Dear Penny,

Yes, it might be premature for the menstrual cups. Would be happy to meet when you are in Nairobi to discuss this further. Just let me know when you are around.

Best regards

Doreen

Many thanks Doreen

Yes, it would be good to hear from the NGO community whether they encounter hygiene issues. It may be premature for feedback regarding hygiene issues around cup distribution, however, feedback on how NGOs are able to support handwashing and hygiene practices of schoolgirls when using pads would also be of great interest.

When I am next in Nairobi, perhaps we can organize a meeting to discuss this further
very best, Penny

Dear Penny,

Thanks a lot for the information. Of course it would be interesting for us to know the activities that were carried out to monitor safety.
My only issue is the long term (health) effects that lack of water and hand washing can have on the girls.

I don't know how other organisations/NGOs that are promoting cups in low income areas and schools are dealing with the hygiene issues. Maybe they could shed a bit of light on this issue.

Best regards,

Doreen

reference: Waterlines publication by Linda Mason, Kayla F. Laserson, Kelvin Oruko, et al, 2015

Many thanks Doreen for your comments

In response to your concern about hygiene, the paper published reported qualitative findings generated after girls had experienced use of menstrual cups, or sanitary pads. We also conducted extensive activities to monitor safety, which will be reported duly. No hazards were reported over the study duration. Schools were evaluated pre-intervention for WASH conditions. Because most lacked soap we provided monthly soap powder to all schools (across the three study arms) to support hand-washing throughout the study. We allocated research nurses to schools, who provided regular screening with girls (approx twice each term). These screenings, plus girls self-reports, include information collected on girls' hand-washing behaviour before and after using the latrines at school. A paper is in press with Waterlines which examines this.

As there was no assurity of the quality or availability of 'clean' water in or close to latrines, girls were advised to empty their menstrual cup then immediately reinsert, to minimize any risk of contamination.

Note below -the article authorship is incorrectly referenced - the correct reference is:

Linda Mason, Kayla F. Laserson, Kelvin Oruko, Elizabeth Nyothach, Kelly T. Alexander, Frank O. Odhiambo, Alie Eleveld, Emily Isiye, Isaac Ngere, Jackton Omoto, Aisha Mohammed, John Vulule, Penelope A. Phillips-Howard.

very best, Penny

Thanks Ina for posting about the articles from WaterLines here in this other post . I've had the chance to read the following article:

Adolescent schoolgirls' experiences of menstrual cups and pads in rural western Kenya: a qualitative study
by Linda Mason, Kelly T. Alexander, Penelope A. Phillips-Howard, et al.

The article is available online for free here:
practicalaction.metapress.com/content/e22mlm7630451047/

Was very interesting to read about the girls perspectives on cups and pads.
However I felt like we still lack a clear understanding of the use of cups in areas or schools with poor hygiene facilities (hand washing facilities, water etc.). This would give a proper analysis on the acceptability of the cups for girls who unfortunately attend schools that do not have appropriate hygiene facilities.

I am referring to the need to clean your hands well, with clean water, when removing and inserting the cup.

Nevertheless I was pleased to read such an article comparing different MHM products and see the positive acceptance level of the girls regarding the cups.

Best regards,

Doreen


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Authors

Linda Mason1, Kelly T. Alexander1, Penelope A. Phillips-Howard1, Kayla F. Laserson2, Kelvin Oruko3, Elizabeth Nyothach3, Frank O. Odhiambo3, John Vulule3, Alie Eleveld4, Emily Isiye5, Isaac Ngere6, Jackton Omoto7, Aisha Mohammed8
1Liverpool School of Tropical Medicine, UK
2Center for Global Health, Centers for Disease Control and Prevention, Atlanta, US
3KEMRI/CDC Research and Public Health Collaboration, Kisumu, Kenya
4Safe Water and AIDS Project, Kisumu, Kenya
5District Education Office, Gem District, Sawagongo, Siaya County, Kenya
6District Medical Office, Gem District, Yala, Siaya County, Kenya
7Department of Obstetrics and Gynaecology, Siaya District Hospital, Ministry of Health, Siaya, Kenya
8Division of Reproductive Health, Ministry of Public Health and Sanitation, Kenya

Abstract
Poor menstrual hygiene management (MHM) among schoolgirls in low income countries affects girls' dignity, self-esteem, and schooling. Hygienic, effective, and sustainable menstrual products are required. A randomized controlled feasibility study was conducted among 14-16-year-old girls, in 30 primary schools in rural western Kenya, to examine acceptability, use, and safety of menstrual cups or sanitary pads. Focus group discussions (FGDs) were conducted to evaluate girls' perceptions and experiences six months after product introduction. Narratives from 10 girls' and 6 parents’ FGDs were analysed thematically. Comparison, fear, and confidence were emergent themes. Initial use of cups was slow. Once comfortable, girls using cups or pads reported being free of embarrassing leakage, odour, and dislodged items compared with girls using traditional materials. School absenteeism and impaired concentration were only reported by girls using traditional materials. Girls using cups preferred them to pads. Advantages of cups and pads over traditional items provide optimism for MHM programmes

Keywords

menstruation, menstrual cups, sanitary pads, WASH in schools, MHM

Thanks Elizabeth, sorry for the delay in response.
In answer to your questions:

(1)When do you think it will all be ready for dissemination?

