Discussion
Our analysis provides evidence that the provision of free menstrual products through community-based, peer-led hubs increased AGYW’s use of appropriate products to manage their menstruation, particularly among adolescent girls aged 15–19, among whom there was almost universal use (96%) of an appropriate material at last period in the Yathu Yathu arm. Despite this impact, use of an appropriate product at last menstruation was high in the control arm, with 85% of adolescents self-reporting use of an appropriate product. Almost one-third of AGYW in both arms were not always satisfied with the comfort of their menstrual materials, did not always have enough material, and did not always feel they could get more materials when needed. In the Yathu Yathu arm, the proportion who accessed menstrual products through Yathu Yathu was higher among adolescents aged 15–19 years (82%) than among 20–24-year-olds (72%). Provision of free menstrual products through easily accessible community-based spaces may be particularly valuable for supporting adolescent girls to achieve good menstrual health.The availability of free menstrual products through Yathu Yathu led to almost universal use of an appropriate menstrual product at last menstruation among adolescent girls who were aged 15–19 at the time of the Yathu Yathu census. To reduce the burden of menstruation, governments need to develop and implement policies that require free provision of appropriate menstrual products [Despite increased use of appropriate materials, we found no evidence that Yathu Yathu had an impact on comfort of and satisfaction with menstrual products; nor on having enough product or feeling able to access more product when needed. Lack of statistical evidence of impact might reflect the relatively high use of an appropriate material at last menstruation in the control zones, similar to a feasibility study in Uganda, which found high self-reported use of disposable pads among school-going adolescent girls [The majority of AGYW in the intervention arm had accessed menstrual products at least once from peer-led Yathu Yathu hubs. Our risk factor analysis found that adolescent girls aged 15–19 years were more likely to access menstrual products from the hubs than young women aged 20–24 years, with evidence of lower uptake among the relatively small number of AGYW with no or incomplete primary education. This latter finding may reflect the inverse-equity hypothesis, which posits that more educated and wealthier individuals, generally those with less need for new interventions, are initially more likely to benefit from them, thus creating greater inequities in the short term [Although not initially planned as a key Yathu Yathu service, the provision of free menstrual products proved critical to encouraging AGYW to access the hubs and to take up other SRH services. These findings are consistent with a study in Zimbabwe, in which free provision of menstrual products and analgesics through integrated SRH services was acceptable to AGYW aged 16–24, and AGYW appreciated the opportunity of accessing these products alongside SRH services [Our study has limitations. As the hubs provided menstrual products, but did not address other domains relevant to menstrual health, for example improving sanitation and disposal facilities, we limited the number of questions on menstrual health in the endline survey. We therefore included four questions on menstrual materials that we considered reflected domains that Yathu Yathu could influence. However, the MPNS36 includes 36 questions. We were therefore limited in our ability to measure met needs [Supporting AGYW to achieve menstrual health with dignity is fundamental to human rights [