{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T18:37:37Z","timestamp":1791225457737,"version":"4.1.0"},"reference-count":55,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2025,3,4]],"date-time":"2025-03-04T00:00:00Z","timestamp":1741046400000},"content-version":"unspecified","delay-in-days":62,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000265","name":"Medical Research Council","doi-asserted-by":"publisher","award":["MR\/T04036X\/1"],"award-info":[{"award-number":["MR\/T04036X\/1"]}],"id":[{"id":"10.13039\/501100000265","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["bmjph"],"accepted":{"date-parts":[[2025,1,23]]},"published-print":{"date-parts":[[2025,1]]},"abstract":"<jats:sec>\n                  <jats:title>Introduction<\/jats:title>\n                  <jats:p>Out-of-school girls are at higher risk of sexual and reproductive health (SRH) harms. Schools provide a protective environment for adolescents and lessen their exposure to such risks. This paper explores factors associated with school dropout, sexual activity, marriage and pregnancy among out-of-school girls in western Kenya.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>Eligible adolescents were systematically recruited from area households in Siaya County. Generalised linear models were fit to obtain adjusted ORs (aOR) and 95% CIs of key covariates against individual outcomes. Factors with p values &lt;0.1 in the univariate analysis were added to a multivariable model using backward stepwise regression techniques, and factors significant at p&lt;0.05 were retained in the final adjusted models. Models were bootstrapped at 1000 replications to validate factor selection.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Of the 915 girls enrolled (mean 18.3 years, SD: 1.3), 2.1% had never attended school. Of those who started school, 34.6% dropped out during primary education. Reasons for dropout included marriage, pregnancy and needing childcare (42.5%), financial reasons (eg, lack of school fees, needing to work, 42.5%), lack of interest (5.6%), illness (3.0%), failing school (2.2%) and other factors (4.1%). Reaching menarche prior to age 13 (aOR 1.50, 95% CI 1.00 to 2.23, p=0.048), experiencing physical violence (aOR 1.48, 95% CI 1.01 to 2.17, p=0.042) or sexual partner violence (aOR 2.16, 95% CI 1.08 to 4.34, p=0.030) were associated with not completing primary school. Experiencing sexual harassment (aOR 2.20, 95% CI 1.35 to 3.58, p=0.002) or needing to engage in transactional sex (aOR 1.74, 95% CI 1.20 to 2.51, p=0.003) were associated with being sexually active. Low socioeconomic status (aOR 1.98, 95% CI 1.36 to 2.90, p&lt;0.001), having an older partner (aOR 1.65, 95% CI 1.10 to 2.47, p=0.016) and higher parity (aOR 2.56, 95% CI 1.42 to 4.62, p=0.002) were associated with being married or cohabiting with a partner. Girls identified provision of school fees and schooling items (67.9%) as the primary solution to resuming school; obtaining counselling, mentorship and support services (22.2%) for their general health; and provision of menstrual products (24.2%) for daily challenges.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Out-of-school girls in western Kenya face numerous SRH challenges related to menstruation, sexual and physical violence, and poverty. Social and financial support and interventions for school re-entry are warranted for this neglected population. National policies and multisectoral strategies to support adolescent girls\u2019 education and health should be prioritised, enforced and monitored for impact.