We are currently preparing analyses - we anticipate completion, ready for dissemination, mid-2015.

(2) What was the role of the Moon Cup company (www.mooncup.co.uk/) by the way? Are they excited about this, too? Do they see it as a potential business opportunity or more as a social venture activity?

The company provided us with Mooncups at a prearranged discount price.
We do not know the views of the company - should there be any interest to discuss with the company then please communicate with them.

(3) What are your plans regarding larger scale trials and who would fund those?

We would be most keen to move forward to a larger trial, and are currently exploring opportunities for funding.

very best, Penny

Dear Penny
(I refer to your post above from 16 July)

I just read your attachment ("Successful completion of a feasibility study on menstrual solutions for schoolgirls in rural western Kenya") and found that it is very well written. It’s great that you explained the methodology in so much detail and I look forward to seeing your final results and dissemination activities. When do you think it will all be ready for dissemination?

What was the role of the Moon Cup company (www.mooncup.co.uk/) by the way? Are they excited about this, too? Do they see it as a potential business opportunity or more as a social venture activity?

What are your plans regarding larger scale trials and who would fund those?

Regards,
Elisabeth

P.S. The above mentioned study also looked at pads. I liked these quotes, in particular the last one:

BOX 3 – Reported use and effect of products
‘So it is better if I do not go to school until the period stops.
But since they brought us mooncup ….. after bathing you
insert it you just go to school’ (girl)

‘I have noticed that she is very free and does not absent
herself from school like she used to before’ (parent)

‘Yes, I’m feeling good…when I put that mooncup inside I
can run, I can do anything’ (girl)

‘If she has pads she will now concentrate more and in case
she is a clever girl, she will be more clever now’ (parent)

Dear Penny,

Thanks so much for your answer and research overview. I am looking forward to the overall and statistical results that will provide such valuable insights to all of us.

Best,
Maxie

Note by moderator: The following 3 posts were originally in this thread:
forum.susana.org/forum/categories/24-men...uby-cup-and-research

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We were most interested to read the discussion about menstrual cups, and endorse the view that evidence supporting the relative advantage of cups over other menstrual products would be of value. Through a UK-supported Joint Global Health Trials grant award we have conducted a feasibility (development) study over the past two years to ascertain the acceptability, use, and safety of differing menstrual hygiene products including cups, to generate information on this neglected area of research, and to determine whether a full trial on such a subject could be conducted among rural school girls in western Kenya.

We are currently completing cleaning of our data before getting statistician approval for full analysis. Meanwhile we have made a summary overview of our study to date (see attachment), including web-links to our papers and reports published to date. We are hopeful our feasibility data can contribute towards MHM programmes, and are sufficiently robust to inform a formal trial to test and answer some of the ‘big questions’ on the contribution of menstrual hygiene needs to girls’ schooling, and what interventions can have a cost-effective and measurable impact on girls’ schooling, health, and wellbeing. We will keep everyone posted!




Dr Penelope Phillips-Howard
Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, Liverpool, UK

Dear all,

I have recently been alerted to this interesting article on the Bill and Melinda Gates Foundation blog "The impatient optimist". It is about trials to see if menstrual cups can help Kenyan school girls during menstruation days.

With permission by the journalist (Lynn Schreiber) and the researcher (Penny Phillips-Howard), I copy the article here. This is the link to it:
www.impatientoptimists.org/Posts/2012/10...as-Dont-Go-to-School

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One Reason Kenyan Girls in Poor Areas Don't Go to School
Lynn Schreiber
October 10, 2012

Keeping girls in school is a vital part of any international aid program. It's an issue important to highlight today, on the first ever United Nations International Day of the Girl. Over the past few decades, this has shown to have lasting effects, not only for the girls themselves, but also for their families, their communities and for the economic growth of their countries.

One recurrent issue, in extremely poor countries, is the absences caused by girls not attending school during menstruation. The non-availability of sanitary protection products in these regions of the world means that girls are forced to use other homemade solutions. These included cutting up old blankets, clothes or mattresses, and inserting leaves or other organic matter into their vaginas to stop the menstrual flow. The health risks associated with these practices are clear, but there are other less obvious risks.

