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Menstrual hygiene management (MHM) challenges during changing and disposal of menstrual items are important in low income countries (LICs) where schools lack sufficient water and sanitation. Changing menstrual items in poorly maintained latrines may expose girls’ to excrement and infection. We examine the frequency of dropping menstrual items and disposal of menstrual waste by schoolgirls in a menstrual solutions feasibility study in western Kenya. Drops when changing were reported in 17 per cent (20 per cent girls <16 years;, 16.5 per cent girls 16 years plus; p=0.04) of girls’ reports overall. Differences by socio-economic status were not evident. Half (54Fifty-four per cent) of girls’ dropped at least once. A quarter of girls using pads and cups reported drops in the first few months, reducing to 10 per cent over time, compared with ~30 per cent among traditional item users. One in four accidental drops occurred at school during the study. When dropped at school, most girls reported swappeding the dropped item for a new one, but 24 per cent brushed/washed the item and reused it. While no clinical events occurred during this study, data suggest dropping within latrines could place girls’ at potential risk of exposure to infection. Disposal of used productsitems, or emptying cups, was mostly into the latrine. We conclude that accidental dropping of menstrual items while changing is common, including at school. Prevention will be helped by improving poorly constructed sanitation facilities, shelving, privacy, and staggering/increasing break-time for girls to change. Alternative disposal, such as pProvision of special garbage bins to, is suggested to prevent clogging and overflow of latrines from used menstrual itemsis recommended
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Waterlines Vol. 34 No. 4 October 2015
Menstrual hygiene management (MHM) challenges during changing and disposal of
menstrual items are important in low-income countries (LICs) where schools lack sufficient
water and sanitation. Changing in poorly maintained latrines may expose girls to excrement
and infection. We examine the frequency of dropping menstrual items and disposal of waste by
schoolgirls in a menstrual solutions feasibility study in western Kenya. Drops when changing
were reported in 17 per cent (20 per cent <16 years; 16.5 per cent 16 years plus; p=0.04) of
girls’ reports overall. Differences by socio-economic status were not evident. Fifty-four per cent
of girls dropped at least once. A quarter of girls using pads and cups reported drops in the first
few months, reducing to 10 per cent over time, compared with ~30 per cent among traditional
item users. One in four accidental drops occurred at school during the study. When dropped at
school, most girls swapped the dropped item for a new one, but 24 per cent brushed/washed the
item and reused it. While no clinical events occurred during this study, data suggest dropping
within latrines could place girls at potential risk of exposure to infection. Disposal of items, or
emptying cups, was mostly into the latrine. We conclude that accidental dropping of menstrual
items while changing is common, including at school. Prevention will be helped by improving
poorly constructed sanitation facilities, shelving, privacy, and staggering/increasing break time
for girls to change. Provision of special garbage bins to prevent clogging and overflow of latrines
is recommended.
Keywords: latrine, MHM, menstrual management disposal, accidental dropping,
schoolgirls
Schoolgirls’ experiences of changing and
disposal of menstrual hygiene items and
inferences for WASH in schools
CLIFF ODUOR, KELLY T. ALEXANDER, KELVIN
ORUKO, ELIZABETH NYOTHACH, LINDA MASON,
FRANK O. ODHIAMBO, JOHN VULULE, KAYLA F.
LASERSON, and PENELOPE A. PHILLIPS-HOWARD
Cliff Oduor (oduor.clifford@gmail.com) is data manager, Kelvin Oruko (koruko@kmtc.ac.ke) is field
coordinator, Elizabeth Nyothach (ENyothach@kemricdc.org) is project manager, Frank O. Odhiambo
(frankouma7@gmail.com) is chief of health and demographic surveillance, and John Vulule
(JVulule@kemricdc.org) is chief research officer at KEMRI/CDC Research and Public Health
Collaboration, Kisumu, Kenya. Kelly T. Alexander (kellytesh@gmail.com) is research assistant,
Linda Mason (Linda.Mason@liverpool.ac.uk) is research associate, and Penelope A.
Phillips-Howard (Penelope.Phillips-Howard@lstmed.ac.uk) is senior lecturer at Liverpool School of
Tropical Medicine, UK. Kayla F. Laserson (kel4@cdc.gov), former CDC-Kenya director, Kisumu,
is at the Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA.
© The authors, 2015, This open access article is published by Practical Action Publishing
and distributed under a Creative Commons Attribution Non-commercial No-derivatives
CC BY-NC-ND license. http://creativecommons.org/licenses/by-nc-nd/4.0/
http://dx.doi.org/10.3362/1756-3488.2015.037, ISSN: 0262-8104 (print) 1756-3488 (online)
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398 C. ODUOR ET AL.
October 2015 Waterlines Vol. 34 No. 4
ALTHOUGH THE ONSET OF MENSTRUATION is an important landmark in the transition to
adulthood, menstrual hygiene management (MHM), particularly among schoolgirls
in low-income countries (LICs), is a major concern (Sommer, 2010; Sommer and
Sahin, 2013). Women and girls have developed their own personal strategies to cope
with MHM, depending on available resources, local tradition, cultural beliefs, and
knowledge or education (Sumpter and Torondel, 2013). School-aged girls often have
to manage their menstruation with unhygienic or inconvenient methods, including
old cloths, pieces of mattress or socks, or grass (Mason et al., 2013; McMahon et al.,
2011). Use of these materials reportedly affects girls’ engagement and participation
at school due to fear of leakage and odour (Sommer, 2010; McMahon et al., 2011;
Mason et al., 2013).
Further research is required to evaluate the effects of improved MHM on girls’
schooling and health parameters (Sumpter and Torondel, 2013), and other MHM
challenges in school (Sommer and Sahin, 2013). Changing and hygienic disposal
of the menstrual items is a significant problem in LICs where schools lack suffi-
cient latrines and struggle to maintain high levels of water and sanitation hygiene
(Saboori et al., 2011; Alexander et al., 2013). A review by Sommer et al. (2013)
concluded that there is insufficient research in LICs on the interplay between
menstrual management and sanitation systems; however the knowledge that we
do have points to unmet needs for women and girls, particularly with regard to
changing or disposing of used menstrual items (Sommer et al., 2013). One study
in Uganda noted girls disposed of their pads in the latrine causing them to fill
quickly, and blocking suction pipes when latrines were emptied (Crofts and Fisher,
2012). Studies which look at the effects and impacts of menstrual solutions, such
as reusable or disposable sanitary pads (Montgomery et al., 2012), have not to date
reported issues around emptying or changing, despite this potentially being a time
of increased exposure to excrement and infection. Here we present results from
our study conducted in western Kenya, where the acceptability, use, and safety of
menstrual products were evaluated among primary schoolgirls. The data describes
patterns and challenges related to the changing and disposal of menstrual cups,
sanitary pads, and traditional items by these schoolgirls in rural western Kenya.
Methods
Study area and population
This research was conducted in Gem district, Siaya County (within part of the
former Nyanza Province), in western Kenya, as part of the Menstrual Solutions Study
(MS Study). It was nested within the KEMRI, CDC, and collaborators’ health and
demographic surveillance system (HDSS) which follows a population of ~230,000
individuals, with a typical rural African population profile (Odhiambo et al.,
2012). A rural district, Gem lies 400 km west of Nairobi. The population are mostly
members of the Luo ethnic group, mainly subsistence farmers and fisherfolk (Cohen
and Atieno-Odhiambo, 1989). The education system in Kenya consists of eight years
of primary schooling, four years of secondary and four years of university (Omwami
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CHANGING AND DISPOSAL OF MENSTRUAL ITEMS AT SCHOOL 399
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and Omwami, 2009). Around 98 per cent of children aged 6–16 years enrol into
public primary school in Nyanza Province (Mugo et al., 2012). Primary schools in
this part of western Kenya often struggle with access to a water source, sufficient or
improved latrines, and a lack of hygiene facilities (Blanton et al., 2010; Dreibelbis
et al., 2013; Migele et al., 2007).
