Studies on MHM and schoolgirls' health and schooling - and possible impact or otherwise on absenteeism

  • emmanuelkas2004
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The 5th Annual Virtual Conference on Menstrual Hygiene Management (MHM) in WASH in Schools on October 25th, 2016

Dear friends,
I hope this annual 5th conference will figure out most of the problems our girls experience in schools because many of them have dropped out of school due to menstrual hygiene related cases.

Kisembo Emmanuel
Executive Director Team Work Afrika
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  • muench
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Re: The 5th Annual Virtual Conference on Menstrual Hygiene Management (MHM) in WASH in Schools on October 25th, 2016

I have often read similar statements to the one of Emmanuel who said

many of them have dropped out of school due to menstrual hygiene related cases.


But then I read in this blog post that this is a "myth", see here:

forum.susana.org/forum/categories/24-men...-india-mythri-speaks

I copy here the first part of that blog post but please see there to read the full piece:

Assumption #4. Girls in developing countries are dropping out of school due to lack of menstrual products and toilets

Having functional toilets in schools is an absolute must, not just for girls. But, unnecessarily connecting it to menstrual hygiene seems more agenda driven than real. Let’s look at what existing studies reveal.

A comparison of data owing to school absenteeism during menstruation in developing nations shows that the percentage of girls who remain absent during menstruation is around 12.1% in China [21], 15.6% to 24.2% in Nigeria [19, 20], 24% in India [17] and 31% in Brazil [22].

If the current hypothesis – that school absenteeism is due to lack of toilets or Sanitary Napkins – is true, then surely developed countries must have little or no absenteeism. However, data indicates that it is no different in developed countries.

Studies indicate that 17% teenagers in Canada [23], 21% in Washington D.C [24], 24% in Singapore [25], 26% in Australia [26] and 38% in Texas [27] miss school owing to menstruation.


What do people who have studied this aspect in depth say about this? Is it right or is it wrong? Is it exaggerated perhaps in order to get more funding for MHM for WASH in schools?

Elisabeth

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  • PennyPH
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Re: Studies on MHM and schoolgirls' health and schooling - and possible impact or otherwise on absenteeism

Dear colleagues

We have now just published the results of our pilot study which explored the acceptability, use and safety of menstrual cups and sanitary pads against 'usual practice'controls among primary schoolgirls in rural Kenya.

You can access the full article using the web-link below:
bmjopen.bmj.com/cgi/content/full/bmjopen...x9evDkwP&keytype=ref

Title:
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

In summary - we conducted a feasibility study on the effect of menstrual hygiene on schoolgirls' school and health (reproductive/sexual) outcomes,using a 3-arm single-site open cluster randomized controlled study design in 30 primary schools in rural western Kenya. Girls recruited were provided a menstrual cup, or monthly sanitary pads, against ‘usual practice’ controls. All participants received puberty education pre-intervention, and hand wash soap during intervention. Schools received hand wash soap. We measured school attrition (drop-out, absence) as primary outcomes, and sexually transmitted infection (STI) and reproductive tract infection (RTI) as key secondary outcomes, and toxic shock syndrome, and vaginal Staphylococcus aureus as safety outcomes. Of 751 girls enrolled we were able to follow-up 644 girls for a mean of 10.9 months. Cups or pads did not reduce school dropout risk. Self-reported absence was rarely reported and not assessable. Prevalence of STIs in the end-of-study survey was significantly lower in cup and pad users compared with controls. Overall RTI prevalence did not differ, but 71% of RTI were from bacterial vaginosis, which was significantly less prevalent in girls using cups compared with pads, and lower also than controls among girls followed for 9 months or longer. No adverse events were identified. The paper discusses the strengths and weaknesses of the methods used, and the possible implications of the study results (recognising it was a pilot study not a full trial).

Our study concluded that menstrual cups and sanitary pad provision to schoolgirls for ∼1 school-year was associated with a lower STI risk, and cups with a lower bacterial vaginosis risk, but in this small sample there was no evidence of association with school dropout. A large-scale trial on menstrual cups is warranted.

We hope you find the article interesting, and hope it contributes toward the scanty literature available on the potential health effects of menstrual hygiene products.

