FACTORS AFFECTING MENSTRUAL HYGIENE MANAGEMENT AMONG HIGH

SCHOOL ADOLESCENT GIRLS IN SOWETO

 CHAPTER 1: INTRODUCTION

1.1 Background of the study

Menstrual hygiene management refers to the practices which ensure clean and proper ways of
maintaining hygienic conditions during menstruation. Menstruation (a period) is an exceptional
phenomenon that the nature has planned for women. It is not just a small term but a major stage
where a woman undergoes certain reproductive changes from onset of menstruation till
menopause. Adolescence is the stage of physical, psychological, and reproductive development
that generally occurs during the period from puberty to legal adulthood. The World Health
Organization defines adolescence as individuals between 10 and 19 years of age. Adolescence in
girls has been recognized as a special period in their life cycle that requires specific and special
attention. This period is marked with onset of menarche.
Menstruation is surrounded by various psychological and religious barriers due to lack of
knowledge about the scientific process of menstruation. Many girls residing in slum areas are
unaware of what actually happens during menstrual cycle. Although menstruation is a natural
process, it is linked with several perceptions and practices within the community, which
sometimes may result in adverse health outcomes. Globally, an estimated 2.3 billion girls lack
access to menstrual products and adequate facilities for menstrual hygiene management. In
Africa 300 million girls do not have comfortable environment, safe sanitary products or a private
area in which they can manage their menstruation. In Kenya, girls face serious challenges in
menstrual hygiene management There is growing attention to menstrual hygiene management in
some communities in Kenya. Menstrual hygiene has been approved by UNICEF’s executive
Board as one of its five core priorities for adolescent girls in its Gender Action Plan (2018-2021)
with specific targets in the strategic plan covering the same time period. Improving MHM has
become a central part of UNICEF’s commitment to ensure that girls grow up healthy and reach
their potential. For both adolescent girls and women, UNICEF commits to programming that
strives to increase confidence, knowledge and skills and improve access to materials and
facilities for them to manage their menstruation safely and with dignity
Formative research shows that girls face monthly challenges, with 65% of women and girls in
Kenya unable to afford sanitary pads. Only 39.1% had received absorbents from school in the
preceding month. Majority, 77.2% reported inadequate clean water at school, 64.6% observed
that latrines were inadequate and 80.3% decried inadequate latrine privacy (Eleen Korir and
Florence Nafula Okwara 2018). Some of the schools lacked privacy of latrines; reasons for this
being that latrines were shared by both boys and girls, latrines lacked doors and/or locks which
did not offer privacy. In Kenya report having everything they need to manage their menstruation
(PMA2020). There are also more worrying statistics signaling that menstruation is tied to more
fundamental risks and issues of gender inequity, with studies showing 2 out of 3 of pad users in
rural Kenya receiving them from sexual partners (Alexandra Geertz & Perri Kasen, May 2016).
The existing evidence on menstrual hygiene management lacks objective measurement
approaches. Therefore, the aim of this study is to assess factors affecting menstrual hygiene
management practice among school adolescents in Kenya.

1.2 Problem statement

The issue of menstrual hygiene has the growing attention of adolescent girls in Kenya. Many
researches show that menstruation hygiene has been one of a major challenge in Kenya. With
regards to sanitation facilities, in 2014 only a third of schools were reported to provide a place
for girls to manage their periods. Kenya also has insufficient access to “safe and affordable
materials” according to UNESCO standards, less than half of girls reported having sufficient
feminine hygiene materials in 2016.Additionally, statistics suggest a need for more open
conversation surrounding menstruation. In 2014, only a number of Kenyan girls reported that
they openly discuss menstruation at home, and only a few of girls said that they would be
comfortable receiving menstrual information from their mother. There is also a gap in Kenyan
girls’ knowledge, as evidenced by the fact that 1 in 4 Kenyan girls do not associate menstruation
with the potential to become pregnant in the context where cultural taboos restrict the activities
of menstruating women and girls where the lack of adequate sanitary protection makes
movement away from home physically impossible. The onset of menses will inevitably have an
impact on girls’ access to education. For girls who are not able to continue attending and
participating in school, the widespread reality of poor sanitary facilities, ignorance about
menstruating girls’ needs and experiences, can mean that the schooling experience is far from a
positive one. Regular absence from school for several days a month can even have a negative
impact on girls learning and also on her academic performance in school (Kirk & Sommer, 2014)

