literature review of rural areas

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What improves access to primary healthcare services in rural communities? A systematic review

Zemichael gizaw.

1 Department of Environmental and Occupational Health and Safety, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Tigist Astale

2 International Institute for Primary Health Care- Ethiopia, Ethiopian Public Health Institute, Addis Ababa, Ethiopia

Getnet Mitike Kassie

Associated data.

All the extracted data are included in the manuscript.

To compile key strategies from the international experiences to improve access to primary healthcare (PHC) services in rural communities. Different innovative approaches have been practiced in different parts of the world to improve access to essential healthcare services in rural communities. Systematically collecting and combining best experiences all over the world is important to suggest effective strategies to improve access to healthcare in developing countries. Accordingly, this systematic review of literature was undertaken to identify key approaches from international experiences to enhance access to PHC services in rural communities.

All published and unpublished qualitative and/or mixed method studies conducted to improvement access to PHC services were searched from MEDLINE, Scopus, Web of Science, WHO Global Health Library, and Google Scholar. Articles published other than English language, citations with no abstracts and/or full texts, and duplicate studies were excluded. We included all articles available in different electronic databases regardless of their publication years. We assessed the methodological quality of the included studies using mixed methods appraisal tool (MMAT) version 2018 to minimize the risk of bias. Data were extracted using JBI mixed methods data extraction form. Data were qualitatively analyzed using emergent thematic analysis approach to identify key concepts and coded them into related non-mutually exclusive themes.

Our analysis of 110 full-text articles resulted in ten key strategies to improve access to PHC services. Community health programs or community-directed interventions, school-based healthcare services, student-led healthcare services, outreach services or mobile clinics, family health program, empanelment, community health funding schemes, telemedicine, working with traditional healers, working with non-profit private sectors and non-governmental organizations including faith-based organizations are the key strategies identified from international experiences.

This review identified key strategies from international experiences to improve access to PHC services in rural communities. These strategies can play roles in achieving universal health coverage and reducing disparities in health outcomes among rural communities and enabling them to get healthcare when and where they want.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01919-0.

Introduction

Universal health coverage (UHC) is used to provide expanding services to eliminate access barriers. Universal health coverage is defined by the world health organization (WHO) as access to key promotional, preventive, curative and rehabilitative health services for all at an affordable rate and ensuring equity in access. The term universal has been described as the State's legal obligation to provide healthcare to all its citizens, with particular attention to ensuring that all poor and excluded groups are included [ 1 – 3 ].

Strengthening primary healthcare (PHC) is the most comprehensive, reliable and productive approach to improving people's physical and mental wellbeing and social well-being, and that PHC is a pillar of a sustainable health system for UHC and health-related sustainable development goals [ 4 , 5 ]. Despite tremendous progress over the last decades, there are still unaddressed health needs of people in all parts of the world [ 6 , 7 ]. Many people, particularly the poor and people living in rural areas and those who are in vulnerable circumstances, face challenges to remain healthy [ 8 ].

Geographical and financial inaccessibility, inadequate funding, inconsistent medication supply and equipment and personnel shortages have left the reach, availability and effect of PHC services in many countries disappointingly limited [ 9 , 10 ]. A recent Astana Declaration recognized those aspects of PHC need to be changed to adapt adequately to current and emerging threats to the healthcare system. This declaration discussed that implementation of a need-based, comprehensive, cost-effective, accessible, efficient and sustainable healthcare system is needed for disadvantaged and rural populations in more local and convenient settings to provide care when and where they want it [ 8 ].

Different innovative approaches have been practiced in different parts of the world to improve access to essential healthcare services in rural communities. Systematically collecting and combining best experiences all over the world is important to suggest effective strategies to improve access to healthcare in developing countries. Accordingly, this systematic review of literature was undertaken to identify key approaches from international experiences to enhance access to PHC services in rural communities. The findings of this systematic literature review can be used by healthcare professionals, researchers and policy makers to improve healthcare service delivery in rural communities.

Methodology

Research question.

What improves access to PHC services in rural communities? We used the PICO (population, issue/intervention, comparison/contrast, and outcome) construct to develop the search question [ 11 ]. The population is rural communities or remote communities in developing countries who have limited access to healthcare services. Moreover, we extended the population to developed countries to capture experiences of both developing and developed countries. The issue/intervention is implementation of different community-based health interventions to access to essential healthcare services. In this systematic review, we focused on PHC health services, mainly essential or basic healthcare services, community or public health services, and health promotion or health education. Primary healthcare is “a health care system that addressed social, economic, and political causes of poor health promotes health though health services at the primary care level enhances health of the community” [ 12 ]. Comparison/contrast is not appropriate for this review. The outcome is improved access to essential healthcare services.

Outcome measures

The outcome of this review is access to PHC services, such as preventive, promotive, curative, rehabilitative, and palliative health services which are affordable, convenient or acceptable, and available to all who need care.

Criteria for considering studies for this review

All published and unpublished qualitative and/or mixed method studies conducted to improve access to PHC services were included. Government and international or national organizations reports were also included. Different organizations whose primary mission is health or promotion of community health were selected. We included articles based on these eligibility criteria: context or scope of studies (access to PHC services), article type (primary studies), and publication language (English). Articles published other than English language, citations with no abstracts and/or full texts, reviews, and duplicate studies were excluded. We included all articles available in different electronic databases regardless of their publication years. We didn’t use time of publication for screening.

Information sources and search strategy

We searched relevant articles from MEDLINE, Scopus, Web of Science, WHO Global Health Library, and Google Scholar to access all forms of evidence. An initial search of MEDLINE was undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe articles. We used the aforementioned performance indicators of PHC delivery and the PICO as we described above to choose keywords. A second search using all identified keywords and index terms was undertaken across all included databases. Thirdly, references of all identified articles were searched to get additional studies. The full electronic search strategy for MEDLINE, a major database we used for this review is included as a supplementary file (Additional file 1 : Appendix 1).

Study selection and assessment of methodological quality

Search results from different electronic databases were exported to Endnote reference manager version 7 to remove duplication. Two independent reviewers (ZG and BA) screened out records. An initial screening of titles and abstracts was done based on the PICO criteria and language of publication. Secondary screening of full-text papers was done for studies we included at the initial screening phase. We further investigated and assessed records included in the full-text articles against the inclusion and exclusion criteria. We sat together and discussed the eligibility assessment. The interrater agreement was 90%. We resolved disagreements by consensus for points we had different rating. We used the PRISMA flow diagram to summarize the study selection processes.

Methodological quality of the included studies was assessed using mixed methods appraisal tool (MMAT) version 2018 [ 13 ]. As it is clearly indicated in the user guide of the MMAT tool, it is discouraged to calculate an overall score from the ratings of each criterion. Instead, it is advised to provide a more detailed presentation of the ratings of each criterion to better inform quality of the included studies. The rating of each criterion was, therefore, done as per the detail explanations included in the guideline. Almost all the included full text articles fulfilled the criteria and all the included full text articles were found to be better quality.

Data extraction

We independently extracted data from papers included in the review using JBI mixed methods data extraction form. This form is only used for reviews that follow a convergent integrated approach, i.e. integration of qualitative data and qualitative data [ 14 ]. The data extraction form was piloted on randomly selected papers and modified accordingly. One reviewer extracted the data from the included studies and the second reviewer checked the extracted data. Disagreements were resolved by discussion between the two reviewers. Information was extracted from each included study on: list of authors, year of publication, study area, population of interest, study type, methods, focus of the studies, main findings, authors’ conclusion, and limitations of the study.

Synthesis of findings

The included full-text articles were qualitatively analyzed using emergent thematic analysis approach to identify key concepts and coded them into related non-mutually exclusive themes. Themes are strategies mentioned or discussed in the included records to improve access to PHC services. Themes were identified manually by reading the included records again and again. We then synthesized each theme by comparing the discussion and conclusion of the included articles.

Systematic review registration number

The protocol of this review is registered in PROSPERO (the registration number is: CRD42019132592) to avoid unplanned duplication and to enable comparison of reported review methods with what was planned in the protocol. It is available at https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019132592 .

Schematic of the systematic review and reporting of the search

We used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009 checklist [ 15 ] for reporting of this systematic review.

Study selection

The search strategy identified 1148 titles and abstracts [914 from PubMed (Table ​ (Table1) 1 ) and 234 from other sources] as of 10 March 2022. We obtained 900 after we removed duplicated articles. Following assessment by title and abstract, 485 records were excluded because these records did not meet the criteria as mentioned in the method section. Additional 256 records were discarded because the records did not discuss the outcome of interest well and some records were systematic reviews. The full text of the remaining 159 records was examined in more detail. It appeared that 49 studies did not meet the inclusion criteria as described in the method section. One hundred ten records met the inclusion criteria and were included in the systematic review or synthesis (Fig.  1 ).

Search terms and number of articles found in PubMed Advanced search as of 10 March 2022

Study selection flow diagram

Of 900 articles resulting from the search term, 110 (12.2%) met the inclusion criteria. The included full-text articles were published between 1993 and 2021. Ninety-two (83.6%) of the included full-text articles were research articles, 5(4.5%) were technical reports, 3 (2.7%) were perspective, 4 (3.6%) was discussion paper, 3(2.7%) were dissertation or thesis, 2 (1.8%) were commentary, and 1 (0.9) was a book. Thirty-six (33%) and 29 (26%) of the included full-text articles were conducted in Africa and North America, respectively (Fig.  2 ).

Regions where the included full-test articles conducted

Key strategies identified

The analysis of 110 full-text articles resulted in 10 themes. The themes are key strategies to improve access to PHC services in rural communities. The key strategies identified are community health programs or community-directed healthcare interventions, school-based healthcare services, student-led healthcare services, outreach services or mobile clinics, family health program, empanelment, community health funding schemes, telemedicine, promoting the role of traditional medicine, working with non-profit private sectors and non-governmental organizations (NGOs) including faith-based organizations (Table ​ (Table2 2 ).

Key strategies identified to improve access to PHC services in rural communities

Description of strategies

• a. Community health programs or community-directed healthcare interventions

Twenty-four (21.8%) of the full-text articles included in this review discussed that community health programs (CHPs) or community-directed healthcare interventions are best strategies to provide basic health and medical care close to the community to increase access and coverage of essential health services. Community health programs are locally based health promotion, disease prevention, and treatment programs available typically to communities in need and community-directed intervention strategy is an approach in which communities themselves direct the planning and implementation of intervention delivery. Rural communities, especially, in developing countries have no access to healthcare facilities in the near distance and have less chance to receive healthcare from doctors, health officers, nurses or midwives. In response to this critical problems, many countries have been investing heavily in community based primary health care to bring services to rural and remote areas where most of the population lives. Community health programs include construction of health posts or community health centers close to the community and deployment of community health workers (CHWs), such as health extension workers, to reach-out every village, who play a prominent role as the gatekeepers of healthcare in rural communities. Community-directed healthcare intervention is an approach in which communities themselves direct the planning and implementation of healthcare interventions. Community participation remains crucial in the identification of health problems, planning or designing of health interventions and implementation of the interventions, which enhances need-based and demand-driven provision of health services while promoting sustainability and ownership (Additional file 2 : Appendix 2, Table A1).

• b. School-based primary healthcare

In this review, 9 of 110 (8.2%) of the included full-text articles pointed out that school-based healthcare services can be effective to improve access to PHC services. School-based health services are health programs that offer health care to children and youth either in a school or on school grounds and usually staffed according to school community needs and resources. School-based health services provide a variety of healthcare services to underserved children, youth and vulnerable populations in a convenient and accessible environment. Access to comprehensive health services via schools leads to improved access to healthcare (Additional file 3 : Appendix 3, Table A2).

• c. Student-led healthcare services

In this review, 5 of 110 (4.5%) of the full-text articles discussed that the use of medical and health science students as healthcare service providers can minimize problems related with shortage of health professionals in rural healthcare system and can play appreciable roles to minimize healthcare service access problems in rural communities. Student-led healthcare services are developed through consultation between universities and local health providers and are purposefully designed clinical placements with a focus on clinical educational activities for pre-registration students. Student-led clinics link students, healthcare professionals, community-based organizations, universities, and communities. In this approach, students can gain practical experience in an interdisciplinary setting and through exposure to a community with unique and severe needs (Additional file 4 : Appendix 4, Table A3).

• d. Outreach services or mobile clinics

In this systematic literature review, 18 of 110 (16.4%) of the included studies discussed that outreach services or mobile clinics in primary care and rural hospital settings can improve access to PHC services in rural communities. Mobile outreach service is defined as healthcare services provided by a mobile team of trained providers, from a higher-level health facility to a lower-level health facilities or locally available community facilities that are not used for clinical services, such as schools, health posts, or other community structures. Outreach services improve access to specialists and hospital-based services, strengthen connections between specialists and PHC providers, and give the benefits of consultations in primary care settings. Specialist outreach services have the potential to overcome access barriers faced by disadvantaged rural and remote communities. Furthermore, a community-based mobile clinics can be effective in uncovering illness and in directing patients to a healthcare home (Additional file 5 : Appendix 5, Table A4).

• e. Family health program

Four (3.6%) of the included full-text articles discussed that family health program (FHP) is highly cost-effective tool for improving access to healthcare services for deprived areas (such as rural communities). Family health program means the program is a program designed to provide primary care as well as the prevention and early treatment of communicable and non-communicable diseases in defined populations by deploying interdisciplinary healthcare teams include physicians, nurses, nurse assistants, and full-time community health agents. It has evolved into a robust approach to providing primary care for defined populations by deploying interdisciplinary healthcare teams. The nucleus of each team includes a physician, a nurse, a nurse assistant, and full-time community health agents. This approach is effective on improving access to healthcare and eliminating health disparities (Additional file 6 : Appendix 6, Table A5).

• f. Empanelment

This systematic review of literature identified that empanelment (also known as rostering) is a best strategy to proactively provide coordinated primary healthcare towards achieving universal health coverage. Empanelment is a continuous, iterative set of processes that identify and assign populations to facilities, care teams, or primary care providers who have a responsibility to know their assigned population. It enables health systems to improve health outcomes and to reduce costs. Empanelment establishes a point of care for individuals and simultaneously holds primary healthcare providers and care teams accountable for actively managing care for a specific group of individuals (Additional file 7 : Appendix 7, Table A6).

• g. Community health funding schemes

In this systematic review of literature, 11 (10%) of the included articles discussed that community health funding schemes such as community-based health insurance (CBHI) increases access to healthcare services in low-income rural communities. Community-based health insurance schemes are usually voluntary and characterized by community members pooling funds to offset the cost of healthcare. Moreover, this approach is effective to mobilize domestic resources for health at low income levels. For low-income countries, community health financing has modest ability to increase the total amount of funds for healthcare. Properly structured community health financing system can significantly improve efficiency, reduce the cost of healthcare, improve quality and health outcomes, and pool risks. Community-financing schemes could improve preventive services and reduce the incidence of diseases. It could also improve people’s access to healthcare and the quality of services, thus improving their health status. Community health financing could also improve risk pooling and reduce health-induced impoverishment. Community health insurance has potential positive impacts on health and social security (Additional file 8 : Appendix 8, Table A7).

• h. Telemedicine

In this review, 13 of 110 (11.8%) articles discussed that telemedicine is one of the solutions for rural subspecialty healthcare delivery. Telemedicine can be defined as the use of technology (computers, video, phone, messaging) by a medical professional to diagnose and treat patients in a remote location. The provision of subspecialty services using telemedicine to a remote and medically underserved population provides improved access to subspecialty care. Telemedicine brings sustainable healthcare to rural populations. Use of information and communication technologies in support of health and health-related fields, including healthcare services, health surveillance, health education, and health research has the potential to greatly improve health service efficiency, expand or scale up treatment delivery to thousands of patients in the rural populations (Additional file 9 : Appendix 9, Table A8).

