Dr. Janna Schurer

Background Podoconiosis is a neglected tropical disease commonly found in volcanic regions, where soil is rich in silica. It usually manifests as bilateral lower limb edema. The majority of people affected by podoconiosis are farmers who do not wear shoes. The condition was recently documented in all 30 districts in Rwanda but knowledge, attitudes and practices (KAP) of Rwandan health professionals and environmental officers towards podoconiosis are unknown. Methodology/Findings The objective of this study was to assess the knowledge, attitudes and practices (KAP) of Rwandan health providers and environmental officers towards podoconiosis in order to improve patient healthcare experiences and health outcomes, and to reduce stigma against affected individuals. To achieve this goal, we administered a KAP assessment to physicians (N = 13), nurses/midwives (N = 59), community health workers (N = 226), and environmental officers (N = 38) in the third highest podoconiosis prevalence district in Rwanda (Musanze). All 336 respondents had heard of podoconiosis, but 147 (44%) respondents correctly identified soil as the only direct cause of podoconiosis. The awareness of signs and symptoms and risk groups was lower than any other category (31.5% and 47.5%, respectively). The overall attitude toward podoconiosis was positive (86.1%), with CHWs least likely to harbor negative beliefs against podoconiosis patients. One particular area where most respondents (76%) expressed negative attitude was that they saw people with podoconiosis as a threat to their own health and their family’s health. Prescription of antibiotics and use of ointments/soap to manage wounds was low (5% and 32.2%, respectively), in part due to supply shortages at health facilities. Conclusions This study identified clear gaps in health provider knowledge and practices that affect patient care for those with podoconiosis. Improved access to essential medicines at health facilities and podoconiosis-focused training sessions for practicing health providers are necessary to minimize the burden and stigma of affected individuals.

The Government of Rwanda reported an outbreak of Rift Valley fever (RVF) in the Eastern Province in 2018. To respond to the outbreak, vaccination and education campaigns about the disease were carried out. Because RVF cases continue to be detected in Rwanda and the disease impacts livelihoods and health, accurate knowledge and communication areimperative. The objectives of this study were to evaluate knowledge and risk perceptions of RVF transmission among livestock farmers in Nyagatare District, Eastern Province, Rwanda, and to compare RVF knowledge, risk perceptions, and farming practices between male and female livestock farmers. This cross-sectional, quantitative study was conducted in selected sectors of Nyagatare District in the Eastern Province of Rwanda in June 2019. A 34-question survey was used to ask about demographics, livestock ownership, risk percep tions about zoonotic diseases and livestock management, RVF knowledge, preferred com munication sources and information sharing strategies, and protective strategies for RVF mitigation while working with livestock. Livestock farmers were interviewed at three milk col lection centers, two village meeting points, a farm cooperative meeting, and during door-to door visits in villages. In total, 123 livestock farmers were interviewed. The survey found that most livestock farmers lacked knowledge about epizootic and zoonotic transmission of RVF, more male livestock farmers were familiar with RVF and risk mitigation strategies, and female livestock farmers are not viewed as reliable sources of information. Additionally, most livestock farmers had not vaccinated their animals against RVF despite past vaccina tion campaigns. Radio was the most popular communication channel. These findings show that RVF knowledge and information sharing are inadequate among livestock farmers in Eastern Province. Therefore, vaccination and education campaigns may need to be reeval uated within the context of these trends in order to prepare for future RVF outbreaks.

