Menstrual Health Interventions and School Attendance Among Ugandans
Menstrual Health Interventions and School Attendance Among Ugandans
Management of menstruation can present substantial challenges to girls in low-income
 settings. The aim of this study is to pilot an intervention package to improve menstrual
 health (MH) management among school girls in 2 secondary schools in Entebbe sub-District,
 Uganda, and to prepare for a future cluster randomised trial to evaluate the impact of the
 intervention on school attendance, school performance and bacterial vaginosis.

 The recently completed study (MENstrual hygiene and Safe male Circumcision in Ugandan Schools
 (MENISCUS-1) showed that menstruation is a key reason for school absenteeism in this setting.
 The qualitative research showed substantial embarrassment and fear of teasing regarding
 menstruation, and suggested that this, together with pain and lack of effective materials for
 menstrual hygiene management, led to school absenteeism. In a small quantitative sub-study of
 daily diaries, 40 girls reported school absence on 28% of period-days, compared with 7% of
 non-period days (adjusted odds ratio=5.99, 95%CI 4.4-8.2, p<0.001). Evaluation of menstrual
 management interventions, which address both the psycho social aspects of menstruation
 (knowledge, self-confidence, attitudes), and the physical aspects (management of pain, use of
 appropriate materials to eliminate leakage of menstrual blood, improved WASH facilities) are
 needed.

 In the current study (MENISCUs-2), the investigators will pilot the MH interventions
 developed in MENISCUS-1 as a package delivered to all girls in one school year in two schools
 in Wakiso District. The intervention consists of:

 -  Training teachers to improve current delivery of the Government guidelines for puberty
 education delivered by teachers (usually female).

 -  A drama skit to address issues around menstruation, engaging girls, boys, parents and
 teachers.

 -  Provision of a menstrual management kit, including re-usable pads and training teachers
 and peers to teach girls how to use these menstrual management methods

 -  Supplying analgesics (paracetamol) for menstrual cramps using a voucher scheme

 -  Basic improvements to school sanitation facilities, including ensuring girls' privacy

 The primary outcome is to review whether criteria for progression to a future trial are met.
 The criteria are that i) the education session and drama skit are delivered, the majority of
 girls use the pads, and that soap is available for >50% of observation visits; and ii) the
 retention rate in school over 9 months is >60%. The investigators will compare the relative
 risk of absenteeism on period-days and non-period-days from diaries, within MENISCUS-2 (the
 new pilot study in which the intervention will take place) and within MENISCUS-1 (the
 previous feasibility study where no intervention had taken place when the diaries were
 collected) schools. They will estimate the number of girls who are retained at school in
 order to estimate the likely loss to follow-up within a future trial. They plan to submit a
 proposal for a full trial in 2019.
The study will take place in two secondary schools (one private and another government) in
 Entebbe sub-district. The study will take place among students in Class S2 aged. The study
 will consist of i) A stakeholder workshop to finalise the intervention including a Theory of
 Change workshop ii) Introduction of the intervention package to all S2 students and assess
 outcomes over 9 months (into the next school year), to assess retention (including those
 repeating year S2).

 iii) Provision of daily diaries to a random sample of 50 students per school. A research
 assistant will make unannounced visits to the schools approximately every month to check the
 diaries and will collect them 2 weeks before the end of term (to avoid loss or damage).

 iv) Cross-sectional surveys at baseline and endline in all girls in S2 to assess menstruation
 knowledge, attitudes, management practices and school absenteeism.

 v) Cross-sectional surveys at baseline and endline for all boys in S2 to access menstruation
 attitudes and school absenteeism.

 vi) Endline in-depth interviews (IDIs) will be conducted with 30 female students, 10 teachers
 (male and female) and 10 parents, sampled purposively (e.g. by attendance for girls) to
 assess perceptions of the interventions and impact on self-reported school absence vii) End
 line focus group discussions (FGDs) with two groups of girls in each school to assess their
 perceptions of the intervention and its impact on school attendance as well as one group of
 boys in each school to assess their perceptions of the intervention.

 viii) Analysis of vouchers assessing uptake of analgesics ix) School examination data to
 assess performance x) Strengths & Difficulties questionnaire to assess psychosocial issues
 xi) Second stakeholder workshop will be held to discuss findings and plan for the future
 trial. This will include representatives from schools that are potential sites for the future
 trial.

 Outcomes of the study: Primary outcome is school attendance using menstrual daily diaries for
 menstruating girls. School attendance will be compared using diaries, class registers, direct
 observation check visits and retrospective self-reported school attendance at the endline
 cross-sectional survey.

 Secondary trial outcomes for the girls will be: 1) Knowledge and attitudes towards
 menstruation and MH evaluated using baseline and endline questionnaires with closed
 questions. Information will include menstruation knowledge and attitudes in boys and girls,
 and practices in girls; 2) Acceptability of re-usable pads (AFRIpads): In this trial
 development study, the study will provide girls with re-usable pads and collect further
 qualitative and quantitative data on the MH management methods practiced. To include girls'
 attitudes towards using the re-usable pads including privacy for changing and washing the
 re-usable pad. Ability to do usual activities and comfort or discomfort of use, ease of
 washing, drying and storing the re-usable pads, accessibility of water and soap, use of other
 MH methods alongside the re-usable pad, and feedback on the training given by WoMena the
 implementing partner.

 3) Psychosocial issues: In the main trial the investigators will assess whether the
 intervention affects psychosocial outcomes through multiple methods including the
 quantitative interviews, the 25-item Strengths and Difficulties Questionnaire (self-report
 version; (http://www.sdqinfo.com) for 11-17 year-olds, and through qualitative methods. The
 SDQ consists of 25, 3-point Likert scale items from 0 'not true' to 2 'true', with a midpoint
 of 1 'somewhat true'.
Inclusion Criteria:

 -  Eligible participants were all male and female secondary students in the second school
 year in the 2 selecteed schools. Written informed consent was sought from students
 aged >18 years, and from the parents/caretakers of those aged <18 years, with student
 assent

 Exclusion Criteria:

 -  None