Understanding interventions to improve menstrual health in low and middle income countries: evidence and future directions.

Background. Menstrual health has emerged as an under recognised barrier to women and girls' dignity, health, education, and psychosocial wellbeing in low and middle income contexts. Interventions targeting this issue have seen increasing dissemination, despite little evidence for their effectiveness and sparse research to inform intervention development or evaluation.
Objectives. 1) Appraise current evidence for the effectiveness of menstrual health interventions; 2) Evaluate the effectiveness of a reusable sanitary pad and puberty education intervention for girls’ school attendance; and, 3) Expand understanding of menstrual health to inform future research and practice.
Methods.. The multiple objectives of this thesis were addressed through a range of methodological approaches, reported across six manuscripts. The first collates and critically appraises existing evidence in a systematic review, while the second provides a broader overview in a position piece advocating for an evidence-based approach to menstrual health. The third paper reports on a cluster quasi-randomised control trial of reusable sanitary pad and puberty education interventions undertaken in Uganda. The fourth and fifth papers report secondary analyses of the trial survey data to investigate the prevalence and consequences of menstrual hygiene, and schoolgirls’ experiences with menstrual absorbents. The final manuscript presents a qualitative, framework analysis to describe and compare the menstrual experiences of 27 schoolgirls in the controlled trial.
Results. Systematic review identified eight controlled trials of menstrual health interventions. There was emerging evidence for the effectiveness of both education and product provision interventions, although methodological quality was poor. The controlled trial of reusable sanitary pad and puberty education provision found both interventions were similarly effective in reducing school absenteeism, with a moderate effect size. Follow-up quantitative papers provided insights into girls’ menstrual experiences. In the first of these, the prevalence of inadequate menstrual hygiene was estimated to be 91% when measured consistently with the consensus definition, and did not differ between those using trial-provided reusable sanitary pads and those using existing methods. Aspects of menstrual hygiene were associated with shame, reduced school engagement, and health concerns. In the second follow-up, girls rated the trial-provided reusable sanitary pads favourably. However, greater perceptions of reliability did not translate into reduced rates of soiling or odour in the last menses. Finally, qualitative work provided process evaluation and nuanced understanding of the interventions’ change mechanisms. Reduced fears of soiling improved school attendance for those provided with absorbents, while improvements in social support may have mediated the impact of the puberty education on attendance.
Conclusions. This thesis represents a significant step forward in the emerging field of menstrual health research. The work provides critical appraisal of existing studies and new evidence for the effectiveness of interventions to improve outcomes for girls' in low and middle income contexts. Further, new insights on the prevalence and consequences of menstrual hygiene, girls' appraisal of menstrual absorbents, and qualitative exploration of girls’ experiences provide guidance for the development of future interventions and evaluations.

Advisor: Montgomery, P
Gardner, F