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  Abbreviations: HPV, human papillomavirus; LMIC, low- and middle-income country; M&E, monitoring and evaluation; MHM, menstrual hygiene management; NGO, nongovernmental organization; SRH, sexual and reproductive health; UNESCO, United Nations Educational, Scientific and Cultural Organization; UNICEF, United Nations Children's Fund; WASH, water, sanitation and hygiene; WinS, WASH in Schools Provenance: Not commissioned; externally peer reviewed Summary Points * There is an absence of guidance, facilities, and materials for schoolgirls to manage their menstruation in low- and middle-income countries (LMICs). * Formative evidence has raised awareness that poor menstrual hygiene management (MHM) contributes to inequity, increasing exposure to transactional sex to obtain sanitary items, with some evidence of an effect on school indicators and with repercussions for sexual, reproductive, and general health throughout the life course. * Despite increasing evidence and interest in taking action to improve school conditions for girls, there has not been a systematic mapping of MHM priorities or coordination of relevant sectors and disciplines to catalyze change, with a need to develop country-level expertise. * Columbia University and the United Nations Children's Fund (UNICEF) convened members of academia, nongovernmental organizations, the UN, donor agencies, the private sector, and social entrepreneurial groups in October 2014 (\"MHM in Ten\") to identify key public health issues requiring prioritization, coordination, and investment by 2024. * Five key priorities were identified to guide global, national, and local action. Significant recent events supported the rationale for organizing such a meeting, illustratively including intense discussion around the inclusion of MHM in the post-2015 sustainable development goals, the investment by the Canadian government (Global Affairs Canada) to support MHM research and programming in 14 countries, the annual cohosting of the MHM in Water, Sanitation and Hygiene (WASH) in Schools virtual conference by UNICEF and Columbia University, designation of May 28 as \"Menstrual Hygiene Day,\" and the development of a new puberty policy for the education sector with a focus on menstruation education and MHM by the United Nations Educational, Scientific and Cultural Organization (UNESCO).

Girls and women need effective, safe, and affordable menstrual products. Single-use menstrual pads and tampons are regularly provided by agencies among resource-poor populations. Reusable menstrual pads (RMPs: fabric layers sewn together by an enterprise for manufacture of menstrual products) may be an effective alternative. For this review (PROSPERO CRD42020179545) we searched databases (inception to November 1, 2020) for quantitative and qualitative studies that reported on leakage, acceptability, or safety of RMPs. Findings were summarised or combined using forest plots (random-effects meta-analysis). Potential costs and environmental savings associated with RMPs were estimated. A total of 44 studies were eligible (~14,800 participants). Most were conducted in low- and middle-income countries (LMIC, 78%), and 20% in refugee settings. The overall quality of studies was low. RMP uptake in cohort studies ranged from 22-100% (12 studies). One Ugandan trial among schoolgirls found leakage with RMPs was lower (44.4%, n = 72) compared to cloths (78%, n = 111, p<0.001). Self-reported skin-irritation was 23.8% after 3 months among RMP-users in a Ugandan cohort in a refugee setting (n = 267), compared to 72.8% at baseline with disposable pad use. There were no objective reports on infection. Challenges with washing and changing RMP were reported in LMIC studies, due to lack of water, privacy, soap, buckets, and sanitation/drying facilities. Among 69 brands, the average price for an RMP was $8.95 (standard deviation [sd] $5.08; LMIC $2.06, n = 10, high-income countries [HIC] $10.11), with a mean estimated lifetime of 4.3 years (sd 2.3; LMIC 2.9, n = 11; HIC 4.9 years, n = 23). In 5-year cost-estimates, in LMICs, 4-25 RMPs per period would be cheaper (170-417 US$) than 9-25 single-use pads, with waste-savings of ~600-1600 single-use pads. In HICs, 4-25 RMPs would be cheaper (33-245 US$) compared to 20 single-use tampons per period, with waste-savings of ~1300 tampons. RMPs are used internationally and are an effective, safe, cheaper, and environmentally friendly option for menstrual product provision by programmes. Good quality studies in this field are needed.

