Menstrual Hygiene Management

( MHM) and WASH in Schools

Baseline Survey Report

South Sudan - Eastern Eqautoria State (EES)

Girls preparing to go for Cleaning as School as part of Hygiene Promotion

An adolescent girl demonstrating how a hole is used during menstruation Adolescent girls sharing with the Researcher the experience of using a hole during Menstruation “… Our problem is that our Senior May 2014 Woman Teacher does

not talk to us about Supported by: Netherlands Development Organization Menstruation” (SNV) – South Sudan

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Consulting organization:

Multi Media Skills and Health Consult (MSHC)

Multi - Media Skills & Health Consult (MSHC) provides services in areas of; Research/surveys, support production and application of BCC/IEC Materials in humanitarian, development partners and government.

Consulting Team:

Kabuye GERALD: Principal Investigator (PI), Regional Development communication specialist in primary health care, Education, Research/surveys and governance with experience from Uganda, Kenya, South Sudan and Rwanda. Gerald also uses arts of different forms to enhance community development

Moses OKWII: Principal Investigator (PI)1 He has over 6 years’ experience in social researcher, fundraising, capacity building and organizational development t from East Africa and south Sudan. He has done consulting for a series organizations including NGOs small and large, private companies, academic institutions and government departments.

Nathan OCHATUM: Principal Investigator (PI) 2 He is a statistician with experience in data management, research, M&E, impact assessment and baseline surveys. Worked in East Africa and South Sudan, with projects sponsored by; SNV-South Sudan and Uganda, CABI, PLAN, NAADS among others

Multi-Media Skills and Health Consult (MSHC) Limited P.O. Box 122 Juba, Sou8th Sudan Tel.: +211 929 674 060, +211 977 343 627 E-mail: [email protected] Website: www.mshc-southsudna.org

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Acknowledgement:

The team would like to thanks all the stakeholders for the outstanding support during this exercise. In particular we want to give appreciation to the following:

 State Ministry of Physical Infrastructure (MoPI)  State Ministry of Education (MoE)  County Education Directors (CED) from Magwi, Torit, Lopa/Lafon, Ikwotos, Kapoeta and East, Kapoeta South  Head teachers and Teachers from all the schools visited  Pupils/students (boys and girls) from all the schools (primary/secondary) visited  PTAs/SMCs, Local/opinion leaders and  Whoever contributed to the success of this assignment

In a concerted effort, the team above was able to guide and advise MSHC throughout the work. Not only did they advise/guide us during the assignment but contributed to the discussion and generating information that built up this report.

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Table of Contents:

Consulting organization: ...... 1 Summary: ...... 5 Acronyms: ...... 7 List of tables: ...... 8 List of figures: ...... 9 1.0 CHAPTER ONE: INTRODUCTION AND BACKGROUND TO THE STUDY ...... 10 1.1 Overview: ...... 10 1.2 Objectives of the Assessment: ...... 10 1.2 Rationale: ...... 10 1.3 Organisation of the Report: ...... 11 1.4 Education in South Sudan: ...... 11 1.6 Status of WASH in South Sudan: ...... 13 1.7 Water and sanitation in schools: Addressing feminine hygiene: ...... 14 1.8 Menstrual Hygiene Management: ...... 15 1.9 MHM and school attendance: ...... 16 2.1 Scope and Coverage of the Study: ...... 19 2.2 Study design: ...... 19 2.3 Sampling Techniques: ...... 19 2.4 Sample size of respondents: ...... 20 2.5 Data collection: ...... 20 2.6 Ethical considerations: ...... 20 2.7 Data Analysis: ...... 20 2.8 Challenges, Limitations to consultations: ...... 21 3.0 CHAPTER THREE: PRESENTATION OF FINDINGS AND DISCUSSION ...... 22 3.1 Introduction: ...... 22 3.2 Education: ...... 22 3.2.1 Average enrolment in primary and secondary schools ...... 22 3.2.2 Total enrolment of pupils in selected schools per county ...... 23 3.2.3 Enrolment age of girls in primary school ...... 24 3.2.4 Teachers: ...... 25 3.2.5 Reasons for dropping out of school ...... 26 3.3 MENSTRUAL HYGIENE MANAGEMENT ...... 28 3.3.1 Knowledge on menstruation: ...... 28 3.3.2 Information on Menstrual Hygiene Management: ...... 29 3.3.3 Source of information on Menstrual Hygiene Management: ...... 30 3.3.4 Materials used during Menstruation:...... 31 3.3.5 Use of sanitary pads in the last 3 months ...... 32 3.3.6 Reasons for not using sanitary pads: ...... 33 3.3.7 Usage of Knickers/underwear: ...... 0 3.3.8 How boys react to girls during menstrual periods ...... 1 3.3.9 How the community treats girls during menstrual periods ...... 2 3.3.10 Channels of ensuring availability of sanitary materials ...... 3 3 | P a g e

3.3.11 Menstruation and school attendance: ...... 3 3.3.12 Why menstruation makes girls miss school ...... 4 3.4 WASH: ...... 5 3.4.1 Presence of changing rooms for girls in school: ...... 5 3.4.2 Presence of Latrines: ...... 6 3.4.3 Presence of water in schools: ...... 7 3.5 DISCUSSION OF RESULTS ...... 9 3.5.1 EDUCATION: ...... 9 3.5.2 MENSTRUAL HYGIENE MANAGEMENT: ...... 10 4.1 RECOMMENDATIONS:...... 13 4.1.1 Menstrual Hygiene Management: ...... 13 4.1.2 EDUCATION: ...... 14 4.1.3 WASH: ...... 15 4.2 Conclusion: ...... 15 Annex One: Sample population ...... 16 Annex Two: List of Selected School per County for MHM Baseline Survey Project ...... 17 Annex Three: Questionnaires ...... 19 Annex Four: QUESTIONNAIRE FOR GIRLS IN PRIMARY & SECONDARY SCHOOLS ..... 24 Annex five: OBSERVATION CHECKLIST...... 28 Annex 6: INTERVIEW SCHEDULE FOR GIRLS AND BOYS (FGD) ...... 30 Annex seven: INTERVIEW SCHEDULE WITH LOCAL LEADER, PTA/SMC AND PARENTS . 31 Annex eight: List of Enumerators ...... 32

