practices of menstrual hygiene (Supplementary file 1). It was designed in English version and then translated into Kinyarwanda (local language) by the research team. Before the actual data collection, the questionnaire was pretested to assess its reliability, which provided a Cronbach alpha of 0.870. Similarly, in the qualitative part, a discussion guide was designed based on the literature [27,28,29,30] to assess the participant’s views on the perceived effect and recommendation of the audio-recorded intervention (Supplementary file 2).

Data collection procedures

Following ethical clearance approval, the research team sought for the study setting permissions to access the study participants. Then, after obtaining consent and assent and establishing rapport, the visually impaired young girls were interviewed in a private and conducive environment using a structured and pretested questionnaire. The data were collected by the research team. Age of the respondents and age of menarche were asked as continuous variables and then grouped into categories during analysis. The socio-economic status was assessed using the 2015 Rwanda’s social categories established by the Rwandan Ministry for Local Government and Social Affairs as follows: category 1, extremely poor; category 2, poor; category 3, self-sustaining; and category 4, rich [31].

First, pre-intervention data was collected from the visually impaired young girls before the audio-recorded tape intervention was given. This pretest intervention data was aimed to assess the knowledge and practice of menstrual hygiene before audiotape is administered. Then a posttest intervention data was collected after three months to assess outcomes of the audio-recorded tape intervention program on knowledge and practice of menstrual hygiene.

In the qualitative part, the data were collected through FGDs by the research team who exhibited extensive experience and skills in qualitative data collection. Each FGD had a moderator and a note-taker, and after the discussion, the keynotes were shared and examined to confirm what had been stated. Kinyarwanda language was used to collect the data and each FGD took approximately 45 min.

In terms of our positionality, none of the members of the research team was classified as visually impaired according to the World Health Organization’s definition, as outlined in the International Classification of Diseases 11 (ICD-11). This definition states that a person is considered visually impaired if the visual acuity (VA) in the better eye is worse than 3/60. The revised definition also includes near vision impairment, defined as a near VA worse than N6 even with existing correction. In line with the guidance provided by Callus (2019) on non-disabled individuals researching disability [32], we carefully and continuously reflected on how our positionality, personal experiences, and beliefs about visual impairment might influence our methodological choices, our interactions with participants, and our data analysis throughout the research process.

Quality assurance (reliability and validity)

The research team, comprising of experts in the field, ensured the collection of high quality and reliable quantitative data. To ensure the consistency and reliability of the intervention, regular follow-up phone calls were conducted to ensure that each participant involved in the study received the same level of exposure to the audio-recorded program. Additionally, the data collection tool was pretested before the actual data collection to assess its reliability and make necessary adjustments.

To ensure the rigor of the qualitative piece, the research team carefully followed the four criteria proposed by Lincoln and Guba [33]. These are credibility, dependability, confirmability and transferability. Credibility was ensured through prolonged engagement with the study participants and the development of an interview guide based on the literature. Utilizing experienced data collectors in qualitative research and reproductive health, while incorporating field notes into the data analysis process coupled with regular team meetings contributed to the credibility of the study. To achieve dependability, an audit trail and team coding were followed. Confirmability was achieved through exercising reflexivity and regular debriefing meetings. Lastly, transferability was ensured by using purposive sampling.

Analysis

Data were entered using a data entry form created with the help of MS Excel. Then the data were exported to Statistical Package for Social Sciences (SPSS) Version 25.0 for analysis. Descriptive statistics were used for the analysis of socio-demographic data using frequency and percentages. A score assessment was conducted for both knowledge and practice of menstrual hygiene before and after the audio-recorded program. The correct response for each item was given a score of ‘1’, and a score of ‘0’ was assigned for incorrect answers/responses. An aggregate score for knowledge as well as practice was calculated to generate the mean. Then paired t-test was used to test the effect of the audio-recorded program on knowledge and practices towards menstrual hygiene. McNemar test was also used to compare categorical knowledge and practice variables between pretest and posttest intervention. The significance level was set at 5% at a confidence interval (CI) of 95%.

The qualitative data was analyzed using Braun and Clarke’s framework of thematic analysis following six steps [34]: familiarization of data, generation of codes, combining codes into themes, reviewing themes, determining the significance of themes, and reporting of findings. The discussions were transcribed verbatim in Kinyarwanda (the local language) and then translated into English by the research investigators who are fluent in both the local language and English. This also enhanced data immersion. After translation, data were imported to Dedoose software for organization and initial coding. Two research team members coded data independently and held regular meetings to discuss the discrepancies. After having the list of codes, the entire research team held several meetings to search for sub-themes and themes. Identified themes and sub-themes remained provisional during the meetings until the team members mutually agreed on them.

