Menstrual Hygiene Management Among Adolescent Girls in Kenya

Summary

Menstrual hygiene management (MHM) is the processes and resources surrounding menstruation, including the knowledge, products, and social norms associated with it. For many adolescent girls in Kenya, MHM is a serious and impactful issue. Although there are likely more causal factors, research suggests that some of the largest causes of this problem are poverty, the culture surrounding menstruation, inadequate sexual health education, and poor sanitation infrastructure. These barriers to adequate menstrual hygiene management create adverse consequences for the Kenyan girls, including infections, poor mental well-being, increased sexual activity, decreased education attainment, and gender inequality. Although changing the status quo of MHM in Kenya will require long-term solutions to both the consequences and causes of poor MHM, many practices are being implemented today to alter this status quo. Especially common or innovative practices include feminine hygiene pad and cup distribution, workshops, and magazine education.

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Key Terms

Menstruation—A "cyclical discharging of blood, secretions, and tissue debris from the uterus" that recurs on a monthly basis among reproductive-age women. 1

Menarche–The first occurrence of menstruation.

Stigma–A “mark of disgrace [or shame] associated with a particular circumstance, quality, or person." 2

Sexual health–A “state of physical, mental, and social well-being in relation to sexuality” . 3 Sexual health includes safe and consensual sexual experiences, access to contraceptives, and a lack of sexual violence and discrimination.

Menstrual cup–A cup made of rubber that is inserted into the vagina and collects the menstrual blood. Menstrual cups last roughly two to four years.

Adolescent–An individual in the process of developing from childhood to adulthood, which begins with the onset of puberty. For the purposes of this paper, an adolescent is considered to be girls that have begun menstruating (as early as age 9 but at an average age of 13.9 4 ), to girls that have completed secondary school (age 18 5 ).

Context

According to the United Nations Children’s Foundation and the World Health Organization (WHO), ‘good’ menstrual hygiene management (MHM) can be defined as when “adolescent girls are using a clean menstrual management material to absorb or collect blood,” and when these materials can be changed privately as often as necessary. WHO goes on to define good MHM as “using soap and water for washing the body as required, and having access to facilities to dispose of used menstrual management materials.” 6 The United Nations Educational, Scientific, and Cultural Organization (UNESCO) further defines good MHM as consisting of eight key factors:

  • Accurate and timely knowledge
  • Informed and comfortable professionals
  • Sanitation and washing facilities
  • Safe and hygienic disposal
  • Available, safe and affordable materials
  • Referral and access to health services
  • Positive social norms
  • Advocacy and policy 7

Historically, Kenyan women have struggled with attaining the aforementioned factors of good MHM. With regards to sanitation facilities, in 2014 26% of Kenyan women report their main environment for MHM as their backyard or sleeping area rather than a bathroom, and in rural areas, only a third of schools [were] reported to provide a place for girls to manage their periods. 8 Kenya also has insufficient access to “safe and affordable materials” according to UNESCO standards, as less than half of women reported having sufficient feminine hygiene materials in 2016. 9 Additionally, statistics suggest a need for more open conversation surrounding menstruation. In 2014, only 50% of Kenyan women and girls reported that they openly discuss menstruation at home, and only 12% of girls said that they would be comfortable receiving menstrual information from their mother. 10 There is also a gap in Kenyan girls’ knowledge, as evidenced by the fact that 1 in 4 Kenyan girls do not associate menstruation with the potential to become pregnant. 11

A comparison of Kenya’s menstrual trends and MHM with other countries also provides insight on the scope of Kenya’s problem. In Kenya “menarche and start of puberty [are] delayed by approximately 1.5-2 years compared to a US reference population,” 12 likely due to low Body Mass Indexes caused by extrinsic factors such as poor living conditions. 13 In the United States and higher income European countries, in 2017 “73 to 92% of menstruating women [used] disposable menstrual management products.” 14 This number does not include those who use reusable products, meaning that the percentage of women who use any menstrual management products is likely even larger. In comparison, according to one 2016 study, only 46.1% of women in Kenya report having the feminine hygiene materials they need to manage menstruation. 15 In contrast to other eastern and southern African countries, however, Kenya’s MHM is relatively strong. For example, PMA2020 estimates that the prevalence of sanitary pad use in Kenya is 87%, whereas it is only 65% in Uganda and 45% in Ethiopia. 16 Note that the percentage of women that reported using pads (87%) is much higher than the percentage of women that reported having all materials they needed (46.1%), which is likely because the fact that a woman sometimes uses a pad does not mean she feels that she has all the materials she needs to manage her menstration.

Unfortunately, the research on MHM in Kenya is limited due to difficulties quantifying MHM and discrepancies between regions. For example, research on the average income in Kenya is often contradictory. While several individuals have researched the average daily income of Kenyans, the numbers often vary by as much as 200%. 17 Additionally, many of the causes and consequences of poor MHM such as culture and mental health are difficult to quantify, largely because of their subjectivity. Studies have been conducted to address this limitation, but quantifying how a community feels about periods or the anxiety a girl feels through surveys is not a perfect measure. 18

Contributing Factors

Poverty

Poverty is a cause of poor MHM in Kenya, largely because it limits the menstrual resources Kenyan families can provide for young girls. Global analyses of poverty in Kenya are somewhat varied by year, measurement criteria, and source, but organizations consistently report high levels of poverty. According to the World Bank’s 2015 report, 36.8% of Kenyan families live below the poverty line, which was globally considered to be $1.90 USD per day. 19 UNICEF reported that in 2015, the average rural family in Kenya had a wage of $124 USD per month, meaning that their spending power was roughly $4.50 USD a day. 20

This poverty limits Kenyan girls’ ability to buy menstrual hygiene products. The prices of menstrual pads from large distribution channels vary from cheaper brands to more expensive brands; as of 2016, cheaper sanitary pads cost approximately $0.50 USD for a package of eight, whereas P&G Always pads costs $0.80 USD for a package of eight. 21 This means Kenyans making about a dollar a day would need to spend almost a full day’s earning on one package of pads. Put in a more broad context, a 2015 study found that “approximately 65% of Kenyan women and girls are unable to afford sanitary pads.” 22

When Kenyan girls cannot afford pads, they often resort to unsanitary methods in order to manage their periods. Substitutes for pads and tampons include easily accessible materials such as newspapers, corn cobs, cotton gauze, cloth strips, or even old rags, leaves, or cow dung. 23 24 Not only can these substitutes be less comfortable than pads or tampons, but they also are less absorbent and sterile.

Spending power matters when paying for sanitary infrastructure in schools as well. According to a 2016 study, “current expenditures of WASH [water, sanitation, and hygiene] [. . .] averaged $1.83 USD per student per year.” 25 This number includes recurrent costs, but not the cost of installing or setting up WASH infrastructure, which was $4.92 per student per year for a school of 400 students. 26 The total cost of about $6.75 per student can be too large of a burden on Kenyan schools and families, leading to many sanitary stations in schools to be inadequate for the needs of Kenyan girls.

Culture

The culture surrounding menstruation in Kenya also contributes to inadequate MHM because the perceptions and stigmas common in Kenya do not support open conversation regarding the topic. Although perceptions of menstruation vary from country to country, global studies suggest that, in less-developed countries, menstruation is often viewed as contaminating and debilitating. 27 These perceptions can be especially prominent in public schools where girls are at higher risk of being ostracised for being on their period. According to a 2013 study of 120 Kenyan girls, many reported “seeking permission from a teacher to bathe or to go home, hiding until a friend could help them, or leaving school without permission” 28 when they bled at school. In short, some primary and secondary schools in Kenya may not be facilitating an environment of support and acceptance girls need to feel comfortable in school when on their period.

Family settings also often exhibit a lack of communication and support surrounding menstruation. In Kenya, menstruation is rarely discussed in families, 29 and many girls reported feeling like they could not openly discuss menstruation at home because “it is too private to even share with their mother.” 30 The prevalence of this view surrounding menstruation was shown by a 2015 Kenyan national survey, which found that less than 50% of parents discuss sex-related topics with their children, including menstruation. 31 These findings suggest that there is a lack of discussion surrounding menstruation which limits girls’ understanding and comfort surrounding periods, even in private settings.

These perceptions and poor communication can create a cycle of inadequate support because, if Kenyan girls have limited discussion of menstruation with their mothers, they are more likely to have limited discussion of menstruation with their future children. This “belief system surrounding menstruation [is] handed down from one generation to the the next,” and “the socio-cultural context perpetuates an environment in which these issues remain taboo to discuss with parents” 32 and girls’ future children.

Inadequate Sexual Health Education

A lack of sexual health education is another large contributor to poor MHM in Kenya because this education is directly tied to the feminine-health knowledge needed for adequate MHM. According to one study of three Kenyan counties, 86% of adolescent Kenyans attended primary school in 2015. While 96% of these children received some level of sexual education in primary school, over two-thirds of children reported wishing that they had more information and hours dedicated to sexual education topics. 33 This primary-school based education is especially important because only 33% of the students continued on to secondary school where they would have access to additional sexual education. Furthermore, in 2017 almost a third of the students reported that they did not receive sexual health education from their parents 34 suggesting that if these girls do not receive menstrual education in primary school, they may not receive it at all.

Although the government has mandated sexual education in schools, the curriculum insufficiently focuses on menstrual health. In 2013, the Kenyan government committed to “scale up comprehensive rights-based sexuality education beginning in primary school.” 35 However, the majority of sexual education focuses primarily on the biological rather than psycho-social changes, such as the hygienic use and disposal of sanitary pads. 36 As of 2015, three-fourths of schools covered all topics that constitute a comprehensive curriculum, but only 2% of students reported learning all the topics, and more significantly, menstrual health is not included in this curriculum. 37 This curriculum is also often not given its own class time: in one Kenyan study, girls reported only “receiving some information on reproductive health and puberty from science and biology classes.” 38

Additionally, the quality of instruction by teachers varies significantly across Kenya. 39 In 2017 as many as 85% of schools required teachers to have sexual education training, but 68% of those teachers reported feeling that they needed more training. Moreover, of those teachers trained, only 36% were trained on all topics that constitute a comprehensive curriculum, and nearly half of the teachers studied reported feeling “unprepared or uncomfortable answering students’ questions on sexual education.” 40 Other studies found that teachers will sometimes wander from the official curriculum to provide their own point of view 41 or skip over parts of sexual education because the students are tested on other mandatory subjects and not sexual education. 42

Sanitation

Poor sanitation is another major cause of inadequate MHM because of the lack of feminine materials and good facilities. This poor sanitation can be concentrated into two main categories: accessibility to sanitation infrastructure and quality of sanitation infrastructure (where quality is determined by the presence of handwashing stations, places to dispose of used sanitary products, and cleanliness).

Many Kenyans often have limited access to sanitation infrastructure. According to one 2018 study in rural Kenya, “only 32% of schools [had] a private place for girls to change their sanitary products.” 43 Another 2014 study, also conducted in rural Kenya, found that 84% of schools had separate toilets for girls, but only 33% of these toilet rooms had locks. 44 This 50% disparity between the two studies suggests that the availability of sanitary rooms may be highly variable from one region of Kenya to another. In fact, another 2015 study has found that “only 30% of Kenyans [had] access to improved sanitation facilities, with large regional disparities in sanitation access (15% in rural Northern Kenya compared to 99% in central provinces of Nairobi).” 45 This suggests that both accessibility to sanitation infrastructure in general and the disparities between regions contribute to Kenya’s poor MHM.

The quality of the sanitation infrastructure also contributes to poor MHM. Put simply, it is good to have a bathroom for girls, but the quality of the bathroom must also be considered. This quality can be determined by three main indicators: handwashing stations, places to dispose of used sanitary products, and overall cleanliness. In a 2014 study of 62 primary schools in Kenya, researchers found that 60% had hand washing water, but only 2% had soap. 46 In this same study, researchers found that Kenyan girls frequently did not had a place to dispose of their used sanitary products. When asked their form of pad disposal, almost a fourth of girls reported carrying the used pads home or burning them in a garbage pit because they did not have access to a sanitary place to dispose of it. 47 Furthermore, the overall cleanliness of bathrooms in Kenya is low. 48 As shown in the aforementioned 2014 study, “most toilets provided were found to be structurally sound, but only 16% were considered clean.” 49

Consequences

Health

Infections

The lack of feminine hygiene products can lead to increased likelihood of infection. As previously discussed, extreme poverty can lead girls to turn to means such as old rags, leaves, or cow dung in order to manage their period. 50 These unhygienic substitutes can have serious health consequences such as fungal infections, reproductive tract infections (RTIs) and urinary tract infections (UTIs). 51 These UTIs may occur because the unhygienic MHM practices “create abnormally moist conditions [. . .] that promote infection.” 52 Within the umbrella of RTIs, one study suggests that the infections most closely linked to MHM are bacterial vaginosis (BV) and vulvovagial candidasis (VVC). These infections come from vaginal imbalances and may be introduced to the reproductive tract through the materials used for absorbing blood. 53 These infections often first result in itchiness, soreness, and abnormal discharge. 54 Beyond the initial health complications, BV and VVC are also linked with increased risk of HIV infection and pregnancy complications. 55

It is also worth noting that it is not simply extreme substitutes (like leaves or cow dung) that can lead to infection. One study suggests that women who use reusable absorbent pads are more likely to have symptoms of infection or be diagnosed with urogenital infection than women using disposable pads. 56 Because of how expensive disposable pads are over time, many Kenyan girls use reusable pads, again increasing their risk of infection.