The girls stay at home to prevent being embarrassed by bloodstained clothes, and because the onset of menstruation is seen in some communities as the girl becoming sexually mature. This puts the girls at risk of unwanted attention - 45 percent of young Kenyan women report that their first sexual experience was non-consensual.

Sanitary pads are expensive, even in Kenya, and very difficult to come by. Before visiting Kenya this summer, I asked an African-based blogger for gift ideas to take to the women and children we would be visiting and was surprised that the answer was sanitary pads. At a Dispensary (health clinic) in the Laikipia District, I cautiously took the packets out of my bag. Within seconds, I was surrounded by a crowd of women, who laughed delightedly at my present. I had also been told to take some packets of underpants, as some girls don’t have underwear in which to put san pro (or their homemade equivalent).

A few days previous, I had been discussing this issue with Dr. Kayla Laserson, of the CDC (Centers for Disease Control) Kenya. I had noted a sign on the door of the staff toilet advertising the Mooncup, "a menstrual cup." I asked Dr. Laserson if it was something that they were considering.

A menstrual cup is a small silicone vessel that is inserted into the vagina. It collects menstrual blood and is emptied into a toilet several times a day, before being washed under clean water and re-inserted. In developed countries, it is sold as environmentally friendly, but for women living in poverty it would seem, at first glance, to be a solid alternative to disposable sanitary pads.

There are however several aspects of menstrual cup use than require further investigation. The most important issue is hygiene. Not all girls in Kenya have access to clean water, and facilities for the monthly sterilization required. There is also concern that the girls would share their menstrual cup with other family members. Toxic shock syndrome, which was associated with high absorbency tampons in the 1980’s, has never been reported with menstrual cups but is a concern, particularly in rural areas, where medical assistance could take hours to reach the afflicted.

To investigate both the medical issues, and cultural ones such as acceptance in the community, a collaborative study between Liverpool School of Tropical Medicine, KEMRI/CDC, Ministry of Health, and a number of other agencies and NGOs is underway in the Nyanza district of Kenya. It is funded by the British MRC/DfID/Wellcome Trust (Joint Global Health Trials; Protect Research) and headed by Dr. Penny Phillips-Howard.

750 girls between the ages of 14 and 16 years old are testing various methods of menstruation management in 30 schools across the district. I spoke with the researchers to find out what they were expecting to find.

Dr. Phillips-Howard explained that the acceptance of the parents and of the wider community, as well as the girls, is vital for the success of the project. The schools must have adequate sanitation, with a set ratio of school children per latrine, separate toilet areas for boys and girls, and locks on the doors to ensure that the girls have privacy.

The parents are informed of the possible risks and benefits of using menstrual cups, and of the importance of reporting illness or fever to the research nurses who are overseeing the project in the schools. The nurses teach the girls how to use the menstrual cups, and the importance of hygiene to prevent infection. They will closely monitor the girls’ progress.

The girls are split into three groups. One group will use Mooncups, the second group will use disposable san pro, the third is a control group using their normal methods (but with hygiene information). The girls will be screened every month to check if they are using the different solutions, any difficulties they may have, and any health problems. As well as keeping vigilant about toxic shock syndrome, they will also check for any reproductive tract infections like bacterial vaginosis or candida which may lead to inflammation or PID (Pelvic Inflammatory Disease), and could cause ectopic pregnancy or infertility.

At the same time there will be checks to see if the girls are attending school and document their reasons for being absent. The researchers are also keen to see if Mooncups improve girls’ wellbeing. Girls’ cups will be checked to see if they are really using them, and to make sure they are viable, are being cleaned properly, and haven’t torn (or been eaten by rats!). A sample of the cups will also be exchanged to test for any signs of infection.

According to Dr Phillips-Howard,

“The outcomes from the proof of concept study will be used as a platform for larger scale studies, such as a trial to look at the cost-effectiveness of a menstrual solution to improve girls’ schooling.

What we don’t know is if improving menstrual management alone will impact on school absenteeism, -- it may nevertheless impact on engagement, ability to do schoolwork, and wellbeing."

Studies like this one, and the investigation currently being undertaken by Dr. Vivian Hoffman of the University of Maryland (funded by the Gates Foundation) could well have a long-term positive effect on the lives of millions of women and young girls.

What can you do to help? The first ever crowdfunding platform for women and girls launches today, October 11th: Catapult. On Catapult, you can donate to global programs specifically intended for women and girls and create teams to help fund a project together, create a community around these projects and track the progress together. 100 percent of the contributions go to programs only, not to overhead costs. Once projects are funded, NGOs will report updates on how your money directly helped women and girls in their programs.
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Regards,
Elisabeth