Menstrual health solutions for out-of-school adolescent girls

Poor menstrual management deleteriously impacts girls' and women's lives. In low-income countries, the use of makeshift materials such as rags, paper, tissues and other unhygienic items to absorb blood, an inability to access sanitation facilities and supplies, and the lack of knowledge and open dialogue to support these needs detrimentally impact girls' and women's health, education, and productivity. Substantive efforts in the past decade have galvanised international donor and agency support to fund research to improve the menstrual health of schoolgirls. Findings have informed policy and programmes at local and national level, and pledges to support action. Research findings have illustrated how interventions contribute towards improvements in schoolgirls' health and schooling.

This progress must now expand the evidence base to reach out-of-school adolescent girls. These girls comprise school dropouts (often pregnancy related), child brides, orphans and streetgirls, who have the least agency over their lives and are among the poorest. They are likely to have fewer resources to access hygienic materials, water and sanitation facilities, or other supplies. Because they do not attend school they are less likely to have knowledge about their bodies or understand their health needs or negotiate relationships, placing them at heightened risk of SRH harms. Isolation away from their in-school peers and burdens of daily living may place additional mental health risks to these girls, as well as SRH (mSRH) harms. No evidence-base exists on what menstrual health (MH) problems these girls face, which interventions are most needed to improve these girls MH and mSRH, and how to best deliver them in community settings.

Our project proposes to engage out-of-school girls, communities, and stakeholders to conduct a series of studies, using menstrual management as an entry point, to identify girls needs and current mSRH harms, select and evaluate optimal interventions and delivery mechanisms, to build evidence and inform large-scale implementation studies. We will conduct this with our Kenyan partners following on from our pioneering UKRI-funded research that successfully evaluated MH solutions for schoolgirls and informed national policy.

A community survey in out-of-school girls in the KEMRI research site will investigate their menstrual needs, and MH and mSRH challenges. Information gathering through participatory methods (focus groups, community 'transect' walks, girls' menstrual journals), in parallel with a systematic review of interventions and delivery mechanisms, will determine what types of interventions are optimal, and how best they can be delivered in the community. Workshops with researchers, girls and other stakeholders will use findings to co-create single or multi-component packages for evaluation. We will evaluate uptake, acceptability, use, and perceived benefits of the selected interventions and identify what challenges and barriers affect successful delivery. Outcomes from this evaluation will be jointly deliberated with researchers, girls, and stakeholders, to recommend which intervention package/s and delivery mechanisms can be applied in large-scale implementation studies. Due to girls vulnerability in the community, we will promote safeguarding systems with stakeholders to ensure girls' safety. Capacity strengthening will be integrated within the project, supporting early career researchers to build experience and expertise.

Findings will be shared with the local community and stakeholders, and a national cross-sector stakeholder workshop will be held to discuss findings with decision-makers and implementers. We will disseminate across our existing MH platforms to expand the research and programme agenda beyond schoolgirls and share findings with UK and other agencies to develop action for period poverty in high as well as low-income countries. Research will be published and presented at conferences.

This research comprises formative, multi-disciplinary, observational studies among out-of-school adolescent girls aged 10-19 years in rural western Kenya. Such girls, defined as those not having completed secondary education, including school dropouts, streetgirls, orphans, and child brides are highly vulnerable to mental, sexual and reproductive health (mSRH) harms. This project examines girls' menstrual health (MH) and related mSRH problems, followed by an evaluation of which optimal interventions are required to reduce MH/mSRH harms, and how these interventions can be delivered in community settings. A cross-sectional survey among 1000 out-of-school girls nested in KEMRI's health and demographic surveillance system (HDSS) will identify girls menstrual needs and practices and their mSRH. Participatory field studies (focus group discussions, community transect walks, and girls menstrual journals) will generate contextual data on girls challenges, identify locational risk exposures, and explore community structures in place to support delivery of interventions. These findings and data from a systematic review and meta-analysis on critical MH/mSRH interventions and community delivery systems will inform girls and stakeholders on co-creation of optimal interventions (single or combined package). We will deliver selected interventions to 300 out-of-school girls, to assess uptake, acceptability, use, and perceived impact on key mSRH outcomes through surveys and participatory studies at timepoints during intervention, and evaluate challenges associated with intervention delivery. Outcomes will presented to stakeholders to consider recommendations for large-scale implementation studies, including preparation for a formal multi-site trial. Findings, methods, and tools will be widely disseminated to inform MH/mSRH researchers and stakeholders internationally. The platform established to reach out-of-school adolescents can be used for other research programmes.

UNESCO estimates that one in five children are out of school globally; the highest proportion are girls in Sub-Saharan Africa where some 52 million are estimated to not attend school. Menstrual health significantly affects girls' health, wellbeing, and ability to lead productive lives. International efforts have focused on improving the menstrual health of girls in school, but the most vulnerable of girls are out-of-school and have not received attention. Our study will focus on the development of interventions for these girls. The effect of such interventions will contribute to improving their mental, sexual and reproductive health by reducing their exposure to unhygienic practices and risky sexual behaviours. This will improve their quality of life, strengthen their ability to work and reach their employment goals, and reduce their ill-health. We envisage these benefits will help break the cycle of poverty they currently experience. Individuals, families, children and communities will gain from these improvements on the lives of adolescent girls and young women. We will conduct a series of studies (surveys, focus group discussions, workshops and other community activities) to determine out-of-school adolescent girls (aged 10-19 years) their menstrual health and related mental and sexual reproductive health issues. Using evidence from a systematic review and mapping, girls and stakeholders will contribute toward selection of optimal interventions and delivery mechanisms, which will be evaluated among 300 out-of-school girls in the community, informing large-scale implementation studies including a multi-site intervention trial.
The immediate impact of the study will be to determine the menstrual health and menstrual, sexual and reproductive health needs of out-of-school girls. Prevalence of harms will be shared with stakeholders, including ministry officials to feed into their health plan, and provides a baseline for developing further research intervention studies. Participants will benefit from improvements in their menstrual health (MH), a reduction in stress and shame from their inability to deal with their menstruation, and a lowering of mental, sexual and reproductive health (mSRH) harms. Other non-menstrual interventions selected will similarly impact on girls' mSRH. Girls involved with participatory activities and workshops will also feel empowered to be spokespersons for their peers providing experience and guidance to researchers, on community delivery of interventions, and decision making on selection of interventions and delivery mechanisms. Feedback from girls on difficulties in their daily lives, will lead to the strengthening of a safeguarding framework within their communities. This will be shared to support widespread use among other programmes, enabling further studies and helping other vulnerable populations to receive care and support. The research will also create a community-based platform to support delivery of other interventions for out-of-school adolescents. Families and communities at this time will also benefit by having increased support for out-of-school girls, reducing ill health and menstrual related harms. Stakeholders will benefit from the study by learning about the public health issues around menstruation, training on study activities, research techniques, and sharing of outcomes. They will benefit from participation in workshops, building their network and engaging with programme and research staff. Findings will impact on other researchers, by providing data on a currently absent evidence-base on the health needs of out-of-school girls, including on their mental health status, facilitating broader research on other topics. Our project will create tools and methods which will be shared to encourage further research on the needs of out-of-school girls.