1.3 Justification

Menstruation is still regarded as something unclean in many parts of Kenya. Despite the
challenges related to menstrual hygiene management, it has been routinely overlooked in the
school setting. The existing evidence on menstrual hygiene management lacks objective
measurement approaches. Therefore, the aim of this study is to assess factors affecting menstrual
hygiene management practice among school adolescents in Soweto Adolescent reproductive
health is one of the vital components of overall reproductive health. Reproductive and preventive
health programs in developing countries as Kenya has been given very little attention on the
issue of adolescent reproductive health and focused mainly on the reproductive functions of
married women

1.4 Research questions

1. How many high school females practiced unsafe MHM?

2. What were the underlying determinants of MHM practices among high school females?

1.5 Objectives
1.5.1 Broad objectives
To determine factors affecting menstrual hygiene practices among high school adolescent girls

1.5.2 Specific objectives

 To determine reasons for school absenteeism during menstruation

 To assess the knowledge and sources of information on menstruation to adolescent school
girls
 To identify the socio-cultural traditions and restrictions practiced during menstruation
1.6 Study Limitations
It is essential to acknowledge potential limitations such as data availability, budget constraints
and poor sanitation and bad hygiene practices that could impact this study
 CHAPTER II LITERATURE REVIEW

2.1 Background information

Menstrual hygiene management (MHM) is personal hygiene practices during menstruation
which starts with the choice of the best sanitary materials, their proper use, disposal, and body
cleanliness Menstruation is still regarded as something unclean or dirty in some societies. The
seclusion of menstruating females and restrictions imposed on them in the family not to
participate in a range of activities while on menses have reinforced a negative attitude toward
this phenomenon. Worldwide, nearly 52% of the female populations are of reproductive age.
challenges related to menstrual hygiene management; menstrual hygiene has been routinely
ignored by professionals in the education sector. A comprehensive definition of MHM was
developed by the Joint Monitoring Program of the Emory University and

UNICEF in 2012, defining MHM as: “Women and adolescent girls using a clean menstrual
management material to absorb or collect blood that can be changed in privacy as often as
necessary for the duration of the menstruation period, using soap and water for washing the body
as required and having access to facilities to dispose of used menstrual management
materials”.17
Menstrual Hygiene Management (MHM) is an essential aspect of women’s health that has social
and cultural connections worldwide. In Kenya, menstrual hygiene has long been a taboo topic,
with limited information and inadequate infrastructure to support menstrual health Menstrual
hygiene management (MHM) is a crucial aspect of women’s health, and various studies have
explored its implications. Research indicates that inadequate MHM can lead to health issues and
negatively impact the well-being of women and girls. Inadequate menstrual hygiene management
(MHM)–including a lack of accurate and timely knowledge, sanitation and washing facilities,
safe and affordable materials, positive social norms, and sexual health education–is a serious
issue for adolescent girls in Kenya although there are likely more factors, this poor MHM is
largely caused by poverty, the culture surrounding menstruation, inadequate sexual health
education, and poor sanitation infrastructure. Poor MHM creates serious consequences for these
girls, including health consequences of infections and poor mental well-being, sexual activity,
and education and gender inequality Several practices are currently in place to address
inadequate MHM, the most prominent or noticeable of which are feminine hygiene pad and cup
distribution, workshops, and magazine education.
Although this social issue is far from being solved, these practices, along with the increased
universal understanding and prioritization of MHM, create an optimistic view of the future of
menstrual hygiene management among adolescent girls in Kenya These barriers to adequate
menstrual hygiene management create adverse consequences for the Kenyan girls, including
infections, poor mental well-being, increased sexual activity, decreased education attainment,
and gender inequality. Although changing the status quo of MHM in Kenya will require long-
term solutions to both the consequences and causes of poor MHM, many practices are being
implemented today to alter this status quo. Here are some contributing factors to it

