Table 1 MENISCUS intervention reported according to the TIDieR framework

MENISCUS intervention components

1. Menstrual Health (MH) Action Group

2. Puberty education

3. Drama skit

4. Menstrual health kit and training

5. Pain management

6. Water, sanitation, and hygiene (WASH) improvements

Why: rationale for each component

1. To facilitate school-ownership of the MENISCUS intervention and hence that it is implemented well in the school

2. To strengthen schools’ capacity to deliver knowledge of puberty and menstruation

3. To enable a supportive school environment and reduce stigma and teasing

4. To improve menstrual management and provide product choice

5. To improve ability to manage menstrual pain

6. To improve menstrual hygiene management

What: materials and procedures

1. The WoMena staff training the Action Group will receive a manual and training to deliver the training. The MH Action Group members will receive in-person training in puberty and menstruation and on running an MH Action Group. The MH Action Group members will receive a T-shirt with the MENISCUS logo, the budget for running the Group, an MH kit and an MH Action Group Charter, guide and action plan to complete. The MH Action Group will receive support by WoMena Uganda after the initial training in follow-up sessions.

2. The schools’ staff delivering puberty education will receive in-person training on how to deliver the Ministry of Education and Sports’ (MoES) training on menstrual health management and a copy of the MoES Training Manual for teachers and other stakeholders on Menstrual Health Management.

3. The drama group members (facilitators and students) will receive two facilitation sessions on menstruation and the drama skit. They will receive an outline of a MH-related drama to be developed into a drama skit and performed at an existing school meeting. A small budget, managed by the MH Action Group, will be available to buy props and supporting materials for the performance and the students taking part. The students taking part will receive a T-shirt with a MENISCUS logo.

4. i) Trained school members (“MENISCUS trainers”) including student leaders and prefects to provide peer support to girls will receive in-person training on how to deliver menstruation education sessions (a joint session of menstruation for boys and girls and separate girls’ and boys’ sessions), alongside receiving specially developed materials to deliver these sessions, flipcharts and a training manual. The trainers will receive a certificate, a T-shirt, and an MH kit.

ii) S2 students will receive in-person education sessions delivered by the MENISCUS trainers. The students will receive a MENISCUS booklet developed by WoMena to accompany the education sessions. The girls’ session includes puberty, how to use the MH kit components, and tracking and managing their periods, including managing menstrual pain. Students will receive a MH kit consisting of the AFRIpads “schoolgirl kit” of 5 reusable pads, a towel, soap, two pairs of underwear, and MH booklet with a menstrual tracker, plus a menstrual cup and container for girls who consented to the cup. The boys’ session will include male puberty, genital hygiene, male circumcision, and attitudes towards girls who are menstruating.

iii) Female caregivers will receive in-person education around menstruation and the use and care of reusable menstrual products (menstrual cup and reusable pads). Caregivers will receive a MH kit of the AFRIpads “standard kit” of 6 reusable pads, a towel, soap, and underwear plus a menstrual cup and container to those who consent and are willing to receive the cup.

5. S2 female students will receive (i) an information sheet about safe use of paracetamol and ibuprofen, plus information on pain management methods more broadly in the MENISCUS MH booklet, and (ii) vouchers to be redeemed for a maximum of 6 tablets per month from the school nurse or designated senior teacher who will be trained in administering these by the MENISCUS clinical officer.

6. Basic improvements to school WASH facilities (installation of locks, repair of broken doors, provision of bins and toilet paper holders fixed to the wall, liquid hand washing soap, and water drums).

Who provided

1. The MH Action Group will consist of 6–8 people selected by school management and will be responsible for implementing and maintaining the intervention. They will be MH champions within the school. The MH Action Group members will include a minimum of at least one representative of school management, a senior woman teacher, a student, and a parent. The group will receive:

• 1-day training on menstruation and being a member of the MH Action Group by WoMena Uganda

• Follow-up and support from WoMena Uganda facilitators at 3 MH Action Group meetings

2. Up to 5 male and female teachers per school who usually deliver puberty education to secondary students will attend a 2-day training, followed by 1-day training by WoMena Uganda.

