Menstrual health interventions and school attendance in Uganda (MENISCUs-2)

In many resource-poor settings, girls lack adequate knowledge, facilities and materials to manage their menstruation. Challenges girls face include: feelings of embarrassment, fear of leaking menstrual blood or of teasing from boys due to a lack of privacy at school. Many girls do not have access to adequate materials (pads, tampons or cups) to manage their menstruation. These factors can lead girls to be absent from school during menstruation.

We recently completed an MRC-funded study (MENISCUS-1) among girls aged 14-17 years old in peri-urban Wakiso District in Uganda. This was a series of small sub-studies to understand perceptions about menstruation, to estimate the association with school absenteeism, and to develop an intervention package designed to improve school attendance and performance, knowledge and attitudes towards MHM, and prevalence of the reproductive tract infection bacterial vaginosis.

The study showed that menstruation is a key reason for school absenteeism, along with poverty. In a sub-study in which girls were asked to complete a daily diary recording school attendance and menstrual cycles, girls reported missing school on 1 in 4 schooldays when they were menstruating compared with 1 in 14 days when not menstruating.

We tested the components of a possible MHM intervention, each in a small number of girls. In the current study (MENISCUs-2), we plan to pilot test the interventions together as a package, delivered to all girls (about 150 per school) in one school year (S2) in two schools in Wakiso District.

The intervention components are:
- Training of teachers to improve delivery of the Government guidelines for puberty education.
- A drama skit to address issues around menstruation while engaging parents, boys and teachers.
- Provision of a menstrual cup kit: Our implementing partner, WoMena, will train selected teachers and older girls to teach girls how to use a menstrual cup (the Ruby Cup) and a re-usable sanitary pad (AfriPad), both provided in a bag with a mirror, sterilisation/storage container and soap. The cup is reusable for 10 years, holds twice the volume of most pads, and can be used for up to 12 hours (i.e. girls do not usually need to empty it at school) so it should help girls manage periods whilst at school.
- Supply painkillers for period pain (delivered using a voucher system)
- Simple improvements to school water and sanitation facilities including locks on the toilet doors, provision of toilet paper, and a soap dispenser for hand-washing.

The primary outcome of MENISCUs-2 is to evaluate the intervention package works sufficiently well to enable a trial to be justified. We will decide this based on how well the intervention package is delivered (e.g. of analgesics delivered). The criteria for progression is that the education session and drama skit were delivered, the majority of girls using the Ruby Cup or re-usable pads provided at endline, and accessing painkillers as needed, and soap and toilet paper available in schools for the majority of the time.

We will also estimate the number of girls who progress to the next school year in order to know the likely loss to follow-up within a future trial. The criteria for progression to a trial will be a retention rate of 80% to allow for an acceptable loss to follow-up in the future trial. We will also estimate the likely intervention effect size. Finally, we will estimate the cost of the intervention delivery, and cost of monitoring trial outcomes.

As part of the study, we also piloted a football-based intervention in Uganda to promote safe male circumcision for HIV prevention, which we have previously used in Zimbabwe. This worked well after modifications, and we will deliver this intervention in the future trial alongside the MHM intervention, but are not including this component in this study as it was fully tested previously.

Poor menstrual health (MH) is a global health and development problem. Our MRC-PHIND study (MENISCUS-1) was a series of sub-studies among girls aged 14-17 years old in Uganda to understand perceptions about menstruation, estimate an association with school absenteeism, and develop an intervention to improve school attendance (primary outcome) and secondary outcomes including school performance and prevalence of bacterial vaginosis.

The study showed that menstruation is a key reason for school absenteeism. Among 40 girls who completed a daily diary, girls reported missing school on 28% of schooldays when menstruating compared with 6% on other days (p<0.001).

In the proposed study (MENISCUs-2), we plan to pilot the MH interventions as a package delivered to all girls in one school year in two schools in Wakiso District. The intervention is:
- Training of teachers to improve delivery of the Government guidelines for puberty education.
- A drama skit to address issues around menstruation, engaging parents, boys and teachers.
- Our implementing partner will train teachers and peers to teach girls how to use a menstrual cup and a re-usable sanitary pad.
- Supply analgesics for cramps using vouchers
- Improvements to school water and sanitation facilities

The primary outcome is to review whether criteria for progression to an RCT are met. The criteria are that i) the education session and drama skit were delivered, the majority of girls used the Ruby Cup or re-usable pads, and accessed painkillers if needed, and that soap and toilet paper available for the majority of the time; and ii) the retention rate from one school year to the next is >80%. We will estimate the likely intervention effect size by comparing the absenteeism on period-days and non-period-days from diaries in MENISCUS-2 (intervention) and MENISCUS-1 (comparison) school. Finally, we will estimate the cost of the intervention delivery, and of monitoring trial o

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. 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 any given day, more than 800 million girls and women between the ages of 15 and 49 are menstruating and many 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. Further, there is evidence that some adolescent girls in countries including Uganda may engage in transactional sex to obtain menstrual hygiene products. In addition, poor menstrual health is linked with absence from school, and gender-based violence.

Menstrual health has been neglected by the academic community and policy makers. There is now increased momentum from donors, governments, and others to address poor menstrual health, 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, teachers, parents) we aim to reduce the stigma and embarrassment associated with menstruation, and also to address common barriers like pain by supplying analgesics and the re-usable Ruby Cup which can be retained for up to 12 hours. Our pathway to impact focuses on including consistent access to products and infra-structure, 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 future trial will evaluate the effectiveness not only on school attendance but also reproductive health (bacterial vaginosis).

Our pathway to impact is also through our established links with relevant national stakeholders, including the Ministries of Education and Health and District Education Officer (see Letters of Support). In August 2016, we presented our findings at a stakeholders meeting, including plans for MENSICUs-2. There is strong support for the study and during MENISCUs-2, we will liaise closely with the Ministries of Educaiton and Health 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 Uganda and East Africa through the monthly MHM steering committee meetings in Kampala. Towards the end of the study, we will hold a second workshop, at which we will present and discuss our findings, and our plans for the future cluster randomised trial. The future cluster randomised trial will take place in 40-50 secondary schools of low SES in the database of Wakiso District, categorised as government or private schools, and we will map potential trial schools during our study, and invite representatives of the schools to our second dissemination workshop.