Original Research Article

Menstrual hygiene management amongst school going girls in Kisii County, Kenya

Definitions

Pubic mixed day secondary schools- government schools with both boys and girls who do not board in the school.

ABSTRACT

Introduction: Menstruation is a natural phenomenon among matured females who experience shedding of blood for 1-7 days every month from the age of maturity until menopause. Menstrual hygiene management is an issue that is insufficiently acknowledged and has not received adequate attention.
Objective: To evaluate the knowledge and practice on menstrual hygiene among school going girls and assess access to clean, safe and private space for menstrual hygiene management in schools

Problem Statement: There is lack of clean, safe and private space for menstrual hygiene purposes. Poor menstrual hygiene practices are affecting the health well being of girls including anxiety, infection, education and discomfort. In mixed day secondary schools, there are no special Water, Sanitation and Hygiene (WASH) facilities for the purposes of handling menstruation safely and in dignity

Methodology: A descriptive crosssectional study was conducted as from March 2014 to April 2014 on 175 girls recruited from two mixed secondary day schools in Kisii Township. Indepth questionnaires were used to collect data from the girls, key informant interviwers conducted on the head teachers and focused discussions held with 16 randomly selected girls. An observation checklist was also used. IBM SPSS version 20 was used for analysis. Descriptive statistics; frequencies and cross tabulations were used to analyze the data.

Findings: Majority (60%) of the respondents were aged between 16 and 18 years and 47% were protestants and 40% Catholics. Schools (26%) and mothers (21%) were the major sources of knowledge on menstruation. 60% of the girls knew effects of unhygienic practices of whom 80% mentioned infection as the effect known. Disposable pads were the most commonly used products with 81.4% of the girls using them. Majority, 60%, of the respondents changed their menstrual product three times or more in a day and 36% changed twice with only 40% changing at night regularly. 86% changed menstrual products from latrines and 86% still disposed their products in pit latrines. Majority, 63% of the respondents took two baths daily when menstruating and 13% bathed only once. 36% experienced body odour during menstruation. 60% experienced itching in the genital area and 30% had suffered from RTIs. There were separate latrines for girls in both schools with 80% having lockable doors but they were smelly. The ratio of latrines to girls was 1:35 at DMMSC and 1:36 at GMSC.There was no water and soap provided in the latrines and no bathrooms or changing rooms. Girls were not satisfied with available WASH facilities.

Conclusion: There is relatively a fair level of knowledge on menstrual hygiene amongst girls but there is need for further reproductive health education; There were some poor menstrual hygiene practices and consequently most of the girls reported to have experienced itching with others having had infections of the lower reproductive tract infections and WASH facilities were not adequate for menstrual management for the girls. Recommendations: schools to have more health education services including reproductive health clubs; provide bathrooms and changing rooms; provide water and soap for both hand washing and other menstrual hygiene needs and provide emergency menstrual hygiene products such as pads. Ministry of education should include menstrual hygiene management in the school curriculum and department of public health should include menstrual hygiene management in their routine school inspection. The NGOs would best support schools in building WASH facilities for menstrual hygiene management needs; promote advocacy campaigns on the effects and coping mechanisms around menstrual hygiene management to policy makers; involve cultural leaders and break the silence around menstrual hygiene management needs so as to get more attention and advocate for further research around specific areas linked to menstrual hygiene management

KEY WORDS: Menstrual hygiene management, menstrual hygiene practices, menstruation, school going girls, Kenya

Introduction

Menstruation is a normal biological process among females from the time they mature, usually from the age of ten years to fifteen years to the time they reach menopause in their late 40s to early 50s. They usually menstruate for about an average of two to seven days every month[1]. This brings about practical needs for water and soap as well as space for washing and cleaning the body (especially the genitalia), washing reusable absorbent material used as menstrual hygiene products and facilities for proper disposal of used materials. This is essential for safe and dignified handling of this biological occurrence in women and girls. The girls and women make up to half the world population and thus require Water, Sanitation and Hygiene (WASH) services ignore these needs.