3. The drama skit component will involve the drama group in the school, including the drama teacher and students who attend. If there is no active drama club or group in the school, the MH Action Group will be encouraged to support the creation of a group. Drama groups, including a drama teacher/facilitator and around 30 students in the school, will be invited to 2 facilitation sessions which contain training on menstruation and puberty and introductions to the concept of the drama skit and the script. The group will also have rehearsals observed and supported by WoMena.

4. Approximately 7 school staff and students will be selected as MENISCUS trainers, responsible for training S2 students in MH and using the MH kit. Selected prefects and student leaders will support the trained staff in training activities and act as peer support in their schools. Training participants will be selected by school management according to specified selection criteria (for example, motivation and agreement to attend trainings and train young people of puberty, menstruation and using reusable menstrual products, as well as having the trust and respect from students). Approximately 8 female caregivers associated with the schools will be selected by school management according to a specified criterion (willing to try products, respected in the community, has a child who attends the school).

5. The school nurse or other designated senior teacher will be trained on safe use and management of paracetamol and ibuprofen by the MENISCUS clinical officer, including how the voucher scheme works.

6. WASH improvements will be made by a contractor employed by MRC/UVRI and LSHTM Uganda Research Unit. The MH Action Group members will be responsible for maintaining the improved WASH facilities.

How — modes of delivery

1. WoMena Uganda will provide face-to-face group training around the MH Action Group and will have in-person follow-up visits for each school to observe and support.

2. WoMena Uganda will provide face-to-face group training in puberty education to teachers.

3. WoMena Uganda will introduce the drama skit and provide a brief training on menstruation in person and will attend a rehearsal to give feedback and support in each school.

4. WoMena Uganda will provide face-to-face group training of MENISCUS Trainers, with follow-up in each school to provide support. WoMena Uganda will provide face-to-face group trainings of female caregivers.

5. The MENISCUS clinical officer will provide training of school nurses or other designated staff on appropriate analgesic use, and WoMena will provide training on alternative pain management strategies to MENISCUS Trainers.

6. WASH improvements will be made at each school by the contractor.

Where

All intervention elements will take place at the school or at an event space in the community for the trainings.

When and how much

All elements will be delivered over the course of a year, following randomisation.

1. The training of the MH Action Groups will take place once, in clusters of about 5 intervention schools based on their location. The training will be for 1 day per cluster of schools. The MH Action Groups following this will run for 8–11 months (depending on when they receive their training). They will have 3 meetings, with one attended by the WoMena Uganda team over this period.

2. The training of the puberty educators will be two sessions in each district. The first training will take place approximately 4 weeks ahead of the second training. The first training will last 2 days and the second training will last 1 day. Those trained will then deliver the puberty education to students they teach over the following 8 months.

3. Two drama skit facilitation sessions will take place in each school followed by an attendance at one rehearsal. The drama skit facilitation sessions, rehearsals, and performance will take place over a period of 3 months.

4. The training of MENISCUS trainers will take place once with two separate sessions firstly, a 2-day session and a 1-day follow-up session, approximately 1 month after the initial training session. The MENISCUS trainers will then deliver this training to students at the school over the following 3 months. The training of female caregivers will take place once in a 1-day session.

Tailoring

There are plans for adaptations and tailoring based on attendance at the initial trainings and the delivery of the training by the MENISCUS trainers to the S2 students. If there is no attendance at the initial trainings, schools will be offered these trainings at their schools individually unless there are enough schools who did not attend and then another training will be held in a central location. If schools do not deliver the training to S2 students, they will be supported to do so by WoMena Uganda by either delivering the sessions or being present when the school delivers all the sessions.

How well

This will be evaluated in the process evaluation (please see details in Table 4)