• i. Promoting the role of traditional medicine

Seven (6.4%) of the included articles showed that incorporating traditional healers into public health system addresses healthcare needs of people with limited access to allopathic medicine. Traditional medicine is the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness. Knowledge about traditional medicine has a catalyzing effect in meeting health sector development objectives. Integrating traditional medicine into national health systems in combination with national policy and regulation for products, practices and providers can enhance access to PHC services in remote populations (Additional file 10 : Appendix 10, Table A9).

• j. Working with non-profit private sectors and non-governmental organizations

In this systematic review, 15 of 110 (13.6%) of the included articles revealed that working with non-profit private sectors and NGOs strengthens the healthcare system. Involving the non-profit private sectors, faith-based organizations (FBOs), and NGOs for health system strengthening eventually contributes to create a healthcare system reflecting an increased efficiency, more equity and good governance in health. International and local NGOs have endeavored to fill the gaps in access to healthcare services, research and advocacy. Non-profit private sectors and NGOs have a key role in improving health in low- and middle-income countries. With networks that reach even the most remote communities, many FBOs are well positioned to promote demand and access for healthcare services. Partnership among FBOs is critical in increasing access to healthcare services, and ensuring sustainability by influencing behaviors at the community, family and individual level. Faith-based organizations play an integral role in the healthcare system by increasing health seeking behaviors and delivering supportive services that address common access and cultural barriers (Additional file 11 : Appendix 11, Table A10).

This systematic literature review found that community health programs or community-directed healthcare interventions, school-based healthcare services, student-led healthcare services, outreach services or mobile clinics, family health program, empanelment, community health funding schemes, telehealth, integrative medicine, and working with non-profit private sectors and NGOs are key strategies to improve access to PHC services in rural communities. The identified strategies address the four major pillars of primary healthcare (i.e., community participation, inter-sectoral coordination, appropriate technology, and support mechanism made available) [ 126 ]. Moreover, the identified strategies are effective to improve access to healthcare services to rural communities. Moreover, the identified strategies are effective to solve shortage of manpower and to build knowledge and skill of the local health workforces in rural healthcare system. The ability of a healthcare system to meet health needs of the population depends largely on the knowledge, skills, motivation and deployment of the people responsible for organizing and delivering health services. The results of this review can strengthen the health information system, which are core elements of the healthcare system that ensure community engagement through dissemination and use of timely and reliable health information to rural populations. This review also suggests strategies to narrow down the health disparities among rural populations, which is wide in most Least and Middle Income Countries (LMICs). Healthcare services are usually disproportionately concentrated in major urban areas. As a result, rural communities face growing health disparities, largely attributed to weak policies, inefficiencies, poor leadership, and governance in healthcare system.

This review identified that community health programs or community-directed healthcare interventions address health disparities by ensuring equitable access to health resources in communities where health equity is limited by socioeconomic and geographical factors. Community health programs include identifying and prioritizing public health problems in a specific geographic area; designing and implementing public health interventions (such as establishing community health centers, mobile clinics, and outreach programs); providing services (such as health education, screenings, social support, and counseling), and deploying community health workers to promote healthy behaviors; advocating for improved care for populations at risk; and working with stakeholders to address community healthcare needs [ 16 – 18 , 127 – 130 ]. The community-oriented PHC model which is socially responsive medicine makes a healthcare system more rational, accountable, appropriate, and socially relevant to the public. Consequently, this model serves as a paradigm for reforming healthcare systems. Community-directed interventions can be considered as a realistic means to increase accessibility of interventions at community-level in rural areas [ 32 – 38 ]. This approach is best in situations where there are cultural barriers to implement interventions because this strategy is effective to develop ownership in the community. In-service and on-the-job training for community health workers, close supervision and government support, and program evaluation is very important to strengthen the community health program [ 131 – 133 ].

This review identified that school-based PHC services are effective strategies to improve access to PHC services. School-based health services provide a variety of healthcare services to children, youth and vulnerable populations in a convenient and accessible environment which indirectly improve leadership and governance. Science teachers and home room teachers play important roles to implement this strategy. It impacts on delivering preventive care such as immunizations, managing chronic illnesses and providing reproductive health services for adolescents. Comprehensive health services via schools improve access to healthcare information [ 40 – 47 ]. Access to school around the world increased drastically in the last century [ 134 ]. This high schooling rate is a good opportunity to provide healthcare services to school learners in accessible places and to disseminate health messages to families. Prior researches suggest that school-based healthcare services increase access to healthcare by increasing utilization of primary care, prevention services, and health maintenance visits [ 135 , 136 ]. Including science teachers, home room teachers, school principals, students, communities, community health workers, and other interested parties in the school-based healthcare system as main actors or promoters must be considered to sustain the impact. Health and education sectors should work in collaboration with the above-mentioned actors to plan, implement and monitor the progress. School-based healthcare services are preferable in situations when there is high schooling rate and limited access to healthcare institutions. This strategy is also an alternative way in areas where the health seeking behavior of the community is low.

The use of medical and health science students in rural healthcare system was identified as a key strategy to minimize health inequalities in rural communities due to shortages in health workforce and distribution of healthcare resources [ 49 – 53 ]. Student-led health intervention is an alternative approach to provide essential healthcare services to the community where there is shortage of healthcare workers [ 137 , 138 ]. Students will have opportunities to learn professional skills and competencies while they are providing healthcare services to the community. Moreover, benefits for student learning include increased communication, collaboration, and leadership skills [ 53 , 139 ]. Student-led health intervention also enables increased access to services, more time for assessments and treatments, increased depth of health teaching, holistic and integrated healthcare, and free health supports [ 140 – 143 ]. However, the use of medical and health science students in the rural healthcare system may have ethical and competency issues. Supporting strategies such as close supervision, preparing clear protocols, and including senior experts in the team should be considered.

This systematic review of literature found that outreach services or mobile clinics can improve access to PHC service delivery in rural populations [ 54 – 69 ]. In developing countries, the highest proportion of people lives in rural areas where doctor services are not available. Rural communities travel to major cities to get specialist services. This reflects a desire for closer integration between primary and secondary care. Specialist outreach services or mobile clinics have become one of the effective solution to solve health disparities, to improve access to healthcare services, and to build capacity of local healthcare workforces. This strategy is preferable in situations when there are high loads in tertiary or referral level hospitals and when there is high patient leakage in the referral system [ 63 – 69 ]. However, the implementation may not be easy. It needs well established healthcare system and budget. Moreover, the efficiency of care may be lower compared with hospital-based cares and the effect on patients’ health outcomes might be small [ 56 , 57 , 61 ] . Irregular specialist visits in rural areas may not have real impacts unless the services are sustainable with a strong commitment at national and local levels. Outreach activities should be included in health policies with strong leadership, healthcare financing, and private initiatives must be encouraged to maintain the activities over time.

This review revealed that FHP is highly effective tool for improving health for rural communities. The FHP has provided a new, more robust model of primary healthcare services designed to provide accessible, first contact, comprehensive, and whole person care that is coordinated with other healthcare services. It has positive results to improved availability, access to, and use of health services, and improved health indicators, such as reduced infant mortality, improved detection of cases of neglected diseases, and reduced health disparities [ 73 , 144 – 146 ]. The FHP deploys interdisciplinary healthcare teams. The team includes a physician, a nurse, a nurse assistant, and full-time community health agents. Family health teams are organized geographically. The teams are responsible for delivering public health interventions [ 72 , 74 ]. Family health program is an alternative strategy in rural healthcare system in situations when there are inequities in access to care; when there is high hospitalization rate; when there is low health seeking behavior in the community; and when there is poor case detecting and reporting system. Despite these remarkable achievements, the FHP has some challenges include difficulties in the recruitment and retention of doctors trained appropriately to deliver primary healthcare, large variations in quality of local care, patchy integration of primary care services with existing secondary and tertiary care, and slow adoption of FHP in large population [ 147 ].

In this review, empanelment has been identified as a best strategy to deliver coordinated primary healthcare towards achieving universal health coverage [ 76 – 79 ]. The goal of empanelment is provide people-centered healthcare services based on their needs to ensure that every established patient receives optimal care, whether he/she regularly visits healthcare centers. Major activities in this approach include assignment of all patients to a healthcare provider panel; update panel assignments on a regular basis; and use panel data to educate, and track patients [ 79 ]. Empanelment enables healthcare systems to improve patient experiences, reduce costs, and improve health outcomes. Empanelment is an effective strategy to deliver four key functions: first-contact accessibility, continuity, comprehensiveness, and coordination [ 148 ]. Effective empanelment requires responsibility for the health of a target population, including providing healthcare services based on their health status, which is an important step in moving towards people-centered integrated healthcare [ 79 ].

This review identified that community health funding schemes such as community-based health insurance (CBHI) increases access to healthcare in low-income rural communities. Moreover, this approach is effective to mobilize domestic resources for health at low income levels [ 80 – 90 ]. Community-based health insurance is an emerging strategy to provide financial protection against the cost of illness. It is an effective strategy to improve access to quality health services for low-income rural households [ 149 ]. Existence of social capital in the community is a determinant factor for the effectiveness of CBHI as social capital has a positive effect on the community's demand for insurance [ 150 , 151 ]. Moreover, solidarity and trust between the members are the key principles for the good functioning of a CBHI. Solidarity and trust stir-up members who are susceptible to risk to put together their resources for common use [ 149 , 152 , 153 ]. Affordability of premiums or contributions, technical arrangements made by the scheme management, timing of collecting the contributions, trust in the integrity and competence of the managers of the CBHI, The quality of care offered through the CBHI, accessible across different population groups are some of the determinant factors to be considered to increase people’s decision to join the CBHI schemes [ 154 , 155 ].

In this review, telemedicine has been identified as one of the many possible solutions for rural subspecialty healthcare delivery. Telemedicine is a vital technological tool to increase healthcare access, improve care delivery systems, engage in culturally competent outreach, health workforce development, and health information system [ 91 – 100 ]. Telemedicine can be a great alternative to the traditional healthcare system in situations like diagnoses of common medical problems; inquiries about various medical issues for home treatments; post-treatment check-ins or follow-up for chronic care; holidays, weekends, late night or any other situation when regular medical care is not possible; patient inability to leave the house; patients who lack regular access to relevant medical expertise in their geographic area ; and etc. However, technological issues are challenges when dealing with telemedicine, especially in developing countries. General problems of Internet connectivity and access to infrastructure can minimize benefits of this strategy. Costs associated with technology can also be a barrier. Furthermore, health technology requires human capacity to use it. Therefore, strengthening the information communication technologies (ICT) and human capacity building on ICT are important to address the health needs of the rural communities.

This systematic review of literature identified that promoting the role of TM solves problems of access to allopathic medicine. Integration of TM in health system will result in increased coverage and access to healthcare services. The role of complementary and alternative medicine for health is undisputed particularly in light of its role in health promotion and well-being. It also supports local health workforces [ 104 – 109 ]. Incorporating traditional healers into the public health system addresses healthcare needs [ 156 , 157 ]. However, integrating TM to the public healthcare system is challenging. It is a general belief that TM defies scientific procedures in terms of objectivity, measurement, codification and classification [ 157 ]. If integrated, who provides training to medical doctors on the ontology, epistemology and the efficacies of TM in modern medicine [ 157 ]. Due to these, some scholars suggest that both TM and modern medicine be allowed to operate and develop independent of one another [ 158 , 159 ]. Another fundamental challenge to TM is the widespread reported cases of fake healers and healings [ 157 ]. Generally, this strategy is more of feasible in areas where formal trainings on integrative medicine are available. Even though the integration is challenging, the health sector can use traditional healers as health educators or health promoters by providing training and continuous support. It can be also possible to use traditional healers as facilitators in the community-directed approaches. In general TM can be used in the primary healthcare system where no access to allopathic medicine and when conventional medicine is ineffective in treatment of disease [ 160 ].

Working with non-profit private sectors and NGOs has been identified as effective strategies to strengthen the healthcare system in developing countries [ 111 – 118 ]. Since governments in developing countries are challenged to meet the health needs of their populations because of financial constraints, limited human resources, and weak health infrastructure; the private sector (especially the non-profit private sectors) and non-governmental organizations can help expand access to healthcare services through its resources, expertise, and infrastructure. However, the presence of an NGO in the operation, may contribute to unrealistic expectations of health services, affecting perceptions of the latter negatively [ 113 ]. Moreover, reports have it that besides other issues in many instances NGOs allocated funds only to disease specific projects (vertical programming) rather than to broad based investments (horizontal programming) [ 161 ]. There are also concerns that donor expenditures in developing countries are not only unsustainable but may be considered as inadequate considering the enormous healthcare burden [ 161 – 164 ]. To avoid unrealistic expectations and dissatisfaction, and to increase and sustain the population’s trust in the organization, NGOs should operate in a manner that is as integrated as possible within the existing structure and should work close to the population it serves, with services anchored in the community. Moreover, faith-based organizations contribute in health such as disease prevention, health education or promotion, and community health development beyond psychological and spiritual care [ 119 – 124 ]. Religious organizations can reach all segments of rural populations. Therefore, integrating PHC services, especially health education and promotion, diseases prevention and community health development with religious organizations intensifies delivery of healthcare services. Working with FBOs is a best way in situations where cultural and faith-based barriers are common and in areas, where access problems are often related to lack of providers. However, religious organizations need intensive training on health promotion and health system to enable them to respond to local contexts within the framework of national policies. Moreover, there should be strong partnership with government agenesis to sustain the effort [ 165 – 168 ].

Contribution of this review

Various studies reported one or more strategies to improve access to primary healthcare services. However, the strategies reported by individual studies are not compiled together and there is lack of pooled evidence on effective strategies to improve access to healthcare system. This systematic literature review was, therefore, conducted to compile effective strategies to improve access to healthcare services in rural communities. The review suggests key strategies to improve access to PHC services in rural communities. These suggested strategies are implementable in countries that suffer from shortage of health workers and healthcare financing because all the strategies used locally available opportunities. The local healthcare system needs, therefore, scan the available opportunities in the locality for implementing the suggested strategies and needs to integrate the strategies in the healthcare system to sustain the impacts. Healthcare providers, researchers and policy makers could use the results of this systematic literature review to increase access to healthcare services in hard-to-reach areas. As the strategies are compiled from experiences of different countries (developed and least developed countries), there might be contextual differences like socio-economic, cultural, institutional, and geographical challenges to adopt the identified strategies. Moreover, some of the experiences only come from one or two countries. Therefore, strategy developers and implementers need to consider these contextual challenges or variation during adopting and implementing different strategies.

Strengths and limitations of the study

As a strength, this systematic review explores international (both developed and developing countries) best experiences on primary healthcare service delivery and identified ten key approaches to improve access to PHC services in rural communities. We also searched relevant published or unpublished articles, dissertations or theses, discussion papers, and perspectives from a wide range of sources, such as MEDLINE, Scopus, Web of Science, WHO Global Health Library, and Google Scholar.

As a limitation, we entirely relied on electronic databases to search relevant articles. We didn’t include locally available printed out records. We also applied limits for language. We excluded articles published other than English language. We believed we could get more relevant articles if we had access to records available in prints and if we include articles published other than English language. Furthermore, since the strategies are compiled from experiences of different countries (developed and least developed countries), there might be contextual differences like socio-economic, cultural, institutional and geographical challenges to adopt the identified strategies. There was also limited evidence for some articles, especially reports to rate their methodological quality. Readers should also note that our review might missed some important work in improving access to PHC services and the identified strategies are not the only strategies to improve access to PHC services. There might be other effective strategies which are not included in this review. In addition generalizability might be affected since some of the experiences only come from one or two countries. Moreover, this review focuses on access not quality of care delivered.

