Menstrual hygiene management practices and associated health outcomes among school-going adolescents in rural Gambia

Inadequate menstrual hygiene management (MHM) practices have been associated with adverse health outcomes. This study aimed to describe MHM practices among schoolgirls from rural Gambia and assess risk factors associated with urogenital infections and depressive symptoms. A cross-sectional study was conducted among adolescent schoolgirls in thirteen schools in rural Gambia. A questionnaire was used to collect information on sociodemographics, MHM practices and clinical symptoms of reproductive and urinary tract infections (UTIs). A modified Beck Depression Inventory-II was used to screen for depressive symptoms. Mid-stream urine samples were collected to assess for UTIs. Modified Poisson regression analysis was used to determine risk factors for symptoms of urogenital infections and depression among adolescent girls. Three hundred and fifty-eight girls were recruited. Although, 63% of the girls attended schools providing free disposable pads, reusable cloths/ towels were the commonest absorbent materials used. Heavy menstrual bleeding was associated with depressive symptoms (adjusted prevalence ratio, aPR 1.4 [95% CI 1.0, 1.9]), while extreme menstrual pain (aPR 1.3 [95% CI 1.2, 1,4]), accessing sanitary pads in school (aPR 1.4 [95% CI 1.2, 1.5]) and less access to functional water source at school (aPR 1.4 [95% CI 1.3, 1.6]) were associated with UTI symptoms. Conversely, privacy in school toilets (aPR 0.6 [95% CI 0.5, 0.7]) was protective for UTI symptoms. Heavy menstrual bleeding (aPR 1.4 [95% CI 1.1, 2.0]) and taking <30 minutes to collect water at home were associated with RTI symptoms (aPR 1.2 [95% CI 1.0, 1.5]) while availability of soap in school toilets (aPR 0.6 [95% CI 0.5, 0.8] was protective for RTI symptoms. Interventions to ensure that schoolgirls have access to private sanitation facilities with water and soap both at school and at home could reduce UTI and RTI symptoms. More attention is also needed to support girls with heavy menstrual bleeding and pain symptoms. Copyright: This study was conducted in thirteen schools (seven English-based and six Arabic-based) within ten villages (i.e. Bajana, Janneh Kunda, Jiffarong, Kaiaf, Kantongkunda, Keneba, Kwinella, Nema Kuta, Nioro Jattaba and Sibito) in rural Kiang districts, in the lower river region of The Gambia [3]. The villages were within 10 miles of the Medical Research Council Unit The Gambia (MRCG) field station that provides free primary health care services and 24 h emergency care services [35]. There are also Ministry of Health primary health care clinics in the district. The Gambia has two formal education systems: Arabic-based and English-based. The English-based schools are free public schools and the Arabic schools are private schools that focus on Quranic education [19]. The population is predominantly from the Mandinka ethnic group, the majority are Muslims and most families are polygamous [20]. Subsistence farming is the main income generating activity, but food insecurity is a recurring problem particularly in the wet season after a prolonged dry season (November- May) [21, 22]. The majority of the population live below the moderate poverty line of less than US$ 2/ day [21, 23]. This was a school-based cross-sectional study that was preceded by a mixed methods study that explored the knowledge and perceptions of menstruation in this community [3]. Adolescent girls were recruited from thirteen schools (four English-based primary, three English-based secondary, six Arabic-based). Schools were selected based on the proximity to the MRCG field station in Keneba and the recommendation of the regional officials from the Ministry of Basic and Secondary Education. Data presented in this paper are part of a cross-sectional study that aimed to explore the association between school absenteeism and MHM practices (described in other manuscript). In this paper we focus on the results of the association between MHM practices with health outcomes. The samples size calculation was based on estimates from our previous cross-sectional study [3] and estimates of school attendance and prevalence of urogenital infections described in other African Settings [24, 25], as we did not have estimates for these parameters in The Gambia. Using an estimated rate of prevalence of urogenital infection of 27%, use of reusable cloth of 40%, prevalence of drying inside the house of 21.6% and prevalence of school absenteeism of 23%. 