Almost no evidence exists on effectively delivering school violence prevention interventions at scale. The Good School Toolkit (GST), developed by Uganda-based non-governmental organisation (NGO) Raising Voices, is an effective whole-school violence prevention intervention when delivered by NGO staff. This study aimed to determine whether GST, delivered via a scalable delivery model using Regional Resource Persons (RRPs), is effective in changing teachers' attitudes towards violence and improving perceptions of school operational culture.A pre-post study was conducted in 95 schools across Uganda, randomly selected from 1000 schools implementing GST via RRPs. All schools had the opportunity to implement GST. Teachers participated in cross-sectional baseline (February-April 2022) and endline (September-October 2023) surveys. Primary outcomes were acceptance of physical discipline and markers of school operational culture. We fitted mixed-effects linear regression models to examine changes in outcomes over time and influence of GST exposure.Analyses showed that each unit increase in GST exposure was associated with an increase of 0.59 (95% CI 0.49 to 0.69, p<0.001) in teachers' perception of school operational culture, and 0.12 (95% CI 0.09 to 0.14, p<0.001) in perceptions of staff and student involvement in school operations. Although mean acceptance of physical discipline increased over time (β=0.51, 95% CI 0.27 to 0.76, p<0.001)-likely attributable to changes in schools post-COVID-19-each unit increase in GST exposure corresponded to an attenuation in acceptance by 0.06 (95% CI -0.12 to 0.00, p=0.046). Teachers reporting higher exposure to GST were also less likely to report using past year physical violence (OR=0.92, 95% CI 0.89 to 0.96, p<0.001).This study is the first in the Global South to evaluate a new delivery model for implementing an evidence-based violence prevention intervention at scale. GST delivered via RRPs mitigated an increased acceptance of physical discipline and was associated with improvements in school operational culture and reduced teacher physical violence, highlighting the promise of the RRP delivery model for implementing GST.

INTRODUCTION:Access to menstrual products is a key factor for improving menstrual health, but there is limited research on the facilitators and barriers to their uptake and use. We describe menstrual product use, and factors associated with use of freely-distributed reusable pads and menstrual cups among female students in Ugandan secondary schools. METHODS:We analysed one-year follow-up data nested within a cluster-randomised trial evaluating the effectiveness of a multi-component menstrual health intervention among female students in 60 schools. The intervention included provision of five reusable pads and an optional menstrual cup, with training. We used random-effects logistic regression to identify factors associated with reported use of each product type at last menstrual period (LMP) at endline. We conducted focus group discussions and in-depth interviews among students and caregivers to explore product preferences, using thematic analysis. RESULTS:We analysed data from 2622 post-menarche participants present at both baseline and endline (mean age 15.6 years). Of these, 1683 (64.2%) used more than one type of menstrual product at LMP and 2203 (84.0%) used disposable pads at LMP, at endline. Among 1221/1302 (93.8%) intervention arm participants who received menstrual pads, and 613 (47.1%) who received a menstrual cup, 845 (69.2%) and 156 (25.4%) respectively reported using these products at LMP at endline. Reusable pad use was associated with older age, lower socioeconomic status, being a day scholar, prior use of reusable pads, and having higher menstrual self-efficacy at baseline. Use of a menstrual cup was associated with older age and being of non-Muganda ethnicity. Qualitative findings showed that knowledge, perceptions, affordability, prior familiarity, ease of use, comfort, peer influence, social stigma, and access to private washing facilities played key roles in product preference among the students. CONCLUSION:In this setting, participants used more than one product during a single menstrual period and preferred disposable pads when provided with free reusable products, due to challenges including washing and drying, social stigma, and discomfort. Provision of menstrual products needs to address both uptake and sustained use by considering individual preferences, cultural acceptability, sustainability, comfort, and environmental factors. TRIAL REGISTRATION:ISRCTN 45461276; 16/09/2021.