This review identified key strategies from international experiences to improve access to PHC services in rural communities. These strategies are effective to improve access to healthcare services in rural or remote communities. They can also play roles in achieving UHC and reducing disparities in health outcomes and increase access to rural communities to get healthcare when and where they want. Therefore, incorporating these key strategies suggested by this review in to the healthcare system is useful to enhance PHC services and to minimize impacts of health disparity in rural communities. However, the identified strategies may not be easy to implement. Increasing number and capacity of human resource for health; strengthening the healthcare financing system; improving medicine and supplies; working in different partners and communities; establishing monitoring and evaluation system; strong and committed leadership; and encouraging private initiatives must be considered to implement and maintain these strategies over time. Moreover, policy makers, program planners and implementers who want to utilize findings of this review should be aware that these are not the only effective strategies to improve access to primary healthcare services.

Acknowledgements

The author would like to thank IPHC- E for funding this review.

Abbreviations

Authors’ contributions.

ZG prepared the manuscript. TA and GMK critically reviewed the protocol and manuscript. All the authors read and approved the final manuscript.

This review was funded by International Institute for Primary Health Care- Ethiopia (IPHC- E).

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This manuscript does not contain any individual person’s data.

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Managing Logistics and Supply Chain in Rural Areas: A Systematic Analysis of the Literature and Future Directions

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• Pietro Evangelista 6 ,
• Bettina Williger 7 ,
• Girma Gebresenbet 8 &
• Serena Micheletti 6  

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Despite half of the world population lives not in metropolitan areas but in sparsely populated zones, the rural contexts have been at the periphery of logistics and supply chain management research. The main aim of this paper is to explore the state-of-the-art of the literature on rural supply chain management using a systematic approach. A sample of 51 papers from different disciplines with a management focus have been retrieved and analysed in details. A literature classification framework based on three different topic areas and related sub-topic areas was proposed. Seven research gaps have been identified that may inspire future research in this area. Interestingly, none of the papers identified has an explicit focus on the link between rural supply chain management and local development. To the best of the authors’ knowledge, this study is the first attempting to collect, analyse and classify scientific papers related to rural supply chain management.

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Due to space limitation, the references in square brackets concerning background or methodological papers have been incorporated in the text. To ensure the transparency of method used, the bibliographical references cited in Sect.  4 have been reported in the text indicating the author/s and the year of publications. However, the full list of the 51 papers included in the final sample is available on request.

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Lagorio, A., Pinto, R., Golini, R.: Research in urban logistics: a systematic literature review. Int. J. Phys. Distrib. Logist. Manag. 46 (10), 908–931 (2016). https://doi.org/10.1108/IJPDLM-01-2016-0008

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EPRS: Short food supply chains and local food systems in the EU (2016). http://www.fao.org/family-farming/detail/en/c/427183/ . Accessed 15 Feb 2020

EPRS: Local agriculture and short food supply chains (2013). https://epthinktank.eu/2013/10/14/local-agriculture-and-short-food-supply-chains/ . Accessed 15 Feb 2020

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Evangelista, P., Williger, B., Gebresenbet, G., Micheletti, S. (2021). Managing Logistics and Supply Chain in Rural Areas: A Systematic Analysis of the Literature and Future Directions. In: Bevilacqua, C., Calabrò, F., Della Spina, L. (eds) New Metropolitan Perspectives. NMP 2020. Smart Innovation, Systems and Technologies, vol 178. Springer, Cham. https://doi.org/10.1007/978-3-030-48279-4_15

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Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention

Affiliation.

• 1 School of Public Health, University of the Western Cape, Bellville 7535, South Africa. [email protected]
• PMID: 18215313
• PMCID: PMC2259330
• DOI: 10.1186/1472-6963-8-19

Background: Many countries in middle- and low-income countries today suffer from severe staff shortages and/or maldistribution of health personnel which has been aggravated more recently by the disintegration of health systems in low-income countries and by the global policy environment. One of the most damaging effects of severely weakened and under-resourced health systems is the difficulty they face in producing, recruiting, and retaining health professionals, particularly in remote areas. Low wages, poor working conditions, lack of supervision, lack of equipment and infrastructure as well as HIV and AIDS, all contribute to the flight of health care personnel from remote areas. In this global context of accelerating inequities health service policy makers and managers are searching for ways to improve the attraction and retention of staff in remote areas. But the development of appropriate strategies first requires an understanding of the factors which influence decisions to accept and/or stay in a remote post, particularly in the context of mid and low income countries (MLICS), and which strategies to improve attraction and retention are therefore likely to be successful. It is the aim of this review article to explore the links between attraction and retention factors and strategies, with a particular focus on the organisational diversity and location of decision-making.

Methods: This is a narrative literature review which took an iterative approach to finding relevant literature. It focused on English-language material published between 1997 and 2007. The authors conducted Pubmed searches using a range of different search terms relating to attraction and retention of staff in remote areas. Furthermore, a number of relevant journals as well as unpublished literature were systematically searched. While the initial search included articles from high- middle- and low-income countries, the review focuses on middle- and low-income countries. About 600 papers were initially assessed and 55 eventually included in the review.

Results: The authors argue that, although factors are multi-facetted and complex, strategies are usually not comprehensive and often limited to addressing a single or limited number of factors. They suggest that because of the complex interaction of factors impacting on attraction and retention, there is a strong argument to be made for bundles of interventions which include attention to living environments, working conditions and environments and development opportunities. They further explore the organisational location of decision-making related to retention issues and suggest that because promising strategies often lie beyond the scope of human resource directorates or ministries of health, planning and decision-making to improve retention requires multi-sectoral collaboration within and beyond government. The paper provides a simple framework for bringing the key decision-makers together to identify factors and develop multi-facetted comprehensive strategies.

Conclusion: There are no set answers to the problem of attraction and retention. It is only through learning about what works in terms of fit between problem analysis and strategy and effective navigation through the politics of implementation that any headway will be made against the almost universal challenge of staffing health service in remote rural areas.

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• Career Choice*
• Developing Countries*
• Medically Underserved Area*
• Personnel Loyalty
• Personnel Selection
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• Rural Health Services*

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• Published: 27 May 2024

Knowledge creates value: the role of financial literacy in entrepreneurial behavior

• Shulin Xu 1 &
• Kangqi Jiang 2  

Humanities and Social Sciences Communications volume  11 , Article number:  679 ( 2024 ) Cite this article

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Under the backdrop of economic globalization and the digital economy, entrepreneurial behavior has emerged not only as a focal point of management research but also as an urgent topic within the domain of family finance. This paper scrutinizes the ramifications of financial literacy on household entrepreneurial behavior utilizing data from China’s sample of the China Household Finance Survey spanning the years 2015 and 2017. Employing the ordered Probit model, we pursue our research objectives. Our findings suggest that financial literacy exerts immediate, persistent, and evolving positive effects on households’ engagement in entrepreneurial activities and their proclivity toward entrepreneurship. Through the mitigation of endogeneity in the regression model, the outcomes of the two-stage regression corroborate the primary regression results. An examination of heterogeneity unveils noteworthy disparities between urban and rural areas, as well as gender discrepancies, in how financial literacy influences household entrepreneurial behavior. Furthermore, this study validates three potential pathways—namely income, social network, and risk attitude channels—demonstrating that financial literacy significantly augments household income, expands social networks, and enhances risk attitudes. Moreover, through supplementary analysis, we ascertain that financial education amplifies the impact of financial literacy on entrepreneurial behavior. Our study contributes to the enrichment of human capital theory and modern entrepreneurship theory. It advocates for robust efforts by governments and financial institutions to widely disseminate financial knowledge and foster family entrepreneurship, thereby fostering the robust and stable operation of both the global financial market and the job market.

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Introduction.

With the advancement of the global digital economy, entrepreneurship has increasingly emerged as a pivotal strategy for corporate strategic development (Cheng et al., 2024 ) and for the accumulation of residents’ wealth. Entrepreneurial behavior entails the optimization and integration of one’s own resources to generate substantial economic or social value. Individuals are expected to possess organizational and managerial abilities and to deliberate upon and determine the operational strategies for services, technologies, and equipment to engage in rational entrepreneurial endeavors (Levesque and Minniti, 2006 ). Entrepreneurial activities play a crucial role in fostering labor market prosperity, achieving social equity, enhancing the flow of social capital, and sustaining the healthy and stable functioning of the social economy (Hombert et al., 2020 ; Schmitz, 1989 ). They also hold promise for alleviating the current economic crisis through the exploitation of renewable energy sources (Abou Houran, 2023 ) and enhancing firm productivity (Tao et al., 2023 ). According to human capital theory, as posited by Becker ( 2009 ), human capital encompasses the cumulative knowledge, skills, cultural sophistication, and health status of an individual. Financial literacy, as a form of scarce human capital, constitutes a significant driver of entrepreneurial decision-making and motivation. On the one hand, the migration of individuals possessing high financial literacy fosters the transfer of theoretical knowledge and technical expertise, while the symbiotic interaction of knowledge, skills, and capabilities nurtures a reservoir of knowledge and entrepreneurial dynamism. On the other hand, individuals with elevated financial literacy are more likely to enhance their awareness and identification of opportunities within an imbalanced market, thereby bolstering their self-awareness and catalyzing independent innovation and entrepreneurship. Moreover, in line with modern entrepreneurship theory, Alvarez and Busenitz ( 2001 ) contend that entrepreneurial opportunities are endogenous. Entrepreneurs equipped with the requisite skills and knowledge pertaining to entrepreneurship are better positioned to identify and exploit opportunities. Additionally, they possess extensive and efficacious social networks, enabling them to access valuable information and resources conducive to enhancing entrepreneurial performance. Against the backdrop of economic globalization and the digital economy, governments worldwide are actively encouraging entrepreneurial engagement. They have enacted financial support policies and preferential tax measures to enhance the domestic entrepreneurial ecosystem and to galvanize individuals’ entrepreneurial potential. For instance, the Chinese government introduced numerous policies aimed at fostering entrepreneurial endeavors in 2018. Similarly, the U.S. government is proactively implementing several initiatives to foster an environment conducive to the flourishing of small and medium-sized enterprises, striving to institute permanent tax relief measures for small businesses.

However, the enhancement of the entrepreneurial environment can engender a proliferation of entrepreneurial opportunities (Segaf, 2023 ). Yet, the ability of entrepreneurs to seize such opportunities for proactive entrepreneurship remains constrained by numerous factors, including the development of the digital economy (Sussan and Acs, 2017 ; Firmansyah et al., 2023 ; Zhao and Weng, 2024 ), social networks (Karlan, 2007 ; Qi and Chun, 2017 ), human capital (Dawson et al., 2014 ), risk attitudes (Osman, 2014 ), government regulations (Black and Strahan, 2002 ), institutional environments (Burtch et al., 2018 ; Lan et al., 2018 ), institutional changes within universities (Eesley et al., 2016 ), financial constraints (Hurst and Lusardi, 2004 ; Asongu et al., 2020 ), policy interventions (Sharipov and Zaynuidinova, 2020 ), cognitive abilities (Haynie et al., 2012 ), personal beliefs regarding character and opportunity (Pidduck et al., 2023 ), household background, income levels, and trust (Kwon and Arenius, 2010 ). Entrepreneurial activities entail the identification and exploitation of entrepreneurial opportunities and the utilization of entrepreneurial resources. These endeavors invariably entail considerations of business management, financial matters, and professional concerns. Entrepreneurs must possess adequate financial literacy to ensure the rationality of entrepreneurial decision-making, the judicious allocation of entrepreneurial resources, the mitigation of venture capital risks, and the effective operation of enterprises. Drawing from a review of international experiences, scholars predominantly emphasize macroeconomic environments (Arin et al., 2015 ), institutional frameworks, cultural disparities (Liang et al., 2018 ), credit constraints (Ma et al., 2018 ), liquidity constraints (Beck et al., 2018 ), as well as micro-level factors such as social networks (Yueh, 2009 ), and information availability (Companys and McMullen, 2007 ), when examining the determinants of entrepreneurial activities.

From a current static perspective, existing studies indicate a close association between financial literacy and a range of financial behaviors and economic outcomes. A wealth of evidence demonstrates that financial literacy fosters household income growth (Behrman et al., 2012 ), facilitates the expansion of social networks (Kinnan and Townsend, 2012 ; Suresh, 2024 ), and enhances residents’ risk attitudes (Mishra, 2018 ), all of which can also impact entrepreneurial behavior. Thus, we posit that financial literacy may influence household entrepreneurial activities through three primary channels. Firstly, prior research has affirmed that higher levels of financial literacy correlate with enhanced information acquisition and processing abilities, leading to more informed decision-making (Forbes and Kara, 2010 ; Molina-García et al., 2023 ), fostering healthier and more rational investment philosophies and habits. These factors, in turn, contribute to improved investment returns and elevated household income levels. Household entrepreneurial activities necessitate sufficient financial support for use as entrepreneurial funds, and throughout the entrepreneurial process, a continuous stream of funds is required for operational and managerial purposes. Household wealth and income serve as the principal resources for family entrepreneurship, indispensable for entrepreneurial endeavors.

Secondly, studies by Korkmaz et al. ( 2021 ), Mishra ( 2018 ), and Mushafiq et al. ( 2023 ) reveal that heightened levels of financial literacy correlate with an increased likelihood of risk-taking or risk-neutrality and diminished tendencies toward risk aversion. This indicates that enhancing financial literacy significantly bolsters individuals’ risk appetites and reduces risk aversion. Entrepreneurship inherently entails risk-taking behavior and a willingness to embark on new ventures. Therefore, risk attitudes are intricately linked to entrepreneurial behavior. Research by Van Praag and Cramer ( 2001 ), as well as Long et al. ( 2023 ), spanning a 41-year study of 5800 Danish students, illustrates significant disparities in entrepreneurial willingness among individuals with varying risk preferences, with risk-conscious individuals exhibiting stronger inclinations towards entrepreneurship. Thirdly, Hong et al. ( 2004 ) and Chen et al. ( 2023 ) posit that financial literacy may proliferate through word-of-mouth or observational learning methods, thereby expanding social network structures. Social networks, as a distinct form of family capital alongside physical and human capital, facilitate risk-sharing (Munshi and Rosenzweig, 2016 ) and augment the likelihood of accessing formal or informal financing (Kinnan and Townsend, 2012 ). It is widely acknowledged that family entrepreneurial activities, to some extent, depend on the support offered by family members, relatives, and friends in terms of information, financing, and business operations and management (Munshi and Rosenzweig, 2016 ). Consequently, broader family social networks correlate with heightened probabilities of choosing entrepreneurship. Financial literacy can effectively mitigate information asymmetry in financial markets by enhancing family social networks, reducing monitoring costs and risky borrowing, and addressing adverse selection and moral hazard issues, thereby alleviating financing constraints and fostering family entrepreneurial activities.

The aforementioned analysis offers insights into the impact of financial literacy on household entrepreneurial activities. Nevertheless, a pivotal inquiry remains: can financial literacy effectively bolster the likelihood of family entrepreneurial choices and entrepreneurial motivation in the long term, thereby dynamically enhancing family entrepreneurial behavior? Furthermore, the urban–rural dichotomy and gender disparities in financial literacy prevalent in numerous countries may introduce variations in the current, long-term, and dynamic effects of financial literacy on residents’ entrepreneurial behavior. This prompts us to explore the existence of such disparities and whether the mechanisms underlying these differences are mediated through income, social networks, and risk attitudes. To address these gaps in the literature and elucidate the raised questions, we propose to establish a robust empirical framework. This framework will enable us to examine how financial literacy influences local households’ entrepreneurial behavior. Figure 1 illustrates our theoretical framework, delineating how financial literacy impacts household entrepreneurial activities through three primary channels.

Theoretical design and framework.

