Mensural Hygiene Management in Schools of Oromia Region, Ethiopia

Background: Management of menstruation as a biological occurrence for women of reproductive age and men’s role is determined by socio-cultural factors. There is dearth of evidence on men in general and boys support on menstrual hygiene and management. This study aims to identify school based menstrual hygiene and management interventions and the role of boys in Oromia region, Ethiopia. Method: The study was carried out in 2017-18 academic year in eight Oromia Development Association (ODA) supported public schools with sport for life interventions. Schoolboys and girls aged 12-15, parents and school teachers participated in the study. Focus Group Discussion with boys, girls, and key informant interviews with parents were completed. Data were transcribed and translated into English and themes were developed following the objectives. Interpretation and presentation of the ndings were substantiated with quoted shared opinions. Result: Finding shows that after two years of school based sport for life intervention, study participants invariably recognized menstruation as a natural occurrence and is a blessing rather than a curse. Girls who used to shy and abstain from school for fear of bullying and teasing attended their classes regularly and became competitors in their academic performance. Common arguments by all participants alike show that ‘We learnt that menstruation is a mark of healthy growth of girls. The absence of it that should be the source of concern’ . With dedicated room and availability of water and sanitary napkin; and support from boys and schoolteachers and management of menstrual hygiene has improved at school level. Boys not only stopped teasing girls but also started contributing money to purchase sanitary napkins. Liaising such school level intervention with parents has extended support to girls at home level. Conclusion: School level non-curricular intervention that has involved not only students but also the school community and parents have brought fundamental change to the way menstruation was understood and its implications. Menstruation is no more a source of shame and reason to tease and bully girls with its far reaching implication on the school performance of girls. Further study using mixed method may help document specic changes and sustainability.


Background
Adolescents and youth are the largest single section of the population across the globe. This segment of the population exhibits a multitude of characteristics such as rapid physical, cognitive, social, emotional and sexual change with detrimental effects on young people's self-concept and their future. (1,2,3) Young people are often active and run relatively limited risk to health problems and burden of diseases that has compromised organized health response. (4) Yet, advocacy for more investment in adolescent and youth development in general and health in particular is getting momentum. (5,4) Among key areas of investment, Sexual Reproductive Health including menstrual hygiene management is major area of focus. (6) Gender inequality and discrimination in connection to socio-cultural foundations of communities in Africa maintains menstrual hygiene and management outstanding challenge. (7) The problem is pronounced in school, compromising girl's educational performance and their participation in school affairs. During menstruation, girls fear teasing by boys and embarrassed if their menstruation is seen. (8) Evidences reveal that adequate menstrual hygiene and management is about availability of sanitary pad, water and soap and separate room for privacy to change and disposal facility. (9) Nonetheless, lack of awareness about the problem at family, school and community level, consideration of menstruation as taboo and consequent teasing and bullying by boys, poor availability of supply including sanitary pad, water, soap, disposal facilities and privacy at school level contributed to girl's school dropout and their poor performance. (10,11,12,13) Few available evidences from Ethiopia shows limitation of awareness about menstrual management at different levels and lack of resources to manage when and if menstruation occurs while in school. There is lack of evidence on what support by whom could improve menstrual hygiene management. However, anecdotes and few available evidences reveal that with support including by boys in connection to menstrual hygiene management, school enrollment of girls has increased from 46% in 2012 to 52% in 2015. (14) David and Lucile Packard Foundation has collaborated with Oromia Development Association (ODA) where it introduced Sport For Life, a club-based extra-curricular regular game-based learning activities to empower adolescents and youth with relevant sexual reproductive health awareness including menstrual hygiene management in over 100 schools in the region. (15,16) The purpose of this study is to explore and describe the sport for life intervention in the schools and implications to improve menstrual hygiene management and indicative implication on academic achievement of girls.

Study settings
The David and Lucile Packard Foundation has collaborated with the Oromia Development Association (ODA) since 2009 to improve access to and use of quality comprehensive SRH information and services among young people among others. Such collaboration bene tted Jimma, Illu Ab Abor, east Arsi, South West and west Shoa zones. Eight ODA supported districts and school within these districts were chosen for the study. Socio-ecological model was employed to explore the support to school girls from schoolteachers and managers, boys and parents to address menstrual hygiene and management concerns of schoolgirls. Schoolboys and girls aged 12-15 who were active members of the Sport for Life club during the 2018 academic year, school teachers and parents participated in the study. Twenty-four Focus Group Discussion (FGDs) with separate boys and girls sessions, 23 Key Informant Interviews (KII) with schoolteachers and with 16 parents were completed. Data was collected using checklists that served as interview guide developed by the authors in line with the objective of the study. The investigators carried out the interviews supported by a trained research assistant. Data was collected using local languages and later transcribed and translated into English. The transcripts were read, and re-read to reduce data into themes. With the application of open code free software, the transcripts were categorized in to themes as: local conceptualization of menstruation, role of Sport for life initiative and supportive school environment. Findings were interpreted and presented without in uencing its original meaning. For direct quotes, names were avoided to ensure unanimity while sources of data and places were provided.