With best wishes

Dr Penelope A Phillips-Howard
Department of Clinical Sciences
Liverpool School of Tropical Medicine, Liverpool, UK
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  • F H Mughal
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Re: studies on MHM and schoolgirls' health and schooling

Dear Dr Penelope,

This is an interesting and informative study. However, I do not quite understand, what do you mean by “transactional sex.” Is it dating, or the commercial sex?

Is there a similar study in a Muslim country? How would the religious beliefs impact, or influence, your study.

Best regards,

F H Mughal

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Re: Reply: studies on MHM and schoolgirls' health and schooling

Dear Penelope,
Thank you for this very interesting information.
2 Questions:
  1. What was the percentage of girls who got RTI?*
  2. It is sometimes feared to give menstrual cups to Primary School girls, as the cup might damage the hymen. Any information on this from your study?


Regards
Dirk

Dirk Ullerich
Welthungerhilfe Moroto/ Uganda


* RTI = Reproductive tract infection (added by moderator)
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  • JenniferRubli
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Re: Reply: studies on MHM and schoolgirls' health and schooling

Hello Dirk,

You bring up an interesting point regarding the hymen and its connotations with virginity. This is an issue that Femme International has come across, and one of the reasons menstrual cups should not be distributed without an education component.

In our workshops, we have a section on the hymen, talking about what it is and how it is never truly 'closed' as that would completely block off the vagina, and emphasising that virginity has to do with sexual acts whereas the hymen is tissue. Sensitising the greater community (including boys, parents, etc) increases uptake of menstrual cup use.

Also, we have found that primary-age girls prefer reusable pads, whereas older girls and women are more likely to prefer a cup.

Cheers,
Jen
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  • PennyPH
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Re: studies on MHM and schoolgirls' health and schooling

Dear Mr Mughal

Thank you for your feedback on our study.

By 'transactional sex' we mean girls that have sexual intercourse with males who provide them with money or products that they cannot afford. They are not 'commercial sex' workers. We think 'transactional sex' is not the best way of describing for the girls in our study area, however, as the girls are impoverished and vulnerable, and thus can be coerced by males into having sex to obtain basic necessities (such as sanitary pads). We would like to further study and better understand this as a social, wellbeing and public health issue.

To my knowledge, there are no studies in Muslim countries, or among a range of populations with different cultures, which is indeed a shortfall. There is likely a hesitancy to test among some cultures because an insertable product may be considered unacceptable by the community, and leaders - but as there is no actual data we do not know if this is true or not.

Best wishes
Penelope Phillips-Howard
Liverpool School of Tropical Medicine
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Re: Reply: studies on MHM and schoolgirls' health and schooling

Dear Dirk

Thank you for your questions. I see you have response already, which is good for opening the forum for discussion.

1. The RTI* prevalence (so could have been acquired 'anytime' as opposed to within a specific time, as we were unable to measure at baseline) was 26%. We only measured candida albican and bacterial vaginosis. note that 71% of RTI were bacterial vaginosis, with a prevalence of 18.5% of all girls.

2. You raise questions about the hymen. We recognise this could be a concern with regard to understanding of virginity. We explained at public meetings (parents) and directly to girls about this, using very similar explaination as noted by the other respondee (Jen) below.

I attach a paper of ours on the focus group discussions we had with girls and parents, on their perceptions and response to provision of cups and pads. Note girls assented to take part after they understand the study, and had parenbtal consent (approval) also.

Best wishes
Penelope Phillips-Howard
Liverpool School of Tropical Medicine


*RTI - reproductive tract infection

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  • Camilla
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Re: studies on MHM and schoolgirls' health and schooling

Dear all,

Thank you for your great and important research.

The Cup is working in Kenya since spring 2015 and we are distributing menstrual cups and comprehensive education including human rights, sex ed, MHM etc. We also train the parents and boys. Most of the 5500 girls we have trained are between 11-16.

Transactional sex is common in Nairobi slums and we welcome an in-depth study focusing on this problem as most girls are not aware of the dangers of HIV, STDs and unwanted pregnancy (or unsafe abortions).

My question is, why isnt the introduction of menstrual solutions affecting attendance in school at high level?

We have all been informed this is such a common practice. Or is this where the transactional sex plays in?

Warm regards

Camilla
thecup.org

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Re: studies on MHM and schoolgirls' health and schooling

Hi Penny,

Thanks for posting this paper here. I have moved two earlier posts to the beginning of this thread because they fist very well to this topic.
I repeat here something from my post in July:

Assumption/Myth #4. Girls in developing countries are dropping out of school due to lack of menstrual products and toilets


--> It's one of these statements that we often read about and which somehow makes sense intuitively but which is actually not proven and might not be true after all.