Menstrual Solutions Study overview
The MS Study was a mixed-methods cluster randomized controlled feasibility study.
Thirty of 71 schools in the area were selected based on agreement to participate
and their achieving the minimum water, sanitation, and hygiene (WASH) criteria,
described elsewhere (Alexander et al., 2014; Mason et al., 2013; Phillips-Howard,
2013). Randomization of schools into three groups (menstrual cups, sanitary pads,
or usual practice) took place in the community, with participation of school head
teachers and district officials. Parent and pupil meetings discussed the study prior
to obtaining informed written parental consent at home and participant assent at
school. Pre-intervention, girls received puberty and hygiene education, training
on their menstrual item, and on how to use field netbooks (2goTM Convertible
Classmate PC). Girls were eligible if they were in classes 5 through (final year) 8, aged
between 14 and 16 years old, and had experienced three or more menstrual periods.
The study examined the acceptability, use, and safety of menstrual products, and
social and schooling experiences of girls followed across a full academic year. Study
nurses provided girls with the assigned menstrual items after baseline screening.
Follow-up screening ran from August 2012 to November 2013 (the end of the school
year). At each nurse screening participants received bar soap and new menstrual
calendars, and schools received detergent for making soapy water to support hand
washing. Girls in the pad and cup groups were told to continue usual practice for
disposal, according to what was available in the schools. Our pilot aimed to examine
common practice, and adding a new intervention, such as receptacles for disposal,
would have influenced this.
Quantitative data collection
Examination of schools’ WASH, including the supply of water and soap, and the
number, type, and quality of latrines, was conducted at baseline and has been presented
in detail elsewhere (Alexander et al., 2014). Pupil-latrine ratios were calculated for
each school, using the total number of pupils divided by the total number of latrines.
Data from study participants was collected in their school, at the time of screening by
research nurses who were attached to study schools. Screening took place, on average,
twice per school term. At each visit nurses performed face-to-face interviews with girls
about their menstruation, menstrual item use, and problems encountered, including
dropping and disposal, and other questions regarding illness or discomfort. Separately
girls completed a private survey answering similar questions using netbooks. Questions
were in English and translated in Duluo. Survey instruments were piloted in the target
age group as paper questionnaires prior to use to ensure comprehension. The question
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400 C. ODUOR ET AL.
October 2015 Waterlines Vol. 34 No. 4
on accidental dropping asked, ‘This recent period, did you drop your menstrual item
while changing or emptying?’. Data were downloaded weekly onto external hard
drives before transferring to the SQL server databases at the KEMRI research station.
Recognizing girls may not use items allocated, we asked them, ‘What was the main
menstrual item you used for this recent period?’.
Qualitative data collection
Focus group discussions (FGDs) were held with girls, parents, and teachers before,
during, and after the study, reported elsewhere (Mason et al., 2013, 2015). In
summary, each school was visited by field staff and a meeting held with girls
participating in the MS Study. The FGD methods were discussed, with question and
answer sessions enabling girls to understand the purpose of the FGD. Parents of
girls wishing to participate were visited at home to request approval and written
consent for their daughter to participate in a school-based FGD. Once parental
consent was received, the girls provided written assent. Following completion of
girls’ FGDs, parents of participating girls were invited to join a parent FGD, and
consented if they agreed. FGDs had a maximum of 12 participants per group, each
lasting ~1.5 hours. All discussions were held in classrooms, except one in a centrally
located church hall for parents.
MHM items
Girls in the menstrual cup group were provided with one Mooncup®, size B for
nulliparous women, or size A for those who had given birth. This brand was selected
because it has been tested internationally (Stewart et al., 2010; Oster and Thornton,
2012), and was approved by the US Food and Drug Administration, and by the
Kenyan Pharmacy and Poisons Board for pilot testing in Nairobi. When inserted into
the vagina it collects ~30 ml of menstrual blood, lasting 4–8 hours before emptying
is required, according to the manufacturer. Girls in the sanitary pad arm were each
given two packs (total 16 pads) monthly of Always®, a brand commonly available
in Kenya. Girls in the usual practice group purchased their own pads if they had
the resources, or continued using traditional items such as cloths (Mason et al.,
2013, 2015). Our study used FDA-approved and well-known brands, to minimize
any risk of unforeseen adverse events that could have been ascribed to products
with an unknown safety record. We acknowledge that such products are expensive
for purchase in most low-income communities, and other cheaper local products
may be available.
Analysis
Quantitative. Data analysed to evaluate girls’ experience of accidentally dropping
their menstrual item, and their disposal of items, such as pads, or emptying
menstrual cups is derived from girls’ reported experience. We did not use intention-
to-treat analysis (i.e. by study arm), but instead conducted analysis according to the
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CHANGING AND DISPOSAL OF MENSTRUAL ITEMS AT SCHOOL 401
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menstrual item girls reported using in their private surveys. Data were analysed in
STATA 13 (StataCorp. 2013, College Station, TX: StataCorp LP). General frequencies
and proportions were generated on variables of interest (i.e. dropping of item and
method of disposal) and comparisons made between intervention groups using
Chi-squared analysis, with 0.05 significance level. Characteristics were stratified by
age and duration since menstrual items were provided, aggregated into three-month
intervals. Age categories were collapsed into younger (below 16 years) and older
(16 years and above) girls. Duration of use of menstrual items was aggregated into
three-month categories, starting from initial provision of menstrual product to girls
by nurses. To evaluate socio-economic status (SES), we constructed five quintiles based
on asset ownership using multiple component analysis. This was then collapsed into
the poorest (lower two quintiles) and less poor (upper three quintiles).
Qualitative. Thematic analysis was conducted (Boyatzis, 1998) on transcripts
prepared from girls’ focus group discussions, as previously described (Mason et al.,
2013, 2015). Transcripts were entered in NVIVO version 10 and codes assigned
to relevant sections of the transcripts. Text assigned to the theme of water and
sanitation, and changing of menstrual items was extracted from prior analysis of
main themes (Mason et al., 2013, 2015).
Ethics
The MS Study was granted ethical approval by the Scientific and Ethical Review
Boards of the Kenya Medical Research Institute (SSC No 2198), the Institutional
Review Board of the US Centers for Disease Control and Prevention, and the Ethics
Committee of the Liverpool School of Tropical Medicine (12.11).
Results
The study enrolled 766 girls, who fulfilled the eligibility criteria, across the
30 study schools. The average pupil-latrine ratio for girls in study schools was 37:1
(range 11:1 to 70:1). The Kenyan national girls’ target ratio of 25:1 was met by
25 (40 per cent) schools (Alexander et al., 2014). The majority of latrines at school
were ventilated improved pit latrines with concrete floors, in various states of
cleanliness and structural integrity. At baseline four in five girls reported some
sanitary pad use but also improvised with cloth, bedding, socks, and other items
(Mason et al., 2013). During repeat screening from August 2012 to November 2013,
6,198 girls’ reports were completed, of which 5,771 recorded actual use of item in
most recent menstruation.
Overall reported dropping of menstrual items while changing/emptying
Of 5,771 recorded responses to the question on accidental dropping of menstrual
items when changing or emptying during their previous menstruation; there were
971 (17 per cent) reported drops. Of the 725 girls who completed the private surveys,
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October 2015 Waterlines Vol. 34 No. 4
388 (54 per cent) reported drops at least once. Overall, there was no statistically signif-
icant relationship between socio-economic status and dropping (p=0.153). Younger
girls were more likely to accidentally drop items than older girls (20 per cent among
<16 years vs. 16.5 per cent among 16 years plus; p=0.04). Frequency of drops in
most recent menstruation was inversely proportional to time since introduction of
menstrual items (Figure 1). A quarter of girls who reported actual use of cups and pads
recorded drops in the first three months after introduction. This reduced to 10 per
cent as the study progressed. This compares with around a third of girls using tradi-
tional items, which appeared to continue throughout the study. Older girls (16 years
or more) initially reported more accidental drops than younger girls, but this reversed
over time.