This may be due to Menstrual Hygiene remaining a taboo subject in many parts of the world especially in the third world countries[2]

Dealing with menstruation has implications for physical, social and mental wellbeing of women and girls. According to a study done in Korogocho, Makadara and Jericho slums in Nairobi, Kenya, there is limited access to safe, clean, private, affordable and culturally appropriate methods of dealing with menstruation[3].

The study was done in two randomly selected schools in Kisii Township, Kisii County to represent the six public mixed secondary day schools. The schools selected were Daraja Mbili Mixed Secondary School and Getembe Mixed Secondary School located within the town, accessible through public transport within about 5 minutes when driving or 30 minutes while walking.

Problem statement

Menstrual hygiene has been routinely ignored by professionals in water, health and education sectors.[4] As a result, girls get little or no education on proper menstrual hygiene practices.

The average age for girls in secondary school in Kenya is 14 to 18 years[5]. At this age, most of the girls are menstruating, as the age of starting menstruation is between 10 and 15 years[6]. Despite this fact that almost all girls in secondary schools are menstruating, there is lack of appropriate and adequate sanitation facilities across the developing world, preventing girls from attending school, particularly when they are menstruating[7]. There is lack of or inadequate water to clean and wash the body, lack of materials for managing menstrual hygiene, no private space and inappropriate facilities for disposal of materials for those who have used pads[8]. There are no changing rooms or bathrooms either and thus girls use latrines as the only place available to change menstrual hygiene products.

There is also a major concern on absence of hand washing facilities (water and soap) in most schools. Girls require these facilities to wash hands before and after changing sanitary products especially those that require insertion and especially after touching blood.

Disposal of used menstrual hygiene products is also of significant concern. In most day schools, the girls use methods such as throwing them in latrines which may make the latrines full faster than they should. The girls who need to wash their re-usable pads or washable cloths/pads do not access these facilities at school. They therefore have to wait until they are home for them to change and wash them. In case of emergency leaks, girls have to go home in order to clean up.

Poor menstrual hygiene management is linked to lower reproductive tract infections, urinary tract infections, bacterial vaginosis, vulvovaginal cardiosis and dysmenorrhoea, also indicating linkages with higher aenemia and infertility[9]. In case of not being able to change the products on time, the girls may get Toxic Shock Syndrome (TSS). Some scientists say there could also be a link between poor menstrual hygiene practices and cervical cancer. For instance, India, nearly 12% of menstruating women who use sanitary napkins are at lower risk of cervical than women who resort to unhygienic sanitary practices.[10]

Problems due to menstruation may restrict girls’ access to education as well or make them uncomfortable while at school. Girls may feel bored, lethargic and irritable during menstruation or become uneasy about everything during menstruation. Lack of access to sanitary pads causes discomfort, irritation and rashes, embarrassment, anxiety and shame. Fear of leakage and stained clothes, ‘smelling bad’ are also part of the challenges girls face[11].

Justification

The practical challenges such as lack of access to safe clean and private space for menstrual hygiene management necessitated this study because of the negative impacts on health and wellbeing of girls such as discomfort, anxiety, infections and education.

It was important to conduct the study as there was little research and interventions on menstrual hygiene especially among the urban poor in Africa during the time of this study. Results and recommendations of the study are meant to improve of menstrual hygiene management in schools and thus promote school girls’ health and rights.

The Broad Objective was to evaluate the knowledge on menstrual hygiene and hygiene practices among school going girls in mixed secondary day schools in Kisii Township, Kisii County, Kenya.

Literature Review

Menstrual hygiene management is an area that faces many challenges including access to sanitary towels, privacy, and hygiene. This leads to negative impacts on health and wellbeing: discomfort, anxiety, infections and education. Lack of knowledge and favorable facilities are the main problems to poor menstrual hygiene management.