40% prevalence was taken which gave us a larger sample size. Based on these estimates and using precision/absolute error of 5% and a type 1 error of 5%, a sample size of 368 was calculated. All the schoolgirls aged 15–21 years were selected from the school registers provided by the teachers. Eligible participants were those girls had already had their menarche at the time of selection. Girls who were pregnant. This was ascertained by asking the girls if they were pregnant and those who said “yes” were excluded. Written informed consent was sought from students aged ≥18 years, and from the parents/caretakers of those aged <18 years, with student assent [26]. Participation was voluntary, and confidentiality was ensured by conducting interviews in a private area and keeping the data collected on secure servers without identifying information. All the field received training on how to take consent from the lead researcher using resources from the London School of Hygiene and Tropical Medicine (LSHTM) research governance. Data were collected from the adolescent girls by two trained female field assistants in a private room on the school grounds. Each field assistant administered a standard pretested questionnaire to collect sociodemographic data and quantify knowledge and practices of menstruation (including age of menarche; knowledge and attitudes about menstruation; menstrual hygiene practices such as type of menstrual absorbent used, change frequency, washing and drying practices of reusable material; access to water, sanitation and hygiene at home; frequency of symptoms suggestive of urinary or reproductive tract infections). In addition, a modified Beck Depression Inventory II (BDI II) was used to screen for symptoms suggestive of depression among the adolescents. Participants were requested to provide a mid-stream urine sample in a sterile specimen container. All specimen containers were labelled with participant’s study ID. The urine samples were analysed by the lead researcher (who had been trained to conduct these tests by the clinic staff at MRC Keneba) in the school setting, using urine dipstick analysis with the Combur-test strips [27]. This is a quick screening test for a urinary tract infection (UTI) in children and adolescents, whose results are interpreted in the context of clinical feature suggestive of a UTI (and microscopy for evidence of bacteriuria where laboratory support is available) [28]. The guidance for urine collection that was given to the participants and the protocol for urine testing can be found in the S1 File. Urine samples were available for 352 (98%) of girls. Participants whose urine dipstick tests were suggestive of a UTI (i.e. positive for both leucocyte esterase and nitrites or positive for only nitrites) or that had symptoms of UTI, were sent to the MRC Keneba clinic for further assessment and treatment. Unannounced visits to conduct spot check of WASH facilities were conducted in each school by the team’s supervisor. A pre-determined tool was used to assess the WASH hardware available; number and type of toilets, handwashing facilities and disposal facilities. As well as access the quality of these facilities; functionality, gender specificity, privacy, cleanliness, and availability of water and soap. Permissions to conduct unannounced visits were obtained from each school at the beginning of the study. Data completeness and consistency were reviewed at the end of each data collection day by the team’s supervisor (VS). In the development of the questionnaire, we used existing validated tools for assessing socio-economic status and WASH in this rural Gambian community [3]. These were complemented by additional questions from validated tools for assessing menstrual hygiene management among adolescents in other LMICs [12, 13]. BDI II has 21 items with a score range of 0–3 (0 = symptom absent) and (3 = severe symptom), with a total potential score of 63 [29]. It is a validated screening tool for symptoms suggestive of depression among adolescents in sub-Saharan Africa [29, 30]. A score of > 16 is suggestive of clinical depression [31] and among adolescents in Malawi had a specificity of >80% for depression [30]. An experienced team consisting of a senior research assistant (VS) and 2 field assistants translated and adapted the BDI-II to optimise its acceptability among adolescents in this rural Gambian community. They had extensive discussions about the meaning of each item and the corresponding phrases in Mandinka (the main local language in this community) to ensure that the equivalent cultural concepts were derived in a standardised manner. Forward and backward translation was done to ensure accuracy of the translations. We dropped one item that explore “interest in sex” from our study as it was not culturally appropriate for adolescent girls in this setting to discuss this. Our modified version therefore had 20 items (with a total potential score of 60) but we maintained the cut off score of >16. The questionnaire and