Building a sustainable model to promote menstrual, sexual and reproductive health (MSRH) amongst secondary school girls in Tanzania

A girl's education impacts her health, the health of her future family, and her future economic potential. The growing evidence of this positive association has strengthened international resolve to improve educational opportunities for adolescent girls. Evidence from East and Southern Africa has shown that girls' participation in schools is severely hampered by menstrual, sexual, and reproductive health (MSRH) issues. In particular, young girls lack the knowledge, menstrual management products, water and sanitation facilities in schools, and social support to manage their menses. Pervasive bullying by male students and staff adds to the high levels of shame and anxiety surrounding menstruation, and encourages girls to exclude themselves from school activities. Furthermore a 2017 Human Rights watch report stated that more than 8,000 girls in Tanzania are expelled from school each year due to pregnancy.

The long-term aim of this research project is to improve health and development outcomes among girls in Tanzania and beyond by developing a sustainable and scaleable intervention to improve girls' health and wellbeing. The aims of this project directly relate to the majority of Sustainable Development Goals including: number 1 (end poverty), 3 (good health and wellbeing), 4 (quality education), 5 (gender equality), 6 (clean water and sanitation), 10 (reduced inequalities) 11 (sustainable cities and communities), 13 (climate action), 16 (peace, justice, and strong institutions) and 17 (partnerships for the goals).

The project is a partnership between two leading research institutes (one in the UK and one in Tanzania), a Tanzanian-based international NGO, and the local government authorities within two northern regions of Tanzania.
The overall aim is to develop a scaleable comprehensive MSRH intervention within Tanzanian government structures to improve MSRH practices and perceptions and the overall school climate to ensure the psychosocial wellbeing and optimal school participation and performance of secondary school girls.

This will be achieved through 3 specific objectives:

1) To refine an existing NGO-led MSRH programme to better engage local governments, and enhance the school component through the engagement of boys, refinement of the pain management activities, and inclusion of water and sanitation facility improvement activities.

2) To work with government and schools to develop mechanisms to integrate the MSRH intervention within government schools.

3) To pilot the refined MSRH intervention to assess (a) feasibility (including cost per student, school and district), sustainability and acceptability and (b) effect on MSRH practice and perceptions and the overall school climate.

Our research project will directly benefit (i) Tanzanian adolescent girls and boys and their communities; (ii) teachers and school officials and (iii) local and national government. Our project will advance empirical knowledge and further develop theoretical dispositions on how holistic and embedded menstrual, sexual and reproductive health projects can impact on a girl's development. These findings will be beneficial to (iv) policy makers, (v) researchers and (vi) international/implementing organisations.

The project addresses a critical evidence gap in how to comprehensively address menstrual, sexual, and reproductive health (MSRH) challenges of adolescent girls in Tanzania.

Poor MSRH is associated with subsequent psychosocial (high levels of shame, depression, anxiety) and physical (pain, increased risk of reproductive and urinary tract infections) ill health, and poor school outcomes (including poor performance, participation, and completion). Our Theory of Change builds on a model which was developed after a qualitative metasynthesis of 76 studies and over 6,000 women and girls. The model shows how the social and cultural context underpin social support, behavioural expectations, knowledge, and the physical and economic environment that affect elements of girls' menstrual experience, including practices and perceptions, confidence to participate, and menstrual-anxiety, all ultimately impacting on girls' mental and physical health and education.

The project will be conducted in four phases. An initial inception phase (Phase 1) will be followed by a formative phase (Phase 2) to iteratively refine an existing MSRH intervention and collaboratively design strategies to embed the intervention into government structures thereby promoting scaleability. In Phase 3 we will pilot and evaluate the refined intervention and implementation strategies using a before-after mixed methods design to assess (a) feasibility (including cost per student, school and district), sustainability, and acceptability and (b) effect on MSRH practice and perceptions and the overall school climate. In the final phase (Phase 4) we will collaboratively synthesise the research findings. Our phased project approach will enable us to develop a scaleable MSRH intervention that fits within Tanzanian government structures to improve MSRH practices and perceptions and the school climate to ensure the psychosocial wellbeing and optimal school participation and performance of secondary school girls.

A girl's education impacts her health, the health of her future family, and her future economic potential. The growing evidence of this positive association has strengthened international resolve to improve educational opportunities for adolescent girls. However, the physical and social environment of many schools across sub Saharan Africa can prohibit a girl reaching her potential. Young girls are ill-equipped and poorly supported to manage their menses. Poor menstrual health is associated with high levels of shame, depression and anxiety, pain, increased risk of reproductive and urinary tract infections and poor participation in school. The way in which our project proposes to improve the menstrual, sexual and reproductive health (MSRH) of girls will contribute to the achievement of the majority of the Sustainable Development Goals including: number 1 (end poverty), 3 (good health and wellbeing), 4 (quality education), 5 (gender equality), 6 (clean water and sanitation), 10 (reduced inequalities) 11 (sustainable cities and communities), 13 (climate action), 16 (peace, justice and strong institutions) and 17 (partnerships for the goals). Our proposed study leverages an opportunity for two well-established partners to team up with the local government authorities and a passionate, evidence-based non-government organisation in Tanzania to effect change in the MSRH of secondary school girls.

The results of this study are expected to have multiple impacts. The study will be the first in Tanzania to respond to the demands and interests of policy makers as well as other researchers for the production of rigorous evidence using well-designed and validated tools. It will also respond to calls for empirical data to capture the real costs of implementing in-school interventions by child, school, district and beyond. These results will also be of interest to policy makers in other African countries as they refine and update their guidelines and recommendations as to how to provide adequate support and health-related education to girls and boys in schools.

Our study will not only focus on the outcome of the intervention, but also on the processes required to implement to scale. The research questions will directly address current policy and implementation gaps in Tanzania and across the region regarding the process to scale up effective MSRH intervention in schools. The objectives build on a compendium of team experience of developing and testing context-sensitive and scaleable interventions.
The UK government recently pledged its support to end period poverty by 2030. Through our media strategy and close collaborations with the Cup Foundation we will support and drive efforts to raise awareness of the needs of girls all around the world, including the UK, thereby further supporting the UK and its development goals and leveraging multiple channels to increase the attention on MSRH challenges amongst international donors.

Ultimately, the results are expected to improve the health, well-being, and future opportunities of adolescent school girls through the combination of comprehensive MSRH education and kits that include a reusable product of their choice. The project will effect a positive change in the school climate through improved school water and sanitation facilities and by addressing pervasive bullying most often perpetrated by boys and school staff.
The research will provide an excellent opportunity for the capacity development of African researchers. Alongside propelling the promising trajectory of the African, female principal investigator, the project will also develop needed skills in under-represented research disciplines in Tanzania, such as health economics and implementation research. The project will also open up channels for further study for talented and driven African junior scientists, thereby strengthening the pipeline for African research leadership.