‘The Girl With Her Period Is The One To Hang Her Head’ Reflections On Menstrual Management Among Schoolgirls In Rural Kenya

Background: The onset of menstruation is a landmark event in the life of a young woman. Yet the complications and challenges that can accompany such an event have been understudied, specifically in resource-poor settings. As interventions aim to improve female attendance in schools, it is important to explore how menstruation is perceived and navigated by girls in the school setting. This research conveys rural Kenyan schoolgirls’ perceptions and practices related to menstruation.Methods: Data were collected at six rural schools in the Nyanza Province of Western Kenya. Using focus group discussions, in-depth interviews, and field notes from observations, researchers collected information from 48 primary schoolgirls and nine teachers. Systematic analysis began with a reading of transcripts and debriefing notes, followed by manual coding of the narratives.Results: Focus group discussions became opportunities for girls to share thoughts on menstruation, instruct one another on management practices and advise one another on coping mechanisms. Girls expressed fear, shame, distraction and confusion as feelings associated with menstruation. These feelings are largely linked to a sense of embarrassment, concerns about being stigmatized by fellow students and, as teachers explained, a perception that the onset of menstruation signals the advent of a girl’s sexual status. Among the many methods for managing their periods, girls most frequently said they folded, bunched up or sewed cloth, including cloth from shirts or dresses, scraps of old cloth, or strips of an old blanket. Cloth was reported to frequently leak and cause chafing, which made school attendance difficult particularly as the day progressed. Attitudes and practices of girls toward menstruation have been arranged into personal, environmental and behavioural factors.Conclusion: Further research on menstrual management options that are practical, sustainable and culturally acceptable must be conducted to inform future programs and policies that aim to empower young girls as they transition into womanhood. Stakeholders working within this and similar contexts must consider systematic mechanisms to explain to young girls what menstruation is and how to manage it. Providing sanitary supplies or guiding girls on how to create supplies serve as critical components for future interventions

Anal Cleansing Practices And Fecal Contamination: A Preliminary Investigation Of Behaviors And Conditions In Schools In Rural Nyanza Province, Kenya

Objective: To learn how children in rural schools in Nyando District, Kenya clean themselves after defecation.Methods: Six focus group discussions were held with boys and girls ages 12–15 in three rural schools in mid-2009. Parents were interviewed in one setting. In early 2010, a survey of head teachers was conducted in 114 schools in Nyanza Province, Kenya, to assess the provision of anal cleansing materials and handwashing water and soap in schools.Results: Anal cleansing behaviour is linked with access to materials, age, social pressure, perceived personal risk of illness and emotional factors. Materials used for anal cleansing include schoolbook paper, leaves, grasses, stones, corncobs and one’s own hands. Students have knowledge gaps in terms of personal hygiene. They were forthcoming with information on their anal cleansing practices. Almostno schools budgeted for or provided anal cleansing materials regularly.Conclusion: Anal cleansing is a necessary human activity. However, because of social taboos, there are few articles on the topic. School health plans overlook it as well. Researchers need to determine if and how current practices could harm child health to inform policy

Economic Impact Of A Rotavirus Vaccination Program In Mexico

Objectives. To evaluate the cost and benefits of a national rotavirus childhood vaccination program in Mexico. Methods. A decision-analysis model was designed to take the Mexican health care system’s perspective on a comparison of two alternatives: to vaccinate against rotavirus or not. Using published, national data, estimations were calculated for the rotavirus illnesses, deaths, and disability-adjusted life years (DALYs) that would be averted and the incremental cost-effectiveness ratios (US$/DALY) of a hypothetical annual birth cohort of 2 285 000 children,with certain assumptions made for cost, coverage, and efficacy rates.Results. With 93$ 16 per course (2 doses), a rotavirus vaccination program in Mexico would prevent an estimated 651 deaths (or 0.28 deaths per 1 000 children); 13 833 hospitalizations (6.05 hospitalizations per 1 000 children); and 414 927 outpatient visits (182 outpatient visits per 1 000 children) for rotavirus-related acute gastroenteritis (AGE). Vaccination is likely to reduce the economic burden of rotavirus AGE in Mexico by averting US$14 million (71$ 16 per course, the cost-effectiveness ratio would be US$1 139 per DALY averted. A reduction in the price of the rotavirus vaccination program (US$ 8 per course) would yield alower incremental cost-effectiveness ratio of US$ 303 per DALY averted. Conclusions.A national rotavirus vaccination program in Mexico is projected to reducechildhood incidence and mortality and to be highly cost-effective based on the World HealthOrganization’s thresholds for cost-effective interventions

Economic Costs of Rotavirus Gastroenteritis and Cost-Effectiveness of Vaccination in Developing Countries

