Menstrual hygiene remains a huge challenge in low-income countries and settings of great concern is girls’ absenteeism from school during their menstruation and the impact this has on their academic performance and retention in school. The goal of this research is to generate information based upon which strategies to promote menstrual hygiene and develop affordable products in particular, re-usable sanitary pads will be based.. The need is huge to address the issues girls face holistically by advocating for the provision of affordable solutions for every girl in every school as a basic right.
Definition
Menstrual hygiene (MH): Is the absorption of menstrual blood onto clean material which can be changed in privacy. It also incorporates the availability of soap and clean water, to wash re-usable sanitary materials and the body, as well as a suitable place of disposal for used materials (WHO-UNICEF 2012). MH is basic hygiene and sanitation in relation to managing the monthly flow of blood for girls or women.
Re-usable sanitary pads: Are the materials that are specifically designed to absorb menstrual blood; are washed and dried for re-using.
Introduction and Background
Menstrual hygiene remains a huge challenge in low income countries and settings. Of great concern is girls’ absenteeism from school during their menstruation and the impact this has on their academic performance and retention in school. Several researches conducted in Uganda and elsewhere highlight that reasons resulting into absenteeism include stigma, being laughed at and teased when their uniforms get stained and due to poverty and or lack of prioritization at household level, girls lack proper sanitary products and facilities to use during menstruation, hence are forced to resort to using unhygienic methods. This places them at higher risk for diseases and reproductive tract infections. Efforts to address this challenge include the introduction of re-usable sanitary pads. These are accessible at reasonably affordable prices and in some instances, girls are taught to produce their own which further enhances access. Conditions for proper use of the re-usable sanitary pads include ease of hanging them out to dry completely. This, the possible odor from damp cloth, health risks, privacy needs, ease to change pads & storage in crowded, shared facilities and other issues raise questions of acceptability and practicability of the re-usable pads in Kampala; hence this study.
Problem Statement & Rationale
Problems adequately managing menstruation have been identified in low income countries and this impacts school attendance, psychosocial wellness, routine activities. (Emily Wilson et al, 2012). Some of the most common method for managing menstruation which girls are familiar with or are taught traditionally is to use rags from old materials and blankets. ‘’Sometimes girls pick dirty rugs from the road on their way to or from school”, lamented a development worker of Africa Network for Prevention and Protection Against Child (ANPCANN, 2012). According to WoMena, 2017, 25% of girls and women in rural Uganda use traditional materials like cloth or paper or tissue, with 10% of girls under 15 years of age depending on makeshift items. Other studies show girls use cloth that is “found” in the household. Research shows these rugs and materials are seldom absorbent, quick drying, or secure; do not manage the menstrual flow hence the affected girls resort to absenting themselves from school. Research also demonstrates that in rural Uganda, and elsewhere, menstruation causes absenteeism from school; adolescent girls miss school every 3-5 days in a month. 50.2% girls reported menstruation as a cause of school absenteeism (Emily Wilson et al, 2012). While most schools have facilities such as water collection points, tanks and boreholes, some schools do even have such facilities. Furthermore, the rags used during this period are dried in secret places not visible to siblings, especially brothers and other male. This is often in the nearby bush or in their bedrooms for those with this latter facility. A notable proportion of parents and guardians are unable to provide sanitary towels to their girls and very few schools if any are able to provide sanitary towels to the girls. Over 50% of the senior women teachers confirmed that there is no provision for menstrual pads to school girls. (SNV). Of 86.8% who wanted to buy sanitary towels, 71% reported cost as a barrier to this. (Emily Wilson et al, 2012).