2.2 Causes of Poor Menstrual Hygiene Management (MHM)

2.2.1 Poverty
Poverty is a cause of poor MHM in Kenya, largely because it limits the menstrual resources
Kenyan families can provide for young girls. Global analyses of poverty in Kenya are somewhat
varied by year, measurement criteria, and source, but organizations consistently report high
levels of poverty.

2.2.2 Culture

The culture surrounding menstruation in Kenya also contributes to inadequate MHM because the
perceptions and stigmas common in Kenya do not support open conversation regarding the topic.
Although perceptions of menstruation vary from country to country, global studies suggest that,
in less-developed countries, menstruation is often viewed as contaminating and
debilitating.27 These perceptions can be especially prominent in public schools where girls are at
higher risk of being ostracised for being on their period. According to a 2013 study of 120
Kenyan girls, many reported “seeking permission from a teacher to bathe or to go home, hiding
until a friend could help them, or leaving school without permission”28 when they bled at school.
In short, some primary and secondary schools in Kenya may not be facilitating an environment
of support and acceptance girls need to feel comfortable in school when on their period. Family
settings also often exhibit a lack of communication and support surrounding menstruation. In
Kenya, menstruation is rarely discussed in families, 29 and many girls reported feeling like they
could not openly discuss menstruation at home because “it is too private to even share with their
mother.”30 The prevalence of this view surrounding menstruation was shown by a 2015 Kenyan
national survey, which found that less than 50% of parents discuss sex-related topics with their
children, including

2.2.3 Inadequate Sexual Health Education

A lack of sexual health education is another large contributor to poor MHM in Kenya because
this education is directly tied to the feminine-health knowledge needed for adequate MHM.
According to one study of three Kenyan counties, 86% of adolescent Kenyans attended primary
school in 2015. While 96% of these children received some level of sexual education in primary
school, over two-thirds of children reported wishing that they had more information and hours
dedicated to sexual education topics.33 This primary-school based education is especially
important because only 33% of the students continued on to secondary school where they would
have access to additional sexual education. Furthermore, in 2017 almost a third of the students
reported that they did not receive sexual health education from their parents34 suggesting that if
these girls do not receive menstrual education in primary school, they may not receive it at all.
Although the government has mandated sexual education in schools, the curriculum
insufficiently focuses on menstrual health. In 2013, the Kenyan government committed to “scale
up comprehensive rights-based sexuality education beginning in primary school.”35 However,
the majority of sexual education focuses primarily on the biological rather than psycho-social
changes, such as the hygienic use and disposal of sanitary pads.36

2.2.4 Sanitation

Poor sanitation is another major cause of inadequate MHM because of the lack of feminine
materials and good facilities. This poor sanitation can be concentrated into two main categories:
accessibility to sanitation infrastructure and quality of sanitation infrastructure (where quality is
determined by the presence of handwashing stations, places to dispose of used sanitary products,
and cleanliness). Many Kenyans often have limited access to sanitation infrastructure. According
to one 2018 study in rural Kenya, “only 32% of schools had a private place for girls to change
their sanitary products.”43 Another 2014 study, also conducted in rural Kenya, found that 84% of
schools had separate toilets for girls, but only 33% of these toilet rooms had locks.44 This 50%
disparity between the two studies suggests that the availability of sanitary rooms may be highly
variable from one region of Kenya to another. In fact, another 2015 study has found that “only
30% of Kenyans [had] access to improved sanitation facilities, with large regional disparities in
sanitation access (15% in rural Northern Kenya compared to 99% in central provinces of
Nairobi).”45 This suggests that both accessibility to sanitation infrastructure in general and the
disparities between regions contribute to Kenya’s poor MHM.