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Summary:

Policy-makers and other actors have cited knowledge on key menstrual hygiene management issues, inadequate WASH facilities and lack of sanitary products as barriers to girls' schooling. In this assessment, we evaluated the status of WASH in schools, examined the knowledge, attitudes and practices in relation to Menstrual Hygiene Management as well as explored available opportunities, challenges and recommendations aimed towards improvement of WASH and menstrual hygiene management in Eastern Equatorial State, South Sudan.

A qualitative and quantitative study design was adopted and questionnaires, FGDs, Observation checklist and interviews were used in collecting data from various respondents that included school girls, boys, teachers, parents, PTAs/SCMs, Local leaders and Chiefs. Data was collected from 1280 respondents with a response rate of 71.1% within 49 primary and secondary schools in Eastern equatorial State.

The findings of this baseline assessment revealed that in Eastern Equatoria State, enrolment of both boys and girls is mainly concentrated at lower classes (P.1 – P.4) with upper classes (P.5 – P.8) having fewer pupils. Detailed analysis of class enrolment by gender revealed that, the number of girls in per classes (P.5 – P.8) including secondary is relatively very low with most schools in Kapoeta East, Kapoeta South and Lopa-Lafon having no girls completely in some of these classes. Findings further exposed that there are only 705 girls enrolled in primary eight compared to 1,263 boys meaning that there is one girl in every six boys in primary eight. The low level of enrolment of girls in upper classes of primary including secondary has largely been attributed to early forced marriages and pregnancies.

Limited availability of trained teachers in schools was also revealed by the assessment as one the major challenges surrounding education. Male teachers were the majority in all schools with some schools completely lacking a female teacher.

The assessment established that most girls both in primary and secondary had limited knowledge on what menstruation is about. With 62.9% of girls in Lopa-Lafon citing menstruation as a disease and 59.9% of the girls citing that someone is unhealthy during menstruation periods. Findings further revealed issues of menstruation are generally regarded as a big secret and taboo and that men are not completely supposed to know.

The materials and approaches used by many girls and women for menstrual hygiene management in Eastern Equatoria State, South Sudan were found to highly diverse ranging from modern to traditional materials which could regarded as the worst in the world. The assessment specifically established that most women and school going girls reported to be using goat’s skin, bark cloth, soil, rags, pieces of mattress, digging holes on the ground, leaves of trees and traditional herbs like “bene” popular among the Lotuko tribe used for controlling blood flow.

Findings further revealed that42.7% of girls who responded reported that they do not wear underwear, and this is greatly attributed to the cultural factors surrounding underwear among the tribes like the Toposa where it’s traditionally illegal for women to wear underwear’s. 5 | P a g e

Based on the findings of this assessment, the issue of menstrual hygiene management is a serious challenge amongst the girls and is also attributed to the poor attendance in school. We therefore recommend that teachers, especially males be capacitated on MHM issues and life skills education so as to empower them in supporting adolescence pupils. In addition massive community awareness campaigns need to be undertaken targeting parents on MHM and value of education. There is lack of supplies on menstrual hygiene kits and hence there is need to explore cost effective methods of making re-usable sanitary pads to improve access by girls and women. Advocacy is required in relation to designing appropriate sanitation structures that cater for menstrual hygiene management in schools.

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Acronyms:

WASH Water Sanitation and Hygiene PTAs Parents Teachers Association SMCs School Management Committees UNICEF United Nations Children’s Fund MHM Menstrual Hygiene Management FDGs Focused Group Discussions NGOs Non-Governmental Organizations SNV Netherlands Development Organization MoPI State Ministry of Physical Infrastructure MoE State Ministry of Education CED County Education Directors K.E.C Kapoeta East County K.S.C Kapoeta South County EMIS Education Management Information Systems CPA Comprehensive Peace Agreement MWRI Ministry of Water Resources and Irrigation GESS Girls Education South Sudan USAID United States Agency for International Development SSA Studies for Sub-Saharan Africa MDGs Millennium Development goals HIV Human Immunodeficiency Virus UNHCR United Nations High Commissioner for Refugees SPSS Statistical Package for Social Sciences CSOs Civil Society Organizations

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List of tables:

Table 1: Showing total enrolment of pupils in primary schools ...... 23 Table 2; Number of trained and untrained teachers by gender ...... 26 Table 3; Showing reasons why girls drop out of school ...... 26 Table 4; Showing perception of pupils/students on menstruation ...... 29 Table 5; Showing sources of information on MHM ...... 31 Table 6; Showing materials and approaches used during menstruation ...... 32 Table 7; Showing perceptions and beliefs associated with menstruation ...... 2 Table 8; Average number of school days missed by girls during menstruation ...... 4 Table 10; Availability of changing room and materials in schools ...... 5 Table 11; Showing presence and state of latrines ...... 6 Table 12; Showing presence and condition of water sources ...... 7

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List of figures:

