1. Piloting menstrual hygiene management (MHM) interventions among urban and rural schools in Bangladesh
Farhana Sultana
Principal Investigator
Environmental Interventions Unit Infectious Disease Division

2. Background
Girls in low-income countries, including Bangladesh, lack MHM facilities in schools
Inadequate MHM practices contribute to14 to 40% of school absences among girls
Little attention has been paid to how menstruation affects school attendance and performance among girls
Little attention has been paid to how menstruation affects girls at school and the challenges it presents to their attendance, performance and right to education

3. Aim To develop a novel intervention that:
Creates a supportive school environment for girls
Empowers them to attend school during menstruation

4. Trial of improved practices (TIPs)
Year 1 activities
Formative research
in 4 schools
Qualitative interviews
Intervention development workshop
(after 6 months)
Trial of improved practices (TIPs)
(after 1 month)

5. Year 2 activities Pilot testing of intervention in 4 different schools
Baseline and endline survey
(after 6 months)
Qualitative assessment
(after endline)

6. Objectives
To develop a feasible low-cost menstrual hygiene management intervention
To develop strategies for measuring school attendance, performance and self efficacy
To pilot and evaluate the preferred set of interventions and measure uptake of target practices
To assess the acceptability, feasibility and potential for sustainability of the intervention
Encourage the use of low-cost menstrual hygiene management products and disposal options
Explore and identify support required from relevant stakeholders to maintain facilities

7. Proposed intervention design
Supportive environment:
Locally available disposal bins
Menstrual hygiene management products
Behaviour change communication materials
Training of teachers:
Training of male and female teachers
Improving policy implementation:
Formation of a steering committee
Maintenance
Formation of gender clubs and maintenance committees in each school

8. Methods Sample size: Study sites: Target population: Study period:
4 urban and 4 rural purposively selected co-ed schools
Study sites:
Dhaka division
Target population:
School children aged yrs
Study period:
2 years

9. Formative research

10. Data collection techniques
Type of respondents
# of interviews/
activities = 109
N = 184
Spot checks of facilities
MHM facilities 4 -
In-depth Interviews
Girls 48
Boys 24
Teachers 8
SMC members 2
Parents 3
Key Informant interviews
Janitors
Vignette approaches 23
Ranking exercises
Drawing exercises

11. Data collection techniques
In-depth interview with girl student
Vignette approaches with boys
Drawing exercises with girl students
In-depth interview with boy student

12. Spot checks of MHM facilities
Characteristics
Urban
(2 schools)
Rural
Total
n/N (%)
# of girls students (class 3-10)
1445
775
2220/4214 (53)
# of functional toilets 17 11
28 (7)
# of toilet for girls only 2 4 6
# of girl students per toilet
723
194
370
Soap available inside girls toilet -
# of handwashing basin with tap 5 13
18 (4.5)
Soap available at the basin 3 1
4/18 (22)
Waste bin inside the toilet cubicle
3/28 (11)
Sanitary pad disposal bin inside the toilet cubicle
2/28 (7)
1/62

13. Knowledge and perceptions
Girls and boys did not know about menstruation or puberty before they reached puberty
Lack of knowledge caused fear and shame among girls, and misperceptions among boys and fathers
Girls and teachers perceived menstruation as natural process whereas parents and boys as hidden issue
One girl said: “Boys might menstruate also when they reach puberty, aren’t they!”
One boy said: “Girls menstruates thrice a month.”
Elder girls and boys gained knowledge from mothers, grand parents, elder siblings, and media 13

14. Stigma
Girls prefer to not ask permission to leave school, to not dry used rags outside, to not buy pads, and to not share their concerns about late menarche with adults
Both girls and boys mentioned being teased when they reach puberty/menarche
Family restricts eating certain foods, and conversations with boys during menstruation
One girl said: “We do not dry rags outside to avoid kharap batas (evil wind) which might cause serious illness and hospitalization. Our elders prevent us talking boys during menstruation as they are afraid that we might get pregnant. They also prevent us from going out at noon and in the dark as ghostly things can harm.”

15. Current MHM practices
Half of girls reported using cloths during menarche, and continued to use rather than pads due to financial constraints
Most girls reported that they need to be absent from school, and use pads if they must attend school
None either changed or disposed of pads while at school due to inadequate toilet and disposal facilities
Girls leave school to change and dispose pads at home, or reach the end of the school day in considerable discomfort
One girl said: “I miss school, for at least one day (of heavy bleeding), because I could not change my pad, the toilet is dirty to use, and I fear I might stain.”
Toilet environment is not good, cleanliness+water supply+bad smell+visible feces
Half of girls reported using cloths during menarche as they learned to do from their mothers, and continued to use rather than pads due to financial constraints

16. Barriers to MHM practices
Insufficient number of girls’ toilet leads to long queues
Lack of privacy, and facilities with disposal bin, soap and water, and locks
Offensive statements on walls of toilets
Delayed introduction, and lack of detailed explanations about puberty and MHM in curriculum
Embarrassment to discuss or ask questions
Lack of facilities including, disposal bin, insufficient light, cleanliness, water and soap, and locked toilets with walls covered in inappropriate slang, that provide privacy.
One boy said: “Suppose menstruation, we don’t know much about this! We also do not know why erections and ejaculations occurs, what to do if something like this happens, or if this is an illness! Such issues could have been better explained.”