The menstrual needs of girls and women are important to health, education, and well-being. Unmet need and harm from poor menstrual health in low-and- middle-income countries have been documented, but with little empirical research undertaken in high income countries. Continuing austerity in the UK suggests menstruators are likely more vulnerable to 'period poverty' than previously, with the COVID-19 pandemic assumed to exacerbate the situation. To explore the menstrual experiences and perceptions of women in the UK who are living under circumstances of deprivation, alongside views of staff working in organisations supporting these women, to understand whether women's menstrual needs are met. A qualitative study was conducted in an inner-city in NW England. Three focus group discussions and 14 in-depth interviews were conducted across three study sites supporting impoverished women. Data was analysed thematically. Themes were: reflections on menstruation; affordability of products; access to public facilities; organisational support; potential solutions. Many women perceived menstruation as a burden in three aspects: physical discomfort and pain; psychological anxiety; and shame and stigma. Managing menstruation was difficult due to cost relative to low incomes, with food, heating and lighting prioritised, leaving women improvising with materials or wearing products for longer than desired. Most suggested that products should be free, often remarking if men required similar items this would happen. Most women were unaware supporting organisations provided free products. Staff felt the small range of products offered did not meet client needs and were ill-prepared to have conversations on products and clients' menstrual needs. Impoverished women lack the necessary resources to manage their menses well which negatively impacts their health and brings stress, embarrassment, and shame. Support, including access to free products, is needed at both local and national level to help impoverished women manage their menstrual hygiene.

Keeping girls in school offers them protection against early marriage, teen pregnancy, and sexual harms, and enhances social and economic equity. Studies report menstruation exacerbates school-drop out and poor attendance, although evidence is sparse. This study qualitatively examines the menstrual experiences of young adolescent schoolgirls. The study was conducted in Siaya County in rural western Kenya. A sample of 120 girls aged 14-16 years took part in 11 focus group discussions, which were analysed thematically. The data gathered were supplemented by information from six FGDs with parents and community members. Emergent themes were: lack of preparation for menarche; maturation and sexual vulnerability; menstruation as an illness; secrecy, fear and shame of leaking; coping with inadequate alternatives; paying for pads with sex; and problems with menstrual hygiene. Girls were unprepared and demonstrated poor reproductive knowledge, but devised practical methods to cope with menstrual difficulties, often alone. Parental and school support of menstrual needs is limited, and information sparse or inaccurate. Girls' physical changes prompt boys and adults to target and brand girls as ripe for sexual activity including coercion and marriage. Girls admitted 'others' rather than themselves were absent from school during menstruation, due to physical symptoms or inadequate sanitary protection. They described difficulties engaging in class, due to fear of smelling and leakage, and subsequent teasing. Sanitary pads were valued but resource and time constraints result in prolonged use causing chafing. Improvised alternatives, including rags and grass, were prone to leak, caused soreness, and were perceived as harmful. Girls reported 'other girls' but not themselves participated in transactional sex to buy pads, and received pads from boyfriends. In the absence of parental and school support, girls cope, sometimes alone, with menarche in practical and sometimes hazardous ways. Emotional and physical support mechanisms need to be included within a package of measures to enable adolescent girls to reach their potential.

Despite many institutions gaining access to improved water sanitation and hygiene (WASH) services, childcare centres in informal settlements have low access and poor condition of WASH services. It is imperative to understand how existing actors and social networks operate in the WASH sector in childcare centres in Nairobi's informal settlements. To empirically map and understand how different actors within informal settlements influence the provision of adequate and quality water, sanitation and hygiene services within childcare centres in Nairobi's informal settlements. This was a qualitative study. We conducted an ethnographic study using governance diaries with 24 participants from Korogocho and Viwandani informal settlements in Nairobi, Kenya. The governance diaries approach involved conducting bi-weekly governance in-depth interviews (IDIs) with study participants for 4 months, complemented with observations, reflections, participant diaries and informal discussions. We used a framework analysis which is partly deductive, informed by the governance framework and stakeholder framework. Social accountability actors were individuals or groups involved in WASH service provision in childcare centres. The actors included both key actors (actors who are primary to meeting the day-to-day WASH service needs of children) and non-key actors (actors operating in the WASH sector but not always present for day-to-day provision in childcare centres). The key actors were unanimously identified as childcare centre owners/teachers and parents/guardians as they had a more direct role in the provision of WASH services in childcare centres. The actors had direct, possible or desired networks, with the direct networks portrayed more by the parents and childcare centre owners, whose roles included acting as a voice and responding to the WASH service needs of children as it relates to access and quality. Centre owners had more power/authority over WASH services for children in childcare centres than the parents. Key actors derived power by their discretion depending on whether a decision was beneficial to children or not. Lastly, the interest of key actors were diverse ranging from income generation, access to WASH services by children, compliance with government regulations, and promotion of child health, to the prevention of the spread of diseases. Our study highlights that parents and childcare owners play an important role in WASH service provision. While service providers and other players may be statutorily given primary responsibilities for WASH provision, and more visible in official standing, among study participants they are not seen as primary actors but secondary players with ancillary responsibilities. We conclude that WASH service provision in child care centres may be realised when key actors have a voice and work within networks to demand WASH services from desired networks including the government. We also conclude that developing more direct networks and converting desired and potential networks into direct networks in WASH service provision is critical for the success of WASH service delivery. Lastly, actors in WASH services in childcare centres may need to collaborate in identifying potential avenues for strengthening existing networks that enhance access and quality of WASH services in childcare centres.

