Teaching Girls About Puberty and Menstrual Hygiene Management in Rural Ethiopia: Findings From a Pilot Evaluation

Abstract

Educational interventions on menstruation and puberty have emerged as an important element of efforts to improve girls’ knowledge and confidence related to puberty, menstruation, and menstrual hygiene management (MHM). We conducted a mixed-methods evaluation of the Ethiopia Growth and Changes puberty book, developed through research with Ethiopian girls to present scientifically accurate content on MHM in a format appropriate to girls’ lives. Deploying a cluster-randomized approach, we conducted quantitative surveys with girls enrolled in Grades 6 and 7 (n = 636) in 10 intervention and 10 control schools in two rural districts of the West Shewa Zone of Oromia, Ethiopia. We collected qualitative data from girls in intervention schools. We found that the book was associated with a statistically significant improvement in knowledge, and evidence of improvements in attitudes around menstruation. Qualitative evidence underscored a strong interest in interventions that present information on menstruation and puberty in accurate and supportive terms. Consistent with an ecological framework for adolescent health, we conclude that puberty books offer a useful individual-level intervention, whose impact would be magnified if combined with investments aimed at creating more gender equitable physical and social school environments.

Keywords

adolescence early adolescence gender global/international issues

Recognizing that girls’ education is not only a right, but a protective factor for preventing a range of adverse sexual and reproductive health outcomes, including child marriage and early pregnancy, research, programming, and policy in low- and middle-income countries (LMIC) has for many years been directed toward increasing girls’ educational enrollment and success. Such efforts recognize that the benefits of education may be undermined by factors operating at different levels, including in the school environment, which may discriminate against girls in particular, such as the inadequate provision of appropriate water, sanitation, and hygiene (WASH) facilities (Mensch, Clark, Lloyd, & Erulkar, 2001).

More recently, the issue of menstrual hygiene management (MHM) has become a focal point for research and action to address girls’ health and education in LMIC (Sommer, Hirsch, Nathanson, & Parker, 2015). Much of this attention has focused on the barriers posed for girls’ education by inadequate MHM information and support provided to girls, and poor WASH infrastructure in schools (Sommer, Caruso, et al., 2016; Sommer, Hirsch, et al., 2015; Sommer & Sahin, 2013). The latter includes the many ways that a lack of safe, private, and clean toilets, with doors and locks, easy access to water, and mechanisms for disposal of used menstrual materials, may be hindering girls’ active participation and engagement in school. Although significant evidence documents the shame, embarrassment, and discomfort that many girls report experiencing in attempting to manage their menstruation in school environments, empirical evidence is still lacking on the most effective approaches for intervening on the WASH aspects of MHM, and appropriate measures to use for capturing the social and psychological impacts of inadequate school environments for menstruation (Hennegan & Montgomery, 2016).

Along with a growing interest in addressing physical factors in the school environment that undermine girls’ ability to effectively manage menstruation at school, individual knowledge and interpersonal dynamics and social norms around girls’ bodies also constitute promising entry points for improving girls’ health and educational outcomes. Individual and interpersonal factors that relate to MHM may have important ripple effects, given that research has identified early adolescence as an important but underaddressed period for preventive health interventions (Bankole, Biddlecom, Guiella, Singh, & Zulu, 2007; Blum, Bastos, Kabiru, & Le, 2012; Brady, 2011; Igras, Macieira, Murphy, & Lundgren, 2014; Patton et al., 2012). By intervening to build girls’ and boys’ knowledge and skills in ways that reflect gender equitable social norms, and provide accurate, age-appropriate health information, interventions can build healthy habits at a pivotal time of physiological and social development.

The provision of puberty education to very young adolescents has been identified as a promising tool for reaching young people at a window of opportunity before they initiate high-risk sexual behaviors (Bankole et al., 2007; Igras et al., 2014). Such efforts may also address gaps in family-level factors shaping girls’ health and education. Research from various contexts, including LMICs, suggests that very young adolescents often want their parents and other trusted adults to provide guidance on puberty and topics related to sexual and reproductive health, but that parents often feel uncomfortable and uninformed, and avoid these topics (Biddlecom, Awusabo-Asare, & Bankole, 2009; Crichton, Ibisomi, & Gyimah, 2012; Institute for Reproductive Health, 2010; Muhwezi et al., 2015; Namisi et al., 2009; Ybarra, Emenyonu, Nansera, Kiwanuka, & Bangsberg, 2008). Although evidence on the role of parents in improving sexual and reproductive health outcomes remains uneven, interventions that aim to improve parent-child communication have been shown to foster improvements in the quality of this communication and to contribute to reductions in risky sexual behaviors (Bastien, Kajula, & Muhwezi, 2011; Kirby, 1999; Vandenhoudt et al., 2010; World Health Organization, 2007). Thus, puberty education materials that encourage parent-child dialogue may help to dispel myths and misconceptions around puberty and menstruation and serve as a stepping-stone to initiating discussions about more sensitive topics (Sommer, Sutherland, & Chandra-Mouli, 2015).

