27 research outputs found
Menstrual hygiene management among adolescent schoolgirls in low- and middle-income countries: research priorities.
BACKGROUND: A lack of adequate guidance on menstrual management; water, disposal, and private changing facilities; and sanitary hygiene materials in low- and middle-income countries leaves schoolgirls with limited options for healthy personal hygiene during monthly menses. While a plethora of observational studies have described how menstrual hygiene management (MHM) barriers in school impact girls' dignity, well-being, and engagement in school activities, studies have yet to confirm if inadequate information and facilities for MHM significantly affects quantifiable school and health outcomes influencing girls' life chances. Evidence on these hard outcomes will take time to accrue; however, a current lack of standardized methods, tools, and research funding is hampering progress and must be addressed. OBJECTIVES: Compile research priorities for MHM and types of research methods that can be used. RESULTS: In this article, we highlight the current knowledge gaps in school-aged girls' MHM research, and identify opportunities for addressing the dearth of hard evidence limiting the ability of governments, donors, and other agencies to appropriately target resources. We outline a series of research priorities and methodologies that were drawn from an expert panel to address global priorities for MHM in schools for the next 10 years. CONCLUSIONS: A strong evidence base for different settings, standardized definitions regarding MHM outcomes, improved study designs and methodologies, and the creation of an MHM research consortia to focus attention on this neglected global issue
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
Integrating HIV, syphilis, malaria and anaemia point-of-care testing (POCT) for antenatal care at dispensaries in western Kenya: discrete-event simulation modelling of operational impact
Background
Despite WHO advocating for an integrated approach to antenatal care (ANC), testing coverage for conditions other than HIV remains low and women are referred to distant laboratories for testing. Using point-of-care tests (POCTs) at peripheral dispensaries could improve access to testing and timely treatment. However, the effect of providing additional services on nurse workload and client wait times are unknown. We use discrete-event simulation (DES) modelling to understand the effect of providing four point-of-care tests for ANC on nurse utilization and wait times for women seeking maternal and child health (MCH) services.
Methods
We collected detailed time-motion data over 20 days from one high volume dispensary in western Kenya during the 8-month implementation period (2014–2015) of the intervention. We constructed a simulation model using empirical arrival distributions, activity durations and client pathways of women seeking MCH services. We removed the intervention from the model to obtain wait times, length-of-stay and nurse utilization rates for the baseline scenario where only HIV testing was offered for ANC. Additionally, we modelled a scenario where nurse consultations were set to have minimum durations for sufficient delivery of all WHO-recommended services.
Results
A total of 183 women visited the dispensary for MCH services and 14 of these women received point-of-care testing (POCT). The mean difference in total waiting time was 2 min (95%CI: < 1–4 min, p = 0.026) for MCH women when integrated POCT was given, and 9 min (95%CI: 4–14 min, p < 0.001) when integrated POCT with adequate ANC consult times was given compared to the baseline scenario. Mean length-of-stay increased by 2 min (95%CI: < 1–4 min, p = 0.015) with integrated POCT and by 16 min (95%CI: 10–21 min, p < 0.001) with integrated POCT and adequate consult times compared to the baseline scenario. The two nurses’ overall daily utilization in the scenario with sufficient minimum consult durations were 72 and 75%.
Conclusion
The intervention had a modest overall impact on wait times and length-of-stay for women seeking MCH services while ensuring pregnant women received essential diagnostic testing. Nurse utilization rates fluctuated among days: nurses experienced spikes in workload on some days but were under-utilized on the majority of days. Overall, our model suggests there was sufficient time to deliver all WHO’s required ANC activities and offer integrated testing for ANC first and re-visits with the current number of healthcare staff. Further investigations on improving healthcare worker, availability, performance and quality of care are needed. Delivering four point-of-care tests together for ANC at dispensary level would be a low burden strategy to improve ANC
‘You don’t have to sleep with a man to get how to survive’: Girl’s perceptions of an intervention study aimed at improving sexual and reproductive health and schooling outcomes.
