Dear Elisabeth

Thanks for initiating the discussion and keeping it on track.
While answering the link of MHM and sanitation facilities in schools, we need to move step wise. It can be correlated to some kind of service ladder which girls in schools have to move on. It also matters what would be more important and when?
For example, if a girl has to attend examination, she is more likely to attend school if there are appropriate facilities around and less likely if no facilities. Similarly, in normal days, if the facilities are around more likely to attend and if no facilities then less likely and so on. Thus, my take is that, it is good to compare with developing countries and argument above that it absenteeism should be none in countries with all the facilities is argued that it is above level of service one is expecting and used to. For example, many girls in developing countries would be attending the school in spite of no facilities while girls of developed countries would not attend if the facilities are not available on the day of menstruation, so my suggestion is that we should be careful and realistic with due considerations of the situation.

Here is a very interesting article that touches on all the things that we have discussed in this thread and which conclusively answers the question with which I had started this thread. I started the thread which questioning this statement:

many of them have dropped out of school due to menstrual hygiene related cases.

If only the solution was this simple!

Here is the article:
www.npr.org/player/embed/506472549/507287064

The title is: Does Handing Out Sanitary Pads Really Get Girls To Stay In School?

And the answer is: probably no, at least not on its own but it should be important and worthwhile nevertheless.

December 28, 2016
Author: NURITH AIZENMAN
Where: Website of NPR which is a mission-driven, multimedia news organization and radio program producer.

Paragraphs that I found particularly important:

"It's like the straw that breaks the camel's back," says Sommer. "There are many things that make going to school difficult, and it's one more thing."

That's a major concern, because compared with boys, a much larger share of girls in poor countries drop out of high school.

and:

For instance, maybe the most serious impact on girls who are menstruating is not that they don't show up to school, but that their concern about leakages makes it harder for them to concentrate or dissuades them from participating in class.

The researchers also question the very idea that there has to be some educational or health justification for spending aid dollars to help girls manage their period. It suggests this isn't worth doing for its own sake.

"I wonder if boys had a similar biological experience," muses Caruso. "If we would be going through so much effort trying to justify whether or not we were investing in giving them what they need."

Really an excellent article explaining the complexities in all this. The answer is never that simple...

Regards,
Elisabeth


P.S. In my role as moderator, I have split off 7 posts from this thread into a spin-off thread dealing specifically with taboos around menstruation in Nepal, see here:
forum.susana.org/component/kunena/24-men...-nepal-and-elsewhere
Make sure you subscribe to that thread (or to the whole sub-category) if you have an interest in that topic!

Dear Penny,

Sorry for late reply.

We are working in Kenya and would like to start as soon as possible.

Happy New Year

Camilla

Dear Jen and colleagues

Well done for summarizing so nicely the multi-disciplinary issues around potential school absence relating to MHM which, when added to 'other' reasons for school absence, exemplifies the difficulties in quantifying the contribution of MHM to school absence. Have you published your research, it would be well worth it, as it would add to the limited data currently available.

As noted in a prior message to Elizabeth, a group of us have recently published an article, which you can also find on researchgate, summarising some of the gaps in the evidence-base for MHM to enable programmes, policy makers, and funders to better support MHM globally. This highlights that absence, while important, is one among numerous outcomes that require confirmation (or refutation) and may differ in relative contribution by location and culture.

You can download from the researchgate website which also lists other publications and 'new projects' under development:
www.researchgate.net/publication/3115096..._research_priorities

Wishing all readers the very best for 2017, and well done to Elizabeth for keeping these discussions updated, relevant, and on point!

Penny
Liverpool School of Tropical Medicine

Thanks Camilla
What country would this be in, and what would the dates be?
best, Penny

Thanks Elizabeth, for following up.

Marni's response eloquently summarizes the knowledge-base to date. The building of a robust evidence base will likely take many years, recognizing there will be geographical and cultural differences.

We used attrition to cover absence and dropout, ultimately attrition means 'loss' - but evidence is needed to demonstrate [or not] that repeated absence (i.e. from inadequate menstrual care each month) leads to dropout, which also has multiple causes.

A group of us have recently published a MHM research priorities paper, based on discussions at the MHM in 10 meeting group, which we hope will be taken up by researchers, programmers, funders, and policy-makers, to move the research agenda forward.

www.globalhealthaction.net/index.php/gha/article/view/33032

(if people are unable to access, let us know).

best wishes all.

Penny
Liverpool School of Tropical Medicine

Hello Penny and others,

This is such a great discussion happening here!

The issue of deliberate absenteeism is interesting and very important, especially as, as has been mentioned in this thread, in the virtual MHM conference, and in several recent studies, absenteeism does not seem to be a valid indicator; an RCT in Nepal (Oster & Thornton, 2010) showed that providing girls with pads had no significant effect on absenteeism. And as Penny mentioned, we have also seen girls unwilling to disclose menstruation as the reason they are absent, if school records are being used.

Femme has found that there are larger issues beyond supplying a method of menstrual management that need to be addressed, one reason we ask students WHY they were absent (it includes things like pain, fear of leaking, embarrassment, etc). Schoolgirls report pain and/or discomfort in prevalences up to 100%. All schoolgirls mention boys' teasing and unfriendly school atmosphere. We came across an headmaster who did not allow menstruating girls to attend, because there was no disposal system, and disposable pads were filling up and blocking the latrines. Poor WASH facilities inhibit girls' ability to change pads, and they will go home early so as still be be marked 'present.' They might be at school, but not concentrating, not raising their hand, not willing to sit down or go up to the blackboard, and so developing indicators that are a more valid, reliable measure of their situation in school is something we're working on.

Cheers,
Jen

Dear Penny,

I appreciate your elaborate answer. Thank you.

We also encounter similar difficulties in regards to attendance.