Along with constituting a potential form of early intervention in the broader arena of sexual and reproductive health outcomes, puberty education materials that address the immediate concerns that girls face around menarche and menstruation may be of critical importance on their own. Studies across various LMICs, including Ethiopia, have found that for many girls, the experience of menarche is imbued with fear and shame (Mason et al., 2013; McMahon et al., 2011; Sommer, Ackatia-Armah, Connolly, & Smiles, 2015; Tegegne & Sisay, 2014). Girls have reported fearing that blood is a sign of injury or illness (Sommer, Ackatia-Armah, et al., 2015). Many girls have also reported hiding the onset of menstruation because they anticipate punishment from family members who associate menstruation with sexuality or as a sign of sexual activity (Mason et al., 2013; McMahon et al., 2011; Sommer, Ackatia-Armah, et al., 2015; Tegegne & Sisay, 2014). Such findings underscore the need for interventions that fill gaps in girls’ (and caregivers’) knowledge, address misconceptions, as well as harmful taboos or social norms related to menstruation.

In many LMICs, including Ethiopia, students encounter only poor quality education on puberty and MHM. As one United Nations Educational, Scientific and Cultural Organization (UNESCO, 2012) review of national sexuality education curricula in countries in Eastern and Southern Africa found, menstruation was among the topics where content was weakest: Curricula tended to present menstruation solely in negative terms and provide little practical guidance on MHM. Furthermore, evidence from Ethiopia suggests that schools do not deliver even the minimal content that is required under official education policy. For example, in a recent national survey of Ethiopian young people (ages: 12-24 years), just one in four respondents reported having received health and family life education (Population Council, 2010). This and other studies from Ethiopia have found large proportions of girls who report learning either misinformation or nothing at all about menstruation prior to reaching menarche (Population Council, 2010; Tegegne & Sisay, 2014). Across such studies, Ethiopian girls and boys alike report frustration with available sources of information, including low levels and poor quality of communication on reproductive health-related questions with parents (Ayalew, Mengistie, & Semahegn, 2014; Shiferaw, Getahun, & Asres, 2014; Tesso, Fantahun, & Enquselassie, 2012).

In response to the gap in puberty guidance identified in Ethiopia and other LMICs, books that reflect scientifically accurate information and girls’ voiced experiences of the onset of menstruation have emerged as a promising tool for filling girls’ gaps in knowledge and countering stigma and local misconceptions around menstruation (Sumpter & Torondel, 2013). The books offer a potentially scalable approach in countries that often have education systems with teachers that may be uncomfortable teaching on taboo topics, such as menstruation, and undermotivated to add content if it is not part of the national testing requirements. In addition, such books may provide girls with the opportunity to enhance their literacy through reading about a subject matter of profound interest to many of them. However, there exist few quantitative measures of the effectiveness of such books in improving girls’ MHM experiences in school. In addition, context-specific information on menstruating girls’ experiences at home and at school remain insufficiently understood, along with their impressions about the provision of puberty and MHM content in book form.

In an effort to better understand the possibilities of a simple distribution of a puberty book to girls, with no additional human capacity (e.g., teacher involvement) investment needed, we conducted a small, rigorous evaluation encompassing the distribution of one such book, the Ethiopia version of the girl’s puberty book Growth and Changes (Smiles & Sommer, 2013). Save the Children International (SCI) served as the implementing partner in the pilot study. SCI is an international nongovernmental organization (INGO) working to respond to the health, education, and social challenges facing young people in Ethiopia and other LMIC. SCI administers health and education activities in schools and communities throughout the Oromia region in Ethiopia. The rationale for testing a simple distribution was the recognition of the limitations for new school-based interventions in resource-constrained environments that have limited teacher capacity and comfort on MHM.

We drew on an ecological framework of adolescent health to locate our assessment within the context of the individual, interpersonal, institutional, community, and policy-level factors that shape menstruating girls’ MHM practices and school-going experiences (Blum et al, 2012). The ecological framework locates issues of health behaviors and outcomes as shaped by many factors at distinct, yet interrelated levels, while underscoring the importance of interventions that are both focused on specific factors that influence specific health behaviors and outcomes, and linked with the broader context of factors, levels of influence, and health behaviors that contribute to health outcomes (Bronfenbrenner, 1979; Svanemyr, Amin, Robles, & Greene, 2015). In applying the ecological framework, we consider MHM and puberty education as among the factors that shape girls’ health directly, and ultimately their education and participation in school. Within this approach, we focus on assessing the immediate impact of the intervention as it influences girls MHM at the individual level (e.g., knowledge and attitudes about menstruation) while also gathering information on salient factors at the community or environmental level (e.g., school sanitation facilities, presence of female teachers).

Research Setting

The pilot study was conducted in rural schools in two districts in the West Shewa zone of Oromia region (Central Statistical Agency of Ethiopia, 2014). Oromia is characterized by high levels of poverty, and significant health and education challenges (Save the Children, 2013). Just 3.2% of adult women have completed primary education, and more than one in five children are malnourished (Central Statistical Agency of Ethiopia, 2014). As in other regions in Ethiopia, girls in Oromia continue to attend primary school at lower rates than boys, and only small minorities of boys and girls alike continue on to secondary school (Central Statistical Agency of Ethiopia, 2014).