The need is huge to address the issues girls face holistically by advocating for the provision of affordable solutions for every girl in every school as a basic right. (Dorah Egunyu, 2014). Programme considerations when choosing which sanitary materials to support include: washing, drying, storage and disposal options, including access to water supply. (Kerry A. Millington et al, 2015). One of the interventions is to advocate for improved hygiene and the retention of girls in school focusing on provision of affordable, re-usable sanitary towels. This is in some ways supported by the study (42374, internet 2017); in which girls from the more rural schools prioritized re-usable pads as the most important solution. Further endorsement of the above is highlighted in (a bleeding shame). Caritas Lira; a local NGO taught girl in one school how to make reusable menstrual pads; a beneficiary testified; “Now I don’t get ashamed or embarrassed when I get my periods; I even attend classes during my periods and nobody notices.” Related to the aforementioned, organizations such as Afripads, make re-useable menstrual kits and SNV worked with Plan Uganda and Build Africa to teach girls and their parents how to make low-cost reusable menstrual pads out of soft cloths available in their homes. 200 SNV-supported schools have added making reusable pads into their art and craft and school health club activities. Re-usable pads are an improved, more hygienic version of cloth rags. (B-Space LTD,2014). Studies further note that East and West Uganda are covered best; hence Kampala among the less covered.
According to (Julie Hennegan et al, 2017); results found that girls rated the reusable pads positively. Girls using the reusable pads were more likely to report they were easy to change, and were not disgusting to clean. Results of the study were important in understanding girls’ preferences and experiences of menstrual absorbents in low income area: in Kamuli district, Uganda. However, despite a number of researches conducted on re-usable pads and sanitary products, there are no known studies on re-usable sanitary pads in an urban setting, hence this proposed study for urban Kampala with its peculiar urban poverty challenges, wide socio-economic and other environmental variations will add to the body of knowledge and research in the aforementioned areas. The study is essential to inform policy and programmatic decisions on menstrual hygiene products; especially re-usable sanitary pads technology.
Research Questions
- What are Kampala communities’ experiences and perceptions on menstrual hygiene and re-usable pads for school going youth?
- What are the acceptance levels for re-usable pads as an alternative to other methods of blood flow control and the reasons for this?
- Are re-usable pads affordable? What are the affordable solutions?
Goal and Objectives of the Research Project
- The goal of this research is to generate information based upon which strategies to promote menstrual hygiene and develop affordable products in particular, re-usable sanitary pads will be based. Current menstrual hygiene situation, challenges and opportunities for responsive options will be explored.
Objectives
- To assess Kampala school-going girls’ experience on menstrual hygiene.
- To assess Kampala school-going girls’ experience and perceptions on re-usable sanitary pads
- To evaluate acceptability of re-usable sanitary pads.
- 4.To identify and recommend strategies of improving access by school-going girls to affordable, safe materials for improved menstrual hygiene.
Methodology
This section describes the, scope, study population, study design, sample size, study tools and data collection methods and data management.
Scope of the Study:
The study area covers the five (5) Divisions of Kampala Capital City Authority in Central Uganda; these are Central, Kawempe, Lubaga, Makindye and Nakawa.
Study population:
The respondents of this study will be; 1). school going girls aged 13 to19 years, 2). 15 identified Key Informants (KI) from the 5 divisions purposively selected; including 10 heads of households (men, women) from households/communities especially one/two roomed houses (mizigo), crowded areas and low-income households; senior woman/man teacher; Education Officers, Health Officers, NGOs/CBOs involved in making re-usable sanitary pads, head teachers, matrons of boarding houses/schools. All interviews will be recorded.
Study Design and sampling:
This will be a cross-sectional descriptive study that will apply quantitative and qualitative research methods. Respondents for the quantitative aspects (school going girls) will be selected randomly from 10 government schools (also randomly selected). Two (2) schools; one senior secondary level, one primary level; will be selected from each of the 5 Divisions. Government schools attract pupils and students of a defined socio-economic standing.
Sampling the schools:
Two strata of primary & secondary schools will be processed.
A sampling frame of government primary schools in the 5 Divisions will be obtained and 5 primary schools selected by writing all school names on pieces of paper, folding, placing folded papers in a basket, churning and picking.
Sampling- Respondents:
In each of the 10 sampled schools, a sampling frame of girls (13 to 19 years) will be obtained and up to 40 girls randomly selected (using process described above of picking folded papers) in each school to make up the below calculated sample of 344 girls. At the sampling stage, girls will not be screened for having/not started menses as this will attract stigma. This screening will be done during the consenting; hence the bigger number of 40 from each school (instead of 34-35) will make up for those dropped out for not having started menses plus those that will not voluntarily consent to participate in the study.
