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Adolescent Girls Information Needs regarding Menstrual Hygiene Management: The Sindh Experience
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The onset of menstruation, or menarche, during puberty signals girls’ transition into young adulthood and is associated with a range of physical, emotional and social changes. Although the physiological changes during menarche are experienced by all girls, the processes are understood in terms of the beliefs, values and practices embedded within the gender orders of societies girls are members of. For girls in Pakistan, their cultural context, which includes elements from the country’s predominantly Islamic faith along with local traditions, imposes a number of dietary and behavioral restrictions. A considerable body of literature describes the ways reproductive health in Pakistan is influenced by cultural and religious values. Studies suggest that girls typically are not given information about menstruation until after menarche and their knowledge about menstrual hygiene management (MHM) practices may be inadequate, which has consequences for girls’ physical and emotional health.
A growing body of literature indicates a need for adequate WASH facilities for girls in schools, as well as improved menstrual health and hygiene education in order to improve health and education-related outcomes of adolescent females. The work of Dr. Marni Sommer at the Mailman School of Public Health, Columbia University, in Tanzania, Ghana, Ethiopia and Cambodia has aimed to develop girls’ puberty books that provide essential, culturally sensitive information on puberty and menstrual hygiene management (MHM) for 10-14 year-old girls. Her project is now working on developing a culturally contextualized puberty book for girls in Pakistan.
Qualitative research has been conducted to support the development of the Pakistan puberty book. The data include information on girls’ experiences of menarche, aspects of the cultural values, beliefs and practices surrounding menstruation, and how the available WASH facilities impact girls’ MHM during school. Earlier components of this research were conducted in Punjab and Baluchistan provinces in 2015-2016. To ensure Sindh’s cultural beliefs and values are also represented in this national book, the study was repeated in Sindh in 2016-2017. This report focuses only on the findings from Sindh.
This study consisted of a comparative case study (rural vs. urban) in Sindh province from December 2016 to March 2017. Urban data were collected from a neighborhood in Hyderabad, District Hyderabad and rural data from village Babarloe, in Khairpur District. Both sites were selected by UNICEF, Pakistan. In each site, data were collected from both in-school and out-of-school girls.
Data collection involved three methods: 1) Participatory activities with groups of adolescent girls (n= 137); 2) observations of school water, sanitation and disposal facilities; and 3) in-depth interviews with key informants such as parents, teachers, and health workers.
The Sindh data revealed six key themes:
1) Menarche is generally experienced by girls as a traumatic event characterized by fear, distress and worry.
2) Menarche is associated with possibility of immediate marriage. Mothers and girls actively hide onset of menstrual periods from fathers and other male family members in order to avoid very early marriages.
3) Having prior knowledge about menarche normalized the process for some girls, leading to more positive experiences of the first menstrual period.
4) Girls’ knowledge of puberty and menstrual practices was rooted in local, cultural epistemology. However, some were skeptical of this knowledge and questioned it.
5) There are significant information needs, specifically around physiology of puberty and menstruation; recognition and relief of menstrual symptoms; appropriate menstrual hygiene and management practices; and social, physical, religious and dietary restrictions.
6) Water, sanitation and hygiene facilities in schools are inadequate to meet menstruating girls’ needs.
7) Participants identified a range of WASH and menstrual management resources to develop Girl-Friendly school facilities.
Based on the research findings, we recommend:
1) Development of an information resource, such as a book, pamphlet, animated video or web-based resource, to provide girls with knowledge of puberty, menarche and menstrual hygiene management. However, there is a need to remain sensitive to a desire for secrecy regarding onset of menarche, which appears to be based on protecting girls from very early marriages.
2) Development of a MHM health education module to be taught as part of girls’ school curriculum.
3) Training for teachers in sensitive and objective delivery of MHM information.
4) Development of school WASH facilities to make available clean washrooms, running water and disposal facilities located in safe spaces.
5) Advocacy with provincial governments to create positions for cleaners to maintain girls’ washroom facilities.
6) Development of menstruation support facilities, such as making available sanitary supplies in schools.
7) Conduct further research to understand factors impeding the improvement of MHM support and WASH facilities, such as why is there a reluctance to clean and a blindness toward dirty toilet facilities, what are appropriate mechanisms for menstrual waste disposal, teachers’ reluctance to engage students around MHM issues.
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