Method

Intervention

The Ethiopia edition of Growth and Changes is a book aimed at girls aged 10 to 14 years, covering various puberty education topics, including specific content on menstruation and MHM. The book was developed in Ethiopia in 2012 and is one of a series of country and gender-specific puberty books that were first developed in Tanzania (Ackatia-Armah & Sommer, 2012; Sommer, 2009, 2011a; Sommer & Connolly, 2012). Each puberty book presents scientifically accurate information on the physiological changes of puberty integrated with tailored, culturally appropriate framing and stories. In each country, the book development process includes qualitative research conducted with adolescent girls (or, boys, in the case of boy-specific books) and the adults in their lives. This research includes space for girls to describe their own experiences with puberty and MHM, and the stories collected in this process serve as the basis for those included in the final books. All Growth and Changes books incorporate input from local stakeholders, and engage local translators, illustrators, and publishing companies to assure cultural appropriateness. Draft versions of each book are field tested with girls (of similar age and grade as the intended audience), parents, and teachers for appropriateness, relevance, and match with literacy levels. The final versions of the books in each country (Tanzania, Ghana, Ethiopia, Cambodia, and Madagascar) have been approved by the respective countries’ Ministries of Education for distribution in primary schools and in some countries, lower secondary schools.

Research Design

The evaluation used a mixed-methods approach. As Creswell (2003) notes, combining quantitative closed-ended measures with open-ended, qualitative approaches are well-suited to study issues in which the gathering of both generalizable information from a large set of participants, and exploring local, context-specific meanings, relevance, and social context, offer important additional insights. For the quantitative portion, we used a cluster-randomized trial design. Based on established guidance (Hemming & Marsh, 2013), an a priori power analysis for a p value of .05 indicated that at least 20 clusters (10 per arm) with at least 25 participants in each cluster were necessary to achieve the desired power of 80%. We identified an initial pool of 30 eligible schools per district using lists provided to SCI by district education offices.

In order to avoid the risk of contamination across study arms, we randomly assigned one district to intervention and one to control. Schools that had at least 25 girls enrolled in Grades 6 and 7 combined and that were accessible by road were eligible to participate. Once such schools were identified, we randomly selected 20 schools from a list of those fitting our inclusion criteria. Within each school, all girls enrolled in Grades 6 and 7 and present on the day of the survey were eligible to take part in the study. However, only questionnaires completed by those girls who were present at both pre- and posttest were included in the final analysis (n = 636).

In addition, a smaller group of girls in intervention schools (n = 8 schools) were identified to participate in a posttest qualitative research component of the evaluation in order to provide additional insights into the quantitative findings (n = 75).

The research team developed quantitative and qualitative instruments adapted from existing evaluations of puberty education materials, including (unpublished) quantitative and qualitative prior assessments conducted of the Tanzania edition of Growth and Changes (Smiles & Sommer, 2013). SCI then oversaw translation of the instruments into Afaan Oromo, and field tested the tools with girls enrolled in schools in Oromia who were not included in the study. The final versions were back-translated into English.

In addition, we used a checklist to record information of each school’s environment at baseline. The checklist included direct observation of sanitation facilities (e.g., availability of gender segregated latrines, quality of construction materials and/or water sources, as well as cleanliness, measured in terms of visible waste, odor), along with school data such as enrollment by grade and gender, number and gender of teachers, and average time that it takes most female students to walk to school. This information was used to ascertain the ratio of girls (or, where no gender-specific latrine was available, both boys and girls) to latrines. The study team also revisited latrine facilities to verify that no major changes to quality had occurred between pre- and posttest.

We defined a 4-week follow-up period for the evaluation based on what was feasible given the timing of the Ethiopian school year, as well as the challenges in accessing rural schools during the rainy season.

The study received ethical approval from the [University name removed for blind review] Institutional Review Board and the Ministry of Education for the Oromia region of Ethiopia. Informed consent and assent were acquired before all data collection activities.

Data Collection

The pretest was conducted over a period of 2 weeks in classrooms without teachers present. A research team that included a Columbia University Mailman School of Public Health researcher and local SCI staff fluent in Afaan Oromo visited each school, distributed paper copies of the questionnaire, and read the questionnaire aloud in English and in Afaan Oromo. This was intended to assure that all girls, including those girls with lower literacy levels, were able to comprehend the questionnaire. The full procedure took approximately 45 minutes. After the pretest, books were distributed to all of the participants in the intervention schools. Girls were encouraged to read the books, but were not asked to study the material as they would for a test.

After 4 weeks, the research team returned to all of the schools to administer the posttest. In the intervention schools, two items were added to the posttest questionnaire in order to assess girls’ actual use of the books: (a) how many times the girl had read the book, and (b) to whom, among friends and family, each girl had shown the book.