This study empirically examines the immediate, long-term, and evolving impacts of financial literacy on household entrepreneurial activities using data from the China Household Finance Survey (CHFS) for the years 2015 and 2017. We employ the ordered Probit model to fulfill our research objectives. The findings indicate that financial literacy exerts immediate, enduring, and evolving positive effects on households’ involvement in entrepreneurial activities and their propensity toward entrepreneurship. Accounting for the endogeneity of the regression model, the results from the two-stage regression reinforce the primary regression outcomes. Heterogeneity analysis reveals significant urban–rural disparities and gender differences in the influence of financial literacy on household entrepreneurial behavior. Additionally, this research substantiates three potential pathways: income, social network, and risk attitude channels. It demonstrates that financial literacy significantly enhances household income, expands social networks, and improves risk attitudes. Further analysis reveals that financial education amplifies the impact of financial literacy on entrepreneurial behavior.

Our contributions are multifaceted: Firstly, this study advances the understanding of entrepreneurial behavior in several dimensions. Previous research primarily focuses on factors influencing entrepreneurial behavior, such as social networks (Karlan, 2007 ), human capital (Dawson et al., 2014 ), risk attitudes (Osman, 2014 ), government regulation (Black and Strahan, 2002 ), institutional environments (Lu and Tao, 2010 ), financial constraints (Hurst and Lusardi, 2004 ), cognitive ability (Haynie et al., 2012 ), household background, and trust (Kwon and Arenius, 2010 ). Few studies delve into the influence of financial literacy on entrepreneurial behaviors. We address this gap and find that financial literacy positively impacts entrepreneurial behaviors. Secondly, we measure entrepreneurial behavior at the family level, including initiative entrepreneurship in the household finance domain, thereby expanding the existing literature beyond the use of new ventures as a measurement indicator. Most importantly, our study contributes to the enrichment of human capital theory and entrepreneurship theory within the realm of household finance, providing valuable insights into the theoretical understanding of the relationship between financial literacy and entrepreneurial behavior. Thirdly, in mechanism analysis, our study is the first to investigate the three channels through which financial literacy affects household entrepreneurial behavior using CHFS data from 2015 and 2017. Lastly, our study conducts heterogeneity analysis and presents evidence of significant urban-rural disparities and gender heterogeneity in the impact of financial literacy on household entrepreneurial behavior. Furthermore, this research enhances the comprehension of the relationship between financial literacy and financial behavior. While prior studies predominantly focus on the immediate effect of financial literacy on financial behavior, our study delves deeper. We not only explore the immediate impact of financial literacy on entrepreneurial behavior but also probe into its long-term and dynamic improvement characteristics, elucidating the internal mechanisms driving these effects. For policymakers, our research provides a theoretical foundation and empirical validation to formulate entrepreneurship policies. By comprehensively understanding how financial literacy influences household entrepreneurial behavior and acknowledging the heterogeneous effects across urban–rural divides and gender disparities, governments can tailor policies to effectively support and promote entrepreneurship, thereby fostering economic growth and development. Based on the conclusions of this study, governments can fully consider residents’ financial literacy and enhance various influencing channels while encouraging innovation and entrepreneurship, thereby facilitating wealth accumulation, enhancing family welfare, and elevating the national level of innovation and entrepreneurship in entrepreneurial activities. For businesses, our research underscores the pivotal role of financial literacy in entrepreneurial activities, constituting an indispensable aspect of “entrepreneurship.” In the actual operation and management processes of enterprises, managers should prioritize the cultivation of financial literacy, as it can aid in cost reduction and the expansion of social networks, thereby realizing the healthy and stable operation of enterprises.

In the rest of this paper, the section “Literature review” reviews the relevant literature. Section “Methodology” outlines the empirical model and introduces the variables and datasets. Section “Empirical results” describes and discusses the empirical results. Section “Heterogeneity analysis” reports a heterogeneous analysis in geography, gender and income level. The section “Potential mechanism analysis” and “Further analysis: the role of financial education” discusses three channels and analyses. Section “Conclusion” concludes and policy implications.

Literature review

Factors affecting financial literacy.

The financial literacy level of respondents is primarily influenced by both micro and macro environments. Concerning microelements, empirical evidence provided by Lusardi and Mitchell ( 2014 ) suggests that men tend to exhibit higher financial literacy levels than women, largely due to women’s perceived lack of self-confidence. Notably, only elderly women demonstrate high levels of self-assurance, alongside robust investment motivation and financial management interest (Bucher‐Koenen et al., 2017 ). Furthermore, Van Rooij et al. ( 2011 ) contend that age and financial literacy follow a hump-shaped distribution pattern, indicating that young individuals under 15 and seniors over 60 typically exhibit the lowest levels of financial literacy, while the middle-aged group tends to have the highest level. The accumulation of social experience serves to enhance the financial literacy level of the middle-aged demographic (Fong et al., 2021 ; Gamble et al., 2015 ). Moreover, Lusardi et al. ( 2012 ) found a positive correlation between the number of years of education and financial literacy, implying that higher levels of education contribute to the advancement of financial literacy.

The influence of macro-elements on financial literacy permeates various facets, shaping the financial knowledge and skills of young individuals through diverse formal and informal channels such as families, schools, communities, and workplaces (Grohmann et al., 2015 ). Lusardi et al. ( 2010 ) elucidated a direct correlation between the financial literacy of young individuals and the educational level and financial behavior of their parents. Moreover, Lachance ( 2014 ) uncovered that the educational level of neighbors also impacts children’s financial literacy. Danes and Haberman ( 2007 ) observed that while short-term financial literacy education and training exert some effect, direct parental education remains a more potent influencer of children’s financial literacy. Furthermore, parents’ active involvement in financial education and training programs contributes significantly to shaping children’s financial literacy. However, the literature presents mixed findings regarding the efficacy of financial education initiatives. Mandell ( 2008 ) found no enduring effects of financial education in high school on personal financial behavior, whereas Fernandes et al. ( 2014 ) suggested that financial literacy education has a limited impact, with its effectiveness waning over time. Conversely, Bruhn et al. ( 2013 ) and Lührmann et al. ( 2015 ) argued that financial education substantially enhances high school students' financial literacy. Moreover, Song ( 2020 ) conducted a field experiment in China, demonstrating that short-term financial education projects can effectively elevate financial literacy levels, thereby improving financial behavior among individuals with low financial literacy. Regarding social security mechanisms, extant literature indicates that improvements in social security significantly correlate with enhancements in residents’ financial literacy (Lusardi and Mitchell, 2011 ). Additionally, the social milieu plays a pivotal role, with countries experiencing high inflation rates and communities characterized by a high level of financial literacy, transparent banking policies, and frequent interactions with financially literate groups positively influencing individuals’ financial literacy levels (Lachance, 2014 ; Lusardi and Mitchell, 2011 ).

With the rapid proliferation of digital technology in the economic sphere, digitization has emerged as a ubiquitous topic of discussion among scholars (Chen and Jiang, 2024 ; Koskelainen et al., 2023 ; Jiang et al., 2024 ). The digitization of conventional financial industries and the entry of internet companies have catalyzed the growth of the digital finance sector (Jiang et al., 2022 ). Pertinent literature delves into the relationship between the advancement of digital finance and financial literacy (Prete, 2022 ; Yang et al., 2023 ). For instance, Yang et al. ( 2023 ), utilizing data from the China Household Finance Survey, found that financial literacy significantly fosters individuals’ engagement in digital finance, with this effect displaying notable heterogeneity. Drawing from cross-national data, Prete ( 2022 ) observed that the utilization of digital payment tools and platforms correlates with elevated levels of financial literacy. Koskelainen et al. ( 2023 ) endeavored to explore how varied aspects of digitization, encompassing digital financial behaviors, digital interventions, and financial technology, influence individuals’ financial literacy. Furthermore, they propose methodologies for constructing a metric of digital financial literacy.

Entrepreneurial behavior

Existing research concentrates on the determinants of entrepreneurial behavior, encompassing both macroelements and microelements. Macroelements comprise the economic environment, institutional framework, cultural disparities, credit and liquidity constraints, social networks, and information environment.

Economic development stimulates market demand for entrepreneurs and fosters entrepreneurial activities (Arin et al., 2015 ; AlOmari, 2024 ). Zhao and Weng ( 2024 ) observed that the advancement of the digital economy enhances urban innovation activities. Utilizing cross-cultural entrepreneurial cognition models, Lim et al. ( 2010 ) validated the impact of institutions on entrepreneurial activities. A nation’s formal institutions can dictate its level of economic freedom, influencing households’ entrepreneurial motivations and the types of entrepreneurial ventures pursued (McMullen et al., 2008 ; Kshetri, 2023 ). Asoni and Sanandaji ( 2014 ) demonstrated that proportional taxes do not significantly affect entrepreneurial activities, whereas progressive taxes notably boost entrepreneurship. Dong et al. ( 2022 ) revealed that local leadership turnover may serve as a barrier to entrepreneurship. Additionally, the environment for protecting private property rights is intertwined with entrepreneurial activities (Levine and Rubinstein, 2017 ; Hou et al., 2023 ). The deregulation of bank branches has intensified competition within the banking sector while greatly enhancing credit accessibility, thereby promoting household entrepreneurship (Black and Strahan, 2002 ). In terms of cultural disparities, Mora ( 2013 ) posited that such differences lead to variations in entrepreneurial ideas and behavioral tendencies, with entrepreneurial activities more likely to flourish in a cultural milieu characterized by low uncertainty, fostering independent thinking, valuing wealth, and eschewing conformity (Lee et al., 2020 ). Freytag and Thurik ( 2007 ), drawing upon data from European and American countries, concluded that culture exerts a positive and significant impact on entrepreneurial preferences but does not significantly influence actual entrepreneurial activities.

The primary challenge encountered by entrepreneurial endeavors is liquidity constraints (Banerjee and Newman, 1993 ; Ma et al., 2018 ). Banerjee and Newman ( 1993 ) contend that financial support in the form of low-interest loans, financing guarantees, and credit assurances alleviates financing constraints during entrepreneurial pursuits, thereby mitigating business risks. Information asymmetry may curtail the availability of credit services for entrepreneurs and impede household entrepreneurial activities (Stiglitz and Weiss, 1981 ). Wang ( 2012 ) constructed models for employment and housing decision-making, revealing that liquidity constraints influence the interaction between personal wealth and entrepreneurial decision-making. The emergence of digital finance and the Internet has mitigated information asymmetry, moral hazard, and adverse selection, safeguarding entrepreneurs’ financial security (Beck et al., 2018 ; Qing et al., 2024 ). Furthermore, it has expanded product sales channels and enhanced the accessibility of cost-effective financial services (Berger and Udell, 2002 ; He and Maire, 2023 ), thereby fostering household entrepreneurial behavior. However, Hurst and Lusardi ( 2004 ) posit that credit constraints are not the primary impediment to entrepreneurial activities, as entrepreneurs can mitigate such constraints through savings and informal credit channels.

Social networks play a pivotal role in entrepreneurial endeavors. A robust social network can furnish material capital, technical expertise, vital information, and emotional support for household entrepreneurship (Yueh, 2009 ; Yates et al., 2023 ). Social networks effectively alleviate information asymmetry, mitigate adverse selection and moral hazard (Karlan, 2007 ; Kerr and Mandorff, 2023 ), and serve as an implicit guarantee mechanism, reducing the likelihood of default on non-governmental loans (Karlan, 2007 ). Consequently, social networks diminish liquidity constraints, thereby promoting households’ inclination towards entrepreneurship. According to entrepreneurial vigilance theory, information asymmetry gives rise to entrepreneurial opportunities, underscoring the significance of information disparities in entrepreneurial activities (Companys and McMullen, 2007 ; Wang et al., 2024 ). Trust fosters the flow of information among different social groups, cultivating social capital, and residents with greater entrepreneurial opportunities are more inclined towards entrepreneurship (Kwon and Arenius, 2010 ).

Microelements encompass human capital and psychological characteristics. Regarding human capital, Berkowitz and DeJong ( 2005 ) contend that individuals with higher education levels can swiftly and accurately identify potential entrepreneurial opportunities and efficiently allocate internal and external resources. However, compared to those with average education levels, individuals with higher education face higher opportunity costs, leading to lower entrepreneurial motivation. Additionally, some studies find no significant effect of education on entrepreneurial activities (Van der Sluis et al., 2008 ) or observe a non-linear U-shaped relationship (Poschke, 2013 ). Mankiw and Weinzierl ( 2011 ) ascertain that a lack of personal ability significantly dampens households’ entrepreneurial spirit. Entrepreneurial behavior necessitates the acquisition, organization, and analysis of information, with cognitive ability reflecting an individual’s capacity to process, store, and extract information. Thus, Haynie et al. ( 2012 ) posit that cognitive ability may influence an individual’s entrepreneurial activities. Other studies explore the relationship between an individual’s age (Caliendo et al., 2014 ), gender (Koellinger et al., 2013 ), marital status, political outlook (Yueh, 2009 ), entrepreneurial training (Blattman et al., 2014 ), work experience (Lazer, 2005 ), type of employment (Djankov et al., 2005 ), health status (Rey-Martí et al., 2016 ), management elements (Cheng et al., 2022 ), education (Cui and Bell, 2022 ; Adeel et al., 2023 ; Lin et al., 2023 ), entrepreneurial identity (Stevenson et al., 2024 ), and entrepreneurial behavior.

Concerning household wealth, the majority of studies posit a positive correlation between household wealth and entrepreneurial behavior (Evans and Jovanovic, 1989 ). Some studies also explore the impact of accidental exogenous events and policy reforms leading to increased wealth on household entrepreneurial behavior (Blattman et al., 2014 ). In terms of psychological characteristics, extant literature primarily discusses the effect of risk attitude on entrepreneurial behavior. Most studies demonstrate that individual risk preference significantly influences entrepreneurial behavior, with risk-tolerant individuals exhibiting a greater propensity for entrepreneurial activities (Osman, 2014 ). However, Hu ( 2014 ) suggests that risk-neutral individuals are more inclined to engage in active entrepreneurial activities, whereas risk-averse and risk-tolerant individuals are more predisposed to becoming waged workers.

Existing research predominantly concentrates on the determinants of financial literacy and entrepreneurial behavior. Few studies explore the impact of financial literacy on entrepreneurial behavior. This study aims to address this gap.

Methodology

Refer to prior studies (Dong et al., 2022 ; Yang et al., 2023 ; Zhao and Li, 2021 ; Xu et al., 2023 ; Graña-Alvarez et al., 2024 ), this study uses the \({{\rm {Probit}}}\) model to study the current and long-term effects of financial literacy on household entrepreneurial behavior. The basic regression equation is as follows:

When we study the current effect, \({{{\rm {Entrepre}}}}_{i}\) refers to entrepreneurship behavior of household \(i\) in 2015. \({{{\rm {Literacy}}}}_{i}\) represents financial literacy of household i in 2015. \({X}_{i}^{{\prime} }\) refers to control variables in 2015, including \({{\rm {gender}}}\) , \({{\rm {Age}}}\) , \({{{\rm {Age}}}}^{2}\) , \({{\rm {Health}}}\) , \({{\rm {Marriage}}}\) , \({{\rm {Education}}}\) , \({{\rm {RL}}}\) , \({{\rm {RN}}}\) , \({{\rm {RA}}}\) , \({\rm {{CPC}}}\) , \({{\rm {FS}}}\) , \({{\rm {Assets}}}\) , \({{\rm {NC}}}\) , \({{\rm {NE}}}\) , \({{\rm {House}}}\) , and \({{\rm {NU}}}\) . 1 \({\mu }_{i}\) is the error term. In the above regression model, we control the province-fixed effect. The current effect is a static effect based on cross-sectional data, which mainly examines whether the current financial literacy can affect the current household entrepreneurial behavior. Most existing studies only use cross-sectional data to consider current effects.

When we study the long-term effect, \({{{\rm {Entrepre}}}}_{i}\) refers to entrepreneurship behavior of household \(i\) in 2017. \({{{\rm {Literacy}}}}_{i}\) represents the financial literacy of household \(i\) in 2015. Other designs remain unchanged. The long-term effect is mainly to test whether financial literacy can have an effect on lagging entrepreneurial behavior.