Sample size determination
The sample size will be estimated using a modified Kish-Leslie formula (Leslie Kish, 1965) which is n=z2pq/d2; where
n =the desired sample size
z=standard deviation set at 1.96 which corresponds to 95% confidence interval
p=prevalence of re-usable pads 35%; girls using re-usable pads in a survey in Busoga region schools, 2014).
q= 64% girls using cloths in a survey in Busoga region schools, 2014.
d=maximum acceptable sampling error (5%)
n= 1.962 x 0.35 x 0.64 =344
0.052
That is 344 school girls.
Inclusion criteria:
Healthy school-going primary and secondary level girls aged 13 to 19 years who have already started their menses.
Exclusion criteria:
Private schools.
Data collection methods:
Data will be collected using quantitative & qualitative methods including a questionnaire,5 Focus Group Discussions (FGDs) ; 1 in each division (2 in secondary schools and 3 in primary schools) and observation; where school facilities such as the number vis a vis users, privacy & condition of the latrines, access to water and soap, distance to water in 5 schools (2 in secondary schools and 3 in primary schools) will be assessed & the facilities will be rated from 1 to 10; and 15 key informant interviews.
Study Tools:
The tools will aim to generate information that will inform strategies to promote menstrual hygiene and develop affordable products such as re-usable sanitary pads. Data collection tools for this study include a questionnaire (English), Key Informant Interview (KII) guide (English with a Luganda translation; some KIs may prefer local language), Focus group discussion guide (English) and Observation checklist (English).
Ethical considerations, data collection & analysis & quality control:
The Principal Investigator (PI) shall seek approval from respective bodies. Before the interviews are conducted, Informed and written consent will be sought from respondents on explaining to them the purpose of the study. Confidentiality will highly be emphasized.
Data Collection
Research team will be recruited and trained on the various data collection methods. The team will review the tools before pre-testing; the tools will then be pre-tested amongst a similar audience and adjusted in light of the responses obtained. During collection of primary data, de-briefing meetings will be held at the end of each day as part of quality assurance. The desk review of related literature will involve the analysis of relevant reports, research, journals, plans, newspaper articles, TV broadcasts and related documents. A meeting to synchronize the collected data will be held at the end of secondary data collection.
Data Analysis
The data collected will be synthesized in consonance with the major themes of the study and categorized according to social, demographic factors. Data collected will be coded manually and segmented according to viewpoints and analysed using appropriate computer packages such as SPSS or Atlas Ti. The data will finally be used to explain the statistical information from the questionnaire & desk review.
Quality control
Research team; will be constituted of PI, 5 Division Research Supervisors, one for each Division and 10 Research Assistants (2 per division). the PI will be in charge of coordinating the research activities.
Training of Research team: Team will be trained in a 1-day workshop to introduce them to the study protocol, study tools and techniques of data collection. Team will also participate in the translation and back translation of the KII from English to Luganda. Supervision of data collection: The PI and 5 Division supervisors will undertake quality check to ensure that the research assistants collect data according to the tools and procedures provided to minimize bias and ensure completeness. Daily checks of the tools used to ensure completeness and validity will be undertaken. Research team will hold periodic debriefing meetings to review and refine the data collection exercise. PI and Division supervisors will closely supervise the data entry process, ensure data collected is correctly entered, cleaned and analyzed and a report generated.
Dissemination Plan
Research findings will be disseminated at meetings organized in all 5 divisions for participating schools, political leaders, technocrats including Division Education Officers, Community Development Officers, policy makers, academia, civil society organizations (working in school health, girl child/youth empowerment & Adolescent Reproductive Health thematic areas), Development partners and media. Report will also be shared & disseminated through print and electronic media, social media, websites, through institutions including places of worship. Policy makers, donors and development partners will be lobbied to support interventions that translate findings into practices & strategies that promote access to affordable and practical menstrual hygiene products for improved menstrual health of school going girls.
