Puberty health interventions to improve menstrual health and School attendance among Gambian adolescents (MEGAMBO).

Poor menstrual hygiene management among adolescent girls have been associated with school absenteeism and other health outcomes. Globally girls around the world have developed their own personal strategies to cope with menstruation. These vary greatly from country to country, individual's personal preferences, available resources, local traditions and cultural beliefs and knowledge or education. Some of the menstrual practices have been associated with different health outcomes (urogenital infections). Across the globe menstruation and its management also have important social and cultural implications which may in turn impact girl's lives. Absence from school, has been of particular interest to International organisations and research bodies working in this area such a WaterAid, Unicef, the Water Research Commission and Plan International. Challenges girls face when attending to school when menstruating, include: feelings of embarrassment when menstruating, fear of leaking menstrual blood or of teasing from boys, lack of adequate absorbent materials and lack of privacy and access to appropriate water and sanitation facilities at school. These factors can lead girls to be absent from school during menstruation. A literature review we conducted in 2013 found there was good evidence that educational interventions can improve menstrual hygiene practices and reduce social restrictions but there was no quantitative evidence that improvements in menstrual knowledge and management methods reduce school absenteeism and urogenital infections.
A study that we are conducting in Gambia (MRC-PHIND) among school girls in Kiang region shows that challenges related to menstruation management at home or at school could be associated with negative health outcomes and school absenteeism. Our qualitative research showed that students (boys and girls) had poor knowledge about menstruation, largely due to the need for secrecy. We also observed that lack of knowledge of menstruation led to embarrassment and fear of teasing, and this, together with pain and lack of effective materials and WASH facilities for MHM led to school absenteeism. Boys were eager to learn about menstruation, but expressed difficulties talking to adults about it. The qualitative studies showed that menstruation was strongly associated with school attendance in this population, and that there is an unmet need from girls, boys and parents for interventions to enable girls to better manage both the psychosocial aspects of menstruation (anxiety and distress) and the physical aspects (management of use of appropriate materials to eliminate leakage of menstrual blood and hygienic habits practices).In a sub-study of daily diaries to record school attendance and menstrual cycles, 15 girls reported school absence on 29% of period-days, compared with 15% of non-period days. One workshop with different stakeholders (parents, teachers, students, clinicians, education regional officer and NGOs) was held in Keneba in May 2017 in order to present the initial findings, discuss the problems (using a problem tree exercise) and find possible solutions. After the workshop we all decided to create a 4 pack interventions that could be included in programmes already existing in these communities: Mother's club who will work with mums to inform about puberty, menstruation and absorbent and hygienic practices, Peers Education camps, which will involve girls and boys in schools to discuss puberty and menstrual management issues, Community meetings around puberty films and WASH improvements.
The aim of our study is to test, refine and adapt the intervention packages suggested in the first study and to conduct a school-randomised controlled trial to evaluate the effect and cost-effect of an intervention to improve MH among girls to reduce school absenteeism in girls.

A systematic literature review we conducted in 2013 found there was good evidence that educational interventions can improve menstrual hygiene practices and reduce social restrictions but there was no quantitative evidence that improvements in menstrual knowledge and management methods reduce school absenteeism and urogenital infections. A recent study we are conducting among Gambian schoolgirls shows that students (boys and girls) had poor knowledge about menstruation. We also observed that lack of knowledge of menstruation led to embarrassment and fear of teasing, and this, together with pain and lack of effective materials and WASH facilities for MHM led to school girls absenteeism. Our study showed that there is an unmet need from girls, boys and parents for interventions to enable girls to better manage both the psychosocial aspects of menstruation (anxiety and distress) and the physical aspects (management of use of appropriate materials to eliminate leakage of menstrual blood and hygienic habits practices). One workshop with different stakeholders (parents, teachers, students, clinicians, education regional officer and NGOs) was held in Keneba in May 2017 in order to present the initial findings, discuss the problems and find possible solutions. After the workshop we all decided to create a 4 pack interventions that could be included in programmes already existing in these communities: Mother's club who will work with mums to inform about puberty, menstruation and absorbent and hygienic practices, Peers Education camps, which will involve girls and boys in schools to discuss puberty and menstrual management issues, Community meetings around puberty films and WASH improvements.
The aim of our study is to test, refine and adapt the intervention packages suggested in the first study and to conduct a school-randomised controlled trial to evaluate the effect and cost-effect of an intervention to improve MH among girls to reduce school absenteeism in girls.

The long-term impact of the research is to improve health and development outcomes among women in low- and middle income countries (LMIC) through improving girl's education, improving health and wellbeing, improving water and sanitation (WASH) facilities and management at schools. Achieving higher levels of education are correlated to important public health outcomes, including reduction of early pregnancies, risk of HIV infection infant and maternal mortality as well as improvements in the nutritional status of children.
Our study will contribute to the scant evidence base addressing how to rigorously evaluate the impact of menstrual health interventions on girls' education, health and well-being.
On average, a woman between 13 and 50 years old may expect to menstruate for around 1400 days in her lifetime. Many of these women, especially in LMIC face barriers to comfortable and dignified menstrual health which affect their psychosocial health and well-being. Poor menstrual health has been linked with reproductive tract infections (specifically bacterial vaginosis) and urinary tract infections. In addition, poor menstrual health is linked with absence from school, and gender based violence.
Raising awareness regarding menstruation and hygienic practices has remained largely a neglected area in terms of research and policy discussion. There is now increased momentum from donors, governments, and others to address problems with managing menstruation, but the focus to date has largely been on "hardware" (e.g., products and/or facilities). Our Theory of Change is based on our feasibility study which highlighted the need to also address the 'software' (psychosocial issues, societal norms). By including the wider community (boys, parents) we aim to reduce the stigma and embarrassment associated with menstruation, and also to address common barriers like improve WASH maintenance facilities.
Our pathway to impact focuses on including supportive community knowledge, attitudes, and practice; education and awareness; and improved school sanitation facilities. This approach is the recommended one in a recently published report ("An Opportunity to Address Menstrual Health and Gender Equity" http://www.fsg.org/publications/opportunity-address-menstrual-health-and-gender-equity), which emphasizes the critical need to engage with key influencers of girls (parents/guardians, peers, school communities), and for interventions to address not only menstrual hygiene management tools but also WASH facilities, puberty education and awareness and social norms and taboos. We address each of these elements in our intervention package, and the trial will evaluate the effect not only on school attendance but also on other health indicators (urogenital symptoms, psychosocial stress) and community support.
Our pathway to impact is also through our established links with relevant national stakeholders, including the District Education Officer (see Letters of Support). In May 2017, we presented our findings at a stakeholders meeting, including plans for this second study phase. There is strong support for the study and during MEGAM trial, we will liaise closely with the Ministries of Education at the initial workshop to ensure that we are delivering an intervention package which is sustainable and in line with Government guidelines on teaching about puberty and menstruation. We also have strong links with other NGOs and academic researchers involved in MHM interventions in Gambia (UNICEF, see letter of support).