Dasgupta A. et al. (2008) stated that the mean age of menarche girls was 12.8 years in a study undertaken among the adolescent schoolgirls Gobindapur Purnachandra Vidyayatan, a secondary situated at Dearah, Singur block in India. From a similar study conducted in Rajasthan by Khanna et al. (2005) the mean age at menarche was found to be 13.2 years. According to Dasgupta A. et al. (2008), 32.5% girls were ignorant about menstruation before menarche though each and every girl should be aware about menstruation, which is an important event at the threshold of adolescence. In a study conducted among 664 schoolgirls aged 14-18 in Mansoura, Egypt by El-Gilany et al. (2005), mass media were the main source of information about menstrual hygiene, followed by mothers. Another study conducted by Deo et al. (2005) reported that 42.5% of the girls in the urban and 55.4% girls in the rural were aware about menstruation prior to attainment of menarche.

Lack of this knowledge as from an early age can be linked to poor knowledge in later years. According to a study done in Korogocho slums by Rhoune O. (2010), there are taboos around discussing menstruation. Menstrual blood is considered dirty, unclean and harmful to touch.
There is lack of information and knowledge with a number of misconceptions.

With the fact that many girls have poor knowledge on menstrual hygiene, it is very necessary that their knowledge and practice of hygiene be studied. Lack of this leads to infections. Dasgupta A. et al. (2008), after his study, concluded that menstrual hygiene, a very important risk factor for reproductive tract infections, is a vital aspect of health education for girls.

In as such, the hygiene practices of girls during their menstruation should be clearly looked into and access to facilities needed for the proper practices be availed. Girls and women need water for washing and bathing during menstruation. Rhoune O. (2010) found out that majority of the girls and women bathe two times during menstruation and they change cloths and pads changed in bedrooms, bathrooms and toilets as part of their menstrual hygiene management practices. Privacy is difficult for some girls and women. From a study conducted among 664 schoolgirls aged 14-18 years in Mansoura, Egypt by El-Gilany et al. (2005), the different aspects of personal hygiene were generally found to be poor, such as not changing pads regularly or at night, and not bathing during menstruation with lack of privacy being an important problem.

Many girls use various absorbent materials while according to Rhoune O. (2010) most girls preferred to use disposable pads, Dasgupta A. et al. (2008) found out that majority of school girls in India, (42.50%), used old pieces of cloths and only 11.25% used disposable sanitary pads. 6.25% used new cloth pieces 40% used both cloth pieces and disposable sanitary pads during menstruation.

The problem of lack of hand washing facilities is widespread in Africa especially amongst the urban poor. This is evident from Rhoune O. (2010), whereby many girls and women in Korogocho Slums did not easily access hand washing facilities near toilets/latrines.

Disposal of used menstrual hygiene product is a significant solid waste management issue and proper disposal methods should be put in place. In the study done in India by Dasgupta A. et al. (2008), 73.75% girls reused cloth pieces and 57.5% girls properly disposed the cloth pieces or sanitary pads used, that is, they wrapped the used cloth piece or sanitary pad in a paper bag and disposed in a place used for solid waste disposal.

Girls also face other social challenges during menstruation. Dasgupta A. et al. (2008) found out that 85% of girls practiced different restrictions during menstruation including 59% who did not attend any religious occasion; 50% did not eat certain foods such as sour foods, banana, radish and palm; 42.65% did not play; 33.82% did not perform any household work; 16.18% girls did not attend school and 10.29% girls did not attend any marriage ceremony during the menstrual period.

Methodology

This study was carried out in Daraja Mbili Mixed Secondary School and Getembe Mixed Secondary School, both within Kisii Township, Kisii County, Kenya. A descriptive cross sectional was the study design. Simple random sampling was employed whereby names of the six mixed secondary day schools were written on paper and only two schools were picked randomly. From the population of the schools, the number of participants from each school was proportionately determined. Further the populations of girls in each class was determined in the same manner and girls randomly selected through picking pieces of paper written yes or no. those who selected yes participated in the study while those who selected no were exempted. The head teachers in both schools were interviewed as the key informants.