Mental Wellbeing

The fear and anxiety surrounding menstruation can also lead to poor mental wellbeing of girls. While there is little quantitative research on this topic, much of the research qualitatively discusses the high amounts of fear and anxiety surrounding menstruation in Kenya, which suggests that the perceptions and lack of support can negatively affect the mental wellbeing of Kenyan girls. In one study based in Kenya in 2013, researchers conducted 35 in-depth interviews and 18 focus groups to study the emotional impacts of what they deemed “menstrual poverty.” Girls in the interviews described how a lack of products and support was a major cause of “discomfort, embarrassment, anxiety, fear of being stigmatized, and low mood,” 57 all of which are major factors in the mental wellbeing of girls. The study goes on to describe girls that used language such as “‘feeling bad’, feeling ‘stressed’, or ‘fearful’ and ‘wanting to cry,’” 58 further suggesting that poor MHM can contribute to emotional distress for Kenyan girls, which in turn negatively affects their mental wellbeing.

Sexual Activity

Another consequence of inadequate MHM is increased sexual behavior, which can lead to increased risk of abuse, STI, and pregnancy. Kenyan girls in poverty often lack the spending power to purchase pads or tampons, and because these girls are unable to buy the products they need, it is common to engage in transactional sex or seek out a boyfriend to obtain these products. 59 Research provides varied answers to how frequently this sexual activity for sanitation materials occurs. In one study conducted among 3,000 Kenyan women and girls in 2015, researchers found that “1 in 10 15-year-old girls were having sex to get money to pay for sanitary ware.” 60 According to another Kenyan study from 2015, “two out of three pad users in rural Kenya received pads from their sexual partners” , though this statistic does not necessarily imply transactional sex. 61 Although there is a disparity between these percentages, there is strong evidence that young girls may resort to sex in order to get the feminine products they need.

When girls engage in increased sexual activity in order to obtain feminine materials, the power dynamics of intimate relationships are negatively affected, 62 suggesting that these girls may have minimal leverage in sexual relationships and may be more susceptible to abuse. 63 This sexual behavior also increases their risk of contracting sexually transmitted infections (STIs). In situations where girls must use sex to obtain pads, Kenyan girls may be unable to negotiate safe sex practices, which further increases their risk of contracting STIs, including HIV. 64 Unfortunately, there is limited research on the prevalence of HIV caused by engaging in sex in order to obtain feminine hygiene products. It is known, however, that as of 2017 the overall prevalence rate for HIV among young Kenyan women was 2.6%, which was notably higher than the rate for young men, which was 1.3%. 65

Lastly, increased sexual behavior for materials increases girls’ risk of experiencing unwanted pregnancy. 66 In one 2015 study conducted among Kenyan women under 30, 35% of the sexually active women reported pregnancy in the past 12 months. 67 Although the sample was not just girls who were sexually active in order to obtain hygiene materials, this high percentage may suggest that girls using sex for products are likely to get pregnant prematurely. Further research suggests that this early pregnancy affects girls’ ability to stay in school, 68 so as girls resort to sex to get the materials they need, the increased chance of pregnancy can also decrease their educational opportunity, creating a cycle of poverty and poor MHM.

Education & Gender Inequality

Another major consequence of poor MHM is decreased school attendance among Kenyan girls. If girls feel embarrassed or shameful about their period, they are much less likely to attend school while menstruating. Furthermore, girls often do not have appropriate sanitation facilities where they can manage their menstrual flow at school, potentially leading to a decrease in educational attendance. UNICEF estimates that 1 in 10 school-age African girls do not attend school during menstruation, and the World Bank statistics estimates absences to be approximately four days every four weeks. 69

As girls miss school and fall behind, the educational disparity between boys and girls widens. A 2014 study showed that “girls’ enrolment ratios [in Kenya] have increased in recent years, but large inequality gaps in primary education attainment remain.” 70 Other studies have confirmed this trend; multiple studies find that the gap between girls’ and boys’ education is most pronounced during secondary education, suggesting that this gap widens as girls experience menarche. 71 This gap in education also contributes to the gap in literacy rates. Compared to the national illiteracy average of 7% in 2014, “50% of girls 15—19 are illiterate in the rural, conservative North Eastern province.” 72

The gap in education that comes as a result of poor MHM can lead to deeper economic consequences. According to a 1999 study by the World Bank, a 1 percent increase of women with a secondary education causes a .3 percent increase in per capita income on average. 73 This suggests that as poor MHM decreases educational attendance among girls, there may be adverse economic consequences in the form of lower economic productivity.

Practices

Feminine Hygiene Product Distribution: Pads

One of the most common forms of interventions to improve MHM in Kenya is feminine sanitary pad distribution. Organizations generally donate sustainable pads, meaning that they can be washed and reused for up to 18 months. 74 Promoters of this practice believe that pad distribution increases girls’ ability to manage their periods, consequently increasing their attendance and comfort in school. Organizations such as Huru International, Days for Girls, Too Little Children, Kenya Works, and AFRIpads apply this practice in Kenya.

Many of the aforementioned organizations host community events in order to distribute pads. For example, Huru International facilitators host school events in Kenya where pads that are “leak-proof guaranteed for 18 months” are distributed to the girls. 75 Some organizations including Huru International and Kenya Works make all their pads locally in Kenya, which creates a more sustainable way for Kenyans to obtain feminine products. 76 Most of these organizations, including Days for Girls, AFRIpads, and Kenya Works, deliver four to eight reusable pads to Kenyan girls, often accompanied by bars of soap and/or underwear.

Feminine Hygiene Product Distribution: Cups

Like feminine pads, feminine cups are another common intervention to improve MHM in Kenya. Feminine cups are small rubber cups that collect menstrual blood by being folded and inserted into the vagina. The cup collects blood without leakage, and after several hours can be removed, washed, and re-inserted. 77 These cups are durable and long-lasting, meaning that girls do not need to purchase new products on a monthly basis. Like pads, promoters of this practice believe that if girls can manage their flow more easily, they will likely be able to attend school more frequently and have greater peace of mind when on their period.

Femme International and Ruby Cup are two examples of organizations that apply this practice in Kenya. Femme International distributes these products by first enrolling girls in the Twaweza Program, a program that combines education and distribution of products. Once enrolled, the girls are allowed to choose either a menstrual cup or reusable pads, both of which are “sustainable and remove the financial burden of menstruation.” 78 Like Femme International, Ruby Cup, along with ARRIVE Kenya, hosts a classroom-set menstrual health and management workshop where the Ruby Cups are distributed. 79

Impact

Most organizations measure success in delivering a large number of products. For example, Kenya Works reported 20,000 pads distributed in 2018. 80 Huru International reports that, as of 2018, they have produced 1,140,056 pads, distributed 145,000 kits, and reached 200,029 youth. 81 Huru International also states that their program has increased school attendance by 3,780,000 days. 82 While the pads Huru International provides likely increases school attendance, the method behind this statistic is unclear, so it is not certain that Huru International’s pad distribution actually increases school attendance by that amount.

Femme International evaluated their program through a series of six-month long “monitoring and evaluation” studies in five government secondary schools in the Moshi Rural district. 83 Femme International reports that 495 AFRIpads and 495 Ruby Cups were distributed, and of those who received these products, 63.7% of girls reported using the products at the six-month follow up. 84 The use of less hygienic menstrual products decreased drastically–dropping from 32.3% to 8.5%–and at the six-month mark, 85% of girls reported missing zero school days due to menstruation, which was a 25% increase in attendance from the baseline. 85 There was “an 18% decrease in girls missing school due to pain, 6.1% decrease in missing school due to fear of leaking, and 2.9% decrease in missing school because of menstrual shame.” 86 Furthermore, 65.4% of girls attributed a self-reported increase in school performance to the program and products given by Femme International. 87

Gaps

While each of these organizations provide sustainable products, gaps still exist largely because of uncertainty surrounding the actual level of success in increasing school attendance and decreasing menstrual shame. For example, one study conducted in Nepal in 2011 found that better access to feminine hygiene products had little to no effect on the attendance gap. 88 Moreover, a 2016 study in Uganda found that while drops in attendance was worse for those girls that did not receive pads, the pads had no significant impact on girls’ self-reported shame or insecurity while on their period. 89 However, there is research that has found positive impacts because of feminine product donations, despite the research that suggest that donations do not create significant positive results. 90

An additional gap is in the reusable quality of the pads. As previously discussed, a 2015 study found that women who use reusable absorbent pads are more likely to have symptoms of infection or be diagnosed with urogenital infection than women using disposable pads, 91 potentially because of insufficient cleaning processes of the reusable pads. This suggests that this practice may have some negative health effects.

It is also difficult to use feminine cups in an area of the world where sanitary bathrooms are not always available. As previously stated, in rural Kenya in 2018, only 32% of schools had a private place for girls to change their sanitary products. 92 Additionally, according to a 2014 study, only 60% of Kenyan schools have hand-washing water and 2% of schools have soap in their bathrooms. 93 Because the cleaning and reinsertion of a sanitary cup requires a private and sanitary area, menstrual cups may only reach full effectiveness if paired with the installation of bathrooms with soap and water in all Kenyan schools.

Workshops

Workshops are another common practice conducted by organizations improving MHM in Kenya. These workshops usually consist of gathering girls in a classroom or community area where organization leaders teach the girls about feminine health. Most organizations that address MHM conduct some form of workshop, including Femme International, Inua Dada, Huru International, and the Water Supply and Sanitation Collaborative Council (WSSCC).

Femme International works by partnering with schools and communities to deliver a series of interactive workshops. These workshops are centered on creating a safe space where girls feel comfortable asking questions, perhaps providing them with the only opportunity that they will have to openly discuss menstrual topics. 94 While the workshops are adapted to the needs of the group of girls being taught, they are often focused on subjects such as puberty, menstruation, and sexual health. 95 As girls participate in these workshops, Femme International hopes to “empower girls to be confident within their bodies and ensure that menstruation does not cause them to miss school.” 96

Like Femme International, Inua Dada created interactive education sessions where girls can build self-esteem and discuss hygienic ways of using and disposing of sanitary pads. 97 Similarly, Huru International also hosts workshops where Huru leaders speak on menstrual health, sexual and reproductive health, gender norms, gender-based violence, self-confidence, and HIV/AIDS prevention. 98 Huru International is unique in that they do not limit their workshops to girls: “Huru always works with boys, teachers, parents, and community leaders to help foster an environment where [. . .] girls are supported both in and out of the classroom.” 99

Unlike most other workshops, WSSCC’s workshops are conducted primarily to train leaders rather than to educate girls. In their 2016 training, male and female health and educational leaders were gathered from 16 counties in Kenya to participate in six days of training. Each day was focused on different aspects of MHM. For example, on day three of the workshop a three-pronged approach to MHM was taught: breaking the silence, managing menstruation hygienically, and safe reuse and disposal options. WSSCC hopes that as leaders participate in these trainings, they will be able to improve the culture surrounding menstruation and improve girls’ knowledge. 100

Impact

Evaluations conducted by some of the aforementioned organizations suggests that workshops can have high impact increasing knowledge and communication and decreasing anxiety and stigmas surrounding menstruation. However, as with product distribution, many organizations measure success by the number of workshops held, which provides little insight into whether or not the workshops actually decrease stigmas and increase knowledge.

Femme International has conducted several observational studies where they tested the effect of their workshops. Femme asks girls series of questions in order to test for indicators such as “change in knowledge” and “empowerment.” The studies have shown that their workshops reduce deliberate school absence amongst the girls participating and increases their participation in school, work, and social spheres. Femme International further notes that the girls are “more confident and exhibit less menstrual-related shame” and are 1.5 times less likely to report several symptoms of RTIs, UTIs, and STIs associated with poor MHM practices. 101 This leads Femme International to conclude that their workshops have a significant positive impact on the quality of life of their participants. 102

There is limited research on the impact of other organizations. For example, Inua Dada Foundation only reports “10,120 girls reached” and “108 schools reached” , 103 and Huru International reports that they have reached 200,029 youth and 35,000 boys through their educational program. 104 However, the effectiveness of their program in actually increasing knowledge and decreasing stigmas is unknown.

Gaps

There is limited research on both the effectiveness and gaps of workshops. However, the gaps in this practice may come from the reach and scalability. Organizations often enroll girls in workshops through local schools, so those that do not attend school may not see the direct benefits of the program. For example, Femme International and Inua Dada involve girls in these programs by partnering with local schools, 105 so those not in school will not be enrolled. Additionally, if these workshops do not provide training for Kenyan teachers and leaders, the educational program will only last as long as the organizations’ facilitators are there, leading to low scalability.

There is also a gap in the way that workshops do not completely address the root causes of the program. While workshops do seem to decrease social stigmas and increase knowledge, these workshops do not directly alleviate poverty so girls and their families can afford sanitary materials and sanitation facilities.