2.3 Consequences of poor MHM

2.3.1 Health

2.3.1.1 Infections
The lack of feminine hygiene products can lead to increased likelihood of infection. As
previously discussed, extreme poverty can lead girls to turn to means such as old rags, leaves, or
cow dung in order to manage their period.50 These unhygienic substitutes can have serious
health consequences such as fungal infections, reproductive tract infections (RTIs) and urinary
tract infections (UTIs).51 These UTIs may occur because the unhygienic MHM practices “create
abnormally moist conditions that promote infection.”52 Within the umbrella of RTIs, one study
suggests that the infections most closely linked to MHM are bacterial vaginosis (BV) and
vulvovagial candidasis (VVC). These infections come from vaginal imbalances and may be
introduced to the reproductive tract through the materials used for absorbing blood.53 These
infections often first result in itchiness, soreness, and abnormal discharge.54 Beyond the initial
health complications, BV and VVC are also linked with increased risk of HIV infection and
pregnancy complications.55

It is also worth noting that it is not simply extreme substitutes (like leaves or cow dung) that can
lead to infection. One study suggests that women who use reusable absorbent pads are more
likely to have symptoms of infection or be diagnosed with urogenital infection than women using
disposable pads.56 Because of how expensive disposable pads are over time, many Kenyan girls
use reusable pads, again increasing their risk of infection.
2.3.1.2 Mental Wellbeing
The fear and anxiety surrounding menstruation can also lead to poor mental wellbeing of girls.
While there is little quantitative research on this topic, much of the research qualitatively
discusses the high amounts of fear and anxiety surrounding menstruation in Kenya, which
suggests that the perceptions and lack of support can negatively affect the mental wellbeing of
Kenyan girls. In one study based in Kenya in 2013, researchers conducted 35 in-depth interviews
and 18 focus groups to study the emotional impacts of what they deemed “menstrual poverty.”
Girls in the interviews described how a lack of products and support was a major cause of
“discomfort, embarrassment, anxiety, fear of being stigmatized, and low mood,” 57 all of which
are major factors in the mental wellbeing of girls. The study goes on to describe girls that used
language such as “‘feeling bad’, feeling ‘stressed’, or ‘fearful’ and ‘wanting to cry,’”58 further
suggesting that poor MHM can contribute to emotional distress for Kenyan girls, which in turn
negatively affects their mental wellbeing.

2.3.2 Sexual Activity

Another consequence of inadequate MHM is increased sexual behavior, which can lead to
increased risk of abuse, STI, and pregnancy. Kenyan girls in poverty often lack the spending
power to purchase pads or tampons, and because these girls are unable to buy the products they
need, it is common to engage in transactional sex or seek out a boyfriend to obtain these
products.59 Research provides varied answers to how frequently this sexual activity for
sanitation materials occurs. In one study conducted among 3,000 Kenyan women and girls in
2015, researchers found that “1 in 10 15-year-old girls were having sex to get money to pay for
sanitary ware.”60 According to another Kenyan study from 2015, “two out of three pad users in
rural Kenya received pads from their sexual partners” , though this statistic does not necessarily
imply transactional sex.61 Although there is a disparity between these percentages, there is
strong evidence that young girls may resort to sex in order to get the feminine products they
need.