Following the posttest administration of the survey, the research team conducted qualitative data collection in each of the intervention schools. We used a purposive sampling approach to identify students who would represent a diversity of experiences, while also being able to communicate their views in writing. In each school, we asked the head teacher to identify four or five girls each from Grades 6 and 7 (n = 75) who were sufficiently literate as to be able to provide written responses to an anonymous, written, self-administered five-question open-ended questionnaire (see Table 1). The aim was to gather additional information on girls’ views of the book, as well as their existing sources of MHM-related knowledge and social support.

Table 1.

Sociodemographic Characteristics and Menstrual Practices.

Variable	M/%
Age	13.45 (SD = 1.45, range 10-19)
Ethnicity
Oromo	88.7%
Amhara and Oromo	7.2%
Amhara	3.3%
Father’s education
No education	29.5%
Primary education only	49.5%
Mother’s education
No education	48.3%
Primary education only	38.9%
Girls at menarche at pretest	63.6%
Menstrual management
Sanitary pads	41%
Cotton wool	25.7%
Toilet paper or tissue	22.8%
Towel	5.4%
Menstrual waste disposal at school
Put in the latrine	77.4%
Drop it into the flush toilet	22.0%
Put into a bag	5.0%
Burn them	4.6%
Throw them into the bush	4.4%
Throw them in the dustbin	3.7%
Do not change materials at school	17.6%
Missed school because of menstruation	23.9%
Stomach pains	40%
No materials to manage blood	20%
Afraid of latrine	11.4%
Latrine is dirty	3.5%
Parents, teachers, or I believe I should	2.7%

Quantitative Measures

The assessments are based on a 40-item, self-administered multiple-choice questionnaire. The questionnaire included items that elicited basic sociodemographic data, including whether girls had experienced their first menstruation. It also captured the girls’ opinions about school latrine facilities and their suitability for MHM, prior exposure to information on menstruation and the source of that information, and data on the materials and facilities girls typically used to manage their menstruation.

We measured girls’ knowledge of and attitudes toward menstruation and the physiological changes associated with puberty based on a series of nine true/false questions. These items specifically addressed concepts included in Growth and Changes. Sample items include the following: “As girls grow into women, their hips grow smaller,” “All girls get their first menstruation by age 11,” and “Girls should stay home from school when they are menstruating.”

We measured knowledge/attitudes based on a score on the nine-item series. One point was awarded for each correct answer (for the knowledge questions) and each answer that indicated more positive attitudes toward pubertal changes and menstruation (for the attitude questions); the total range of possible scores was 0 to 9. The scale had a Cronbach’s alpha of .77, indicating adequate reliability. We calculated change scores by subtracting the participants’ pretest knowledge/attitudes score from their posttest knowledge/attitudes score. The full possible range was −9 to 9. Positive scores indicate positive change in knowledge and attitudes toward menstruation.

In addition to the knowledge/attitudes score, we also measured changes in feelings of fear or shame about menstruation using two items with dichotomous response options—“Does the idea of menstruating make you feel afraid or shameful?” and “Is talking about menstruation something that is shameful for you?” At posttest, girls in the intervention group were also asked how many times they had read the book and to whom they had shown it.

Data Analysis

Quantitative analysis

A total of 679 participants completed the pretest questionnaire and 670 completed the posttest. Analysis was conducted for those participants who completed both a pre- and posttest (n = 636). The intraclass correlation of the school clusters was .06 (95% confidence interval [CI] = [0.07, 0.12]). A randomization check indicated that the participants in control schools scored an average 0.97 points higher on the knowledge and attitudes scale in pretest. Therefore, we defined pre-to-posttest change scores as the dependent variable (Allison, 1990).

In order to account for the clustering within schools, we used a mixed-effects linear regression analysis to determine whether the book intervention had an impact on the girls’ knowledge surrounding menstruation. The dependent variable in this analysis was the change in scores from pretest to posttest across the nine-item series of knowledge questions. The independent variable was belonging to the intervention (=1) or control (=0) group. In this method of analysis, higher change scores indicate a higher score on the posttest; and negative scores indicate that girls scored lower on the posttest than pretest. We adjusted analyses for age, mother’s education, father’s education, and grade in school. This model was not adjusted for baseline (pretest) scores on the knowledge test, as doing so with change scores as the dependent variable in this model would introduce error into the estimates. A fuller discussion of this is in Allison (1990) and Maris (1998).

In addition, we used mixed-effects logistic regression to compare the intervention and control groups on girls’ feelings of shame and fear toward menstruation. Smaller odds ratios (ORs) indicate that girls were less likely to report feeling fear or shame toward menstruation. We adjusted analyses for age, mother’s education, father’s education, and grade in school.

Qualitative analysis

We utilized thematic analysis to identify the major themes in the girls’ responses in written responses and to analyze the transcripts from the teacher interview transcripts. One researcher conducted an initial analysis to identify the frequency of repetition of responses to each question, and organize similar responses into key themes. For the second stage of analysis, two researchers reviewed the resulting responses and discussed to reach a consensus on the most common and salient themes.