Figure 1.Cross –sectorial schooling profile based on EMIS, 2009 ...... 11 Figure 2.Average enrolment in primary schools Figure 3. Average enrolment in secondary ... 22 Figure 4; Showing the maximum and minimum age of girls per class ...... 24 Figure 5 Primary School girls of Lofus Primary school, Ikwoto County ...... 26 Figure 6; Percentage of girls that have ever heard information on menstrual hygiene care ...... 30 Figure 7; showing whether girls had used sanitary pads in the last 3 months ...... 32 Figure 8; Showing reasons for not using pads in the last 3 months ...... 0 Figure 9; Showing percentage of girls who put on knickers...... 1 Figure 10.Showing how girls are treated by boys during menstrual periods ...... 1 Figure 11; how girls are treated by the community during menstruation ...... 2 Figure 12; most accessible channels of ensuring availability of sanitary materials ...... 3 Figure 13; Showing why menstruation makes girls miss school ...... 4

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1.0 CHAPTER ONE: INTRODUCTION AND BACKGROUND TO THE STUDY

1.1 Overview:

Menstrual hygiene management in schools is receiving renewed attention as its impacts on girl education have been noted in terms of having long-lasting and far-reaching social and economic effects. Through the international day for menstrual hygiene management it has become a primary focus of development efforts in many developing nations including South Sudan. Over the years, the issue of school hygiene, sanitation and water has been put high on the agenda of many, international donors, non-governmental organisations, international agencies including government as a way of promoting a conducive school environment for many girls. In line with girl’s school attainment, menstrual hygiene management has on the other hand attained little or no attention and yet many scholars and actors have attributed it to be having far much reaching implications on overall children schools attainment.

This assessment focused on the current WASH status in schools and how menstruation hygiene is being managed in view of collecting information that will form basis for future programming and current programme implementation.

1.2 Objectives of the Assessment:

The overall objective of the baseline study was to establish baseline data on WASH in schools so as to provide benchmark information on indicators of WASH in school, Menstrual Hygiene and policy interventions in relation to WASH in Eastern Equatorial state. The specific objectives of the baseline study were;

1. To map out trends in the selected schools with regard to schools WASH services which include but not limited to status of WASH in schools, enrolment, Menstrual Hygiene management, key actors, infrastructure availability, management of PTA/SMC, type of material available, costs acceptability and affordability. 2. Analyse existing menstrual hygiene product supply chain/enterprises, with a view to identify entry point (s) into sustainable supply chain menstrual hygiene materials with potential for highest social impact and commercial returns

1.2 Rationale:

The baseline survey was conducted in view of expanding SNVs school WASH programmes especially in creating child friendly schools with emphasis on menstrual hygiene management. SNV and its stakeholders particularly the State Ministry of Education, Youth and Sports, would like to ensure interventions that influenced by evidence from the beneficiary communities in line with current practices, attitudes, knowledge levels and beliefs. It was therefore on this basis that the baseline assessment was undertaken so as to inform planning approaches given the diversity of unmet needs, challenges, including menstrual hygiene in schools and available resources (technology, institutions and organizations). This diversity necessarily suggests a balance between standardization allowing evidence-based innovation experimentation. 10 | P a g e

Menstrual hygiene management has emerged as one of the major challenges confronting all schools in South Sudan and has been attributed to low retention of girls in schools. This baseline survey which was undertaken in 49 schools in Eastern Equatorial provided the benchmarks against which the project successes will be measured. In addition it will contribute to the body of knowledge that will inform roll out of the projects in schools towards addressing the WASH challenges and hence increasing the number of pupils in schools and in particular the girl child.

1.3 Organisation of the Report:

The report is arranged into four chapters. Chapter one presents background, objectives, rational and review of related literature. Chapter two provides an insight into the overall survey methodology that was employed. Chapter three presents assessment findings and discussions. Finally chapter 4 presents conclusion and recommendations based on the findings from the assessment and other studies taken earlier.

1.4 Education in South Sudan:

South Sudan has some of the lowest educational indicators in the whole world. The adult literacy rate stands at only 27 per cent, and 70 per cent of children aged 6–17 years have never set foot in a classroom1. The completion rate in primary schools is less than 10 per cent, and is one of the lowest in the world as shown in the figure 1 below. Gender equality is another challenge, with only 33 per cent of girls in schools.

Figure 1.Cross –sectorial schooling profile based on EMIS, 2009

Source; UNICEF South Sudan

1Unicef South Sudan, Basic Education and Gender Equality, http://www.unicef.org/southsudan/Education.pdf 11 | P a g e

Despite the fact that demand for education in South Sudan far outstrips supply, few children and youth are able to complete the full primary cycle – let alone go on to complete secondary and post-secondary studies2. The failure to complete the full education cycle at all levels has far much reaching implications and as such it’s important to unpin the underlying factors.

Worse still, women and girls in South Sudan are more likely to die at childbirth than to complete primary education3. While enrolment in the primary and secondary systems has increased dramatically in the years since the CPA, over-age children make up 85% of all primary school enrolees, and 90% of those children enrolled in secondary school and this has a negative effect on competition rates4. The average recommended age range for completion of primary cycle in South Sudan is estimated at 14 years and Secondary 18. The Net Enrolment Rate for at-age children in the primary system is only 42.9%5 implying that 57.1% of children in primary schooling are over age.

Currently there are 1.4 million children in primary schools, out of 2.4 million children aged between 5 and 146.

There are only an estimated seven girls for every 10 boys in primary school and five girls for every 10 boys in secondary.7 In the whole country, only five hundred (500) girls are in the last grade of secondary school (Senior four). Only one in four girls enrols in primary school and a mere one in ten completes primary education. Out of 377,085 girls of the secondary level age group only 2.6% (9,898) are in schools. These numbers are among the lowest in the world8.

