Proper menstrual hygiene management is integral to the dignity and health of women and girls. However, it is a neglected issue both in the WASH and health sectors, leading to a crisis of knowledge, facilities and hygienic practice. This briefing paper describes the initiatives taken by the Bangladesh country programme of the international non-governmental organisation WaterAid. As one of the pioneers of Menstrual Hygiene Management (MHM) in Bangladesh, WaterAid’s experiences hold important lessons for those currently working on the issue, and looking to take it forward to make sustainable impact

Hasin Jahan (7217453)

Shahrukh Y. Mirza (7219841)

English

Loughborough University Institutional Repository

MIRZA & JAHAN   1  38th WEDC International Conference, Loughborough University, UK, 2015   WATER, SANITATION AND HYGIENE SERVICES BEYOND 2015: IMPROVING ACCESS AND SUSTAINABILITY  Mainstreaming Menstrual Hygiene Management:  lessons from a decade of programme and policy work   S. Y. Mirza & H. Jahan (Bangladesh)  BRIEFING PAPER 2163   Proper menstrual hygiene management is integral to the dignity and health of women and girls. However, it is a neglected issue both in the WASH and health sectors, leading to a crisis of knowledge, facilities and hygienic practice. This briefing paper describes the initiatives taken by the Bangladesh country programme of the international non-governmental organisation WaterAid. As one of the pioneers of Menstrual Hygiene Management (MHM) in Bangladesh, WaterAid’s experiences hold important lessons for those currently working on the issue, and looking to take it forward to make sustainable impact.   Introduction Although menstruation is a normal part of a woman’s reproductive health, social constructs around menstruation mean that it is often a subject of great sensitivity, secrecy and misconception. The lack of knowledge and awareness of good menstrual hygiene practice can impact schooling (Sommer, 2010; Jewitt and Ryley. 2014; Tegegne and Sisay, 2014), health (House, Mahon and Cavill 2012) and psychology (McPherson and Korfine, 2004). Despite its widespread implications, few organisations in either the health or WASH sector address menstrual hygiene management (MHM) as an issue in its own right. Without adequate information and appropriate facilities, women around the world face the difficult prospect of managing their periods every month, or an average of 3,000 days in their lifetime (Ahmed and Yesmin, 2008), in unsanitary conditions, shrouded in shame and anxiety.  WaterAid Bangladesh (WAB) has been working on MHM since the early 2000s in order to support women and girls manage their periods in comfort and with dignity. As one of the organisations on the forefront of promoting this issue in Bangladesh’s WASH landscape, WaterAid’s experience holds important lessons for sector actors, policymakers and others looking to work in this neglected area.  WaterAid Bangladesh’s journey Menstrual hygiene was identified as an important issue since the early day of WaterAid’s work in Bangladesh. However, initial efforts in the early 2000s were piecemeal in nature, consisting mostly of providing menstrual hygiene information across different programmes, and building toilets with extra space to accommodate washing of menstrual cloths in some project areas. However, the information and facilities provided were limited in nature and were not mainstreamed across all programmes.  Realising the importance of a more coherent, integrated approach, a workshop was held in late 2005 involving staff from WaterAid and its partners. During the workshop, extensive feedback came in on the critical lack of knowledge and facilities across both urban and rural contexts. Taking this forward, WaterAid Bangladesh and its partner NGOs developed a training package exclusively on menstrual hygiene management. However, a review of the sector revealed that appropriate material to educate adolescents on the issue was not available. Existing material was targeted towards adult women, and did not include a number of vital topics such as superstitions and myths around menstruation, the importance of correct disposal of sanitary material, etc. Having identified this serious gap, WaterAid began developing its own MIRZA & JAHAN   2  information, education and communication (IEC) and behaviour change communication (BCC) material on MHM. The first of the IEC and BCC materials included booklets and flash cards for urban and rural contexts, developed in 2006. These materials have been used across all WaterAid projects since, as well as being adapted by other sector actors such as the HYSAWA Fund, Oxfam and NGO Forum for Public Health. The hardware design for MHM facilities is included in the technical design manual followed by all of WAB’s partners.  Currently, WaterAid is working on taking the MHM agenda to the national level, involving policymakers in dialogue through roundtables and other advocacy initiatives, in order to address gaps in the education and health system. Although this is one organisation’s journey, the evolution of MHM from scattered initiatives to an integrated approach to a national level advocacy agenda, holds important lessons on how sector actors can promote MHM for sustainable impact. The next section will give a brief overview of key interventions, followed by reflections on learning from nearly a decade of work in MHM.  Programmatic approach  Building MHM-friendly facilities WAB and partners have designed and are implementing gender friendly latrines in schools, slums and public places. Special considerations have been made to incorporate the needs of women and adolescent girl users into the chamber design. These include a raised platform, and provisions for soap and water inside the toilet to wash menstrual cloths. A bar is provided to allow women to hang the washed cloth for drying. A bin is placed inside the toilet so pads and cloth can be disposed discreetly. All of these features are based on feedback from girls and women, in order to ensure user friendliness and effectiveness.    