Young persons aged 10 to 24 years represent a quarter of the world’s population, with 90% living in low or middle-income countries (LMIC); of these 500 million are girls aged 10-19 years living in less developed countries. Evidence of a positive association between girls’ education, health and economic potential has strengthened resolve to improve this internationally. Menstrual health (MH) challenges girls in LMIC due to inadequate puberty education; poor water, sanitation and hygiene and supplies. A lack of sanitary products force girls to use unhygienic materials causing shame and discomfort. Studies in LMIC described potential effects such as lost dignity, school absence and dropout mostly using qualitative and descriptive methods. A paucity of empirical evidence on quantifying impact, drivers of risk, causal associations, or effectiveness of interventions prevented buy-in by international organisations or funders, yet such factors could predispose girls to increased risk HIV/STI, early marriage, high fertility, and thus contribute to health inequities.
In 2012, a first round of the UK-funded Joint Global Health trials (JGHT) award supported a collaboration between LSTM, Kenya Medical Research Institute (KEMRI), US-Centres for Disease Control (CDC), and Safe Water and AIDS (SWAP) to pilot the use and outcomes of menstrual cups versus sanitary pads, against controls’ usual practice in 30 rural Kenyan primary schools. The collaboration also investigated MH needs across the study area, identifying 1:10 young girls engaged in transactional sex for money to buy pads. Pilot findings documented girls’ MH challenges and suggested poor MH increased girls’ risk of sexual and reproductive harms; e.g. girls in control schools had a two-fold higher prevalence of STI than ‘cup’ or ‘pad’ girls; girls with cups had a lower prevalence of bacterial vaginosis than ‘control’ or ‘pad’ girls; and dropout (with 50% due to pregnancy) was also lower but the pilot sample was inadequate to confirm a protective effect.
The collaboration’s publications have supported research development with provision of guidance to advisory groups, workshops, meetings and conferences, including partnering a GCRF networking grant to strength MH research capacity in east Africa. LSTM, with Columbia University, supported Grand Challenges Canada with technical guidance for its global innovators. The safety findings provide the only rigorous evaluation supporting menstrual cup programmes.
LSTM presented to Government of Kenya stakeholders’ roundtable in April 2016 and contributed to national policy, strategy and training guidelines for MH. Findings supported a JGHT award to examine menstrual cups and cash to improve girls’ health, schooling, and equity in ~4000 Kenyan schoolgirls. Partnership with University of Illinois at Chicago generated a NIH grant to explore the effect of menstrual cups on the vaginal microbiome of post-pubertal girls, with implications for HIV, STI, and reproductive health. A UNICEF-invited grant enabled LSTM to collaborate with Tata Institute of Social Sciences to evaluate schoolgirls MH across India, and development of Government of India guidelines for MH for schoolgirls.
Networking began with a presentation on the JGHT pilot at the UNICEF/Columbia University-lead conference on MHM in schools, 2013. The following year saw formalised partnerships as a member of the MHM in Ten global strategy workshop in New York, publishing in PLOSMED; and stimulating scientific interest at a MH Symposia (American Society of Tropical Medicine). The collaboration with academics, institutions, and NGOs have widely published to galvanise international support for MH in schoolgirls, among women in the workplace, on non-menstrual bleeding (e.g. cervical ca) issues, developing robust research and Lancet commentaries. Now United Nations organisations are initiating action:
- LSTM supported UNFPA develop their East-South African MH Coalition call for action and presented evidence-to-date on the sexual and reproductive health consequences of inadequate MH at plenary, May 2018.
- WHO under Director Adolescent sexual and reproductive health held the first MHM expert panel, August 2018; LSTM presented guidance on research and programme implications of menstrual products; WHO outcomes include development of global guidelines for programmes, regulators and policy-makers world-wide.
- The Water Supply and Sanitation Collaborative Council (WSSCC) invited LSTM as an academic representative in an international MH Grand Coalition.
Further LSTM activities include presenting research at the Cup Summit 2018 and member of a Cup Coalition; invited to present on MH research priorities at the American Public Health Association-Women’s Caucus in November 2018 and an invite by the Commonwealth Council for Education to present MH to Westminster parliamentarians the month before.
LSTM’s growing collaborations internationally aim to strengthen action to prevent and mitigate MH and allied gender-health related disparities across the globe.
For further information on this research area, watch the recent LSTM seminar delivered by Dr Penny Phillips-Howard on menstrual health challenges for girls in low and middle-income countries.