Human rights-based menstrual hygiene management programming for girls enrolled in secondary school

Human rights-based menstrual hygiene management programming for girls enrolled in secondary school in Gebre Guracha, Ethiopia

August 13, 2018

Submitted by:



In Partial Fulfillment of the Requirements for the

Master of Public Health Degree

Milken Institute School of Public Health

The George Washington University


Menstrual hygiene management (MHM) is critical to the promotion of health, hygiene and education for adolescent girls in Gebre Guracha, Ethiopia. Menarche is a milestone in a female’s life that marks the start of her reproductive capacity (Karapanou & Papadimitriou, 2010). This significant time occurs on a spectrum of ages as early as 9 years or as late as 15 years of age (UNICEF, 2014). Studies have shown that globally, menstruation is met by girls with fear, anxiety, misconceptions and embarrassment because of the lack of proper information or materials to ensure a healthy reproductive cycle (Jewitt & Ryley, 2014; Karapanou & Papadimitriou, 2010). The management of menstruation varies and is often dependent upon the individual’s socioeconomic status, local traditions and beliefs, and access to water and sanitation resources (Das et al., 2015). Managing one’s menstruation becomes extremely difficult if the proper sanitary materials are not available, accessible, or affordable. Some girls resort to using cloth, ashes, and even husks to manage the flow of menstrual blood (Soothe Healthcare, 2017).

The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have defined MHM as involving “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” (WHO/UNICEF Joint Monitoring Programme, 2012). MHM is not merely just the management of menstrual blood; it also involves removing stigma and addressing the cultural and/or religious beliefs regarding menstruation.

Due to the heavy stigma attached to menstruation, girls are often discriminated against within the family, around the community, and more notably, at school. Throughout Ethiopia, 51% of female students miss between 1-4 days of school per month due to menses and 39% report reduced academic performance in association with menstruation (House et al., 2012). Primary school participation by female students in Ethiopia from 2008-2012 was 65.5%, while secondary school participation fell to 15.6% (UNICEF, 2013). Many female students report missing school due to embarrassment, unsanitary and unsafe washroom facilities, and lacking basic supplies to properly manage their menstruation (House et al., 2012).

A growing understanding of the impact this problem has on school-aged girls has placed importance on MHM programming by development organizations (Sommer & Sahin, 2013). MHM programming can help achieve the SDGs and realize the rights of girls in Gebre Guracha.

Proposed Program

Education is a universally accepted social determinant of health, and well managed health issues helps to achieve academic success. As the WHO states, “good health involves reducing levels of educational failure” (Marmot & Wilkinson, 2003). For secondary school-aged girls, ages 13-18 years, living in Gebre Guracha to enjoy better health, equality, and job creation in the future, the proposed program will focus on ensuring their MHM needs are met so that they may complete their secondary education on the same footing as their male counterparts. In order to accomplish this goal, knowledge regarding MHM, school infrastructure regarding latrines and handwashing stations, access to MHM materials, and increased community support must be addressed.

Program Objectives

The proposed program objectives have been carefully developed through evidence-based research and are guided by theory to ensure effective results. The intervention objectives are as follows:

Health Objective: Within 5 years of program implementation, graduation rates of female students enrolled in Gebre Guracha Secondary School (GGSS) will increase by 15%.

Behavioral Objective 1: Within 3 years of program implementation, female students enrolled in GGSS ages 13 to 18 years will attend school at a rate increase of 25%.

Behavioral Objective 2: Within 3 years of program implementation, 35% of female students enrolled in GGSS ages 13 to 18 years will change their menstrual materials at the school latrine.

Behavioral Objective 3: Within 2 years of program implementation, 45% of female students enrolled in GGSS ages 13 to 18 years will use hygienic MHM materials (reusable pads or disposable pads).

Immediate Objective 1 (informational support): Within 1 year of program implementation, the target population’s knowledge regarding menstruation and MHM will increase by 50%.

Immediate Objective 2 (emotional support): Within 1 year of program implementation, the target population will identify three (3) MHM sources of support from the community.

Immediate Objective 3 (instrumental support): Within 1 year of program implementation, the use of school facilities (female-only latrines with proper handwashing stations) to manage their menstrual materials will increase by 50%.

Immediate Objective 4 (instrumental support): Within 8 months of program implementation, increased obtainment of menstrual material among the target population will increase by 50%.