Dropping of menstrual items while changing/emptying at school
Among reported accidental drops, 26 per cent occurred at school over the entire
study. For pad users, 29 per cent were at school, 25 per cent for cup users, and among
traditional item users, 20 per cent of drops occurred at school. Moreover, among
reported drops, 74 per cent occurred in schools with latrine ratios greater than
25:1 for girls.
The main place at school where dropping occurred was inside the latrine pit or
on the latrine floor (Figure 2). Of the girls who dropped while at school, 40 per
cent reported they swapped the item for a new one, 24 per cent either washed or
brushed off the dirt and reused the item, 14 per cent took it home to clean before
using again, 6 per cent gave or sold it to someone, 5 per cent left it on the floor, and
11 per cent did other things (Figure 3). When we broke it down by menstrual item,
40%
30%
20%
10%
Proportion of drops
0% <3 months 3<6
months 6<9
months 9<12
months 12
months+
Cups Pads Traditional
Figure 1 Overall frequency of accidental dropping of different menstrual items, by menstrual item
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CHANGING AND DISPOSAL OF MENSTRUAL ITEMS AT SCHOOL 403
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we saw distinct behavioural differences. Cup users were most likely to brush or wash
it off then insert it, while pad users were more likely to swap the dropped pad for a
new one (Figure 4). We note that girls reported similar behaviour when items were
dropped at home.
Focus group discussion responses describe the challenges girls face while
changing menstrual items, creating situations where they are at risk of dropping
menstrual items. Most importantly, girls report insufficient time is available to
change during school break time, forcing girls to rush in and out of the latrines to
get back to class.
It is worse at school since there are fewer latrines compared to the number of
pupils, so if you either knock this or the other one someone is inside thus you
will just have to wait and if you go back to class you find the teacher already in
(P4, girl, School 5).
Girls suggested more latrines should be built but restricted to older (menstruating)
girls, as younger children take up time in the latrines and do not understand older
girls’ needs.
Into/inside the latrine
Floor of a room
Floor of latrine Outside on ground
Other
0%
20% 40% 60%80%
100%
Figure 2 Place where menstrual item is accidentally dropped at school while changing or emptying
0%
20%
Swapped for new one
Took home, or other place to
clean before using again
Left it on floor
Brushed/washed off dirt
and put in/used again
Gave/sold to someone
40% 60%80%
100%
Other
Figure 3 Girls’ reported response after dropping menstrual item while changing or emptying
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404 C. ODUOR ET AL.
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We do not get enough time because at break time is when everybody even
the children in the lower classes goes to the latrine, so when you are going to
change the pad your fellow girl might follow you then she surprises you, then
she wonders why is this girl taking too long (P8, girl, School 4).
Rushed changing, which leads to dropping or spilling of menstrual blood while
emptying the cup was seen to be further complicated by a frequent lack of locks,
reducing privacy, and requiring girls to hold the door shut with one outstretched
hand, or to rush before someone opens the door.
Do we feel comfortable when we want to change them in the school latrine?
(Moderator, School 3)
Aaa! (No!) (Chorus, all girls, School 3)
Why? (Moderator)
The doors are not lockable so you are force to hold it with your one hand so
that it closes (P6, girl, School 3).
Here in school, once you have just entered the latrine, someone is by the door,
so you will be hurrying. And maybe you were changing in school and you did
not hold the cup properly and some blood spills on the surface of the latrine
around the hole. You know, someone will start wondering, X was here! I do not
know what is wrong with her (P8, girl, School 10).
Lack of space or amenities were also blamed:
Sometimes the [water] tank is closed, sometimes you can empty it wrongly and
it pours in the wrong place in the latrine (P8, girl, School 9);
Because in the latrine sometimes when you are squatting to insert, it can slide
then it falls in the latrine, and you know when it falls in the latrine it becomes
another problem (P, girl, School 9).
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0% Left it on floor Brushed/washed
off dirt and put
in use again
Proportions of what did after drop
Took home, or other
place to clean
before using again
Gave/sold
to someone
else to use
Swapped for new
one Other
Mooncup Sanitary Traditional
Figure 4 Girls’ reported actions by intervention group
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CHANGING AND DISPOSAL OF MENSTRUAL ITEMS AT SCHOOL 405
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Parents also reported their daughter’s difficulties with changing or emptying
menstrual cups at school:
My daughter also dropped hers, she told me that hers dropped into the pit latrine
and then she reported to the madam; (talking to herself) what is her name? This
one who always teaches them? Their school nurse, but she [daughter] was lucky
she got another one (P2, parent, School 5).
Many girls mentioned that dirty latrines were off-putting, and that they would
prefer to go without changing their menstrual item. One girl reported: ‘I don’t
change pad and just go back to class since the latrines are dirty’ (P9, girl, School 5).
Delayed changing of items often caused what the girls called ‘over-staying’, or
keeping items in longer than they want to, leading to chafing, or overall discomfort
for the girls. Over-staying was mentioned in multiple FGDs by girls using pads or
traditional items (Mason et al., 2013).
Dropping of pads and traditional items such as cloths and bits of blankets was
frequently noted during FGDs, raising relevant concern for girls’ well-being and
dignity. One cup user noted: ‘and before when we had the pads on, we used to worry
that maybe the pads or cloths can fall’.
Disposal of menstrual product while changing/emptying
Disposal or emptying of menstrual flow in girls using traditional items, pads, and
menstrual cups was mostly in the latrine, with over 80 per cent reporting this method
of disposal at school. As the study continued, disposal in the latrine increased to 90
per cent of all girls. Qualitative studies highlight a lack of alternatives to disposing
in the school latrine. Teachers reported satisfaction that girls no longer threw used
items ‘carelessly’ but instead disposed of them inside the latrine:
They use the latrines to dispose them … I think they dispose them, because
so far I have not come across any that is thrown carelessly … They are taught
well, you will never meet any pads along here unlike high school (P, teacher,
School 6);
So that when they are in school, she knows when to change and where she is
going to keep it, she just don’t dispose it, and even at home she knows after
using she doesn’t dispose in the around the fence or behind the house she
knows where to dispose it, even if it is the latrine (P6, teacher, School 2).
The majority of parents considered throwing pads or cloth into the latrine to be the
best disposal solution: ‘You know in the latrine, it is not a sin to carry it going to
dispose it in the latrine’ (P2, parent, School 2). A minority considered the dumping
of cloths and rags to be a careless act: ‘You will find your cloth missing and later
when you go to the latrine, you find it dumped in the latrine, yes, they are just
carelessly thrown like that’ (P4 parent School 3).
Teachers also commented on development projects improving the quality of
latrines, recognizing menstrual needs for girls, and the problems encountered by
disposal in the latrines:
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Our school is even lucky because right now, we are building a latrine that will
contain almost the whole of it, so that we even get a changing room and a
bucket for them, because we don’t want them to fill the toilet with the pads
they have used, we are working towards that if it succeeds I believe we shall be
somewhere (P10, teacher, School 5).
Discussion
Our study indicates that over half of menstruating primary schoolgirls reported, at
some time during follow-up, to have accidentally dropped their menstrual items
while changing or emptying. Overall, 17 per cent reported they had accidentally
dropped a menstrual item while changing; a quarter of these had occurred in school.