BACKGROUND:School attendance and completion among girls protect them from multiple sexual and reproductive health problems. However, inadequate resources for managing menstruation remains a barrier to school participation and learning in low- and middle-income countries. With the increased global focus on closing the gender gap in education, schoolgirls' voices are important in understanding drivers of suboptimal social and school participation during menstruation. This paper explores how menstruation influences social and school participation from the perspectives of schoolgirls. METHODS:We conducted 40 in-depth interviews with purposively-selected secondary schoolgirls aged 13-20 years in two rural and two urban schools in Northern Tanzania from 2021 to 2022. To be eligible for participation, the schoolgirls must have reported missing school during their last menstruation. We used an in-depth interview guide to elicit girls' menstrual experiences and how such experience influenced their school and social participation. We used NVivo 12 software to code data and employed thematic analysis using the social-ecological model. RESULTS:The respondents described the drivers of suboptimal social and school participation at the individual level (negative menstrual experience, i.e. menstrual pain and constant worries of menstrual blood leaking, and individual economic constraints); interpersonal level (the fear of menstrual status disclosure, and peer's attitude); school level (inadequate emergency pad at school, lack of private place to change, and unhygienic school WASH); and societal level socio-cultural restrictions (girls are prohibited from touching plants/vegetables, engaging in household chores/religious worship, or physical contact with men during menstruation, and refusal to use conventional painkillers to relief menstrual pain). CONCLUSIONS:The findings suggest that drivers of suboptimal social and school participation among secondary schoolgirls exist at the individual, interpersonal relationship, school, and societal levels. Multi-level evidence-based multicomponent interventions to improve menstrual health at all socio-ecological levels are warranted for optimal social and school participation among schoolgirls.

BACKGROUND:Schools provide a unique opportunity to address multiple forms of violence against adolescents. Yet, few whole-school interventions to comprehensively address physical, sexual and emotional violence against adolescents from multiple perpetrators have been evaluated in the Global South. We report results of a pilot trial of the Good School Toolkit-Secondary (GST-S), an intervention for secondary schools in Uganda. The trial aimed to determine whether criteria for progression to a phase 3 trial were met based on pre-specified implementation and research feasibility criteria. METHODS:We conducted a pilot cluster randomised controlled trial with two arms and parallel assignment. The trial was conducted in eight secondary schools, varying by faith status and urban or rural setting, randomly selected from a list of all eligible registered schools in Kampala and Wakiso Districts. Schools were randomised to control or intervention arms and aware of their allocation. The primary outcome was to determine whether criteria for progression to a phase 3 trial were met based on pre-specified criteria regarding fidelity, acceptability and understanding of GST-S, and research feasibility. Outcomes were measured using cross-sectional baseline and endline surveys among eligible school students and staff, and routine monitoring data collected during implementation. RESULTS:Overall, seven of eight schools agreed to participate in the baseline survey, randomisation and endline survey, with three randomised to the control and four to the intervention group. The endline survey included 837 students (response rate: control, 100%; intervention, 99.4%) and 98 staff (response rate: control, 91.1%; intervention, 95.0%). There were delays to the trial due to Covid-19 and an Ebola outbreak. Despite this, all pre-specified implementation and feasibility criteria were met. The intervention was acceptable and understandable to students and staff, was delivered with fidelity, and the trial demonstrated good research feasibility. CONCLUSIONS:We present the first evidence that it is feasible to deliver a whole-school intervention aiming to address physical, sexual and emotional violence against adolescents from multiple perpetrators including peers, teachers and intimate partners in sub-Saharan Africa. Based on our results, we recommend progression to a phase 3 trial with minor refinements to the research methods and intervention. TRIAL REGISTRATION:Pan African Clinical Trials Registry, PACTR202009826515511, 16/09/20.

Experiencing violence in childhood and adolescence is both common and long-lasting, and associated with poor short- and long-term health and economic outcomes. In the current study, we reviewed evidence from longitudinal studies on the association between violence in childhood and work outcomes to determine the direction and magnitude of the association, explore variations by violence type, identify evidence gaps, and describe the extent of research and findings on mediators. We systematically searched nine databases for longitudinal studies reporting on the association between violence in childhood and work outcomes, and conducted a narrative synthesis. We identified 46 reports of 27 cohorts, with all but one cohort from high-income countries. This review shows that there is strong evidence from high-income countries that violence in childhood is associated with a range of negative work outcomes. Evidence is strongest for official reports of child abuse and neglect, physical violence, bullying, and composite violence measures, but is more mixed for sexual violence. There is less evidence for emotional violence, witnessing violence, neglect, and adolescent intimate partner violence. Associations are similar for men and women. Nine reports conducted mediation analyses, mainly examining educational factors as mediators. Evidence suggests that educational factors may partially mediate the relationship between violence and negative work outcomes. Cognition, mental health, and noncognitive skills may also be mediators. There is a need for data from low- and middle-income countries, and further mediation analyses to help guide efforts to reduce negative consequences of violence.

