Menstrual cups and unconditional cash transfer to reduce sexual and reproductive harm and school drop-out in adolescent schoolgirls in western Kenya

Girls in low-income countries leave school early due to pregnancy, illness, early marriage, and lack of money for schooling and personal needs, including for menstrual hygiene management (MHM). School drop-out places girls at greater risk of sexual and reproductive health harms such as pregnancy, increased fertility, sexually transmitted infections (STIs) including HIV, and higher mortality of their children. School drop-out also reduces economic opportunity, keeping girls' in poverty and thereby at risk of increased morbidity and reduced quality of life. For economic, health, and social reasons, these are government ministry priorities, and interventions are needed to keep girls in school and improve their sexual and reproductive health. The Liverpool School of Tropical Medicine, with Kenyan partners including the Ministries of Education and Health (MOE/MOH), have completed a Joint Global Health Trials-funded pilot study, examining girls' use of menstrual cups and sanitary pads in rural primary schools in western Kenya. Pre-intervention, girls reported using rags, bedding or paper for MHM, causing discomfort, humiliating leaks and odour, reducing ability to concentrate in school, and causing them to skip school. Girls followed up revealed pads and cups were comfortable, increased their ability to engage in class, prevented leakage, and reduced the need to have sex with boyfriends in return for money to buy pads. No health or safety issues were found. At study completion girls were checked for STIs, and school drop-out (for pregnancy, marriage or other reasons). These negative outcomes combined were halved in girls using pads or cups compared with girls in control schools. Girls using cups preferred these to pads, because pads are ten-fold more costly, cause chafing if not changed frequently, and packs have to be shared with others. Girls did not share cups for fear of infection. We now propose to conduct a large-scale trial in the same area, in secondary schoolgirls, who are older but have increased drop-out rates (over a third higher), and a higher risk of HIV, STI, and pregnancy. We will examine if cups enable girls to stay in school and reduce their sexual and reproductive harms; while cups will improve dignity, health and wellbeing, and confidence at school, they may not be sufficient to resolve all girls' unmet needs, which cause them to drop-out of school. Cash transfer (CT) is an alternate but more expensive intervention, with studies showing it reduces absenteeism, drop-out, and sexual risks. In Malawi, CT reduced schoolgirls risk of HIV and human simplex virus (HSV-2; an indicator of girls' sexual risk behaviour), and reduced pregnancy. Cash amounts vary by study but the researchers recommend $5(£3.5) a month as sufficient. Our 4.5 year trial will examine if cash, cups, or cash and cups both provided, will prevent school drop-out and improve girls' sexual and reproductive health. For statistical rigor we will recruit 4032 secondary schoolgirls in 56 schools, provide interventions and follow-up them for 2 school years (6 terms). We will evaluate the cost per outcome (school drop-out including for pregnancy, HIV and HSV-2) prevented for single and combined interventions. The study will provide vital information on the comparative value of each intervention, how the interventions are used, any problems encountered, and their effect on girls' sexual behaviour, their wellbeing and school completion. We will seek advice from girls, schools, communities and stakeholders, working with all beneficiaries including MOE/MOH, using workshops to evaluate progress and develop materials for implementation packages. Girls clubs will be funded to encourage peer-support and advocacy. Packages will support scale-up should the trial demonstrate cost-effective outcomes. Findings will be widely disseminated to strengthen the evidence base supporting advocacy to improve the quality and equity of girls' lives.