The need for a strong evidence base

MHM-related research in LMICs has primarily focused on describing the challenges and barriers associated with MHM among schoolgirls, in limited cultural and geographical settings, with early initiatives examining the effect of potential interventions (15, 25) (26). Given the dearth of information on MHM globally, the expected sensitivities around the topic, and the lack of standardized tools and methods, research has predominantly provided evidence from qualitative, participatory, and descriptive methods. While this has built a foundation for action to counter girls’ unmet MHM-related needs (9), a commensurate number of analytical studies have not been performed (27).

There are a number of priority research areas that have been identified as essential for shaping and promoting MHM in schools. Advancing the evidence on these topics will enable the global community to better understand the main negative effects of poor MHM on girls’ well-being, dignity, health, and schooling. This includes strengthening the body of knowledge around MHM's impact on school dropout, absence, and other measureable school indicators (such as stress, self-confidence, and self-efficacy). Efforts to specifically explore the impact of poor MHM on girls’ SRH are also needed to define its contribution toward sexual exposure (18, 19), and subsequent increased risk of schoolgirl pregnancies and sexually transmitted infections (23). Laboratory-based support is required given the limited predictability of girls’ (and women's) reported symptomatology (17, 23) (28). There is also a need to design good and innovative MHM interventions (individually or as a package) for different settings, to evaluate their impact on different outcomes and to measure their sustainability and cost-effectiveness.

The existing MHM evidence to date, which is comprehensive in terms of the barriers facing girls in school across many LMICs, thus provides little verification of critical outcomes affecting girls’ lives and has not fully addressed why MHM remains a neglected issue. While inequitable school environments have been shown to disadvantage girls and increase the risk of pregnancy and dropout (29, 30), evidence of the MHM-specific effects are unknown (27). Ascertainment of intermediate outcomes such as school absence (i.e. which may contribute to dropout or failure to achieve) has been mixed (14, 31), with no strong impact shown after provision of menstrual products (15, 32). No studies have been conducted on girls’ level of attainment in school (27). A sole focus on school misses exploration of important health effects on girls’ SRH and wider effects on girls’ life chances; while pilot studies have explored this (33), verification through larger trials is required. As well as the effect of transactional sex for menstrual products (18, 19), the potential for unintended pregnancy due to a lack of girls’ understanding between the menstrual cycle and fertility has been documented (34), but not studied further.

The topic areas shown in Table 1 are exemplars identified by researchers and practitioners as having critical gaps in knowledge around MHM for adolescent girls (7). Addressing these research topics in multiple sites is essential to understand the breadth and depth of MHM needs as well as to highlight cultural differences in MHM that are critical to intervention roll-out and adoption.

The need for standardized definitions and measures

While MHM has been defined, universal agreement is needed for outcome measures, including targets that indicate successful implementation and endpoints that require laboratory confirmation. Below are a number of outcome measures identified to be important that, to date, have either been examined with variation in their definition, precision, and reliability, or have been neglected (Table 2). Others listed have not yet been measured in association with MHM. Predictors are sub-grouped by main effect topic. Standard definitions have been developed by the Joint Monitoring Programme (Box 1); yet, a wide range of definitions of ‘good’ and ‘bad’ MHM have been used. In order for a robust MHM evidence base that allows for cross-study comparisons, standardized outcome endpoints will prove to be key.

The need for standardized study methodologies

While the priority topics listed above may include methodological components, Table 3 specifically highlight study methodologies that need to be considered in future research designs A wider range of approaches also need to be employed to capture social and cultural factors that influence implementation. Certification of researchers in good clinical practice (i.e. global health training centre: https://globalhealthtrainingcentre.tghn.org/elearning/) and research in human participants (i.e. NIH training: https://phrp.nihtraining.com/users/login.php) are required to ensure ethical practice (across all studies, not specifically trials), and to encourage study rigor. These methodologies will require adherence to standardized guidelines and protocols, such as PRISMA (36), STROBE (37), and CONSORT (38). This will in turn strengthen the existing evidence base motivating increased investment and allowing for measurement of impact.

Inadequate funding for MHM research has been a key factor contributing to many of the methodological issues within existing studies and the limited quantification of MHM in schools. Support is needed to strengthen the MHM study methodologies that have been applied as well as those that have not been undertaken to date. This is critical to ensure that future studies, including impact assessments and those that attempt to quantify outcomes, have adequate sample sizes, and that individual participants are followed up (as the unit of measurement), with loss to follow-up taken into account.

The need for an MHM research consortia

To further facilitate the research agenda, a multi-disciplinary, cross-sectoral, and cross-cultural research consortia panel is required to foster high-quality research studies on priority topics to generate key findings relevant for global policy. An important component of the research agenda will be to provide a conduit for strengthening and supporting research quality through the sharing of methodologies and tools, and developing standard measurement criteria. The latter will allow comparison and pooling of findings across studies for meta-analyses, as well as contributing toward global north–south learning and capacity building. Envisaged functions of a research consortia are presented in Table 4.

Such a consortia once in situ will offer an opportunity for funders to pool resources and establish a funding mechanism through the consortia peer-review research panel. Seed money would be needed in the first instance to develop the research network infrastructure, consortia terms of reference, objectives, milestones, timeframes, work packages, funding mechanisms and accountability system, communication strategies, and to initiate the design and provision of guidelines for researchers. Ultimately, we expect that this collaborative effort will facilitate the generation of local and global evidence-based findings that can be translated into policies and programs globally to promote MHM and improve adolescent girls’ dignity, health, well-being, and schooling, and enable girls to reach their full potential.

Conclusions

This brief article represents a consensus by engaged experts from a range of disciplines, on the priority of MHM in schools’ research topics and methods that need to be explored in order to fill the gaps in the existing MHM evidence base. This collective effort aims to improve the quality and focus of research, enhance effectiveness of programming, strengthen global commitment, increase funding, facilitate sharing of expertise across disciplines to foster multi-disciplinary studies (including intervention research), and eliminate time and money spent on duplication of efforts in topic areas already well researched. We advocate for the creation of a global MHM research network through a research consortia that will help support the development of research guidelines, strengthen translation of evidence-based research into policy, and facilitate funding. Ultimately, while great advances have been made in the MHM research evidence base to date, there remain a number of important gaps in our collective knowledge. Filling these gaps will require new research studies that use an expanded range of methodologies, that enable the global community to better understand the magnitude of the problem surrounding MHM for adolescent girls (in and out of school), the impact of MHM interventions, and the costs incurred to implement them effectively. Without broadening the existing evidence-based knowledge, opportunities to improve an essential component of adolescent lives will remain limited.

Authors’ contributions

The article was conceptualized and drafted by PPH, BC, and MS, and edited by BT, GZ, and MaS.

Conflict of interest and funding

The authors declare no conflict of interest.

Paper context

There is a dearth of data measuring the effects of girls’ menses on health and well-being in low-and middle-income countries. This lack of research has been identified as one of the five top priorities for advancing good menstrual hygiene management (MHM) globally. This article highlights the existing gaps in MHM research and identifies opportunities to build hard evidence and improve the ability of governments, donors, and other agencies to appropriately target resources to support MHM.