Menstrual hygiene management among adolescent girls in sub-Saharan Africa

Introduction

The theme for 2016’s World Population Day was ‘investing in teenage girls’. Sub-Saharan Africa (SSA) is home to one of the world’s fastest-growing teenage girl populations (1), a majority of which will or have had onset of menstruation (menarche). Although menstruation is a natural process, issues surrounding this subject remain poorly prioritized by government sectors such as Health and Education in SSA (2). For adolescent girls, menstruation may present with various challenges owing to their inexperience in menstrual hygiene management (MHM), the lack of disposable incomes to access menstrual absorbent materials and the psychological demands they experience during this delicate period of change (2). Moreover, poor access to dignified and functional water, sanitation and hygiene (WASH) infrastructure in SSA (3) remains a major setback for proper MHM by adolescent girls within this region. Improvement of MHM significantly contributes towards the achievement of a number of sustainable development goals (SDG) contained in the United Nations Resolution: A/RES/70/1, including; (i) good health and well-being (SDG 3); (ii) inclusive and equitable quality education (SDG 4); (iii) gender equality and women’s empowerment (SDG 5); (iv) clean water and sanitation (SDG 6); and (v) economic growth, productive employment and decent work for all (SDG 8). While there is obvious value for investing in MHM, few empirical studies on current knowledge, practices and interventions for MHM among adolescent girls emanate from SSA. This paper provides an insight on the state of menstrual hygiene, perceptions and knowledge in SSA. Specifically, interventions focusing on sustainable, environmentally friendly, ecological and cost-effective options are discussed.

Epidemiology of menstrual hygiene in SSA

Empirical literature on MHM among adolescent girls in SSA dates back over three decades (4), although it still remains scarce (5–7). Most of this literature focuses on knowledge, attitudes and practices, with meager attention to interventions. Many studies report 11–15 years as when menarche occurs, with older onset more common among rural adolescent girls (4,8). At menarche most adolescent girls in SSA are often unprepared. They are poorly equipped with adequate knowledge on menstruation and its hygienic management; this varies between 4% (6) and 90% (9), and has disparities by socio-economic status. Unfortunately, adolescent girls’ dominant sources of information such as peers, female siblings, and mothers, are often not well informed. In addition, most of the time males are in charge of resource allocation, yet possess limited knowledge and interest in menstrual hygiene matters; as such, low priority is often assigned to this matter in the household (10). Access to safe and hygienic menstrual absorbent materials remains a significant challenge, especially for girls from low socio-economic backgrounds. For example, up to 87% of rural school girls from western Uganda used old clothes or rags as menstrual absorbents (10), and yet these materials are infrequently changed, rarely washed with soap and clean water, and not properly dried prior to re-use (11). In rural western Kenya, 1 in 10 adolescents without access to sanitary pads also had no access to old cloth, mattress pieces, tissue or other commonly cited menstrual absorbent alternatives by girls in SSA, owing to household impoverishment (12). Moreover, most community infrastructure, for example in schools, lacks sufficient ‘girl-friendly’ latrine facilities that maximize privacy, are clean, properly lit, designed to accommodate girls with disability, have flowing water and space for drying their menstrual absorbent materials (13). Various studies in SSA reflect the ramifications of such WASH inadequacies. In another study among Ethiopian school girls, the authors reported that 85% of them did not change their menstrual soak-up while at school and 77% disposed of their used sanitary material in to the latrine or open fields (8).

Impacts of poor menstrual hygiene

The poor state of MHM significantly disrupts the achievement of equitable quality education. To this end, some studies from SSA estimate that between 50% and 70% of girls miss on average 1.6–2.1 days of school every month due to menstrual-related issues (8,10). Furthermore, many of those that manage to attend school during menstruation do so, but with low confidence and dignity due to a disregard for their privacy, feelings of shame and embarrassment, in addition to the fear of being teased and bullied (8). These factors have been found to affect academic performance and to interfere with girls’ participation in both school and extracurricular activities (8). The reality that most of the alternative absorbent materials used by girls in resource-poor households of SSA are unsafe or used in unhygienic ways predisposes them to health risks that possibly underlie some common physiological complaints such as vaginal pain, bruising, and reproductive tract infections (14). Also, the failure to address menstrual-related needs is increasingly reported to result in prevalent risky sexual behavior (9). The occurrence of sex in exchange for money to buy sanitary pads and the dependency on boyfriends for sanitary pads is, for instance, reported in two studies among rural Kenyan adolescents (12,14).