Dropping menstrual items is a health concern, particularly for cup users or girls who
may insert traditional items, given that a quarter of girls reported when dropping
at school they either brushed or washed off the dirt and then proceeded to reuse
the item. This also suggests the limited options girls have (such as spares at school)
and their difficulty leaving the latrine without the item in situ to seek alternatives.
Schoolgirls thus need further support when dealing with changing in the latrine,
beyond educational advice (in this study provided by nurses allocated to study
schools). We note that accidental dropping fell over time among girls receiving pads
or the cup, which may have been associated with nurses counselling girls during
follow-up screening. If girls reported dropping their cup into the latrine the nurse
replaced them with a new cup, and physically checked cups each screening, to
maintain good hygiene, and minimize infection risk. The higher rate of dropping
traditional items is a worry, suggesting girls have difficulty maintaining hygiene
and further reinforcing the need for provision of menstrual products and the impor-
tance of improving latrine structure to allow girls, irrespective of menstrual item, to
change in comfort.
In this research setting no adverse events have been identified, but such findings
indicate a need for attention when developing MHM within WASH in Schools
programmes. Our data suggest that dropping of menstrual items, albeit at a
lower frequency, continues after longer-term use and despite nurse presence and
counselling of girls. It raises the need for dialogue and action on how to provide
ongoing guidance to girls on MHM, how to improve latrines to minimize such
accidents, and the need to have emergency stocks available to replace soiled items
in school. Studies investigating the physical challenges associated with changing
menstrual items at school are limited in the research literature (Sommer, 2010;
Crofts and Fisher, 2012). A study in Uganda noted girls opted to change in the latrine
because that was the only private place in school (Crofts and Fisher, 2012). Our
qualitative data provides contextual information from girls, parents, and teachers,
clearly illustrating the difficulties they face using the latrines for MHM. Figure 5 illus-
trates a typical latrine in our study schools showing how little space girls have for
changing, forcing girls to hold the item while manoeuvring to change in the narrow
space, often with little light. Provision of shelving could be a convenient addition
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CHANGING AND DISPOSAL OF MENSTRUAL ITEMS AT SCHOOL 407
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to latrines with limited space. As reported by the girls in focus group discussions,
changing is complicated by a frequent lack of locks, reducing privacy, and requiring
girls to hold the door shut with an outstretched hand, or to rush before someone
opens the door. Qualitative data demonstrated that in cup schools, girls found water
to rinse the latrines when their menstrual blood had spilled.
Our study noted that disposal of menstrual items was mostly inside the latrine.
Disposal of non-biodegradable pads such as Always® in pit latrines is a subject that
has not been sufficiently addressed in policy or research. The Kenyan National
School Health Strategy recognizes this issue stating a ‘lack of appropriate disposal
mechanism for sanitary towels in school’ (MOPHS, 2010). Studies in India have
shown that many women and girls feel uncomfortable with the options they have
for disposal, particularly that of burial or carrying used pads to the facility for burning
rubbish (Sinha and Singh, 2013; Garg et al., 2012). In the Ugandan school study,
researchers estimated that 65 per cent of girls threw their pads inside the latrine pits,
causing the latrines to fill quickly (Crofts and Fisher, 2012). The same study also
described pads blocking suction hoses when latrines were emptied by trucks. Further,
disposable pads do not biodegrade or burn easily. In addition to the challenges girls
face disposing of pads, many commercial pads contain harsh chemicals including
dioxins, a serious pollutant that builds up in the environment (WHO, 2014). Such
Figure 5 Typical school latrine in the study area
Photo credit: KEMRI-CDC Communications/KENYA 2013/Sharon Dianga
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408 C. ODUOR ET AL.
October 2015 Waterlines Vol. 34 No. 4
practical MHM issues, particularly in schools, require further exploration. How
can we provide girls with affordable materials for MHM, yet have a low impact on
the environment, and stop latrine pits filling too quickly? In addition, to reduce
dropping, school latrines need structural improvements (Sommer, 2010); however,
studies show that most rural schools in sub-Saharan Africa continue to lack or have
poorly constructed sanitation facilities without doors or locks (Sibiya and Gumbo,
2013). Provision of adequate space, shelving, locks, and easily accessible water and
soap must be a priority for the health and comfort of menstruating schoolgirls.
Inclusion of peer ‘champions’ and/or sympathetic mentors in MHM programmes
would support girls struggling with MHM in school, particularly younger, inexperi-
enced girls who have just reached menarche. While our study was based in eastern
Africa, and some MHM findings may be limited culturally, particularly on the use
of menstrual cups, we believe our results on the inadequacies of latrine structures
and girls’ difficulty changing their menstrual items are applicable across a wider
geography.
This study has a number of limitations. We recognize that any form of reporting is
likely to incur some bias from girls; however we attempted to limit social desirability
bias by using girls’ private netbook-recorded responses rather than those obtained
from face-to-face interviews with the nurses. We note girls rarely reported accidental
drops when questioned by nurses, suggesting girls fear reprisal such as physical
punishment or cup confiscation. Hygiene safety was a priority within the study;
nurses screened girls nurses screened girls’ health on a regular basis (twice a term),
physically checked girls’ cups with reminders on how to keep them clean, and a
monitoring system was established to identify any clinical febrile events to screen
for toxic shock syndrome. No clinical events were identified or recorded, including
in all health facilities within the study catchment area; however, laboratory confir-
mation studies are pending analyses and may provide additional data on hygiene
hazards.
School closures, holidays, elections, and strikes resulted in girls spending less
time at school; hence the proportion of all drops that took place in school over the
study duration under-estimates the frequency in school. While a higher proportion
of drops during the study were among girls using traditional items, the frequency
of reported drops in school was lower, suggesting possibly more ‘menstrual time’
spent in the home among these girls. We re-questioned a selection of girls at the
end of the study to confirm again whether they had understood that ‘dropping’
described accidental drops, as a separate event to ‘disposal’, and this was verified at
pilot and post-study; however, we caution that some study girls may have confused
the two events. Analysis was based on ‘per protocol’ (what girls stated they actually
used) instead of ‘intent to treat’, recognizing that girls would likely be slow to use
menstrual cups regularly (Oster and Thornton, 2012), and that some girls in control
schools (‘usual practice’) would have access to pads (Mason et al., 2013).
We acknowledge that schools with very low WASH scores were excluded from
school study selection to minimize the risk of potential contamination of menstrual
items. A study in western Kenya found that students at schools with latrines, but
lacking handwashing water, had higher levels of Escherichia coli on their hands
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CHANGING AND DISPOSAL OF MENSTRUAL ITEMS AT SCHOOL 409
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(Greene, 2012). For this reason our study attempted to provide the ‘best case
scenario’ of current WASH conditions by excluding schools with very high pupil/
latrine ratios and no access to water; and by providing study schools (and individual
girls) with soap monthly (Alexander et al., 2014). Due to these exclusions, it is
possible that higher proportions of girls in primary schools outside our study have
poorer access to water, no soap, and an insufficient number of latrines, leaving them
to struggle with the challenges of changing (or choosing not to change) and subse-
quent dropping of menstrual items while at school.
Conclusion
Accidental dropping of menstrual items while changing occurs among adolescent
schoolgirls. This could be due to poorly constructed or insufficient number of
sanitation facilities, lack of privacy, and inadequate time for girls to change. Schools
should strive to build structurally sound and menstruation-appropriate latrines in
schools. Disposal of menstrual items is mainly directly into latrine pits. Alternative
means of disposal, for example, use of special garbage bins with appropriate solid
waste management services for collection and final disposal, should be tested. In
addition, use of alternatives to disposable pads, such as menstrual cups or reusable
pads should be further explored. Findings from this study are relevant for MHM
and school WASH programme work, particularly in regions where schools have
poor or limited sanitation facilities for girls.