When girls engage in increased sexual activity in order to obtain feminine materials, the power
dynamics of intimate relationships are negatively affected,62 suggesting that these girls may
have minimal leverage in sexual relationships and may be more susceptible to abuse.63 This
sexual behavior also increases their risk of contracting sexually transmitted infections (STIs). In
situations where girls must use sex to obtain pads, Kenyan girls may be unable to negotiate safe
sex practices, which further increases their risk of contracting STIs, including HIV.64
Unfortunately, there is limited research on the prevalence of HIV caused by engaging in sex in
order to obtain feminine hygiene products. It is known, however, that as of 2017 the overall
prevalence rate for HIV among young Kenyan women was 2.6%, which was notably higher than
the rate for young men, which was 1.3%.65

Lastly, increased sexual behavior for materials increases girls’ risk of experiencing unwanted
pregnancy.66 In one 2015 study conducted among Kenyan women under 30, 35% of the sexually
active women reported pregnancy in the past 12 months.67 Although the sample was not just
girls who were sexually active in order to obtain hygiene materials, this high percentage may
suggest that girls using sex for products are likely to get pregnant prematurely. Further research
suggests that this early pregnancy affects girls’ ability to stay in school,68 so as girls’ resort to
sex to get the materials they need, the increased chance of pregnancy can also decrease their
educational opportunity, creating a cycle of poverty and poor MHM.

2.3.3 Education & Gender Inequality

Another major consequence of poor MHM is decreased school attendance among Kenyan girls.
If girls feel embarrassed or shameful about their period, they are much less likely to attend
school while menstruating. Furthermore, girls often do not have appropriate sanitation facilities
where they can manage their menstrual flow at school, potentially leading to a decrease in
educational attendance. UNICEF estimates that 1 in 10 school-age African girls do not attend
school during menstruation, and the World Bank statistics estimates absences to be
approximately four days every four weeks.69

As girls miss school and fall behind, the educational disparity between boys and girls widens. A
2014 study showed that “girls’ enrolment ratios in Kenya have increased in recent years, but
large inequality gaps in primary education attainment remain.”70 Other studies have confirmed
this trend; multiple studies find that the gap between girls’ and boys’ education is most
pronounced during secondary education, suggesting that this gap widens as girls experience
menarche.71 This gap in education also contributes to the gap in literacy rates. Compared to the
national illiteracy average of 7% in 2014, “50% of girls 15—19 are illiterate in the rural,
conservative North Eastern province.”72 The gap in education that comes as a result of poor
MHM can lead to deeper economic consequences. According to a 1999 study by the World Bank,
a 1 percent increase of women with a secondary education causes a .3 percent increase in per
capita income on average.73 This suggests that as poor MHM decreases educational attendance
among girls, there may be adverse economic consequences in the form of lower economic
productivity.

CHAPTER III - MATERIALS AND METHODS

3.1 Study design

An institutional-based cross-sectional study will be conducted, and data will be collected during
March to April, 2024.

3.2 Study area

The study will be carried out in Soweto East which is a part of Kibera slum in Nairobi. Its
population has been estimated at 70,000 persons I lies in the following coordinates
1°19′S 36°47′E Soweto is a division of Nairobi Area, Kenya, and neighborhood of the city
of Nairobi, 6.6 kilometers from the city Centre.

3.3 Population
All female students who experience menarche and all the schools found in the district will be the
source population. Representative sample will be drawn female students’ who experience
menstruation and will be available at school during the data collection will be included in the
study.

3.3.1 Inclusion criteria

All female students who will have started experiencing menses will be included.

3.3.2 Exclusion criteria

Female students in the same level who experience menarche but will be seriously sick and absent
from school at the time of data collection will be excluded from the study.
3.4 Variables

3.4.1 Dependent variable

A dependent variable is something that depends on other factors. In this study the dependent
variables include:

 Reasons for school absenteeism during menstruation

 Knowledge and sources of information on menstruation to adolescent school girls
 Socio-cultural traditions and restrictions practiced during menstruation

3.4.2 Independent variable

An independent variable is a variable presumed to cause or influence a dependent variable.