Immediate Objective 5 (appraisal support): Within 6 months of program implementation, the target population will participate in three (3) MHM group support session at school.

Gebre Guracha, Ethiopia

The target community for this program is that of Gebre Guracha, a small, rural but growing kebele (town) located in the Oromiya Region of Ethiopia. According to the Third National Population and Housing Census conducted in 2007 (the Fourth Census has been postponed until 2019 due to civil unrest), the town of Gebre Guracha is home to roughly 20,000 individuals, half of whom are female, and approximately 2,000 of whom fall within the age group of 13 years to 18 years of age (Federal Democratic Republic of Ethiopia Population Census Commission, 2008). While national-level data of school attendance rates among females ages 13 years to 18 years in this community do not exist, it is reasonable to infer that the rates of attendance among the target population in Gebre Guracha mirrors that of the rest of Ethiopia at 15.6 percent (UNICEF, 2013). Gebre Guracha, the largest town in the Kuyu Woreda (county), has a public secondary school, grades 9 through 12, that caters to students not only living in Gebre Guracha, but who also live in the more rural areas of the woreda.

Ethiopia is a strongly religious country. Nearly 41% of the population identify themselves as Orthodox Christian, 36% identify as Muslim and 20% identify as Protestant (Federal Democratic Republic of Ethiopia Population Census Commission, 2008). Historically, all three of these religions have contributed to the cultural stigma surrounding menstruation as the Christian Bible refers to women as impure while menstruating (The Holy Bible, 2017) and the Islamic Quran classifies menstruation as an illness (The Holy Quran, 2013). With religion heavily influencing the people of Gebre Guracha, the topic of menstruation has been deemed taboo.

Gender inequality is also a major challenge the target population faces daily, especially during times of menstruation. Cultural and social norms have added to the complexity of gender inequality with regards to menstruation. Many school-aged girls living in the Oromiya Region report to have a very limited understanding of menstruation as the topic is taboo, even for mothers and daughters (Smiles & Sommer, 2013). In addition, the sign of menstrual blood also culturally signifies the time in a girl’s life when she becomes a woman. The median age for a first marriage among women in Ethiopia is 16.5 years (Central Statistical Agency and ICF International, 2012), corresponding with onset of puberty. Early marriage has several harmful effects on a girl’s health as early pregnancy typically follows, and her ability to complete her education diminishes.

Parameters for Identifying Best Practices/Interventions

Best practices will be identified through peer-reviewed articles and programming that has been replicated in other communities within Ethiopia or in similar contexts (low-income country, East Africa, communities facing gender inequality, low school attendance rates among female secondary students) using Scopus, PubMed, PsychInfo, Medline, Global Health and Google Scholar. Interventions that include a pretest/posttest research design will also be included. Programming resources will also be identified that have been developed by reputable organizations working in related fields such as WaterAid, Plan International, and UNICEF. Furthermore, recommendations from leaders in field, including Marni Sommer and Sarah Fry, will be incorporated into the program planning.

Best practices not based on evidence and interventions with incomplete or ambiguous methods will be excluded from the pool of studies. In addition, any studies or best practices published prior to 2005 will be excluded from this intervention. Lastly, any best practices or interventions not published in English will not be included.

Proposed Theoretical Approach

As MHM is necessary in the realization of girls’ rights to education, health, and water and sanitation, a human rights-based approach to ensuring effective MHM programming will be utilized to identify the rights-holders and the duty-bearers within the community. Through this approach, the root causes of stigma surrounding the topic at the community level can be addressed.

In addition, an interpersonal level of behavior change through the Social Support Theory will compliment these efforts by addressing the key constructs of this theory: informational support will be promoted by educating the target population on the menstrual cycle and reinforcing hygienic management; instrumental support will involve the direct assistance of delivering MHM kits to the target population; emotional support will be garnered from the facilitators of the program, peers, educators and through efforts to decrease the stigma, the community at large; and appraisal support opportunities will be provided for the target population through support and discussion groups.

The program planning framework that will be used in the assessment and development of this intervention will be based on the nine phases of the PRECEDE-PROCEED model. In the PRECEDE portion of the framework, the need, quality of life, health status, and risk factors of the target population will be assessed. The program will then be designed to create change in the underlining factors and health behaviors with consideration of partnerships in Gebre Guracha that can be made. An assessment plan will be developed to monitor and evaluate the implementation and impact of the program.


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