Acknowledgements
We thank the schools, girls, staff, and stakeholders who contributed to this study,
funded by the UK MRC/DfID/Wellcome Trust Joint Global Health Trials; Mooncups
Ltd for providing cups at a discounted price; and the Director of KEMRI for approving
the manuscript. The findings and conclusions of this report are those of the authors
and do not necessarily represent the official position of the Centers for Disease
Control and Prevention.
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... In nested studies, the menstrual and hygiene behaviours of focus were defined by the study objectives. Both Nyothach et al. [35] and Oduor et al. [36] investigated hand washing before and after changing menstrual cups as 'handwashing for menstrual hygiene' and the frequency of dropping menstrual products and subsequent cleaning or management of those products, respectively. In one nested study, [31] authors based the assessment of menstrual hygiene on a pre-existing definition developed by the Joint Monitoring Programme of the World Health Organization and UNICEF in 2012 [74] to report the prevalence of the concept and its association with other outcomes. ...
... Thus, it was unclear what the recall periods, question structures, and response options were for most studies. Five studies disclosed the self-report questions used for core practices assessed [21,30,31,35,36]. Among these, 'usual' practice was most commonly assessed, with some asking for ordinal responses ('always', 'sometimes', 'never') to characterise their practice. ...
... Among these, 'usual' practice was most commonly assessed, with some asking for ordinal responses ('always', 'sometimes', 'never') to characterise their practice. Two studies used 'this recent period' as the recall period [35,36]. ...
Article
Full-text available
Background The lack of established measurement tools in the study of menstrual health and hygiene has been a significant limitation of quantitative studies to date. However, there has been limited exploration of existing measurement to identify avenues for improvement. Methods We undertook two linked systematic reviews of (1) trials of menstrual health interventions and their nested studies in low- and middle-income countries, (2) studies developing or validating measures of menstrual experiences from any location. Systematic searching was undertaken in 12 databases, together with handsearching. We iteratively grouped and audited concepts measured across included studies and extracted and compared measures of each concept. Results A total of 23 trials, 9 nested studies and 22 measure development studies were included. Trials measured a range of outcomes including menstrual knowledge, attitudes, and practices, school absenteeism, and health. Most measure validation studies focused on assessing attitudes towards menstruation, while a group of five studies assessed the accuracy of women’s recall of their menstrual characteristics such as timing and cycle length. Measures of menstrual knowledge, attitudes, beliefs and restrictions were inconsistent and frequently overlapped. No two studies measured the same menstrual or hygiene practices, with 44 different practices assessed. This audit provides a summary of current measures and extant efforts to pilot or test their performance. Conclusions Inconsistencies in both the definition and operationalisation of concepts measured in menstrual health and hygiene research should be addressed. To improve measurement, authors should clearly define the constructs they aim to measure and outline how these were operationalised for measurement. Results of this audit indicate the need for the development and validation of new measures, and the evaluation of the performance of existing measures across contexts. In particular, the definition and measurement of menstrual practices, knowledge, attitudes, norms and restrictions should be addressed. Review protocol registration CRD42018089884.
... 9,23 A number of countries, including South Africa, Kenya, and India include free or subsidized sanitary pads for schoolgirls as part of their policy to promote MHM, raising concerns about equity in distribution nationally, sustainability, and waste disposal. [24][25][26][27][28] The menstrual cup has been evaluated as a possible alternative to sanitary pads or tampons among western women, but it is unclear if findings are transferable to girls in LMIC. 29,32 Three published studies have explored use in schoolgirls in LMIC; a quasi-experimental study among approximately 100 Nepalese girls evaluated uptake and effect on school attendance over one year, a qualitative study in Uganda evaluated girls' and women's acceptance of cup use, and an RCT evaluated feasibility among Kenyan schoolgirls. ...
... 14 In Kenya, the current randomized controlled feasibility study in schoolgirls examined water, sanitation and hygiene (WASH) in schools, qualitative feedback on acceptability of cups and pads, safety and potential infections, and inferences on potential impact on sexual and reproductive health and schooling. 4,28,[34][35][36][37] This present study utilizes data from this study, exploring girls' reported use of the cup or pad (depending on study allocation) and their perception of 'acceptability' in terms of insertion, emptying, comfort, pain and soreness when followed-up over time. ...
... This would suggest that some girls may wear a pad for up to 12 hours at a time putting them at risk of chafing, discomfort leaking and odour. 3,28 Laboratory confirmed evaluation of reproductive tract infections found girls provided with pads in our study had a higher prevalence of bacterial vaginosis compared with girls provided with cups. 4 While our study sought to provide enough pads for each individual girl's needs, they also may be obliged to share, causing extended episodes of wear 'overstaying' and soreness. 3,36 The number of pads reportedly used per day during their menses increased from 2.5 to 3.5 over the study, suggesting girls may have become more confident in keeping them for their own needs; however, we also note that overuse is also dependent on other factors such as having the facilities, time and opportunity to change. ...
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Background: Girls in low and middle-income countries (LMIC) lack access to hygienic and affordable menstrual products. We explore Kenyan schoolgirls’ use and views of the cup compared to girls provided with disposable sanitary pads for a feasibility study.Methods: Schoolgirls aged 14-16 years, received a menstrual cup in 10 schools or 16 pads/month in another10 schools. All were trained by nurses on puberty, hand washing, and product use. They self-completed a net book survey at baseline and twice a term during a year follow-up. We examined their reported ease of insertion and removal, also comfort, soreness, and pain with product use. An aggregate ‘acceptability’ score was compiled for each product and girls’ socio-demographic and menstrual characteristics were compared.Results: 195 participants received cups and 255 pads. Mean age was 14.6 years, menarchial age was 13.6 years, with an average 3.8 days menses per month. Cup use was 39% in month 1, rising to 80% by month 12 (linear trend p<0.001). Pad use rose from 85% to 92% (linear trend p=0.15). Measures of cup acceptability demonstrated girls had initial problems using the cup but reported difficulties with insertion, removal and comfort reduced over time. Girls using pads reported fewer acceptability issues. At baseline, approximately a quarter of girls in the pad arm reported inserting pads intravaginally although this was significantly lower among girls with prior experience of pad use (aRR 0.62; 0.45-0.87).Conclusions: While a smaller proportion of girls provided with cups used them in the first months compared to girls given pads, reported use was similar by study-end, and early acceptability issues reduced over time. Girls in LMIC may successfully and comfortably use cups, but require instruction, support and some persistence.
... 30 Many were concerned it could cause pain (and noted it often did so at first) or worried about reproductive harms (eg, infertility). In quantitative studies, 3% (pooled estimate: n=1251, 95% CI 1-6%, 11 studies; I 2 =79·3%) of participants 5 Nyothach et al (2015), 28 Juma et al (2017), 29 Mason et al (2015), 30 Oduor et al (2015), 31 van Eijk et al (2018) reported they could not insert the menstrual cup and 11% (n=1190, 95% CI 3-23%, ten studies; I 2 =96·4%) reported discontinuation related to the menstrual cup (table 3). Pain on insertion was reported for ten (9%) of 106 menstrual cup users versus none of 104 using their usual method at 3 months of follow-up in a South African crossover trial (p value not reported). ...
... 34,38 This finding might be corroborated by results from a randomised controlled study among schoolgirls (aged 14-16 years) in rural western Kenya that noted a significantly lower prevalence of sexually transmitted infections among participants who were provided by the study with either menstrual cups or disposable pads versus controls (ie, using usual practice), citing lower exposure to transactional sex as a probable reason (table 2; appendix p 24). 5 A study in schoolgirls in Kenya (aged 14-16 years) in an area with poor water and sanitation 76 reported dropping of menstrual products during changing of cloths or disposable pads, or emptying of the cup. 31 The frequency was similar for menstrual cups and sanitary pads. Factors involved included young age, and lack of time and privacy. ...