Ethics

This study was approved by the Institutional Review Board (IRB)/ University of Rwanda (330/CMHS IRB/2022). Permission was also requested and granted from each school to conduct the study. Written informed consent and oral assent were sought from the legal guardians and all study participants respectively. After obtaining both consent and verbal assent from the participants, we took deliberate steps to ensure they felt safe and secure about the information they shared. To enhance their confidence, each participant was informed in advance that their real names would not be used in the questionnaires, during interviews, or in the reporting of results. They were also clearly informed about their rights to confidentiality and anonymity, as well as their right to withdraw from the study at any time without providing a reason. With their permission, interviews were audio-recorded.

Results

Demographic characteristics of the visually impaired young girls

Out of 101 young girls recruited during the pretest, 93 completed the posttest interview (Response Rate = 92%). The mean age of the participants was 17.44 years with the highest percentage (43.0%) aged between 16 and 20 years. The mean age of menarche was 13.03 years. The majority (76.3%) were from rural areas, and most (67.7%) had attended secondary school. The highest proportion were from Rwamagana GHVP School (45.2%). Additionally, 46.2% of the participants belong to Roman Catholic (46.2%). In terms of socio-economic status, 49.5% belonged to category 1 (Table 1).

Table 1 Demographic characteristics of the visually impaired young girls in Rwanda

Knowledge and practices towards menstruation and hygiene among visually impaired young girls

There was a significant increase in percentages after audio-recorded intervention on the knowledge of causes of menstruation (p < 0.001), source of menstrual blood (p < 0.001), age of first menstruation (p < 0.001), average duration of menstruation (p < 0.001) and interval between two cycles (p < 0.001). There was also a significant increase in knowledge regarding menses odor (p < 0.001), menses hygiene (p < 0.001), and whether menstruation continues throughout life after the intervention (p < 0.001) (Table 2).

Table 2 Knowledge and practices towards menstruation and hygiene among visually impaired young girls in Rwanda

A similar trend of increased percentages was observed for practices after the intervention while all participants indicated they were using absorbent materials and taking showers with soap and water daily during menstruation before the intervention. There was a significant increase in practice after the audio record intervention regarding hand washing before changing pads during menstruation (p < 0.001), changing underwear at least twice a day during menstruation (p < 0.001), and drying the underwear in sunlight (p < 0.001) (Table 2).

Knowledge and practices towards menstruation and hygiene during pretest and posttest

The mean knowledge score of the young visually impaired girls increased from 3.62 before the audio-recorded program implementation to 7.55 after the program (t = 19.73; p < 0.001). There was a significant increase in the menstrual practices with the overall mean practice score of 7.30 before the program and significantly increased to 9.03 after the program (t = 12.27; p < 0.001) (Table 3).

Table 3 Knowledge and practices towards menstruation and hygiene among visually impaired young girls during pretest and posttest

Knowledge and practice score in relation to socio-demographic characteristics

According to One Way ANOVA, there was a significant variation of the mean knowledge score in relation to age and level of education during pretest intervention. Young girls aged 16 years and above had significantly (p = 0.006) higher mean knowledge score on menstruation before the intervention. In addition, at the pretest, girls with a secondary level of education had significantly (p = 0.014) higher mean knowledge score on menstruation hygiene compared to those with primary level of education. However, there was no significant differences in knowledge and practice at the posttest (Table 4).

Table 4 Knowledge and practice score in relation to socio-demographic characteristics among visually impaired young girls

Qualitative data findings

In the qualitative analysis, four themes emerged: (a) the audio is convenient; (b) improved knowledge and skills; (c) increased confidence; and (d) perceived needs to improve audio effectiveness.

Convenient and flexible resource

Some study participants expressed appreciation for the initiative of audio-recording program. The audio resource provided was highly valued, particularly because it offered a novel and flexible method for engagement among the study participants. Participants found it useful and convenient, mentioning they could listen to it during breaks, weekends, or any free time, highlighting their busy academic calendar and the need for adaptable resources. One participant noted,

Thank you very much for thinking of us. We could not imagine that some people thought about us to this extent. We are not forgotten. This audio was brought to us when we needed it for sure. We needed a method that is different to what we use. This audio we can listen to it during breaks, weekends… anyway whenever we are free. PC, FGD2.

Some study participants appreciated how this audio is designed as a good mode of delivery. They usually prefer interactive and flexible ways of receiving a message that allow them to access information at their convenience, rather than traditional methods of direct reading or teaching, which require them to attend altogether at once.