The target population was school going girls in the two schools. Fisher et al, 1998 was used to calculate the Sample size of 107 girls from Daraja Mbili Mixed Secondary School and 68 girls from Getembe Mixed Secondary School participated in the study. Eligibility criteria: School girls aged between 13-25 years were eligible to participate in the study. Girls who had not started their menstruation were excluded from participation.
Data collection methods: Interview key informants, Observation, Self administered questionnaires and Focused Group Discussions. Ethical considerations: Permission was sought from the CPHO, the Area Education Officer and the head teachers of the schools where the study was done. Informed consent was sought from the respondents before data collection and confidentiality on information given was upheld consistently and names of the respondents were not asked for.

Data analysis and presentation: Data was cleaned and analyzed through SPSS version 20 and Microsoft Excel 2007 spreadsheets. Descriptive statistics i.e. frequencies and cross tabulations were used as well as correlations to analyze the collected data. The analyzed data was presented in prose, tabular and graphical forms.

Results

Demographics

Most of the respondents (60%) were aged between 16 and 18 years. 26% were aged between 13 and 15 years, and 13% were aged between 19 and 21 years. Only 1% were aged above 21 years.

Majority of the respondents, 47% were Protestants and a minority, 1%, were Muslim. The Catholics made 40% of the respondents’ population and other religions such as paganism was represented by 12% of the respondents.

Most of the girls got information form school (26%) and from their mothers (21%). Very few girls got information from their aunts(6%) or from radios and TVs(6%). From key informants, both headteachers (or persons acting in this capacity) reported that there was counseling offerred at their schools by female teachers, volunteers from churches and organizations and health professionals who come for health education.

Fifty three percent (53%) of the girls don’t participate in sport activities during menstruation while 47% reported to participate. 16% of the girls said they were not allowed to cook when they were menstruating and 11% of the respondents did not attend religious activities during menstruation.

Forty four (44%) of the girls reported not to eat certain foods during menstruation. Below are the foods that were mentioned included chocolate, cocoa, juice, eggs, githeri, beans, sweet potatoes, spicy foods, tea, sugarcane, sugary foods and hot food.

Menstrual hygiene knowledge

The disposable sanitary pads were the most widely known seen by 94% of the respondents. Cotton, tissue paper and washable clothes were also known as menstrual hygiene products by more than half of the respondents, that is, 58.6%, 55.7% and 54.3% respectively. Menstrual cups were the least known with only 11.4% respondents knowing them. A good percentage, 40%, of the respondents did not know any effects of uhnygienic practices during menstruation.

Knowledge on effects of unhygienic practices incresed with age. 55.6% of those aged between 13 and 15 years knew the effects, 57.1% of those aged between 16 and 18 years had the knowledge, 77.8% of those aged between 19 and 21 years had the knwoledge and 100% of those aged bewteen 21 and 25 years knew the effects.

Of the 105 girls who knew effects of unhygienic practices, majority, 80%, knew infection as the major effect. 9% mentioned secondary infertility, 7% bad smell and 4% discomfort and being wet.

Menstrual hygiene practices

Cost of menstrual product used

Half of the respondents used more than kshs. 100 every month on menstrual hygiene products, 37% used between kshs. 50 and kshs. 100 and 13% used less than kshs. 50 every month. This is because most of the girls used disposable pads or napkins. Currently a packet of disposable pads goes for about Kshs. 60 on average and this packet contains eight pads. If on average a girl uses 3 pads then in 5 days whe will need approximately 15 pads. This means she has to buy two packets costing Kshs. 120 on average. This means menstrual hygiene products were quite costly.

Menstrual product used

Disposable sanitary pads were the most commonly used products with 81.4% of the respondents using them. These were followed by washable cloths at 20%, 10% cotton and 8.6% reusable pads. Toilet paper and tampons were the least used with 4.3% and 1.4% respectively. Menstrual Cups and torn mattresses were not used.

Practices

Majority, 60%, of the respondents changed their menstrual product three times or more in a day, 36% changed twice while 4% changed once.