Furthermore, we use the \({{\rm {ordered}}\; {\rm {Probit}}}\) model to study the dynamic effect of financial literacy on household entrepreneurial behavior as follows:

Where \({{{\rm {Entrepre}}}}_{i}^{* }\) represents the changes in entrepreneurial behavior household \(i\) during 2015–2017, it is an ordered variable, denoted by −1, 0, and 1, respectively. \({{{\rm {Literacy}}}}_{i}\) represents financial literacy of household \(i\) in 2015. \({\varphi }_{i}\) refers to control variables in 2015. The expression of \(F\) \(\left(\cdot \right)\) function in the model ( 2 ) is as follows:

Where \({{{\rm {Entrepre}}}}_{i}^{* {\prime\prime} }\) is the latent variable of \({{{\rm {Entrepre}}}}_{i}^{* }\) . \({\varepsilon }_{1} < {\varepsilon }_{2} < L < {\varepsilon }_{3}\) all are tangent points. \({{{\rm {Entrepre}}}}_{i}^{* {\prime\prime} }\) has to satisfy:

Financial literacy

Following prior studies (Lusardi and Mitchell, 2014 ; Zhao and Li, 2021 ), Table 1 reports the descriptive statistics of the answers to questions related to financial literacy as survey respondents’ financial literacy level denoted as \({{{\rm {Literacy}}}1}_{i}\) . It shows that 28.67%, 16.39%, and 51.94% of the households answered the questions of interest rate calculation, inflation understanding, and venture capital correctly, respectively, indicating that most Chinese households do not understand and calculate inflation. A total of 48.17% of the households incorrectly answered the questions about interest rate calculation, implying that Chinese households lack the ability to calculate the interest rate.

Factor analysis is also often used to measure financial literacy. Following Lusardi and Mitchell ( 2014 ), we believe that the level of financial literacy represented by wrong answers and failure to answer differs. Considering this, we construct two dummy variables for each question. Therefore, we obtain six dummy variables, including dum1–dum6. The KMO test results in Table 2 show that factor analysis is reasonable. Finally, this study selects the factors with an eigenvalue greater than one as respondents’ financial literacy denoted as \({{\rm {Literacy}}}2\) .

Referring to Zhao and Li ( 2021 ), the explained variable in this study is household entrepreneurial behavior, including \({{\rm {Enterpre}}}1\) and \({{\rm {Entrepre}}}2\) , \(\,{{Entrepre}1}^{* }\) , and \(\,{{{\rm {Entrepre}}}2}^{* }\) . \({{\rm {Entrepre}}}1\) measures whether the interviewed household participates in entrepreneurial behavior and is equal to one when the household is engaged in a self-employed business operation. \({{\rm {Entrepre}}}2\) measures whether the entrepreneurial behavior of entrepreneurial families is active and is equal to 1 if the reason for the household’s participation in entrepreneurship is “want to be the boss”, “earn more”, and “want to be more flexibles and free”. \({{{\rm {Entrepre}}}1}^{* }\) represents the changes in entrepreneurial behavior of households during 2015–2017. \({{{\rm {Entrepre}}}2}^{* }\) represents the changes in initiative entrepreneurship of households during 2015–2017. Its construction method is shown in Table 3 .

The survey data collected by the China Household Finance Survey in 2015 and 2017 are used in this paper. This database collects a large amount of information about Chinese residents through scientific surveys and statistical methods, and it is widely used in scientific research. The CHFS has designed relevant questions about the financial literacy of the interviewees. Samples with missing values are excluded. Table 4 provides the descriptive statistics of the variables. It is worth mentioning that CHFS has been widely adopted (Zhao and Li, 2021 ; Yang et al., 2023 ).

Empirical results

Financial literacy and entrepreneurial behavior.

Columns (1)–(4) in Table 5 report the estimated results of the current effect. The estimated coefficients of financial literacy in columns (1) and (2) are significant at the level of 5% and 1%, respectively, indicating that the improvement of financial literacy can significantly improve the possibility of household entrepreneurship. This result shows that financial literacy is an important determinant of household entrepreneurship decision-making, and it is the driver of household entrepreneurial activities. We found an interesting conclusion from the estimation results of the control variables. From the results in columns (1)–(4), we find that the education level of the head of the household is significantly negatively correlated with the household entrepreneurial behavior. However, the impact of our financial literacy on household entrepreneurial behavior was positive. This result seems to go against our intuition. We think that because financial literacy education is different from general education. Ordinary education mainly emphasizes the popularization and popularization of knowledge, while financial literacy education should be a kind of targeted specialized education. This conclusion supports the conclusion of the majority of the current literature.

The regression model may suffer endogenous problems. Endogeneity mainly comes from two aspects. First, a reverse causal relationship exists between financial literacy and household entrepreneurial choice. The accumulation of entrepreneurial experience may also lead to improved financial literacy. Second, the respondents may guess the answers to financial questions, leading to inaccurate measurement of financial literacy. Following Bucher-Koenen and Lusardi ( 2011 ) and Jappelli and Padula ( 2013 ), we selected the highest educational level among parents as an instrumental variable. We chose this instrumental variable for two main reasons. First, the family is the first place where individuals acquire and learn knowledge after they are born. Generally speaking, the higher the education level of parents, the more emphasis they will put on the education of their children. Parents with a high level of education can better help their children develop study habits and guide their children to receive more and better education through precepts and deeds and subtle influences in the daily life of the family. This will allow them to know more about their computing power and knowledge of economics and finance and possibly have a higher level of financial literacy. Second, the educational level of parents is determined before their children start a business and is independent of the entrepreneurial decisions of their children’s families. This suggests that parents’ educational level is strictly exogenous relative to their children’s entrepreneurial decisions. Therefore, we think it is appropriate to use parental education level as an instrumental variable. The problem that cannot be ignored is that parents with higher education levels are more likely to provide more resources for their children to start a business through their relationship network. We address this issue by controlling the parental network in our model. The results show that both the correlation test and the exogenous test of the instrumental variable of parental education level have passed, which verifies the validity of the instrumental variable to a certain extent. The results in Columns (3) and (4) in Table 5 support our conclusion.

Columns (5)–(8) in Table 5 report the estimated results of the current effect of financial literacy on household initiative entrepreneurship ( \({{\rm {Entrepre}}}2\) ). The results in columns (5) and (6) of Table 5 show that the estimated coefficients of financial literacy are significant at the level of 10%, indicating that financial literacy can help raise the household’s motivation for entrepreneurship in the current period and promote the initiative in entrepreneurship. Columns (7) and (8) in Table 5 , The DWH test, first-stage estimated and instrumental variables show that financial literacy will help raise the household’s motivation for entrepreneurship in the current period and promote the initiative in entrepreneurship.

Table 6 reports the estimated results of the long-term effect of financial literacy on household entrepreneurial behavior. No matter what index is used to measure financial literacy, the estimated coefficient of financial literacy is statistically significantly positive, indicating that financial literacy is beneficial to increasing the probability of households participating in entrepreneurial activities and taking the initiative in entrepreneurship in the long term.

Table 7 reports the estimation results of the ordered \({{\rm {Probit}}}\) model to estimate the dynamic improvement effect of financial literacy on household entrepreneurial behavior. In Table 7 , columns (1) and (2) show that no matter what index is used to measure financial literacy, the estimated coefficient of financial literacy is statistically significantly positive. After controlling endogenous concerns, we can obtain consistent results in columns (3) and (4). Columns (5)–(8) in Table 7 , no matter what index is used to measure financial literacy, the estimated coefficient of financial literacy is statistically significantly positive. We find that the improvement of financial literacy level is helpful in promoting the development of household entrepreneurial decision-making and initiative in entrepreneurship.

The above empirical results suggest that improving financial literacy levels may significantly promote family participation in entrepreneurial activities and household initiative in entrepreneurship. This conclusion is consistent with the conclusion of Xu et al. ( 2023 ), indicating that financial literacy may have current, long-term, and dynamic effects on some financial behaviors. This effect has the characteristics of current, long-term, and dynamic improvement. This study provides a reasonable explanation for the findings that financial literacy adds to entrepreneurs’ understanding of business activities and market dynamics, enabling them to discover entrepreneurial opportunities better.

Robustness checks

We conduct the robustness checks by replacing the proxy index of financial literacy. We construct three dummy variables, namely, \({{\rm {Dum}}}1\) , \({{\rm {Dum}}}3\) , and \({{\rm {Dum}}}\) 5. We use these three dummy variables to replace the explanatory variable \({{\rm {Entrepre}}}1\) or \({{\rm {Entrepre}}}2\) in the model (1) and model (2). \({{\rm {Dum}}}1\) means the answers the interest rate calculation question correctly, \({{\rm {Dum}}}2\) means the answers the inflation question correctly, \({{\rm {Dum}}}3\) means the answers the inflation question correctly. Table 8 reports the corresponding estimated results. The estimated coefficients of \({{\rm {Dum}}}1\) and \({{\rm {Dum}}}3\) are not significant. However, no matter what index is used to measure financial literacy, the estimated coefficient of \({{\rm {Dum}}}5\) is statistically significantly positive, indicating that venture capital literacy can significantly improve household entrepreneurial activities and motivation to initiate entrepreneurship.

In addition, we use respondents’ attention to economic and financial information to measure it denoted as \({Attention}\) . We use \({attention}\) to replace the explanatory variable \({Literacy}1\) or \({Literacy}2\) in the model (1) and model (2). Table 9 results show that the estimated coefficient of \({Attention}\) is statistically significantly positive. It shows that attention to financial and economic information can significantly improve household entrepreneurial activity and motivation to initiate entrepreneurship, which also indicates that the influence of financial literacy is robust.

Heterogeneity analysis

Urban–rural differences.

Significant differences exist between urban and rural areas in China’s economic environment, and household entrepreneurship behavior may show varying tendencies in different environments. Therefore, the effect of financial literacy on household entrepreneurship may have urban–rural heterogeneity. Table 10 reports the estimated results. Combining the size of the explanatory variable coefficient and the test results of inter-group coefficient difference, we find that the effect of financial literacy on households’ participation in entrepreneurial activities is more pronounced for households in urban areas. However, the effect of financial literacy on the initiative in entrepreneurship is more pronounced for households in rural areas.

Regarding the findings, this study provides a reasonable explanation. Compared with rural areas, urban areas have higher economic and financial development. Highly skilled personnel are also more abundant in urban areas, which leads to more opportunities for entrepreneurship. Therefore, the relationship between financial literacy and the possibility of households’ participating in entrepreneurial activities is stronger for households in urban areas. The level of income and financial development in rural areas is low, and the degree of financing constraints on households is severe. Compared with urban households who have already participated in entrepreneurial activities, rural households who have already participated in entrepreneurial activities are more eager to quickly realize “being your own boss,” “earning more,” and “being flexible and free” through initiative in entrepreneurship.

Gender differences

Gender differences in financial literacy are common in many countries (Hung et al., 2009 ). Lusardi and Mitchell ( 2014 ) found that in the United States, 38.3% of men can correctly answer three financial questions, but only 22.5% of women can. Only in their old age can women have financial investment motivation and a strong interest in household financial management (Tran et al., 2019 ). Table 11 reports the estimated results. Combining the size of explanatory variable coefficient and the test results of inter group coefficient difference, we find that the effect of financial literacy on household participation in entrepreneurial activities is more pronounced in the male sample and the effect of financial literacy on the household initiative in entrepreneurship is more pronounced in the female sample.

This study provides a reasonable explanation for the findings. Compared with women, men tend to be more confident in their economic decision-making abilities and have a stronger interest in family financial management, hoping to realize self-worth through entrepreneurship. Therefore, financial literacy has a stronger effect on men’s participation in entrepreneurial activities. Compared with men who have made entrepreneurial choices, women are more eager to realize personal financial freedom in entrepreneurship. Therefore, financial literacy has a stronger effect on women’s initiative in entrepreneurship.

Potential mechanism analysis

Income channels.

On the one hand, the income gap or expansion of income levels has changed people’s relative status, intensified “relative exploitation” and social differentiation, and affected people’s “material craving” and jealousy, thereby helping to stimulate the enthusiasm of middle- and low-income groups to start a business (Mensah and Benedict, 2010 ). On the other hand, the most important thing at the beginning of entrepreneurship is the initial capital for family entrepreneurship, and the increase in family income provides initial capital for family entrepreneurship, thereby promoting family entrepreneurial activities (Evans and Jovanovic, 1989 ). To this end, this study explores whether financial literacy will affect household entrepreneurial activities through the channel of increasing household income and income level. This study estimates the following regression model to prove the income channel that financial literacy may increase household income and income rank:

where \({{{\rm {Income}}}}_{i}\) refers to the natural logarithm of the total household income. \(\,{{{\rm {Rank}}}}_{i}=1\) represents a high-income household. \({X1}_{i}\) and \({X2}_{i}\) represent control variables in 2015, including \({{\rm {gender}}}\) , \({{\rm {Age}}}\) , \({{{\rm {Age}}}}^{2}\) , \({{\rm {Health}}}\) , \({{\rm {Marriage}}}\) , \({{\rm {Education}}}\) , \({{\rm {RL}}}\) , \({{\rm {RN}}}\) , \({{\rm {RA}}}\) , \({{\rm {CPC}}}\) , \({{\rm {FS}}}\) , \({{\rm {Assets}}}\) , \({{\rm {NE}}}\) , \({{\rm {NC}}}\) , \({{\rm {House}}}\) , and \({{\rm {NU}}}\) . Other designs are consistent with the benchmark model ( 1 ). If \({\omega }_{1}\) and \({\omega }_{2}\) are significantly positive, then we can conclude that financial literacy may increase household income and income rank.

We use CHFS 2015 data to conduct empirical research to prove that financial literacy can increase household income and promote entrepreneurial activities. This study uses two indicators of total household income ( \({{\rm {Income}}}\) ) and income level ( \({{\rm {Rank}}}\) ) as household income variables. The total family income is a total indicator of income, and the income level is a relative indicator that reflects the relative level of family income. We divide the income level into two levels according to the total income of the sample. The top 50% of the total income level is defined as the high-income class, and the bottom 50% is defined as the low-income family. The endogenous problems found in the regression model are solved by the instrumental variable method. The estimation results are shown in Table 12 . It shows that the estimated coefficients for \({{\rm {Literacy}}}1\) and \({{\rm {Literacy}}}2\) are significantly positive, which indicates that income channels are possible. The regression model may suffer endogenous problems. Following Bucher-Koenen and Lusardi ( 2011 ) and Jappelli and Padula ( 2013 ), we select the highest educational level among parents as an instrumental variable. Columns (5)–(8) in Table 12 show that the estimated coefficients of financial literacy are significantly above 1%, which indicates that income channels are possible.

Social network channels

In China, the family social network is mainly based on blood and geography. One of the important means of communication and relationship between relatives and friends is to give gifts to one another during the Spring Festival and other holidays and weddings and funerals. We use CHFS 2015 data for empirical research and select the family’s cash and non-cash expenditures ( \({{\rm {Expenditure}}}\) ), income ( \({{\rm {Revenue}}}\) ), and total income and expenditure ( \({{\rm {Sum}}}\) ) during the Spring Festival and other holidays and weddings and funerals as the proxy variables for the social network. The endogenous problems found in the regression model are solved using the two-stage instrumental variable method. This study strives to prove the social network channel that financial literacy promotes families’ cash and non-cash expenditures, revenue, and total revenue and expenditure during holidays such as the Spring Festival and weddings and funerals. Our model is as following:

where \({{SN}}_{i}\) is \({{Expenditure}}_{i}\) , \({{revenue}}_{i}\) , or \({{Sum}}_{i}\) refer to the social network. \({{Expenditure}}_{i}\) represents the total cash and non-cash expenditures of the family during holidays such as the Spring Festival and weddings and funerals. \({{Revenue}}_{i}\) represents the total cash and non-cash revenue of the family. \({{Sum}}_{i}\) represents the total cash and non-cash expenditures and revenue of the family. \({X3}_{i}\) represents control variables in 2015, including \({gender}\) , \({Age}\) , \({{Age}}^{2}\) , \({Health}\) , \({Marriage}\) , \({Education}\) , \({RL}\) , \({RN}\) , \({RA}\) , \({CPC}\) , \({FS}\) , \({Assets}\) , \({NE}\) , \({NC}\) , \({House}\) , and \({NU}\) . Other designs are consistent with model (1). If \({\psi }_{1}\) is significantly positive, then we can conclude that financial literacy may expand social network.