In sub-Saharan Africa, girls suffer from high rates of morbidity and mortality, enduring high exposure to sexual and reproductive health harms. Staying in school helps protect girls from such harms. Focus group discussions were conducted in a rural, impoverished area of Kenya with adolescent girls participating in a 4-arm cluster randomised controlled trial, evaluating menstrual cups, cash transfer, or combined cups plus cash transfer against controls. To explore girls’ perceptions of how trial interventions affected their SRH risks and schooling, semi-structured discussions were held at baseline, midline, and study end. Data was explored using thematic analysis. At baseline there were no discernible differences between the 4 intervention groups regarding their perceptions of relationships with boys/men, and difficulties attending or remaining in school. Midline and endline discussions found that narratives from those receiving cash transfer only, or alongside a cup were similar; girls noted fewer pregnancies and less school dropout, attributed to the cash transfer reducing the need for transactional sex. Lower absenteeism was reported by the cup only group, with perceived minimal effect on pregnancy and dropout. Girls in control and cup only groups described feeling valued through inclusion, benefitting from puberty and hygiene education. Although seemingly having little effect on reducing pregnancy or dropout, these inputs reportedly empowered girls, whilst cash transfer girls were emboldened to refuse male sexual advances. Girls noticed benefits from trial interventions, with a reduction in transactional sex and resulting pregnancy impacting on school dropout, or reduced menstrual related absenteeism. Education and study inclusion were perceived as important. Future programmes should consider alleviating material deprivation which prevents girls from attending or performing at school through schemes such as cash transfer, alongside hygiene and education packages. This will empower girls to refuse unwanted sex and understand risks, in addition to motivating academic achievement and school completion
“He’ll come with some sugar.” A qualitative study exploring the drivers and consequences of schoolgirls transactional sex behaviours
Transactional sex (TS) is common in areas of sub-Saharan Africa, motivated by reasons beyond financial support. Through this qualitative study we sought to understand the motivation driving TS among adolescent schoolgirls in rural western Kenya where rates are reportedly high. Identifying and understanding drivers within the local context is necessary for implementation of successful public health policy and programming to reduce the associated harms impacting health and wellbeing. To understand the drivers of sexual behaviors, individual views, and socio-cultural norms, we spoke with schoolgirls, male peers, parents and teachers. The three latter groups may influence, encourage, and shape girls’ views and behaviors and thus contribute to the perpetuation of cultural and societal norms. One hundred and ninety-nine participants took part across 20 FGDs; comprised of schoolgirl groups, and 4 each of schoolboy, parent or teacher groups. Through thematic analysis, poverty emerged as the key driver of TS and a normative behaviour amongst secondary school girls. Subthemes including parental influence, need for menstrual pads, pressure from boda boda drivers, peer pressure, and blame were part of a complex relationship linking poverty with TS. We conclude that whilst TS is perceived as inevitable, normal and acceptable it is not really a choice for many girls. Exploring ways to encourage communication between families, including around menstruation, may help enable girls to ask for help in acquiring essential items. In addition, education at a community level may shift social norms over time and decrease the prevalence of age-disparate TS among schoolgirls and older, wealthier men in the community
Exploring menstrual products: A systematic review and meta-analysis of reusable menstrual pads for public health internationally
Background: Girls and women need effective, safe, and affordable menstrual products. Single-use menstrual pads and tampons are regularly provided by agencies among resource-poor populations. Reusable menstrual pads (RMPs: fabric layers sewn together by an enterprise for manufacture of menstrual products) may be an effective alternative. Methods: For this review (PROSPERO CRD42020179545) we searched databases (inception to November 1, 2020) for quantitative and qualitative studies that reported on leakage, acceptability, or safety of RMPs. Findings were summarised or combined using forest plots (random-effects meta-analysis). Potential costs and environmental savings associated with RMPs were estimated. Results: A total of 44 studies were eligible (~14,800 participants). Most were conducted in low- and middle-income countries (LMIC, 78%), and 20% in refugee settings. The overall quality of studies was low. RMP uptake in cohort studies ranged from 22–100% (12 studies). One Ugandan trial among schoolgirls found leakage with RMPs was lower (44.4%, n = 72) compared to cloths (78%, n = 111, p<0.001). Self-reported skin-irritation was 23.8% after 3 months among RMP-users in a Ugandan cohort in a refugee setting (n = 267), compared to 72.8% at baseline with disposable pad use. There were no objective reports on infection. Challenges with washing and changing RMP were reported in LMIC studies, due to lack of water, privacy, soap, buckets, and sanitation/drying facilities. Among 69 brands, the average price for an RMP was 5.08; LMIC 10.11), with a mean estimated lifetime of 4.3 years (sd 2.3; LMIC 2.9, n = 11; HIC 4.9 years, n = 23). In 5-year cost-estimates, in LMICs, 4–25 RMPs per period would be cheaper (170–417 US) compared to 20 single-use tampons per period, with waste-savings of ~1300 tampons. Conclusion: RMPs are used internationally and are an effective, safe, cheaper, and environmentally friendly option for menstrual product provision by programmes. Good quality studies in this field are needed
Cost-Effectiveness and Cost–Benefit Analyses of Providing Menstrual Cups and Sanitary Pads to Schoolgirls in Rural Kenya
Objective: To analyze the relative value of providing menstrual cups and sanitary pads to primary schoolgirls.