BACKGROUND:Menstrual health is a human rights issue, affecting many aspects of life including mental health, wellbeing, and education. We assessed the effectiveness and costs of a school-based, multi-component menstrual health intervention (MENISCUS) to improve mental health problems and educational performance among in-school adolescents. METHODS:We conducted a parallel-arm, cluster-randomised trial in secondary schools in Wakiso and Kalungu districts in Uganda. Schools were eligible for inclusion if they had both male and female students; senior 1-4 classes; day or mixed day and boarding students; at least minimal water, sanitation, and hygiene (WASH) facilities; and enrolments of 50-125 female Senior 1 students in Wakiso district and 40-125 female Senior 1 students in Kalungu district. Schools were randomised (1:1) to the intervention or control condition, stratified by district and baseline mean school examination score. The intervention included creating action groups, strengthening teacher-delivered puberty education, distributing menstrual kits, supporting student-led drama skits, providing pain-management strategies, and improving school water and sanitation facilities. The control condition was provision of printed government menstrual health materials. Schools, participants, and implementors, including the study clinician who monitored adverse events, could not be masked to allocation status. Primary outcomes were mental health problems using the Strength and Difficulties Questionnaire (SDQ) Total Difficulties Score and independently assessed educational performance at individual level, assessed in all female participants at endline. We estimated cluster-intention-to-treat intervention effects using mixed-effects models accounting for school clustering and adjusted for randomisation strata and baseline school-level means of outcomes. The study was registered at the ISRCTN registry, ISRCTN45461276 and is completed. FINDINGS:60 randomly selected schools (44 from Wakiso and 16 from Kalungu) were randomly assigned (30 per group) to the intervention or the control group, and none withdrew. Between March 21 and July 5, 2022, 3841 female students participated in baseline assessments (89·7% of those eligible) and between June 5 and Aug 22, 2023, 3356 participated in endline assessments (1666 in the control group and 1690 in the intervention group). Female participants had a median age of 16 years (IQR 15-16). At endline, there was no evidence of a difference in mental health problems (mean SDQ score, 10·8 in the intervention group vs 10·7 in the control group; adjusted mean difference [aMD] 0·05 [95% CI -0·40 to 0·50]) nor educational performance (mean z score, 0·20 in the intervention group vs 0·12 in the control group; aMD 0·05 [95% CI -0·10 to 0·19]), despite improvements to menstrual health. The annual implementation cost was US$85 per Senior 2 female student. One participant had a serious adverse event (severe anaemia secondary to excess vaginal bleeding), which was deemed to be possibly related to the intervention. INTERPRETATION:Improving multiple dimensions of menstrual health in secondary schools in Uganda is important for health and human rights but is not sufficient to improve mental health or educational performance over 1 year. FUNDING:UK Foreign, Commonwealth and Development Office; Medical Research Council; Department of Health and Social Care; and Wellcome.

Background: The National Surveys of Sexual Attitudes and Lifestyles COVID study (Natsal-COVID) was designed to understand the impact of COVID-19 on Britain’s sexual and reproductive health (SRH). Natsal-COVID Wave 1 survey and qualitative follow-up interviews were conducted in 2020. The Wave 2 survey was designed to capture one-year prevalence estimates for key SRH outcomes and measure changes over the first year of the pandemic. We describe the Wave 2 survey methodology and assess the sample representativeness. Methods: Natsal-COVID Wave 2 was conducted March-April 2021; approximately one year after the start of Britain’s first national lockdown. Data were collected using an online web-panel survey administered by Ipsos. The sample comprised a longitudinal sample of Wave 1 participants who had agreed to re-contact plus a sample of participants residing in Britain, aged 18-59, including a boost sample comprising people aged 18-29. Questions covered reproductive health, relationships, sexual behaviour and SRH service use. Quotas and weighting were used to achieve a quasi-representative sample of the British population. Comparisons were made with recent national probability surveys, Natsal-3 (2010-12) and Natsal-COVID Wave 1 to understand bias. Results: A total of 6,658 individuals completed the survey. In terms of gender, age, ethnicity, and rurality, the weighted Natsal-COVID Wave 2 sample was like the general population. Participants were less likely to be married or to report being in good health than the general population. The longitudinal sample (n=2,098) were broadly like participants who only took part in Wave 1 but were older. Among the sexually active, longitudinal participants were less likely to report multiple sexual partners or a new sexual partner in the past year compared to those who only took part in Wave 1. Conclusions: Natsal-COVID collected longitudinal, quasi-representative population data to enable evaluation of the population-level impact of COVID-19 on SRH and to inform policy.