Figure 1. MHM-friendly facility design  Source: WaterAid Bangladesh Design Manual  MIRZA & JAHAN   3  Improving knowledge and awareness   Menstrual hygiene sessions in schools  Though a chapter on adolescence including information on menstrual hygiene is available in textbooks from Grade 6 (which is the beginning of secondary school in Bangladesh’s public education system) onwards, teachers customarily ask students to read this on their own at home. Many male and often even female teachers are uncomfortable discussing the topic of menstruation, reinforcing the prevalent stigma and lack of information. In order to address this, WaterAid orients school teachers (at least one male teacher and one female teacher per school) on menstrual hygiene, and their roles and responsibilities to adolescents experiencing menarche and menstruation. Teachers disseminate and discuss hygiene promotion issues on water and sanitation among students. Adolescent girls’ groups are formed in schools and MHM issues are discussed utilising pictorial books (see Figure 2) which elaborate on menstruation related activities and the importance of basic cleanliness during this time. Girls in secondary school as well as in Grade 5 (the final grade of primary school) are included in the sessions.   Adolescent girls groups Frontline staff facilitate in gathering groups of friends and forming “Kishori Dol” (girls groups). These groups together with staff discuss hygiene promotion issues, including MHM. The session uses a doll and flash cards to cover subjects such as menarche, menstruation, and proper management of sanitary cloths. The last of these is especially important as over 80% of women and girls in Bangladesh use old cloth or rags to manage their periods (icddr,b 2014). Washing and drying these cloths for reuse are a constant source of difficulty given the fear of exposure. Many girls also do not have the awareness or lack adequate supplies to ensure proper cleaning of cloth by washing with improved water and soap. Another common practice is to dry the washed cloths in hiding, often selecting dark, damp places such as behind cupboards to maintain secrecy, though recommended practice is to dry cloths in sunlight to kill germs. These practices can cause health problems including vaginal itching and urinary problems (Ahmed and Yesmin, 2008). Proper washing and drying techniques are therefore an important component of sessions conducted with adolescents. Food requirements during menstruation are also discussed, as cultural practices in some areas forbid eating certain foods such as fish or eggs during periods, meaning girls from low income families can be deprived of key sources of protein at a critical time unless these myths are dispelled. Overall, the topics addressed include both physical management of periods as well as prevalent myths and misconceptions.   Courtyard meetings Courtyard meetings are held to address the hygiene education for women of reproductive age. The meetings are organised for women only, held at periodic intervals and facilitated by female frontline staff or community volunteers. Specific sessions on menstrual hygiene management are organised in the courtyard using flash cards and dolls for demonstration, covering many of the issues mentioned above.  Advocating at the national level Since 2014, WaterAid Bangladesh has begun advocating at the national level for promoting the visibility of MHM as an issue, as well as influencing policymakers towards access to better facilities and more information at the school and community level. This includes an innovative campaign around the ICC Cricket World Cup, where various events such as workshops, training sessions and games took place with girls groups in ICC match venue locations, all centring on the issue of menstrual hygiene. A roundtable in May 2014 invited sector actors, policymakers and academics to discuss and provide recommendations on the way forward which was entitled “Let’s Talk about Menstruation”. These activities are changing the status quo by opening up dialogues at the government level, and advocating for reform in school systems that can make large-scale, long-term impact.  Lessons learned  The importance of local context  Menstrual hygiene practices are shaped to a large extent by the locality in which one lives, such as access to facilities, living space, etc. For example, space constraints may mean very different drying and storing practices in urban areas compared to rural areas. To address the unique challenges of each region, separate MIRZA & JAHAN   4  MHM modules were prepared for rural, urban and Hill Tracts regions, with illustrations and information relevant to each area.              Figure 2. Illustrations from MHM pocketbooks for Urban, Rural and Chittagong Hill Tracts  Source: Menstrual hygiene education material for women and adolescent girls, WaterAid Bangladesh  Designing with the community and partners  Programme interventions need to incorporate knowledge of local management practices, food habits, misconceptions, etc. in order to be effective. WaterAid’s extensive consultations with partners and community members have been key to its MHM module as well as the design of hardware facilities, which has seen several modifications in different areas based on feedback from users. For example, community toilets were initially built with a separate chamber exclusively for MHM purposes. However, users reported that they felt uncomfortable using these chambers as men would identify anyone entering them as menstruating. This led to a redesigning of community toilets to incorporate MHM features within female toilets instead of as a separate facility.   