There are about 26,000 teachers and 30,000 classrooms meaning on average 118 children will need to share a classroom and about 88 share 1 teacher.9 There are 3.400 primary schools, and 196 secondary schools.

The unbalance of pupil-classroom and pupil-teacher ratio in the Country has led to a huge shortage of qualified primary school teachers with government resorting to use volunteer untrained staff as an option. In addition poor management and supervision of teachers, lack of physical infrastructure, inadequate teaching and learning materials, and low participation of PTAs/School Management Committees and communities in school management contribute to access and quality challenges10

The underlying factors for this trend are enormous from few numbers of secondary schools to rigid cultures in terms of early forced marriages for girls as low as 9 years, and general preference by parents to educating boys than girls. Just only 12% of teachers are female. Literacy rates for girls are 40% compared to 60% for boys.11 Girls’ lack of access to educational opportunity has been exacerbated by certain cultural practices as well as widespread insecurity

2DFID, Business Case for the Girls Education South Sudan (GESS) Programme, December 2012 3Comparison made using data from South Sudan Statistical Yearbook 2011 and Education National Statistics Booklet 2011 4 EMIS Data 2011 5 EMIS Data 2011 6EMIS Data 2011 7World Bank, Education in the Republic of South Sudan – Status and Challenges for a New System , 2012 8 EMIS Data 2011 9 EMIS Data 2011 10DFID, Business Case for the Girls Education South Sudan (GESS) Programme, December 2012 11World Bank, Education in the Republic of South Sudan-Status and Challenges for a New System, 2012 12 | P a g e

and conflict. Whilst education is voiced by many communities as a priority, opportunity costs in girls’ education mean that demand is actually low.

A combination of supply and demand side constraints underlies this unusual gender disparity in education in South Sudan. Lack of schools, especially secondary schools; low numbers of female teachers; and inadequate water and sanitation facilities in schools are some of the supply side factors. Poverty, insecurity, early marriage and pregnancy have been identified across the States as key causes of drop out from schools12. Each percentage point increase in poverty reduces a girl’s chance of being enrolled at a primary school by 0.3 percentage point13.

A cattle culture and economy is predominant in South Sudan and in many communities women are viewed as a household resource, commonly valued by the number of cows they would bring as dowry; and as a tool for domestic chores14. These social views and the economic realities that underpin them result in further barriers for girls’ education. Communities fear that girls will be ‘spoilt’ by going to school, mixing with boys and men un-chaperoned, and that educated girls’ will not respect their men folk and thus their future husbands and therefore they will be harder to marry off15.

1.6 Status of WASH in South Sudan:

Recent surveys show that more than 30 per cent of people in South Sudan do not have access to safe water supplies with only 13 per cent having access to adequate sanitation facilities16. This makes South Sudan to be one of the lowest service coverage statistics in the world. The lack of access to clean water has propelled increase in Guinea worm cases making South Sudan a host to 98% of the whole world’s population despite a reduction in caseload from more than 20,500 in 2006 to below 1,000 in 201117

The Ministry of Water Resources and Irrigation (MWRI) states that 30-50 percent of water facilities are non-functional at any point in time due to the lack of spare part supply chains, weak maintenance capacity, poor management and/or inappropriate choice of technology18. Thus, the actual level of access to an improved water source in rural areas is estimated to be only 34 percent – which affects most of the country as over 80 percent live in rural areas, representing 90 percent of those living in poverty19. Furthermore, only 13 percent of the population has access to adequate sanitation facilities and for those using an improved water source, 34 percent travel less than 30 minutes20 the recommended minimum average time to access a water point according to the World Health organization.

Beyond limited access to improved water and sanitation there is low knowledge and practice of good hygiene behaviours. The lack of access to improved water and sanitation and poor hygiene behaviours is a principal cause of water-related diseases such as diarrhoea and cholera, infection

12UNICEF, 2008. A Study on Socio-economic and Cultural Barriers to Schooling in South Sudan

13 Michael Morris, 2010. Analysis of Provincial Education Statistics of South Sudan.Unpublished.DFID Sudan 2010 14 DFID, Business Case for the Girls Education South Sudan (GESS) Programme, December 2012 15DFID, Business Case for the Girls Education South Sudan (GESS) Programme, December 2012 16Unicef, South Sudan “ Water, Sanitation and Hygiene”, http://www.unicef.org/southsudan/WASH.pdf

17Unicef, South Sudan “ Water, Sanitation and Hygiene”, http://www.unicef.org/southsudan/WASH.pdf 18 USAID, Draft Water Sanitation and Hygiene Programme, 2013 19 USAID, Draft Water Sanitation and Hygiene Programme, 2013 20 USAID, Draft Water Sanitation and Hygiene Programme, 2013 13 | P a g e

from guinea worm, and contributes to malnutrition21. Water, sanitation, and hygiene (WASH) is also associated with educational access and nutritional outcomes. Access to water and sanitation can be the reason why girls are kept out of school and improved access to water and sanitation at schools has been shown to increase school attendance among girls22

Access to improved drinking water sources and improved sanitation and hygiene can improve nutritional outcomes and can prevent intestinal parasitic infections alongside diarrhoea, and these infections also have synergistic effects with increasing incidences of malnutrition. Improved access to safe water, sanitation, and adequate hygiene can predict child growth and malnutrition and is associated with improved child development outcomes. Improving WASH is necessary to improve health, nutrition, and educational outcomes in South Sudan. Beyond these burdens related to poor WASH access and behaviours, it is also associated with economic losses, environmental impacts, gender/social burdens, and potential conflict. Access to and good management of water resources improves health and education outcomes, brings more certainty and efficiency in productivity across economic sectors, and contributes to the health of the ecosystem.