Article
Full-text available
Background: Girls and women need effective, safe, and affordable menstrual products. Single-use products are regularly selected by agencies for resource-poor settings; the menstrual cup is a less known alternative. We reviewed international studies on menstrual cup leakage, acceptability, and safety and explored menstrual cup availability to inform programmes. Methods: In this systematic review and meta-analysis, we searched PubMed, Cochrane Library, Web of Science, Popline, Cinahl, Global Health database, Emerald, Google Scholar, Science.gov, and WorldWideScience from database inception to May 14, 2019, for quantitative or qualitative studies published in English on experiences and leakage associated with menstrual cups, and adverse event reports. We also screened the Manufacturer and User Facility Device Experience database from the US Food and Drug Administration for events related to menstrual cups. To be eligible for inclusion, the material needed to have information on leakage, acceptability, or safety of menstrual cups. The main outcome of interest was menstrual blood leakage when using a menstrual cup. Safety outcomes of interest included serious adverse events; vaginal abrasions and effects on vaginal microflora; effects on the reproductive, digestive, or urinary tract; and safety in poor sanitary conditions. Findings were tabulated or combined by use of forest plots (random-effects meta-analysis). We also did preliminary estimates on costs and environmental savings potentially associated with cups. This systematic review is registered on PROSPERO, number CRD42016047845. Findings: Of 436 records identified, 43 studies were eligible for analysis (3319 participants). Most studies reported on vaginal cups (27 [63%] vaginal cups, five [12%] cervical cups, and 11 [25%] mixed types of cups or unknown) and 15 were from low-income and middle-income countries. 22 studies were included in qualitative or quantitative syntheses, of which only three were of moderate-to-high quality. Four studies made a direct comparison between menstrual cups and usual products for the main outcome of leakage and reported leakage was similar or lower for menstrual cups than for disposable pads or tampons (n=293). In all qualitative studies, the adoption of the menstrual cup required a familiarisation phase over several menstrual cycles and peer support improved uptake (two studies in developing countries). In 13 studies, 73% (pooled estimate: n=1144; 95% CI 59-84, I2=96%) of participants wished to continue use of the menstrual cup at study completion. Use of the menstrual cup showed no adverse effects on the vaginal flora (four studies, 507 women). We identified five women who reported severe pain or vaginal wounds, six reports of allergies or rashes, nine of urinary tract complaints (three with hydronephrosis), and five of toxic shock syndrome after use of the menstrual cup. Dislodgement of an intrauterine device was reported in 13 women who used the menstrual cup (eight in case reports, and five in one study) between 1 week and 13 months of insertion of the intrauterine device. Professional assistance to aid removal of menstrual cup was reported among 47 cervical cup users and two vaginal cup users. We identified 199 brands of menstrual cup, and availability in 99 countries with prices ranging US$0·72-46·72 (median $23·3, 145 brands). Interpretation: Our review indicates that menstrual cups are a safe option for menstruation management and are being used internationally. Good quality studies in this field are needed. Further studies are needed on cost-effectiveness and environmental effect comparing different menstrual products. Funding: UK Medical Research Council, Department for International Development, and Wellcome Trust.
... The available disposal used pads found in the school were toilets or pit latrines. The findings concur with those of Oduor, Alexande, Oruko and Nyothach (2015) in West Kenyathat disposing of used sanitary pads in toilets or latrine is because of the absence of proper disposal areas to dispose of used sanitary. They added that disposing of used sanitary pads in the latrine in secondary school increases to 90% of all adolescent girls due to improper disposal areas. ...
Article
The study aimed at examining menstrual hygiene management practices among adolescent girls in public secondary schools in Kibondo District. The study used the mixed research approach with the convergent parallel design. The study was comprised of the sample size of 99 respondents from four out of 17 schools, including ten parents, 12 female teachers, 68 students, 4 matrons, 4 Heads of schools and 1 District Education Officer. Data collection was done through semi-structured interview, focus group discussion and questionnaire. Qualitative data analysis was done through content analysis while quantitative data were analyzed descriptively with the help of the Statistical Package for Social Science (SPSS) version 20 and presented in tables through percentages, and frequencies. The study discovered that there are problems in MHM practices among public secondary schools under investigation. There were shortages of menstrual hygiene management practice facilities such as toilets and private areas to change absorbent pads, disposable mechanisms and water. The study recommended that adolescent girls should be provided with sanitary pads and education. There is need to improve MHM facilities such as water, disposable mechanisms and private rooms for changing absorbent materials for effective management of menstrual periods. Menstrual hygiene management topics should be integrated into the syllabi in order to increase awareness on MHM to adolescent girls. Teachers and health workers should closely provide guidance and health talks to adolescent girls, advising them on how to manage their menstrual-related illness effectively for their good performance in school.
... Studies have found a lack of safe and clean hygiene facilities, which leads to unsatisfactory opportunities to clean external genitalia and to change stained absorbents (8,23). The existing evidence highlights either a lack of disposal facilities for absorbents or inadequate and poorly maintained means of disposal (24,25). ...
Article
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Background: Girls and women face substantial menstrual hygiene management (MHM) challenges in low- and middle-income countries. These challenges are related to inadequate knowledge and insufficient water, sanitation, and hygiene (WASH) facilities. Currently, the literature on MHM among college-attending women in Bhutan is scarce. We aimed to explore the knowledge, attitudes, and practices (KAP) of female college students from all the 10 government colleges of Bhutan, documenting the conditions of available MHM facilities, from August to September 2018. Methods: A cross-sectional KAP survey was conducted with a random sample of female students from all years and a random sample of MHM facilities at each college and hostel. A questionnaire was adapted from a similar study conducted with school students in Bhutan. Socio-demographics, overall KAP findings, and differences in KAP between first and final year students were analyzed; college and hostel toilets were self-reported and directly observed. Results: In the survey, 1,010 participants completed the self-administered questionnaire. The comprehensive knowledge of menstruation was found to be low (35.5%) among participants. Half of the participants (50.3%) reported their mother as the source of information, and 35.1% of the participants agreed that women should not enter a shrine during menstruation. It was also reported that approximately 4% of median monthly pocket money was spent on the absorbents, and 96.9% of absorbents were wrapped before disposal. Half of the participants (55.1%) reported that their daily activities were affected due to menstruation, and 24.2% of the female students missed college due to dysmenorrhea. One-fifth of the participants (21.3%) reported unavailability of water in college, 80.1% of the participants reported absence of soap for hand washing, and 24.1% described no bins for disposal. The participants also reported that in 33.7% of hostel toilets, the door locks were missing. The direct observations also had similar findings. Conclusions: Female students living in hostels during college years lose considerable resources during their formative years of learning, such as time, energy, and money, due to issues of menstruation management. Although the overall understanding of menstruation was low, the MHM practices of our participants scored highly, and the vast majority of them asked for a platform to discuss menstruation. Despite some agreement with menstrual taboos (e.g., visiting shrine), only 5.1% of the participants were uncomfortable conversing about MHM. Improved public health knowledge, psychosocial/medical support, and WASH infrastructure with freely available menstrual products could lead to more effective MHM practices among female college students.
... Studies have found a lack of safe and clean hygiene facilities, which leads to unsatisfactory opportunities to clean external genitalia and to change stained absorbents (8,23). The existing evidence highlights either a lack of disposal facilities for absorbents or inadequate and poorly maintained means of disposal (24,25). ...
