Indicators for National and Global Monitoring of Girls' Menstrual Health and Hygiene: Development of a Priority Shortlist

PURPOSE

Despite the importance of menstrual health and hygiene (MHH) for adolescent girls' health, education, and gender equality, few countries monitor MHH. MHH needs remain underprioritized, and progress achieved through policies, programs, or investments go unmeasured. This article reports the systematic development of an indicator shortlist to monitor adolescent girls' MHH at the national and global levels across low- and middle-income countries.

METHODS

A core group of MHH researchers and practitioners collaborated with stakeholders from three countries with demonstrated commitment to monitoring MHH (Bangladesh, Kenya, and the Philippines), measures experts, and a global advisory group. The approach included the following: (1) define domains for monitoring MHH; (2) review and map existing indicators and measures; (3) iteratively shortlist indicators through appraising quality, feasibility, and stakeholder input; and (4) refine the shortlist and develop guidance for use.

RESULTS

The shortlist comprises 21 indicators across seven domains covering menstrual materials, water, sanitation, and hygiene facilities, knowledge, discomforts and disorders, supportive social environments, menstrual health impacts, and policies. Indicators are accompanied by measures that have been tested or are expected to provide reliable data, alongside justification for their selection and guidance for use.

DISCUSSION

The shortlisted indicators reflect the multisectoral collaboration necessary for ensuring girls' MHH. Uptake requires integration into monitoring systems at national and global levels. Future work remains to evaluate the performance of the indicators over time and to support their widespread use. Governments and stakeholders can use these indicators to track the progress of programs and policies, monitor unmet MHH needs, identify disparities, and set targets for improvement.

Union of the medial clavicular epiphysis in a South African Black skeletal sample

Current research points to an increase in the interest in and focus on the age at which the medial end of the clavicle begins and completes union in various populations worldwide. As it currently stands, no information exists for the South African population detailing the age at which this skeletal developmental marker commences or completes union. The aim of this study was to establish the age at which partial and complete unions occur and to find if there is any correlation between the age and the assigned stage score in a South African Black skeletal sample. Paired clavicles of 211 males and females (M = 101, F = 110) with ages ranging between 12 and 45 years from the Raymond A. Dart Collection of Human Skeletons were included. A strong correlation between age and the assigned stage score was observed for both males and females (rs = 0.73). No statistically significant differences between the stage of union at the left and right clavicles were observed (p = 0.9). In this sample, partial union was commonly observed in individuals in their third decade of life; while complete union occurred more often in individuals older than 30 years of age. Assessing and recording the degree of union at the medial end of the clavicle can be a helpful additional age-at-death indicator to use when establishing an age-at-death range. However, overlap and variability between the ages of individuals categorized as either displaying signs of partial or complete union were evident.

Beyond menstrual hygiene: addressing vaginal bleeding throughout the life course in low and middle-income countries

Girls and women experience numerous types of vaginal bleeding. These include healthy reproductive processes, such as menstruation and bleeding after childbirth, but also bleeding related to health conditions, such as fibroids or cancer. In most societies, the management of menstruation is handled covertly, something girls are often instructed about at menarche. The management of other vaginal bleeding is often similarly discreet, although behaviours are not well documented. In many societies, cultural taboos frequently hinder open discussion around vaginal bleeding, restricting information and early access to healthcare. Additionally, the limited availability of clean, accessible water and sanitation facilities in many low and middle-income countries augments the challenges girls and women face in conducting daily activities while managing vaginal bleeding, including participating in school or work, going to the market or fetching water. This paper aims to highlight the key vaginal bleeding experiences throughout a woman's life course and the intersection of these bleeding experiences with their access to adequate water and sanitation facilities, information and education sources, and supplies. The aim is to address the silence around girls and women's vaginal bleeding and their related social, physical and clinical management needs across the life course; and highlight critical gaps that require attention in research, practice and policy around this neglected topic of health and gender equality.

Menstrual hygiene management among Bangladeshi adolescent schoolgirls and risk factors affecting school absence: results from a cross-sectional survey

BACKGROUND

Many adolescent girls in low-income and middle-income countries lack appropriate facilities and support in school to manage menstruation. Little research has been conducted on how menstruation affects school absence. This study examines the association of menstrual hygiene management knowledge, facilities and practice with absence from school during menstruation among Bangladeshi schoolgirls.