Introduction No whole-school interventions which seek to reduce physical, sexual and emotional violence from peers, intimate partners and teachers have been trialled with adolescents. Here, we report a protocol for a pilot trial of the Good School Toolkit-Secondary Schools intervention, to be tested in Ugandan secondary schools. Our main objectives are to (1) refine the intervention, (2) to understand feasibility of delivery of the intervention and (3) to explore design parameters for a subsequent phase III trial.Methods and analysis We will conduct a pilot cluster randomised controlled trial, with two arms and parallel assignment. Eight schools will be randomly selected from a stratified list of all eligible schools in Kampala and Wakiso Districts. We will conduct a baseline survey and endline survey 18 months after the baseline, with 960 adolescents and 200 teachers. Qualitative data and mixed methods process data collection will be conducted throughout the intervention. Proportion of staff and students reporting acceptability, understanding and implementing with fidelity will be tabulated at endline for intervention schools. Proportions of schools consenting to participation, randomisation and proportions of schools and individual participants completing the baseline and endline surveys will be described in a Consolidated Standards of Reporting Trials diagram.Ethics and dissemination The ethical requirements of our project are complex. Full approvals have been received from the Mildmay Ethics Committee (0407-2019), the Uganda National Council for Science and Technology (SS 6020) and the London School of Hygiene & Tropical Medicine (16212). Results of this study will be published in peer-reviewed academic journals, and shared with public bodies, policy makers, study participants and the general public in Uganda.Trial registration number PACTR202009826515511.

Background The National Surveys of Sexual Attitudes and Lifestyles COVID study (Natsal-COVID) was designed to understand the impact of COVID-19 on Britain’s sexual and reproductive health (SRH). Natsal-COVID Wave 1 survey and qualitative follow-up interviews were conducted in 2020. The Wave 2 survey was designed to capture one-year prevalence estimates for key SRH outcomes and measure changes over the first year of the pandemic. We describe the Wave 2 survey methodology and assess the sample representativeness. Methods Natsal-COVID Wave 2 was conducted March-April 2021; approximately one year after the start of Britain’s first national lockdown. Data were collected using an online web-panel survey administered by Ipsos. The sample comprised a longitudinal sample of Wave 1 participants who had agreed to re-contact plus a sample of participants residing in Britain, aged 18-59, including a boost sample comprising people aged 18-29. Questions covered reproductive health, relationships, sexual behaviour and SRH service use. Quotas and weighting were used to achieve a quasi-representative sample of the British population. Comparisons were made with recent national probability surveys, Natsal-3 (2010-12) and Natsal-COVID Wave 1 to understand bias. Results A total of 6,658 individuals completed the survey. In terms of gender, age, ethnicity, and rurality, the weighted Natsal-COVID Wave 2 sample was like the general population. Participants were less likely to be married or to report being in good health than the general population. The longitudinal sample (n=2,098) were broadly like participants who only took part in Wave 1 but were older. Among the sexually active, longitudinal participants were less likely to report multiple sexual partners or a new sexual partner in the past year compared to those who only took part in Wave 1. Conclusions Natsal-COVID collected longitudinal, quasi-representative population data to enable evaluation of the population-level impact of COVID-19 on SRH and to inform policy.