Magazine Education

Another current practice is the distribution of a magazine created to provide sexual and menstrual education for Kenyan girls. This practice is only currently implemented by one organization, Zana Africa, which created a “referable health magazine called Nia Teen” to be distributed throughout Kenya. 106 The goal of Nia Teen is that girls reading will receive “menstrual and reproductive health education [. . .] to foster self-efficacy, and to support [them] to safely and confidently navigate adolescence and stay in school” . 107 As they become more educated, it is anticipated that they will increase in confidence and knowledge, leading to decreased adverse health consequences such as infection and more knowledge and healthy perceptions surrounding menstruation.

The process of creating Nia Teen started with gathering data from over 10,000 questions concerning feminine issues collected from 1,000 girls. Answers are then compiled into an issue, which was designed for measurable increases in knowledge and behavioral changes. 108 These issues feature pictures of Kenyan girls, bright colors, and other illustrations that make the magazine entertaining to read. Articles such as “Understanding Relationships” and “Amazing Women” are included, as well as a comic on healthy decision-making and a calendar for period-tracking. 109 Nia Teen is designed to be scaled to a large number of girls at a low cost and with minimal reliance on Zana Africa representatives to distribute the magazines. 110

Impact

There has been significant evaluation surrounding the impact Zana Africa’s Nia Teen magazine has on Kenyan girls. This project is “the first study conducted in Sub-Saharan Africa to rigorously measure the individual and combined effects of sanitary pads and reproductive health education on girls’ educational, social, and health outcomes. 111 In this randomized controlled trial (RCT), Kenyan girls are assigned to one of four interventions: schools receive disposable sanitary pads, schools receive reproductive health education, schools receive disposable sanitary pads plus reproductive health education, or no intervention. 112 Unfortunately, the results of this impact evaluation will not be published until late 2019. However, what is known that the magazine has reached 3,489 girls in 140 schools. 113

Gaps

Gaps for this practice include insufficient distribution chains for the magazines, as reaching every girl in Kenya is an incredibly demanding task. Another gap is illiteracy: in Kenya in 2017, 74.9% of women (including both adolescents and adults) could read, and while that number is on the incline, it still suggests that this magazine will not be effective with the fourth of the population that is still illiterate. 114

Key Takeaways

  • Inadequate menstrual hygiene management (MHM)–including a lack of accurate and timely knowledge, sanitation and washing facilities, safe and affordable materials, positive social norms, and sexual health education–is a serious issue for adolescent girls in Kenya.
  • Although there are likely more factors, this poor MHM is largely caused by poverty, the culture surrounding menstruation, inadequate sexual health education, and poor sanitation infrastructure.
  • Poor MHM creates serious consequences for these girls, including health consequences of infections and poor mental well-being, sexual activity, and education and gender inequality.
  • Several practices are currently in place to address inadequate MHM, the most prominent or noteable of which are feminine hygiene pad and cup distribution, workshops, and magazine education.
  • Although this social issue is far from being solved, these practices, along with the increased universal understanding and prioritization of MHM, create an optimistic view of the future of menstrual hygiene management among adolescent girls in Kenya.
by Kelsey Sampson

Kelsey is a BYU sophomore studying Business Strategy and Professional Writing and Rhetoric. After taking on a few research assistant jobs, she found her love for research and technical writing, and she has enjoyed using those skills to study social innovation ever since. She has found her niche in the combination of business and social impact, and she hopes to continue to work in a combination of those areas. Besides school, Kelsey is a big fan of being with friends and family, volleyball, really hot weather, and staying in the Harold B. Library until it closes.


Volume 2

POVERTY
HEALTH
GENDER INEQUALITY
SEXUAL HEALTH
EDUCATION
SUB-SAHARAN AFRICA
WOMEN
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1 "Menstruation." Merriam-Webster.org., accessed Dec 8, 2018, https://www.merriam-webster.com/dictionary/menstruation.

2 "Stigma." oxforddictionaries.com., accessed Dec 8, 2018,https://en.oxforddictionaries.com/definition/stigma.

3 WHO. "Sexual Health." who.int., accessed Dec 8, 2018,https://www.who.int/topics/sexual_health/en/.

4 Rogo, K. O., R. A. Oniang'o, and L. A. Muruli. 1987. "Menarche in African Girls in some Post-Secondary Institutions in Kenya." East Africa Medical Journal 64 (11): 745-750. https://www.ncbi.nlm.nih.gov/pubmed/3505850.

5 Kenya: Age Distribution and School Attendance of Girls Aged 9-13 Years. 2012.

6 UNICEF and WHO. 2012. “Report of the Second Consultation on Post-2015 Monitoring of Drinking-Water, Sanitation and Hygiene.” The Hague, 3-5. http://www.unosd.org/content/documents/151Report%20on%20WHO%20UNICEF%20Hague%20Consultation%20December%202012_28Mar_final%20draft.....pdf.

7 Puberty Education & Menstrual Hygiene Management. Menstrual Hygiene Management. 2014: the United Nations Educational, Scientific and Cultural Organization. https://asanteafrica.org/wp-content/uploads/2018/03/UNESCO-Puberty-rpt.pdf.

8 Alexander, Kelly T. Oduor, et al. 2014. "Water, Sanitation and Hygiene Conditions in Kenyan Rural Schools: Are Schools Meeting the Needs of Menstruating Girls?" Water 6, no. 5: 1453-1466.

9 PMA 2020. 2016. Menstrual Hygiene Management;Menstrual Hygiene Management.

10 Facility Solutions Group. 2016. Menstrual Health in Kenya; Country Landscape Analysis. http://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- Landscape_Kenya.pdf.

11 Facility Solutions Group. 2016. Menstrual Health in Kenya; Country Landscape Analysis. http://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- Landscape_Kenya.pdf.

12 AMERICAN ACADEMY OF PEDIATRICS and AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS. 2006. "Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign." The American Academy of Pediatrics 118 (5): 2245-2250. doi:10.1542/peds.2006-2481.

13 THOMAS, FRÉDÉRIC, FRANÇOIS RENAUD, ERIC BENEFICE, THIERRY DE MEEÜS, and JEAN-FRANÇOIS GUEGAN. "International Variability of Ages at Menarche and Menopause: Patterns and Main Determinants." Human Biology 73, no. 2 (2001): 271-90. http://www.jstor.org/stable/41465935.

14 Kuhlumann Anne, Henry Kaysha, and Wall L. Lewis. 2017. "Menstrual Hygiene Management in Resource-Poor Countries." Obstetrical Gynecological Survey 72 (6): 356—376. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5482567/.

15 PMA 2020. 2016. Menstrual Hygiene Management;Menstrual Hygiene Management.

16 Tellier, Seiri and Maria Hyttel. 2017. Menstrual Health Management in East and Southern Africa: A Review Paper: Menstrual Health Management Symposium.

17 Ankler, Richard and Martha Ankler. 2016. Living Wage Report. ; Mawathe, Anne. "Period Misery for Kenya Schoolgirls." BBC.co.uk., last modified Mar 17, accessed Oct 16, 2018, http://news.bbc.co.uk/2/hi/africa/4816558.stm.

18 Linda Mason , Elizabeth Nyothach, Kelly Alexander, Frank O. Odhiambo, Alie Eleveld, John Vulule, Richard Rheingans, Kayla F. Laserson, Aisha Mohammed, Penelope A. Phillips- Howard. 2013. "‘We Keep it Secret so no One should Know’ — A Qualitative Study to Explore Young Schoolgirls Attitudes and Experiences with Menstruation in Rural Western Kenya." Public Library of Service. doi://doi.org/10.1371/journal.pone.0079132.

19 The World Bank. 2015. Kenya. http://povertydata.worldbank.org/poverty/country/KEN.

20 Ankler, Richard and Martha Ankler. 2016. Living Wage Report.

21 Ibid.

22 USAID. 2015. Afri-can Trust: Empowering Women and Girls through Affordable Sanitary Pads.

23 Njeri Ngugi, Margaret and Jasper Edward Nyaura. 2014. "Demystifying the Menstruation Process among the Kenyan Girl-Child “A Period of Shame” : A Socio-Cultural Perspective." International Journal of Science and Research 3 (10): 1077-1083. https://www.ijsr.net/archive/v3i10/MDMwOTE0MDQ%3D.pdf.

24 Tellier, Seiri and Maria Hyttel. 2017. Menstrual Health Management in East and Southern Africa: A Review Paper: Menstrual Health Management Symposium.

25 Alexander, K. T., A. Mwaki, D. Adhiambo, M. Cheney-Coker, R. Muga, and M. C. Freeman. 2016. "The Life-Cycle Costs of School Water, Sanitation and Hygiene Access in Kenyan Primary Schools." Int. J. Environ. Res. Public Health 7 (13). doi:10.3390/ijerph13070637.

26 Ibid.

27 Buckley T, Gottlieb A (1988) Blood magic: The anthropology of menstruation. Berkeley: University of California Press. ; Szarewski A, von Stenglin A, Rybowski S (2012) Women’s attitudes towards monthly bleeding: results of a global population-based survey. Eur J Contracept Reprod Health Care 17: 270—283.

28 Ibid.

29 Njeri Ngugi, Margaret and Jasper Edward Nyaura. 2014. "Demystifying the Menstruation Process among the Kenyan Girl-Child “A Period of Shame” : A Socio-Cultural Perspective." International Journal of Science and Research 3 (10): 1077-1083. https://www.ijsr.net/archive/v3i10/MDMwOTE0MDQ%3D.pdf.

30 Linda Mason , Elizabeth Nyothach, Kelly Alexander, Frank O. Odhiambo, Alie Eleveld, John Vulule, Richard Rheingans, Kayla F. Laserson, Aisha Mohammed, Penelope A. Phillips- Howard. 2013. "‘We Keep it Secret so no One should Know’ — A Qualitative Study to Explore Young Schoolgirls Attitudes and Experiences with Menstruation in Rural Western Kenya." Public Library of Service. doi://doi.org/10.1371/journal.pone.0079132.

31 Jewitt, Sarah and Harriet Ryley. 2014. "It’s a Girl Thing: Menstruation, School Attendance, Spatial Mobility and Wider Gender Inequalities in Kenya." Geoforum 56: 137-147.

32 J Glor, Sarala Thapa, L J Severy, and Ian Askew. 1993. "Menstrual Experiences and Beliefs: A Multicountry Study of Relationships with Fertility and Fertility Regulating Methods." Women & Health 20 (2): 1-20.https://www.researchgate.net/publication/14825781_Menstrual_experiences_and_beliefs_A_multicountry_study_of_relationships_with_fertility_and_fertility_regulating_methods.

33 Sexuality Education in Kenya: New Evidence from Three Counties. 2017. New York: Guttmacher Institute.

34 Ibid.

35 Ibid.

36 Facility Solutions Group. 2016. Menstrual Health in Kenya; Country Landscape Analysis. http://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- Landscape_Kenya.pdf.

37 Sexuality Education in Kenya: New Evidence from Three Counties. 2017. New York: Guttmacher Institute.

38 Njeri Ngugi, Margaret and Jasper Edward Nyaura. 2014. "Demystifying the Menstruation Process among the Kenyan Girl-Child “A Period of Shame” : A Socio-Cultural Perspective." International Journal of Science and Research 3 (10): 1077-1083. https://www.ijsr.net/archive/v3i10/MDMwOTE0MDQ%3D.pdf.

39 Facility Solutions Group. 2016. Menstrual Health in Kenya; Country Landscape Analysis. http://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- Landscape_Kenya.pdf.

40 Sexuality Education in Kenya: New Evidence from Three Counties. 2017. New York: Guttmacher Institute.

41 African Population and Health Research Center. 2010. Experiences and Problems with Menstruation among Poor Women and Schoolgirls in Nairobi, Kenya. Longonot Road: Shelter Afrique Center.

42 Facility Solutions Group. 2016. Menstrual Health in Kenya; Country Landscape Analysis. http://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- Landscape_Kenya.pdf.

43 Higgins, Abigail. "Having a Period is Unaffordable in Kenya, Yet no One Wants to Talk about It." theguardian.com., last modified Jan 5, accessed Oct 16, 2018, https://www.theguardian.com/global-development-professionals- network/2017/jan/05/having-a-period-is-unaffordable-in-kenya-yet-no-one-wants-to-talk-about-it.

44 Kelly T. Alexander, Clifford Oduor, and Elizabeth Nyothach. 2014. "Water, Sanitation and Hygiene Conditions in Kenyan Rural Schools: Are Schools Meeting the Needs of Menstruating Girls?" Water1 (6): 1453-1466. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwicjqOQgpLeAhXIqlQKHW20DPUQFjAAegQICRAC&url=http%3A%2F%2Fwww.mdpi.com%2F2073-4441%2F6%2F5%2F1453%2Fpdf&usg=AOvVaw3HaIFK5zn9eL2lmIdrqnPs.