METHODS

We conducted a nationally representative, cross-sectional study in Bangladeshi schools from March to June 2013 among girls 11 to 17 years old who reached menarche. We sampled 700 schools from 50 urban and 50 rural clusters using a probability proportional to size technique. We interviewed 2332 schoolgirls and conducted spot checks in each school for menstrual hygiene facilities. To assess factors associated with reported school absence, we estimated adjusted prevalence difference (APD) for controlling confounders' effect using generalised estimating equations to account for school-level clustering.

RESULTS

Among schoolgirls who reached menarche, 41% (931) reported missing school, an average of 2.8 missed days per menstrual cycle. Students who felt uncomfortable at school during menstruation (99% vs 32%; APD=58%; CI 54 to 63) and who believed menstrual problems interfere with school performance (64% vs 30%; APD=27; CI 20 to 33) were more likely to miss school during menstruation than those who did not. School absence during menstruation was less common among girls attending schools with unlocked toilet for girls (35% vs 43%; APD=-5.4; CI -10 to -1.6). School absence was more common among girls who were forbidden from any activities during menstruation (41% vs 33%; APD=9.1; CI 3.3 to 14).

CONCLUSION

Risk factors for school absence included girl's attitude, misconceptions about menstruation, insufficient and inadequate facilities at school, and family restriction. Enabling girls to manage menstruation at school by providing knowledge and management methods prior to menarche, privacy and a positive social environment around menstrual issues has the potential to benefit students by reducing school absence.

Managing menstruation in the workplace: an overlooked issue in low- and middle-income countries

The potential menstrual hygiene management barriers faced by adolescent girls and women in workplace environments in low- and middle-income countries has been under addressed in research, programming and policy. Despite global efforts to reduce poverty among women in such contexts, there has been insufficient attention to the water and sanitation related barriers, specifically in relation to managing monthly menstruation, that may hinder girls’ and women’s contributions to the workplace, and their health and wellbeing. There is an urgent need to document the specific social and environmental barriers they may be facing in relation to menstrual management, to conduct a costing of the implications of inadequate supportive workplace environments for menstrual hygiene management, and to understand the implications for girls’ and women’s health and wellbeing. This will provide essential evidence for guiding national policy makers, the private sector, donors and activists focused on advancing girls’ and women’s rights.

A Time for Global Action: Addressing Girls' Menstrual Hygiene Management Needs in Schools

Marni Sommer and colleagues reflect on priorities needed to guide global, national, and local action to address girls' menstrual hygiene management needs in schools.

The fraction of inspired oxygen in infants receiving oxygen via nasal cannula often exceeds safe levels

OBJECTIVE

Measure the fraction of inspired oxygen (F(IO(2))) in infants receiving supplemental oxygen via nasal cannula and identify clinical variables that affect F(IO(2)).

METHODS

Hypopharyngeal gas samples were obtained from 20 infants receiving oxygen via nasal cannula at flows between 0 and 4 L/min. F(IO(2)) was calculated using the alveolar gas equation and measurements of partial pressure of oxygen in the samples and the barometric pressure.

RESULTS

F(IO(2)) increased as oxygen flow was increased. F(IO(2)) exceeded safe levels (> 60%) in two thirds of samples when the oxygen flow was 2 L/min or higher. Tachypnea (respiratory rate > 40 breaths/min) was associated with lower F(IO(2)).

CONCLUSION

Infants receiving oxygen via nasal cannula at > or = 2 L/min may be at risk for hyperoxic lung injury. Therefore, we recommend using the lowest possible oxygen flow needed to maintain normoxia in infants requiring prolonged oxygen therapy via nasal cannula.

Identification of inappropriate radiological referrals with suspected gallstones: a prospective audit

The objective of this study was to derive and test clinical scoring system in order to predict the presence of gallstones and to identify inappropriate referrals. The design of this scoring system comprised a prospective audit of all referrals with suspected gallstones and a prospective validation of the system on new patients. The subjects used in the study consisted of 300 inpatient, outpatient and general practitioner referrals to a radiology department with suspected gallstones during the period 1984-1986 (1st cohort) and 200 similar referrals from 1987 to 1988 (2nd cohort). The main outcome measures were gallstones as determined by oral cholecystogram and/or ultrasound of the gallbladder. 32.7% and 24.0% of referrals in the first and second cohorts, respectively, had gallstones. A scoring system to predict gallstones was derived on the first cohort based on age, Murphy's sign, duration and type of pain, presence or absence of flatulence, and source of referral. This scoring system discriminated well between those with and without stones in both cohorts. Low risk groups, comprising about 15% of the referrals in each cohort, were identified with a prevalence of gallstones of 4.5% (1st cohort) and 3.0% (2nd cohort). If these patients had not been referred the radiological workload would have dropped by 15%, with a very small reduction in diagnostic yield. We conclude that prior to radiological assessment it is possible, on the basis of source of referral and symptoms, to identify a group of patients with a low prevalence of gallstones. These cases, with a low diagnostic yield, contribute substantially to the workload of a radiological department.

