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

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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.