45 The World Bank. 2015. People using Safely Managed Sanitation Services (% of Population).

46 Kelly T. Alexander, Clifford Oduor, and Elizabeth Nyothach. 2014. "Water, Sanitation and Hygiene Conditions in Kenyan Rural Schools: Are Schools Meeting the Needs of Menstruating Girls?" Water1 (6): 1453-1466. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwicjqOQgpLeAhXIqlQKHW20DPUQFjAAegQICRAC&url=http%3A%2F%2Fwww.mdpi.com%2F2073-4441%2F6%2F5%2F1453%2Fpdf&usg=AOvVaw3HaIFK5zn9eL2lmIdrqnPs.

47 Ibid.

48 Garn, J. V., Caruso, B. A., Drews-Botsch, C. D., Kramer, M. R., Brumback, B. A., Rheingans, R. D., & Freeman, M. C. (2014). Factors Associated With Pupil Toilet Use in Kenyan Primary Schools. International Journal of Environmental Research and Public Health, 11(9), 9694—9711. http://doi.org/10.3390/ijerph110909694.

49 Kelly T. Alexander, Clifford Oduor, and Elizabeth Nyothach. 2014. "Water, Sanitation and Hygiene Conditions in Kenyan Rural Schools: Are Schools Meeting the Needs of Menstruating Girls?" Water1 (6): 1453-1466. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwicjqOQgpLeAhXIqlQKHW20DPUQFjAAegQICRAC&url=http%3A%2F%2Fwww.mdpi.com%2F2073-4441%2F6%2F5%2F1453%2Fpdf&usg=AOvVaw3HaIFK5zn9eL2lmIdrqnPs.

50 Njeri Ngugi, Margaret and Jasper Edward Nyaura. 2014. "Demystifying the Menstruation Process among the Kenyan Girl-Child “A Period of Shame” : A Socio-Cultural Perspective." International Journal of Science and Research 3 (10): 1077-1083. https://www.ijsr.net/archive/v3i10/MDMwOTE0MDQ%3D.pdf.

51 "Impact of Unhygienic Sanitary Practices on Women’s Health." soothehealthcare.org., accessed Oct 17, 2018, http://soothehealthcare.com/impact-of-unhygienic-sanitary-practices- on-womens-health/.

52 Das, Padma et al. 2015. "Menstrual Hygiene Practices, WASH Access and the Risk of Urogenital Infection in Women from Odisha, India." PloS One 10 (6). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4488331/.

53 Sumpter Colin and Torondel Belen. 2013. "A Systematic Review of the Health and Social Effects of Menstrual Hygiene Management." PloS One 8 (4). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3637379/.

54 French Kathy. "Bacterial Vaginosis and Vulvovaginal Candidiasis." nursinginpractice.com., last modified July 25, accessed February 15, 2019, https://www.nursinginpractice.com/article/bacterial-vaginosis-and-vulvovaginal-candidiasis.

55 Sumpter Colin and Torondel Belen. 2013. "A Systematic Review of the Health and Social Effects of Menstrual Hygiene Management." PloS One 8 (4). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3637379/.

56 Das, Padma et al. 2015. "Menstrual Hygiene Practices, WASH Access and the Risk of Urogenital Infection in Women from Odisha, India." PloS One 10 (6). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4488331/.

57 Crichton Joanna, Okay Jerry, Kabiru Caroline, and Zulu Msiyaphazi Eliya. 2013. "Emotional and Psychosocial Aspects of Menstrual Poverty in Resource-Poor Settings: A Qualitative Study of the Experiences of Adolescent Girls in an Informal Settlement in Nairobi." Health Care for Women International 34 (10). https://www.tandfonline.com/doi/pdf/10.1080/07399332.2012.740112?needAccess=true.

58 Ibid.

59 Crichton Joanna, Okay Jerry, Kabiru Caroline, and Zulu Msiyaphazi Eliya. 2013. "Emotional and Psychosocial Aspects of Menstrual Poverty in Resource-Poor Settings: A Qualitative Study of the Experiences of Adolescent Girls in an Informal Settlement in Nairobi." Health Care for Women International 34 (10). https://www.tandfonline.com/doi/pdf/10.1080/07399332.2012.740112?needAccess=true. ; Duke Global Health Institute. "Why Adolescent Girls Miss School in Rural Kenya." global health.duke.edu., last modified Jan 24, accessed Oct 18, 2018, https://globalhealth.duke.edu/media/news/why-adolescent-girls-miss-school-rural-kenya.

60 Higgins, Abigail. "Having a Period is Unaffordable in Kenya, Yet no One Wants to Talk about It." theguardian.com., last modified Jan 5, accessed Oct 16, 2018, https://www.theguardian.com/global-development-professionals-network/2017/jan/05/having-a-period-is-unaffordable-in-kenya-yet-no-one-wants-to-talk-about-it.

61 Facility Solutions Group. 2016. Menstrual Health in Kenya; Country Landscape Analysis. http://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- Landscape_Kenya.pdf.

62 Ibid.

63 Phillips-Howard, P. A., Otieno, G., Burmen, B., Otieno, F., Odongo, F., Odour, C., . . . Laserson, K. F. (2015). Menstrual Needs and Associations with Sexual and Reproductive Risks in Rural Kenyan Females: A Cross-Sectional Behavioral Survey Linked with HIV Prevalence. Journal of Women’s Health,24(10), 801—811. http://doi.org/10.1089/jwh.2014.5031.

64 Facility Solutions Group. 2016. Menstrual Health in Kenya; Country Landscape Analysis. http://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- Landscape_Kenya.pdf.

65 UNAIDS. 2017. Kenya | 2017 Country Factsheet.

66 Facility Solutions Group. 2016. Menstrual Health in Kenya; Country Landscape Analysis. http://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- Landscape_Kenya.pdf.

67 Phillips-Howard, Penelope, George Otieno, and Barbra Burmen. 2015. "Menstrual Needs and Associations with Sexual and Reproductive Risks in Rural Kenyan Females: A Cross-Sectional Behavioral Survey Linked with HIV Prevalence." Journal of Women's Health 24 (10): 801-811. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4624246/.

68 Ibid.

69 Onjoro, Veronica. "Are Menses a Hindrance to Girls Education in Kenya."academia.edu.

70 Jewitt, Sarah and Harriet Ryley. 2014. "It’s a Girl Thing: Menstruation, School Attendance, Spatial Mobility and Wider Gender Inequalities in Kenya." Geoforum 56: 137-147. doi://doi.org/10.1016/j.geoforum.2014.07.006.

71 Jewitt, Sarah and Harriet Ryley. 2014. "It’s a Girl Thing: Menstruation, School Attendance, Spatial Mobility and Wider Gender Inequalities in Kenya." Geoforum 56: 137-147. doi://doi.org/10.1016/j.geoforum.2014.07.006. ; Linda Mason , Elizabeth Nyothach, Kelly Alexander, Frank O. Odhiambo, Alie Eleveld, John Vulule, Richard Rheingans, Kayla F. Laserson, Aisha Mohammed, Penelope A. Phillips- Howard. 2013. "‘We Keep it Secret so no One should Know’ — A Qualitative Study to Explore.

72 Jewitt, Sarah and Harriet Ryley. 2014. "It’s a Girl Thing: Menstruation, School Attendance, Spatial Mobility and Wider Gender Inequalities in Kenya." Geoforum 56: 137-147. doi://doi.org/10.1016/j.geoforum.2014.07.006.

73 Dollar David and Gatti Roberta. 1999. "Gender Inequality, Income, and Growth: Are Good Times Good for Women?" World Bank 1. http://documents.worldbank.org/curated/en/251801468765040122/pdf/multi-page.pdf.

74 Huru International. "The Problem." huruinternational.org., accessed October 20, 2018, https://huruinternational.org/what-we-do/.

75 Huru International. "The Problem." huruinternational.org., accessed October 20, 2018, https://huruinternational.org/what-we-do/.

76 Ibid.

77 Ibid.

78 Femme International. "Our Programs." 2018. femmeinternational.org., accessed November 5, 2018, https://www.femmeinternational.org/our-work/the-issue/.

79 Arranz, Amaia. "Distributing Menstrual Cups in Kenya." ruby cup.com., last modified July 27, accessed November 13, 2018, https://rubycup.com/blog/distributing-menstrual-cups-in-kenya/.

80 "Kenya Works." kenyaworks.org., https://www.kenyaworks.org.

81 Huru International. "Impact." huruinternational.org., accessed October 20, 2018, https://huruinternational.org/impact/.

82 Ibid.

83 Rubli, Jennifer. 2017. Monitoring and Evaluation Report.https://www.femmeinternational.org/wp-content/uploads/2018/09/Femme-International-ME-Report-2017.pdf

84 Ibid.

85 Ibid.

86 Ibid.

87 Ibid.

88 Oster, Emily and Rebecca Thornton. 2011. "Menstruation, Sanitary Products, and School Attendance: Evidence from a Randomized Evaluation." American Economic Journal: Applied Economics 3 (1): 91-100. https://www.aeaweb.org/articles?id=10.1257/app.3.1.91.

89 Montgomery, Paul, Julie Hennegen, and Cathrine Dolan. 2016. "Menstruation and the Cycle of Poverty: A Cluster Quasi-Randomised Control Trial of Sanitary Pad and Puberty Education Provision in Uganda." Plos One 11 (12). https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0166122.

90 Scott, Linda and Sue Dopson. 2009. "Impact of Providing Sanitary Pads to Poor Girls in Africa." University of Oxford.https://www.semanticscholar.org/paper/Impact-of-Providing-Sanitary-Pads-To-Poor-Girls-in-Scott-Dopson/af284935d59ccbf3c0c50ba61fee65f3e531147b. ; Hennegan, Julie, Cathrine Dolan, Maryalice Wu, Linda Scott, and Paul Montgomery. 2016. "Schoolgirls’ Experience and Appraisal of Menstrual Absorbents in Rural Uganda: A Cross-Sectional Evaluation of Reusable Sanitary Pads." Reproductive Health 13 (143).

91 Das, Padma et al. 2015. "Menstrual Hygiene Practices, WASH Access and the Risk of Urogenital Infection in Women from Odisha, India." PloS One 10 (6). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4488331/.

92 Higgins, Abigail. "Having a Period is Unaffordable in Kenya, Yet no One Wants to Talk about It." theguardian.com., last modified Jan 5, accessed Oct 16, 2018, https://www.theguardian.com/global-development-professionals- network/2017/jan/05/having-a-period-is-unaffordable-in-kenya-yet-no-one-wants-to-talk-about-it.

93 Kelly T. Alexander, Clifford Oduor, and Elizabeth Nyothach. 2014. "Water, Sanitation and Hygiene Conditions in Kenyan Rural Schools: Are Schools Meeting the Needs of Menstruating Girls?" Water1 (6): 1453-1466. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwicjqOQgpLeAhXIqlQKHW20DPUQFjAAegQICRAC&url=http%3A%2F%2Fwww.mdpi.com%2F2073-4441%2F6%2F5%2F1453%2Fpdf&usg=AOvVaw3HaIFK5zn9eL2lmIdrqnPs.

94 Femme International. "Our Programs." 2018. femmeinternational.org., accessed November 5, 2018, https://www.femmeinternational.org/our-work/the-issue/.

95 Femme International. "Our Programs." 2018. femmeinternational.org., accessed November 5, 2018, https://www.femmeinternational.org/our-work/the-issue/.

96 Femme International. "Our Programs." 2018. femmeinternational.org., accessed November 5, 2018, https://www.femmeinternational.org/our-work/the-issue/.

97 Inua Dada. "Menstrual Health Management (Mhm) Program." inuadadafoundation.org., accessed September 20, 2018, https://www.inuadadafoundation.org/menstrual-health- management-mhm-program/.

98 Huru International. "The Problem." huruinternational.org., accessed October 20, 2018, https://huruinternational.org/what-we-do/.

99 Huru International. "The Problem." huruinternational.org., accessed October 20, 2018, https://huruinternational.org/what-we-do/.

100 WSSCC. 2016. First National Training of Trainers on Menstrual Hygiene Management - Kenya. Geneva, Switzerland.

101 Ibid.

102 Ibid.

103 Inua Dada. "Menstrual Health Management (Mhm) Program." inuadadafoundation.org., accessed September 20, 2018, https://www.inuadadafoundation.org/menstrual-health- management-mhm-program/.

104 Huru International. "The Problem." huruinternational.org., accessed October 20, 2018, https://huruinternational.org/what-we-do/.

105 Femme International. "Our Programs." 2018. femmeinternational.org., accessed November 5, 2018, https://www.femmeinternational.org/our-work/the-issue/. ; Inua Dada. "Menstrual Health Management (Mhm) Program." inuadadafoundation.org., accessed September 20, 2018, https://www.inuadadafoundation.org/menstrual-health- management-mhm-program/.

106 Zana Africa Foundation. "Zana Africa." zanaafrica.org., accessed November 1, 2018, http://www.zanaafrica.org/health-education/.

107 Zana Africa Foundation. "Zana Africa." zanaafrica.org., accessed November 1, 2018, http://www.zanaafrica.org/health-education/.

108 Ibid.

109 Ibid.

110 Ibid.

111 Muthengi, Eunice, Emily Farris, and Karen Austrian. 2017. The NIA Project: Baseline Report: The Population Council, Inc.