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/bmjph-2024-001528","type":"journal-article","created":{"date-parts":[[2025,3,4]],"date-time":"2025-03-04T19:00:34Z","timestamp":1741114834000},"page":"e001528","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":7,"title":["Factors associated with school dropout and sexual and reproductive health: a cross-sectional analysis among out-of-school girls in western Kenya"],"prefix":"10.1136","volume":"3","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1154-2289","authenticated-orcid":false,"given":"Susan","family":"Nungo","sequence":"first","affiliation":[{"name":"Liverpool School of Tropical Medicine, Liverpool, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1635-1289","authenticated-orcid":false,"given":"Anna Maria","family":"van Eijk","sequence":"additional","affiliation":[{"name":"Liverpool School of Tropical Medicine, Liverpool, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1568-9261","authenticated-orcid":false,"given":"Linda","family":"Mason","sequence":"additional","affiliation":[{"name":"Liverpool School of Tropical Medicine, Liverpool, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0904-9081","authenticated-orcid":false,"given":"Elizabeth","family":"Nyothach","sequence":"additional","affiliation":[{"name":"Kenya Medical Research Institute, Nairobi, Kenya"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Benard","family":"Asuke","sequence":"additional","affiliation":[{"name":"Kenya Medical Research Institute, Nairobi, Kenya"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philip","family":"Spinhoven","sequence":"additional","affiliation":[{"name":"Leiden University, Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"Obor","sequence":"additional","affiliation":[{"name":"Safe Water and AIDS Project, Kisumu, Kenya"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christine","family":"Khaggayi","sequence":"additional","affiliation":[{"name":"Kenya Medical Research Institute, Nairobi, Kenya"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel","family":"Kwaro","sequence":"additional","affiliation":[{"name":"Kenya Medical Research Institute, Nairobi, Kenya"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1018-116X","authenticated-orcid":false,"given":"Penelope A","family":"Phillips-Howard","sequence":"additional","affiliation":[{"name":"Liverpool School of Tropical Medicine, Liverpool, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1452-6225","authenticated-orcid":false,"given":"Garazi","family":"Zulaika","sequence":"additional","affiliation":[{"name":"Liverpool School of Tropical Medicine, Liverpool, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,3,4]]},"reference":[{"key":"2025083110315753000_3.1.e001528.1","unstructured":"UNICEF . The state of the world\u2019s children 2011-executive summary: adolescence an age of opportunity. UNICEF, 2011."},{"key":"2025083110315753000_3.1.e001528.2","doi-asserted-by":"crossref","first-page":"S154","DOI":"10.1097\/QAI.0000000000000178","article-title":"Effective approaches for programming to reduce adolescent vulnerability to HIV infection, HIV risk, and HIV-related morbidity and mortality: a systematic review of systematic reviews","volume":"66","author":"Mavedzenge","year":"2014","journal-title":"J Acquir Immune Defic Syndr"},{"key":"2025083110315753000_3.1.e001528.3","doi-asserted-by":"publisher","DOI":"10.1037\/0022-006X.63.1.154"},{"key":"2025083110315753000_3.1.e001528.4","doi-asserted-by":"publisher","DOI":"10.1136\/sti.2006.022590"},{"key":"2025083110315753000_3.1.e001528.5","unstructured":"Otieno M . Gender-based violence in primary schools: Kenya. 2020."},{"key":"2025083110315753000_3.1.e001528.6","unstructured":"Together for girls . Kenya: school-related gender-based violence fact sheet. 2020. Available: https:\/\/www.togetherforgirls.org\/en\/resources\/kenya-school-related-gender-based-violence"},{"key":"2025083110315753000_3.1.e001528.7","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2012-2172"},{"key":"2025083110315753000_3.1.e001528.8","doi-asserted-by":"publisher","DOI":"10.1177\/0044118X02033004002"},{"key":"2025083110315753000_3.1.e001528.9","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1007\/s12310-012-9073-1","article-title":"Relationships Between Perceived School Climate and Adolescent Mental Health Across Genders","volume":"4","author":"Suldo","year":"2012","journal-title":"School Ment Health"},{"key":"2025083110315753000_3.1.e001528.10","doi-asserted-by":"crossref","unstructured":"Wodon Q , Montenegro CE , Nguyen H , et al . Missed oportunities: the high cost of not educating girls. 