“This is the best method I have ever seen. It is easy for us to get accurate and quick information. It’s better than standing in front of us reading, and you go or for us to read. We listen to it whenever we want or in our free time”. PE, FGD3.

Other participants expressed a desire to have had access to this audio resource from the very beginning of their studies or even in primary level before they had menarche. They believe that having such a tool earlier in their educational journey would have significantly enhanced their knowledge and skills in managing menstruation.

“I wish we had this audio resource back in primary school—before I even started my period. It would have made things so much easier to understand.” PC, FGD1.

“Hmmm….Having something like this back in primary school would have really helped us feel more prepared and confident about our periods.” PE, FGD3.” PF, FGD4.

Improved knowledge and skills

Some study participants reported that they lacked comprehensive knowledge regarding proper menstrual hygiene practices. These practices were mainly related to the proper cleaning and handling menstrual pads. However, through this exposure to the audio recording, they have acquired knowledge and skills regarding the proper hygiene practices.

“Before the audio, I did not know how to handle a used pad. I didn’t fully understand the role of that plastic pad layer you use to wrap your worn pad. I used to wrap it on paper, but through this audio, I learned how and why to do it.” PC, FGD1.

“I would say that before I understood that once a day was enough for cleaning my genital area during my periods. But, from the audio, I learned that I should use it as often as possible and use clean water. We all thought we could wash with soap. However, we also learned that soap is bad.” PD, FGD2.

This improvement in knowledge and skills has been noted by the majority of the participants to contribute to the collaborative efforts to help each other when they face challenges. They reported that during their conversations with each other outside class and in their free time, they often recall and reference the content from the audio. This shared information becomes particularly valuable when they encounter challenges during menstruation. The study participants narrated that reminding one another of the audio content helps reinforce their way of managing their menstruation better. This collaboration demonstrates the effectiveness of the audio content in fostering a collective understanding and application of the knowledge gained.

Increased confidence

Study participants reported that the audio significantly boosted their confidence in managing menstrual hygiene. They mentioned that after listening to the audio, they felt capable of teaching and discussing the topic with others. Previously, they were too shy to discuss such issues publicly or with peers who were not visually impaired. One participant elaborated on this experience with the following quote:

Sometimes it happens to us when other colleagues who are not visually impaired talk about menstruation. When I approached them, they kept quiet because they thought I knew nothing. They thought we could not know much because we do not see. Now, when they talk, I give my input, and sometimes I am even better than them; encouraging me to teach them more. PE, FGD2.

Several other participants also reported that they felt empowered to share the knowledge they had gained with others. This newfound confidence enabled them to educate peers, the community and family members, spreading good practices of menstrual hygiene. A participant said,

“I’m pretty sure I can teach even my siblings since our parents don’t always tell us everything. I am ready to do so when we are on holiday.” PC, FGD4.

Perceived needs to ensure audio effectiveness

Some study participants suggested ways to put the audio content in writing to facilitate those with visual and auditory impairments, as reflected in the following quote:

After realizing the importance of the message inside this audio, I would suggest putting this audio into our reading system designed for people with visual impairments. I say this because we still have those with visual and auditory impairments who cannot listen or read on the projector. PB, FGD3.

Other participants suggested distributing this audio to other schools and communities. This ensures they are on the same page as their colleagues and parents. For instance, one participant said,

“It would be better if this audio is given to other schools with students who live with visual impairment. They will benefit from it.” PE, FGD2.

A few other participants mentioned that the audio length was very short. Six participants from different groups requested to lengthen the audio to ensure that it has a lot of information especially practical tips which are very helpful for girls who live with visual impairment. For instance, one participant stated,

“This audio was very interesting but quite short. There are a lot of things we want to know especially those we cannot see. It would be better to make a second part or make it long and put many practical skills.” PA, FGD1.

Discussion

Empirical studies demonstrating the beneficial effects of menstrual hygiene interventions for visually impaired young girls are limited, and to the best of our knowledge, this is the first study conducted in East African countries addressing menstrual hygiene issues. It is in this regard, the present study was undertaken to assess the effect of an audio-recorded program on the knowledge and practices of menstrual hygiene among visually impaired young girls. The result of the study revealed that the audio-recorded program had significantly enhanced knowledge and practice of menstrual hygiene among the young visually impaired girls. The quantitative findings were further supported by qualitative results, which highlighted the program’s convenience, improved knowledge and skills, increased confidence, and the perceived need to enhance the effectiveness of the audio program.