Wild canids are hosts to a wide range of parasites and can play a role in transmission of zoonoses. As many parasites are transmitted through food webs, and wild canids are at high trophic levels, parasite prevalence and diversity in wild canids can serve as excellent indicators of ecosystem health. Our main objectives were to update knowledge on the composition of gastrointestinal helminths in wild canids from Qu´ebec, Canada, and to describe differences in parasite prevalence and diversity among canid species and regions. Hunters and trappers provided whole carcasses of red foxes (Vulpes vulpes) (N = 176), and intestinal tracts of coyotes (Canis latrans) (N = 77) and gray wolves (Canis lupus) (N = 23) harvested for non-research purposes over the winter of 2016–2017. A modified Stoll’s centrifugation sucrose flotation on feces of 250 wild canids was used, and eggs of one family and eight genera of parasitic helminths were recovered: diphyllobothriids, Taenia/Echinococcus spp., Capillaria spp., Toxascaris sp., Toxocara sp., Trichuris sp., Uncinaria sp., and Metorchis sp. Adult Taenia spp. cestodes were recovered from 61 of 276 (22%) canids. Six different species (T. hydatigena, T. twitchelli, T. crassiceps, T. polyacantha, T. krabbei, and T. pisiformis-“like”) were differentiated based on DNA sequenced from 65 indi vidual adult cestodes using primers for the nicotinamide adenosine dinucleotide dehydrogenase subunit 1 (ND1) and cytochrome c oxidase subunit 1 (CO1) mitochondrial DNA loci. Alaria sp. trematodes infected 89 of 276 canids (32%). A subset were identified as A. americana at the CO1 locus. The marine trematode Cryptocotyle lingua was reported for the first time in foxes in the province of Qu´ebec. These results help us understand more fully the predator-prey relationships within this group of canids. This baseline data in regional parasite preva lence and intensity is critical in order to detect future changes following ecological disturbances due to climate and landscape alterations.

Background: Dental fuorosis is caused by prolonged exposure to excessive fuoride during the period of permanent tooth formation and is characterized by tooth discoloration, pitting, and loss of shape. Communities living near Lake Kivu in Western Rwanda exhibit a high prevalence of dental fuorosis; however, data on prevalence and risk factors are scarce. Methods: This cross sectional, quantitative study used a One Health approach to investigate dental fuorosis preva lence among people and livestock and to measure fuoride content in the environment. In 2018, oral health examina tions were conducted to assess the prevalence of fuorosis in children (aged 9 to 15 years), cattle and goats residing on Gihaya Island (Rwanda, East Africa). All children and cattle/goats meeting basic eligibility criteria (e.g., island resi dence) were invited to participate. Presence and severity of dental fuorosis was categorized according to the Dean’s Fluorosis Index. Samples of local foods, water, soil and grass were collected from communal sources and individual households and analyzed for fuoride content using standard laboratory techniques. Descriptive and binomial analy ses (Fisher Exact Test) were used to assess this dataset. Results: Overall, 186 children and 85 livestock owners (providing data of 125 livestock -23 cattle and 102 goats) participated. Dental fuorosis was recorded in 90.7% of children and 76% of livestock. Moderate to severe fuorosis was observed in 77% children while goats and cattle most often exhibited mild or absent/questionable severity, respectively. Water from Lake Kivu (used primarily for human cooking water and livestock drinking water) contained fuoride levels that were consistently higher than the maximum threshold (1.5 mg/L) recommended by the World Health Organization. Other sources (borehole and rainwater) were within safe limits. All food, soil and grass samples contained fuoride. The highest levels were observed in porridge (0.5 mg/g) and small fshes (1.05 mg/g). Conclusions: Altogether, dental fuorosis was highly prevalent among children and goats on Gihaya Island with vari ous food and water sources contributing a cumulative exposure to fuoride. An immediate and coordinated response across human, animal and water professionals is needed to reduce fuoride exposure within safe limits for island residents

Women comprise the majority of small livestock keepers,but the productivity of their livestock is constrained by limited access to vaccines that could prevent and control animal diseases. This study examined the factors driving low adoption of vaccination against Newcastle disease(NCD) and Rift Valley fever(RFV) among smallholder women farmers of Nyagatare Districtin order to identify appropriate strategies that can lead to improved livestock production. Focus group discussions and key informant interviews were used to collect data on the level of women’s participation in household decision making and their involvement atdifferent levels along the vaccine value chain (VVC) for the NCD and RVF. Data were collected from 55 chicken and goat farmers—36 of which were women—as well as representatives of chicken farmer cooperatives, sector veterinarians, agrovet shop owners, and personnel from local NGOs working on livestock production and improvement. Our results reveal that women’s ability to use livestock vaccines is constrained by cultural norms that limit theirdecisionsover productive assets and income that they can use for buying vaccines. Women are also hindered by unavailability of livestock vaccines, lack of information and knowledge about livestock vaccination,and limited access to veterinary extension services. Our results highlight a need to organize gender training targeting men and women to change the attitudes, beliefs,and behaviors that affect women’s ability to make independent decisions regarding the purchase and use of vaccines. Women also needtrainingon livestock disease management through vaccination and easy access to veterinary services. Keywords: Newcastle disease, Rift Valley fever, livestock vaccines, Rwanda, female smallholder farmer, gendered decision making