The estimated results are shown in Table 13 . Following Bucher-Koenen and Lusardi ( 2011 ) and Jappelli and Padula ( 2013 ), we selected the highest educational level among parents as an instrumental variable. As can be seen from columns (1)–(6) in Panel A, \({Literacy}1\) and \({Literacy}2\) are both significantly positive at the 1% level. From columns (1)–(6) in Panel B, after controlling for endogenous factors, \({Literacy}1\) and \({Literacy}2\) are both statistically significantly positive at the 1% level. These results imply that social network channels are possible and reliable.

Risk attitude channels

We use CHFS 2015 data to conduct empirical research to prove that financial literacy can improve household risk attitudes and promote family entrepreneurial activities. We measure risk attitudes in multiple dimensions. First, we construct a comprehensive index of risk attitude. Risk preference ( \({{\rm {RL}}}\) ), risk neutrality ( \({{\rm {RN}}}\) ), and risk aversion ( \({{\rm {RA}}}\) ) are assigned values of 3, 2, and 1, respectively, to examine the effect of financial literacy on risk attitudes. Then, we divide risk attitudes into risk preference ( \({{\rm {RL}}}\) ), risk aversion ( \({{\rm {RA}}}\) ), and risk neutrality ( \({{\rm {RN}}}\) ) and generate dummy variables to examine the effect of financial literacy on these three types. Similarly, considering that there may be endogenous problems in the regression model, we use the instrumental variable method to solve the problem. This study strives to prove the risk attitude channel that financial literacy promotes risk attitude:

where \({{{\rm {Risk}}\_{\rm {attitude}}}}_{i}\) is \({{{\rm {RL}}}}_{i}\) , \({{{\rm {RN}}}}_{i,}\) or \({{{\rm {RA}}}}_{i}\) in model ( 8 ), and \({{{\rm {Risk}}}}_{i}\) is \({{\rm {Risk}}}\) in model ( 9 ). Risk preference ( \({{\rm {RL}}}\) ), risk aversion ( \({{\rm {RA}}}\) ), and risk neutrality ( \({{\rm {RN}}}\) ) are generated as dummy variables to examine the effect of financial literacy on the three types of risk attitudes. \({{{\rm {Risk}}}}_{i}\) is a comprehensive indicator of risk attitude. We assign the values of 3, 2, and 1 to respondents’ risk preference, risk neutrality, and risk aversion, respectively, and examine the effect of financial literacy on risk attitudes. \({X4}_{i}\) represents control variables in 2015, including \({{\rm {gender}}}\) , \({{\rm {Age}}}\) , \({{{\rm {Age}}}}^{2}\) , \({{\rm {Health}}}\) , \({{\rm {Marriage}}}\) , \({{\rm {Education}}}\) , \({{\rm {CPC}}}\) , \({{\rm {FS}}}\) , \({{\rm {Assets}}}\) , \({{\rm {NE}}}\) , \({{\rm {NC}}}\) , \({{\rm {House}}}\) , and \({{\rm {NU}}}\) . Other designs are consistent with the benchmark model ( 1 ). If \({\omega }_{3}\) and \({\sigma }_{1}\) are significantly positive, then we can conclude that financial literacy may improve risk attitude.

The estimation results are shown in Table 14 . Columns (1)–(8) in Panel A demonstrate that the marginal effect of financial literacy on risk appetite and risk neutrality is positive, while the marginal effect on risk aversion is significantly negative. This indicates that enhancing financial literacy has led to an increase in residents’ willingness to take risks and a reduction in their aversion to risk. Additionally, the positive marginal effect of financial literacy on risk attitudes further underscores its role in improving residents’ overall risk perception. Following Bucher-Koenen and Lusardi ( 2011 ) and Jappelli and Padula ( 2013 ), we selected the highest educational level among parents as an instrumental variable. The estimation results in columns (1)–(8) of Panel B indicate that after solving the endogenous problem, the estimated coefficients or marginal effect coefficients of \({{\rm {Literacy}}}1\) and \({{\rm {Literacy}}}2\) are significantly positive at the level of 5% and above. The above results confirm the rationality of the empirical evidence that financial literacy promotes family entrepreneurial behavior by improving residents’ risk attitudes.

Further analysis: the role of financial education

The aforementioned findings substantiate the significant impact of financial literacy on family entrepreneurial behavior, thereby underscoring the importance of delving deeper into strategies aimed at enhancing residents’ financial literacy within the context of family entrepreneurship. According to Lusardi and Mitchell ( 2011 ), implementing financial education programs emerges as the most effective means to bolster residents’ financial literacy. Can financial education truly serve as a catalyst for elevating residents’ financial literacy? Furthermore, can it effectively amplify the influence of financial literacy on residents’ entrepreneurial endeavors? Investigating the intricate interplay between financial literacy, financial education, and familial entrepreneurial conduct is paramount.

In initial exploration, it becomes imperative to scrutinize the correlation between financial education and the level of financial literacy. To operationalize financial education, a binary variable is constructed, wherein a value of 1 denotes participation in coursework related to economics or finance, while a value of 0 indicates otherwise. Subsequently, the variables Literacy1 or Literacy2 are introduced to replace the interpreted variable, and the variable Learn stands in place of the interpreted variable. The control variables adhere to the framework outlined in Model (1). The estimated outcomes are presented in Table 15 . Regardless of the method employed to measure financial literacy, the estimated coefficient of financial education ( Learn ) consistently demonstrates a statistically significant positive impact at the 1% significance level, suggesting that engagement in financial education initiatives can indeed enhance residents’ financial literacy levels. Additionally, three PSM methodologies are employed to scrutinize the influence of financial education on financial literacy. The estimated results, as detailed in Table 16 , consistently reveal positive and statistically significant ATT values, thereby affirming the robustness of the aforementioned findings. These robustness checks further underscore the foundational assertion, highlighting the pivotal role of financial education in enriching family financial literacy.

Moving forward, our investigation extends to assessing whether financial education can effectively augment the influence of financial literacy on family entrepreneurial behavior. To address this inquiry, we construct an interaction term, denoted as Literacy × Learn, which captures the combined impact of financial education and financial literacy. This interaction term is incorporated into the analysis. Table 17 presents the estimated results. Irrespective of the method employed to measure financial literacy, the estimated coefficient of Literacy × Learn consistently displays a statistically significant positive association. This signifies that financial education effectively amplifies the impact of financial literacy on family entrepreneurial behavior.

An intriguing discovery emerges from our analysis: the estimated marginal effect coefficient for the interaction terms of Literacy1 × Learn or Literacy2 × Learn is notably positive, surpassing the coefficient of financial literacy alone. This observation suggests a close relationship between the impact of financial literacy on entrepreneurial behavior and individuals’ exposure to financial education. Consequently, our study substantiates that financial education serves as a moderating variable in shaping the influence of financial literacy on residents’ entrepreneurial behavior, effectively augmenting its impact. In practical terms, nationwide financial education initiatives and inclusive activities led by the People’s Bank of China, in collaboration with other financial institutions, have yielded noteworthy results over time. However, the current lack of enthusiasm and initiative among residents toward learning may hinder their engagement with financial education programs. Yet, with the proliferation of financial education efforts, this apathy is expected to wane, paving the way for increased attention and participation in financial education and training endeavors.

Theoretical implications

Our study draws upon human capital theory and modern entrepreneurship theory to empirically analyze the present, long-term, and evolving effects of financial literacy on household entrepreneurial behaviors, utilizing data from the CHFS in 2015 and 2017. The findings reveal that financial literacy exerts immediate, persistent, and evolving positive effects on households’ engagement in entrepreneurial activities and their propensity towards entrepreneurship. Addressing the endogeneity of the regression model, the results from the two-stage regression analysis corroborate the primary regression findings. Heterogeneity analysis highlights significant disparities between urban and rural areas as well as gender differences in how financial literacy influences household entrepreneurial behavior. Moreover, this study validates three potential mechanisms: income, social network, and risk attitude channels. We observe that financial literacy significantly enhances household income, broadens social networks, and fosters improved risk attitudes. Furthermore, our analysis indicates that financial education reinforces the impact of financial literacy on entrepreneurial behavior. These research findings carry significant theoretical implications, enriching both human capital theory and modern entrepreneurship theory.

Practical implications

This research carries significant implications for policymakers and stakeholders alike. Firstly, governments should recognize the pivotal role of financial literacy and embark on comprehensive initiatives to promote it through various channels, including television programs, radio broadcasts, informational brochures, training sessions, and specialized lectures. Establishing a sustained mechanism for the dissemination of financial literacy is crucial for enhancing the financial acumen of our nation’s populace. Secondly, special emphasis should be placed on promoting financial literacy in rural areas and among women. Collaborative efforts with financial institutions can facilitate targeted and tailored financial education projects aimed at these demographics, thereby fostering inclusivity and empowerment. By addressing the disparities in financial literacy, governments can pave the way for more equitable access to financial resources and opportunities. Thirdly, governments should actively promote financial education activities, including entrepreneurship training programs. These initiatives can mitigate the inhibitory effects of low financial literacy on entrepreneurial pursuits and enhance the management capabilities of entrepreneurs. By equipping individuals with the necessary skills and knowledge, such programs contribute to the resilience and dynamism of China’s financial market and stimulate growth in the employment landscape. In conclusion, concerted efforts to promote financial literacy and education are essential for advancing economic prosperity, fostering entrepreneurship, and ensuring inclusive development. By prioritizing these initiatives, policymakers can lay the foundation for a more resilient and prosperous future for China’s economy and society.

Future research and limitations

While our study has yielded significant insights, there are several avenues that merit further exploration in future research endeavors. Firstly, the complex relationship between cultural diversity and entrepreneurial behavior warrants deeper investigation. Unfortunately, due to the lack of detailed data on cultural diversity at the market segment level, this aspect remains largely unexplored in our study. Future research could delve into this aspect to better understand how cultural factors influence entrepreneurial decisions. Secondly, our analysis is constrained by the utilization of cross-sectional data from 2015 and 2017. Access to longitudinal data covering a broader timeframe could provide more nuanced insights and facilitate stronger conclusions. Therefore, future studies could benefit from employing larger datasets and extended panel data to comprehensively analyze the dynamics of the relationship between financial literacy and entrepreneurial behavior over time. Thirdly, the simplicity of the questionnaire used in our study may limit the depth of understanding regarding residents’ entrepreneurial behavior. Future research could address this limitation by employing more sophisticated questionnaires developed through an interdisciplinary approach, incorporating insights from psychology and other relevant fields. This holistic approach may offer a more nuanced understanding of residents’ entrepreneurial behavior, thereby enhancing the validity and reliability of the findings.

Furthermore, with the advent of the digital age, integrating elements of digitization or digital technology into academic research has become imperative. In our future research endeavors, we aim to expand our focus in several key areas. Firstly, we will explore the determinants of digital entrepreneurial behavior, examining how digital technologies influence entrepreneurial decisions and strategies. Secondly, we will emphasize the importance of digital financial literacy in shaping entrepreneurial behavior, considering how individuals’ proficiency in digital financial tools and platforms impacts their entrepreneurial activities. Lastly, we will endeavor to leverage digital technology to enhance causal identification in empirical analysis, employing innovative methodologies to better understand the mechanisms underlying the relationship between financial literacy and entrepreneurial behavior in the digital era.

Data availability

The datasets generated during and/or analyzed during the current study are available in the Harvard Dataverse repository: https://doi.org/10.7910/DVN/NRZ1K1 .

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We thank the support provided by the STU Scientific Research Initiation Grant [Grant No. STF24004T] and the National Natural Science Foundation of China [Grant No. 72203047].

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Evaluation of knowledge, attitude, practices and effectiveness of menstrual hygiene interventions in rural schools from Lilongwe, Malawi

• Russel Chidya 1 , 2 ,
• Olivia Kachuma 3 ,
• Tchaka Thole 3 ,
• Louis Banda 3 ,
• Mark Loewenberger 3 &
• Jennifer Nicholson 3  

BMC Public Health volume  24 , Article number:  1435 ( 2024 ) Cite this article

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Menstrual hygiene management (MHM) is associated with the menstrual process in women and adolescent girls who face cultural and financial challenges in rural areas of many developing countries. As part of the pilot study, we assessed the sustainability and effectiveness of the approaches and lessons learned from the MHM project intervention in rural areas of Lilongwe, Malawi.

Rural primary schools ( n  = 4) were purposively selected where an MHM intervention was implemented in Lilongwe, Malawi. The study employed a mixed-method research design. Assessments and data collection were performed through surveys of learners, literature reviews, key informant interviews (KIIs) ( n  = 90), and 20 focus group discussions (FGDs). The study participants included boys and adolescent girls ( n  = 100, 11–19 years; grades 5–8), teachers, mother groups, and community leaders from the selected schools.

All the schools had water sanitation and hygiene facilities and latrines (45% improved, 54% ventilated improved pit latrines – VIPs) that promoted menstrual hygiene for adolescent girls. However, two of the schools studied (50%, n  = 4) did not have separate washrooms for changing sanitary materials. There was a slight increase in latrine coverage in Kabuthu zone communities (90% at baseline versus 93.4% at midterm). However, the coverage dropped to 85.7% at the final evaluation, which was attributed to too much rain received in the area that damaged most of the latrines. There was a significant reduction ( p  < 0.05) in the number of girls failing to attend classes due to menstruation (70% at baseline versus 14% at final evaluation). Furthermore, the project resulted in the majority of girls (94.4%) having access to school. There was a strong uptake and adoption of sanitary products (reusable pads and menstrual cups) among adolescent girls of all age groups. The study has demonstrated that the inclusion of key stakeholders such as health workers, parents, mother groups and community leaders promoted the uptake and sustainability of reusable pads and menstrual cups and MHM interventions and programs.

The MHM project implementation improved adolescent girls’ education in the area. The inclusion of boys and other key stakeholders in the health education talks addressed issues of stigma and discrimination. The study, therefore, calls for comprehensive training on MHM and hygiene education to remove discrimination and harmful cultural practices.

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Introduction

Background information.

Women and girls, especially from developing countries, are faced with problems in managing their menstruation as a result of cultural taboos, lack of knowledge, inadequate access to safe and secure water, sanitation, hygiene (WASH) services, and lack of affordable menstrual products [ 1 , 2 ]. According to WHO/UNICEF, menstrual hygiene management (MHM) is simply defined as the management of hygiene associated with the menstrual process. Furthermore, adequate MHM is ‘ access to clean absorbents including sufficient washing, drying, storage and wrapping of reusable absorbents; adequate frequency of absorbent change; washing the body with soap and water; adequate disposal facilities; privacy for managing menstruation; and basic understanding of menstruation and how to manage it with dignity and without fear or embarrassment’ [ 1 , 3 ]. The concept of MHM has been expanded to menstrual health and hygiene (MHH) to encompass the sociocultural and economic elements that influence the menstrual management of women and girls [ 3 , 4 ].