The current study’s findings on the socio-demographic characteristics showed that nearly half were aged between 16 and 20 years with an average age of 17.44. At the pretest, older girls (16 years and above) were significantly more likely to have a higher mean knowledge score on menstruation. This is concurrent with other studies which indicated that knowledge was more among older young girls [35, 36]. This could be explained by the fact that older young girls have more experience due to having several menstrual cycles in their lifetime. This implies early or younger adolescents are not receiving enough information about menstruation [37] hence putting them at a risk of menstrual-related diseases. Menarche occurred on average at 13.03 years old which is in agreement to two similar studies done in Egypt reported both at 13.9 years [22, 24].

The girls with a secondary level of education had significantly more to have higher mean knowledge scores on menstruation hygiene than those with primary education at the pretest. This may be attributed to the girls becoming more educated about menstruation and how to manage it hygienically as they advance in their education [37].

Regarding the pretest and posttest of the knowledge and practice of menstrual hygiene, the present study demonstrated a considerable significant improvement in mean score among the visually impaired young girl students. The mean score of knowledge significantly increased from 3.62 before the audio-recorded program was implemented to 7.55 after the audio-program implementation. Similarly, in the pretest, the mean practice was 7.30, and it considerably rose to 9.03 after the program. These results concur with other similar studies [9, 22, 24, 38, 39] that found visually challenged or impaired young girls had higher knowledge and practice levels or scores after implementing audio-recorded programs.

These quantitative findings on the significant association between audio-recorded program and knowledge and practice of menstrual hygiene are further supported by the qualitative findings. Most of the participants in the qualitative research highly expressed that the audio program boosted their knowledge and skills towards menstruation hygiene behavior after the listening to the audio program for 3 months.

The possible explanation for this significant improvement could be attributed to the audio-recorded program. It is evidenced that students who are visually impaired are very motivated to listen, and those who can help them hear well find it simple to teach them [40]. The audio player can be used repeatedly to produce the desired effects while conserving time [19, 23]. These are supported by the qualitative findings of the study as it was indicated that the audio-recorded program was convenient to use and this increased their confidence towards menstrual hygiene. Similar studies also found that visually impaired young girls expressed great satisfaction with the audio-recorded program sessions [22,23,24]. Therefore, from this study, it can be said that audio-recorded educational programs may play a crucial part in enhancing the knowledge and practice of visually impaired young girls regarding menstruation hygiene.

Furthermore, the analysis of the qualitative findings identified some perceived needs and recommendations to improve the effectiveness of audio-recorded program. These include putting the contents written in braille especially for those with both visual and auditory impairments, scaling up this approach to other schools, and adding more content or information, especially focusing more on practical sessions. The last recommendation however contradicts with other findings [22] which found that young girls who have visual impairments were happy with the educational sessions’ covered material. Therefore, these recommendations should be taken into consideration in future audio-played programs or interventions among young girls with visual impairment for more robust outcomes.

While our study demonstrated positive association between the audio-recorded interventions and enhanced menstrual hygiene knowledge and practices among visually impaired young girls, its design limitation and small sample necessitate further investigation. Thus, to strengthen the evidence base, we recommend conducting a large scale randomized controlled trial. This would provide more robust and valuable insights for policy makers and stakeholders, contributing to the development of evidence-based programs aimed at enhancing menstrual health and overall well-being for visually impaired girls.

Strengths and limitations

This study has some strengths. First, to the best of our knowledge, this is the first audio program developed and implemented in Rwanda to support visually impaired young girls in menstruation hygiene. Second, since the research team collected quantitative data, we added the qualitative part to give value to the study participants’ voices. Third, after the initial intervention, there was a regular phone call follow-up to make sure each participant involved in the study received the same level of exposure to the audio program intervention. However, this study does have some limitations. First, since the results of this study were based on self-reported outcomes, there is possibility of response bias, which could be influenced by social desirability, potentially affecting the validity of the results. Secondly, although the study aimed to be comprehensive by including all schools for visually impaired girls in Rwanda, the total sample size remained limited. Thirdly, the study evaluated the effect only once after three months, focusing solely on pretest and posttests. However, the study could have been enhanced with additional assessments of the effect during the follow-up period to see the progress. Finally, the study design posed a limitation, as it lacked randomization, which would have helped minimize potential bias and unmeasured confounding factors.

Conclusion

In conclusion, this study found that targeted audio-based intervention was significantly associated with enhanced knowledge and improved practices menstrual hygiene among visually impaired young girls in Rwanda. However, considering the limitations of the study, including its design and sample size, further research using a large scale randomized controlled trial is recommended.