Results
A total of 692 adolescents whose mean age is 11.7, 12.9, 14 and 14.6 for grades 5-8. 53% of the participants were girls. A total of 23 schoolteachers and 16 parents took part on the study. Sixty four percent of the participating school teachers and 63% of the parents were male.
Local understanding menstruation: In all the study settings, parents refer to menstruation as 'legu', which literally means menstruation contextually it means not clean and distancing oneself from people especially the elders. Talking about sex and sex related regular bleeding [laguu] is a taboo and particularly seen with a stain of blood on dress by parents especially male members of the household is breaking Safu [1] (agreed on norms). As a result, menstruation remains personal issue and girls keep it as their top secret" (KII, 25 year old mother, Adami Tulu). For adolescents talking about menstruation in presence of father and elder brother is considered breaking safu and is sign of disrespect. One of the participants explained that, "Normally, girls are not expected to ask or tell about lagu to family members including mother but probably an elder sister" (KII, 32 years old school teacher, Jibat). Preparation of daughters for healthy menstruation did not come out during discussion with parents particularly mothers. "My mother didn't tell me what I will encounter as a girl. It happened to me when I was 15 years and was shocking at the beginning but eventually I learnt my own way. Of course, my elder sister who was then married helped me. Unfortunately, I did not tell any of my three daughters all of whom I believe are through now. Our culture makes this a taboo to talk about and as parents we nd it di cult to talk" (KII, 42 years old women, Jibat).
My mother did not tell me what I will encounter as a girl: Girls argued to enter puberty without appropriate information about menstruation, how to manage when it occurs and unprepared to cope with it and unsure of when and where to seek help. Reasons were found to include lack of support by adults around them including parents and teachers for these are ill-informed and uncomfortable to discuss about sex, reproduction and menstruation. Before the intervention was started in this school, parents and schoolteachers associate menstruation with dirt, polluting and shameful. The nding reveals that even mothers who went through the same process do not recognize menstruation as normal state of life and do not guide their daughters. One of the participants said, "If my mother has told my sister she would not have felt ashamed. I know my sister was shocked and felt alienated. I do not see why she would be in that state if mom has prepared her" (KII, 16 year schoolgirl, Nono).
Another participant pointed out that, "If we see bloodstain on a girl's clothe, we lough, tease and bully them. They feel ashamed of this and isolate themselves probably stays at her desk in class until everyone is gone since she is ashamed of this and fear being teased and bullied by us [boys]. We did not know how harmful such action was until intervention started in our school " (FGD, 14 yea old boy, Dodota). Implication of sport for life initiative: Participating unanimously reported that Sport for Life activities are valuable not only improving students and school community's awareness on SRH and gender based discrimination, it was found to have empowered students to seek support and make decisions about their sexual health. One of the participants stated that, "Our classmate boys did not know that we [girls] bleed on a regular basis until this 'Sport for life' initiative. During our joint discussion boys told us that they learnt that girls menstruate every month and this is normal and healthy for girls" (FGD, 15 years old Schoolgirl. Yebu).
With the implementation of 'Sport for Life' in the school and involvement of male and female students in regular activities, support to female students has improved at school level. Male students from study sites reported to consider menstruation as normal part of life for females. One of the students explained that, "Before my involvement with Sport for Life activities, I felt menstruation is girl's problem that they have to deal with. Now, all male students have refrained from teasing and are in fact mobilizing money from students and teachers on a regular basis to buy them sanitary pad" (FGD, 15-year schoolboy, Dugdaa). Another student explained that, "I feel bad about how negative I was to a girl two years back, whom my friends and I laughed and teased at for we saw blood on her dress. I remember how embarrassed she was and we never see her again in our school. I regret that -we were wrong Had this sport for life was introduced early more of our sisters wouldn't have suffered" (14 year old, Nono).
Participants argued that Sport for Life has helped them realize that menstruation is normal life process for girls and the need to support them. One of the participants noted that, "In our group, we realized it is an identity for girls/women. If girls do not menstruate then she is not healthy. This is contrary to what I as well as my friends knew before. Now we learnt our mistakes that all boys in this school are in support of girls in this school and at home. Girls do not fear and feel ashamed any more due to menstruation" (FGD, 14 schoolboy, Dugda). Female students are not teased in connection to menstruation unlike it is usually the case, "I remember one of our classmate encountered menstruation in class. One of our colleagues gave her his jacket to cover herself to walk to the room where should could clean herself. Now, it is not something we [male students] lough about but we help." (14 years schoolboy, Toke Kutaye).
Through Sport for Life initiative, parental support to their daughters has improved in all settings. What has been considered as a taboo to discuss is not a problem any more at least with mothers. "Although discussing sex including menstruation with parents is considered 'safuu' (disrespectful), during school day, parents are educated about the challenges girls encounter in connection to menstruation through drama. Besides, parent are engaged through school-parent committee to discuss on menstruation and its implication on girls academic performance. This has brought useful result where parents now started giving money for purchase of sanitary pad" (KII, 28 Schoolteacher, Yebu). One of the students explained that, "During the school day at the end of academic year, we show drama to parents emphasizing how support from parents, siblings and the school community on menstrual hygiene management would improve girls academic performance and implication of lack of support. Parents expressed regrets for not supporting" (FGD, 14 year schoolgirls, Dugda).
Friendly school environment for girls: The school environment has become so friendly for girls improving girls participation in non-curricular activities and their academic performance. One of the students argued that "Sport for Life did not only removed our worries but girls are now active participating in school activities as leaders of clubs, class monitors and students representative. There is no girl that dropped out of school the last two years neither due to pregnancy or menstruation" (FGD, 14 year, Schoolgirl, Toke Kutaye). Another girl emphasized that "During the last academic year, a girl stood rst from the entire school. This is the result of sport for life and am sure this will be the case this year too" (FGD, 15 year schoolgirl, Jibat). Furthermore, school dropout is not a problem during the last two years in the school. One of the participants argued that, "Usually regular menstruation has affected proper class follow up especially with lack of support. Now, with more support there is no reason for girls to drop out of school. During the last two years, no girl student has dropped out of school" (KII, 27 years schoolteacher, Dodota).
Finding shows that students are playing roles in sharing information they gained from 'Sport for Life'.
One of the participants explained this, "Through mini-media, we share such information as HIV, unwanted pregnancy, saving, menstruation, gender based violence and implications to girl's school performance on a regular basis. This is what we learnt from the 'sport for life' activities. This has made the changes wider beyond few of us who participated in the sport for life"(FGD, 14 year schoolboy, Yayo).
Schoolboys who participated in 'Sport for Life' suggest the need to expand this initiative to reach out to more students. "I think students who participated in the 'Sport for Life' realized our limitation and the problems we posed to our female colleagues. I wish all students in school get same opportunity. It is only that way could sex and menstruation related problems of girls could be solved. 'Sport for Life', I found, is a very good initiative that has to expand to all schools in Oromia" (KII, 30 years, schoolteacher, Nono). One of the students who was a member of sport for life club since last year emphasized that, "Only few students participate at a time. As a result, most other students bene t through mini-media teaching. It would be useful if more facilitators are made available" (FGD, 16 year schoolgirl, Yebu). In as much as what is known about sex and menstruation has changed and positive attitudes were built, sustaining access to sanitary pad is argued important. As such one of the participants argued that, "Continuous provision of sanitary pad may be di cult. Perhaps building skills on how to make local sanitary pad may help. These are some experiences on ground as initiated by some NGOs and this may have to expand to ensure access to sanitary pad may not be a concern" (KII, 29 year, schoolteacher, Toke Kutaye).