Results

Girls

Sociodemographic information and background

The vast majority of girls in both groups were members of the Oromo ethnic group. Parents’ education was low, as most girls in both control and intervention sites reported that both parents had either a primary education or no education at all. More girls reported that their mothers had no education compared with their fathers. The girls in the control group reported lower overall education of their mothers, χ² = 13.38, p = .004, and their fathers, χ² = 18.81, p = .001, than the girls in the intervention group. Girls reported their ages as between 10 and 19 years (Table 1), with a mean of 13.45. Nearly two-thirds reported that they had experienced their first menstruation; there were no differences between the intervention and control groups. Girls’ normal methods of managing their menstruation are reported in Table 1. Among girls who had begun menstruating, approximately one in four reported that they had ever missed school for reasons due to menstruation.

Puberty and MHM-related knowledge, attitudes and practices

The mean change score for all participants was 0.67, with a standard deviation of 1.53. The change scores ranged from −5 to 6. The average change score for girls in the intervention group was 1.06, with a standard deviation of 1.52; the average change score for girls in the control group was 0.18, with a standard deviation of 1.4. Using change scores on the nine-item scale to measure knowledge, we found evidence that the book had a positive effect on girls’ knowledge about menstruation (Table 2). The intervention group had on average a 0.88 higher change score than the control group, meaning that their scores increased by a bit less than 10% more than the control group’s from pretest to posttest. The effect size (Cohen’s d) of this change was 0.6, which is considered a medium-sized effect. Furthermore, we used change scores to account for the higher scores among the control group at baseline. However, while the control group began with significantly higher scores on the knowledge-related variables, that significant difference was gone by posttest. This indicates that the intervention group improved, while there was no change in scores of the control group.

Table 2.

Multivariate Mixed-Effects Linear Regression Results for Association Between Intervention and Change Scores for Knowledge About Menstruation.

Variable	Wald χ²(7) = 357.11, p < .001		p
Variable	Coefficient	SE	p
Intervention (group)	0.96**	0.25	<.001
Age	0.07	0.04	.155
Grade level	0.11	0.14	.420
Mother in home	0.01	0.20	.942
Mother’s education	−0.20*	0.09	.026
Father’s education	<−.001	<.001	.827

p < .05. **p < .01.

Age, father’s education, grade level, and mother’s residence in the home were not significant predictors of change from pretest to posttest. The only family background variable statistically significantly related to change in knowledge was mother’s education, and this was in a negative direction. That is, girls whose mothers had any primary education had lower change scores.

In addition to the gain in knowledge, analysis of the two attitudinal variables suggested that the book had a positive effect on girls’ attitudes regarding menstruation. At pretest, 73.6% of the girls said that the idea of menstruating made them feel afraid or fearful, and approximately half (50.8%) said that talking about menstruation was something that was shameful to them. At the posttest, girls in the intervention group were less likely to indicate that they felt fear regarding menstruation (OR = 0.70, 95% CI = [0.51, 0.95]) or shame (OR = 0.61, 95% CI = [0.38, 0.96]) than girls in the control group. However, girls’ reported comfort with managing menstruation at school did not improve between pre- and posttests for either group.

Girls’ responses to the qualitative questions (Table 3) indicated, overwhelmingly, that the book had a positive impact on their knowledge and comfort with discussing the physiological changes associated with puberty, including menstruation. In general, girls tended to agree that “all parts” of the book were important, either providing information that was new to them or providing a helpful, affirming presentation of known information. Responses further followed three broad themes:

Table 3.

Selected Quotes From Girls in Intervention Sites.

1. Did you find this book useful? Why or why not?

Reduced shame and confusion:
• Girls normally fear when they see their menstruation for the first time. This book teaches us not to be frustrated as it is a process and natural. (14, Grade 7)
• It is important as it clearly shows that menstruation does not mean that the girl has started sexual intercourse with male. (15, Grade 7)
Overcoming secrecy:
• It encourages us to tell our family when we see menstruation for the first time. Moreover, it also gives us confidence about our physical growth. (15, Grade 6)
• Yes, it is very important book because I have learned a lot from it and I can boldly say that I can be a good model in sharing the experience to other girls who cannot read and write. I can also advise them that they should not feel ashamed of the changes and menstruation they see monthly. (17, Grade 6)

2. What did you find interesting about this book?

Reduced shame and confusion:
• I should not be frightened when I see menstruation. (15, Grade 6)
• The part that tells me not to worry during menstruation makes me feel free. (14, Grade 7)
• It is not shameful to ask people like my mother about menstruation. (14, Grade 6)
Overcoming secrecy:
• The part that motivates me to help my sister or friend during menstrual cycle is very important. (14, Grade 6)
• Most parents used to punish for bloods during menstruation traditionally. This book gives awareness to all that it is normal for a girl and other women to see menstruation. (14, Grade 7)

3. What did you not like in the book?

Insufficient support:
• Telling it to my father and my mother because uneducated fathers may not understand about menstruation. (no age, Grade 7)
• Every part in the book is vital. (14, Grade 6; 15, Grade 7)
• Nothing, we have to advise our youngsters. (15, Grade 7)