Background Adaptation is a key strategy to extend the reach of evidence-based interventions to prevent violence in new populations, but there is a dearth of practical case examples. The Good School Toolkit was developed by Ugandan NGO Raising Voices for use in primary schools (GST-P). We describe our systematic approach to adapting the GST-P for use in secondary schools in Uganda, and reflect on the utility of the process as well as limitations of existing adaptation frameworks. Methods We adapted the GST-P in four phases, which included: I) clarifying the logic model and core intervention components using a streamlined process; II) conducting formative research (cross-sectional survey, focus groups, etc.) to understand the new population; III) selecting and preparing new intervention components and modifying existing intervention components; and IV) pretesting new intervention components with teachers and students in Uganda. Results We identified core components using a logic model. Formative research showed results largely in line with our apriori hypotheses. Teacher violence remained highly prevalent in secondary versus primary schools (> 65% of secondary students reported past year exposure), while peer violence significantly increased (secondary = 52% vs. primary girls = 40%, P < 0.001; secondary = 54% vs. primary boys = 44%, P = 0.009) in secondary versus primary schools. Significantly more secondary girls (51%) than secondary boys (45%) reported past year dating/intimate partner violence ( P = 0.03). Inequitable, gendered educational practices emerged as a salient theme, perceived to heighten female students’ vulnerability to violence. In light of these findings, we made several adjustments to the adapted intervention. We strengthened existing teacher and peer violence intervention components. We also developed, pretested and revised new program components to prevent dating violence and promote ‘gender fairness in schools’. Finally, original activities were modified to support engagement with school administration and promote increased student agency in secondary schools. Conclusions Based on our experience, it was difficult to apply mechanistic models to clarify the intervention logic of the GST-P, a complex multicomponent intervention, and simpler methods may be sufficient. Our team had high levels of contextual knowledge before the adaptation, and formative research to understand the new target population provided only limited additional insight. In similar situations, a simplified approach to mapping the core intervention components, qualitative research to understand the new target population, and pre-testing of new intervention components may be the most informative elements of systematic adaptation processes.

Introduction: Improving menstrual health among schoolgirls is essential to meeting the Sustainable Development Goals for gender equality, good health and wellbeing, and quality education. School participation and wellbeing among girls in low and middle-income countries are impacted by a lack of access to quality menstrual materials, taboos around menstruation, inadequate knowledge, and poor WASH facilities. Comprehensive evidence is needed to address these challenges and guide policy and practice. Methods A self-administered questionnaire was used to collect socio-demographic information, menstrual-related data, and school environment data from girls in four mixed-gender government schools in Mwanza. Mean (SD) scores for three Menstrual Practices and Needs Scale (MPNS-36) sub-scores focusing on the extent to which girls perceived needs for carrying menstrual material to school and changing (transport and school environment); washing and drying menstrual material (reuse needs); and privacy and drying menstrual material in school (reuse insecurity) were calculated. An ANOVA test was used to compare MPNS scores for groups, and logistic regression was used to examine the association between menstrual health and wellbeing outcomes (self-efficacy, menstrual anxiety, school attendance, and participation) and MPNS subscale scores. Results The mean age of the 486 participants was 15.6 years (SD 1.3); 87% had started menstruating; and the mean age at menarche was 14.2 years (SD 1.15). Of all participants who had reached menarche, 310 (75%) experienced pain during the last menstrual period, 165 (39%) had menstrual-related anxiety, and 63 (16%) missed at least one day of school due to menstruation. Participants reported using reusable menstrual material (72%), and/or disposable pads (62%), during the last period. Between 36% and 94% of girls in participating schools reported that water was available in school at least half of the time. The mean school climate score ranged from 5.6 to 7.1 out of 8. The mean score for the MPNS subscales ranged from 1.0 to 2.1 out of a maximum score of 3, across schools for the reuse needs subscale; 1.6 to 2.1 for reuse insecurity; and 0.9 to 1.8 for transport and school environment needs. A lower reuse insecurity score was associated with lower odds of menstrual anxiety (OR 0.58; 95% CI 0.45–0.76) and non-participation in school activities (OR 0.72; 0.53–0.97). Higher scores for transport and school environment were associated with confidence to ask a female friend and teacher for menstrual support (OR 1.54; 1.24–1.89), stand up and answer questions in class (OR 1.59; 1.29–1.95), and predict when periods are about to start (OR 1.40; 1.13–1.72). Conclusions Schoolgirls have unmet menstrual practice needs related to transporting and using menstrual material in school and these needs differ across schools in northern Tanzania. Interventions that can address menstrual practice needs in schools in this setting are required.

Purpose The COVID-19 pandemic and lockdown restrictions introduced personal and relationship stressors that potentially increased the risk of intimate partner violence (IPV) for some. We estimated the population prevalence and correlates of fearing a partner in the first year of the pandemic in Britain. Method We used data from Natsal-COVID Wave 2—a web-panel survey undertaken one year after the initial British lockdown from 23 March 2020. Quotas and weighting were used to achieve a quasi-representative sample of the general population. Participants were asked about fearing a partner, which is a simple and valid screening tool to identify IPV experiences. Results In our sample (unweighted n = 6302, aged 18–59), 9.0% of women and 8.7% of men reported fearing a partner in the first year of the pandemic. Women (73.3%) were more likely than men (49.9%) to indicate that fearing a partner made them feel anxious or depressed; men were more likely to report increased substance use (30.8% vs. 18.4%) and affected work/studies (30.0% vs. 20.0%). For both women and men, fearing a partner during the first year of the pandemic was associated with established health and wellbeing outcomes like anxiety/depression, alcohol use, accessing sexual/reproductive health services, and relationship dissolution as well as feeling that the “pandemic made things worse” across various life domains. Conclusions Population-level estimates of IPV during the COVID-19 pandemic highlight harmful experiences that occurred alongside other wide-ranging hardships, and the associations presented identify key populations with potential ongoing need. We make recommendations for primary, secondary, and tertiary prevention of IPV.