The provision of adequate MHH among girls and women is reported to contribute to the attainment of Sustainable Development Goals (SDGs) for good health (SDG 3), education (SDG 4), gender equality (SDG 5), and clean water and sanitation (SDG 6) [ 3 ]. However, many girls and women in low- and middle-income countries (LMICs) do not have adequate MHH services [ 3 , 4 ]. Access to WASH services for MHM and MHH must be considered a basic right of girls and women to lessen gender discrepancies in education, health and sociopolitical and economic participation [ 4 , 5 ]. Previous studies in Sub-Saharan Africa and elsewhere have shown that WASH interventions through the provision of sanitary materials, water, soap and privacy keep girls in school and have a mixed impact on school absenteeism and performance [ 6 , 7 , 8 ]. In Malawi, various institutional/legal frameworks and strategies on gender equality, the empowerment of women and girls and human dignity are employed by several key stakeholders and organizations. For example, the Canadian Physicians for Aid & Relief (CPAR) Malawi implemented an MHM project intervention in Lilongwe rural schools aligned with Global Affairs Canada’s Feminist International Assistance Policy (FIAP). Furthermore, the MHM project implementation is in line with the National Gender Policy (2015), which aims to increase advocacy for girls’ and boys’ conducive learning environment, and Malawi 2063, which stresses the need to reinforce the gender equality and empowerment of women and girls to shape their decisions at the household, community and national levels.

Malawi has approximately 50.7% of its population living below the poverty line and approximately 25% living in poverty, especially in rural areas [ 3 ]. Poverty is exacerbated by low educational outcomes, including failure to complete primary schooling, especially among girls and women in rural areas. As girls start menses, they begin to miss school activities to the point where they drop out of school entirely, jeopardizing their ability to contribute more effectively to their own and their families’ social and economic well-being. A study conducted under the Malawi Red Cross showed that girls in their menses had a significantly higher level of knowledge compared to boys, and knowledge in girls was associated with better MHM practices and with reduced absenteeism [ 9 ]. A study conducted in seven schools in and around Lilongwe, Malawi by WaterAid in 2021 concluded 3 recurring issues impacting MHM for adolescent girls: (a) cultural around menstruation – menstruation being seen as strictly secret, and parents do not talk to children about it; (b) ignorance about menstrual issues being prevalent among schoolgirls and in their communities; and (c) inadequate WASH facilities and infrastructure in visited schools. Several projects and interventions on MHM and MHH have been implemented in rural Malawi to address such issues and challenges [ 8 , 9 , 10 ].

Context of the study

Several studies on linkages between menstruation and school absenteeism have been widely conducted in Africa and elsewhere [ 8 , 11 , 12 , 13 ]. An earlier study by Grant et al. [ 14 ] on menstruation and absenteeism in rural Malawi noted several factors contributing to menstruation-related absenteeism. This included lack of school toilet privacy, lack of education by family and teachers on puberty and MHM, and physical menstrual discomfort. In the same study, long distances between home and school also prevented girls from going back and forth, hence contributing to absenteeism [ 14 ]. Such barriers and challenges significantly disrupt girls’ education and development, which later leads to ripple effects. There are no recent disaggregated data on school drop-out rates in Malawi [ 9 ]. However, UNICEF Malawi gathered significant anecdotal evidence that girls stay home while menstruating [ 10 ].

Menstrual cup promotion has been promoted among university girls at Mzuzu University in Malawi [ 10 ]. Although the project was successful, a small sample size (10 women) was used. Furthermore, the project did not target girls below university age, and there was no follow-up program. Many MHM projects in Malawi have focused simply on providing menstrual products and some WASH activities [ 8 , 9 , 10 ]. This addresses immediate short-term needs but does not incorporate the approach needed to promote sustainable change. The CPAR MHM project implemented an innovative MHM project in rural Lilongwe through a participatory approach by testing and promoting the use of menstrual cups and reusable pads alongside MHM behavior change interventions. The current study on MHM and MHH, therefore, provides a significant opportunity for knowledge sharing among WASH practitioners, education, and health promoters in the country. This study, therefore, assessed the sustainability and effectiveness of the approaches and lessons learned from the CPAR MHM/MHH project intervention for scaling up and replicability in other rural areas in Malawi and elsewhere. It aimed to evaluate knowledge, attitudes, and practices among learners, teachers and community members and the effectiveness and sustainability of menstrual hygiene interventions in rural schools from Traditional Authority (TA) Kabudula in Lilongwe, Malawi. The study aimed to achieve the following specific objectives: (a) to evaluate availability and access to water and sanitation facilities, menstrual products, and menstruation management among adolescent girls; (b) to assess the knowledge, attitude, and practices regarding MHM among learners (girls and boys), teachers and community members in the study area; (c) to assess the project intervention on feasibility, acceptability, and changes in menstruation-related knowledge, practices, perceptions, and self-reported school absenteeism from baseline to end line among girls; and (d) to determine the sustainability, replicability and scalability of the MHM interventions in rural schools from Malawi and elsewhere.

Theoretical framework of the study

This study is grounded on a general hypothesis that the inability of girls up to the age of 18 to effectively manage their menstrual health is a significant cause of absenteeism and school dropout and that the use of menstrual cups and/or reusable sanitary pads improves girls’ menstrual health management and reduces absenteeism and dropout rates. The implementation of the MHM project was centered on gender-based analysis (GBA). The GBA underpins an understanding that health variances between boys (or men) and girls (or women) can be related to the various roles and responsibilities that culture assigns to them. This study employed the “ Theory of Change ” ( ToC ) approach to evaluate the knowledge, attitudes, and practices among learners, teachers and community members and the effectiveness of menstrual hygiene interventions in rural schools from the study area. Furthermore, the study used the “ Theory of Planned Behavior ” (TPB) [ 15 ]. The ToC is a theory that gives a detailed description and illustration of how and why the desired change is expected to happen in a particular situation [ 16 ]. It explains how activities are understood to contribute to a series of results that produce the final intended impacts. The TPB depicts that human action is influenced by three major factors: a favorable or unfavorable evaluation of the behavior, perceived social pressure to perform or not perform the behavior, and perceived capability to perform the behavior [ 15 ].

Methodology

Study setting and mhm interventions.

This study was conducted in Lilongwe District located in the central region (Fig.  1 ). It is the capital city of Malawi, which stands at an altitude of 1,050 m. Specifically, the study was conducted in TA Kabudula under the Kabuthu education zone where rural primary schools ( n  = 4), namely, Kabuthu, Milala, Kamphelatsoka, and Chifeni, were selected. The schools under study were purposively selected based on the implementation of the MHM project by CPAR. The rural locations were initially identified by CPAR’s Rapid Gender Analysis (RGS) (September 2021) and more in-depth GBA (December 2021). The two analyses showed traditional and cultural beliefs being more ingrained, less available menstrual products and unaffordable, and having fewer opportunities to acquire information to dispel misconceptions and ignorance regarding MHM. The CPAR MHM/MHH project interventions implemented in the area included training and provision of menstrual cups and sanitary pads to adolescent girls from the four schools. Furthermore, the project involved MHM education, awareness campaigns and capacity building among adolescent boys, teachers, mother groups, girls’ councilors, traditional leaders, school and health management committees; parents and community members.

Source Authors

Map of Lilongwe showing the study area.

Study design, methods, and data collection tools

In July and August 2023, we implemented a mixed-methods research design where both quantitative and qualitative data were collected. Quantitative assessment was performed through school and household surveys. Quantitative data were collected through surveys of learners in the 4 selected schools, while qualitative data were collected using direct observations, key informant interviews (KIIs) or in-depth interviews (IDIs) and focus group discussions (FGDs). A literature review of project documents (baseline, midterm, and end-line progress reports) was made. Furthermore, community-level knowledge-sharing workshop reports and other related MHM/MHH project documents were reviewed and analyzed. The girl’s MHM questionnaire, boys’ FGD guide, household MHM questionnaire, and mother group’s FGD guide were prepared and implemented.

Participants, sample size and inclusion criteria

The study participants included adolescent boys and girls (11–19 years; grades 5–8), Teachers/Head Teachers, Mother Group members, Girls Councilors, Parent-Teacher Association (PTA), Chiefs/GVH, School Management Committees (SMCs), and Community Health Committees. We purposively selected and surveyed a total of 100 adolescents girls at the menarche stage to understand their level of knowledge, adoption, uptake and impact of the MHM interventions. Next, a total of 90 households where the adolescents came from were engaged in interviews to sort their understanding and support of the MHM to their adolescent girls. The study targeted households (HH) with adolescent girls only because of their experience in managing girls during menstruation. Due to the scarcity of such types of households, the study targeted the nearest HHs with such girls. In addition, 8 FGDs, 4 KIIs and 1 survey with boys on myths and misconceptions were conducted in each of the four schools. A total of 20 FGDs were conducted in all the schools, with groups of 5–10 people purposively selected for their first-hand information. Discussions were centered on selected topics specifically on WASH and menstruation while allowing for interesting, new, or unplanned follow-up questions to be asked. Concurrently, direct observation was used to confirm or triangulate the information given through the questionnaire survey and photographic pictures.

The sample size and distribution of participants are summarized and presented in Table  1 . The study used convenience and purposive sampling to identify study participants, namely, teachers, mother group members, PTAs, chiefs, health center management groups, youth groups, and parents. Participants who had stayed in the area for at least 6 months and/or were involved in the MHM/MHH interventions were engaged. To validate the quantitative data, KIIs targeting key districts and community-level informants connected to adolescent girls were employed. Furthermore, the study participants were selected using the inclusion and exclusion criteria summarized in Table  2 . Android tablets programmed in mWater were used for data collection to minimize errors since the program was developed with built-in data validation, skip rules, and constraints in the questionnaire.

Data management and statistical analysis

The qualitative data were analyzed manually through content analysis to contextualize quantitative findings. First, the qualitative data were entered into Microsoft Excel and Word for transcription, translation and cleaning. Preliminary reading of all reports was performed to identify initial key issues. All three approaches to qualitative content analysis as outlined in [ 17 ] were employed. The study assessed the MHM/MHH project intervention uptake and impact by computing prevalence differences at 95% confidence intervals using fixed-effects logistic regression. To ensure the validity and reliability of the results, the authenticity of statements and information received were verified with experts and stakeholders in the area. Furthermore, all the data collection tools were piloted and pretested for their efficiency and correctness before the actual data collection.

Ethical consideration

Ethical approval.

To conduct this study, ethical approval was obtained from the Mzuzu University Research Ethics Committee (MZUNIREC) (Ref. No. MZUNIREC/DOR/23/95). During the implementation of the MHM/MHH interventions in the area, permission and partnerships were made with all relevant government offices, including Ministries of Health, Education, and Community Health Centers outreach clinics. Confidentiality was followed, and instead of names, identification codes were used for analysis purposes. A written informed consent form was signed or thumb printed before any form of data collection. For adolescent boys and girls under 18, written informed assent was obtained from their parents, guardians, or teachers. The adolescent boys and girls aged 18 and above provided consent to take part in the interventions and study.

Access to water and sanitation facilities in schools and at home

The study findings showed that all schools had latrines (45% improved, and 54% ventilated improved pit latrines – VIPs, n  = 4). Despite having separate latrines for boys and girls, all the schools lacked handwashing facilities. As an alternative, schools drew water using basins and buckets and provided it to the students by placing them in front of classrooms for easy access. Although water was available for the students, no soap was provided for cleaning and handwashing. During midterm evaluation, it was noted that the Milala school had no water source following the theft of a pump and vandalized boreholes. At this school, students reportedly carried some water in small bottles to cater to all basic sanitation needs. Only the Milala and Kampheratsoka schools had separate washrooms for changing sanitary materials for adolescent girls. Coupled with the unavailability of water and soap in the washrooms and latrines, the study noted that adolescent girls had challenges cleaning themselves at school. However, this circumstance did not pose a significant impact ( p  < 0.05) on school attendance among the girls, as depicted by improved school attendance during the reporting period.

In communities surrounding the schools

The results showed that there was a significant variation ( p  > 0.05) in access to latrines in the communities surrounding the schools (Fig.  2 ). There was a slight increase in latrine coverage in the Kabuthu zone (90% at baseline (BL) versus 93.4% at midterm evaluation (MTE), n  = 4). However, the coverage dropped to 85.7% at the final evaluation (FE). During the final evaluation, the majority of people used traditional latrines (84.4%) (Fig.  3 ). Conversely, there was a moderate increase (11 to 36.4%) in the presence of hand-washing facilities in homes around the schools (Fig.  3 ). The increase was attributed to the engagement meetings where parents were urged to ensure girls had access to sanitation facilities at home. Improved access to water resulted in adolescent girls being able to clean up and maintain hygiene during menstruation.

Access to latrines in the communities surrounding the schools in the study area

Type of latrine ( a ) and hand-washing facilities ( b ) used in surrounding communities

Absenteeism from primary school

Girls missing out on classes because of menstruation.

The study showed a significant reduction ( p  < 0.05) in the number of girls failing to attend classes due to menstruation from 70% at baseline to 21% at midterm and 14% at the final evaluation. All the girls interviewed (100%, n  = 90) felt comfortable using sanitary products, hence resulting in girls having more classroom learning time, similar to their male counterparts. Furthermore, the FGDs conducted with both teachers and parents revealed that there had been an improvement in the performance of girls during the project compared to the pre-project period. Despite helping reduce absenteeism, the improved availability of menstrual services in the area were noted to bring enormous positive impact and reduction in stigma and discrimination against girls.

Number of days girls missed classes due to menstruation

The number of girls who missed classes and stayed away from school due to monthly periods of less than 3 days, 3 to 5 days and more than 5 days decreased significantly. The girls who missed classes for less than 3 days because of monthly periods reduced from 18 to 8%, while for 3 to 5 days, there was a significant reduction from 63 to 6% ( p  < 0.05). For girls missing classes for more than 5 days, the number reduced to 0% because of the availability of sanitary pads and menstrual cups that helped them manage their menses well. The reduction in the number of days girls stay away from school has had a positive change in school academic performance comparable to that of boys, owing to the availability of MHM services and products.

Improved access to schooling as a result of MHM support

Percentage of girls accessing improved education.

The majority of girls who participated in the program (94.4%, n  = 100) reported improved access to school as a result of overall MHM support provided during the project implementation (Fig.  4 ). Many adolescent girls sampled (83.2%, n  = 100) reported having used reusable sanitary materials compared to baseline findings where only 10% had access and used the same. Similarly, a considerable number of adolescent girls (70%) reportedly used menstrual cups. Thus, the increase in the percentage of girls accessing improved education was attributed to the availability and usage of sanitary pads and menstrual cups, hence resulting in reduced absenteeism. On average, each adolescent girl was reported to have a minimum of 5 reusable sanitary pads and 1 menstrual cup. In addition, the increase in the number of girls accessing improved education was attributed to awareness of menstrual hygiene among boys who stopped bullying girls when in menses. The awareness focused on myths and misconceptions related to MHM as well as the negative impacts of bullying that result in girls staying away from school or completely dropping out.

Percentage of girls accessing improved education after the project intervention

Number of learners comfortable attending school during menstruation

With the MHM project’s interventions, the majority of girl learners (97%, n  = 100) became more comfortable attending school during menstruation compared to the pre-project period (Fig.  5 ). This is an improvement from 26% at baseline to 79.2% during the mid-term evaluation. The girls felt comfortable because they had sanitary pads and menstrual cups that prevented them from messing up during menstruation, hence reducing absenteeism and dropping out. The results from the interviews with girl counselor teachers confirmed that the schools had reusable sanitary pads ready for girls who reached puberty and started menstruation. There was a strong adoption of sanitary products among all age groups, with 99% and 94% coverage for girls aged 10 to 14 and 15 to 18 years, respectively.