2018.","DOI":"10.1596\/29956"},{"key":"2025083110315753000_3.1.e001528.11","doi-asserted-by":"crossref","unstructured":"Lloyd CB , Young J . New lessons: the power of educating adolescent girls\u2014a girls count report on adolescent girls. 2009.","DOI":"10.31899\/pgy17.1011"},{"key":"2025083110315753000_3.1.e001528.12","unstructured":"Argaw BA . The effect of female education on health knowledge and fertility behavior: evidence from primary schooling reform in Ethiopia. Working paper. 2013."},{"key":"2025083110315753000_3.1.e001528.13","doi-asserted-by":"publisher","DOI":"10.1016\/j.ehb.2007.03.005"},{"key":"2025083110315753000_3.1.e001528.14","doi-asserted-by":"crossref","first-page":"e470","DOI":"10.1016\/S2214-109X(15)00087-X","article-title":"Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment","volume":"3","author":"De Neve","year":"2015","journal-title":"Lancet Glob Health"},{"key":"2025083110315753000_3.1.e001528.15","doi-asserted-by":"crossref","first-page":"158","DOI":"10.2989\/16085906.2021.1918733","article-title":"Effectiveness of the Sista2Sista programme in improving HIV and other sexual and reproductive health outcomes among vulnerable adolescent girls and young women in Zimbabwe","volume":"20","author":"Oberth","year":"2021","journal-title":"Afr J AIDS Res"},{"key":"2025083110315753000_3.1.e001528.16","unstructured":"UNESCO . New estimation confirms out-of-school population is growing in Sub-Saharan Africa. Factsheet 2022;62(policy paper 48):1-0. 2022."},{"key":"2025083110315753000_3.1.e001528.17","doi-asserted-by":"crossref","unstructured":"Inoue K , Gropello E , Taylor YS , et al . Out-of-school youth in Sub-Saharan Africa: a policy perspective. World Bank Publications, 2015.","DOI":"10.1596\/978-1-4648-0505-9"},{"key":"2025083110315753000_3.1.e001528.18","unstructured":"UNESCO . Leaving no one behind: how far on the way to universal primary and secondary education. Policy paper 27\/fact sheet. 2016.37."},{"key":"2025083110315753000_3.1.e001528.19","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2016-013229","article-title":"Menstrual cups and sanitary pads to reduce school attrition, and sexually transmitted and reproductive tract infections: a cluster randomised controlled feasibility study in rural Western Kenya","volume":"6","author":"Phillips-Howard","year":"2016","journal-title":"BMJ Open"},{"key":"2025083110315753000_3.1.e001528.20","doi-asserted-by":"crossref","DOI":"10.1016\/j.eclinm.2023.102261","article-title":"Menstrual cups and cash transfer to reduce sexual and reproductive harm and school dropout in adolescent schoolgirls in western Kenya: a cluster randomised controlled trial","volume":"65","author":"Zulaika","year":"2023","journal-title":"EClinicalMedicine"},{"key":"2025083110315753000_3.1.e001528.21","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0262858","article-title":"Impacts of multisectoral cash plus programs after four years in an urban informal settlement: Adolescent Girls Initiative-Kenya (AGI-K) randomized trial","volume":"17","author":"Kangwana","year":"2022","journal-title":"PLoS One"},{"key":"2025083110315753000_3.1.e001528.22","doi-asserted-by":"crossref","first-page":"943","DOI":"10.1007\/s11121-017-0817-x","article-title":"A School Support Intervention and Educational Outcomes Among Orphaned Adolescents: Results of a Cluster Randomized Controlled Trial in Kenya","volume":"18","author":"Cho","year":"2017","journal-title":"Prev Sci"},{"key":"2025083110315753000_3.1.e001528.23","doi-asserted-by":"publisher","DOI":"10.1186\/s12978-021-01223-7"},{"key":"2025083110315753000_3.1.e001528.24","unstructured":"The basic education act, 2013. no.14 of 2013 of the constitution of Kenya. 2013."},{"key":"2025083110315753000_3.1.e001528.25","unstructured":"UNESCO . Launch of the UNESCO 2021 Kenya national study report on out of school children. 2021."},{"key":"2025083110315753000_3.1.e001528.26","unstructured":"Kenyan Ministry of Education M . National education sector strategic plan: 2023-2027. Government of Kenya; 2024."},{"key":"2025083110315753000_3.1.e001528.27","unstructured":"National Syndemic Diseases Control Council N . A commitment plan to end the \u2018Triple threat, 2023-2030. Government of Kenya; 2024."