112 Ibid.

113 Ibid.

114 Howard, Ashely. Kenya's Female Literacy Rate Continues to Improve.

Your Comments

Menstrual Hygiene Management Among Adolescent Girls in Kenya

Summary

Menstrual hygiene management (MHM) is the processes and resources surrounding menstruation, including the knowledge, products, and social norms associated with it. For many adolescent girls in Kenya, MHM is a serious and impactful issue. Although there are likely more causal factors, research suggests that some of the largest causes of this problem are poverty, the culture surrounding menstruation, inadequate sexual health education, and poor sanitation infrastructure. These barriers to adequate menstrual hygiene management create adverse consequences for the Kenyan girls, including infections, poor mental well-being, increased sexual activity, decreased education attainment, and gender inequality. Although changing the status quo of MHM in Kenya will require long-term solutions to both the consequences and causes of poor MHM, many practices are being implemented today to alter this status quo. Especially common or innovative practices include feminine hygiene pad and cup distribution, workshops, and magazine education.

"" by is licensed under

Key Terms

Menstruation—A "cyclical discharging of blood, secretions, and tissue debris from the uterus" that recurs on a monthly basis among reproductive-age women. 1

Menarche–The first occurrence of menstruation.

Stigma–A “mark of disgrace [or shame] associated with a particular circumstance, quality, or person." 2

Sexual health–A “state of physical, mental, and social well-being in relation to sexuality” . 3 Sexual health includes safe and consensual sexual experiences, access to contraceptives, and a lack of sexual violence and discrimination.

Menstrual cup–A cup made of rubber that is inserted into the vagina and collects the menstrual blood. Menstrual cups last roughly two to four years.

Adolescent–An individual in the process of developing from childhood to adulthood, which begins with the onset of puberty. For the purposes of this paper, an adolescent is considered to be girls that have begun menstruating (as early as age 9 but at an average age of 13.9 4 ), to girls that have completed secondary school (age 18 5 ).

Context

According to the United Nations Children’s Foundation and the World Health Organization (WHO), ‘good’ menstrual hygiene management (MHM) can be defined as when “adolescent girls are using a clean menstrual management material to absorb or collect blood,” and when these materials can be changed privately as often as necessary. WHO goes on to define good MHM as “using soap and water for washing the body as required, and having access to facilities to dispose of used menstrual management materials.” 6 The United Nations Educational, Scientific, and Cultural Organization (UNESCO) further defines good MHM as consisting of eight key factors:

  • Accurate and timely knowledge
  • Informed and comfortable professionals
  • Sanitation and washing facilities
  • Safe and hygienic disposal
  • Available, safe and affordable materials
  • Referral and access to health services
  • Positive social norms
  • Advocacy and policy 7

Historically, Kenyan women have struggled with attaining the aforementioned factors of good MHM. With regards to sanitation facilities, in 2014 26% of Kenyan women report their main environment for MHM as their backyard or sleeping area rather than a bathroom, and in rural areas, only a third of schools [were] reported to provide a place for girls to manage their periods. 8 Kenya also has insufficient access to “safe and affordable materials” according to UNESCO standards, as less than half of women reported having sufficient feminine hygiene materials in 2016. 9 Additionally, statistics suggest a need for more open conversation surrounding menstruation. In 2014, only 50% of Kenyan women and girls reported that they openly discuss menstruation at home, and only 12% of girls said that they would be comfortable receiving menstrual information from their mother. 10 There is also a gap in Kenyan girls’ knowledge, as evidenced by the fact that 1 in 4 Kenyan girls do not associate menstruation with the potential to become pregnant. 11

A comparison of Kenya’s menstrual trends and MHM with other countries also provides insight on the scope of Kenya’s problem. In Kenya “menarche and start of puberty [are] delayed by approximately 1.5-2 years compared to a US reference population,” 12 likely due to low Body Mass Indexes caused by extrinsic factors such as poor living conditions. 13 In the United States and higher income European countries, in 2017 “73 to 92% of menstruating women [used] disposable menstrual management products.” 14 This number does not include those who use reusable products, meaning that the percentage of women who use any menstrual management products is likely even larger. In comparison, according to one 2016 study, only 46.1% of women in Kenya report having the feminine hygiene materials they need to manage menstruation. 15 In contrast to other eastern and southern African countries, however, Kenya’s MHM is relatively strong. For example, PMA2020 estimates that the prevalence of sanitary pad use in Kenya is 87%, whereas it is only 65% in Uganda and 45% in Ethiopia. 16 Note that the percentage of women that reported using pads (87%) is much higher than the percentage of women that reported having all materials they needed (46.1%), which is likely because the fact that a woman sometimes uses a pad does not mean she feels that she has all the materials she needs to manage her menstration.

Unfortunately, the research on MHM in Kenya is limited due to difficulties quantifying MHM and discrepancies between regions. For example, research on the average income in Kenya is often contradictory. While several individuals have researched the average daily income of Kenyans, the numbers often vary by as much as 200%. 17 Additionally, many of the causes and consequences of poor MHM such as culture and mental health are difficult to quantify, largely because of their subjectivity. Studies have been conducted to address this limitation, but quantifying how a community feels about periods or the anxiety a girl feels through surveys is not a perfect measure. 18

Contributing Factors

Poverty

Poverty is a cause of poor MHM in Kenya, largely because it limits the menstrual resources Kenyan families can provide for young girls. Global analyses of poverty in Kenya are somewhat varied by year, measurement criteria, and source, but organizations consistently report high levels of poverty. According to the World Bank’s 2015 report, 36.8% of Kenyan families live below the poverty line, which was globally considered to be $1.90 USD per day. 19 UNICEF reported that in 2015, the average rural family in Kenya had a wage of $124 USD per month, meaning that their spending power was roughly $4.50 USD a day. 20

This poverty limits Kenyan girls’ ability to buy menstrual hygiene products. The prices of menstrual pads from large distribution channels vary from cheaper brands to more expensive brands; as of 2016, cheaper sanitary pads cost approximately $0.50 USD for a package of eight, whereas P&G Always pads costs $0.80 USD for a package of eight. 21 This means Kenyans making about a dollar a day would need to spend almost a full day’s earning on one package of pads. Put in a more broad context, a 2015 study found that “approximately 65% of Kenyan women and girls are unable to afford sanitary pads.” 22

When Kenyan girls cannot afford pads, they often resort to unsanitary methods in order to manage their periods. Substitutes for pads and tampons include easily accessible materials such as newspapers, corn cobs, cotton gauze, cloth strips, or even old rags, leaves, or cow dung. 23 24 Not only can these substitutes be less comfortable than pads or tampons, but they also are less absorbent and sterile.

Spending power matters when paying for sanitary infrastructure in schools as well. According to a 2016 study, “current expenditures of WASH [water, sanitation, and hygiene] [. . .] averaged $1.83 USD per student per year.” 25 This number includes recurrent costs, but not the cost of installing or setting up WASH infrastructure, which was $4.92 per student per year for a school of 400 students. 26 The total cost of about $6.75 per student can be too large of a burden on Kenyan schools and families, leading to many sanitary stations in schools to be inadequate for the needs of Kenyan girls.

Culture

The culture surrounding menstruation in Kenya also contributes to inadequate MHM because the perceptions and stigmas common in Kenya do not support open conversation regarding the topic. Although perceptions of menstruation vary from country to country, global studies suggest that, in less-developed countries, menstruation is often viewed as contaminating and debilitating. 27 These perceptions can be especially prominent in public schools where girls are at higher risk of being ostracised for being on their period. According to a 2013 study of 120 Kenyan girls, many reported “seeking permission from a teacher to bathe or to go home, hiding until a friend could help them, or leaving school without permission” 28 when they bled at school. In short, some primary and secondary schools in Kenya may not be facilitating an environment of support and acceptance girls need to feel comfortable in school when on their period.

Family settings also often exhibit a lack of communication and support surrounding menstruation. In Kenya, menstruation is rarely discussed in families, 29 and many girls reported feeling like they could not openly discuss menstruation at home because “it is too private to even share with their mother.” 30 The prevalence of this view surrounding menstruation was shown by a 2015 Kenyan national survey, which found that less than 50% of parents discuss sex-related topics with their children, including menstruation. 31 These findings suggest that there is a lack of discussion surrounding menstruation which limits girls’ understanding and comfort surrounding periods, even in private settings.

These perceptions and poor communication can create a cycle of inadequate support because, if Kenyan girls have limited discussion of menstruation with their mothers, they are more likely to have limited discussion of menstruation with their future children. This “belief system surrounding menstruation [is] handed down from one generation to the the next,” and “the socio-cultural context perpetuates an environment in which these issues remain taboo to discuss with parents” 32 and girls’ future children.

Inadequate Sexual Health Education

A lack of sexual health education is another large contributor to poor MHM in Kenya because this education is directly tied to the feminine-health knowledge needed for adequate MHM. According to one study of three Kenyan counties, 86% of adolescent Kenyans attended primary school in 2015. While 96% of these children received some level of sexual education in primary school, over two-thirds of children reported wishing that they had more information and hours dedicated to sexual education topics. 33 This primary-school based education is especially important because only 33% of the students continued on to secondary school where they would have access to additional sexual education. Furthermore, in 2017 almost a third of the students reported that they did not receive sexual health education from their parents 34 suggesting that if these girls do not receive menstrual education in primary school, they may not receive it at all.

Although the government has mandated sexual education in schools, the curriculum insufficiently focuses on menstrual health. In 2013, the Kenyan government committed to “scale up comprehensive rights-based sexuality education beginning in primary school.” 35 However, the majority of sexual education focuses primarily on the biological rather than psycho-social changes, such as the hygienic use and disposal of sanitary pads. 36 As of 2015, three-fourths of schools covered all topics that constitute a comprehensive curriculum, but only 2% of students reported learning all the topics, and more significantly, menstrual health is not included in this curriculum. 37 This curriculum is also often not given its own class time: in one Kenyan study, girls reported only “receiving some information on reproductive health and puberty from science and biology classes.” 38

Additionally, the quality of instruction by teachers varies significantly across Kenya. 39 In 2017 as many as 85% of schools required teachers to have sexual education training, but 68% of those teachers reported feeling that they needed more training. Moreover, of those teachers trained, only 36% were trained on all topics that constitute a comprehensive curriculum, and nearly half of the teachers studied reported feeling “unprepared or uncomfortable answering students’ questions on sexual education.” 40 Other studies found that teachers will sometimes wander from the official curriculum to provide their own point of view 41 or skip over parts of sexual education because the students are tested on other mandatory subjects and not sexual education. 42

Sanitation

Poor sanitation is another major cause of inadequate MHM because of the lack of feminine materials and good facilities. This poor sanitation can be concentrated into two main categories: accessibility to sanitation infrastructure and quality of sanitation infrastructure (where quality is determined by the presence of handwashing stations, places to dispose of used sanitary products, and cleanliness).

Many Kenyans often have limited access to sanitation infrastructure. According to one 2018 study in rural Kenya, “only 32% of schools [had] a private place for girls to change their sanitary products.” 43 Another 2014 study, also conducted in rural Kenya, found that 84% of schools had separate toilets for girls, but only 33% of these toilet rooms had locks. 44 This 50% disparity between the two studies suggests that the availability of sanitary rooms may be highly variable from one region of Kenya to another. In fact, another 2015 study has found that “only 30% of Kenyans [had] access to improved sanitation facilities, with large regional disparities in sanitation access (15% in rural Northern Kenya compared to 99% in central provinces of Nairobi).” 45 This suggests that both accessibility to sanitation infrastructure in general and the disparities between regions contribute to Kenya’s poor MHM.

The quality of the sanitation infrastructure also contributes to poor MHM. Put simply, it is good to have a bathroom for girls, but the quality of the bathroom must also be considered. This quality can be determined by three main indicators: handwashing stations, places to dispose of used sanitary products, and overall cleanliness. In a 2014 study of 62 primary schools in Kenya, researchers found that 60% had hand washing water, but only 2% had soap. 46 In this same study, researchers found that Kenyan girls frequently did not had a place to dispose of their used sanitary products. When asked their form of pad disposal, almost a fourth of girls reported carrying the used pads home or burning them in a garbage pit because they did not have access to a sanitary place to dispose of it. 47 Furthermore, the overall cleanliness of bathrooms in Kenya is low. 48 As shown in the aforementioned 2014 study, “most toilets provided were found to be structurally sound, but only 16% were considered clean.” 49

Consequences

Health

Infections

The lack of feminine hygiene products can lead to increased likelihood of infection. As previously discussed, extreme poverty can lead girls to turn to means such as old rags, leaves, or cow dung in order to manage their period. 50 These unhygienic substitutes can have serious health consequences such as fungal infections, reproductive tract infections (RTIs) and urinary tract infections (UTIs). 51 These UTIs may occur because the unhygienic MHM practices “create abnormally moist conditions [. . .] that promote infection.” 52 Within the umbrella of RTIs, one study suggests that the infections most closely linked to MHM are bacterial vaginosis (BV) and vulvovagial candidasis (VVC). These infections come from vaginal imbalances and may be introduced to the reproductive tract through the materials used for absorbing blood. 53 These infections often first result in itchiness, soreness, and abnormal discharge. 54 Beyond the initial health complications, BV and VVC are also linked with increased risk of HIV infection and pregnancy complications. 55

It is also worth noting that it is not simply extreme substitutes (like leaves or cow dung) that can lead to infection. One study suggests that women who use reusable absorbent pads are more likely to have symptoms of infection or be diagnosed with urogenital infection than women using disposable pads. 56 Because of how expensive disposable pads are over time, many Kenyan girls use reusable pads, again increasing their risk of infection.

