Menstrual health interventions, schooling, and mental health problems among Ugandan students (MENISCUS): study protocol for a school-based cluster-randomised trial

Abstract

Background Menstrual health is an increasingly recognised public health issue, defined as complete physical, mental, and social well-being in relation to the menstrual cycle. The MENISCUS trial aims to assess whether a multi-component intervention addressing physical and emotional aspects of menstrual health improves educational attainment, mental health problems, menstrual management, self-efficacy, and quality of life among girls in secondary school in Uganda. Methods The study is a parallel-arm cluster-randomised controlled trial with 60 schools (clusters) in Wakiso and Kalungu districts, with a mixed-methods process evaluation to assess intervention fidelity and acceptability and economic and policy analyses. The schools will be randomised 1:1 to immediate intervention or to optimised usual care with delayed intervention delivery. The intervention includes creation of a Menstrual Health Action Group at schools and NGO-led training of trainers on puberty education, development of a drama skit, delivery of a menstrual health kit including reusable pads and menstrual cups, access to pain management strategies including analgesics, and basic improvements to school water, sanitation, and hygiene facilities. Baseline data will be collected from secondary 2 students in 2022 (median age ~15.5 years), with endline after 1 year of intervention delivery (~3600 females and a random sample of ~900 males). The primary outcomes assessed in girls are (i) examination performance based on the Mathematics, English, and Biology curriculum taught during the intervention delivery (independently assessed by the Uganda National Examinations Board) and (ii) mental health problems using the Total Difficulties Scale of the Strengths and Difficulties 25-item questionnaire. Secondary outcomes are menstrual knowledge and attitudes in girls and boys and, in girls only, menstrual practices, self-efficacy in managing menstruation, quality of life and happiness, prevalence of urogenital infections, school and class attendance using a self-completed menstrual daily diary, and confidence in maths and science. Discussion The trial is innovative in evaluating a multi-component school-based menstrual health intervention addressing both physical and emotional aspects of menstrual health and using a “training of trainers” model designed to be sustainable within schools. If found to be cost-effective and acceptable, the intervention will have the potential for national and regional scale-up. Trial registration ISRCTN 45461276. Registered on 16 September 2021

Systematic review of the effectiveness of menstrual health interventions in low- and middle-income countries in the East Asia and Pacific region

“…Menstrual knowledge is hypothesised to improve girls’ MH and reduce negative psychosocial consequences such as distress. 5 , 53 , 54 , 55 No included studies assessed broader outcomes although they have been included in trials of MH interventions in other regions, such as a menstrual health trial in Uganda which included mental health and quality of life outcomes 55 , 56 In the present review, interventions tested to improve MH knowledge were small-scale training initiatives delivered outside of formal education systems to school-aged females, and to a lesser extent, female university students. This differs from progress in the region, 9 where our regional review of practice identified progress in policy objectives for MH education taught through school curriculums.…”

“…Trials in other geographic regions (Sub-Saharan Africa, South Asia) have trialled product provision including but not limited to school attendance, wellbeing, and reproductive health including urogenital infection, with mixed results to date. 5 , 7 , 55 All interventions that tested product provision included reusable menstrual products, reflective of the growing attention to reusables and environmental sustainability. 9 , 62 …”

The Menstrual Practice Needs Scale Short Form (MPNS-SF) and Rapid (MPNS-R): Development in Khulna, Bangladesh, and validation in cross-sectional surveys from Bangladesh and Uganda

“…Trials using the MPNS measures as primary or secondary outcomes will provide insights into the sensitivity of the measure to change and use for evaluation. [8,12] Finally, future research should investigate the validity of the shorter MPNS forms in new cultural contexts, languages and age groups. As found previously, [6] the dimensionality of the MPNS-36 differs for adult women, and we would hypothesise similar differences for the short form.…”

“…[1,2] The Menstrual Practice Needs Scale (MPNS-36) [3] was published in 2020 to address this gap and has seen rapid uptake in research and practice. [4][5][6][7][8][9][10][11][12] However, this comprehensive scale is 36-items in length, presenting a barrier to implementation in short needs assessments or multicomponent surveys. Stakeholders have requested a short form to enable greater uptake.…”

Understanding the social and physical menstrual health environment of secondary schools in Uganda: A qualitative methods study

“…The intervention addressed health promotion (education, attitudes, well-being) and goods (menstrual products, improved WASH facilities, pain management), and was feasible to deliver and highly acceptable to stakeholders. This led to development of a cluster-randomised trial in 60 secondary schools in Wakiso and Kalungu districts to evaluate the effectiveness of the MENISCUS intervention on education, health and wellbeing outcomes [ 9 ].…”