Formative Menstrual Hygiene Management Research: Adolescent Girls in Pakistan.

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  • Menarche is the onset of menstruation, and is part of the complex physical changes that occur during girls’ transition from childhood into young adulthood. These changes relate to lifestyle, behavior, growth and development. While menarche is a physiologically normal process, in many countries it is embedded within a host of cultural beliefs, values and practices. In Pakistan, these include dietary restrictions including eating eggs, beef and fish, hygienic practices that forbid bathing, religious practices that restrict prayer and contact with the Quran. A small body of literature suggests a key element of cultural practices surrounding reproductive health in Pakistan, including menstruation, is the ‘culture of silence’. Part of a larger value system that is embedded within the gender order of society, information around menstruation is actively withheld until after the onset of menstruation. A number of studies have suggested girls’ knowledge around menstruation and hygiene practices may be inadequate. Lack of knowledge about menstruation is associated with profound psychological and emotional problems. Alongside growing attention to the MHM needs of girls in schools that lack adequate WASH facilities, a growing body of literature recommends menstrual health and hygiene education in order to improve health and education-related outcomes of adolescent females. Dr. Marni Sommer at the Mailman School of Public Health, Columbia University, has addressed this gap by developing girls’ puberty books that provide essential, culturally sensitive information on puberty and menstrual hygiene management (MHM) for 10-14 year old girls in Tanzania, Ghana, Ethiopia and Cambodia8. Her project is now expanding into Pakistan with a plan to develop a culturally contextual puberty book for girls. As a first step in development of the puberty book, qualitative data were collected to understand girls’ experiences of menarche, explore cultural values, beliefs and practices surrounding menstruation, and how the lack of water, sanitation and disposal infrastructure may be negatively impacting girl’s management of menstruation in schools, and their ability to participate in the classroom. The original project was conducted in the province of Punjab, Pakistan. UNICEF commissioned the researchers to expand the research site to the province of Baluchistan to ensure the book captures the cultural beliefs and values of an additional key province of the country. This report focuses on the findings from Baluchistan only. Methods A comparative case study (rural vs. urban) was conducted from September to December 2015 in rural and urban Baluchistan. Urban data were collected from Kuchlaak, a neighborhood in Quetta City, District Quetta and rural data from village Sakuran Goth, Tehsil Hub, in Lasbela District. Both sites were selected by UNICEF, Pakistan. In each site, data were collected from both in-school and out-of-school girls. Three methods of data collection were utilized: 1) Participatory activities were conducted with groups of adolescent girls (n= 177); 2) observations were conducted of school water, sanitation and disposal facilities; and 3) in-depth interviews were conducted with key informants such as parents, teachers, and health workers. Preliminary Results Overall, our data identified six key themes: 1) Menarche is generally experienced by girls as a traumatic event characterized by fear, distress and worry. 2) Prior knowledge of menarche normalized the process, leading to positive experiences of the first menstrual period. 3) Currently, girls’ knowledge of puberty and menstrual practices was rooted in local, cultural epistemology. However, they were skeptical of this knowledge and questioned it. 4) 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. 5) Water, sanitation and hygiene facilities in schools are inadequate to meet menstruating girls’ needs. 6) Participants identified a range of WASH and menstrual management resources to develop Girl-Friendly school facilities. Recommendations Based on the research findings, we recommend: 1) Development of an information resource to provide girls knowledge of puberty, menarche and menstrual hygiene management. This could be a book, pamphlet, an animated video or a web-based resource. 2) Development of a MHM health education module that should be taught as part of girls’ school curriculum. 3) Train teachers to deliver MHM information in a sensitive and objective manner. 4) Develop school WASH facilities, including availability of clean washrooms, running water and disposal facilities, located in safe spaces. 5) Create positions for cleaners to clean the washroom facilities through advocacy with provincial government. 6) Develop menstruation support facilities such as availability of sanitary supplies in schools. 7) Conduct further research to understand why teachers are reluctant to engage students around MHM issues, why is there a blindness to dirty toilet facilities, why there is reluctance to clean toilet facilities, what are appropriate mechanisms for menstrual waste disposal and if there are opportunities to manufacture sanitary pads using local, cheap materials.

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    Attribution-NoDerivatives 4.0 International