[pic]

There was no relationship between the age of the respondents and the number of times they changed their menstrual hygiene products. 50% of the respondents aged between 13 and 15 years changed menstrual hygiene products twice and 50% changed thrice or more. 7.1% of those aged between 16 and 18 years changed once, 28.6% changed twice and 64.3% changed thrice or more. 44.4% of those aged between 19 and 21 years changed twice and 55.6% changed thrice or more in a day. All thos aged between 21 and 25 changed their products twice in a day.

Foty percent (40%) of the respondents said they change menstrual hygiene products at night, 37% did not change and 23% changed only sometimes.

Majority of girls, 86%, changed their menstrual hygiene products from the toilet/latrine while 7% changed their products from their rooms at home, and 6% in bathrooms. Forty one percent (41%) of the respondents were comfortable changing menstrual hygiene products where they did and 33% were not comfortable. 23% stated to be very comfortable whereas 3% said they were very uncomfortable.

Majority, 63% of the respondents took two baths/showers daily when on menstruation, 24% bathed three times or more and 13% bathed only once.

[pic]

There was no relationship between the frequency of bathing and the age of the respondents. 5.6% of those aged between 13 and 15 years bathed once per day during menstruation, 66.7% bathed twice and 27.8% bathed thrice or more in a day while on menstruation. 19% of those aged between 16 and 18 bathed once, 57.1% bathed twice and 23.8% bathed thrice or more. 77.8% of those aged between 19 and 21 years bathed twice and 22.2% bathed thrice or more in a day while on mensrtruation. All those who were aged between 21 and 25 bathed twice in a day during menstruation.

Eighy six percent (86%) of the respondents disposed their used sanitary products by throwing them in pit latrines while 13% reused them and 1% reported to throw them in dustbin. Half of the respondents used more than kshs. 100 every month on menstrual hygiene products, 37% used between kshs. 50 and kshs. 100 and 13% used less than kshs. 50 every month.

A majority, 51%, said they did not wash hands before changing menstrual hygiene products while 36% of the respondents experienced body odour during menstruation and 34% of the respondents reported to have missed school during menstruation

Out of the 60 ( 34%) of respondents who missed school during their menstruation, 47% missed school due to lack of sanitary products or fear for leaks. 46% missed school due to menstrual cramps while 7% had missed school due to both menstrual cramps and lack of sanitary products or fear for leaks.

Majority of the respondents, 61%, reported to have ever experienced itching in their genital area and 30% of the respondents reported to have had an infection of their repoductive tract.

Level of comfort during changing menstrual products

Majority, 75%, of those who changed their menstrual hygiene products at the bathrooms were very comfortable and 25% were uncomfortable. 40% of those who changed in bedrooms or rooms were very comfortable and 60% comfortable. For those who changed in latrines/toilets, 3.3% were very comfortable, 43.3% were comfortable, 36.7% were uncomfortable and 16.7% were very uncomfortable. Those who changed in any other place reported to be very comfortable.

Hand washing facility near latrines

In Daraja Mbili mixed Secondary school, there was no hand washing facility near the latrines. In Getembe Secondary School, there was a well of water fitted with a pump that the students used for hand washing but it was far from the latrines. It was about 50 metres away and located in front of the schools offices. There was no soap for hand washing provided in either of the schools and the latrines in both schools were fairly clean but had terrible odour.

Presence of water and soap for washable cloths and reusable commercial pads

There was no water and no soap for the washable cloths and reusable pads. There were no bathrooms for the girls for emergency baths. During a focused group discussion, the girls reported to ask for permission to go home in order to access these facilities and thus missing school. They wrapped a sweater on their waist incase menstrual blood leaked, and before going home to wash and change. From the focussed group discussion, it was said that if one did not observe proper hygiene, they would smell bad and friends would discriminate them. The group also recognized that infection was the biggest risk one exposed herself to when not practising hygiene during menstruation

At Daraja Mbili Mixed Secondary School, there was a provision for emergency pads but no emer gency uniform. At Getembe Mixed Secondary School, there were no such provisions. From both the head teacher and the focused group discussion, it was said that girls had to go back home in case of any emergency. In both schools, the latrines were adequately private with 80% having lockable doors. There were no sanitary bins. Girls used the latrines instead, where they threw used pads.