BackgroundSchool-related gender-based violence (SRGBV) includes sexual, physical or psychological violence occurring in and around schools often perpetrated by teachers or peers. In this review, we focus on studies comparing how data collection methodologies affect children's disclosures of SRGBV.MethodsWe conducted a systematic review, searching nine databases for studies from high, middle and low-income countries using search terms related to violence, disclosure and data collection methodology. Records were initially screened by abstract and then full-texts were retrieved and data from eligible reports extracted. In this paper, we draw on results from this larger systematic review highlighting studies conducted with children which either collected data in schools or asked about violence in schools. We also describe methods compared and results of studies that were not conducted in schools, but that included children and young people. Finally, we describe how multi-country nationally representative surveys conducted in at least one low and middle-income country measure children's experiences of SRGBV.ResultsWe screened 28,780 records, of which fourteen are included in this article. Only four studies compared data collection methodologies in schools or about violence in schools. These showed a 0 to more than 500-percent variation in the prevalence of violence measured using different data collection methodologies. An additional ten studies which were not conducted in schools, examined disclosure of violence in children and young people that was not specifically school-related. We assessed five multi-country national surveys that measured SRGBV. This limited evidence suggests that methods allowing increased anonymity (e.g. audio computer assisted self-interview, online surveys) may result in higher disclosure of violence, including SRGBV, than face-to-face interviewing. No studies included reported on safety, experiences of young people, or the costs of different methods. Multi-country national surveys used self-completion methods if completed in schools or face-to-face interviewing if completed in households, to measure SRGBV.ConclusionEvidence on the impact of data collection method on SRGBV disclosure is limited, however current prevalence of SRGBV in international surveys used to monitor SDG progress may be underestimated due to data collection methods used. Further research on SRGBV should aim to test the effects of data collection methodology on the disclosure of violence. Efforts to improve the measurement of SRGBV is central to understanding the epidemiology, monitoring changes, and developing school and community-based programs as well as policies to prevent and respond to SRGBV.

Adolescent girls face social, psychological, and physical problems managing menstruation in schools in low-resource settings. This study aimed to evaluate the social and physical menstrual health environment of secondary schools in Wakiso and Kalungu districts, Uganda, in preparation for a subsequent menstrual health intervention trial to improve education, health and wellbeing. We conducted a qualitative rapid assessment in 75 secondary schools in Uganda. This involved conducting in-depth interviews with 150 head/senior teachers and 274 students, 26 Focus Group Discussions with students, and 13 transect walks to observe school Water, Sanitation and Hygiene (WASH) facilities between May and October 2021. Due to COVID-19 related school closures, face-to-face research activities were halted and in-depth interviews were conducted over phone and replaced focus group discussions. We employed a thematic framework analysis approach using the social-ecological model (which focuses on the complex interplay between individual, interpersonal, institutional, and societal factors) to generate themes and key concepts. Participants described the social and physical menstrual health environment of secondary schools at the individual level (knowledge gaps on menstruation before menarche, negative norms and beliefs about menstrual health); interpersonal level (limited psycho-social support, myths and misconceptions about the disposal of sanitary materials and pain relief, menstrual hygiene management (MHM) support from school nurses, peers and senior teachers); institutional level (non-implementation of Government circulars on MHM, lack of school-level guidelines policies and programs on MHM and poor WASH facilities, i.e. lack of soap, safe water and unclean toilets); and societal level (MHM programmes provided by civil society groups, health workers, and students’ school associations). The findings showed individual, societal and institutional burdens related to menstrual experiences. Multi-level evidence-based interventions aimed at improving the social and physical environment for menstrual health among school-going girls are needed.