Many adolescent girls drop out of school in sub-Saharan Africa. Mental health problems in this population and their risk factors are a neglected research area. This community-based cross-sectional survey studied 904 out-of-school girls in rural western Kenya. Outcome variables were a positive screen for anxiety (GAD-7), depression (PHQ-A), post-traumatic stress disorder (PTSD; PCL-C), and a composite measure for overall symptom severity. Survey data were analysed with univariable and multivariable binary logistic and multiple linear regression analyses using SPSS 29.0. The prevalence of probable anxiety was 10.6%, of probable depression 15.9%, and of probable PTSD 18.0%. One of the three items on suicidal ideation or past suicide attempt was reported by 40.2% of girls. In multivariable analyses controlling for age, fear of sexual assault and functional limitations due to menstruation were uniquely associated with each of the outcome variables, and exposure to physical violence to each outcome except anxiety. Other risk factors showed a less consistent relationship with outcome. The cross-sectional study design precludes any temporal and causal inference for the reported significant associations. Out-of-school girls constitute a vulnerable group with high levels of PTSD and suicide risk. Multi-level and multi-sector interventions are needed to help these girls cope with their mental health problems and to address mutable risk factors such as gender-based partner and non-partner sexual and physical violence, poor menstrual hygiene, and poverty.

To continue working during menses, female sex workers (FSW) may use unhygienic absorbents to hide their menstrual status. The menstrual disc may provide a solution. Little is known about men’s knowledge and views, specifically around sex during menstruation with FSW, a population who are particularly vulnerable to violence which may be heightened during menses. To identify constructs for successful and safe menstrual disc implementation we sought to identify knowledge and attitudes towards menstruation among male clients of FSW, including views on FSW menstrual disc use during intercourse. We conducted six focus group discussions comprising a total of 51 male clients of FSW, in Kisumu, Kenya, exploring their perceptions of menses and sex during menses. In preparation for future implementation of a menstrual disc intervention, we introduced the disc to participants with an information session, answering their questions and gathering their opinions on it. Thematic analysis found most clients had limited or inaccurate knowledge about menstruation, viewing blood and the menstruator, as dirty or unclean. Sources of knowledge included school, female relatives/partners, community or church. Those reporting formal education described the biological processes more accurately, while church education lent towards stigmatized perceptions. Most participants expressed negative views towards sex during menses (i.e., unpleasurable, forbidden or risky), usually stemming from misconceptions, and reported seeking FSW services because their wife / girlfriend was menstruating. Many felt deceived if a FSW was menstruating, were often aware of materials placed vaginally to absorb blood, but generally continued with the service. No clients had prior knowledge of the menstrual disc but accepted it as a safe, hygienic, and cost-effective alternative, with some voicing interest to purchase for their wife / girlfriend. We conclude there is a need to provide accurate information on menstruation to boys and men including in school curricula and faith teaching to address lack of knowledge and negativity. These findings suggest potential for adoption of menstrual discs by FSW with minimal adverse client reaction, and highlight possible partner support for women considering adopting a menstrual disc.