All the girls in the focused group discussion were not satisfied with sanitary facilities in their school. They wished the school provided adequate WASH facilities for them including changing rooms, bath rooms, adequate water at the facilities and soap for both hand washing and washing re-usable pads/washable cloths.

Discussion

Demographics

Being a secondary school, most of the respondents (60%) were aged between 16 and 18 years. only 1% were aged above 21 years. These ages fall in the average age for girls in secondary school in Kenya is 14 to 18 years[12]. Majority of the respondents, 47% were Protestants followed by 40% being catholic and a minority were Muslim who were represented by only 1%. Therefore, the majority of the respondents were Christians. This brings to a majority of the respondents being Christians, i.e. either Protestants or Catholics. The figures are almost the same as the 82% Christian population in Kisii as documented from earlier data[13]

Knowledge on menstrual hygiene

Schools were the most common source of information on menstrual hygiene for most of the girls (26%) followed by mothers (21%) and friends at 20%. Very few girls got information from their aunts (6%) or from radios and TVs (6%). School was a common cause beacause that is where female teachers, health professionals and other volunteers may offer this kind of knowledge. In contrast, in a study conducted among 664 schoolgirls aged 14-18 in Mansoura, Egypt by El-Gilany et al. (2005), mass media were the main source of information about menstrual hygiene, followed by mothers.

The headteachers reported that there was counseling offerred at their schools by female teachers, volunteers from churches and health professionals who come for health education.

There was no relationship between knowledge on menstrual hygiene and their practices. This shows a disparity between knowledge and practice. However, with the knowledge, still 53% of the girls reported not to participate in sport activities during menstruation, 16% of the girls said they were not allowed to cook when they were menstruating and 11% did not attend religious activities. This shows that there was lack of knowledge that the girls can participate in normal activities as usual during menstruation.

Foty four percent (44%) of the girls reported not to eat certain foods during menstruation including chocolate, cocoa, juice, eggs, githeri, beans, sweet potatoes, spicy foods, tea, sugarcane, sugary foods and hot food. There is no scientific reason barring girls from not. Information on nutrition during menstruation needs to be disseminated to the girls, female teachers and mothers.

Dasgupta A. et al. (2008) found out that 85% of girls practiced different restrictions during menstruation including 59% who did not attend any religious occasion; 50% did not eat certain foods such as sour foods, banana, radish and palm; 42.65% did not play; 33.82% did not perform any household work; 16.18% girls did not attend school and 10.29% girls did not attend any marriage ceremony during the menstrual period

This agrees with the study done by Rhoune O. (2010) in Korogocho slums whereby he said that girls did not have proper knowledge and information on menstruation but rather had misconceptions. In his study findings, there were taboos around discussing menstruation and menstrual blood is considered dirty, unclean and harmful to touch.

Knowledge on menstrual hygiene products

All girls knew at least one product that can be used for menstrual hygiene management. The disposable sanitary pads were the most widely known seen by 94% of the respondents. Cotton, tissue paper and washable clothes were also known as menstrual hygiene products by more than half of the respondents, that is, 58.6%, 55.7% and 54.3% respectively. Menstrual cups were the least known with only 11.4% respondents knowing them. This can be linked to the affordability, acceptability and availability of the products. Menstrual cups and tampons, which were least known are the most expensive menstrual hygiene products in the Kenyan market with one menstrual cup costing as much as Kshs 1,800 initially on average and tampons cost as much Kshs.175.