Background. Rotavirus is the leading cause of severe gastroenteritis in children worldwide. We evaluated the economic burden of rotavirus and the cost-effectiveness of vaccination from the health care perspective. Methods. Estimates were based on existing epidemiological data, cost estimates, vaccine coverage, and efficacy data, as well as hypothetical vaccine prices. Outcome measures included health care and societal costs of rotavirus and benefits and incremental cost-effectiveness ratio of vaccination. Sensitivity analyses evaluated the impact of estimate uncertainty.Results. Treatment costs increased with income level, and health burden decreased; however, burden varied across regions. On the basis of current vaccination coverage and timing, rotavirus vaccination would annually prevent 228,000 deaths, 13.7 million hospital visits, and 8.7 million disability-adjusted life-years, saving $188 million in treatment costs and$243 million in societal costs. At $5 per dose, the incremental cost-effectiveness ratio in low-, lower-middle–, and upper-middle–income countries was$88, $291, and$329 per disability-adjusted life-year averted, respectively, and $3,015,$9,951 and $11,296 per life saved, respectively. Vaccination would prevent 45% of deaths and 58% of associated medical visits and costs. Conclusions. Vaccination is a cost-effective strategy to reduce the health and economic burden of rotavirus. The cost-effectiveness of vaccination depends mostly on vaccine price and reaching children at highest risk of mortalit

Water Insecurity In 3 Dimensions: An Anthropological Perspective On Water And Women’s Psychosocial Distress In Ethiopia

Water insecurity is a primary underlying determinant of global health disparities. While public health research on water insecurity has focused mainly on two dimensions, water access and adequacy, an anthropological perspective highlights the cultural or lifestyle dimension of water insecurity, and its implications for access/adequacy and for the phenomenology of water insecurity. Recent work in Bolivia has shown that scores on a water insecurity scale derived from ethnographic observations are associated with emotional distress. We extend this line of research by assessing the utility of a locally developed water insecurity scale, compared with standard measures of water access and adequacy, in predicting women’s psychosocial distress in Ethiopia. In 2009e2010 we conducted two phases of research. Phase I was mainly qualitative and designed to identify locally relevant experiences of water insecurity, and Phase II used a quantitative survey to test the association between women’s reported water insecurity and the Falk Self-Reporting Questionnaire (SRQ-F), a measure of psychosocial distress. In multiple regression models controlling for food insecurity and reported quantity of water used, women’s water insecurity scores were signi?cantly associated with psychosocial distress. Including controls for time required to collect water and whether water sources were protected did not further predict psychosocial distress. This approach highlights the social dimension of water insecurity, and may be useful for informing and evaluating interventions to improve water supplies

Water, Sanitation And Hygiene Conditions In Kenyan Rural Schools: Are Schools Meeting The Needs Of Menstruating Girls?

Water, sanitation and hygiene (WASH) programs in African schools have received increased attention, particularlyaround the potential impact of poor menstrual hygiene management (MHM) on equity for girls’ education. This studywas conducted prior to a menstrual feasibility study in rural Kenya, to examine current WASH in primary schools andthe resources available for menstruating schoolgirls. Cross-sectional surveys were performed in 62 primary schoolsduring unannounced visits. Of these, 60% had handwashing water, 13% had washing water in latrines for menstruatinggirls, and 2% had soap. Latrines were structurally sound and 16% were clean. Most schools (84%) had separate latrinesfor girls, but the majority (77%) had no lock. Non-governmental organizations (NGOs) supported WASH in 76% ofschools. Schools receiving WASH interventions were more likely to have: cleaner latrines (Risk Ratio (RR) 1.5; 95%Confidence Intervals [CI] 1.0, 2.1), handwashing facilities (RR 1.6, CI 1.1, 2.5), handwashing water (RR 2.7; CI 1.4,5.2), and water in girls’ latrines (RR 4.0; CI 1.4, 11.6). Schools continue to lack essential WASH facilities formenstruating girls. While external support for school WASH interventions improved MHM quality, the impact of thesecontributions remains insufficient. Further support is required to meet international recommendations for healthy,gender-equitable schools

Shamba Maisha: Pilot Agricultural Intervention For Food Security And HIV Health Outcomes In Kenya: Design, Methods, Baseline Results And Process Evaluation Of A Cluster-Randomized Controlled Trial