Abstract Background Snakebite envenomation (SBE) is a serious and potentially life-threatening condition that most often targets rural, subsistence-based farmers in sub-Saharan Africa. Rwanda is home to 13 venomous and medically important snake species. Those bitten are known to seek care from traditional healers and/or formal health facilities. No information is available on patient management at government health facilities. Methods This quantitative evaluation aimed to characterize knowledge, attitudes and practices related to snakebite management in Rwanda. Target respondents included physicians working at hospitals with the highest SBE caseload and medical interns. Respondents were asked to complete questionnaires on paper or online through Qualtrics. Results Overall, 105 physicians and 171 interns agreed to participate. Our findings suggest that overall knowledge scores were low for both groups (mean 49.4%, minimum–maximum 31.3–70.8%). Respondents were keen to receive SBE training but often lacked essential supplies needed to adhere to recommended guidelines for SBE management. One-third of respondents (34.8%) believed that traditional healers could manage SBE successfully and two-thirds (66.3%) felt that black stone therapy was an appropriate first aid practice. Conclusions These findings indicate a clear need for improved curricula related to SBE, enhanced supply chain management and practical mechanisms for supporting clinicians.

Background: Podoconiosis is a preventable, progressive, and non-infectious form of elephantiasis that can contribute to significant disability and economic burden when not treated early. Nurses play a critical role in early detection and response in rural Africa, but it is unclear if they receive adequate training on podoconiosis. We aimed to characterize podoconiosis instruction at all government accredited, post-secondary nursing institutions in three African countries.MethodsData for this cross-sectional study was collected through a quantitative survey with several open-answer questions. Through a rigorous online search, we identified all post-secondary institutions in Kenya, Rwanda and Uganda accredited to teach human nursing. A total of 289 accredited programs, including 85 certificate, 56 degree and 148 diploma programs were invited to participate. Respondents completed surveys online or by telephone. Measures focused on podoconiosis knowledge, perceptions of quality/quantity of podoconiosis instruction, and barriers to sufficient podoconiosis education.ResultsWe obtained information about 212 curricula across 149 nursing institutions in the three countries (participation rate: 73.4%). Podoconiosis coverage was limited across programs (certificate—24.1%; diploma—55.6%; degree—30.3%). Most respondents felt that the quality and quantity of instruction were insufficient (60.6%, 62.9%), respectively. Exclusion from government curricula, low priority and faculty lack of knowledge were commonly reported barriers to podoconiosis inclusion.ConclusionsThis study demonstrated clear gaps in podoconiosis training for nurses across the three countries and highlights a serious challenge in eliminating podoconiosis as a public health problem. Interventions to improve nurses’ knowledge could include the development and free distribution of podoconiosis teaching materials, designed for integration into pre-existing courses.

Abstract In 2018, rural residents of northern Rwanda raised water, sanitation, and hygiene (WASH) access and availability as a community concern; however, no baseline information was available to prioritize communities for intervention. This study aimed to assess WASH for people and animals in four cells in Butaro Sector and to identify the cell with the lowest WASH access. This cross-sectional, quantitative study utilized telephone surveys to collect data. Households were randomly selected, and 539 male and female heads-of-household agreed to participate. Overall, 56.8% of households reported access to safe drinking water, but this differed significantly by cell (p < 0.001). Approximately half (54.2%) of respondents walked 30 min or longer to fetch water, travelling one or more times per day. Nearly all (98.5%) households reported the presence of sanitation infrastructure, most often a pit latrine. Across cells, animals experienced poorer access to clean water and sanitation than people. One cell, Gatsibo, reported the poorest overall access to WASH services. Multi-sector collaboration among public health, water authorities, and local leaders is needed to reduce travel times for fetching water and to ensure that all residents can access sufficient safe water to meet the health and hygiene needs of people and animals.