17. Barriers to MHM practices
I love you, let's have sex whole night. I can’t live without you
Girls queuing
in front of the toilet
Toilet without water source
Toilet with broken door

18. Absenteeism and performance
Nearly three quarter of girls mentioned class absence due to menstruation leads to low performance
Lack of MHM facilities causes them difficulty in exam attendance and concentration
Scanner and class captain approach perceived as good measures for accurate attendance
Quick tests using math and English questions can be used to assess performance

19. Recommendations: Disposal system and sanitary products
School 1
School 2
School 3
School 4
Final
MHM products
1st choice
Sanitary pad (belt)
2nd choice
Sanitary pad (wings)
Rags
3rd choice
Disposal system
Paddle bin with lid
Swing top bin
MHM products needs to dispose to reduce disgust and shame, and evil eye
One janitor said: “We have emergency pads, though girls do not buy may be due to cost (15/20 taka each).”

20. Recommendations: Behavior change communication activities
Portable behavior change communications materials
Gender segregated MHM and Puberty sessions
Girls preferred female, and boys preferred male teacher led sessions
Destigmatization and awareness of family and community
Educating both girls and boys about each others’ puberty
Cue to action inside the toilet
Absorbent

21. Conclusion Low-cost MHM facilities ready for TIPs/pilots
Training of female and male teachers as focal points
Formation of gender clubs to sensitize MHM and puberty issues
Teaching young girls to prepare before menarche.
Acknowledgment of MHM, and development of action plan/guideline/policy for school girls
17-19 h1

22. Trial of Improved Practices (TIPs)

23. Month 1: MHM product 1
Low-cost (US$ 0.05 per piece), environment and health friendly pads
Made by youth organization group
Service agreement with PSTC to supply pads
Reusable cotton belts (US$ 0.4) to support using the pads

24. Month 2: MHM product 2
Locally available sanitary pads (US$ 0.12 per piece)
Service agreement with SMC to supply pads
Underwear to support using the pads

25. Month 3: MHM product 3
Reusable rags (US$ 0.6 per piece) made by a local tailor
Cotton belt and/or underwear to support using the rags
Provision of plastic bags to store stained rag in school premise

26. Disposal system Items Picture Location Cost (US$) Partner TIPs period
Swing top bin
Urban school 1
4.5
N/A
March to June 2017
Paddle bin
Urban school 2 6
Bucket with lid
Rural school 1 4
Piped system
Rural school 2 65
DSK

27. Absenteeism trackers Items Picture Location Cost (US$) Pre-test period
Finger print device
Urban school 1
400
March
to May 2017
Barcode scanner
Rural school 2
138
0.12
ID card for scanner
Mobile messaging system
Urban school 2
Class captain approach
Rural school 1

28. Next steps: Baseline survey and pilot test of intervention

29. Baseline Survey
Survey of 510 girls and 100 boys on puberty and MHM knowledge, practices and self efficacy
Wide Range Achievement Test (WRAT) of 200 girls as part of performance test

30. Intervention roll out
Free provision of 2 cloth pads + 1 plastic bags + 1 underwear + 1 emergency cloth bag
Free provision wing pads (to the janitors) for sudden menstruation management
Installation of piped disposal system
Toilet renovation (e.g. cleaning, repairing, painting and others)
Gender club formation to discuss and sensitize puberty and MHM issues
Training of teachers to deliver weekly puberty and MHM sessions
Provision of flipcharts, cue cards and puberty booklets
Fingerprint scanners with UPS to measure absenteeism

31. Formation of advisory committee
Formed a project-based MHM advisory committee
Committee meets quarterly basis
Members include:
Ministry of Education and their departments
Ministry of LGRD&C
Ministry of MOH&FW and their departments
NGOs and development partners
School teachers and Education officers
Shorno Kishoree Network Foundation (media partner)

32. Study team Farhana Sultana Mohammad Nuruzzaman
Mahbub Ul Alam Sarah Sharmin
Md. Mahbubur Rahman Shifat Khan
Farzana Begum Farhana Akhand
Dr. Fahmida Tofail Rezwana Hossain
Leanne Unicomb Mohammad Rofiuddin Steve Luby Jyoti Bhuson
Peter J. Winch Shirina Akter
Diana DiazGranados
Astrid K. Dier