BDI-II were first pilot tested among 4 female health care providers in rural Gambia, three of who were members of the local community. The purpose was to test translation and acceptability of questions and to support the training of field assistants. After incorporating the comments from this first phase, they were then pilot tested among three adolescent girls from the community to test feasibility, acceptability and quality of questions and responses. Feedback from this second phase was used to further amend the tools. All the tools were administered by the field assistants in the local language Mandinka. Data were collected using hard copy questionnaires that were double entered into SQL (SQL server 2017) and analysed using Stata (version 15.0, StataCorp, College Station, TX). Descriptive statistics using number and percentage for categorical data, and the mean and standard deviation (SD) or median and interquartile range (IQR) for continuous data, were used to summarise sociodemographic, menstrual hygiene practices and health outcome data. A principal component analysis (PCA) was used to determine household socioeconomic status using an asset based index in which we included the following fourteen socioeconomic indicators: ownership of television, radio, cooker/stove, refrigerator, sofa/couch, boat, car/truck, electricity, motorcycle, bicycle, animal cart, mobile phone (all binary) and type of walls and flooring in the family house [32]. The households that the adolescent girls belonged to were classified into three quantiles (i.e. Poorest/2nd quantile/least poor) based on Filmer and Pritchett’s method [33]. Guidelines on latrine to student ratio vary widely. WHO recommendations for latrine to female student ratio is 1:25 [34]. The WASH in Schools (WinS) standard for Eastern and Southern Africa Recommendations (ESAR) suggests 20–50 students per latrine [35]. Since no national guidelines for Gambia were found, the wider range of WinS standard for ESAR was used as a comparison for the analysis. A participant was classified as having at least one symptom suggestive of a UTI if they had any of the following symptoms in the preceding 24 hours: feeling of burning or discomfort when urinating, passing urine more than once at night, having cloudy urine or blood in your urine, foul-smelling urine or having lower abdominal or vaginal pain. A urine dipstick test was classified as positive i.e. suggestive of a UTI if it was positive for both leucocyte esterase and nitrites or positive for nitrites alone [36, 37]. A participant was classified as having at least one symptom suggestive of a reproductive tract infection (RTI) if they had any of the following symptoms in the preceding 2 months: abnormal vaginal discharge, foul-smelling/fishy smell from genital area, or feeling of burning or itching in the genitalia. Girls who reported any of the above symptoms on the day the study team visited the schools were referred to either the MRCG field station clinic or a government primary health care clinic (depending on the proximity from the school). Univariable and multivariable Poisson regression analyses of binary outcome variables were applied to provide both unadjusted and adjusted prevalence ratios in exploring factors associated with poor MHM and adverse health outcomes. Confidence intervals were adjusted for the binary nature of the data using robust standard errors [38]. In the multivariable Poisson regression analysis, we used three models, one for each of the health outcomes of interest (i.e. depression, UTI, RTI). For each model we included explanatory variables that were statistically significant in the univariable analysis (Table 5) as well as those that had biologically plausible associations with each of the three health outcomes [39]. The details of the selected variables can be found in Table 6. The final models for each health outcome had between 12–14 explanatory variables. Models that included school level variables were adjusted for clustering at school level using robust standard errors. *Only 4 (tertiary level maternal education) The sociodemographic variables included in the models had up to 19% of the data missing and the menstrual hygiene management modules had up to 14% of data missing. Missing data were not imputed. Adjusted prevalence ratios with 95% confidence intervals (CI) using a P-value< 0.05 were considered to be statistically significant associations with the outcome variable. Ethics approval for the study was granted by the London School of Hygiene and Tropical Medicine, UK [Ref: 10225] and by the Gambia Government/Medical Research Council Joint ethics committee [SCC1426 and SCC1509]. Permission to conduct the study in the schools was obtained from the Ministry of Basic and Secondary Education, The Gambia.