Design: Cost-effectiveness and cost–benefit analyses of three-arm single-site open cluster randomized controlled pilot study providing menstrual cups or sanitary pads for 1 year.
Participants: Girls 14–16 years of age enrolled across 30 primary schools in rural western Kenya.
Methods: Cost-effectiveness analysis was conducted based on the health effects (reductions in disability-adjusted life years [DALYs]) and education effects (reductions in school absenteeism) of both interventions. The health and education benefits were separately valued and compared with relative program costs.
Results: Compared with the control group, the cost of menstrual cups was estimated at 24,000 for sanitary pads. The benefit of the menstrual cup program (1.4 DALYs averted, 95% confidence interval [CI]: −4.3 to 3.1) was higher compared with a sanitary pad program (0.48 DALYs averted, 95% CI: −4.2 to 2.3), but the health effects of both interventions were not statistically significant likely due to the limited statistical power. Using point estimates, the menstrual cup intervention was cost-effective in improving health outcomes (300/student-school year in reducing school absenteeism. When considering improvements in future earnings from reduced absenteeism, the sanitary pad program had a net benefit of +32,000 to +$169,000).
Conclusions: The menstrual cup may provide a cost-effective solution for menstrual hygiene management in low-income settings. This study outlines a methodology for future analyses of menstrual hygiene interventions and highlights several knowledge gaps that need to be addressed
Pregnancy and marriage among teenage schoolgirls in rural western Kenya; a secondary analysis of a menstrual solution feasibility COHORT study
Background: Adolescent pregnancy increases the risk of adverse health outcomes, social stigma, loss of education and employment, and early marriage. Research characterising at risk girls will inform targeting of effective interventions.
Methods: Risk characteristics for adolescent pregnancy were evaluated in schoolgirls aged 14-16 years as a secondary analysis in a longitudinal study evaluating menstrual products in 30 primary schools in rural western Kenya. Characteristics of participants were collected at baseline and follow-up. Descriptive and multivariate analysis were conducted.
Results: Of 766 girls enrolled into the study, aged 14-16 years and followed over a school year, 53 (7%) were or became pregnant, with three (6%) neonatal deaths reported. Girls with the lowest compared with the highest socio-economic status had 2.5-fold higher risk of pregnancy (13.1% vs 5.0%: adjusted risk ratio (aRR) 2.48, confidence limits 1.32-4.64). Girls reporting early menarche (<13 years) had a 2.5-fold higher risk of pregnancy (aRR 2.61, 1.38-4.92), while those happy in school had a reduced risk (aRR 0.60, 0.34-1.04). Age, presence of parents, and being harassed by boys or men were not associated with pregnancy risk. Twenty-two girls (2.9%) married by the study end. Marriage was significantly associated with pregnancy (aRR 13.44, 5.50-32.83) and a history of sex at baseline (3.15, 1.55-6.38). All but two girls dropped out of school when pregnant with only five girls returning after delivery.