4. Who would you recommend read this book in Ethiopia? Please explain why.

Overcoming secrecy:
• Girls, females and teachers because menstruation is considered as secret among females. (14, Grade 6)
• Girls at lower grades like 4 should also get access to this book. (14, Grade 7)
Insufficient support:
• Girls, friends and women should read the book. It is educative for boys and males as well. If they know about it, they may advise their sisters. (13, Grade 6)
• All the parents in Ethiopia should read and know what this book says. If they have awareness, it is easy for them to advice their children. They should understand that it is normal for girls to experience the changes and menstruation at certain age in their life. (14, Grade 6)

5. Is there anything else you would like to tell us about this book?

6. Thank you for the book and keep on providing us with helpful books like this. (16, Grade 7)
7. Yes, the book is interesting. We need other books that tells us about our rights! (14, Grade 7)
8. Clean and tidy toilets should be built in all schools for girls to use during menstruation. (no age, Grade 7)

Reduced shame and confusion about puberty and menstruation

Many girls praised the book because it made clear that menstruation and puberty are “natural processes” common to all girls, about which they should not feel shame. Several also cited specific examples of bodily changes, such as menarche and the development of public hair, which they had previously found confusing or upsetting, now made sense. Some remarked that thanks to the book, they now had a better understanding of how to manage menstrual bleeding.

Overcoming secrecy around menstruation

Many girls said that the book helped them “feel free” when discussing menstruation because it was a natural process. Several girls remarked that the book helped them to understand that it was acceptable to ask questions about menstruation, including to their mothers. Many girls further articulated the importance of removing the shroud of secrecy that is pervasive within their families and communities around the topic of menstruation. In response to one question on who else should read the book, several girls suggested that the book would be useful for younger girls to learn about their bodies, while older girls and women should read it as a tool for helping them to teach younger girls about menstruation and puberty and to guide open and informed discussions.

Insufficient support and knowledge about menstruation and pubertal changes from other sources

Girls’ responses to questions on what they found useful about the book in general, as well as who else should read the book reflected a general sense that neither adults nor peers are currently informed or equipped to provide the support girls need to prepare for the onset of puberty. Although the questions did not specifically seek girls’ views on whether the book was relevant to boys and men, a few girls suggested that they should also read the book to learn about the experiences that girls have, and to help their female family members. A few girls specifically said that it was not relevant or appropriate for boys or men, although they did not elaborate on reasons for their opposition.

Notably, no girls wrote “negative” responses to the open-ended questions exploring their opinions about the book and its relevancy (or not) for others in their communities. In response to one question that specifically asked what they did not like about the book, nearly all girls answered that they liked all parts of the book, or that there was no part they did not like. Those few who did identify an example of something they did not like cited one story that involved girls being punished unfairly, suggesting that they had simply had an emotional response to the events in the story. While it is possible that cultural and power dynamics influenced their responses, the anonymous nature of the data collection process was intended to balance out such biases. Many respondents also elaborated on their positive responses, by, for example, citing clear and specific examples of topics that they had previously considered shameful but now felt grateful to learn were acceptable to more openly discuss and were normal aspects of growing up.

Observation Checklists

School enrollment ranged from 320 to 1,400. One school enrolled students in Grades 1 to 6, while 19 schools included Grades 1 to 8. While there were two schools with more girls enrolled than boys, boys accounted for majorities (between 55% and 60%) of students in the remaining schools. In each school, a majority of teachers were male, and one school had no female teachers at all.

Across both intervention and control schools, latrine facilities were of poor quality. Although most schools in both districts had separate facilities for boys and girls, girls’ facilities lacked features such as locks on the inside of the doors to preserve girls’ privacy, or a place to discreetly dispose of soiled menstrual materials. In addition, the ratio of students to latrines was typically greater than 100:1, and in some schools, it was as high as 500:1. Facilities were generally dirty and in disrepair, with visible waste present on the floor of nearly all latrines. Just five of the 20 schools involved in the study had a reliable supply of water of any kind on school grounds, and none had water in or adjacent to the latrines.

Discussion

Despite holding promise for filling important gaps in girls’ current levels of puberty and MHM knowledge and understandings, there have not been rigorous efforts to quantify the effects of puberty books for girls. Therefore, our key finding—that the simple distribution of the Ethiopia girl’s puberty book to a large sample of girls in Ethiopia had a positive effect on girls’ levels of knowledge regarding puberty and menstruation—is notable. Our qualitative findings underscore the lack of girl-friendly resources on such topics and the potential for even a minimally intensive intervention to dispel taboos and misconceptions around menstruation. This was evidence in the three interconnected themes of reduced shame and confusion about puberty and menstruation; overcoming secrecy around menstruation; and insufficient support and knowledge about menstruation and pubertal changes from other sources. Together, these themes outline girls’ views of the book as trustworthy and affirming resource, not only for themselves but also as a way to encourage dialogue with mothers, friends, and others on topics they previously found too uncomfortable to discuss.

