Menstrual hygiene remains a taboo in many settings, with poor knowledge and misconceptions as great a challenge as access to adequate facilities. In recent years, a solid body of evidence has revealed the discriminatory nature of many school environments, with menstruating girls unable to adequately manage their monthly menses with safety, dignity and privacy. Further compounding the problem is the lack of a positive enabling at all levels, from national policies to local school regulations. In recognition of the positive impact on girls’ education, initiatives around the world are addressing adolescent girls’ menstrual hygiene management (MHM) needs in coordination with ongoing efforts to improve water, sanitation and hygiene (WASH) facilities and knowledge gaps.
Since March 2014 the Canadian Department of Foreign Affairs, Trade and Development (DFATD) has been funding the project ‘WASH in Schools for Girls: Advocacy and Capacity Building for MHM through WASH in Schools Programmes’ (also known as the Wins4Girls Programme). Phase I involved the development and delivery of a web-based course to strengthen capacity of national research partners, WASH practitioners and policymakers to carry out rigorous research on MHM. Participants from 14 countries (Afghanistan, Bolivia, Burkina Faso, Eritrea, Ghana, India, Indonesia, Kyrgyzstan, Mongolia, Nepal, Niger, Nigeria, Pakistan and Zambia) took part in the WinS for Girls E-Course. Each of the 14 countries is currently conducting MHM research in schools. The results will inform the development of interventions to improve WinS for Girls.
To document the successes, challenges and lessons learned during the research undertaken in Indonesia, Jeff Sinden (UNICEF Consultant) spoke with Aidan Cronin (WASH Chief) and Claire Quillet (WASH Specialist) from UNICEF’s Indonesia Country Office.
What was the focus of the WinS4Girls research in your country? Why was this focus chosen?
Studies in other countries have shown that poor access to information, appropriate materials for managing menstruation, WASH facilities, and socio-cultural beliefs and restrictions contribute to school absenteeism, stigma and potential health risks. While we knew about the scale of the problem in Indonesia – with one quarter of girls not even having discussed menstruation with anyone before their first menses – prior to the research we had limited information on MHM in the country, particularly among adolescent girls. As a result of this knowledge gap, the determinants and impacts of MHM are not well understood and the evidence-base for programming and interventions is weak.
To help bridge the gap, UNICEF Indonesia commissioned a study to explore current MHM practices, determinants and impacts among school-going adolescent girls. The long-term objective is to use the research findings to inform evidence-based interventions and policies to improve WinS for Girls, thereby contributing to improved health and education outcomes.
How was the research conducted?
The research was conducted by the Burnet Institute, an Australia-based agency, in partnership with SurveyMeter, WaterAid Australia and a local youth network. The team conducted a school-based mixed-methods study across four provinces: Papua, East Java, South Sulawesi and Nusa Tenggara Timur (NTT). Sixteen urban and rural public secondary schools were randomly selected from these provinces.
Adolescent girls 12 to 19 years of age were asked to complete a semi-structured questionnaire to quantify knowledge and attitudes, practices and self-reported health, education and social impacts related to menstruation. Adolescent girls were also invited to participate in focus group discussions; girls who had experienced their first period were also recruited to participate in in-depth interviews.
At each school, the school principal, or a representative nominated by them, completed a semi-structured interview and participated in the completion of the school observation checklist to assess current water, sanitation, disposal and hygiene facilities. Adolescent boys, mothers and health workers also participated in group discussion and interviews. Overall, more than 1,400 participants were involved in the research.
What were the major findings? Did any of the findings surprise you?
The study identified a number of challenges that impact girls’ ability to manage menstruation hygienically and with dignity in schools. Not surprisingly, insufficient knowledge about menstruation, the menstrual cycle and MHM result in lack of preparation for menarche, misconceptions about disposal of soiled absorbent materials, and inadequate understanding about how to manage menstruation safely at school. Prior to the research, we knew about a range of common misconceptions, such as the idea that menstruating girls should not wash their hair or eat a range of foods (see text box). More surprisingly, nearly all girls described a need to wash soiled disposable sanitary pads prior to disposal, a practice that is unnecessary and uncommon in other countries, requiring girls to spend time fetching scarce water. As 99 per cent of girls use disposal pads, this belief, together with the fact that the majority of schools do not provide adequate water or private spaces for such practices, means that girls are unable to dispose of absorbent materials discretely. A belief that burning menstrual materials is harmful also contributes to girls’ reluctance to change and dispose of pads at school.
Inadequate WASH facilities at school also present challenges for menstruating girls. In addition to insufficient water for washing, small unclean latrines and lack of privacy further reinforce the reluctance to change pads at school. As a result, girls often resort to returning home to change absorbent materials or to wearing soiled materials for up to eight hours, leading to genital itching, leakage and staining of clothes.
