The aim of the MENISCUS trial is to assess whether the intervention improves educational attainment, mental health symptoms, menstrual management and quality of life outcomes among girls in secondary school in Uganda.

Background

Many girls lack basic knowledge, facilities and/or materials for managing menstruation safely and with dignity. Improving menstrual health can lead to sustained, long-term benefits to education, health and development. Though many governmental and non-governmental organisations are interested in introducing interventions to improve menstrual health, there is a lack of evidence to guide policies and ensure interventions are effective.

Our previous studies have shown that poor menstrual health is associated with anxiety among girls and with missing secondary school or class in Wakiso District Uganda. An effective intervention needs to be holistic, and address not only lack of knowledge of puberty and menstruation, but also the social environment (to reduce stigma) and training in practical methods to enable girls to better manage their periods i.e. provision and training in use of period products, education about effective pain management, and improvements to school sanitation facilities. Our studies suggest that an intervention addressing these elements can potentially improve education and mental health outcomes, but a randomised controlled trial is needed for definitive results to drive forward policy changes.

The intervention

The MENISCUS intervention was developed with teachers and schools and was successfully piloted in two schools in 2017-2018. It is a multi-component intervention and involves:   

• Training teachers to provide puberty education to boys and girls
• Working with school drama clubs to tackle menstrual health issues, with performances to parents and teachers.
• Providing menstrual kits, including a supply of re-usable pads and optional menstrual cups with training on their use.
• Providing strategies for pain management, including vouchers for pain relief medication.
• Simple upgrades to school toilets, including providing items such as bins and soap, and repairing locks.
• Establishing a menstrual health action group at each school to oversee the delivery of the intervention.

Trial Design

We will evaluate the impact of the intervention through a cluster-randomised trial. A total of 60 secondary schools in Wakiso and Kalungu districts will be randomised, so that 30 schools receive the MENISCUS intervention in 2022, and 30 receive optimised usual care (provision of Government Menstrual Health guidelines and other relevant printed materials). At the end of the trial, schools in the control arm will be offered the intervention package.

The primary outcomes are i) examination performance based on the curriculum taught during the intervention year; and ii) mental health symptoms including emotional symptoms, attention and peer relationship problems.

We will also assess the impact of the intervention on other outcomes including (in both girls and boys) menstrual knowledge and attitudes; and (in girls only) menstrual practices (correct use of pads and/or menstrual cups), self-efficacy (stigma and embarrassment around menstruation), quality of life, prevalence of urogenital infections, and school and class attendance. The outcomes in secondary students exposed to the intervention will be compared between the intervention and control arms after one year, adjusting for baseline measures.

Impact

The MENISCUS intervention is novel in several ways. It will be the first to:

• Be truly multi-component, not focusing primarily on either education, provision of pads, or improvement of toilet facilities;
• Address pain management, a major reason for school absence in girls;
• Focus on boys as well as girls, enabling us to address stigma and improve the school environment; and
• Include secondary schools in both rural and peri-urban areas, as most previous studies have been in primary schools in rural areas.

The intervention has been designed to be culturally appropriate, aligned with Government guidelines, cost-effective, environmentally-friendly and practically sustainable within the schools. We will assess these elements through a process evaluation, health economics component and policy analysis.

Our intention is that the MENISCUS trial will provide needed evidence to guide the rapidly growing community of implementing partners working to improve menstrual health globally. We will share findings with local, national and international stakeholders through a workshop and meetings so that the intervention can be scaled-up as appropriate.