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

在许多资源贫乏的环境中，女孩缺乏足够的知识、设施和材料来管理她们的月经。女孩面临的挑战包括：尴尬的感觉、害怕经血流出或因在学校缺乏隐私而受到男孩的戏弄。许多女孩没有足够的材料（卫生巾、卫生棉条或杯子）来管理她们的月经。这些因素可能导致女孩在月经期间缺课，我们最近完成了一项由MRC资助的研究（MENISCUS-1），对象是乌干达城郊Wakiso区14-17岁的女孩。这是一系列小型子研究，以了解对月经的看法，估计与学校缺勤的关联，并制定一个干预方案，旨在提高学校出勤率和表现，对MHM的知识和态度，以及生殖道感染细菌性阴道病的患病率。研究表明，月经是缺课的一个主要原因，沿着的还有贫穷。在一项子研究中，女孩被要求填写一份记录上学和月经周期的日记，女孩报告说，在上学的4个上学日中有1个上学日，而在不上学的14天中有1个上学日。我们测试了可能的MHM干预的组成部分，每一个在少数女孩。在目前的研究（MENISCUs-2）中，我们计划在Wakiso区的两所学校的一个学年（S2）内对所有女孩（每所学校约150名）进行一揽子干预措施的试点测试。- 培训教师，以更好地执行政府关于青春期教育的指导方针。- 一个戏剧短剧，以解决月经周围的问题，同时吸引父母，男孩和老师。提供月经杯工具包：我们的执行伙伴WoMena将培训选定的教师和年龄较大的女孩，教女孩如何使用月经杯（红宝石杯）和可重复使用的卫生巾（AfriPad），这两种工具包都装在一个袋子里，里面有镜子、消毒/储存容器和肥皂。这种杯子可以重复使用10年，容量是大多数护垫的两倍，可以使用长达12小时（即女孩通常不需要在学校清空它），所以它应该帮助女孩在学校管理月经。- 供应止痛药的时期疼痛（使用代金券系统交付）-简单的改善学校的水和卫生设施，包括锁在厕所门上，提供厕纸，和洗手的肥皂分配器。MENISCUs-2的主要成果是评估干预包工程足够好，使试验是合理的。我们将根据干预包的交付情况（例如，镇痛剂的交付情况）来决定这一点。进步的标准是，教育课程和戏剧短剧已经完成，大多数女孩使用红宝石杯或在终点线提供的可重复使用的护垫，并在需要时获得止痛药，大部分时间学校提供肥皂和卫生纸。我们还将估计进入下一学年的女孩人数，以了解在未来试验中可能失去随访的情况。进展至试验的标准是留存率80%，以允许在未来试验中失访可接受。我们还将估计可能的干预效应大小。最后，我们将估计干预措施的成本，以及监测试验结果的成本。作为研究的一部分，我们还在乌干达试点了一项基于足球的干预措施，以促进安全的男性包皮环切术预防艾滋病毒，我们以前在津巴布韦使用过。这在修改后效果良好，我们将在未来的试验中与MHM干预一起提供这种干预，但在本研究中不包括这一成分，因为它之前已经过充分测试。

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.