Mental Wellbeing

The fear and anxiety surrounding menstruation can also lead to poor mental wellbeing of girls. While there is little quantitative research on this topic, much of the research qualitatively discusses the high amounts of fear and anxiety surrounding menstruation in Kenya, which suggests that the perceptions and lack of support can negatively affect the mental wellbeing of Kenyan girls. In one study based in Kenya in 2013, researchers conducted 35 in-depth interviews and 18 focus groups to study the emotional impacts of what they deemed “menstrual poverty.” Girls in the interviews described how a lack of products and support was a major cause of “discomfort, embarrassment, anxiety, fear of being stigmatized, and low mood,” 57 all of which are major factors in the mental wellbeing of girls. The study goes on to describe girls that used language such as “‘feeling bad’, feeling ‘stressed’, or ‘fearful’ and ‘wanting to cry,’” 58 further suggesting that poor MHM can contribute to emotional distress for Kenyan girls, which in turn negatively affects their mental wellbeing.

Sexual Activity

Another consequence of inadequate MHM is increased sexual behavior, which can lead to increased risk of abuse, STI, and pregnancy. Kenyan girls in poverty often lack the spending power to purchase pads or tampons, and because these girls are unable to buy the products they need, it is common to engage in transactional sex or seek out a boyfriend to obtain these products. 59 Research provides varied answers to how frequently this sexual activity for sanitation materials occurs. In one study conducted among 3,000 Kenyan women and girls in 2015, researchers found that “1 in 10 15-year-old girls were having sex to get money to pay for sanitary ware.” 60 According to another Kenyan study from 2015, “two out of three pad users in rural Kenya received pads from their sexual partners” , though this statistic does not necessarily imply transactional sex. 61 Although there is a disparity between these percentages, there is strong evidence that young girls may resort to sex in order to get the feminine products they need.

When girls engage in increased sexual activity in order to obtain feminine materials, the power dynamics of intimate relationships are negatively affected, 62 suggesting that these girls may have minimal leverage in sexual relationships and may be more susceptible to abuse. 63 This sexual behavior also increases their risk of contracting sexually transmitted infections (STIs). In situations where girls must use sex to obtain pads, Kenyan girls may be unable to negotiate safe sex practices, which further increases their risk of contracting STIs, including HIV. 64 Unfortunately, there is limited research on the prevalence of HIV caused by engaging in sex in order to obtain feminine hygiene products. It is known, however, that as of 2017 the overall prevalence rate for HIV among young Kenyan women was 2.6%, which was notably higher than the rate for young men, which was 1.3%. 65

Lastly, increased sexual behavior for materials increases girls’ risk of experiencing unwanted pregnancy. 66 In one 2015 study conducted among Kenyan women under 30, 35% of the sexually active women reported pregnancy in the past 12 months. 67 Although the sample was not just girls who were sexually active in order to obtain hygiene materials, this high percentage may suggest that girls using sex for products are likely to get pregnant prematurely. Further research suggests that this early pregnancy affects girls’ ability to stay in school, 68 so as girls resort to sex to get the materials they need, the increased chance of pregnancy can also decrease their educational opportunity, creating a cycle of poverty and poor MHM.

Education & Gender Inequality

Another major consequence of poor MHM is decreased school attendance among Kenyan girls. If girls feel embarrassed or shameful about their period, they are much less likely to attend school while menstruating. Furthermore, girls often do not have appropriate sanitation facilities where they can manage their menstrual flow at school, potentially leading to a decrease in educational attendance. UNICEF estimates that 1 in 10 school-age African girls do not attend school during menstruation, and the World Bank statistics estimates absences to be approximately four days every four weeks. 69

As girls miss school and fall behind, the educational disparity between boys and girls widens. A 2014 study showed that “girls’ enrolment ratios [in Kenya] have increased in recent years, but large inequality gaps in primary education attainment remain.” 70 Other studies have confirmed this trend; multiple studies find that the gap between girls’ and boys’ education is most pronounced during secondary education, suggesting that this gap widens as girls experience menarche. 71 This gap in education also contributes to the gap in literacy rates. Compared to the national illiteracy average of 7% in 2014, “50% of girls 15—19 are illiterate in the rural, conservative North Eastern province.” 72

The gap in education that comes as a result of poor MHM can lead to deeper economic consequences. According to a 1999 study by the World Bank, a 1 percent increase of women with a secondary education causes a .3 percent increase in per capita income on average. 73 This suggests that as poor MHM decreases educational attendance among girls, there may be adverse economic consequences in the form of lower economic productivity.

Practices

Feminine Hygiene Product Distribution: Pads

One of the most common forms of interventions to improve MHM in Kenya is feminine sanitary pad distribution. Organizations generally donate sustainable pads, meaning that they can be washed and reused for up to 18 months. 74 Promoters of this practice believe that pad distribution increases girls’ ability to manage their periods, consequently increasing their attendance and comfort in school. Organizations such as Huru International, Days for Girls, Too Little Children, Kenya Works, and AFRIpads apply this practice in Kenya.

Many of the aforementioned organizations host community events in order to distribute pads. For example, Huru International facilitators host school events in Kenya where pads that are “leak-proof guaranteed for 18 months” are distributed to the girls. 75 Some organizations including Huru International and Kenya Works make all their pads locally in Kenya, which creates a more sustainable way for Kenyans to obtain feminine products. 76 Most of these organizations, including Days for Girls, AFRIpads, and Kenya Works, deliver four to eight reusable pads to Kenyan girls, often accompanied by bars of soap and/or underwear.

Feminine Hygiene Product Distribution: Cups

Like feminine pads, feminine cups are another common intervention to improve MHM in Kenya. Feminine cups are small rubber cups that collect menstrual blood by being folded and inserted into the vagina. The cup collects blood without leakage, and after several hours can be removed, washed, and re-inserted. 77 These cups are durable and long-lasting, meaning that girls do not need to purchase new products on a monthly basis. Like pads, promoters of this practice believe that if girls can manage their flow more easily, they will likely be able to attend school more frequently and have greater peace of mind when on their period.

Femme International and Ruby Cup are two examples of organizations that apply this practice in Kenya. Femme International distributes these products by first enrolling girls in the Twaweza Program, a program that combines education and distribution of products. Once enrolled, the girls are allowed to choose either a menstrual cup or reusable pads, both of which are “sustainable and remove the financial burden of menstruation.” 78 Like Femme International, Ruby Cup, along with ARRIVE Kenya, hosts a classroom-set menstrual health and management workshop where the Ruby Cups are distributed. 79

Impact

Most organizations measure success in delivering a large number of products. For example, Kenya Works reported 20,000 pads distributed in 2018. 80 Huru International reports that, as of 2018, they have produced 1,140,056 pads, distributed 145,000 kits, and reached 200,029 youth. 81 Huru International also states that their program has increased school attendance by 3,780,000 days. 82 While the pads Huru International provides likely increases school attendance, the method behind this statistic is unclear, so it is not certain that Huru International’s pad distribution actually increases school attendance by that amount.

Femme International evaluated their program through a series of six-month long “monitoring and evaluation” studies in five government secondary schools in the Moshi Rural district. 83 Femme International reports that 495 AFRIpads and 495 Ruby Cups were distributed, and of those who received these products, 63.7% of girls reported using the products at the six-month follow up. 84 The use of less hygienic menstrual products decreased drastically–dropping from 32.3% to 8.5%–and at the six-month mark, 85% of girls reported missing zero school days due to menstruation, which was a 25% increase in attendance from the baseline. 85 There was “an 18% decrease in girls missing school due to pain, 6.1% decrease in missing school due to fear of leaking, and 2.9% decrease in missing school because of menstrual shame.” 86 Furthermore, 65.4% of girls attributed a self-reported increase in school performance to the program and products given by Femme International. 87

Gaps

While each of these organizations provide sustainable products, gaps still exist largely because of uncertainty surrounding the actual level of success in increasing school attendance and decreasing menstrual shame. For example, one study conducted in Nepal in 2011 found that better access to feminine hygiene products had little to no effect on the attendance gap. 88 Moreover, a 2016 study in Uganda found that while drops in attendance was worse for those girls that did not receive pads, the pads had no significant impact on girls’ self-reported shame or insecurity while on their period. 89 However, there is research that has found positive impacts because of feminine product donations, despite the research that suggest that donations do not create significant positive results. 90

An additional gap is in the reusable quality of the pads. As previously discussed, a 2015 study found that women who use reusable absorbent pads are more likely to have symptoms of infection or be diagnosed with urogenital infection than women using disposable pads, 91 potentially because of insufficient cleaning processes of the reusable pads. This suggests that this practice may have some negative health effects.

It is also difficult to use feminine cups in an area of the world where sanitary bathrooms are not always available. As previously stated, in rural Kenya in 2018, only 32% of schools had a private place for girls to change their sanitary products. 92 Additionally, according to a 2014 study, only 60% of Kenyan schools have hand-washing water and 2% of schools have soap in their bathrooms. 93 Because the cleaning and reinsertion of a sanitary cup requires a private and sanitary area, menstrual cups may only reach full effectiveness if paired with the installation of bathrooms with soap and water in all Kenyan schools.

Workshops

Workshops are another common practice conducted by organizations improving MHM in Kenya. These workshops usually consist of gathering girls in a classroom or community area where organization leaders teach the girls about feminine health. Most organizations that address MHM conduct some form of workshop, including Femme International, Inua Dada, Huru International, and the Water Supply and Sanitation Collaborative Council (WSSCC).

Femme International works by partnering with schools and communities to deliver a series of interactive workshops. These workshops are centered on creating a safe space where girls feel comfortable asking questions, perhaps providing them with the only opportunity that they will have to openly discuss menstrual topics. 94 While the workshops are adapted to the needs of the group of girls being taught, they are often focused on subjects such as puberty, menstruation, and sexual health. 95 As girls participate in these workshops, Femme International hopes to “empower girls to be confident within their bodies and ensure that menstruation does not cause them to miss school.” 96

Like Femme International, Inua Dada created interactive education sessions where girls can build self-esteem and discuss hygienic ways of using and disposing of sanitary pads. 97 Similarly, Huru International also hosts workshops where Huru leaders speak on menstrual health, sexual and reproductive health, gender norms, gender-based violence, self-confidence, and HIV/AIDS prevention. 98 Huru International is unique in that they do not limit their workshops to girls: “Huru always works with boys, teachers, parents, and community leaders to help foster an environment where [. . .] girls are supported both in and out of the classroom.” 99

Unlike most other workshops, WSSCC’s workshops are conducted primarily to train leaders rather than to educate girls. In their 2016 training, male and female health and educational leaders were gathered from 16 counties in Kenya to participate in six days of training. Each day was focused on different aspects of MHM. For example, on day three of the workshop a three-pronged approach to MHM was taught: breaking the silence, managing menstruation hygienically, and safe reuse and disposal options. WSSCC hopes that as leaders participate in these trainings, they will be able to improve the culture surrounding menstruation and improve girls’ knowledge. 100

Impact

Evaluations conducted by some of the aforementioned organizations suggests that workshops can have high impact increasing knowledge and communication and decreasing anxiety and stigmas surrounding menstruation. However, as with product distribution, many organizations measure success by the number of workshops held, which provides little insight into whether or not the workshops actually decrease stigmas and increase knowledge.

Femme International has conducted several observational studies where they tested the effect of their workshops. Femme asks girls series of questions in order to test for indicators such as “change in knowledge” and “empowerment.” The studies have shown that their workshops reduce deliberate school absence amongst the girls participating and increases their participation in school, work, and social spheres. Femme International further notes that the girls are “more confident and exhibit less menstrual-related shame” and are 1.5 times less likely to report several symptoms of RTIs, UTIs, and STIs associated with poor MHM practices. 101 This leads Femme International to conclude that their workshops have a significant positive impact on the quality of life of their participants. 102

There is limited research on the impact of other organizations. For example, Inua Dada Foundation only reports “10,120 girls reached” and “108 schools reached” , 103 and Huru International reports that they have reached 200,029 youth and 35,000 boys through their educational program. 104 However, the effectiveness of their program in actually increasing knowledge and decreasing stigmas is unknown.

Gaps

There is limited research on both the effectiveness and gaps of workshops. However, the gaps in this practice may come from the reach and scalability. Organizations often enroll girls in workshops through local schools, so those that do not attend school may not see the direct benefits of the program. For example, Femme International and Inua Dada involve girls in these programs by partnering with local schools, 105 so those not in school will not be enrolled. Additionally, if these workshops do not provide training for Kenyan teachers and leaders, the educational program will only last as long as the organizations’ facilitators are there, leading to low scalability.

There is also a gap in the way that workshops do not completely address the root causes of the program. While workshops do seem to decrease social stigmas and increase knowledge, these workshops do not directly alleviate poverty so girls and their families can afford sanitary materials and sanitation facilities.