Making improvements in the areas of water and sanitation is vital to transforming people’s lives. Engaging with communities about choices they wish to make over safe water and sanitation improvements provides an important entry point for human rights principled dialogue on peace building and sustainable service delivery. Achieving community stability through timely and appropriate safe water improvement interventions is a key priority for WASH interventions in South Sudan23.

However, the negative effect of inadequate sanitary care on female educational achievement is completely undocumented by research in South Sudan. Thus, despite the problem’s rising salience, many international aid community members resist the notion that providing care will improve educational outcomes.

1.7 Water and sanitation in schools: Addressing feminine hygiene:

Studies in Sub-Sahara African (SSA) countries show that the lack of adequate toilet facilities is a common feature in many schools where the child-toilet ratios is on average 1:10024.

It has been argued that only 45 per cent of South Sudan’s 3,349 basic primary schools have access to safe water and a mere 17 per cent have adequate sanitary latrines for both girls and boys25. Even the few 17% that exist in schools have unfriendly environments for girl’s management of menstrual hygiene. This happens in many schools of South Sudan though it has been stressed that school toilets, are built to accommodate menstruating girls’ specific needs for privacy, space, washing facilities and correct disposal or cleaning of menstrual pads26.

Access to improved drinking water sources and improved sanitation and hygiene can improve nutritional outcomes and can prevent intestinal parasitic infections alongside diarrhoea, and

21 USAID, Draft Water Sanitation and Hygiene Programme, 2013 22 USAID, Draft Water Sanitation and Hygiene Programme, 2013 23 USAID, Draft Water Sanitation and Hygiene Programme, 2013 24Unicef ESARO, “Impact of puberty and feminine hygiene on girls’ participation in education –Kenya and Malawi”, 2010 25Unicef, South Sudan “ Water, Sanitation and Hygiene”, 2013 26 UNICEF, Raising clean hands: Advancing learning, health and participation through WASH in schools, UNICEF, New York, 2010 14 | P a g e

these infections also have synergistic effects with increasing incidences of malnutrition27. Improved access to safe water, sanitation, and adequate hygiene can predict child growth and malnutrition and is associated with improved child development outcomes. Improving WASH is necessary to improve health, nutrition, and educational outcomes in South Sudan28. Access to and good management of water resources improves health and education outcomes, brings more certainty and efficiency in productivity across economic sectors, and contributes to the health of the ecosystem.

1.8 Menstrual Hygiene Management:

Menstruation is a natural process, which begins to occur for girls between the ages of 9 and 16 years with a mean of 13 years29. The menstruation period usually lasts for an average of five days, but may vary from three to over seven days30. The duration and heaviness of a period influences its management, menstrual products used and frequency of change.

In South Sudan, like in many parts of the developing world, menstrual hygiene management is one of the critical challenges adolescent girls face while they are in school. This is largely due to lack of facilities as well as poor management of the existing facilities coupled with many cultural norms and taboos against menstruation.

Young girls in developing countries often receive minimal instruction on menstrual hygiene management because menstruation is seen as taboo by many communities, which makes it extremely difficult for adolescent girls to acquire necessary information and support from parents and school teachers31.There is evidence that boys, male teachers and even male head of schools are completely ignorant of girls menstruation needs32 and therefore are unable to provide a supportive environment to girls in school during menstruation periods.

Menstruation has often been dealt with secrecy in many cultures33 and such perceptions coupled with poor and inadequate sanitary facilities have often kept girls from attending schools especially during periods of menstruation.

There is gross lack of information on menstrual management among adolescent girls, a situation made worse by the shyness and embarrassment with which discussions about menstruation is treated. Most of these girls seek information about menstruation from their peers who do not know better34.

Adolescence being a time of tremendous opportunity, and at the same time also a time of heightened vulnerabilities, it is imperative to empower adolescent girls with adequate information and skills on crucial issues like menstrual hygiene and its management.

27 USAID, Draft Water Sanitation and Hygiene Programme, 2013 28 USAID, Draft Water Sanitation and Hygiene Programme, 2013 29Dasgupta A and Sarkar M (2008). Menstrual hygiene: how hygienic is the adolescent girl in India, Journal of Community Medicine, 33(2): 77-80. 30Ezra Guya, Aloyce W. Mayo, Richard Kimwaga, Menstrual Hygiene Management in Secondary schools in Tanzania, International Journal of Science and Technology, January 2014 31Shannon A, Peter J, Bethany A, Alfredo F, Emily A, Imelda A and Richard D (2011). The girl with her period is the one to hang her head. Reflections on menstrual management schoolgirls in rural Kenya, BMC International Health and Human Rights Journal, 11(7): 689-698 32Ezra Guya, Aloyce W. Mayo, Richard Kimwaga, Menstrual Hygiene Management in Secondary schools in Tanzania, International Journal of Science and Technology, January 2014 33Unicef India, Sharing simple facts handbook “useful information about menstrual health and hygiene”, 2008

34 Same as one above 15 | P a g e

1.9 MHM and school attendance:

Lack of soap, hand wash facilities, emergency pads and privacy which are important determinant for proper practice of menstrual hygiene and school attendance has been identified as main problems35in many schools in developing countries.

Various studies have shown that girls who attend schools without appropriate water supply and sanitation facilities prefer to remain at home during menstruation36. A Menstrual Hygiene Management (MHM) survey conducted by SNV Uganda in 120 schools across six Districts revealed that girls are more likely to remain at home from school during their period due to a lack of facilities for and embarrassment about menstrual hygiene37.

