Back to school for malaria prevention: a new tool in the era of malaria elimination?

Children and pregnant women are vulnerable groups for malaria. Among children, research to date has focussed on pre-school children (aged <5 years) because this group bears the brunt of malaria illness and deaths. With changing malaria endemicity, however, vulnerability patterns among children of different age groups may change.1 Furthermore, children aged 5-15 years predominantly have the highest risk of asymptomatic malaria and gametocytaemia, and yet low use of long-lasting insecticide treated nets which puts them at risk.1,2 As part of global efforts to reduce and eliminate malaria transmission, it is only logical to find effective malaria prevention strategies for school children

Menstrual hygiene management among adolescent girls in India: a systematic review and meta-analysis

Objectives To assess the status of menstrual hygiene management (MHM) among adolescent girls in India to determine unmet needs. Design Systematic review and meta-analysis. We searched PubMed, The Global Health Database, Google Scholar and references for studies published from 2000 to September 2015 on girls’ MHM. Setting India. Participants Adolescent girls. Outcome measures Information on menarche awareness, type of absorbent used, disposal, hygiene, restrictions and school absenteeism was extracted from eligible materials; a quality score was applied. Meta-analysis was used to estimate pooled prevalence (PP), and meta-regression to examine the effect of setting, region and time. Results Data from 138 studies involving 193 subpopulations and 97 070 girls were extracted. In 88 studies, half of the girls reported being informed prior to menarche (PP 48%, 95% CI 43% to 53%, I2 98.6%). Commercial pad use was more common among urban (PP 67%, 57% to 76%, I2 99.3%, n=38) than rural girls (PP 32%, 25% to 38%, I2 98.6%, n=56, p<0.0001), with use increasing over time (p<0.0001). Inappropriate disposal was common (PP 23%, 16% to 31%, I2 99.0%, n=34). Menstruating girls experienced many restrictions, especially for religious activities (PP 0.77, 0.71 to 0.83, I2 99.1%, n=67). A quarter (PP 24%, 19% to 30%, I2 98.5%, n=64) reported missing school during periods. A lower prevalence of absenteeism was associated with higher commercial pad use in univariate (p=0.023) but not in multivariate analysis when adjusted for region (p=0.232, n=53). Approximately a third of girls changed their absorbents in school facilities (PP 37%, 29% to 46%, I2 97.8%, n=17). Half of the girls’ homes had a toilet (PP 51%, 36% to 67%, I2 99.4%, n=21). The quality of studies imposed limitations on analyses and the interpretation of results (mean score 3 on a scale of 0–7). Conclusions Strengthening of MHM programmes in India is needed. Education on awareness, access to hygienic absorbents and disposal of MHM items need to be addressed

‘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

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

Menstrual cups and sanitary pads to reduce school attrition, and sexually transmitted and reproductive tract infections: a cluster randomised controlled feasibility study in rural Western Kenya

Objectives: Conduct a feasibility study on the effect of menstrual hygiene on schoolgirls’ school and health (reproductive/sexual) outcomes. Design: 3-arm single-site open cluster randomised controlled pilot study. Setting: 30 primary schools in rural western Kenya, within a Health and Demographic Surveillance System. Participants: Primary schoolgirls 14–16 years, experienced 3 menses, no precluding disability, and resident in the study area. Interventions: 1 insertable menstrual cup, or monthly sanitary pads, against ‘usual practice’ control. All participants received puberty education preintervention, and hand wash soap during intervention. Schools received hand wash soap. Primary and secondary outcome measures: Primary: school attrition (drop-out, absence); secondary: sexually transmitted infection (STI) (Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoea), reproductive tract infection (RTI) (bacterial vaginosis, Candida albicans); safety: toxic shock syndrome, vaginal Staphylococcus aureus. Results: Of 751 girls enrolled 644 were followed-up for a median of 10.9 months. Cups or pads did not reduce school dropout risk (control=8.0%, cups=11.2%, pads=10.2%). Self-reported absence was rarely reported and not assessable. Prevalence of STIs in the end-of-study survey among controls was 7.7% versus 4.2% in the cups arm (adjusted prevalence ratio (aPR) 0.48, 0.24 to 0.96, p=0.039), 4.5% with pads (aPR=0.62; 0.37 to 1.03, p=0.063), and 4.3% with cups and pads pooled (aPR=0.54, 0.34 to 0.87, p=0.012). RTI prevalence was 21.5%, 28.5% and 26.9% among cup, pad and control arms, 71% of which were bacterial vaginosis, with a prevalence of 14.6%, 19.8% and 20.5%, per arm, respectively

Analysis of Bacterial vaginosis, the vaginal microbiome, and sexually transmitted infections following the provision of menstrual cups in Kenyan schools: results of a nested study within a cluster randomized controlled trial