Percentage of girl learners comfortable attending school during menstruation

Use of reusable pads and menstrual cups

There was an increase in the number of girls ( n  = 100) using reusable pads (83.2%) compared to menstrual cups (70%). This is because the latter was introduced by the project lately, while the former was fairly being used by some of the students before the project. Furthermore, reusable sanitary pads were fairly cheaper and locally made compared to menstrual cups (Table  3 ). Analysis by schools showed that Milala (100%) was the best to use menstrual cups compared to Chifeni (32%). This was mainly because the large cup sizes purportedly caused pain to young adolescent girls at Chifeni. Chifeni School had younger adolescent girls who participated in the interventions compared to Milala School. The majority of girls (82%) preferred reusable sanitary pads over menstrual cups (Fig.  6 ). Very few girls (18%) reported using menstrual cups exclusively for several reasons, such as pain and difficulty to wear. Furthermore, it was revealed that some girls indicated that the cups were large. Through the provision of sewing machines and pad fabrication training, skills and knowledge were gained by women and adolescent girls to produce pads packaged as part of the MHM kit for girls who had just started their menses. Such an initiative was highlighted by both teachers and community members as a success and the project’s sustainability strategy.

Girls’ preference between reusable sanitary pads and menstrual cups

The majority of girls (60%, n  = 145) trained in the fabrication of reusable sanitary pads were actively involved in continuous production, surpassing the project target of 20%. Interestingly, the girls in the age group of 10–14 years scored the highest (99%) in fabricating reusable sanitary pads. Furthermore, the key informant interviews with mother group members, teachers and local leadership showed that mother group members were highly involved in the fabrication of reusable sanitary pads and training other learners, hence representing a great sign of sustainability. During health education talks and parent engagement meetings, men and boys were deliberately included to improve their knowledge and perceptions toward MHM. A total of 458 men and boys (10–14 years, n  = 187; 15–18 years, n  = 241 and 19 above, n  = 30) were reached during the MHM health talks and a quiz on myths and misconceptions. A total of 144 boys out of 180 managed to score 75% above, representing 80%, a percentage slightly higher than the midterm score of 45.2%.

Improved knowledge and attitudes toward the application of MHM solutions

Parents and community members.

The percentage of parents that encourage girls to attend primary school even during periods of menstruation was evaluated and disaggregated. This was done to assess their level of knowledge and support given to adolescent girls during the monthly periods. In the final evaluation of the project, the results showed that the majority of the parents (64%) encouraged their daughters to attend school even during monthly periods. This was significantly higher than the midterm (46%) and baseline evaluations (8%). After implementation of the MHM interventions, the majority of the parents and community members (62.3%, n  = 90) were comfortable with the menstrual products used by their daughters.

Boys and men

After MHM interventions and awareness campaigns, many boys gained knowledge about menstruation, especially myths and misconceptions. For example, approximately 80% of the boys trained on MHM were able to score above 75% in the post training quizzes compared to 45% during midterm and 0% during baseline. This is an indication of the absorption of knowledge on MHM. In addition, there were no fathers who felt that discussing issues of menstruation with their children was taboo and against cultural beliefs, with 2.40% at baseline, 1.3% at midterm to 0% at final evaluation. Furthermore, there was a significant difference ( p  < 0.05) in the reaction and attitudes of male parents responding to questions about the menstrual issues of their daughters between the baseline and the final evaluation assessments.

Availability of wash facilities in schools and surrounding communities

The four schools involved in our study had latrines separate for girls and boys (45% improved, 54% ventilated improved pit latrines – VIPs). However, these schools lacked handwashing facilities and soap for cleaning and handwashing. This is a problem considering that adolescent girls undergoing menstruation require handwashing facilities and soap for sanitary purposes. Correspondingly, two schools namely Chifeni and Kabuthu did not have separate washrooms for changing sanitary materials, hence depriving them of their privacy and dignity during menstruation. Similar results on the lack of washrooms for changing sanitary materials and poor access to clean water, sanitation and hygiene facilities have been reported in Malawi and elsewhere [ 8 , 18 ]. The lack of latrines both at school and at home has been reported widely in the literature to pose negative impacts on menstrual health for adolescent girls [ 2 , 13 , 19 ]. Furthermore, the absence of proper latrines both in schools and homes has globally been reported to deprive adolescent girls of privacy, safety and dignity to change used menstrual materials within the household in Zambia and Kenya [ 11 , 20 ]. The decrease in the latrine coverage from 90 to 85.7% at the final evaluation in Kabuthu zone (Chifeni school communities) was attributed to too much rain received in the area, which damaged most of the latrines constructed using unburnt bricks and mud. Although the schools are found within the same geographical area, Milala School communities did not receive too much rain naturally, hence managed to maintain their latrine coverage both at the project midterm and final evaluation (90.9%).

Absenteeism from school

The reduction in the number of girls failing to attend classes due to menstruation was attributed to the availability of reusable sanitary pads and menstrual cups provided during the MHM project implementation. During the study girls confessed that the pads and the cups gave them freedom and dignity to attend school even during monthly periods. The positive association between retention of girls and the implementation of MHM education talks, parent engagement meetings, and provision of sanitary pads and menstrual cups showed that the MHM interventions were successful. Generally, the tendency of girls to miss classes was attributed to menstrual-related health problems. The lack of medication for managing menstrual-related health problems (such as abdominal cramps, headaches, and backache) for adolescent girls was attributed to a lack of funding and poverty levels.

MHM products and training provided in project schools

The current study noted the need to procure age-specific menstrual cups to match the young adolescent age ranges that were prevalent at Chifeni School. The differences in adoption of MHM products among schools were attributed to opposing preferences and attitudes toward menstrual cups, hence a need for more awareness of the utilization of menstrual cups. Varied adoption and use of menstrual cups and reusable pads by adolescent girls have been reported in many countries, including rural Nepal [ 21 ], rural western Kenya [ 18 ], and in rural schools of Zambia [ 11 ]. In this study, at the time of the assessment, the project had made available a total of 3084 reusable pads and 580 cups. A total of 1534 reusable pads were locally produced by mother group members and students, while 1550 pads were procured and distributed to students. Conversely, a total of 580 menstrual cups were distributed to 366 adolescent girls, 23 mother group members, 35 female teachers, and 156 women from the community. Through the provision of reusable sanitary pads and menstrual cups in the four schools, the endline survey results showed a positive adoption and usage of the distributed reusable sanitary pads and menstrual cups. Generally, there was increased participation in reusable pad fabrication by students and mother group members in project schools and the community. The enormous leap in availability and usage of reusable sanitary pads after project implementation was attributed to the provision of reusable sanitary pads and training on the fabrication of pads conducted on 145 adolescent girls (representing 39% of adolescent girls in the Kabuthu education zone) and 30 mother group members from the four primary schools studied. Similar findings on MHM among women and girls in Malawi noted that the use of disposable pads was favored by most girls who participated in the study [ 8 ]. Conversely, studies conducted elsewhere showed that rural and poor women and girls resort to using old clothes for menstruation rather than menstrual cups and reusable sanitary pads due to their poor economic status, availability on the local market, cultural acceptability and personal preferences, among others [ 11 , 22 , 23 , 24 , 25 , 26 ]. The use of unsuitable and unhygienic menstrual products is reported to increase rates of pelvic pain, lower genital tract infections, and inflammatory conditions, further exacerbating absenteeism [ 10 ].

To ensure the sustainability of the MHM interventions in the study area, there is a need to make the menstrual products available on the local market. Furthermore, the project implementers and key stakeholders in the area should consider subsidizing menstrual products so that adolescent girls and women can afford to purchase them. Some scholars and previous researchers have advocated for all-inclusive sanitation and hygiene education in schools [ 8 , 27 , 28 ], and this is the same recommendation in the study area and elsewhere in the country and beyond. Thus, there is a need for comprehensive training on MHM and hygiene education so that all groups (boys, girls, women and men) fully understand and remove discrimination and harmful cultural practices.

Knowledge and MHM solutions for community leaders and health workers

The current study showed limited knowledge and understanding of MHM and menstruation by all study participants before MHM education implementation. Similar studies on limited knowledge of MHM by boys and men have been reported in Zambia [ 11 ] and in India [ 29 ]. However, after MHM project implementation in Kabuthu education zone in Lilongwe, the study demonstrated that MHM education talks and parent engagement meetings played a major role in the improved retention of girls throughout the project lifetime in the Kabuthu education zone. The comfortability of parents and community members with the menstrual products used by their daughters was attributed to increased awareness campaigns and engagement meetings, where information on proper MHM was shared. Such efforts and campaigns changed the attitude of parents toward the use of improved menstrual materials as well as offering MHM support to girls. Furthermore, community leaders and members hailed the MHM project for challenging harmful cultural norms that projected MHM talks to be feminine and taboo. There were 8 community engagement meetings conducted in all the schools (2 per school) where both men ( n  = 240) and women ( n  = 461) participated. The leaflets (400) and posters (32) distributed in the four schools played a crucial role in raising MHM awareness among adolescent girls and community members. Although the project engaged a few healthcare workers (35%, n  = 20) in facilitating MHM health talks and menstrual cup orientation, the impact was statistically significant ( p  < 0.05). Regarding the perception and knowledge of men and boys in MHM, deliberate efforts made to engage men and boys in addressing menstrual-related challenges such as stigma and bullying adolescent girls at school showed positive results. From the study findings, it is indeed vital that crucial stakeholders such as community members and health workers, parents and community leaders, among others, are included in MHM interventions and programs for sustainability. Such multistakeholder engagement and inclusion also ensure that MHM interventions are monitored and supported even when the project is finished [ 8 ].

Lessons learned and upscaling of the MHM elsewhere

The study has shown that during the implementation of the MHM project, several risks and challenges were encountered. These included cultural resistance to innovation adoption, especially menstrual cups; inflation (adjustment of all the planned activities); COVID-19 lockdowns and restrictions, limited access to MHM products (cups, reusable pad components); cholera outbreaks; and uncertainty of sustainability of the MHM products. To mitigate cultural resistance, the gatekeepers and all key communities and stakeholders were engaged through meetings and the adoption of engagement information, training, and constant impact monitoring of the project in communities surrounding the 4 schools. Several activities were implemented during the same field trip to reduce travel costs and other logistics. During the cholera outbreak, community members surrounding the schools and all members of the school community (learners and teachers) were sensitized to take precautionary measures on how to prevent cholera and to rush to the nearest health facilities in case of cholera cases. On the sustainability of the innovation, the mother group members were sensitized to continue producing the reusable pads and selling the extra ones to the community members so that they would be able to continue buying materials for sewing.

Other lessons learned during the implementation of the MHM in the study area showed that the inclusion and involvement of female teachers and other key stakeholders (mother groups and health officers) during MHM training increased ownership of the project interventions. On the one hand, the presence of female teachers as stakeholders made it easier to manage the delivery of MHM services, including health education. Furthermore, the inclusion of female teachers in the MHM solutions brought girls closer to their teachers and eventually opened up issues of menstruation. On the other hand, the inclusion of boys in the health education talks addressed issues of stigma and discrimination. This allowed for a holistic approach to MHM and helped the boys to better understand issues of MHM, hence support adolescent girls well.

The gender analysis revealed gender gaps in the Kabuthu education zone that exacerbated school absenteeism and dropout among girls. Menstruation was singled out as the main driver of school absenteeism and dropout among adolescent girls. Contributing to challenges of menstruation were cultural and traditional norms related to menstruation, lack of proper and adequate menstrual knowledge and products among girls and communities, lack of adequate female teachers to act as mentors and role models, and stigma and ignorance perpetuating bullying toward adolescent girls. Gratefully, the MHM project addressed these challenges to ensure equitable access to educational learning outcomes for both boys and girls and reduced school absenteeism and dropout related to menstruation among adolescent girls in the Kabuthu education zone. Such lessons learned can be implemented anywhere in Malawi and beyond. To ensure the sustainability and proper promotion of MHM products and hygiene education in the country, the Malawi Government is developing standard protocols, guidelines, and implementation strategies. The ongoing revised National Sanitation and Hygiene Policy (2024) and National Sanitation and Hygiene Strategy (2018–2024) aim to promote user-friendly sanitation and hygiene facilities; establishment of gender equality and social inclusion (GESI) in menstrual health and hygiene management in all sectors; and waste management and MHM in all schools and facilities. The established policy and strategies on sanitation and hygiene in Malawi will ensure that MHM is regulated and provide guidance for decision-making and that menstrual products and services are moderated and accepted for promotion.

Conclusion and recommendations

This study has confirmed that access to sanitary products in schools and at home is crucial for menstrual hygiene and reducing absenteeism for adolescent girls in Malawi. Some schools did not have separate washrooms for changing sanitary materials for adolescent girls. Furthermore, the use of unburnt bricks and nondurable materials was found to compromise the durability of latrines. The results suggest that there is a need for the construction of girl-friendly and durable WASH facilities and washrooms. Following MHM interventions and implementation, the study has shown a significant reduction in girls who missed classes. The awareness and involvement of boys, men and other community leaders and healthcare workers removed the myths and misconceptions related to menstrual hygiene and the impacts of bullying that result in girls staying away from school or completely dropping out. The study, therefore, calls for comprehensive training on MHM and hygiene education so that all groups (boys, girls, women and men) can remove discrimination and harmful cultural practices. Additionally, the study has shown that key stakeholders such as community members and healthcare workers, parents, mother groups and community leaders must be included to promote the uptake and sustainability of reusable pads and menstrual cups and MHM interventions and programs in general. Further areas of research would include longer-term evaluation of the impact and sustainability of the MHM project to support the observations of this study. Key areas would include assessment of continued access and use of menstrual health products, community involvement and impact on girls’ level of education.

Data availability

Useful data are presented in Tables and charts in the report. Additional datasets and files for the study are available from the corresponding author upon request.

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Acknowledgements

We thank teachers, mother groups, head teachers, girls, boys, and their parents for their participation in this study. We are grateful to field and office staff, community leaders and healthcare workers for their support during project implementation and study. Furthermore, we thank the Canadian Physician for Aid and Relief (CPAR), Fund for Innovation and Transformation (FIT), Global Affairs Canada (GAC), and ICN for providing funding for an independent study and assessment of the project implementation.

This study is part of the project “Freedom to Learn for Girls in Rural Malawi – Addressing the Menstruation Barrier” implemented in Lilongwe District, Malawi. The authors are grateful to Canadian Physician for Aid and Relief (CPAR), Fund for Innovation and Transformation (FIT), Global Affairs Canada (GAC), and ICN for the financial support of the study. Funders had no direct role in the study design, data collection, analysis or preparation of the manuscript.

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Department of Water and Sanitation, Mzuzu University, P/Bag 201. Luwinga, Mzuzu, Malawi

Russel Chidya

Innovation Research and Training Centre (INNORET), Head Office, P.O. Box 195, Mzuzu, Malawi

Canadian Physicians for Aid & Relief (CPAR), P.O. Box 30998, Lilongwe, Malawi

Olivia Kachuma, Tchaka Thole, Louis Banda, Mark Loewenberger & Jennifer Nicholson

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Contributions

RC and OK conceptualized and drafted the paper; OK, TT, and LB supported data collection; RC and OK processed and analyzed the data. OK, TT, LB, JN and ML provided technical advice on reusable pads and menstrual cups and manuscript writing. All authors reviewed the manuscript.

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Correspondence to Russel Chidya .

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Ethics approval and consent to participate.

Ethical approval to conduct the study was provided by the Mzuzu University Research Ethics Committee (MZUNIREC) (Ref No. MZUNIREC/DOR/23/95). Further engagement and permission were sought from government authorities. Confidentiality was considered, and a written informed consent form was signed or thumb printed during data collection. For boys and adolescent girls under 18, written informed assent was obtained from their parents, guardians, or teachers.

The findings and conclusions in this report are those of the authors and do not necessarily represent or reflect the official position of the CPAR or sponsors of the study.

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The authors declare no competing interests.

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Chidya, R., Kachuma, O., Thole, T. et al. Evaluation of knowledge, attitude, practices and effectiveness of menstrual hygiene interventions in rural schools from Lilongwe, Malawi. BMC Public Health 24 , 1435 (2024). https://doi.org/10.1186/s12889-024-18940-w

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Received : 07 November 2023

Accepted : 23 May 2024

Published : 29 May 2024

DOI : https://doi.org/10.1186/s12889-024-18940-w

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