Improving the impact of menstrual health innovations in low- and middle-income countries: a theory of change and measurement framework

There exists growing global attention focused on tackling the menstrual management related challenges facing adolescent girls and women in low- and middle-income countries (LMIC). This includes a surge of growth in new and locally produced menstrual products, often accompanied by innovative distribution approaches aimed at enhancing accessibility, along with the provision of menstruation-related education. Increasing global investments support the development of such products by local and international menstrual innovators, with the aim of shifting from product development towards achieving scale. Parallel to such efforts, there is a need for rigorous monitoring to evaluate the process and impact of implementation, to ensure resources are effectively utilized. In response, a new measurement model was developed that includes a Theory of Change (ToC) and measurement framework, to enable improved measurement of the impact and growth of menstrual product innovations. These tools aim to help investors to more effectively monitor and assess the impact of investments. They will also support social entrepreneurs, innovators, and non-governmental organizations to adopt approaches that are most effective for impacting the lives of menstruating adolescent girls and women across LMIC. This paper seeks to introduce the ToC and monitoring and evaluation framework as supportive resources that provide a common framework for the global community to utilize as both investors and social entrepreneurs seek to develop more scalable menstrual solutions globally

The Application of Geographic Information Systems (GIS) to Improving Health Systems in the Upper East Region of Ghana

Despite the increased use of Geographic Information System (GIS) for health research, the technology is least used in settings where evidence based decision-making is needed most: High mortality settings of Africa where resource constraints impede the provision of essential care. This paper reports on a case study of GIS application in the Upper East Region (UER), one of the poorest regions in Ghana. Methods: Ghana Health Service (GHS) workers were trained to use GPS handheld devices to gather waypoints (coordinates) of all health care facilities and amenities throughout the UER. The waypoints data were then exported to Excel spreadsheets and cleaned of all inconsistencies. The final data was imported into ArcMap 10.2.2 software for data manipulation, display, and analysis. Results: Preventive health issues portrayed by GIS visualization included a substandard access to potable water in one community and health facility deficiencies in the Binduri district. As examples of GIS morbidity surveillance, we map the temporal incidence of cholera in two districts, and evidence of a pattern in the seasonal outbreaks of cerebral spinal meningitis (CSM). Conclusion: Results attest to the feasibility of using GIS to clarify health issues in a severely health service deprived setting, enabling public health authorities to optimize system responses where mostly needed. GIS technology has enabled health officials in the region to visualize the geographic pattern of disease outbreaks in ways that permit the imposition of efficient containment strategies

What is the scope for addressing menstrual hygiene management in complex humanitarian emergencies? A global review.

Global attention on improving the integration of menstrual hygiene management (MHM) into humanitarian response is growing. However, there continues to be a lack of consensus on how best to approach MHM inclusion within response activities. This global review assessed the landscape of MHM practice, policy, and research within the field of humanitarian response. This included an analysis of the limited existing documentation and research on MHM in emergencies and global key informant interviews (n=29) conducted with humanitarian actors from relevant sectors (water, sanitation, and hygiene; women's protection; child protection; health; education; non-food items; camp management). The findings indicate that despite a growing dialogue around MHM in emergencies, there remains a lack of clarity on the key components for a complete MHM response, the responsible sectoral actors to implement MHM activities, and the most effective interventions to adapt in emergency contexts, and insufficient guidance on monitoring and evaluation. There is a critical need for improved technical guidance and documentation on how to integrate MHM into existing programming and monitoring systems and to ensure adequate coordination and communication about MHM across relevant sectors. There is also a need for improved evidence on effective MHM approaches, the development of MHM-specific indicators, improved consultation with girls and women in crisis-afflicted areas, and the documentation of practical learning. It is only through improving the resources available and enhancing this evidence base that MHM can be perceived as an integral and routine component of any humanitarian response

Innovative strategies for providing menstruation-supportive water, sanitation and hygiene (WASH) facilities: learning from refugee camps in Cox’s bazar, Bangladesh