The World Bank has put concrete numbers on the menstruation problem and asserts that; if a girl misses 4 days of school every 4 weeks due to her period, she will miss 10 to 20% of her school days38. Tion and Varina, (2007) are also in great agreement with this analysis. 39

UNICEF (2005) estimated that about 10% of school-age African girls do not attend school during menstruation, or drop out at puberty because of the lack of clean and private sanitation facilities in schools.

This possible role for menstruation limiting school attendance has received significant attention, and nearly all arguments indicate that menstruation is likely to be a significant factor in schooling40, 41.This argument has received mixed reactions among various scholars for example, Kristof (2009) writes that education experts increasingly believe that a cost effective way to keep high school girls from dropping out in poor countries is to help provide them with sanitary products42.

On a practical level many schools lack hygiene facilities such as toilets, water, washrooms, changing rooms, pads and pain killers. Providing these facilities would make regular school attendance easier for girls43. In addition to providing benefit to the schoolgirls, opportunities for the local development of sanitary pads including manufacturing and marketing of innovative low-cost sanitary towels should be explored.

Emily and Thornton (2010) strongly assert that these arguments are based largely on anecdotal evidence. In their experimental design on menstruation hygiene management using the menstrual cup in Nepal, they have argued that, the impact of menstruation on attendance is very

35Ezra Guya, Aloyce W. Mayo, Richard Kimwaga, Menstrual Hygiene Management in Secondary schools in Tanzania, International Journal of Science and Technology, January 2014 36Nahar Q and Ahmed R (2006). Addressing special needs of girl’s challenges in schools, Paper presented at the 2nd South Asian Conference on Sanitation, Islamabad, Pakistan, 2006. 37 SNV Uganda, Keeping girls in school with improved menstrual hygiene management, June 2013 38World Bank, “Toolkit on Hygiene Sanitation & Water in Schools: Gender Roles and Impact," 2005 39Tjon A Ten, Varina, - Menstrual Hygiene: A Neglected Condition for the Achievement of Several Millennium Development Goals," Europe External Policy Advisors, October 2007 40Kristof, Nicholas, “A Most Meaningful Gift Idea”, New York Times, December 23 2009.

41BBC News, Sanitary pads help Ghana girls go to school," 2010. 42Kristof, Nicholas, “A Most Meaningful Gift Idea”, New York Times, December 23 2009.

43SNV Uganda, Keeping girls in school with improved menstrual hygiene management, June 2013 16 | P a g e

small. They estimate that girls miss a total of 0.4 days in a 180 day school year due to period44. Moreover, using a randomized evaluation they argue that providing better sanitary products (in their case, a menstrual cup) had no impact on closing the small attendance gap.

This critical issue of MHM has been largely overlooked by the Water, Sanitation and Hygiene (WASH) sector in general 45 in many developing countries including south Sudan. Failure to provide appropriate menstrual hygiene facilities at home or school could prevent WASH services being used as intended46. In recent years, some governments, institutions and NGOs have realized that without addressing the problems associated with menstruation, the achievement of at least three MDGs (no. 2, 3 and 7) will be hampered47, female school drop-out rates will remain high and the dignity of schoolgirls will be compromised.

The consequence of this is that many girls grow up with low self-esteem and disempowered from poor educational attainments. Menstruation has also been identified to cause discomfort and high incidences of pain for a majority of women. It can also cause shifts in mood, depression, vomiting, pyrexia, endometriosis, haemorrhage, migraines, anaemia and fibroids48.

Menstruation can potentially cause cancer if cells mistakenly divide uncontrollably49. Poor management of menstruation can result in health problems such as infections of urinary or reproductive tracts, although the route of transmission and the strength of the effects have not been adequately established50. The potential risk of contracting blood-borne diseases such as HIV or Hepatitis B through unprotected sex is also increased during menstruation because the highest concentrations of virus are found in blood51. As a result many girls suffer from these diseases and their complications can even lead on to the infection being transmitted to the offspring when they conceive52. In recognition of the impact of menstruation on school attendance, a number of NGOs and sanitary product manufacturers have launched a series of campaigns to increase availability of sanitary products, with a stated goal of improving school attendance53

The largest of these is a program by Proctor & Gamble, which pledged $5 million toward providing puberty education and sanitary products, with the goal of keeping girls in school. The Clinton Global Initiative has pledged $2.8 million to aid businesses that provide inexpensive sanitary pads in Africa; again, the stated goal is improvement in school and work attendance.

In South Sudan, little information is available on who is doing what and where in regard to MHM, however notable among them are, Plan South Sudan54 and United nations High

44Emily Oster and Rebecca Thornton, “Menstruation, Sanitary Products and School Attendance: Evidence from a Randomized Evaluation”, American Economic Journal, April 2010

45Guya E (2013). Menstrual Hygiene Management in Secondary Schools: A case of Kinondoni District in Tanzania, Masters of Integrated Sanitation Management, Department of Water Resources Engineering, University of Dar es Salaam. 46 Shoemaker D (2008). Proper procedure for sanitary napkin disposal, Cleaning and Maintenance Journal, 45(4): 33-37. 47Tjon V (2007). Menstrual Hygiene: A neglected condition for the achievement of several millennium development goals, EEPA, Zoetermeer, Netherlands. 48Dalton K (1964).The influence of menstruation on health and disease.Proceeings of the Royal Society of Medicine, 57(4): 262-264. 49Donimirski, M (2013). Health Effects of Menstruation and Birth Control Pills http://serendip.brynmawr.edu/biology/b103/f00/web2/donimirski2.html.Retrieved on October 23rd 2013. 50Sumpter C and Torondel B (2013). A systematic review of the health and social effects of menstrual hygiene management, PLOS One, 8(4): 1-15. 51UNAIDS, UNFPA and UNIFEM (2004).Women and HIV/AIDS: Confronting the Crisis, Joint Report on the Global AIDS Epidemic. 52Shanbhag D, Shilpa R, D’Souza N, Josephine P, Singh J and Goud R (2012). Perceptions regarding menstruation and Practices during menstrual cycles among high school going adolescent girls in resource limited settings around Bangalore city, Karnataka, India. 53Callister, Lynn Clark, \Always Stay in School," Journal of Maternal Child Nursing, May/June 2008. 17 | P a g e

Commissioner for Refugees, UNHCR55 who have recently distributed sanitary pads in the fragile states of Lake state and Jonglei.