Magazine Education

Another current practice is the distribution of a magazine created to provide sexual and menstrual education for Kenyan girls. This practice is only currently implemented by one organization, Zana Africa, which created a “referable health magazine called Nia Teen” to be distributed throughout Kenya. 106 The goal of Nia Teen is that girls reading will receive “menstrual and reproductive health education [. . .] to foster self-efficacy, and to support [them] to safely and confidently navigate adolescence and stay in school” . 107 As they become more educated, it is anticipated that they will increase in confidence and knowledge, leading to decreased adverse health consequences such as infection and more knowledge and healthy perceptions surrounding menstruation.

The process of creating Nia Teen started with gathering data from over 10,000 questions concerning feminine issues collected from 1,000 girls. Answers are then compiled into an issue, which was designed for measurable increases in knowledge and behavioral changes. 108 These issues feature pictures of Kenyan girls, bright colors, and other illustrations that make the magazine entertaining to read. Articles such as “Understanding Relationships” and “Amazing Women” are included, as well as a comic on healthy decision-making and a calendar for period-tracking. 109 Nia Teen is designed to be scaled to a large number of girls at a low cost and with minimal reliance on Zana Africa representatives to distribute the magazines. 110

Impact

There has been significant evaluation surrounding the impact Zana Africa’s Nia Teen magazine has on Kenyan girls. This project is “the first study conducted in Sub-Saharan Africa to rigorously measure the individual and combined effects of sanitary pads and reproductive health education on girls’ educational, social, and health outcomes. 111 In this randomized controlled trial (RCT), Kenyan girls are assigned to one of four interventions: schools receive disposable sanitary pads, schools receive reproductive health education, schools receive disposable sanitary pads plus reproductive health education, or no intervention. 112 Unfortunately, the results of this impact evaluation will not be published until late 2019. However, what is known that the magazine has reached 3,489 girls in 140 schools. 113

Gaps

Gaps for this practice include insufficient distribution chains for the magazines, as reaching every girl in Kenya is an incredibly demanding task. Another gap is illiteracy: in Kenya in 2017, 74.9% of women (including both adolescents and adults) could read, and while that number is on the incline, it still suggests that this magazine will not be effective with the fourth of the population that is still illiterate. 114

Key Takeaways

  • Inadequate menstrual hygiene management (MHM)–including a lack of accurate and timely knowledge, sanitation and washing facilities, safe and affordable materials, positive social norms, and sexual health education–is a serious issue for adolescent girls in Kenya.
  • Although there are likely more factors, this poor MHM is largely caused by poverty, the culture surrounding menstruation, inadequate sexual health education, and poor sanitation infrastructure.
  • Poor MHM creates serious consequences for these girls, including health consequences of infections and poor mental well-being, sexual activity, and education and gender inequality.
  • Several practices are currently in place to address inadequate MHM, the most prominent or noteable of which are feminine hygiene pad and cup distribution, workshops, and magazine education.
  • Although this social issue is far from being solved, these practices, along with the increased universal understanding and prioritization of MHM, create an optimistic view of the future of menstrual hygiene management among adolescent girls in Kenya.

1 "Menstruation." Merriam-Webster.org., accessed Dec 8, 2018, https://www.merriam-webster.com/dictionary/menstruation.

2 "Stigma." oxforddictionaries.com., accessed Dec 8, 2018,https://en.oxforddictionaries.com/definition/stigma.

3 WHO. "Sexual Health." who.int., accessed Dec 8, 2018,https://www.who.int/topics/sexual_health/en/.

4 Rogo, K. O., R. A. Oniang'o, and L. A. Muruli. 1987. "Menarche in African Girls in some Post-Secondary Institutions in Kenya." East Africa Medical Journal 64 (11): 745-750. https://www.ncbi.nlm.nih.gov/pubmed/3505850.

5 Kenya: Age Distribution and School Attendance of Girls Aged 9-13 Years. 2012.

6 UNICEF and WHO. 2012. “Report of the Second Consultation on Post-2015 Monitoring of Drinking-Water, Sanitation and Hygiene.” The Hague, 3-5. http://www.unosd.org/content/documents/151Report%20on%20WHO%20UNICEF%20Hague%20Consultation%20December%202012_28Mar_final%20draft.....pdf.

7 Puberty Education & Menstrual Hygiene Management. Menstrual Hygiene Management. 2014: the United Nations Educational, Scientific and Cultural Organization. https://asanteafrica.org/wp-content/uploads/2018/03/UNESCO-Puberty-rpt.pdf.

8 Alexander, Kelly T. Oduor, et al. 2014. "Water, Sanitation and Hygiene Conditions in Kenyan Rural Schools: Are Schools Meeting the Needs of Menstruating Girls?" Water 6, no. 5: 1453-1466.

9 PMA 2020. 2016. Menstrual Hygiene Management;Menstrual Hygiene Management.

10 Facility Solutions Group. 2016. Menstrual Health in Kenya; Country Landscape Analysis. http://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- Landscape_Kenya.pdf.

11 Facility Solutions Group. 2016. Menstrual Health in Kenya; Country Landscape Analysis. http://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- Landscape_Kenya.pdf.

12 AMERICAN ACADEMY OF PEDIATRICS and AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS. 2006. "Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign." The American Academy of Pediatrics 118 (5): 2245-2250. doi:10.1542/peds.2006-2481.

13 THOMAS, FRÉDÉRIC, FRANÇOIS RENAUD, ERIC BENEFICE, THIERRY DE MEEÜS, and JEAN-FRANÇOIS GUEGAN. "International Variability of Ages at Menarche and Menopause: Patterns and Main Determinants." Human Biology 73, no. 2 (2001): 271-90. http://www.jstor.org/stable/41465935.

14 Kuhlumann Anne, Henry Kaysha, and Wall L. Lewis. 2017. "Menstrual Hygiene Management in Resource-Poor Countries." Obstetrical Gynecological Survey 72 (6): 356—376. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5482567/.

15 PMA 2020. 2016. Menstrual Hygiene Management;Menstrual Hygiene Management.

16 Tellier, Seiri and Maria Hyttel. 2017. Menstrual Health Management in East and Southern Africa: A Review Paper: Menstrual Health Management Symposium.

17 Ankler, Richard and Martha Ankler. 2016. Living Wage Report. ; Mawathe, Anne. "Period Misery for Kenya Schoolgirls." BBC.co.uk., last modified Mar 17, accessed Oct 16, 2018, http://news.bbc.co.uk/2/hi/africa/4816558.stm.

18 Linda Mason , Elizabeth Nyothach, Kelly Alexander, Frank O. Odhiambo, Alie Eleveld, John Vulule, Richard Rheingans, Kayla F. Laserson, Aisha Mohammed, Penelope A. Phillips- Howard. 2013. "‘We Keep it Secret so no One should Know’ — A Qualitative Study to Explore Young Schoolgirls Attitudes and Experiences with Menstruation in Rural Western Kenya." Public Library of Service. doi://doi.org/10.1371/journal.pone.0079132.

19 The World Bank. 2015. Kenya. http://povertydata.worldbank.org/poverty/country/KEN.

20 Ankler, Richard and Martha Ankler. 2016. Living Wage Report.

21 Ibid.

22 USAID. 2015. Afri-can Trust: Empowering Women and Girls through Affordable Sanitary Pads.

23 Njeri Ngugi, Margaret and Jasper Edward Nyaura. 2014. "Demystifying the Menstruation Process among the Kenyan Girl-Child “A Period of Shame” : A Socio-Cultural Perspective." International Journal of Science and Research 3 (10): 1077-1083. https://www.ijsr.net/archive/v3i10/MDMwOTE0MDQ%3D.pdf.

24 Tellier, Seiri and Maria Hyttel. 2017. Menstrual Health Management in East and Southern Africa: A Review Paper: Menstrual Health Management Symposium.

25 Alexander, K. T., A. Mwaki, D. Adhiambo, M. Cheney-Coker, R. Muga, and M. C. Freeman. 2016. "The Life-Cycle Costs of School Water, Sanitation and Hygiene Access in Kenyan Primary Schools." Int. J. Environ. Res. Public Health 7 (13). doi:10.3390/ijerph13070637.

26 Ibid.

27 Buckley T, Gottlieb A (1988) Blood magic: The anthropology of menstruation. Berkeley: University of California Press. ; Szarewski A, von Stenglin A, Rybowski S (2012) Women’s attitudes towards monthly bleeding: results of a global population-based survey. Eur J Contracept Reprod Health Care 17: 270—283.

28 Ibid.

29 Njeri Ngugi, Margaret and Jasper Edward Nyaura. 2014. "Demystifying the Menstruation Process among the Kenyan Girl-Child “A Period of Shame” : A Socio-Cultural Perspective." International Journal of Science and Research 3 (10): 1077-1083. https://www.ijsr.net/archive/v3i10/MDMwOTE0MDQ%3D.pdf.

30 Linda Mason , Elizabeth Nyothach, Kelly Alexander, Frank O. Odhiambo, Alie Eleveld, John Vulule, Richard Rheingans, Kayla F. Laserson, Aisha Mohammed, Penelope A. Phillips- Howard. 2013. "‘We Keep it Secret so no One should Know’ — A Qualitative Study to Explore Young Schoolgirls Attitudes and Experiences with Menstruation in Rural Western Kenya." Public Library of Service. doi://doi.org/10.1371/journal.pone.0079132.

31 Jewitt, Sarah and Harriet Ryley. 2014. "It’s a Girl Thing: Menstruation, School Attendance, Spatial Mobility and Wider Gender Inequalities in Kenya." Geoforum 56: 137-147.

32 J Glor, Sarala Thapa, L J Severy, and Ian Askew. 1993. "Menstrual Experiences and Beliefs: A Multicountry Study of Relationships with Fertility and Fertility Regulating Methods." Women & Health 20 (2): 1-20.https://www.researchgate.net/publication/14825781_Menstrual_experiences_and_beliefs_A_multicountry_study_of_relationships_with_fertility_and_fertility_regulating_methods.

33 Sexuality Education in Kenya: New Evidence from Three Counties. 2017. New York: Guttmacher Institute.

34 Ibid.

35 Ibid.

36 Facility Solutions Group. 2016. Menstrual Health in Kenya; Country Landscape Analysis. http://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- Landscape_Kenya.pdf.

37 Sexuality Education in Kenya: New Evidence from Three Counties. 2017. New York: Guttmacher Institute.

38 Njeri Ngugi, Margaret and Jasper Edward Nyaura. 2014. "Demystifying the Menstruation Process among the Kenyan Girl-Child “A Period of Shame” : A Socio-Cultural Perspective." International Journal of Science and Research 3 (10): 1077-1083. https://www.ijsr.net/archive/v3i10/MDMwOTE0MDQ%3D.pdf.

39 Facility Solutions Group. 2016. Menstrual Health in Kenya; Country Landscape Analysis. http://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- Landscape_Kenya.pdf.

40 Sexuality Education in Kenya: New Evidence from Three Counties. 2017. New York: Guttmacher Institute.

41 African Population and Health Research Center. 2010. Experiences and Problems with Menstruation among Poor Women and Schoolgirls in Nairobi, Kenya. Longonot Road: Shelter Afrique Center.

42 Facility Solutions Group. 2016. Menstrual Health in Kenya; Country Landscape Analysis. http://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- Landscape_Kenya.pdf.

43 Higgins, Abigail. "Having a Period is Unaffordable in Kenya, Yet no One Wants to Talk about It." theguardian.com., last modified Jan 5, accessed Oct 16, 2018, https://www.theguardian.com/global-development-professionals- network/2017/jan/05/having-a-period-is-unaffordable-in-kenya-yet-no-one-wants-to-talk-about-it.

44 Kelly T. Alexander, Clifford Oduor, and Elizabeth Nyothach. 2014. "Water, Sanitation and Hygiene Conditions in Kenyan Rural Schools: Are Schools Meeting the Needs of Menstruating Girls?" Water1 (6): 1453-1466. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwicjqOQgpLeAhXIqlQKHW20DPUQFjAAegQICRAC&url=http%3A%2F%2Fwww.mdpi.com%2F2073-4441%2F6%2F5%2F1453%2Fpdf&usg=AOvVaw3HaIFK5zn9eL2lmIdrqnPs.

45 The World Bank. 2015. People using Safely Managed Sanitation Services (% of Population).

46 Kelly T. Alexander, Clifford Oduor, and Elizabeth Nyothach. 2014. "Water, Sanitation and Hygiene Conditions in Kenyan Rural Schools: Are Schools Meeting the Needs of Menstruating Girls?" Water1 (6): 1453-1466. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwicjqOQgpLeAhXIqlQKHW20DPUQFjAAegQICRAC&url=http%3A%2F%2Fwww.mdpi.com%2F2073-4441%2F6%2F5%2F1453%2Fpdf&usg=AOvVaw3HaIFK5zn9eL2lmIdrqnPs.

