Does Menstrual Hygiene Matter? Investigating the Impact of a Menstrual Hygiene Program on Ugandan Girls' School Absenteeism
Condition: Menstrual Hygiene Management
Study type: Interventional

Summary: 
      This study builds on the pilot work of the Irise research group to investigate the impact of
      menstrual hygiene interventions on East African girls' school attendance, activities of daily
      living and self-esteem. The trial will be carried out in 40 schools to either intervention or
      control arms. Schools will receive a menstrual hygiene program, including the distribution of
      reusable sanitary pads and menstrual health education. The impact of the programme on girls'
      school attendance will be monitored using the validated Irise questionnaire and school
      registers. The impact of the programme on activities of daily living during menstruation and
      self-esteem during menstruation will also be measured using the Irise Questionnaire and
      explored using focus groups.
    

Detailed description: 
      Research Aims and Objectives

      Aims

      - To assess the impact of a Menstrual Hygiene Management (MHM) Programme, based around the
      distribution of reusable pads and delivery of health education in schools, on East African
      schoolgirls.

      Objectives

        -  To explore initial (baseline) MHM practices and knowledge

        -  To assess school absenteeism during the study period

        -  To assess the impact of menstruation on activities of daily living at baseline and at 6
           and 12 months into the study

        -  To assess girls' self-esteem during menstruation at baseline and at 6 and 12 months into
           the study

      Background

      Irise International

      Irise International is a small charitable organisation and research group founded in 2011 in
      response to Kenyan school girls' accounts of their difficulties attending school during
      menstruation. School enrolment in East Africa is the highest it has ever been. In Uganda
      primary school enrolment is 94% with almost equal numbers of girls and boys enrolled in the
      first grade. However primary school completion rates are only 25% for girls, compared to 56%
      for boys. This data highlights a need for interventions to help keep girls in school so they
      can make the most of the opportunities they are being offered. It is in this context that
      menstrual hygiene and sanitation interventions may become an important means of promoting
      girls' education and empowerment.

      Pilot work

      Irise undertook a pilot study in Kisumu Kenya. Groups of 30 girls from 10 schools were
      randomly allocated to control or intervention groups. The intervention group received
      training on how to make a reusable pad and enough equipment to make three. Data was collected
      at baseline and at one month using a questionnaire. The mean number of days girls reported
      missing specifically due to menstruation was 1.66 with responses ranged from 0-11. Overall 5
      in 10 girls reported missing some school because of menstruation compared to just 1 in 10 in
      the UK.

      After one month follow-up, absenteeism was reduced, on average, by 1.5 days in the schools
      that received the intervention. A covariate adjusted t-test of group mean number of days
      missed, control group vs intervention group, showed a result that was close to the 95%
      significance level (2.01 mean days (±2.14) vs 1.32 mean days (±1.89); P=0.077; 95% CI -3.17:
      0.21).

      For all schools in the intervention group the mean number of days of school missed decreased
      or stayed constant; schools in the control group either stayed constant or increased.

      More research is needed to investigate the long term effect of menstrual hygiene programmes
      on school girls' attendance, activities of daily living and self-esteem. This study will
      therefore build on the investigators previous pilot work and is part of an on-going process
      to research this neglected issue.

      Preliminary work

      A preliminary round of data collection took place in June and July 2013 in 30 schools through
      the delivery of a questionnaire. A more detailed investigation using interviews was carried
      out in a select number of schools in order to understand local menstrual hygiene practices in
      more depth and collect context specific information relevant to the delivery of a menstrual
      hygiene program. It also enabled us to introduce the concept of research and how it should be
      conducted to the investigators local partner and helped to identify logistical issues which
      the investigators can take steps to avoid in the main study.

      Research methods

      Design

      A step wedge design was chosen to provide a control group for 6 months but allow all girls
      enrolled in the study to receive the intervention at 12 months. The investigators will also
      be able to see if the effect of the intervention in the intervention group is replicated in
      the control when they receive the intervention at six months. Class 6 in each school will be
      enrolled in the study and will receive pads and menstrual health education. Schools will be
      selected a predefined distance apart in order to avoid contamination. If schools do fall less
      than the predefined distance apart they will be classed as a cluster and be analysed
      together. At baseline half the schools will be randomly allocated to receive the intervention
      and while the other half will act as a control group. After six months the remaining schools
      will also be given the intervention and all schools will be followed up for the remainder of
      the study period.

      Recruitment of schools

      Forty schools in Western Uganda will be recruited through local Irise partner, LuYoDeFo and
      through contacts at Kampala International University and the Department of Health. These
      Irise partners and contacts will provide a list of schools in the areas selected to take part
      in the research. These schools will then be visited by an Irise researcher and be given
      information about the study. They will have the opportunity to opt in or out at this point.
      Written informed consent will be obtained from the head teachers of the schools and from the
      girls themselves.

      Planned Intervention

      During the first 6 months 20 schools will receive menstrual health education and free
      promotional reusable pads from a local social enterprise set-up as part of Irise's project
      work in Uganda. During the second 6 months the remaining 20 schools will receive menstrual
      health education and free promotional pads from the local social enterprise.
    

Intervention name(s): Irise Easy Pad & Menstrual Health Education
Intervention type(s): Device
Intervention description(s): Reusable manufactured sanitary pad produced by Irise Uganda Limited and education sessions provided by qualified menstrual health educators
Allocation: Randomized
Intervention model: Crossover Assignment
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: Menstruation; MHM; Menstrual Hygiene Management; Girls Education; Absenteeism; Access to Education; Menstrual Health Education; Reusable Sanitary Product