Article
Full-text available
Background: Girls and women face substantial menstrual hygiene management (MHM) challenges in low- and middle-income countries. These challenges are related to inadequate knowledge and insufficient water, sanitation, and hygiene (WASH) facilities. Currently, the literature on MHM among college-attending women in Bhutan is scarce. We aimed to explore the knowledge, attitudes, and practices (KAP) of female college students from all the 10 government colleges of Bhutan, documenting the conditions of available MHM facilities, from August to September 2018. Methods: A cross-sectional KAP survey was conducted with a random sample of female students from all years and a random sample of MHM facilities at each college and hostel. A questionnaire was adapted from a similar study conducted with school students in Bhutan. Socio-demographics, overall KAP findings, and differences in KAP between first and final year students were analyzed; college and hostel toilets were self-reported and directly observed. Results: In the survey, 1,010 participants completed the self-administered questionnaire. The comprehensive knowledge of menstruation was found to be low (35.5%) among participants. Half of the participants (50.3%) reported their mother as the source of information, and 35.1% of the participants agreed that women should not enter a shrine during menstruation. It was also reported that approximately 4% of median monthly pocket money was spent on the absorbents, and 96.9% of absorbents were wrapped before disposal. Half of the participants (55.1%) reported that their daily activities were affected due to menstruation, and 24.2% of the female students missed college due to dysmenorrhea. One-fifth of the participants (21.3%) reported unavailability of water in college, 80.1% of the participants reported absence of soap for hand washing, and 24.1% described no bins for disposal. The participants also reported that in 33.7% of hostel toilets, the door locks were missing. The direct observations also had similar findings. Conclusions: Female students living in hostels during college years lose considerable resources during their formative years of learning, such as time, energy, and money, due to issues of menstruation management. Although the overall understanding of menstruation was low, the MHM practices of our participants scored highly, and the vast majority of them asked for a platform to discuss menstruation. Despite some agreement with menstrual taboos (e.g., visiting shrine), only 5.1% of the participants were uncomfortable conversing about MHM. Improved public health knowledge, psychosocial/medical support, and WASH infrastructure with freely available menstrual products could lead to more effective MHM practices among female college students.
... To date, much of the evidence, including formative learning on how periods impact girls' experiences in schools, has been concentrated in low-and middle-income countries (LMIC) (Hennegan et al., 2019;P.A. Phillips-Howard et al., 2016;Scorgie et al., 2015;Van Eijk et al., 2016). Findings highlight a range of challenges, spanning from poor access to menstrual products, to a lack of supportive toilets for managing their periods, and insufficient menstrual health and hygiene (MHH) education; all which can negatively impact girls' health and well-being (Coast et al., 2019;Crankshaw et al., 2020;Hennegan et al., 2019;Oduor et al., 2015;P.A. Phillips-Howard et al., 2016). These issues are often exacerbated by menstrual stigma, as girls may feel anxious about potentially staining their clothing with blood or revealing odours; both which may reveal their menstruating status to others (Girod et al., 2017;Mason et al., 2013;Sivakami et al., 2019). ...
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Evidence on U.S.A. girls’ experiences with menstruation, especially in schools, remains limited. This includes learning from low-income, urban and Black, Indigenous and People of Colour (BIPOC) girls; with the latter often experiencing puberty and menarche earlier than their peers. Qualitative and participatory research methodologies were utilized with girls (15-19) and adults working with youth in three U.S.A. cities (New York City, Los Angeles, Chicago), exploring experiences of menstruation within school and family contexts. Findings revealed gaps in girls’ practical knowledge and support around menstruation, challenges with menstrual pain while in school, and the negative impact of menstruation on girls’ engagement in physical or sports-related activities. There is a need for improved guidance on the practicalities of period management and strategies to support girls with menstrual pain. Lastly, given the benefits of physical activity on girls’ health, new approaches are needed to improve their sport and physical activity experiences while menstruating.
... This paper focuses exclusively on girls' experience of the menstrual cup in the 10 schools randomly allocated to the cup group. Findings on main outcomes [5], focus group discussions [22], the laboratory confirmed safety of the cups, examining Staphylococcus aureus infection, toxic shock syndrome toxin-1, and cup contamination [24], and water, hygiene, and sanitation associated with MHM in the schools [36][37][38], have been published elsewhere. ...
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Background: A menstrual cup can be a good solution for menstrual hygiene management in economically challenged settings. As part of a pilot study we assessed uptake and maintenance of cup use among young school girls in Kenya. Methods: A total of 192 girls between 14 to 16 years were enrolled in 10 schools in Nyanza Province, Western Kenya; these schools were assigned menstrual cups as part of the cluster-randomized pilot study. Girls were provided with menstrual cups in addition to training and guidance on use, puberty education, and instructions for menstrual hygiene. During repeated individual visits with nurses, girls reported use of the menstrual cup and nurses recorded colour change of the cup. Results: Girls were able to keep their cups in good condition, with only 12 cups (6.3%) lost (dropped in toilet, lost or destroyed). Verbally reported cup use increased from 84% in the first 3 months (n = 143) to 96% after 9 months (n = 74). Colour change of the cup, as 'uptake' indicator of use, was detected in 70.8% of 192 participants, with a median time of 5 months (range 1-14 months). Uptake differed by school and was significantly higher among girls who experienced menarche within the past year (adjusted risk ratio 1.29, 95% CI 1.04-1.60), and was faster among girls enrolled in the second study year (hazard ratio 3.93, 95% CI 2.09-7.38). The kappa score comparing self-report and cup colour observation was 0.044 (p = 0.028), indicating that agreement was only slightly higher than by random chance. Conclusions: Objective evidence through cup colour change suggests school girls in rural Africa can use menstrual cups, with uptake improving with peer group education and over time. Trial registration: ISRCTN17486946 . Retrospectively registered 09 December 2014.
Chapter
Menstruation hygiene management (MHM) is an important factor in gender-sensitive sanitation promotion. MHM is a concept and an approach in international development that gained greater attention in the last decade. This chapter first reviews the development of MHM (also recently referred to as menstrual health and hygiene: MHH) as an international agenda. The second part focuses on the cultural aspects of menstruation. To illuminate the local reality and cultural context of female students in a secondary school, a case study from the Manafwa district in Uganda will be described. The research results show that seemingly simple behaviors associated with menstrual management pass through the filter of cultural norms and girls’ perceptions. Those behaviors include (1) changing menstrual absorbents, (2) using a latrine, (3) discarding used sanitary pads or other sanitary items, (4) washing menstrual items or underwear, and (5) drying them. The chapter will provide some recommendations for MHM interventions.
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Progress has been made in recent years to bring attention to the challenges faced by school-aged girls around managing menstruation in educational settings that lack adequate physical environments and social support in low- and middle-income countries. To enable more synergistic and sustained progress on addressing menstruation-related needs while in school, an effort was undertaken in 2014 to map out a vision, priorities, and a ten-year agenda for transforming girls’ experiences, referred to as Menstrual Hygiene Management in Ten (MHM in Ten). The overarching vision is that girls have the information, support, and enabling school environment for managing menstruation with dignity, safety and comfort by 2024. This requires improved research evidence and translation for impactful national level policies. As 2019 marked the midway point, we assessed progress made on the five key priorities, and remaining work to be done, through global outreach to the growing network of academics, non-governmental organizations, advocates, social entrepreneurs, United Nations agencies, donors, and national governments. This paper delineates the key insights to inform and support the growing MHM commitment globally to maximize progress to reach our vision by 2024. Corresponding to the five priorities, we found that (priority 1) the evidence base for MHM in schools has strengthened considerably, (priority 2) global guidelines for MHM in schools have yet to be created, and (priority 3) numerous evidence-based advocacy platforms have emerged to support MHM efforts. We also identified (priority 4) a growing engagement, responsibility, and ownership of MHM in schools among governments globally, and that although MHM is beginning to be integrated into country-level education systems (priority 5), resources are lacking. Overall, progress is being made against identified priorities. We provide recommendations for advancing the MHM in Ten agenda. This includes continued building of the evidence, and expanding the number of countries with national level policies and the requisite funding and capacity to truly transform schools for all students and teachers who menstruate.