Introduction Sexual health is essential for general health and well-being. Sexual health services for middle-aged and older adults are not prioritised and optimising available services for this population is often overlooked. Not much is known about preferences for accessing sexual health services among middle-aged and older people or level of satisfaction with current services. The aim of this study is to explore preferences for seeking sexual health services among middle-aged and older adults in the UK. This study will use discrete choice experiments (DCEs) including initial qualitative interviews followed by the survey, which have been used as a tool to explore preferences in various health service delivery. Methods and analysis The project will be carried out in two phases. First, we will conduct in-depth semi-structured interviews with 20–30 adults (aged 45+), including disabled people, and those from sexual minority groups resident in the UK. Interviews will explore indications, preferences and factors related to accessing sexual health services. Themes and subthemes emerging from the analysis of the interviews will then be used to design the choice sets and attribute level for the DCEs. For the second phase, for the DCEs, we will design choice sets composed of sexual health service delivery scenarios. The software Ngene will be used to develop the experimental design matrix for the DCE. We will use descriptive statistics to summarise the key sociodemographic characteristics of the study population. Multinomial logit, latent class and mixed logit models will be explored to assess sexual health service preferences and preference heterogeneity. Ethics and dissemination Ethical approval for both parts of this study was granted by the Research and Ethics Committee at the London School of Hygiene & Tropical Medicine. Findings from this study will be disseminated widely to relevant stakeholders via scheduled meetings, webinars, presentations and journal publications.

ObjectivesTo assess sexual behaviour, and sexual and reproductive health (SRH) outcomes, after 1 year of the COVID-19 pandemic in Britain.Methods6658 participants aged 18–59 and resident in Britain completed a cross-sectional web-panel survey (Natsal-COVID-Wave 2, March-April 2021), 1 year after the first lockdown. Natsal-COVID-2 follows the Natsal-COVID-Wave 1 survey (July-August 2020) which captured impacts in the initial months. Quota-based sampling and weighting resulted in a quasi-representative population sample. Data were contextualised with reference to the most recent probability sample population data (Natsal-3; collected 2010–12; 15 162 participants aged 16–74) and national surveillance data on recorded sexually transmitted infection (STI) testing, conceptions, and abortions in England/Wales (2010–2020). The main outcomes were: sexual behaviour; SRH service use; pregnancy, abortion and fertility management; sexual dissatisfaction, distress and difficulties.ResultsIn the year from the first lockdown, over two-thirds of participants reported one or more sexual partners (women 71.8%; men 69.9%), while fewer than 20.0% reported a new partner (women 10.4%; men 16.8%). Median occasions of sex per month was two. Compared with 2010–12 (Natsal-3), we found less sexual risk behaviour (lower reporting of multiple partners, new partners, and new condomless partners), including among younger participants and those reporting same-sex behaviour. One in 10 women reported a pregnancy; pregnancies were fewer than in 2010–12 and less likely to be scored as unplanned. 19.3% of women and 22.8% of men were distressed or worried about their sex life, significantly more than in 2010–12. Compared with surveillance trends from 2010 to 2019, we found lower than expected use of STI-related services and HIV testing, lower levels of chlamydia testing, and fewer conceptions and abortions.ConclusionsOur findings are consistent with significant changes in sexual behaviour, SRH, and service uptake in the year following the first lockdown in Britain. These data are foundational to SRH recovery and policy planning.

Objectives To investigate how differential access to key interventions to reduce STIs, HIV and their sequelae changed during the COVID-19 pandemic. Methods British participants (18–59 years) completed a cross-sectional web survey 1 year (March–April 2021) after the initial lockdown in Britain. Quota-based sampling and weighting resulted in a quasi-representative population sample. We compared Natsal-COVID data with Natsal-3, a household-based probability sample cross-sectional survey (16–74 years) conducted in 2010–2012. Reported unmet need for condoms because of the pandemic and uptake of chlamydia testing/HIV testing/cervical cancer screening were analysed among sexually experienced participants (18–44 years) (n=3869, Natsal-COVID; n=8551, Natsal-3). ORs adjusted for age and other potential confounders describe associations with demographic and behavioural factors. Results In 2021, 6.9% of women and 16.2% of men reported unmet need for condoms because of the pandemic. This was more likely among participants: aged 18–24 years, of black or black British ethnicity, and reporting same-sex sex (past 5 years) or one or more new relationships (past year). Chlamydia and HIV testing were more commonly reported by younger participants, those reporting condomless sex with new sexual partners and men reporting same-sex partners; a very similar distribution to 10 years previously (Natsal-3). However, there were differences during the pandemic, including stronger associations with chlamydia testing for men reporting same-sex partners; with HIV testing for women reporting new sexual partners and with cervical screening among smokers. Conclusions Our study suggests differential access to key primary and secondary STI/HIV prevention interventions continued during the first year of the COVID-19 pandemic. However, there was not strong evidence that differential access has changed during the pandemic when compared with 2010–2012. While the pandemic might not have exacerbated inequalities in access to primary and secondary prevention, it is clear that large inequalities persisted, typically among those at greatest STI/HIV risk.