You also point this out in your paper where you said:

Lack of quantifiable school absence here and in other pilot studies,10 ,51 contrasts with girls',3–5 ,10 and parents narratives.37 It is unclear if girls in this environment exaggerate missed time when in focus groups but not in structured questionnaires,15 if girls avoid reporting reasons that are associated with stigma (such as teenage pregnancy), fear repercussions when reporting absence (which we consider possible in our study), or if menstrual absence due to abdominal cramps or other reasons over-ride any menstrual product effect.15 ,23 Further research is needed to better quantify the effects of menstrual interventions on school absence, and it seems prudent that studies validate their measurement tools in pilot studies and spot-checks.


This makes a lot of sense.

I had also exchanged e-mails with Marni Sommer about this - I asked her if this was a topic at the recent MHM Virtual conference and she said:

I don’t think that the conference actually had any presentations that ultimately delved into that issue. There was some discussion of the need to move beyond the focus on absenteeism given the challenge of getting accurate attendance data for so many reasons – and the existing evidence having its limitations. I am not sure the studies have been done yet to really answer that question with certainty – although certainly plenty of girls have articulated across various countries that it’s an issue. However I think many of us would like to see an expansion of the interest to look at other measures that might better capture the impact (e.g. educational engagement, self-efficacy managing menstruation in school, etc)


By the way, I noticed you used the term "school attrition" in your paper title. This term was new to me in this context and you only used it once more in your paper where you wrote:

school attrition (drop-out, absence)

Is "attrition" therefore a better word to use than "absenteeism"?

Regards,
Elisabeth

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Re: studies on MHM and schoolgirls' health and schooling

Dear Camilla

Many thanks for your interest and response.

Regarding the question - why has the cup not shown clear evidence of a reduction in absence is an important observation. we concluded we did not have adequate reporting on absence in any of the groups to analyse the effect. We try to address the absence question in our 'discussion' section - as girls and parents in the very same study during focus group discussions reported they were less absent from school. Generating high quality information on changes in absence rates over time has proved tricky for us, and I think also for a number of other researchers. During our study, there were a number of school closures due to teacher strikes, council elections, as well as exams and holidays so the amount of time spent in school was less. As there was a strong safety component to our study, we had study nurses regularly in the schools, including in control schools - this was well received by the girls, and we conjecture that this (in all groups) may have improved their liking of school and thus attendance. We also wonder if girls were not willing to disclose when and reasons for absence in case it got back to the teachers. Lastly, we have to consider that absence may be due to so many different factors, in some school settings, that provision of a menstrual product alone may not generate clear cut data - for example, if girls are absent due to menstrual period pains (but would also leak had they gone to school) - they would respond equally in all treatment groups including intervention - and also may answer a questionnaire stating the reason they were absent was 'illness' rather than menstruation.

As such, we feel for comparison studies, particularly in a setting such as ours, that markers of success of the intervention may be better focused on 'hard' outcomes that we can measure more objectively. further studies on absence are of course very welcome, but should not be the only consideration - studies on self-efficacy, self-esteem, dignity, well-being, ability to concentrate in class, ability to reach potential are all important questions. We have a new publication just coming out on research priorities on MHM which we will share very soon.

best wishes
Penny

Liverpool School of Tropical Medicine
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Re: studies on MHM and schoolgirls' health and schooling

Dear Penny,

I appreciate your elaborate answer. Thank you.

We also encounter similar difficulties in regards to attendance.

In complete agreement regarding doing research focusing on "self-efficacy, self-esteem, dignity, well-being, ability to concentrate in class". When I worked with Peepoople we did a nice SROI study. I like that methodology.

What I have encountered when discussing the provision of menstrual solutions to underprivileged adolescent girls (not only cups) with different donors and organizations is the necessity to confirm girls attendance in school is increased.

A person who works at Unicef expressed this as key to get them on board.

As we interview each girl we train before starting the education part it is easy to integrate a baseline study in our program.

Our target for next year is to reach 10 000 girls.

If you know of any masters student or university who is interested in supporting us to start an attendance study please let me know.

With warm regards

Camilla

Camilla Wirseen
The Cup
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