Background There is growing attention to addressing the menstrual hygiene management (MHM) needs of the over 21 million displaced adolescent girls and women globally. Current approaches to MHM-related humanitarian programming often prioritize the provision of menstrual materials and information. However, a critical component of an MHM response includes the construction and maintenance of water, sanitation and hygiene (WASH) facilities, including more female-friendly toilets. This enables spaces for menstruating girls and women to change, dispose, wash and dry menstrual materials; all of which are integral tasks required for MHM. A global assessment identified a number of innovations focused on designing and implementing menstruation-supportive WASH facilities in the Rohingya refugee camps located in Cox’s Bazar (CXB), Bangladesh. These pilot efforts strove to include the use of more participatory methodologies in the process of developing the new MHM-supportive WASH approaches. This study aimed to capture new approaches and practical insights on innovating menstrual disposal, waste management and laundering in emergency contexts through the conduct of a qualitative assessment in CXB. Methods The qualitative assessment was conducted in the Rohingya refugee camps in CXB in September of 2019 to capture new approaches and practical insights on innovating for menstrual disposal, waste management and laundering. This included Key Informant Interviews with 19 humanitarian response staff from the WASH and Protection sectors of a range of non-governmental organizations and UN agencies; Focus Group Discussions with 47 Rohingya adolescent girls and women; and direct observations of 8 WASH facilities (toilets, bathing, and laundering spaces). Results Key findings included: one, the identification of new female-driven consultation methods aimed at improving female beneficiary involvement and buy-in during the design and construction phases; two, the design of new multi-purpose WASH facilities to increase female beneficiary usage; three, new menstrual waste disposal innovations being piloted in communal and institutional settings, with female users indicating at least initial acceptability; and four, novel strategies for engaging male beneficiaries in the design of female WASH facilities, including promoting dialogue to generate buy-in regarding the importance of these facilities and debate about their placement. Conclusions Although the identified innovative participatory methodologies and design approaches are promising, the long term viability of the facilities, including plans to expand them, may be dependent on the continued engagement of girls and women, and the availability of resources

Using Participatory Design to Develop a Menstrual Hygiene Management Intervention: Designing WASH UP! Girl Talk in Zimbabwe

Globally, as more girls transition from primary to secondary education, there is a new generation of girls who will have to manage their menses in school environments. Few schools are designed with girls’ menstrual hygiene management (MHM) needs in mind and many girls begin menstruating without knowing what is happening to them. This lack of knowledge about menstruation is associated with profound psychological and reproductive health issues. As such, school-based WASH interventions, especially those focused on MHM, can improve educational opportunities, promote lifelong health, and enhance the wellbeing of children and their families. In Zimbabwe, these global realities hold true, where menstruation is a taboo subject and girls find it difficult to access accurate information and are unable to manage their menstruation safely, hygienically, and with dignity and privacy. An effective solution to these challenges must address school infrastructure concerns and limitations in knowledge, attitudes, and practices around MHM. In response, Sesame Workshop, in collaboration with World Vision, launched WASH UP! Girl Talk in Zimbabwe, targeting students 10-14 years old. Girl Talk involved the development and implementation of an intervention aimed at improving students’ knowledge and practice of healthy hygiene behaviors. Girl Talk also focused on increasing girls’ confidence in their personal MHM. This article highlights the development of Girl Talk and its focus on participatory design to standardize a curriculum framework, implementation process, and research approach to contextualize education content. This process of program design, grounded in the intersections of best practices and local knowledge, provides both a conceptual and practical framework to inform future MHM interventions

Understanding the menstrual hygiene management challenges facing displaced girls and women: findings from qualitative assessments in Myanmar and Lebanon.

BACKGROUND: There is a significant gap in empirical evidence on the menstrual hygiene management (MHM) challenges faced by adolescent girls and women in emergency contexts, and on appropriate humanitarian response approaches to meet their needs in diverse emergency contexts. To begin filling the gap in the evidence, we conducted a study in two diverse contexts (Myanmar and Lebanon), exploring the MHM barriers facing girls and women, and the various relevant sectoral responses being conducted (e.g. water, sanitation and hygiene (WASH), Protection, Health, Education and Camp Management). METHODS: Two qualitative assessments were conducted: one in camps for internally displaced populations in Myanmar, and one with refugees living in informal settlements and host communities in Lebanon. Key informant interviews were conducted with emergency response staff in both sites, and focus group discussion and participatory mapping activities conducted with adolescent girls and women. RESULTS: Key findings included that there was insufficient access to safe and private facilities for MHM coupled with displacement induced shifts in menstrual practices by girls and women. Among staff, there was a narrow interpretation of what an MHM response includes, with a focus on supplies; significant interest in understanding what an improved MHM response would include and acknowledgement of limited existing MHM guidance across various sectors; and insufficient consultation with beneficiaries, related to discomfort asking about menstruation, and limited coordination between sectors. CONCLUSIONS: There is a significant need for improved guidance across all relevant sectors for improving MHM response in emergency context, along with increased evidence on effective approaches for integrating MHM into existing responses

Does the design and implementation of proven innovations for delivering basic primary health care services in rural communities fit the urban setting...