The findings indicate that the distribution of Growth and Changes (or other similarly locally developed puberty books) may have an important role to play in equipping girls with the skills to navigate conversations with friends and close female relatives around a topic that is normally embarrassing or shameful to discuss. More specifically, our qualitative findings expand on past small qualitative evaluations that girls view puberty books as valuable sources of basic information about themselves and their bodies, as a tool to build confidence in discussing matters of menstruation and puberty, and as a way to dispel misconceptions and taboos around menstruation (Sommer, 2011b). In addition, our mixed-methods approach underscores the need for combined research methodologies, given the sensitivity of the topic of menstruation in many contexts, and the critical importance of capturing girls’ voiced experiences and perspectives in tandem with quantitative impact of interventions.

As girls’ responses indicate, this intervention can provide girls with basic developmentally appropriate health education, such as improved knowledge and reduced shame, and potentially facilitate communication between girls and the adults in their lives. In this way, the findings suggest that Growth and Changes holds promise for shaping factors beyond the individual level, and may set the stage for addressing more sensitive topics as they enter adolescence. However, as the scope of this evaluation was limited to girls, additional research is needed to assess family-level effects distributing a book to girls.

Interventions that build knowledge are, however, often insufficient for reshaping behaviors and practices. Both the research team’s observations and the girls’ reports noted that school sanitation infrastructure was of poor quality. This may explain why no improvement was observed in girls’ reported measures of comfort with managing menstruation at school. Girls’ responses to questions about how they handle used materials at school reflect key challenges in sanitation infrastructure. For example, nearly 20% of girls reported not changing soiled materials at school, perhaps because they find existing facilities, which are shared by large numbers of students, and lack privacy and water, to be unusable (Alexander et al., 2014). In addition to these structural barriers present at the institutional level, future approaches may benefit from directly engaging parents to assure girls have adequate clean materials (e.g., pads or cloth, underwear) for managing menses while in school.

Girls’ self-reported experiences of MHM and its relationship to school participation are broadly consistent with other research from Ethiopia, as pain and lack of appropriate supplies has been reported elsewhere to hinder girls’ ability to comfortably attend and participate in school (Population Council, 2010; Tegegne & Sisay, 2014). Past studies in Ethiopia have highlighted additional challenges, such as girls’ fear that male classmates will tease them if they are seen handling sanitary pads that are distributed in school (Tegegne & Sisay, 2014). In our study, several girls suggested that sharing the books with boys might be useful for helping to improve boys’ understanding of girls’ experiences with puberty and menstruation. Likewise, given that all schools had overwhelming majorities of male teachers—and one school had no female teachers at all—the social environment in schools may itself serve as a further barrier to girls’ comfort discussing issues of puberty or menstruation during the school day. Such findings serve to underscore the importance of building an enabling social environment for adolescent girls’ health and well-being through interventions that incorporate measures to address both girls’ and boys’ information gaps and underscore the importance of healthy gender dynamics (Haberland, 2015; Lailulo, Susuman, & Blignaut, 2015; Svanemyr et al., 2015). At the same time, they reflect the highly gendered nature of both social and structural dimensions of school environments.

Overall, the findings suggest the importance of the application of the ecological model to the challenge of menstruation and puberty for girls as part of the adolescent developmental experience and transition to young adulthood. The evaluation identified positive individual-level effects of a relatively narrow intervention (e.g., girls’ levels of knowledge and shift in attitudes), while also underscoring the limiting influence of environmental (poor sanitation facilities) and community (potential for female teacher support) levels. There are possible interpersonal level (positive peer support) benefits from distributing the books to girls to read on their own or with friends, siblings, and family members; however, this was not specifically assessed in our study.

Along with evidence that girls in many contexts have a strong and, as yet unmet, interest in straightforward, accessible information and guidance on menstruation, programmers and policy makers have shown an interest in ascertaining how the provision of puberty and MHM guidance may impact girls’ levels of confidence in managing their menstruation in school, and their perception that menstruation is a natural, and not a negative, event (Sommer & Sahin, 2013). The provision of puberty education provides one such opportunity. Approaches that focus on equipping girls with an understanding of the physical and social changes associated with puberty can help to build the knowledge, skills, and confidence they need to make healthy transitions to adulthood (Haberland & Rogow, 2015; UNESCO, 2013; Vandenhoudt et al., 2010). The changes documented in this evaluation suggest that Growth and Changes may present an important resource on its own: a significant finding given that evidence on effective approaches, as well as programmatic resources for interventions on puberty and MHM remain scarce. Finally, consistent with the ecological framework, the quantitative findings presented here are indeed modest, suggesting that much of the potential for improving Ethiopian girls’ experiences of menstruation at school will come from comprehensive interventions that operate on various levels, addressing factors such as the sensitization and training of teachers in schools, improving the poor quality of sanitation infrastructure, shifting the norms and attitudes of adults and male peers that stigmatize girls’ bodies, and improving caregivers’ skills and confidence in addressing girls’ questions about puberty, menstruation, and sexuality.