Discussion
Management of menstrual hygiene is an important part of women's life that remains poorly discussed in Ethiopia. Especially for girls in school, it management coupled with limited interventions in terms of awareness building and provision of relevant services makes its occur acne and management very di cult for girls. This has been documented to have far-reaching implications on the educational attainment of girls.
Finding clearly reveal that menstruation has been a taboo and is a source of shame for adolescent girls both in school and at home. UNICEF's document reveals that more than half girls in Ethiopia have never received information about menstruation, do not know what to do when it happens and do not have support during menstruation. At home, adolescents and their mothers do not share same knowledge about menstruation and value different traditions. Local socio-cultural domains restrict discussions about menstruation between daughters and parents including mothers. (17) Neither do schools teach girls about menstruation and its management. (18,19) Two-Third of the girls do not talk or discuss about menstruation with another person because they feel ashamed and often restrict their mobility. (20) Such cultural foundation of menstruation that consider it as taboo is challenged with the Sport for Life initiatives at School level. Now students stay at home and do not feel embarrassed at the settings where the study was conducted.
Consequently, hindrances from seeking advice from parents and teachers on appropriate menstrual hygiene management was not reported during the study. Strategies to encourage positive social norms towards menstruation was found to prevail in the study setting which is an encouraging experience for Oromia Development Association as well as the Packard Foundation. Similar call to promote open discussions about menstruation and its management at the family, community and school levels is documented to support improvements of menstrual hygiene management in low and middle income settings. (21) A report form PMA2020 shows that 28% of women in Ethiopia have resources to manage their menstruation with no variation by age. (22) This means majority of women are unable to meet their menstrual management needs. Coupled with glaringly evident limited awareness, girls in school are likely to lack such resources and the problem is much at worst at this level.
Lack of water supply, hygiene and sanitation (WASH) facilities, limited access to sanitary materials and information on safe menstrual hygiene management (MHM) at school aggravate these situations. (18,20) Finding from this study reveals that schools weren't built with the consideration of menstrual hygiene management nor were any guidance for schools to dedicate rooms for menstrual management. However, the schools visited during the study have started to dedicate a room for this purpose only following the 'sport for action' training given to school directors of the selected schools.
From this nding, it is clear that boys tease and bully girls if bloodstain is seen on girls uniform. This is an embarrassment for girls and cause school dropout. One could realize the irony of government's effort to ensure girl's enrollment and keep them in school while schools are not friendly to girls with appropriate facilities to manage their mensuration while in school. Most schools in Ethiopia are not equipped with basic amenities for menstrual management: easy access to sanitary pads, place to change pad, availability of running water and disposal facilities. (23,24) This has accounted for school absenteeism and at worst school dropout for girls which is the case from this study. Studies show over three-quarter of female students miss class every month in connection to menstruation and some who still attend class during menstruation exhibit reduced class performance due to poor concentration. (25,19,20) The initiative by Oromia Development Association with support from Packard Foundation has generated useful lessons where due to 'Sport for Life' initiative support from boys has shown results in harnessing more support from parents. Following the initiative schoolboys were motivated to support girls where teasing and bulling has become obsolete as practice which was attributed to mere naivety about menstruation. In as much as gender inequalities that compromise women's ability to manage menstruation is rooted in the cultural norms around menstruation, the role of men and boys is equally compromised the potential role of boys and men menstrual hygiene management. (17)Available evidences attested that initiatives that involved boys and men in menstrual hygiene management have shown remarkable successes within schools and households. (26) So, in efforts to improve girls' educational accomplishment, the role of boys, parents and school community was evident. Anonymous evidences have long documented that girls education is effective tool for improved women's health outcomes such as in the reduction of infant and maternal mortality, protection against early and unwanted pregnancy and other sexual reproductive problems including HIV/AIDS. (27,28) In view of this, ensuring friendly school with appropriate services for girls and expanding such support to family through family-parent partnership could play pivotal role.
Further studies with more geographical coverage for potential scale up of the experiences from Orimia development through Packard Foundation is important to consider.