Through a multisectoral approach, the DREAMS Partnership aimed to reduce HIV incidence among adolescent girls and young women (AGYW) by 40% over 2 years in high-burden districts across sub-Saharan Africa. DREAMS promotes a combination package of evidence-based interventions to reduce individual, family, partner, and community-based drivers of young women's heightened HIV risk. We evaluated the impact of DREAMS on HIV incidence among AGYW and young men in 2 settings. We directly estimated HIV incidence rates among open population-based cohorts participating in demographic and HIV serological surveys from 2006 to 2018 annually in uMkhanyakude (KwaZulu-Natal, South Africa) and over 6 rounds from 2010 to 2019 in Gem (Siaya, Kenya). We compared HIV incidence among AGYW aged 15 to 24 years before DREAMS and up to 3 years after DREAMS implementation began in 2016. We investigated the timing of any change in HIV incidence and whether the rate of any change accelerated during DREAMS implementation. Comparable analyses were also conducted for young men (20 to 29/34 years). In uMkhanyakude, between 5,000 and 6,000 AGYW were eligible for the serological survey each year, an average of 85% were contacted, and consent rates varied from 37% to 67%. During 26,395 person-years (py), HIV incidence was lower during DREAMS implementation (2016 to 2018) than in the previous 5-year period among 15- to 19-year-old females (4.5 new infections per 100 py as compared with 2.8; age-adjusted rate ratio (aRR) = 0.62, 95% confidence interval [CI] 0.48 to 0.82), and lower among 20- to 24-year-olds (7.1/100 py as compared with 5.8; aRR = 0.82, 95% CI 0.65 to 1.04). Declines preceded DREAMS introduction, beginning from 2012 to 2013 among the younger and 2014 for the older women, with no evidence of more rapid decline during DREAMS implementation. In Gem, between 8,515 and 11,428 AGYW were eligible each survey round, an average of 34% were contacted and offered an HIV test, and consent rates ranged from 84% to 99%. During 10,382 py, declines in HIV incidence among 15- to 19-year-olds began before DREAMS and did not change after DREAMS introduction. Among 20- to 24-year-olds in Gem, HIV incidence estimates were lower during DREAMS implementation (0.64/100 py) compared with the pre-DREAMS period (0.94/100 py), with no statistical evidence of a decline (aRR = 0.69, 95% CI 0.53 to 2.18). Among young men, declines in HIV incidence were greater than those observed among AGYW and also began prior to DREAMS investments. Study limitations include low study power in Kenya and the introduction of other interventions such as universal treatment for HIV during the study period. Substantial declines in HIV incidence among AGYW were observed, but most began before DREAMS introduction and did not accelerate in the first 3 years of DREAMS implementation. Like the declines observed among young men, they are likely driven by earlier and ongoing investments in HIV testing and treatment. Longer-term implementation and evaluation are needed to assess the impact of such a complex HIV prevention intervention and to help accelerate reductions in HIV incidence among young women.

Education is an effective way to improve girls' self-worth, health, and productivity; however there remains a gender gap between girls' and boys' completion of school. The literature around factors influencing girls' decision to stay in school is limited. Seven focus group discussions took place among 79 girls in forms 2 to 4 at secondary schools in rural western Kenya, to examine their views on why girls absent themselves or dropout from school. Data were analysed thematically. Lack of resources, sexual relationships with boyfriends, and menstrual care problems were reported to lead directly to dropout or school absence. These were tied to girls increased vulnerability to pregnancy, poor performance in school, and punishments, which further increase school absence and risk of dropout. Poverty, unmet essential needs, coercive sexual relationships, and an inequitable school environment collude to counter girls' resolve to complete their schooling. Lack of resources drive girls to have sex with boyfriends or men who provide them with essentials their family cannot afford, such as sanitary pads and transport to school. While these improve quality of their school life, this dynamic increases their exposure to sexual risk, pregnancy, punishment, and dropout. Evaluation of interventions to ameliorate these challenges is warranted, including provision of pocket money to address their needs.

In sub-Saharan Africa, HIV, syphilis, malaria and anaemia are leading preventable causes of adverse pregnancy outcomes. In Kenya, policy states women should be tested for all four conditions (malaria only if febrile) at first antenatal care (ANC) visit. In practice, while HIV screening is conducted, coverage of screening for the others is suboptimal and early pregnancy management of illnesses is compromised. This is particularly evident at rural dispensaries that lack laboratories and have parallel programmes for HIV, reproductive health and malaria, resulting in fractured and inadequate care for women. A longitudinal eight-month implementation study integrating point-of-care diagnostic tests for the four conditions into routine ANC was conducted in seven purposively selected dispensaries in western Kenya. Testing proficiency of healthcare workers was observed at initial training and at three monthly intervals thereafter. Adoption of testing was compared using ANC register data 8.5 months before and eight months during the intervention. Fidelity to clinical management guidelines was determined by client exit interviews with success defined as ≥90% adherence. For first ANC visits at baseline (n = 529), testing rates were unavailable for malaria, low for syphilis (4.3%) and anaemia (27.8%), and near universal for HIV (99%). During intervention, over 95% of first attendees (n = 586) completed four tests and of those tested positive, 70.6% received penicillin or erythromycin for syphilis, 65.5% and 48.3% received cotrimoxazole and antiretrovirals respectively for HIV, and 76.4% received artemether/lumefantrine, quinine or dihydroartemisinin-piperaquine correctly for malaria. Iron and folic supplements were given to nearly 90% of women but often at incorrect doses. Integrating point-of-care testing into ANC at dispensaries with established HIV testing programmes resulted in a significant increase in testing rates, without disturbing HIV testing rates. While more cases were detected and treated, treatment fidelity still requires strengthening and an integrated monitoring and evaluation system needs to be established.