Knowledge on effects of unhygienic menstrual practices

Majority of the respondents, 60%, knew effects of uhnygienic practices during menstruation. However, the 40% who did not know the effects were at risk of not being careful enough to practice proper menstrual hygiene. Of the 60% girls who knew effects of unhygienic practices, majority, 80%, knew infection as the effect. 9% mentioned secondary infection, 7% bad smell and 4% discomfort and being wet. Further, they said that if one did not observe proper hygiene, they would smell bad and friends would discriminate them. Knowledge on effects of unhygienic practices increased with age. 55.6% of those aged between 13 and 15 years knew the effects, 57.1% of those aged between 16 and 18 years had the knowledge, 77.8% of those aged between 19 and 21 years had the knwoledge and 100% of those aged bewteen 21 and 25 years knew the effects.

Menstrual hygiene practices

Disposable sanitary pads were the most commonly used products with 81.4% of the respondents using them. These were followed by washable cloths at 20%, 10% cotton and 8.6% reusable pads. Toilet paper and tampons were the least used with 4.3% and 1.4% respectively. Torn mattresses and menstrual cups were not used. Toilet paper is usually a bad absorbent and may cause leaking of menstrual blood and this could have led to the low usage. Torn mattresses are not hygienic and may not be available to use every month. Menstrual cups are expensive and not readily available in Kenya as well as in Africa. This may have lack of usage. However, they are good because they are environmental friendly and cost effective on the long run. Because they can be used up to 10 years, their disposal is not a problem to the environment and when one buys it once, they do not need money every other month.

While according to Rhoune O. (2010) most girls preferred to use disposable pads, Dasgupta A. et al. (2008) found out that majority of school girls in India, 42.50% used old pieces of cloths and only 11.25% used disposable sanitary pads. 6.25% used new cloth pieces 40% used both cloth pieces and disposable sanitary pads during menstruation.

Majority, 60%, of the respondents changed their menstrual product three times or more in a day, 36% changed twice while 4% changed once. Normally, it is expected that one changes every four to six hours. Leaving the product for too long can cause rashes, bad smell, toxic shock syndrome or possible infections. There was no relationship between the age of the respondents and the number of times they changed their menstrual hygiene products.

40% of the respondents said they change menstrual hygiene products at night, 37% did not change and 23% sometimes changed. This shows that a big number did not embrace this hygienic practices. Not changing menstrual products for long can lead to TSS or infection. It does not matter wether it is at night or during the day. When menstrual blood flow is low, the the absorbent material used as the menstrual hygiene product absorbs all the blood and starts absorbing the natrual fluids in the vaginal area. This is what can lead to TSS. Blood, being a medium that cultures bacteria, leads to infection after it has been left for too long without changing. This together with raised temperatures and wetness may be held responsible for itchiness and even rashes.

Also a majority, 63% of the respondents took two baths/showers daily when on menstruation, 24% bathed three times or more and 13% bathed only once. When menstruating, it is expected that one takes at least two baths or showers a day. This will keep the person comfortable, reduce chances to smell and also prevent infections. There was no relationship between the frequency of bathing and the age of the respondents. Thus menstrual hygiene practices were not linked to the ages of the respondents although older girls had better knowledge than younger ones.

Rhoune O. (2010) found out that majority of the girls and women bathe two times during menstruation and they change cloths and pads changed in bedrooms, bathrooms and toilets as part of their menstrual hygiene management practices. Privacy is difficult for some girls and women.

From a study conducted among 664 schoolgirls aged 14-18 years in Mansoura, Egypt by El-Gilany et al., the different aspects of personal hygiene were generally found to be poor, such as not changing pads regularly or at night, and not bathing during menstruation with lack of privacy being an important problem.

Place where sanitary product is changed

Most girls, 86%, changed their menstrual hygiene products from the toilet/latrine. 7% changed their products from their rooms at home, 6% in bathrooms. This can be explained due to the fact that there was no other alternative while at school other than the latrines. Latinres, being private, was the only available space to use while changing since there were no changing rooms or bathrooms at school. The latrines were however smelly and there was not water and soap provided in case one needed to wash up during the changing.

Comfort during changing menstrual product

Forty one percent (41%) of the respondents were comfortable changing menstrual hygiene products where they did and 33% were not comfortable. 23% stated to be very comfortable whereas 3% said they were very uncomfortable.