Abstract Background: Non-hygienic products for managing menstruation are reported to cause reproductive tract infections. Menstrual cups are a potential solution. We assessed whether menstrual cups would reduce Bacterial vaginosis (BV), vaginal microbiome (VMB), and sexually transmitted infections (STIs) as studies have not evaluated this. Methods and Findings: A cluster-randomized controlled trial was performed in 96 Kenyan secondary schools, randomized (1:1:1:1) to control, menstrual cup, cash transfer, or menstrual cup plus cash transfer. This sub-study assessing the impact of menstrual cups on BV, VMB, and STIs, included 6 schools from the control (3) and menstrual cup only (3) groups, both receiving BV and STI testing and treatment at each visit. Self-collected vaginal swabs were used to measure VMB (16S rRNA gene amplicon sequencing), BV (Nugent score), and STIs. STIs were a composite of Chlamydia trachomatis and Neisseria gonorrhoeae (nucleic acid amplification test)¸ and Trichomonas vaginalis (rapid immunochromatographic assay). Participants were not masked and were followed for 30 months. The primary outcome was diagnosis of BV; secondary outcomes were VMB and STIs. Intention to treat blinded analyses used mixed effects generalized linear regressions, with random effects term for school. The study was conducted between May 2, 2018, and Feb 7, 2021. 436 participants were included: 213 cup, 223 control. There were 289 BV diagnoses: 162 among control participants and 127 among intervention participants (odds ratio 0.76 [95% CI 0.59–0.98]; p=0.038). The occurrence of Lactobacillus crispatus dominated VMB was higher among cup group participants (odds ratio 1.37 [95% CI 1.06–1.75]), as was the mean relative abundance of Lactobacillus crispatus (3.95% [95% CI 1.92–5.99]). There was no effect of intervention on STIs (relative risk 0.82 [95% CI 0.50–1.35]). The primary limitations of this study were insufficient power for sub-group analyses, and generalizability of findings to non-school and other global settings. Conclusions: Menstrual cups with BV and STI testing and treatment benefitted adolescent schoolgirls through lower occurrence of BV and higher L. crispatus compared with only BV and STI testing and treatment during the 30 months of a cluster-randomized menstrual cup intervention. ClinicalTrials.gov, NCT03051789

Increased reproductive tract infections among secondary school girls during the COVID-19 pandemic: associations with pandemic-related stress, mental health, and domestic safety

Background: Kenya, like many countries, shuttered schools during COVID-19, with subsequent increases in poor mental health, sexual activity, and pregnancy. Aim: We sought to understand how the COVID-19 pandemic may mediate the risk of reproductive tract infections. Methods: We analyzed data from a cohort of 436 secondary schoolgirls in western Kenya. Baseline and 6-, 12-, and 18-month study visits occurred from April 2018 to December 2019 (pre–COVID-19), and 30-, 36-, and 48-month study visits occurred from September 2020 to July 2022 (COVID-19 period). Participants self-completed a survey for sociodemographics and sexual activity and provided self-collected vaginal swabs for bacterial vaginosis (BV) testing, with sexually transmitted infection (STI) testing at annual visits. We hypothesized that greater COVID-19–related stress would mediate risk via mental health, feeling safe inside the home, and sexual exposure, given the pandemic mitigation–related impacts of school closures on these factors. COVID-19–related stress was measured with a standardized scale and dichotomized at the highest quartile. Mixed effects modeling quantified how BV and STI changed over time. Longitudinal mediation analysis quantified how the relationship between COVID-19 stress and increased BV was mediated. Outcomes: Analysis outcomes were BV and STI. Results: BV and STI prevalence increased from 12.1% and 10.7% pre–COVID-19 to 24.5% and 18.1% during COVID-19, respectively. This equated to 26% (95% CI, 1.00–1.59) and 36% (95% CI, 0.98–1.88) higher relative prevalence of BV and STIs in the COVID-19 vs pre–COVID-19 periods, adjusted for numerous sociodemographic and behavioral factors. Higher COVID-19–related stress was associated with elevated depressive symptoms and feeling less safe inside the home, which were each associated with a greater likelihood of having a boyfriend. In mediation analyses, the direct effect of COVID-19–related stress on BV was small and nonsignificant, indicating that the increased BV was due to the constellation of factors that were affected during the COVID-19 pandemic. Clinical Translation: These results highlight factors to help maintain reproductive health for adolescent girls in future crises, such as anticipating and mitigating mental health impacts, domestic safety concerns, and maintaining sexual health services. Strengths and Limitations: Impacts of the COVID-19 pandemic on drivers of reproductive tract health among those who did not attend school or who live in different settings may differ. Conclusions: In this cohort of adolescent girls, BV and STIs increased following COVID-19–related school closures, and risk was mediated by depressive symptoms and feeling less safe in the home, which led to a higher likelihood of sexual exposures

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

High Prevalence of Lactobacillus crispatus Dominated Vaginal Microbiome Among Kenyan Secondary School Girls: Negative Effects of Poor Quality Menstrual Hygiene Management and Sexual Activity

The vaginal microbiome (VMB) impacts numerous health outcomes, but evaluation among adolescents is limited. We characterized the VMB via 16S rRNA gene amplicon sequencing, and its association with Bacterial vaginosis (BV) and sexually transmitted infections (STIs; chlamydia, gonorrhea, trichomoniasis) among 436 schoolgirls in Kenya, median age 16.9 years. BV and STI prevalence was 11.2% and 9.9%, respectively, with 17.6% of girls having any reproductive tract infection. Three community state types (CST) accounted for 95% of observations: CST-I L.crispatus-dominant (N=178, BV 0%, STI 2.8%, sexually active 21%); CST-III L.iners-dominant (N=152, BV 3.3%, STI 9.7%, sexually active 35%); CST-IV G.vaginalis-dominant (N=83, BV 51.8%, STI 25.3%, sexually active 43%). In multivariable adjusted analyses, sexually active girls had increased odds of CST-III and CST-IV, and use of cloth to manage menses had 1.72-fold increased odds of CST-IV vs. CST-I. The predominance of L.crispatus-dominated VMB, substantially higher than observed in prior studies of young adult and adult women in sub-Saharan Africa, indicates that non-optimal VMB can be an acquired state. Interventions to maintain or re-constitute L.crispatus dominance should be considered even in adolescents