},{"key":"2025083110315753000_3.1.e001528.28","unstructured":"2015 Kenya national adolescents and youth survey (NAYS). Siaya County National Council for Population and Development (NCPD); 2017."},{"key":"2025083110315753000_3.1.e001528.29","unstructured":"KNBS and ICF . Kenya demographic and health survey 2022: volume 1. Nairobi, Kenya and Rockville, Maryland, USA KNBS and ICF; 2023."},{"key":"2025083110315753000_3.1.e001528.30","unstructured":"Norich Muindi Munyasia JO . Quality CBC education in Kenya by 2030: projecting enrolment in primary and secondary schools in Siaya county. 2020."},{"key":"2025083110315753000_3.1.e001528.31","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0178884","article-title":"Early menarche: A systematic review of its effect on sexual and reproductive health in low- and middle-income countries","volume":"12","author":"Ibitoye","year":"2017","journal-title":"PLoS One"},{"key":"2025083110315753000_3.1.e001528.32","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0079132","article-title":"We keep it secret so no one should know\u2019--a qualitative study to explore young schoolgirls attitudes and experiences with menstruation in rural western Kenya","volume":"8","author":"Mason","year":"2013","journal-title":"PLoS One"},{"key":"2025083110315753000_3.1.e001528.33","doi-asserted-by":"publisher","DOI":"10.1016\/j.adolescence.2009.03.008"},{"key":"2025083110315753000_3.1.e001528.34","doi-asserted-by":"publisher","DOI":"10.1186\/1472-698X-11-1"},{"key":"2025083110315753000_3.1.e001528.35","doi-asserted-by":"crossref","unstructured":"Benshaul-Tolonen A , Zulaika G , Sommer M , et al . Measuring menstruation-related absenteeism among adolescents in low-income countries. In: The Palgrave handbook of critical menstruation studies. 2020: 705\u201323.","DOI":"10.1007\/978-981-15-0614-7_52"},{"key":"2025083110315753000_3.1.e001528.36","doi-asserted-by":"crossref","first-page":"3277","DOI":"10.18203\/2320-1770.ijrcog20213440","article-title":"Pregnancy and marriage among teenage schoolgirls in rural western Kenya; a secondary analysis of a menstrual solution feasibility COHORT study","volume":"10","author":"Nyothach","year":"2021","journal-title":"Int J Reprod Contracept Obstet Gynecol"},{"key":"2025083110315753000_3.1.e001528.37","unstructured":"Birchall J . Early marriage, pregnancy and girl child school dropout. Knowledge, evidence and learning for development. 2018."},{"key":"2025083110315753000_3.1.e001528.38","first-page":"72","article-title":"Early and Forced Child Marriage on Girls\u2019 Education","volume":"5","author":"Ganira","year":"2015","journal-title":"World J Educ"},{"key":"2025083110315753000_3.1.e001528.39","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1007\/s11125-016-9379-0","article-title":"Addressing child marriage and adolescent pregnancy as barriers to gender parity and equality in education","volume":"46","author":"Psaki","year":"2016","journal-title":"Prospects"},{"key":"2025083110315753000_3.1.e001528.40","doi-asserted-by":"crossref","unstructured":"Zulaika G , Kwaro D , Nyothach E , et al . Menstrual cups and cash transfer to reduce sexual and reproductive harm and school dropout in adolescent schoolgirls: study protocol of a cluster-randomised controlled trial in western Kenya. BMC Public Health 2019;19. doi:10.1186\/s12889-019-7594-3","DOI":"10.1186\/s12889-019-7594-3"},{"key":"2025083110315753000_3.1.e001528.41","doi-asserted-by":"crossref","first-page":"277","DOI":"10.20473\/jn.v14i3.17019","article-title":"Trends of Early Marriage in Developing Countries: A Systematic Review","volume":"14","author":"Suhariyati","year":"2019","journal-title":"J Ners"},{"key":"2025083110315753000_3.1.e001528.42","doi-asserted-by":"crossref","first-page":"705","DOI":"10.1007\/s10896-023-00520-y","article-title":"Path Analysis of Adverse Childhood Experiences, Early Marriage, Early Pregnancy, and Exposure to Intimate Partner Violence Among Young Women in Honduras","volume":"39","author":"Huber-Krum","year":"2024","journal-title":"J Fam Viol"},{"key":"2025083110315753000_3.1.e001528.43","first-page":"35","article-title":"Early