Majority of those who changed their menstrual hygiene products at the bathrooms were very comfortable and 25% uncomfortable. 40% of those who changed in bedrooms or rooms were very comfortable and 60% very comfortable. For those who changed in latrines/toilets, 3.3% were very comfortable, 43.3% were comfortable, 36.7% were uncomfortable and 16.7% were very uncomfortable. The results for high levels of discomfort while using latrines as the place for changing menstrual hygiene products can be linked to the bad smell at the latrines. The latrines were also not satisfactorily clean. The latrines did not offer a clean place to use while changing such as a bar to place the pads or pants while doing the changing.

Changing in a room or bedroom was reported to be very comfortable and therefore having changing rooms in mixed day schools could make the girls more comfortable. The reason for those who were comfortable using the latrines could be due to privacy as there were lockable doors in 80% of the latrines.

Disposal of menstrual product

Eighty six percent (86%) of the respondents disposed their used sanitary products by throwing them in pit latrines while 13% reused them. Only 1% disposed in the dustbin. This can be attributed to the fact that it is only the pit latrine which was available. Even those who used reusable pads and washable cloths did not have the water and soap for washing available at school. They then had to go home to change and wash their reusable pads or washable pieces of cloths. In the study done in India by Dasgupta A. et al. (2008), 73.75% girls reused cloth pieces and 57.5% girls properly disposed the cloth pieces or sanitary pads used, that is, they wrapped the used cloth piece or sanitary pad in a paper bag and disposed in a place used for solid waste disposal. Disposal of these menstrual hygiene products needs intentional planning lest they can be a menace, for example in filling pit latrines unnecessarily.

Cost of menstrual hygiene products per month

The cost of the menstrual hygiene products used, commercial pads, were relatively expensive in the two schools. This coincides with other research findings in other studies such as in the WIN-SA research where 60% of women and girls in South Africa do not have access to traditional sanitary wear (pads and tampons). And as alternative to pads and tampons, they have no option but to use rags, toilet paper, leaves, “recycled” tampons/pads and disposable nappies. Girls from poverty stricken families find it difficult to access sanitary resources or rather find it too expensive thus receive less priority when compared to other household needs such as food.[14]

Hand washing before changing mentrual product

A majority, 51%, said they did not wash hands before changing menstrual hygiene products. It is necessary that one washes their hands before changing the sanitary products they are using especially those that require insertion. This is to reduce the chance of getting infection from the hands. The genitalia of a woman is very sensitive can easily get infected especially with poor hygiene practices which may lead to reproductive tract infections.

Experiencing body odour

Thirty six percent (36%) of the respondents experienced body odour during menstruation and 64% did not experience body odour while menstruating. This may be possible since most of the girls had at least two baths a day during menstruation thus many girls not experiencing body odour. However, the bad smell it can also be attributed to preformed attitudes towards menstrual blood or generally blood. Not changing menstrual products regularly, that is within four to six hours, may also be responsible for the body ordour experienced by some girls.

Missing school during menstruation

Thirty four percent (34%) of the respondents reported to have missed school during menstruation with reasons such as majorly lack of sanitary products or fear for leaks or due to menstrual cramps. Some also missed school due to both menstrual cramps and lack of sanitary products or fear for leaks. This shows how menstruation can interupt a girl’s education by making her miss school. During emergencies, many girls also went home to seek water and soap for washing as well as get menstrual products. If they had leaks, they reported that they warpped a sweater around their waist to cover the stains, asked for permission and went home. This translates to missing hours or days of classwork.

Infections

During menstruation girls and women face both practical and strategic gender problems which have negative impactions including potential vaginal infections that may result in the worst case in infertility.[15] There was a significant propotion of the girls experiencing itching and infections in the two schools with a majority of the respondents, 61%, reporting to have ever experienced itching in their genital area and 30% having ever had an infection of their repoductive tract.according tosuneela et al.[16] There is a significant association between poor genital hygiene and vaginitis (p