47 Ibid.

48 Garn, J. V., Caruso, B. A., Drews-Botsch, C. D., Kramer, M. R., Brumback, B. A., Rheingans, R. D., & Freeman, M. C. (2014). Factors Associated With Pupil Toilet Use in Kenyan Primary Schools. International Journal of Environmental Research and Public Health, 11(9), 9694—9711. http://doi.org/10.3390/ijerph110909694.

49 Kelly T. Alexander, Clifford Oduor, and Elizabeth Nyothach. 2014. "Water, Sanitation and Hygiene Conditions in Kenyan Rural Schools: Are Schools Meeting the Needs of Menstruating Girls?" Water1 (6): 1453-1466. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwicjqOQgpLeAhXIqlQKHW20DPUQFjAAegQICRAC&url=http%3A%2F%2Fwww.mdpi.com%2F2073-4441%2F6%2F5%2F1453%2Fpdf&usg=AOvVaw3HaIFK5zn9eL2lmIdrqnPs.

50 Njeri Ngugi, Margaret and Jasper Edward Nyaura. 2014. "Demystifying the Menstruation Process among the Kenyan Girl-Child “A Period of Shame” : A Socio-Cultural Perspective." International Journal of Science and Research 3 (10): 1077-1083. https://www.ijsr.net/archive/v3i10/MDMwOTE0MDQ%3D.pdf.

51 "Impact of Unhygienic Sanitary Practices on Women’s Health." soothehealthcare.org., accessed Oct 17, 2018, http://soothehealthcare.com/impact-of-unhygienic-sanitary-practices- on-womens-health/.

52 Das, Padma et al. 2015. "Menstrual Hygiene Practices, WASH Access and the Risk of Urogenital Infection in Women from Odisha, India." PloS One 10 (6). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4488331/.

53 Sumpter Colin and Torondel Belen. 2013. "A Systematic Review of the Health and Social Effects of Menstrual Hygiene Management." PloS One 8 (4). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3637379/.

54 French Kathy. "Bacterial Vaginosis and Vulvovaginal Candidiasis." nursinginpractice.com., last modified July 25, accessed February 15, 2019, https://www.nursinginpractice.com/article/bacterial-vaginosis-and-vulvovaginal-candidiasis.

55 Sumpter Colin and Torondel Belen. 2013. "A Systematic Review of the Health and Social Effects of Menstrual Hygiene Management." PloS One 8 (4). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3637379/.

56 Das, Padma et al. 2015. "Menstrual Hygiene Practices, WASH Access and the Risk of Urogenital Infection in Women from Odisha, India." PloS One 10 (6). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4488331/.

57 Crichton Joanna, Okay Jerry, Kabiru Caroline, and Zulu Msiyaphazi Eliya. 2013. "Emotional and Psychosocial Aspects of Menstrual Poverty in Resource-Poor Settings: A Qualitative Study of the Experiences of Adolescent Girls in an Informal Settlement in Nairobi." Health Care for Women International 34 (10). https://www.tandfonline.com/doi/pdf/10.1080/07399332.2012.740112?needAccess=true.

58 Ibid.

59 Crichton Joanna, Okay Jerry, Kabiru Caroline, and Zulu Msiyaphazi Eliya. 2013. "Emotional and Psychosocial Aspects of Menstrual Poverty in Resource-Poor Settings: A Qualitative Study of the Experiences of Adolescent Girls in an Informal Settlement in Nairobi." Health Care for Women International 34 (10). https://www.tandfonline.com/doi/pdf/10.1080/07399332.2012.740112?needAccess=true. ; Duke Global Health Institute. "Why Adolescent Girls Miss School in Rural Kenya." global health.duke.edu., last modified Jan 24, accessed Oct 18, 2018, https://globalhealth.duke.edu/media/news/why-adolescent-girls-miss-school-rural-kenya.

60 Higgins, Abigail. "Having a Period is Unaffordable in Kenya, Yet no One Wants to Talk about It." theguardian.com., last modified Jan 5, accessed Oct 16, 2018, https://www.theguardian.com/global-development-professionals-network/2017/jan/05/having-a-period-is-unaffordable-in-kenya-yet-no-one-wants-to-talk-about-it.

61 Facility Solutions Group. 2016. Menstrual Health in Kenya; Country Landscape Analysis. http://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- Landscape_Kenya.pdf.

62 Ibid.

63 Phillips-Howard, P. A., Otieno, G., Burmen, B., Otieno, F., Odongo, F., Odour, C., . . . Laserson, K. F. (2015). Menstrual Needs and Associations with Sexual and Reproductive Risks in Rural Kenyan Females: A Cross-Sectional Behavioral Survey Linked with HIV Prevalence. Journal of Women’s Health,24(10), 801—811. http://doi.org/10.1089/jwh.2014.5031.

64 Facility Solutions Group. 2016. Menstrual Health in Kenya; Country Landscape Analysis. http://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- Landscape_Kenya.pdf.

65 UNAIDS. 2017. Kenya | 2017 Country Factsheet.

66 Facility Solutions Group. 2016. Menstrual Health in Kenya; Country Landscape Analysis. http://menstrualhygieneday.org/wp-content/uploads/2016/04/FSG-Menstrual-Health- Landscape_Kenya.pdf.

67 Phillips-Howard, Penelope, George Otieno, and Barbra Burmen. 2015. "Menstrual Needs and Associations with Sexual and Reproductive Risks in Rural Kenyan Females: A Cross-Sectional Behavioral Survey Linked with HIV Prevalence." Journal of Women's Health 24 (10): 801-811. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4624246/.

68 Ibid.

69 Onjoro, Veronica. "Are Menses a Hindrance to Girls Education in Kenya."academia.edu.

70 Jewitt, Sarah and Harriet Ryley. 2014. "It’s a Girl Thing: Menstruation, School Attendance, Spatial Mobility and Wider Gender Inequalities in Kenya." Geoforum 56: 137-147. doi://doi.org/10.1016/j.geoforum.2014.07.006.

71 Jewitt, Sarah and Harriet Ryley. 2014. "It’s a Girl Thing: Menstruation, School Attendance, Spatial Mobility and Wider Gender Inequalities in Kenya." Geoforum 56: 137-147. doi://doi.org/10.1016/j.geoforum.2014.07.006. ; Linda Mason , Elizabeth Nyothach, Kelly Alexander, Frank O. Odhiambo, Alie Eleveld, John Vulule, Richard Rheingans, Kayla F. Laserson, Aisha Mohammed, Penelope A. Phillips- Howard. 2013. "‘We Keep it Secret so no One should Know’ — A Qualitative Study to Explore.

72 Jewitt, Sarah and Harriet Ryley. 2014. "It’s a Girl Thing: Menstruation, School Attendance, Spatial Mobility and Wider Gender Inequalities in Kenya." Geoforum 56: 137-147. doi://doi.org/10.1016/j.geoforum.2014.07.006.

73 Dollar David and Gatti Roberta. 1999. "Gender Inequality, Income, and Growth: Are Good Times Good for Women?" World Bank 1. http://documents.worldbank.org/curated/en/251801468765040122/pdf/multi-page.pdf.

74 Huru International. "The Problem." huruinternational.org., accessed October 20, 2018, https://huruinternational.org/what-we-do/.

75 Huru International. "The Problem." huruinternational.org., accessed October 20, 2018, https://huruinternational.org/what-we-do/.

76 Ibid.

77 Ibid.

78 Femme International. "Our Programs." 2018. femmeinternational.org., accessed November 5, 2018, https://www.femmeinternational.org/our-work/the-issue/.

79 Arranz, Amaia. "Distributing Menstrual Cups in Kenya." ruby cup.com., last modified July 27, accessed November 13, 2018, https://rubycup.com/blog/distributing-menstrual-cups-in-kenya/.

80 "Kenya Works." kenyaworks.org., https://www.kenyaworks.org.

81 Huru International. "Impact." huruinternational.org., accessed October 20, 2018, https://huruinternational.org/impact/.

82 Ibid.

83 Rubli, Jennifer. 2017. Monitoring and Evaluation Report.https://www.femmeinternational.org/wp-content/uploads/2018/09/Femme-International-ME-Report-2017.pdf

84 Ibid.

85 Ibid.

86 Ibid.

87 Ibid.

88 Oster, Emily and Rebecca Thornton. 2011. "Menstruation, Sanitary Products, and School Attendance: Evidence from a Randomized Evaluation." American Economic Journal: Applied Economics 3 (1): 91-100. https://www.aeaweb.org/articles?id=10.1257/app.3.1.91.

89 Montgomery, Paul, Julie Hennegen, and Cathrine Dolan. 2016. "Menstruation and the Cycle of Poverty: A Cluster Quasi-Randomised Control Trial of Sanitary Pad and Puberty Education Provision in Uganda." Plos One 11 (12). https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0166122.

90 Scott, Linda and Sue Dopson. 2009. "Impact of Providing Sanitary Pads to Poor Girls in Africa." University of Oxford.https://www.semanticscholar.org/paper/Impact-of-Providing-Sanitary-Pads-To-Poor-Girls-in-Scott-Dopson/af284935d59ccbf3c0c50ba61fee65f3e531147b. ; Hennegan, Julie, Cathrine Dolan, Maryalice Wu, Linda Scott, and Paul Montgomery. 2016. "Schoolgirls’ Experience and Appraisal of Menstrual Absorbents in Rural Uganda: A Cross-Sectional Evaluation of Reusable Sanitary Pads." Reproductive Health 13 (143).

91 Das, Padma et al. 2015. "Menstrual Hygiene Practices, WASH Access and the Risk of Urogenital Infection in Women from Odisha, India." PloS One 10 (6). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4488331/.

92 Higgins, Abigail. "Having a Period is Unaffordable in Kenya, Yet no One Wants to Talk about It." theguardian.com., last modified Jan 5, accessed Oct 16, 2018, https://www.theguardian.com/global-development-professionals- network/2017/jan/05/having-a-period-is-unaffordable-in-kenya-yet-no-one-wants-to-talk-about-it.

93 Kelly T. Alexander, Clifford Oduor, and Elizabeth Nyothach. 2014. "Water, Sanitation and Hygiene Conditions in Kenyan Rural Schools: Are Schools Meeting the Needs of Menstruating Girls?" Water1 (6): 1453-1466. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwicjqOQgpLeAhXIqlQKHW20DPUQFjAAegQICRAC&url=http%3A%2F%2Fwww.mdpi.com%2F2073-4441%2F6%2F5%2F1453%2Fpdf&usg=AOvVaw3HaIFK5zn9eL2lmIdrqnPs.

94 Femme International. "Our Programs." 2018. femmeinternational.org., accessed November 5, 2018, https://www.femmeinternational.org/our-work/the-issue/.

95 Femme International. "Our Programs." 2018. femmeinternational.org., accessed November 5, 2018, https://www.femmeinternational.org/our-work/the-issue/.

96 Femme International. "Our Programs." 2018. femmeinternational.org., accessed November 5, 2018, https://www.femmeinternational.org/our-work/the-issue/.

97 Inua Dada. "Menstrual Health Management (Mhm) Program." inuadadafoundation.org., accessed September 20, 2018, https://www.inuadadafoundation.org/menstrual-health- management-mhm-program/.

98 Huru International. "The Problem." huruinternational.org., accessed October 20, 2018, https://huruinternational.org/what-we-do/.

99 Huru International. "The Problem." huruinternational.org., accessed October 20, 2018, https://huruinternational.org/what-we-do/.

100 WSSCC. 2016. First National Training of Trainers on Menstrual Hygiene Management - Kenya. Geneva, Switzerland.

101 Ibid.

102 Ibid.

103 Inua Dada. "Menstrual Health Management (Mhm) Program." inuadadafoundation.org., accessed September 20, 2018, https://www.inuadadafoundation.org/menstrual-health- management-mhm-program/.

104 Huru International. "The Problem." huruinternational.org., accessed October 20, 2018, https://huruinternational.org/what-we-do/.

105 Femme International. "Our Programs." 2018. femmeinternational.org., accessed November 5, 2018, https://www.femmeinternational.org/our-work/the-issue/. ; Inua Dada. "Menstrual Health Management (Mhm) Program." inuadadafoundation.org., accessed September 20, 2018, https://www.inuadadafoundation.org/menstrual-health- management-mhm-program/.

106 Zana Africa Foundation. "Zana Africa." zanaafrica.org., accessed November 1, 2018, http://www.zanaafrica.org/health-education/.

107 Zana Africa Foundation. "Zana Africa." zanaafrica.org., accessed November 1, 2018, http://www.zanaafrica.org/health-education/.

108 Ibid.

109 Ibid.

110 Ibid.

111 Muthengi, Eunice, Emily Farris, and Karen Austrian. 2017. The NIA Project: Baseline Report: The Population Council, Inc.

112 Ibid.

113 Ibid.

114 Howard, Ashely. Kenya's Female Literacy Rate Continues to Improve.


About Kelsey Sampson

Kelsey is a BYU sophomore studying Business Strategy and Professional Writing and Rhetoric. After taking on a few research assistant jobs, she found her love for research and technical writing, and she has enjoyed using those skills to study social innovation ever since. She has found her niche in the combination of business and social impact, and she hopes to continue to work in a combination of those areas. Besides school, Kelsey is a big fan of being with friends and family, volleyball, really hot weather, and staying in the Harold B. Library until it closes.

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