Objectives Population-representative studies of the sexual health of middle-aged and older adults are lacking in ageing societies. This study aimed to identify latent patterns of sexual behaviours and health of people aged 45–74 years. Methods We conducted a latent class analysis of the National Attitudes and Sexual Lifestyles Survey (Natsal-3), a nationally representative survey conducted in Britain in 2011. Results Of the 5260 respondents aged 45–74 years, 48.86% of men and 44.91% of women belonged to the Content Caseys class who reported good sexual health. The Infrequent Indigos (30.94% of men, 44.38% of women) were characterised by a lack of sexual activity, reported some dissatisfaction, and were more likely to have a disability. The Low-Functioning Lees (11.65% of men, 8.41% of women) reported some more disability and had issues with sexual functioning and higher levels of distress. The Multiple-Partnered Morgans (8.62% of men, 2.30% of women) were characterised by a greater number of sexual partners and several risk behaviours. Conclusions The use of these four classes can aid in improved targeting of tailored sexual health services to improve sexual function, sexual satisfaction, reduce distress and risky behaviours among middle-aged and older adults. These services should be inclusive of the disabled community.

Collecting data to understand violence against women and children during and after the COVID-19 pandemic is essential to inform violence prevention and response efforts. Although researchers across fields have pivoted to remote rather than in-person data collection, remote research on violence against women, children and young people poses particular challenges. As a group of violence researchers, we reflect on our experiences across eight studies in six countries that we redesigned to include remote data collection methods. We found the following areas were crucial in fulfilling our commitments to participants, researchers, violence prevention and research ethics: (1) designing remote data collection in the context of strong research partnerships; (2) adapting data collection approaches; (3) developing additional safeguarding processes in the context of remote data collection during the pandemic; and (4) providing remote support for researchers. We discuss lessons learnt in each of these areas and across the research design and implementation process, and summarise key considerations for other researchers considering remote data collection on violence.

Background: Britain’s National Surveys of Sexual Attitudes and Lifestyles (Natsal) have been undertaken decennially since 1990 and provide a key data source underpinning sexual and reproductive health (SRH) policy. The COVID-19 pandemic disrupted many aspects of sexual lifestyles, triggering an urgent need for population-level data on sexual behaviour, relationships, and service use at a time when gold-standard in-person, household-based surveys with probability sampling were not feasible. We designed the Natsal-COVID study to understand the impact of COVID-19 on the nation’s SRH and assessed the sample representativeness. Methods: Natsal-COVID Wave 1 data collection was conducted four months (29/7-10/8/2020) after the announcement of Britain’s first national lockdown (23/03/2020). This was an online web-panel survey administered by survey research company, Ipsos MORI. Eligible participants were resident in Britain, aged 18-59 years, and the sample included a boost of those aged 18-29. Questions covered participants’ sexual behaviour, relationships, and SRH service use. Quotas and weighting were used to achieve a quasi-representative sample of the British general population. Participants meeting criteria of interest and agreeing to recontact were selected for qualitative follow-up interviews. Comparisons were made with contemporaneous national probability surveys and Natsal-3 (2010-12) to understand bias. Results: 6,654 participants completed the survey and 45 completed follow-up interviews. The weighted Natsal-COVID sample was similar to the general population in terms of gender, age, ethnicity, rurality, and, among sexually-active participants, numbers of sexual partners in the past year. However, the sample was more educated, contained more sexually-inexperienced people, and included more people in poorer health. Conclusions: Natsal-COVID Wave 1 rapidly collected quasi-representative population data to enable evaluation of the early population-level impact of COVID-19 and lockdown measures on SRH in Britain. Although sampling was less representative than the decennial Natsals, Natsal-COVID will complement national surveillance data and Natsal-4 (planned for 2022).