Background: Rapid urban population growth is of global concern as it is accompanied with several new health challenges. The urban poor who reside in informal settlements are more vulnerable to these health challenges. Lack of formal government public health facilities for the provision of health care is also a common phenomenon among communities inhabited by the urban poor. To help ameliorate this situation, an innovative urban primary health system was introduced in urban Ghana, based on the milestones model developed with the rural Community-Based Health Planning and Services (CHPS) system. This paper provides an overview of innovative experiences adapted while addressing these urban health issues, including the process of deriving constructive lessons needed to inform discourse on the design and implementation of the sustainable Community-Based Health Planning and Services (CHPS) model as a response to urban health challenges in Southern Ghana. Methods: This research was conducted during the six-month pilot of the urban CHPS programme in two selected areas acting as the intervention and control arms of the design. Daily routine data were collected based on milestones initially delineated for the rural CHPS model in the control communities whilst in the intervention communities, some modifications were made to the rural milestones. Results: The findings from the implementation activities revealed that many of the best practices derived from the rural CHPS experiment could not be transplanted to poor urban settlements due to the unique organizational structures and epidemiological characteristics found in the urban context. For example, constructing Community Health Compounds and residential facilities within zones, a central component to the rural CHPS strategy, proved inappropriate for the urban sector. Night and weekend home visit schedules were initiated to better accommodate urban residents and increase coverage. The breadth of the disease burden of the urban residents also requires a broader expertise and training of the CHOs. Conclusions: Access to improved urban health services remains a challenge. However, current policy guidelines for the implementation of a primary health model based on rural experiences and experimental design requires careful review and modifications to meet the needs of the urban settings

Menstrual Product Insecurity Resulting From COVID-19‒Related Income Loss, United States, 2020.

To identify key effects of the pandemic and its economic consequences on menstrual product insecurity with implications for public health practice and policy. Study participants (n = 1496) were a subset of individuals enrolled in a national (US) prospective cohort study. Three survey waves were included (March‒October 2020). Menstrual product insecurity outcomes were explored with bivariate associations and logistic regression models to examine the associations between outcomes and income loss. Income loss was associated with most aspects of menstrual product insecurity (adjusted odds ratios from 1.34 to 3.64). The odds of not being able to afford products for those who experienced income loss was 3.64 times (95% confidence interval [CI] = 2.14, 6.19) that of those who had no income loss and 3.95 times (95% CI = 1.78, 8.79) the odds for lower-income participants compared with higher-income participants. Pandemic-related income loss was a strong predictor of menstrual product insecurity, particularly for populations with lower income and educational attainment. Provision of free or subsidized menstrual products is needed by vulnerable populations and those most impacted by pandemic-related income loss.( 2022;112(4):675-684. (https://doi.org/10.2105/AJPH.2021.306674)

\u3cem\u3eABCC9\u3c/em\u3e Gene Polymorphism Is Associated with Hippocampal Sclerosis of Aging Pathology

Hippocampal sclerosis of aging (HS-Aging) is a high-morbidity brain disease in the elderly but risk factors are largely unknown. We report the first genome-wide association study (GWAS) with HS-Aging pathology as an endophenotype. In collaboration with the Alzheimer\u27s Disease Genetics Consortium, data were analyzed from large autopsy cohorts: (#1) National Alzheimer\u27s Coordinating Center (NACC); (#2) Rush University Religious Orders Study and Memory and Aging Project; (#3) Group Health Research Institute Adult Changes in Thought study; (#4) University of California at Irvine 90+ Study; and (#5) University of Kentucky Alzheimer\u27s Disease Center. Altogether, 363 HS-Aging cases and 2,303 controls, all pathologically confirmed, provided statistical power to test for risk alleles with large effect size. A two-tier study design included GWAS from cohorts #1-3 (Stage I) to identify promising SNP candidates, followed by focused evaluation of particular SNPs in cohorts #4-5 (Stage II). Polymorphism in the ATP-binding cassette, sub-family C member 9 (ABCC9) gene, also known as sulfonylurea receptor 2, was associated with HS-Aging pathology. In the meta-analyzed Stage I GWAS, ABCC9 polymorphisms yielded the lowest p values, and factoring in the Stage II results, the meta-analyzed risk SNP (rs704178:G) attained genome-wide statistical significance (p = 1.4 × 10-9), with odds ratio (OR) of 2.13 (recessive mode of inheritance). For SNPs previously linked to hippocampal sclerosis, meta-analyses of Stage I results show OR = 1.16 for rs5848 (GRN) and OR = 1.22 rs1990622 (TMEM106B), with the risk alleles as previously described. Sulfonylureas, a widely prescribed drug class used to treat diabetes, also modify human ABCC9 protein function. A subsample of patients from the NACC database (n = 624) were identified who were older than age 85 at death with known drug history. Controlling for important confounders such as diabetes itself, exposure to a sulfonylurea drug was associated with risk for HS-Aging pathology (p = 0.03). Thus, we describe a novel and targetable dementia risk factor