Background: Despite advances in treatment of people living with HIV, morbidity and mortality remains unacceptably high in sub-Saharan Africa, largely due to parallel epidemics of poverty and food insecurity.Methods/Design: We conducted a pilot cluster randomized controlled trial (RCT) of a multisectoral agricultural and microfinance intervention (entitled Shamba Maisha) designed to improve food security, household wealth, HIV clinical outcomes and women’s empowerment. The intervention was carried out at two HIV clinics in Kenya, one randomizedto the intervention arm and one to the control arm. HIV-infected patients >18 years, on antiretroviral therapy, with moderate/severe food insecurity and/or body mass index (BMI) <18.5, and access to land and surface water were eligible for enrollment. The intervention included: 1) a microfinance loan (~$150) to purchase the farming commodities,2) a micro-irrigation pump, seeds, and fertilizer, and 3) trainings in sustainable agricultural practices and financial literacy. Enrollment of 140 participants took four months, and the screening-to-enrollment ratio was similar between arms. We followed participants for 12 months and conducted structured questionnaires. We also conducted a process evaluation with participants and stakeholders 3–5 months after study start and at study end.Discussion: Baseline results revealed that participants at the two sites were similar in age, gender and maritalstatus. A greater proportion of participants at the intervention site had a low BMI in comparison to participants at the control site (18% vs. 7%, p = 0.054). While median CD4 count was similar between arms, a greater proportionof participants enrolled at the intervention arm had a detectable HIV viral load compared with control participants (49% vs. 28%, respectively, p < 0.010). Process evaluation findings suggested that Shamba Maisha had high acceptability in recruitment, delivered strong agricultural and financial training, and led to labor saving due to use of the water pump.Implementation challenges included participant concerns about repaying loans, agricultural challenges due to weather patterns, and a challenging partnership with the microfinance institution. We expect the results from this pilotstudy to provide useful data on the impacts of livelihood interventions and will help in the design of a definitive cluster RCT

Economic and Health Burden of Rotavirus Gastroenteritis in Latin America

Objective. To estimate the health and economic burden of rotavirus gastroenteritis in hos-pital and outpatient settings in eight Latin American and Caribbean countries (Argentina, Brazil, Chile, Dominican Republic, Honduras, Mexico, Panama, and Venezuela). Methods. An economic model was constructed using epidemiological data from published articles, national health administration studies, and country-specific cost estimates. For each of the eight countries, the model estimated the rotavirus outcomes for the 2003 birth cohort during the first five years of life. The main outcome measures included health care costs, trans-portation costs, lost wages, and disease burden expressed in disability-adjusted life years. Es-timates were expressed in 2003 US dollars. All future costs and disability-adjusted life year estimates were discounted at a rate of 3%. Sensitivity analyses evaluated the impact of specific variables on the medical cost of treating rotavirus. Results. For every 1 000 children born during 2003 in the eight Latin American and Caribbean countries studied here, we estimated that rotavirus gastroenteritis would result in an average of 246 outpatient visits, 24 hospitalizations, 0.6 deaths, and US$ 7 971 in direct medical costs during their first five years of life. The incidence of rotavirus-associated outpa-tient visits and the cost of outpatient visits were predicted to have the largest impact on the total medical cost per child. Conclusions. Rotavirus gastroenteritis is likely to result in substantial disease and economic burden to health systems in Latin American and Caribbean countries, and the foreseeable bur-den should be an important consideration in evaluating the cost-effectiveness of vaccination

Sustaining School Hand Washing And Water Treatment Programmes: Lessons Learned And To Be Learned

In Nyanza Province, Kenya, a sustainability evaluation of 55 pilot primary schools 2.5 years after the implementation of the Safe Water System (SWS) intervention revealed that programme activities were not successfully sustained in any of the schools visited. The most common criterion met was drinking water provision. We identified six enabling environment domains: financial capacity; accountability; technical feasibility and availability; community support; school leadership and management; and student engagement. While these domains pertain to the sustaining of the SWS activities in schools, they are likely to be applicable in creating an enabling environment and serve as proxy indicators for other school water, sanitation, and hygiene initiatives as well

Estimating the Cost and Payment for Sanitation in the Informal Settlements of Kisumu, Kenya: A Cross Sectional Study.

Lack of sanitation facilities is a common occurrence in informal settlements that are common in most developing countries. One challenge with sanitation provision in these settlements is the cost and financing of sanitation. This study aimed at estimating the cost of sanitation, and investigating the social and economic dynamics within Kisumu's informal settlements that hinder provision and uptake of sanitation facilities. Primary data was collected from residents of the settlements, and using logistic and hedonic regression analysis, we identify characteristics of residents with sanitation facilities, and estimate the cost of sanitation as revealed in rental prices. Our study finds that sanitation constitutes approximately 54% of the rent paid in the settlements; and dynamics such as landlords and tenants preferences, and sharing of sanitation facilities influence provision and payment for sanitation. This study contributes to general development by estimating the cost of sanitation, and further identifies barriers and opportunities for improvement including the interplay between landlords and tenants. Provision of sanitation in informal settlements is intertwined in social and economic dynamics, and development approaches should target both landlords and tenants, while also engaging various stakeholders to work together to identify affordable and appropriate sanitation technologies