Marriage: A Gender\u2013Based Violence and A Violation of Women\u2019s Human Rights in Nigeria","volume":"7","author":"Nnadi","year":"2014","journal-title":"JPL"},{"key":"2025083110315753000_3.1.e001528.44","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1003756","article-title":"Factors associated with the prevalence of HIV, HSV-2, pregnancy, and reported sexual activity among adolescent girls in rural western Kenya: A cross-sectional analysis of baseline data in a cluster randomized controlled trial","volume":"18","author":"Zulaika","year":"2021","journal-title":"PLoS Med"},{"key":"2025083110315753000_3.1.e001528.45","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1111\/sifp.12100","article-title":"'When He Asks for Sex, You Will Never Refuse': Transactional Sex and Adolescent Pregnancy in Zambia","volume":"50","author":"Austrian","year":"2019","journal-title":"Stud Fam Plann"},{"key":"2025083110315753000_3.1.e001528.46","first-page":"773","article-title":"Experiences of pregnancy and motherhood among teenage mothers in a suburb of Accra, Ghana: a qualitative study","volume":"5","author":"Gyesaw","year":"2013","journal-title":"Int J Womens Health"},{"key":"2025083110315753000_3.1.e001528.47","unstructured":"UNESCO . Opportunities lost: the impact of grade repetition and early school leaving. 2012."},{"key":"2025083110315753000_3.1.e001528.48","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijedudev.2016.10.004"},{"key":"2025083110315753000_3.1.e001528.49","unstructured":"Ndaruhutse S . Grade repetition in primary schools in Sub-Saharan Africa: an evidence base for change. 2008."},{"key":"2025083110315753000_3.1.e001528.50","unstructured":"Osoro LB . The effect of overage learning on guidance and counseling programs in selected public primary schools; the case of Langata sub-county (doctoral dissertation). Nairobi County, University of Nairobi, 2015"},{"key":"2025083110315753000_3.1.e001528.51","doi-asserted-by":"crossref","first-page":"36","DOI":"10.18546\/IJSD.01.1.08","article-title":"The challenge of overage children in two South African primary schools","volume":"1","author":"Ntombela","year":"2003","journal-title":"Int J School Disaffect"},{"key":"2025083110315753000_3.1.e001528.52","unstructured":"Henry PC . Overage students in the classroom: teachers lived experiences: doctoral dissertation. Walden University, 2008"},{"key":"2025083110315753000_3.1.e001528.53","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1007\/s40609-017-0102-8","article-title":"Adolescent Pregnancy and Challenges in Kenyan Context: Perspectives from Multiple Community Stakeholders","volume":"5","author":"Kumar","year":"2018","journal-title":"Glob Soc Welf"},{"key":"2025083110315753000_3.1.e001528.54","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0307532","article-title":"Poverty, childcare responsibilities, and stigma hinder adolescent mothers from returning to school in a low-income urban informal settlement in Kenya","volume":"19","author":"Mukabana","year":"2024","journal-title":"PLoS One"},{"key":"2025083110315753000_3.1.e001528.55","doi-asserted-by":"crossref","DOI":"10.3389\/fpubh.2024.1440930","article-title":"Interventions aiming to improve menstrual, sexual, reproductive, and mental health among out-of-school girls: a systematic review","volume":"12","author":"Farquharson","year":"2024","journal-title":"Front Public Health"}],"container-title":["BMJ Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjph-2024-001528","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,31]],"date-time":"2025-08-31T17:32:09Z","timestamp":1756661529000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjpublichealth.bmj.com\/lookup\/doi\/10.1136\/bmjph-2024-001528"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,1]]},"references-count":55,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,3,4]]},"published-print":{"date-parts":[[2025,1]]}},"alternative-id":["10.1136\/bmjph-2024-001528"],"URL":"https:\/\/doi.org\/10.1136\/bmjph-2024-001528","relation":{},"ISSN":["2753-4294"],"issn-type":[{"value":"2753-4294","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,1]]}}}