Conclusion
This study clearly depicted that school level comprehensive non-curricular intervention with an involvement of male students, teachers and school management as well as parents has shown improved menstrual management at school level. Menstruation has been the source of shame and reason for boys to tease and bully the girls with implications for girl's to drop school. The intervention helped particularly boys and parents that it is normal part of girl's life. This was made possible through consistent noncurricular activity within school that involves multiple stakeholder. This is a very good model for other sexual reproductive health interventions targeting adolescents and youth. Furthermore, a mixed method study may help to document the speci c changes as well as implications. The IRB of the Oromia Regional Health Bureau cleared the project and approved use of verbal, informed consent for data collection. In addition, letter of support from the Packard Foundation and the Oromia Development Association to the study weredas and subsequent letter to the schools by the respective wereda administration facilitated smooth entry into the schools. School principals mobilized parents and schoolteachers where the study team explained about the purpose of the study and implications to improve healthy learning especially of the girls. Research team secured verbal, informed consent both from parents on their participation as well as participation of their children under the age of 16. In addition, participating schoolteachers and students got explanation on the purpose of the study and implications. In the manuscript, quotes that represent shared opinion were presented without names but age of participants, places and type of data collection.

Consent for publication
Not applicable Availability of data and material All data for this manuscript are available for submission if the need arises

Competing interest
We declare to have no con ict of interest what so ever