Approximately 752 million of the world's poor keep livestock to produce food, generate income, and build assets. Women represent two-thirds (~400 million people) of low-income livestock keepers. Infectious diseases are a major issue in preventing livestock keepers from optimizing production earnings and improving food security. In Rwanda, highly contagious yet preventable diseases that affect animals that women manage, such as Rift Valley fever in goats and Newcastle disease in chickens have a high-mortality rate and can devastate their herds. Women are disproportionately affected because they bear primary responsibility for goats and chickens. These diseases are preventable through vaccination, but smallholder women farmers rarely benefit from livestock vaccines. Social norms and entrenched cultural stereotypes limit women's confidence and decision-making and restrict their access to resources and information. Women smallholder farmers find that there is little support for the small livestock they manage, because of the official preference given to cattle. They are also challenged by limited availability of livestock vaccines due to lack of a cold chain, inadequate extension, and veterinary services, especially for goats and chickens, and unreliable structures for vaccine delivery. To identify opportunities for women's engagement in the livestock vaccine value chain (LVVC) and reduce their barriers to accessing and using livestock vaccines, we used Outcome Mapping, a stakeholder engagement tool, and the Gender Equality Continuum Tool to classify and engage critical partners in the LVVC. We analyzed each critical partner's capacities, incentives, and drivers for engagement with women, challenges and barriers that hinder their support for women farmers, opportunities at systemic and programmatic levels for women's participation and benefit in the LVVC, and the gender capacities and perceptions of different stakeholders. Enhanced positioning and visibility of women in the LVVC can occur through a systemic engagement of all stakeholders, and recognition of the roles that women play. Women smallholder farmer involvement when determining and shaping the potential entry-points is critical to ensure support for their existing responsibilities in family food security, and future opportunities for generating income. Strengthening gender capacities of LVVC stakeholders, addressing identified barriers, and building on existing opportunities can increase women's participation in the LVVC.

Approximately 752 million of the world's poor keep livestock to produce food, generate income, and build assets. Women represent two-thirds (~400 million people) of low-income livestock keepers. Infectious diseases are a major issue in preventing livestock keepers from optimizing production earnings and improving food security. In Rwanda, highly contagious yet preventable diseases that affect animals that women manage, such as Rift Valley fever in goats and Newcastle disease in chickens have a high-mortality rate and can devastate their herds. Women are disproportionately affected because they bear primary responsibility for goats and chickens. These diseases are preventable through vaccination, but smallholder women farmers rarely benefit from livestock vaccines. Social norms and entrenched cultural stereotypes limit women's confidence and decision-making and restrict their access to resources and information. Women smallholder farmers find that there is little support for the small livestock they manage, because of the official preference given to cattle. They are also challenged by limited availability of livestock vaccines due to lack of a cold chain, inadequate extension, and veterinary services, especially for goats and chickens, and unreliable structures for vaccine delivery. To identify opportunities for women's engagement in the livestock vaccine value chain (LVVC) and reduce their barriers to accessing and using livestock vaccines, we used Outcome Mapping, a stakeholder engagement tool, and the Gender Equality Continuum Tool to classify and engage critical partners in the LVVC. We analyzed each critical partner's capacities, incentives, and drivers for engagement with women, challenges and barriers that hinder their support for women farmers, opportunities at systemic and programmatic levels for women's participation and benefit in the LVVC, and the gender capacities and perceptions of different stakeholders. Enhanced positioning and visibility of women in the LVVC can occur through a systemic engagement of all stakeholders, and recognition of the roles that women play. Women smallholder farmer involvement when determining and shaping the potential entry-points is critical to ensure support for their existing responsibilities in family food security, and future opportunities for generating income. Strengthening gender capacities of LVVC stakeholders, addressing identified barriers, and building on existing opportunities can increase women's participation in the LVVC.

