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

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. Many governmental and non-governmental organisations are interested in introducing interventions to improve menstrual health, (including the UK Government Period Poverty Taskforce). However, there is a lack of evidence to guide policies and ensure interventions are effective. We have completed formative studies showing that i) poor menstrual health is a key factor associated with anxiety among girls, and with missing secondary school or class in Wakiso District, Uganda, and ii) an effective intervention needs to address lack of knowledge of puberty and menstruation, and the social environment (to reduce stigma), as well as practical methods to enable girls to better manage their periods i.e. pad provision, education about effective pain management, and improvements to school toilet 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 aim of the trial is to assess whether the intervention ("MENISCUS") improves educational attainment, mental health symptoms, menstrual management and quality of life outcomes among girls in secondary school in Uganda. The intervention has been developed with teachers and schools, and was successfully piloted in two schools in 2017-2018. The trial will evaluate the impact of the intervention by randomising 48 secondary schools in two districts, so that 24 schools receive the MENISCUS intervention, and 24 receive optimised usual care (provision of Government Menstrual Health guidelines and other relevant printed materials). The outcomes will be compared in secondary students (mean age 15 years) between arms after one year, adjusting for baseline measures. 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), school and class attendance, and prevalence of urogenital infections. The main outcomes will be assessed in all students who were exposed to the intervention in Secondary 2. The latter two outcomes will be assessed in a sub-group of 1920 girls. 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 analysis and policy analysis. The intervention is novel in several ways. It will be the first to i) be truly multi-component (i.e. not focusing primarily on either education, provision of pads, or improvement of toilet facilities), ii) address pain management (a major reason for school absence in girls), iii) focus on boys as well as girls (enabling us to address stigma and improve the school environment), and iv) include secondary schools in rural and peri-urban areas (most previous studies have been in primary schools in rural areas). At the end of the trial, the schools in the control arm will be offered the intervention package. 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, and provide needed evidence to guide the rapidly growing community of implementing partners working to improve menstrual health globally.