In complete agreement regarding doing research focusing on "self-efficacy, self-esteem, dignity, well-being, ability to concentrate in class". When I worked with Peepoople we did a nice SROI study. I like that methodology.

What I have encountered when discussing the provision of menstrual solutions to underprivileged adolescent girls (not only cups) with different donors and organizations is the necessity to confirm girls attendance in school is increased.

A person who works at Unicef expressed this as key to get them on board.

As we interview each girl we train before starting the education part it is easy to integrate a baseline study in our program.

Our target for next year is to reach 10 000 girls.

If you know of any masters student or university who is interested in supporting us to start an attendance study please let me know.

With warm regards

Camilla

Dear Camilla

Many thanks for your interest and response.

Regarding the question - why has the cup not shown clear evidence of a reduction in absence is an important observation. we concluded we did not have adequate reporting on absence in any of the groups to analyse the effect. We try to address the absence question in our 'discussion' section - as girls and parents in the very same study during focus group discussions reported they were less absent from school. Generating high quality information on changes in absence rates over time has proved tricky for us, and I think also for a number of other researchers. During our study, there were a number of school closures due to teacher strikes, council elections, as well as exams and holidays so the amount of time spent in school was less. As there was a strong safety component to our study, we had study nurses regularly in the schools, including in control schools - this was well received by the girls, and we conjecture that this (in all groups) may have improved their liking of school and thus attendance. We also wonder if girls were not willing to disclose when and reasons for absence in case it got back to the teachers. Lastly, we have to consider that absence may be due to so many different factors, in some school settings, that provision of a menstrual product alone may not generate clear cut data - for example, if girls are absent due to menstrual period pains (but would also leak had they gone to school) - they would respond equally in all treatment groups including intervention - and also may answer a questionnaire stating the reason they were absent was 'illness' rather than menstruation.

As such, we feel for comparison studies, particularly in a setting such as ours, that markers of success of the intervention may be better focused on 'hard' outcomes that we can measure more objectively. further studies on absence are of course very welcome, but should not be the only consideration - studies on self-efficacy, self-esteem, dignity, well-being, ability to concentrate in class, ability to reach potential are all important questions. We have a new publication just coming out on research priorities on MHM which we will share very soon.

best wishes
Penny

Liverpool School of Tropical Medicine

Hi Penny,

Thanks for posting this paper here. I have moved two earlier posts to the beginning of this thread because they fist very well to this topic.
I repeat here something from my post in July:

Assumption/Myth #4. Girls in developing countries are dropping out of school due to lack of menstrual products and toilets

--> It's one of these statements that we often read about and which somehow makes sense intuitively but which is actually not proven and might not be true after all.

You also point this out in your paper where you said:

Lack of quantifiable school absence here and in other pilot studies,10 ,51 contrasts with girls',3–5 ,10 and parents narratives.37 It is unclear if girls in this environment exaggerate missed time when in focus groups but not in structured questionnaires,15 if girls avoid reporting reasons that are associated with stigma (such as teenage pregnancy), fear repercussions when reporting absence (which we consider possible in our study), or if menstrual absence due to abdominal cramps or other reasons over-ride any menstrual product effect.15 ,23 Further research is needed to better quantify the effects of menstrual interventions on school absence, and it seems prudent that studies validate their measurement tools in pilot studies and spot-checks.

This makes a lot of sense.

I had also exchanged e-mails with Marni Sommer about this - I asked her if this was a topic at the recent MHM Virtual conference and she said:

I don’t think that the conference actually had any presentations that ultimately delved into that issue. There was some discussion of the need to move beyond the focus on absenteeism given the challenge of getting accurate attendance data for so many reasons – and the existing evidence having its limitations. I am not sure the studies have been done yet to really answer that question with certainty – although certainly plenty of girls have articulated across various countries that it’s an issue. However I think many of us would like to see an expansion of the interest to look at other measures that might better capture the impact (e.g. educational engagement, self-efficacy managing menstruation in school, etc)

By the way, I noticed you used the term "school attrition" in your paper title. This term was new to me in this context and you only used it once more in your paper where you wrote:

school attrition (drop-out, absence)

Is "attrition" therefore a better word to use than "absenteeism"?

Regards,
Elisabeth

Dear all,

Thank you for your great and important research.

The Cup is working in Kenya since spring 2015 and we are distributing menstrual cups and comprehensive education including human rights, sex ed, MHM etc. We also train the parents and boys. Most of the 5500 girls we have trained are between 11-16.

Transactional sex is common in Nairobi slums and we welcome an in-depth study focusing on this problem as most girls are not aware of the dangers of HIV, STDs and unwanted pregnancy (or unsafe abortions).

My question is, why isnt the introduction of menstrual solutions affecting attendance in school at high level?

We have all been informed this is such a common practice. Or is this where the transactional sex plays in?

Warm regards

Camilla
thecup.org

Dear Dirk

Thank you for your questions. I see you have response already, which is good for opening the forum for discussion.

1. The RTI* prevalence (so could have been acquired 'anytime' as opposed to within a specific time, as we were unable to measure at baseline) was 26%. We only measured candida albican and bacterial vaginosis. note that 71% of RTI were bacterial vaginosis, with a prevalence of 18.5% of all girls.

2. You raise questions about the hymen. We recognise this could be a concern with regard to understanding of virginity. We explained at public meetings (parents) and directly to girls about this, using very similar explaination as noted by the other respondee (Jen) below.

I attach a paper of ours on the focus group discussions we had with girls and parents, on their perceptions and response to provision of cups and pads. Note girls assented to take part after they understand the study, and had parenbtal consent (approval) also.

Best wishes
Penelope Phillips-Howard
Liverpool School of Tropical Medicine


*RTI - reproductive tract infection