Abstract Background Malaria is a potentially fatal disease spread by the bites of Plasmodium-infected Anopheles mosquitoes. Despite long-term efforts to control malaria in Rwanda, malaria incidence increased from 48 to 403 cases/1000 individuals between 2012 and 2016. The diagnosis and treatment of malaria occurs at multiple levels, but the costs of these activities are not well understood. This research was conducted to estimate the direct medical costs incurred by the Ministry of Health in diagnosing and treating malaria in three districts of Rwanda in 2018. Methods A cross-sectional and retrospective costing analysis was conducted in three districts that represented low (5–200 cases per 1000 individuals), moderate (> 200–400 cases per 1000 individuals), and high (> 400 cases per 1000 individuals) endemicity regions. Data on malaria cases managed at three healthcare levels (community, health centre, district hospital) was obtained from national databases. The direct medical costs of cases per malaria severity (‘simple malaria’, ‘simple malaria with minor digestive symptoms’, and ‘severe malaria’) were calculated based on the minimum package of health services provided. Total costs for each of the three districts were also calculated. Results A total of 298,381 malaria cases were recorded in Burera, Kirehe, and Southern Kayonza districts in 2018. The average unit cost per case ranged from USD 1.36 (for simple malaria at the community level) to USD 92.80 (for severe malaria with cerebral complications at district hospitals). Simple malaria cases managed at health centres and district hospitals were more than two-fold (USD 2.99–USD 3.00) and more than eight-fold (USD 12.10–USD 12.12) higher, respectively, than those managed in the community (USD 1.36). Overall, the Ministry of Health incurred USD 645,647.68 in direct medical costs related to malaria management across the three districts in 2018. Changes in disease rates from different endemicity regions and costs of anti-malarial oral medications significantly impacted the study results. Conclusion In Rwanda, severe malaria results in much higher expenses compared to other malaria types. Prompt diagnosis and appropriate treatment are crucial to prevent the progression of simple malaria to severe malaria, to reduce Ministry of Health malaria expenditures, and to reduce community transmission.

Snakebite envenomation (SBE) is a serious medical condition with human, animal, and environmental factors driving occurrence. In Rwanda, the number of SBE cases reported by the medical system is far lower than regional estimates for SBE incidence, suggesting that victims might be seeking care outside of formal medical structures. Our goals were to describe circumstances surrounding snakebite and to explore experiences of snakebite victims in accessing treatment. For this qualitative study, our team recruited individuals bitten by snakes between 2013 and 2018, who sought care either from traditional healers (N = 40) or hospitals (N = 65). In-depth interviews based on a semi-structured interview guide were conducted by telephone in Kinyarwanda. Inductive thematic analysis was conducted by two team members. Our respondents reported similar environ mental circumstances surrounding their snake encounters; namely, farm fields, roads, and their homes, as well as inadequate lighting. Unsafe First Aid practices, including burning/sucking/cutting the skin and tourniquet, were often performed immediately after bites. Respondents reported various reasons for seeking traditional or hospital care, such as perceived cost, distance, transportation, and especially, community beliefs and treatment outcomes of other victims. Respondents described envenomation of livestock as well as the sale of livestock to pay SBErelated medical expenses. Improving trust and use of formal medical services will require enhanced hospital delivery of high quality medical services for SBE through improved stocking of appropriate anti-venom and reduced delays during intake. Communities might also benefit from education campaigns that discourage unsafe First Aid practices and address the common misperception that physicians are not trained to treat SBE.

Introduction: Dental fluorosis, caused by prolonged and excessive fluoride exposure during childhood enamel formation, often leads to aesthetic changes in tooth shape, pitting and color. It is highly prevalent on Gihaya Island, Rwanda. To better understand potential fluoride sources and community impact, our research aimed to identify food and water sources consumed by island residents and to characterize social experiences of young adults impacted by dental fluorosis. Methods: All families (N=137) with children up to nine years of age were invited to complete surveys on food/water consumption. Mothers with small children and young adults were invited to participate in focus group discussions on food preparation and stigma, respectively. Results: In total, 136 families participated in the survey. High fluoride content items frequently consumed by children were drinking water from Lake Kivu, infant formula, green marog (amaranth), ugali (made of cassava flour), fish,cooked beans, and porridge (made of sorghum, millet, wheat, etc.). Focus group data identified safe water access as a major community concern and confirmed the presence of social stigma for those with dental fluorosis. This was described as negative impacts on marriage prospects, self-esteem, and social identity. The aesthetic consequences of dental fluorosis, likely caused by combined exposure to fluoride-containing foods and water, negatively impact Gihaya Island residents. Conclusion: Interventions to reduce dental fluorosis must be multi dimensional, addressing reduced access to safe water, poverty, the nutritional trade-offs of locally sourced foods, and the social consequences of this stigmatizingcondition.

Given the recent emergence of Rift Valley Fever (RVF) in Rwanda and its profound impact on livelihoods and health, improving RVF prevention and control strategies is crucial. Vaccinating livestock is one of the most sustainable strategies to mitigate the impact of RVF on health and livelihoods. However, vaccine supply chain constraints severely limit the effectiveness of vaccination programs. In the human health sector, unmanned aerial vehicles, i.e., drones, are increasingly used to improve supply chains and last-mile vaccine delivery. We investigated perceptions of whether delivering RVF vaccines by drone in Rwanda might help to overcome logistical constraints in the vaccine supply chain. We conducted semi-structured interviews with stakeholders in the animal health sector and Zipline employees in Nyagatare District in the Eastern Province of Rwanda. We used content analysis to identify key themes. We found that stakeholders in the animal health sector and Zipline employees believe that drones could improve RVF vaccination in Nyagatare. The primary benefits study participants identified included decreased transportation time, improved cold chain maintenance, and cost savings.