Conclusions:Pregnancy leading to school dropout and child marriage remains an urgent public health concern among teenage girls in rural Kenya. Interventions are needed to enable schoolgirls to reach their educational potential
Water, sanitation and hygiene at sex work venues to support menstrual needs
Introduction:
Adequate menstrual health and hygiene (MHH) is necessary for women’s health and equity of all menstruators. Female sex workers (FSW) require good MHH to prevent discomfort and exposure to pathogens. No studies have evaluated water, sanitation, and hygiene (WASH) conditions of FSW. We report on a cross-sectional WASH assessment at FSW venues in Kisumu, western Kenya.
Methods:
Stakeholders identified 77 FSW venues in Kisumu, of which 47 were randomly sampled and visited between April-May 2023. A standardized structured survey of WASH conditions was deployed by trained research staff using Android tablets after proprietor’s consent. WASH scores ranging 0 – 3 were computed based on point each for direct observation of water available, soap available, and acceptable latrine. MHH scores ranging between 0-4 were computed (one point each) for direct observation of: currently available soap and water, locking door on a usable latrine, functional lighting, and a private area for changing clothes or menstrual materials, separate from the latrine(s). WASH and MHH scores were compared by venue type using non-parametric Kruskal-Wallis tests, and non-parametric Spearman rank tests.
Results:
Full WASH criteria was met by 29.8% of venues; 34.0% had no adequate WASH facilities; 46.8% had no female latrine, and 25.5% provided soap and water in private spaces for women. While 76.6% had menstrual waste disposal only 14 (29.8%) had covered bins. One in 10 venues provided adequate MHM facilities. Poorest WASH facilities were in brothels and in bars, and three-quarters of bars with accommodation had no MHH facilities.
Discussion:
WASH and MHH services were sub-optimal in the majority of FSW venues, preventing menstrual management safely, effectively, with dignity and privacy. This study highlights the unmet need for MHH support for this population. Poor MHH can deleteriously impact FSW health and wellbeing and compound the stigma and shame associated with their work and ability to stay clean. Acceptable and cost-effective solutions to sustainably improve WASH facilities for these populations are needed
Quality of life and well-being problems in secondary schoolgirls in Kenya: Prevalence, associated characteristics, and course predictors
Background:
Adolescents in sub-Saharan Africa often report low levels of quality of life (QoL) and well-being, but reliable data are limited. This study examines which sociodemographic, health, and behavioral risk factors and adverse adolescent experiences are associated with, and predictive of, QoL in Kenyan secondary schoolgirls.
Methods and findings:
3,998 girls at baseline in a randomised controlled trial in Siaya County, western Kenya were median age 17.1 years. Subjectively perceived physical, emotional, social and school functioning was assessed using the Pediatric Quality of Life (QoL) Inventory-23. Laboratory-confirmed and survey data were utilized to assess sociodemographic, health and behavioral characteristics, and adverse adolescent experiences. We identified a group of girls with Low QoL (n=1126; 28.2%), Average QoL (n=1445; 36.1%); and High QoL (n=1427; 35.7%). Significantly higher scores on all well-being indicators in the LQoL compared with HQoL group indicated good construct validity (Odds Ratio's (ORs) varying from 3.31 (95% CI:2.41-4.54, p<.001) for feeling unhappy at home to 11.88 (95%CI:7.96-17.74, p< .001) for PHQ9 defined possible caseness (probable diagnosis) of depression. Adverse adolescent experiences were independently statistically significant in the LQoL compared to the HQoL group for threats of family being hurt (aOR=1.35,1.08-1.68, p=.008), sexual harassment out of school (aOR=2.17,1.79-2.64, p<.001), and for menstrual problems like unavailability of sanitary pads (aOR=1.23,1.05-1.44, p=.008) and stopping activities due to menstruation (aOR=1.77,1.41-2.24, p<.001). After 2-years follow-up of 906 girls in the LQoL group, 22.7% persisted with LQoL. Forced sex (aOR=1.56,1.05-2.32, p=.028) and threats of family being hurt (aOR=1.98,1.38-2.82, p<.001) were independent predictors of persistent LQoL problems.
Conclusions:
Persistent QoL problems in Kenyan adolescent girls are associated with adverse physical, sexual and emotional experiences and problems with coping with their monthly menstruation. A multi-factorial integral approach to reduce the rate of adverse adolescent experiences is needed, including provision of menstrual hygiene products