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Menstrual hygiene management (MHM) is a largely overlooked issue in the water, sanitation and hygiene (WASH) sector. Every day, millions of menstruating girls and women in low-income countries struggle to find clean water for washing, private places for changing and adequate blood absorbing materials. This study aims to explore the difficulties experienced by schoolgirls in Uganda in managing menstrual hygiene and investigates the extent to which low-cost sanitary pads are part of the solution. Low-cost sanitary pads, either re-usable or disposable, are a timely, simple and innovative means of improving menstrual hygiene and of addressing a broader set of problems related to MHM in schools. Other factors highlighted are: pain relief, education, safe water provision, clean and private latrines, hygienic and secure bathing facilities, use of soap, sealed waste disposal points, private drying places, anal cleansing materials and effective facility operation and management strategies.
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Poor menstrual hygiene management (MHM) among schoolgirls in low-income countries affects girls' dignity, self-esteem, and schooling. Hygienic, effective, and sustainable menstrual products are required. A randomized controlled feasibility study was conducted among 14–16-year-old girls, in 30 primary schools in rural western Kenya, to examine acceptability, use, and safety of menstrual cups or sanitary pads. Focus group discussions (FGDs) were conducted to evaluate girls' perceptions and experiences six months after product introduction. Narratives from 10 girls' and 6 parents' FGDs were analysed thematically. Comparison, fear, and confidence were emergent themes. Initial use of cups was slow. Once comfortable, girls using cups or pads reported being free of embarrassing leakage, odour, and dislodged items compared with girls using traditional materials. School absenteeism and impaired concentration were only reported by girls using traditional materials. Girls using cups preferred them to pads. Advantages of cups and pads over traditional items provide optimism for MHM programmes [Clinical Trials Registration: ISRCTN 17486946].
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Background and objectives Menstrual hygiene is far from satisfactory among a large proportion of Indian women. To overcome the barriers for using sanitary napkins among rural women in Haryana, a social marketing scheme was launched. As the program is in nascent stage of implementation the factors influencing it need to be evaluated. Therefore, this study aimed to analyze the stakeholder's perspectives and factors influencing this scheme. Materials and methods We carried out a qualitative study during April’ 2011 in Lalpur, Naraingarh, Ambala, Northern India. The experience and opinion of rural girls, women, ANM, ASHA and Sakshar Mahila Samooh (SMS) members were elicited during 10 in-depth interviews and four FGDs. Results Majority of women were motivated to use sanitary napkins. They perceived that use of sanitary napkin was beneficial for them. The grass root workers involved in production work of sanitary napkins were disappointed with irregular flow of funds. The other stakeholders in the community were not actively involved in the implementation of this scheme. Conclusion To conclude, there is a huge marketing potential of low cost sanitary napkins in this rural area of Haryana. The program needs to actively involve various stakeholders and to ensure regular flow of fund. How to cite this article Sinha S, Singh A. Adolescent Health-Tackling Menstrual Hygiene Issue through Social Marketing of Sanitary Napkins Scheme: An Evaluation study from Haryana J Postgrad Med Edu Res 2013;47(3):127-130.
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Water, sanitation and hygiene (WASH) programs in African schools have received increased attention, particularly around the potential impact of poor menstrual OPEN ACCESS Water 2014, 6 1454 hygiene management (MHM) on equity for girls' education. This study was conducted prior to a menstrual feasibility study in rural Kenya, to examine current WASH in primary schools and the resources available for menstruating schoolgirls. Cross-sectional surveys were performed in 62 primary schools during unannounced visits. Of these, 60% had handwashing water, 13% had washing water in latrines for menstruating girls, and 2% had soap. Latrines were structurally sound and 16% were clean. Most schools (84%) had separate latrines for girls, but the majority (77%) had no lock. Non-governmental organizations (NGOs) supported WASH in 76% of schools. Schools receiving WASH interventions were more likely to have: cleaner latrines (Risk Ratio (RR) 1.5; 95% Confidence Intervals [CI] 1.0, 2.1), handwashing facilities (RR 1.6, CI 1.1, 2.5), handwashing water (RR 2.7; CI 1.4, 5.2), and water in girls' latrines (RR 4.0; CI 1.4, 11.6). Schools continue to lack essential WASH facilities for menstruating girls. While external support for school WASH interventions improved MHM quality, the impact of these contributions remains insufficient. Further support is required to meet international recommendations for healthy, gender-equitable schools.
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Keeping girls in school offers them protection against early marriage, teen pregnancy, and sexual harms, and enhances social and economic equity. Studies report menstruation exacerbates school-drop out and poor attendance, although evidence is sparse. This study qualitatively examines the menstrual experiences of young adolescent schoolgirls. The study was conducted in Siaya County in rural western Kenya. A sample of 120 girls aged 14-16 years took part in 11 focus group discussions, which were analysed thematically. The data gathered were supplemented by information from six FGDs with parents and community members. Emergent themes were: lack of preparation for menarche; maturation and sexual vulnerability; menstruation as an illness; secrecy, fear and shame of leaking; coping with inadequate alternatives; paying for pads with sex; and problems with menstrual hygiene. Girls were unprepared and demonstrated poor reproductive knowledge, but devised practical methods to cope with menstrual difficulties, often alone. Parental and school support of menstrual needs is limited, and information sparse or inaccurate. Girls' physical changes prompt boys and adults to target and brand girls as ripe for sexual activity including coercion and marriage. Girls admitted 'others' rather than themselves were absent from school during menstruation, due to physical symptoms or inadequate sanitary protection. They described difficulties engaging in class, due to fear of smelling and leakage, and subsequent teasing. Sanitary pads were valued but resource and time constraints result in prolonged use causing chafing. Improvised alternatives, including rags and grass, were prone to leak, caused soreness, and were perceived as harmful. Girls reported 'other girls' but not themselves participated in transactional sex to buy pads, and received pads from boyfriends. In the absence of parental and school support, girls cope, sometimes alone, with menarche in practical and sometimes hazardous ways. Emotional and physical support mechanisms need to be included within a package of measures to enable adolescent girls to reach their potential.
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While the sanitation sector is gaining increased recognition in policy and research, its inherent inter-linkage with menstrual hygiene management remains an under-researched subject. This review explores knowledge about menstrual beliefs and behaviors, and how women and girls currently handle their monthly menses in relation to existing sanitation systems in low-income countries. It further explores how used menstrual materials are disposed of, and the consequences of different disposal practices for the functioning of sanitation systems. Conclusions point towards the inadequacy of research in the area of menstrual management. The lack of privacy and space for changing, cleaning, drying or discarding materials, as well as insufficient availability of water for personal hygiene stand out as important areas where sanitation systems often fail to cater to the needs of menstruating girls and women. Information on proper disposal of menstrual materials as well as the actual provision of disposal facilities are important for improving menstrual management and ensuring that absorption materials do not impair the functioning of sanitation systems. Training of sanitation system designers and planners with regard to menstrual management could lead to sanitation systems becoming more inclusive of the full needs of all people.
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This cross-sectional analysis examined the influence of school and household water, sanitation, and hygiene (WASH) conditions on recent primary school absence in light of other individual, household, and school characteristics in western Kenya. School latrine cleanliness was the only school WASH factor associated with reduced odds of absence. The marginal effect of household characteristics, such as distance to water source, child involvement in water collection, and presence of a latrine, differed by gender. Demographic features were more important predictors of absence, suggesting that interventions to improve attendance must consider existing differentials attributable to gender, socio-economic status, and other household characteristics.
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