Background One Health approach is crucial to tackling complex global public health threats at the interface of humans, animals, and the environment. As outlined in the One Health Joint Plan of Action, the international One Health community includes stakeholders from different sectors. Supported by the Bill & Melinda Gates Foundation, an academic community for One Health action has been proposed with the aim of promoting the understanding and real-world implementation of One Health approach and contribution towards the Sustainable Development Goals for a healthy planet. Main text The proposed academic community would contribute to generating high-quality scientific evidence, distilling local experiences as well as fostering an interconnected One Health culture and mindset, among various stakeholders on different levels and in all sectors. The major scope of the community covers One Health governance, zoonotic diseases, food security, antimicrobial resistance, and climate change along with the research agenda to be developed. The academic community will be supported by two committees, including a strategic consultancy committee and a scientific steering committee, composed of influential scientists selected from the One Health information database. A workplan containing activities under six objectives is proposed to provide research support, strengthen local capacity, and enhance global participation. Conclusions The proposed academic community for One Health action is a crucial step towards enhancing communication, coordination, collaboration, and capacity building for the implementation of One Health. By bringing eminent global experts together, the academic community possesses the potential to generate scientific evidence and provide advice to local governments and international organizations, enabling the pursuit of common goals, collaborative policies, and solutions to misaligned interests.

Background: Despite the increasing focus on strengthening One Health capacity building on global level, challenges remain in devising and implementing real-world interventions particularly in the Asia-Pacific region. Recognizing these gaps, the One Health Action Commission (OHAC) was established as an academic community for One Health action with an emphasis on research agenda setting to identify actions for highest impact. Main text: This viewpoint describes the agenda of, and motivation for, the recently formed OHAC. Recognizing the urgent need for evidence to support the formulation of necessary action plans, OHAC advocates the adoption of both bottom-up and top-down approaches to identify the current gaps in combating zoonoses, antimicrobial resistance, addressing food safety, and to enhance capacity building for context-sensitive One Health implementation. Conclusions: By promoting broader engagement and connection of multidisciplinary stakeholders, OHAC envisions a collaborative global platform for the generation of innovative One Health knowledge, distilled practical experience and actionable policy advice, guided by strong ethical principles of One Health.

The Government of Rwanda recently instated a minimum menstrual hygiene management (MHM) package for all schools; however, coverage is not universal, and there remains little information on the availability or financial burden of MHM resources in rural and remote areas. This study sought to describe Rwandese secondary school girls’ perceptions and practices of MHM, their financial costs, and their access to MHM related infrastructure and products. A mixed-methods survey was conducted in three phases, namely (1) a quantitative questionnaire (2) a qualitative ‘Jar Voices’ activity, and (3) an observational Water, Sanitation and hygiene (WASH) checklist. One Lower Secondary School (LSS) of each type (private, public and government-aided) was randomly selected from each of Rwanda’s five provinces, and all LSS2 and LSS3 girls who reached menarche were invited to participate. Overall, 1,117 girls participated, including 351 (31.4%) from public schools, 543 (48.6%) from government aided schools and 223 (20.0%) from private schools. Only 35.7% of the girls correctly identified the origin of menstruation. The main source of information on menstruation was mothers. Most girls (82.5%) used single-use sanitary pads, and a small proportion (14.6%) relied on reusable cloth pads. The most identified barriers to accessing sanitary products were financial barriers. The average cost of menstrual products per cycle varied between RWF 3,100 in private schools, to RWF 4,000/4,300 in public/government-aided schools, and were covered mainly by parents. Most schools had gender-sensitive sanitation facilities, mainly pit latrines (86.7%), but only 53.3%, 33.33% and 20% provided water, soap and MHM commodities respectively. The results underscored the need for continuous menstrual education aimed at both girls and parents, and capitalizing on low-cost initiatives that can improve access to sanitary pads and WASH/sanitary facilities in schools.