However, some of the critical issues that arise in regard to current interventions are; 1) what is the actual short and long-term impact of these interventions to girls’ attendance and performance in school? 2) How sustainable are these interventions? 3) Have the traditional beliefs and practices that surround MHM been addressed? And 4) have all the relevant stakeholders been involved in forging a way forward for sustainability and creation of a conducive learning environment for girls in schools.

54http://plan-international.org/where-we-work/africa/south-sudan/what-we-do/our-successes/adolescent-girls-benefit-from-menstrual- hygiene-tips/ 55http://www.sca.com/en/Media/News-features/2014/SCA-help-refugee-girls-in-South-Sudan-to-stay-in-school/ 18 | P a g e

2.0 CHAPTER TWO: METHODOLOGICAL APPROACH

2.1 Scope and Coverage of the Study:

The Menstrual Hygiene Management and WASH Baseline Survey (2014) was carried out in 49 primary and secondary schools in Eastern Equatoria State, South Sudan in the counties of; Torit, Magwe, Lopa-lafon, Kapoeta East, Kapoeta South and Ikwotos in May 2014.

2.2 Study design:

This was a descriptive cross-sectional study in which quantitative and qualitative methods were applied. Self-administered structured close-ended questionnaire survey, Observation (inspection visits), Observation Checklist (quantitative), Focus Group Discussions (FGD) and semi- structured in-depth interviews (qualitative) were applied to collect the information. All these tools were pre-tested at Torit East Primary School and revised accordingly before they were used for the study population. All the tools were prepared in English however, during FGD and semi- structured in-depth interviews they were translated to relevant local languages.

In each of the schools (primary and secondary), two sets of questionnaires were used in the study. The Head teachers/teacher questionnaire was the main questionnaire and collected information on availability of a conducive learning environment in schools with focus on girls. The second set of the questionnaire was administered to only girls and was used to collect detailed information on Menstrual Hygiene Management in schools, homes and communities.

In addition, 2 focus group meetings, 2 key Informant Interviews and one observation checklist were used in each school.

The respondents for the Focus Group Discussions included pupil/students both boys and girls in the respective schools including parents both male and female with whom discussions were separately held with. The Key Informant Interviews questionnaires were on the other hand administered to opinion leaders especially chiefs and women leaders from surrounding communities of the schools

2.3 Sampling Techniques:

The schools were selected by the state Ministry of Education, Youth and Sports officials using stratified random sampling technique in the six counties of Eastern Equatoria State for this purpose. The sample population included girls, boys, parents (male and female), local leaders, head teachers, senior women teachers and other teachers.

Stratified random technique was employed in the selection of girls from the age of 11 and above studying in all grades at both primary and secondary schools. Only girls who were staying in the nearby homes surrounding the school and were willing to participate in the study were included. Convenient sampling technique was used in the selection of boys for the FGD as well as their willingness to be involved in the study.

Purposive sampling technique was used in the section of head teachers and teachers while convenience and snow ball sampling methods were employed to select parents (male and

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female), community/local leaders depending on availability willingness and readiness to participate in the study.

2.4 Sample size of respondents:

A total of 1,800 respondents were targeted in the baseline assessment. Out of these, 1280 respondents were successfully interviewed, yielding a response rate of 71.1% Percent. Refer to appendix

2.5 Data collection:

Data collection was carried out at the school site with prior communication (written) and due verbal consent from respective head of schools. Voluntary willingness from the respondents to participate in the study was also sought before they were requested to fill the questionnaires and engage in FGDs and were allowed to enquire any clarifications from the research team.

Different FGD’s were conducted in each of the 49 schools with both parents and pupils/students who were selected out of the respondents with the help of teachers. The pupils/students and parents were asked open-ended questions and the moderator included probes and follow-up questions. To make the respondents feel at ease and express freely, male and female pupils were separated during FGD. On the other hand, in FGDs with parents, relevant local language was used in communication. A closed ended questionnaire was administered to both head of school and senior woman teacher or any other available female teacher at the school at the time of data collection in each of the 49 schools.

Observation (inspection visits) was done by the research team using pre-designed checklist guide by visiting into relevant school areas that are related to menstrual hygiene management and WASH. These areas included latrines, staff latrines, school water source facilities, dormitories (for boarding), Classrooms, staff room/office and in some school special room used to attend menstrual emergency need was visited if found available.

2.6 Ethical considerations:

Rights, anonymity and confidentiality of the respondents were respected in all phases of the study. Informed verbal consent with the respective head of school and the respondents were taken before data collection. Through verbal consent process, the type and purpose of the survey, discussion or interview; issues of anonymity and confidentiality; voluntary participation and freedom to discontinue the interview/discussion at any stage; and absence of any known risk or benefit for participating in the study was explained beforehand. Photos were made with due verbal permission from the respondents. To preserve anonymity, all findings are presented without ascribing names or identifiable personal description.