In this study this variable will be the Menstruation
3.5 Sampling techniques

A multi stage sampling procedure will be employed so as to select a fair representative sample
from female students who experience menarche and attending class in the selected schools. First,
from a total of 10 schools 5 from east and 5 from west, 1-5 schools will be selected
proportionally using simple random sampling respectively. From each selected schools, sections
and then individual female students who will have started menarche at the time of data collection
will be selected using simple random sampling

3.6 Sample size determination

The sample size was determined based on the assumption of a simple random sampling (SRS)
method and using a single population proportion formula. Since we were unable to locate a
similar study, we decided to take P=50%, assuming that 50% of school female adolescents were
practicing unsafe MHM. With a 0.05 margin of error, the sample size was calculated as follows:
 N = 1.96 2 Pexp (1- Pexp)/d

Where, N = required sample size; Pexp = expected value; d2 = desired absolute prelusion.
By substituting these values in the formula, 384 respondents will be required
Since the source population was finite (<10,000), the sample size correction formula was applied
and a 10%
non-response rate was added. The final sample size was 364. The participants from each school
were selected based on the proportion of female students they had.

3.7 Development of data collection tool/instrument

Self-administered semi-structured questionnaires will used to collect data. The questionnaires

will be adapted from UNICEF’s tools developed to assess MHM in the school setting and other
related literature. Bethany C, Freeman M, Dooley T, et al.2013)

3.8 Data collection process

The questionnaire will first be prepared in English and then translated into Swahili (the local
languages). Observational checklists, which assess the WASH status in the schools, will also be
used. a systematic random sampling technique to select the study participant will be used. The
students’ admission number will be retrieved from each school record offices and used as a
sample frame.

3.9 Pre-testing/piloting
To ensure the quality of the data, first, the questionnaire will be pre-tested well in sequence to
assess content validity so that the objectives of the study to be met and to check if the
translations and the research instrument will be suitable for the targeted study population and the
time available to pupils to complete the questionnaire.
3.10 Validity
Validity assesses whether the tool measures what it intends to measure, the pilot test will inform
us whether the questionnaire will indeed be able to test and answer the objectives of this study

3.11 Reliability
Reliability assesses the consistency of the measurements. These are critical for the credibility of
this data
3.12 Data analysis
After checking for completeness, collected data will be then categorized and coded in
preparation for data entry using the computer. MS Excel will be used to do data entry the data
will then be exported to SPSS for descriptive and inferential analysis. The results will be
summarized and presented in frequency tables, graphs, cross tabulations and associations
through chi-square tests to assess relationships in variables tested
3.13 Ethical considerations

This study will be conducted in accordance with the Helsinki declaration. The ethical clearance
will be obtained from the KMTC ethical review committee. A written permission of the district
education office must be obtained and a letter of support will must be written to all respective
head of the selected schools. Before starting the data collection process, the confidentiality of the
data to be collected will be ensured to the participants, and both written and informed verbal
consent will be taken from each respondent and their families. In order to ensure the anonymity
of the collected data, code number will be assigned to the questionnaire, and study participation
will be entirely voluntary.
 REFERENCES

1. UNICEF and Emory University. WASH in schools empowers girls’ education proceedings of
the menstrual hygiene management in schools virtual conference 2013 III UNICEF and Centre
for global safe water, Emory University. New York. 2013. Available from:
www.unicef.org/wash/schools. Accessed April 15, 2019.

2. Lawan UM, Yusuf NW, Musa AB. Menstruation and menstrual hygiene amongst adolescent
school girls in Kano, Northwestern
Nigeria. Afr J Reprod Health. 2010;14:201–207. 3. Wall LL, Belay S, Bayray A, Salih S,
Gabrehiwot M. A community-based study of menstrual beliefs in Tigray, Ethiopia. Int J
Gynaecol Obstet. 2016;135:310–313. doi:10.1016/J. IJGO.2016.05.015

Bethany C, Freeman M, Dooley T, et al. Tools for assessing menstrual hygiene management in
schools. 2013. Available from: www. unicef.org/wash/schools. Accessed March 25, 2020.