Menstrual cups and unconditional cash transfer to reduce sexual and reproductive harm and school drop-out in adolescent schoolgirls in western Kenya

低收入国家的女孩由于怀孕、疾病、早婚、缺乏上学和个人需求（包括月经卫生管理）而过早离开学校。辍学使女孩面临更大的性健康和生殖健康危害风险，如怀孕、生育率提高、包括艾滋病毒在内的性传播感染，以及子女死亡率提高。辍学还减少了经济机会，使女孩陷入贫困，从而面临发病率上升和生活质量下降的风险。出于经济、健康和社会原因，这些都是政府部委的优先事项，需要采取干预措施，使女孩留在学校，改善她们的性健康和生殖健康。利物浦热带医学院与包括教育部和卫生部在内的肯尼亚合作伙伴完成了一项由全球健康联合试验资助的试点研究，调查了肯尼亚西部农村小学女孩使用月经杯和卫生巾的情况。干预前，女孩报告说，使用破布，床上用品或纸MHM，造成不适，羞辱泄漏和气味，降低在学校集中注意力的能力，并导致他们逃学。女孩们随后发现护垫和杯子很舒服，提高了她们参与课堂的能力，防止了漏水，减少了与男朋友发生性关系以换取购买护垫的钱的需要。在研究结束时，对女孩进行了性传播感染和辍学（因怀孕、结婚或其他原因）检查。与对照学校的女孩相比，使用护垫或杯子的女孩的这些负面结果减少了一半。使用杯子的女孩更喜欢这些垫，因为垫是十倍更昂贵，如果不经常更换会引起摩擦，包必须与他人分享。女孩们因为害怕感染而不共用杯子。我们现在建议在同一领域进行一项大规模试验，对象是年龄较大但辍学率较高（高出三分之一以上）、感染艾滋病毒、性传播感染和怀孕风险较高的中学女生。我们将研究杯子是否能使女孩留在学校并减少她们的性和生殖伤害;虽然杯子能提高尊严、健康和福祉以及在学校的信心，但它们可能不足以解决所有女孩未得到满足的需求，这导致她们辍学。现金转移（CT）是一种替代但更昂贵的干预措施，研究表明它可以减少缺勤，辍学和性风险。在马拉维，CT降低了女学生感染艾滋病毒和人类单纯疱疹病毒（HSV-2;女孩性风险行为的一个指标）的风险，并减少了怀孕。现金数额因研究而异，但研究人员建议每月5美元（3.5英镑）就足够了。我们为期4.5年的试验将研究现金、杯子或现金和杯子是否能防止辍学，并改善女孩的性健康和生殖健康。为了统计的严谨性，我们将在56所学校招募4032名中学女生，提供干预措施，并对她们进行为期2个学年（6个学期）的随访。我们将评估单一和综合干预措施预防的每项结果（辍学，包括怀孕、艾滋病毒和HSV-2）的成本。这项研究将提供重要信息，说明每项干预措施的相对价值、如何使用这些干预措施、遇到的任何问题及其对女孩性行为、她们的福祉和完成学业的影响。我们将征求女孩、学校、社区和利益攸关方的意见，与包括莫伊/MOH在内的所有受益者合作，利用讲习班评估进展情况，并为实施一揽子计划编写材料。将为女孩俱乐部提供资金，以鼓励同龄人的支持和宣传。如果试验显示出具有成本效益的结果，则将支持扩大规模。调查结果将广泛传播，以加强支持宣传的证据基础，提高女孩生活质量和公平。

Girls in low-income countries leave school early due to pregnancy, illness, early marriage, and lack of money for schooling and personal needs, including for menstrual hygiene management (MHM). School drop-out places girls at greater risk of sexual and reproductive health harms such as pregnancy, increased fertility, sexually transmitted infections (STIs) including HIV, and higher mortality of their children. School drop-out also reduces economic opportunity, keeping girls' in poverty and thereby at risk of increased morbidity and reduced quality of life. For economic, health, and social reasons, these are government ministry priorities, and interventions are needed to keep girls in school and improve their sexual and reproductive health. The Liverpool School of Tropical Medicine, with Kenyan partners including the Ministries of Education and Health (MOE/MOH), have completed a Joint Global Health Trials-funded pilot study, examining girls' use of menstrual cups and sanitary pads in rural primary schools in western Kenya. Pre-intervention, girls reported using rags, bedding or paper for MHM, causing discomfort, humiliating leaks and odour, reducing ability to concentrate in school, and causing them to skip school. Girls followed up revealed pads and cups were comfortable, increased their ability to engage in class, prevented leakage, and reduced the need to have sex with boyfriends in return for money to buy pads. No health or safety issues were found. At study completion girls were checked for STIs, and school drop-out (for pregnancy, marriage or other reasons). These negative outcomes combined were halved in girls using pads or cups compared with girls in control schools. Girls using cups preferred these to pads, because pads are ten-fold more costly, cause chafing if not changed frequently, and packs have to be shared with others. Girls did not share cups for fear of infection. We now propose to conduct a large-scale trial in the same area, in secondary schoolgirls, who are older but have increased drop-out rates (over a third higher), and a higher risk of HIV, STI, and pregnancy. We will examine if cups enable girls to stay in school and reduce their sexual and reproductive harms; while cups will improve dignity, health and wellbeing, and confidence at school, they may not be sufficient to resolve all girls' unmet needs, which cause them to drop-out of school. Cash transfer (CT) is an alternate but more expensive intervention, with studies showing it reduces absenteeism, drop-out, and sexual risks. In Malawi, CT reduced schoolgirls risk of HIV and human simplex virus (HSV-2; an indicator of girls' sexual risk behaviour), and reduced pregnancy. Cash amounts vary by study but the researchers recommend $5(£3.5) a month as sufficient. Our 4.5 year trial will examine if cash, cups, or cash and cups both provided, will prevent school drop-out and improve girls' sexual and reproductive health. For statistical rigor we will recruit 4032 secondary schoolgirls in 56 schools, provide interventions and follow-up them for 2 school years (6 terms). We will evaluate the cost per outcome (school drop-out including for pregnancy, HIV and HSV-2) prevented for single and combined interventions. The study will provide vital information on the comparative value of each intervention, how the interventions are used, any problems encountered, and their effect on girls' sexual behaviour, their wellbeing and school completion. We will seek advice from girls, schools, communities and stakeholders, working with all beneficiaries including MOE/MOH, using workshops to evaluate progress and develop materials for implementation packages. Girls clubs will be funded to encourage peer-support and advocacy. Packages will support scale-up should the trial demonstrate cost-effective outcomes. Findings will be widely disseminated to strengthen the evidence base supporting advocacy to improve the quality and equity of girls' lives.