Interventions to improve menstrual hygiene among adolescents in SSA

Interventions to address MHM include hardware components (physical infrastructure), that deal with providing physical resources such as WASH facilities and sanitary products, and software components (education), that provide knowledge which can help change and shape behavior to improve health outcomes (15) (Figure 1).

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Figure 1.

Hardware and software components of MHM interventions.

Sanitary products are either locally or commercially produced. Local production is generally restricted to pads, given that a number of cultural norms will not accept the insertion of a ‘foreign object’ into young girls (15). Besides being less affordable, commercial sanitary products have been reported to contribute to community waste (2). It should, however, be emphasized that despite creating new jobs in the community, the production of sanitary products may have a limited reach to consumers.

The provision of clean sanitary products has been hypothesized to reduce discomfort as well as concerns regarding soiling outer garments during menstruation (16). Improved management and comfort may also reduce the associated stigma and embarrassment which deters girls from attending school or work (16). There are already several local producers such as AFRIpads (Uganda), Huru International (Kenya) and OneGirl (Sierra Leone) that focus on reusable, locally sourced or low-cost sanitary products to girls and women in SSA, or to teach them how to make their own reusable sanitary pads. By utilizing such sustainable and inclusive innovations in healthcare delivery, these businesses are empowering groups (i.e. adolescents and young women) and people from socio-economically disadvantaged backgrounds (17).

Other aspects of public health intervention include focusing on WASH facilities. Towards this end, developing a standard to which adolescents and young women are able to replace absorbents and wash their body in sex-segregated latrines in privacy, without attracting unwanted attention, is of importance (5).

Education for girls and the wider community (i.e. boys and men) on menstruation is crucial to address discrimination and exclusion, as well as to create a supportive environment where women and girls can express their needs and emotions—particularly in contexts where there are significant taboos and restrictions, coupled with lack of accurate information on sexual and reproductive health. Given the lack of awareness of menarche by many girls in SSA, the stigma and taboo surrounding this topic has often prevented their access to accurate information to understand menstruation and its management (2). Better understanding and knowledge of MHM has been hypothesized to improve management practices, self-efficacy, and reduce anxiety and shame (16). It is recommended that puberty education begins in primary school so that girls understand what is happening to their bodies and know what to expect before menarche (2). Towards this end, co-educational schools should place emphasis on generating a curriculum that focuses on encouraging respectful and understanding interpersonal relationships between boys and girls (2).

Conclusion and recommendations

Poor MHM represents a crucial human rights issue that impacts social and economic rights, including health, water, sanitation, education and work (5,13,18,19). In order to demonstrate the magnitude of the problem to governments, donors and public health bodies, high-quality studies which focus on providing substantiating evidence (i.e. quantitative research) on MHM practices will be essential as a means to better understand how widespread poor MHM is. In this regard, public health intervention research that focuses on delineating causal mechanisms as a means to generate knowledge about effective program and policy interventions (20) that shape current MHM practices will be of key significance.

An emphasis should be given to implementing policy changes in resource-poor settings to improve the health and quality of life for women, and ultimately help them realize their potential through self-empowerment (16). Similarly, increased awareness should be placed on the needs of menstruating women and girls by those working within the WASH and education sectors.

In order to deal with the current MHM-related barriers lacing SSA, changes are required in terms of women’s education regarding their reproductive health, environmental impact through the appropriate disposal of menstrual waste, and the production, marketing and accessibility of low-cost sanitary products. Together, these initiatives will help demystify taboos around menstruation and empower girls and women.