Noradrenergic responses to clonidine in acute and remitted depressed male patients

To investigate noradrenergic function in depression, plasma 3-methoxy-4-hydroxyphenylglycol (MHPG), plasma norepinephrine (NE), mean arterial pressure (MAP), and heart rate responses to intravenous clonidine (2 micrograms/kg), an alpha 2-adrenergic agonist, were measured in 27 acutely depressed patients, 18 remitted depressed patients, and 27 normal control subjects; a placebo infusion was administered to a subgroup. Clonidine compared with placebo, over a 150-minute time course, decreased plasma NE, MAP, and heart rate, but not plasma MHPG, in the control subjects. Plasma MHPG, plasma NE, MAP, and heart rate at baseline or in response to clonidine and placebo over 150 minutes did not indicate any group differences. The only significant plasma MHPG response to clonidine in the normal control subjects occurred 60 minutes after the infusion. A significantly diminished plasma MHPG response to clonidine at 60 minutes was found in the acutely depressed group compared with the normal control subjects. These results suggest that peripheral inhibitory noradrenergic responses to clonidine are normal in depressed patients, while plasma MHPG responses to clonidine, which have a limited central contribution, appear to be a weak reflection of central noradrenergic function and appear insufficiently robust for a meaningful evaluation of hypothetical group differences in central inhibitory alpha 2-adrenergic activity in this population.

Technical report: an injection technique for repositioning subclavian catheters

Malpositioned central venous catheters need to be repositioned so as to avoid local toxicity from chemotherapeutic and other agents and to prevent venous thrombosis. We describe a simple, safe and effective technique for repositioning silicone central venous catheters, by using a hand injection of sterile saline. It was successful in all nine patients in whom it was attempted, with no complications. Five catheters were single lumen and four were double lumen. We feel that this method should be attempted prior to the use of more invasive techniques.

The effects of ioxaglate 320, iohexol 350, and iopamidol 370 on erythrocyte aggregation

The authors report a randomized, double-blind prospective trial comparing the effects of nonionic with ionic low-osmolar contrast media on erythrocyte aggregation. The study group comprised 40 consecutive patients with pathology necessitating selective angiography. Patients were examined using either ioxaglate 320, iohexol 350, or iopamidol 370. Erythrocyte aggregation was assessed both macroscopically and microscopically. Erythrocyte aggregation occurred more frequently in the iopamidol group (13 of 45 samples examined) than in the iohexol (4 of 46) or ioxaglate (5 of 51) groups (P = .002).

Eye tracking impairment in clinically identified patients with schizotypal personality disorder

Eye tracking accuracy, which has been found to be impaired in schizophrenic patients and their relatives, was assessed in 26 patients with schizotypal personality disorder, 17 control subjects with other non-schizophrenia-related personality disorders, 29 normal control subjects, and 44 schizophrenic patients. Both schizotypal and schizophrenic patients, but not control subjects with other personality disorders, demonstrated significantly more impaired tracking than the normal control subjects. These results suggest that patients with clinically defined schizotypal personality disorder may be biologically related to schizophrenic patients as part of a spectrum of schizophrenia-related disorders.

Failure of ultrasound to detect extra-pancreatic abscesses in severe acute pancreatitis

The development of intra-abdominal abscesses in patients with severe acute pancreatitis can be associated with a mortality as high as 100%. The clinical findings in these patients may be non specific and therefore imaging is essential. Computed tomography (CT) is the imaging modality of choice. However, a satisfactory ultrasound examination may be regarded as sufficient, particularly when there is limited availability of CT. A case of extra-pancreatic abscess complicating severe acute pancreatitis, in whom sonography was "normal", but CT demonstrated the abscess is presented. The importance of CT in these patients in whom an abscess is suspected and our experience with similar cases is discussed.