Limitations

The study had some limitations that are important to note. First, a larger than expected proportion of girls were older than the designated age for grade. Many girls had begun menstruation already while the book is ideally intended for premenarcheal girls. As a result, girls may have entered the study with a higher level of knowledge on menstruation than anticipated, thereby lessening the effect of the books. Second, although books were carefully field tested with 10- to 14-year-old Ethiopian girls prior to printing and approval to assure the content was appropriate for the literacy levels of girls in Grades 5 and 6, we did not conduct individual literacy assessments or seek to ascertain whether girls fully comprehended the book content beyond the survey itself. Finally, the relatively short follow-up period necessitated by the school year and rainy season (4 weeks) limited the potential for identifying any longer term potential impact on MHM practices. Given that previous research has found a delayed effect, with changes in practices only observed at a longer time interval, evaluations with longer follow-up periods are needed (Montgomery, Ryus, Dolan, Dopson, & Scott, 2012).

Recommendations

The evidence provided here suggests that distributing Growth and Changes in Ethiopian schools holds promise for improving girls’ knowledge and attitudes around menstruation, and that these aims may be achieved without a complex or expensive intervention. However, situating these findings within an ecological framework underscores the degree to which more comprehensive intervention and evaluation approaches are needed to understand the potential impacts on girls’ health and education beyond such short-term, individual-level shifts.

Given the findings that Growth and Changes may build girls’ confidence and create a means for discussing matters related to puberty and menstruation at home, we suggest incorporating distribution of the book into efforts that aim to establish supportive school and home environments for girls. This may entail intervening at the interpersonal and community levels to counter norms that stigmatize girls’ menstruating bodies and discourage them from fully participating in school, such as interventions directed at caregivers that build their knowledge and confidence discussing puberty and menstruation with girls.

We recommend exploring the effect of an intervention such as Growth and Changes as part of a package of interventions that simultaneously influences the social and physical environment girls experience during early adolescence. At the policy (and school) level, this may include investments in upgrading sanitation systems that are better suited for MHM. At the level of the school social environment, we recommend exploring the effects of pairing Growth and Changes with interventions conducted with boys. This would include interventions that aim to sensitize and build teachers’ confidence to engage girls on menstruation and MHM, and also to provide more formal introduction of the book to girls, including offering encouragement to girls to read and discuss the books. This involvement by female role models may precipitate even greater potential impact on girls’ knowledge and attitudes around the experience and management of menstruation. This would also include interventions that influence boy’s levels of knowledge regarding the physiological changes associated with puberty for both boys and girls, and exploring how intervening with boys may positively (or negatively) influence pubescent girls’ abilities to participate comfortably in school, and have longer term impacts on boys’ and girls’ future sexual and reproductive health.

As the ecological framework that shapes our approach suggests, we strongly endorse exploring interventions that act to address multiple, specific factors shaping girls’ education and health outcomes. However, we also recognize that less intensive interventions, particularly ones in resource-poor areas, or interventions that need to target large numbers of children, may yield strong positive results. Our approach—simply distributing books and suggesting that girls take them home and read them—yielded a positive effect. This finding holds promise for a simple intervention to achieve positive effects at scale, particularly under conditions where more comprehensive programming may not be feasible.

In sum, the findings here clearly show that high-quality culturally appropriate puberty books can achieve marked improvements in girls’ knowledge and attitudes around menstruation and its management, even in environments where social support and school sanitation infrastructure are severely constrained. While this alone is not sufficient to address the complex, multilevel barriers to MHM, our findings fit with the ecological approach, identifying a very specific intervention for building individual-level knowledge and improving attitudes around MHM.

Footnotes

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Marni Sommer is a co-author of the Ethiopia puberty book that was evaluated in this study.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The funding for this study was provided by Grow and Know, Inc. and from the Lerner Center for Health Promotion, Columbia University Mailman School of Public Health. There is no grant number associated with the funding.

Author Biographies

Sarah Blake is a PhD student in sociology at the University of California San Francisco School of Nursing. Her research interests center on the social and structural factors influencing adolescent reproductive health in low resource settings, including policy and programming aimed at preventing child marriage and adolescent pregnancy. She has over a decade of experience working in global reproductive health research and evidence-based programming and policy.

Melissa Boone was a postdoctoral research fellow in the Preventing and Methodology Training Program at Pennsylvania State University’s Methodology Center. Her research has focused on the intersection between drug use and HIV risk in communities of color.

Alene Yenew Kassa is a head of the Sponsorship Unit, Program Development and Quality, at Save the Children International, Ethiopia. He has many years of experience implementing and evaluating programs with children and adolescents in various regions of Ethiopia, focused on improving their educational and health outcomes.

Marni Sommer is an associate professor of sociomedical sciences at the Columbia University Mailman School of Public Health. She has been conducting participatory and qualitative research on adolescent transitions through puberty, with a specific focus on intersection of menstruation and education, in low-income countries for over a decade. She has published puberty books for boys and girls in multiple low-income countries.

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