A qualitative content analysis of rural and urban school students’ menstruation-related questions in Bangladesh

Nearly half of Bangladeshi girls reach menarche without knowledge of menstruation and many fear seeking support due to pervasive menstrual stigma. We aimed to explore the types of menstruation-related information and support adolescent female and male students want but may be uncomfortable verbalising. We installed a locked box in four school classrooms in rural and urban Bangladesh as part of a menstrual hygiene management pilot intervention between August 2017 and April 2018. Trained teachers provided puberty education to female and male students in classes 5–10 (ages 10–17 years) and encouraged students to submit questions anonymously to the boxes if they did not want to ask aloud. We conducted a content analysis of the 374 menstruation-related questions from a total of 834 submissions. Questions regarded experiences of menstrual bleeding (35%); menstrual symptoms and management (32%); menstrual physiology (19%); behavioural prescriptions and proscriptions (6%); concerns over vaginal discharge (4%); and menstrual stigma, fear, and social support (4%). Students wanted to understand the underlying causes of various menstrual experiences, and concern over whether particular experiences are indicative of health problems was pervasive. Ensuring comprehensive school-based menstruation education and strengthening engagement among schools, parents, and healthcare providers is important for improving access to reliable menstrual health information and may relieve adolescents’ concerns over whether their menstrual experiences are ’normal’

WASH Benefits Bangladesh trial: management structure for achieving high coverage in an efficacy trial

Abstract Background Water, sanitation, and hygiene (WASH) efficacy trials deliver interventions to the target population under optimal conditions to estimate their effects on outcomes of interest, to inform subsequent selection for inclusion in routine programs. A systematic and intensive approach to intervention delivery is required to achieve the high-level uptake necessary to measure efficacy. We describe the intervention delivery system adopted in the WASH Benefits Bangladesh study, as part of a three-paper series on WASH Benefits Intervention Delivery and Performance. Methods Community Health Workers (CHWs) delivered individual and combined WASH and nutrition interventions to 4169 enrolled households in geographically matched clusters. Households were provided with free enabling technologies and supplies, integrated with parallel behaviour-change promotion. Behavioural objectives were drinking treated, safely stored water, safe feces disposal, handwashing with soap at key times, and age-appropriate nutrition behaviours (birth to 24 months). The intervention delivery system built on lessons learned from prior WASH intervention effectiveness, implementation, and formative research studies. We recruited local CHWs, residents of the study villages, through transparent merit-based selection methods, and consultation with community leaders. CHW supervisors received training on direct intervention delivery, then trained their assigned CHWs. CHWs in turn used the technologies in their own homes. Each CHW counseled six to eight intervention households spread across a 0.2–2.2-km radius, with a 1:12 supervisor-to-CHW ratio. CHWs met monthly with supervisor-trainers to exchange experiences and adapt technology and behaviour-change approaches to evolving conditions. Intervention uptake was tracked through fidelity measures, with a priori benchmarks necessary for an efficacy study. Results Sufficient levels of uptake were attained by the fourth intervention assessment month and sustained throughout the intervention period. Periodic internal CHW monitoring resulted in discontinuation of a small number of low performers. Conclusions The intensive intervention delivery system required for an efficacy trial differs in many respects from the system for a routine program. To implement a routine program at scale requires further research on how to optimize the supervisor-to-CHW-to-intervention household ratios, as well as other program costs without compromising program effectiveness. Trial registration ClinicalTrials.gov, ID: NCC01590095. Registered on 2 May 2012

Exemplar tasks across categories which girls enact to address their menstrual needs, as reported by schoolgirls in Bangladesh during focus group discussions for the development of the Self-Efficacy in Addressing Menstrual Needs Scale, 2017–2018.

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Process of development and testing of the Self-Efficacy in Addressing Menstrual Needs Scale in 8 urban and rural schools in Bangladesh 2017–2018.

Process of development and testing of the Self-Efficacy in Addressing Menstrual Needs Scale in 8 urban and rural schools in Bangladesh 2017–2018.</p

Item response mean, standard deviation, skew, and kurtosis for 34 items formally tested with schoolgirls (n = 381) for the development of the Self-Efficacy in Addressing Menstrual Needs Scale in Bangladesh, 2018.

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Mean Self-Efficacy in Addressing Menstrual Needs Scale (SAMNS) scores by responses to validation items (n = 381).

Mean Self-Efficacy in Addressing Menstrual Needs Scale (SAMNS) scores by responses to validation items (n = 381).</p

Questionnaire instructions and response options developed for the Self-Efficacy in Addressing Menstrual Needs Scale, tested in Bangladesh, 2017–2018.

Questionnaire instructions and response options developed for the Self-Efficacy in Addressing Menstrual Needs Scale, tested in Bangladesh, 2017–2018.</p

Self-Efficacy in Addressing Menstrual Needs Scale (SAMNS-26) [Bengali version].

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Self-Efficacy in Addressing Menstrual Needs Scale (SAMNS-26) [English translation of Bengali version].

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Correlations between Self-Efficacy in Addressing Menstrual Needs Scale (SAMNS) scores and validation measures (n = 381).

Correlations between Self-Efficacy in Addressing Menstrual Needs Scale (SAMNS) scores and validation measures (n = 381).</p