These factors contribute to significant consequences such as reduced participation and performance at school, school absenteeism and potential health risks. For instance, one in seven girls reported missing one or more days of school during their last menstruation.
What recommendations resulted from the research?
First, we need to improve access to and quality of education about menstruation and menstrual hygiene in Indonesia. Girls need to be provided with comprehensive and accurate information that addresses misconceptions and provides practical advice for managing menstruation hygienically. The report recommends strengthened coordination between the Ministry of Health and the Ministry of Education and Culture to improve the provision of menstruation education through the school curriculum and extra-curricular activities.
Second, we need to improve access to free or affordable pads in schools, either through the school canteen or health rooms. Girls should be consulted to identify preferred brands and products, method of dispensing pads, and affordability.
Third, greater coordination is required between the government and the national WASH working group to ensure schools have sufficient, appropriate and functional WASH facilities that support safe, discrete and acceptable MHM. This includes improving existing facilities to meet the needs of menstruating girls and consideration of MHM when designing and building new facilities. For instance, girls’ latrines should be located in a discrete place, away from the boys’ latrines, and include privacy walls to allow for discrete entry and exit. It is also important that latrines have sufficient light and hooks to hang clothes while changing. Finally, schools need to ensure the availability of soap.
What activities will UNICEF Indonesia implement to support the recommendations?
UNICEF’s WASH programme in Indonesia is not about service delivery; we are not directly building toilets or providing sanitary pads. Instead we will focus on supporting the government to increase resources and quality in their programmes by improving the evidence base through formative research and designing and piloting innovative interventions. Based on the research results, we are going to design and implement a number of innovative activities, which will start at a small scale. The goal is to share the knowledge and learnings from the interventions to encourage the government to intervene at a larger scale.
To help address the widely held misconception about the need to wash disposal pads, UNICEF is working with the Ministry of Health to organize a meeting with private sector companies who produce and distribute sanitary napkins. The idea is to inform the companies about the research findings and to collectively discuss how they might help improve the situation. For instance, could pad producers include information on how to dispose of pads on packaging? Could the white wrappers that pads are currently packaged in, which allow the blood to be shown when thrown out, be replaced with black paper, which would provide additional privacy for girls? How could their distribution network and advertising be used to improve knowledge around proper MHM?
Second, in collaboration with UNICEF’s Innovation Lab, the WASH team is planning a human-centred design challenge. Focus group discussions will be held in a junior high school to hear from both girls and boys about what they want to do about the disposal of sanitary pads. For instance, would including lids on rubbish bins in school latrines make girls feel more comfortable disposing of pads? The discussions will also explore where adolescents get information about menstruation and how teasing affects girls.
Third, together with UNICEF’s Communications for Development Unit, we are working with Telkom Indonesia, the largest telecommunications company in the country, to place large multi-media billboards in seven schools in Jakarta. Over the course of 12 months, the billboards will display videos and messages about MHM up to 15 days a month, two hours a day. Messages will include evidence-based information, such as the fact that one in seven girls miss school due to menstruation, and behavior change communication messages to help dispel misconceptions, such as the idea that menstruating girls shouldn’t take painkillers. We will assess the effectiveness of the messages after three months and update them accordingly.
Together with the results of the research, these activities will inform the development of a basic MHM package that will be piloted in 100 schools. The package will focus mostly on communication and will include messages for a number of important stakeholders, including local mayors, who have significant influence around health and development projects in their districts.
What challenges do you anticipate facing when implementing these activities?
One of the challenges that we face in Indonesia is how to reach the large number of adolescent girls who are not in school. While some countries have effective platforms for reaching this vulnerable population through health centres or outreach programmes, these interventions are relatively weak in Indonesia.
Indonesia’s size and diversity also present challenges when creating messages and platforms, especially around a sensitive topic such as MHM. It will be difficult to come up with messages that are effective across the entire country’s multiple regions, ethnicities and religions.
One way to deal with both of these challenges is to optimize the links between our WASH in Schools programmes, including MHM in schools, and our work supporting local governments and communities around community-based total sanitation, which has been the cornerstone of UNICEF Indonesia’s WASH work for years.
What advice do you have for other UNICEF country offices interested in undertaking similar work?
First, it is clear to us that if you are going to discuss MHM with government, you need robust, evidence-based information. When dealing with a sensitive topic around which there are many taboos, it can’t just be about opinions. Everything has to be based on watertight research. Our partnership with the Burnett Institute was crucial in generating clear, evidence-based recommendations based on a solid methodology and robust findings. Our other three partners were also crucial to the success of this work, each providing a unique ‘value add’ to the research.
Second, we believe that it is important to engage with the private sector. While the government, schools and charities may have a role to play in the provision of sanitary pads in some cases, most girls purchase their MHM materials through the private sector. When approached as partners, we have found that pad producers and other private sector companies are willing and able to become constructively engaged in the issue.