Building a body of evidence  MHM has been the topic of a number of studies including two surveys in urban slums conducted in 2005 and 2011, several case studies across different geographical contexts, and a study in the Chittagong Hill Tracts. Most notably, a separate MHM module was included in the Bangladesh National Hygiene Baseline Survey (icddr,b, 2014). This survey, the country’s first nationally representative study on hygiene knowledge and practice, revealed the dire state of menstrual hygiene, including a dearth of knowledge on menstruation (see Table 1), lack of suitable facilities, and the impact on schooling of girls (see Figure 3). These findings feed into programmatic decision-making and approaches, and are critically important to influencing policymakers and other actors recognise the severity of the problem and instigate change.        Table 1. MHM knowledge and practice amongst adolescents at school and households, and adult women (Source: Bangladesh National Hygiene Baseline Survey 2014) Indicators Adolescent school girls Adolescent girls at household Adult women Knew/heard about menstruation at menarche 36% 42% 36% Use cloth during menstruation 86% 85% 82% Washed cloth with soap and improved water, and dried in sunlight for repeated usei 12% 23% 27% MIRZA & JAHAN   5     Figure 3. The challenges of MHM for school girls  Source: Bangladesh National Hygiene Baseline Survey 2014  Taking a multi-pronged approach  WAB works at the individual and community level through MHM sessions and inclusive facilities, as well as across the national level with an agenda to break the silence surrounding the issue. This multi-pronged approach means the organisation directly supports vulnerable groups practice better menstrual hygiene, as well as contributes to a more positive social and policy environment where menstruation is no longer a taboo subject. Initiatives such as roundtables and sports events increase the visibility and acceptance of MHM at the national level, and act as entry points for policy changes such as including MHM in teachers’ training, improving delivery of lessons at the school level, etc.  Way forward While much progress has been made on providing women and girls with more information and better facilities, WaterAid Bangladesh will continue to prioritise this area of work in order to tackle longstanding technical and social barriers. This includes researching and piloting different ways of disposing of used sanitary materials. Alongside, men and boys must be involved further in MHM initiatives in order to create a holistic support system where they are not the cause of harassment or shame, but play a positive role. WAB will also continue its advocacy work with teachers, school authorities and policymakers in order to achieve systematic changes in menstrual hygiene education and facilities across schools.    Conclusion Menstrual hygiene management (MHM) is gradually being acknowledged as a critical health, WASH and rights issue. As one of the foremost organisations working on menstrual hygiene in Bangladesh, WaterAid Bangladesh’s experience holds some important lessons for other initiatives. In terms of programmatic interventions, working closely with communities, partners and actual users is integral to appropriate design of both MH facilities and IEC/BCC material. Alongside, sustained research can guide programmatic directions, as well as support much needed evidence-based advocacy. Finally, it is important for a long-term, prevalent solution that MHM be mainstreamed not only across organisations, but across the health and education systems. Taking a holistic, multi-tiered and learning approach allows WaterAid Bangladesh to MIRZA & JAHAN   6  effectively respond to evolving needs on the ground, as well as positively impact nascent national initiatives that can eventually transform women’s lives for the better.   References Ahmed, R. and Yesmin, K. (2008) Menstrual hygiene: breaking the silence, in Wicken et al. (eds.) Beyond Construction Use By All. IRC International Water and Sanitation Centre and WaterAid. House, S., Mahon, T. and Cavill, S. (2012) Menstrual hygiene matters: A resource for improving menstrual hygiene around the world. WaterAid: UK. Available at: http://www.wateraid.org/what-we-do/our-approach/research-and-publications/view-publication?id=02309d73-8e41-4d04-b2ef-6641f6616a4f.  International Centre for Diarrheal Diseases Research, Bangladesh (icddr,b) (2014). Bangladesh National Hygiene Baseline Survey. Available at: http://www.psu-wss.org/assets/book/bnhbs.pdf.  Jewitt, S. and Ryley, H. (2014) It’s a girl thing: Menstruation, school attendance, spatial mobility and wider gender inequalities in Kenya, Geoforum 56, pp. 137-147. McPherson, M. E. and Korfine, L. (2004) Menstruation Across Time: Menarche, Menstrual Attitudes, Experiences and Behaviors, Women’s Health Issues 14, pp. 193-200. Sommer, M. (2010) Putting menstrual hygiene management on to the school water and sanitation agenda, Waterlines, Vol. 29, No. 4, pp. 268-278. Tegegne, T.K. and Sisay, M. M. (2014) Menstrual hygiene management and school absenteeism among female adolescent students in Northeast Ethiopia. BMC Public Health 14(1).      Note/s i This is considered to be recommended practice (icddr,b 2014). The alternative in this case is washing the cloth for reuse with unimproved water and/or without soap, and/or not drying in sunlight.  Contact details Shahrukh Yasmin Mirza Programme Officer- Organisational Learning WaterAid Bangladesh House 97/B, Road 25, Block A, Banani, Dhaka 1213, Bangladesh Tel: +8801755520184 Fax: +88029882577 Email: ShahrukhMirza@wateraid.org www.wateraid.org    Hasin Jahan Director- Programmes and Policy Advocacy WaterAid Bangladesh House 97/B, Road 25, Block A, Banani, Dhaka 1213, Bangladesh Tel: +8801713036791 Fax: +88029882577 Email: HasinJahan @wateraid.org www.wateraid.org   

Mainstreaming menstrual hygiene management: lessons from a decade of programme and policy work

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Mainstreaming menstrual hygiene management: lessons from a decade of programme and policy work

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