Using qualitative data to build causal pathways on perceived associations between poor menstrual health and hygiene and harms among schoolgirls in western Kenya.

Background: Poor menstrual health and hygiene (MHH) is a global public health concern, particularly in low- and middle-income countries. It can result in adverse health and educational impacts. Narratives from baseline focus group discussions (FGDs) conducted during a pilot intervention study in rural western Kenya were explored to reveal perceived associations. Methods: Transcripts of 19 FGDs involving 87 post-menarche schoolgirls, 47 parents, and 46 teachers were analysed thematically to identify perceived causal links between menstrual issues and health and educational outcomes. Quotes illustrating these perceived cause-and-effect relationships were logged and synthesised into a series of pathways, from which an overarching causal pathway model was produced. Results: Poverty underpinned poor MHH, characterised by the inability to afford products, the use of inadequate products, and the prolonged use of products. Key outcomes included menstrual issues, menstrual accidents (e.g., leaking), psychosocial distress (e.g., humiliation), poor educational outcomes (e.g., school absence), transactional sex, adolescent pregnancy, and infections (e.g., localised or reproductive tract infections). Poor MHH outcomes were often perceived as "nodes" or drivers that led to further distal outcomes. Four pathways emerged, all stemming from poverty. In pathway 1, poverty led to poor educational outcomes via inadequate menstrual materials, menstrual accidents, and psychosocial stress. In pathway 2, poverty led to poor educational outcomes via inadequate menstrual materials and physical discomfort. In pathway 3, poverty caused infections through the use of inadequate materials. In Pathway 4, inadequate materials resulted in transactional sex. Conclusion: Four perceived pathways linking poverty and poor MHH to an endpoint were used to develop a single overall causal pathway. The most frequently perceived outcome was school absence, with pregnancy and school dropout noted much less frequently. As poverty, the perceived underlying cause in this pathway, is a complex target, focusing interventions on proximal perceived key nodes in the pathway, such as poor MHH, would be of value.