2.7 Data Analysis:

Quantitative data from the survey was captured analysed using SPSS software. Descriptive statistics were generated to show the socio-demographic characteristics as well as the

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distribution of knowledge and practices regarding menstrual hygiene and management using frequencies, crosstabs, tables and graphs. Cross-tabulation was run to see the association between some socio-demographic variables with knowledge or practice variables. A Pearson product moment correlation was run to establish the relationship between menstruation and missing school

Data from FGDs and in-depth interviews was captured during the discussions and processed manually based on recurrent themes and patterns.

2.8 Challenges, Limitations to consultations:

 Negative perception of respondents about NGOs on the basis that many NGOs go and collect information about them but they completely never get back  Mobilization of participants was not adequately done by the concerned officials and this resulted into delays and affecting meeting of some respondents and this affected the response rate  Accessibility of some schools in the study was challenging due to the bad nature of roads and rain  Communication in some areas was also a huge challenge and this affected coordination efforts.  Language was also a challenge as respondents had a series of diverse languages. However, translators had to be involved at certain points of the study

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3.0 CHAPTER THREE: PRESENTATION OF FINDINGS AND DISCUSSION

3.1 Introduction:

The findings obtained through different methods and tools used in the study have been organized and presented in this section under three main themes arising from the quantitative and qualitative data. The main themes are: Enrolment, Menstrual Hygiene Management and WASH.

3.2 Education:

3.2.1 Average enrolment in primary and secondary schools Figure 2.Average enrolment in primary schools Figure 3. Average enrolment in secondary

Figure.2 and 3 above show the average enrolment figures per class in primary and secondary schools and the following are explanations.

1. Enrolment for boys is greater than that of girls in all classes and at all levels of education. 2. The average enrolment for boys in primary one is 58 in primary two, and 46 in primary three while that of girls is 48 in primary one, 42 in primary two, and 43 in primary three. This therefore means that the enrolment of both boys and girls in lower classes is relatively the same. 3. The average enrolment for boys in primary eight is 30 in primary seven, and 36 in primary six while that of girls at primary eight is 19, 25 in primary seven, and 26 in primary six. There is therefore a large discrepancy between girls and boys enrolment at upper classes of primary with some schools completely lacking girls in class eight, seven and six. This same trend is being observed in secondary schools with most schools 22 | P a g e

having one or no girls at all in some classes or “---Some parents come here to having a total enrolment of at most 10 girls in school forcefully with guns and school. pick their daughters for marriage The underlying reasons for this low figure on girls ---”. Head Teacher, Primary School, Kapoeta East County enrolment in upper classes and secondary schools is that in the cultures of the communities girls are generally viewed at a major source of wealth and as such immediately the girl grows up to the age of 9 -12 years, she is picked out of school for marriage.

“Some parents bring their daughters to school only when they are still young because they want them to feed well and grow up very fast. Immediately she grows up and fattens, they come and pick them for marriage. That’s why the WFP in schools has been very successful in attracting Toposagirls to school”. Head Teacher, Primary School, Kapoeta East County

Discussions with parents revealed that early pregnancies among girls in upper “Some teachers get into relationships with girls and classes of primary affect their end up impregnating them and that will prevent transitioning in secondary schools. them from going to secondary if she gets pregnant at Parents in Magwi County where primary”. ----Female parent, Magwi Central P/s particularly concerned withthe rate at Magwi County which girls were being impregnated at school especially by teachers thus limiting their chances of joining secondary school

3.2.2 Total enrolment of pupils in selected schools per county

Table 1: Showing total enrolment of pupils in primary schools

COUNT IKWOTOS KAPOETA KAPOETA LOPA- MAGWI TORIT Y EAST SOUTH LAFON CLASS Girl Boy Girl Boys Girl Boy Girl Boy Girl Boy Girls Boys s s s s s s s s s P.1 348 366 212 176 489 707 616 677 332 419 526 499 P.2 240 299 214 179 573 633 350 454 361 357 437 473 P.3 206 256 180 164 569 630 255 327 407 394 522 541 P.4 220 287 148 152 721 893 176 221 565 604 484 531 P.5 192 219 72 142 604 822 111 176 527 496 407 440 P.6 153 235 56 125 435 577 101 161 358 389 327 662 P.7 110 214 20 48 308 403 75 137 265 340 286 375 P.8 90 174 12 54 200 309 46 110 145 287 212 329

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From table 1 above, it can be deduced that Kapoeta East County and Lopa-lafon have the lowest number of girls in primary eight at only 12 and 46 respectively. Magwi and Torit Counties on the other hand had the highest enrolment rates of both boys and girls totalling to 145 and 212 for girls respectively. This could be due to the fact that in Kapoeta East, Lopa-lafon most schools are in rural areas where issues of early forced marriages are reported to be rampant. On the other hand, Magwi, Torit and Kapoeta South had most of the schools visited within town areas where parents value education of girls as a result of being exposed to other countries like Uganda and Kenya.

Findings further exposed that there are only 705 girls enrolled in primary eight compared to 1,263 boys meaning that there is one girl in every six boys in primary eight.

3.2.3 Enrolment age of girls in primary school

Figure 4; Showing the maximum and minimum age of girls per class

The figure 4above presents that the minimum age at which girls enrol for primary One is 11 years and the maximum age being 14 years, while the minimum age of children in class eight is 14 years with a maximum age of 24 years. This finding therefore reveals that the age at which girls are in primary level is over and above the required age of being in primary of between 13 and 14 years. It’s therefore worth noting that children across all schools in Eastern Equatorial State girls generally delay to enrol in primary school and this affects their ability to complete a primary schooling level. This analysis was further reaffirmed during FGDs where a male parent from Pageri in Magwi County was quoted saying, “most of our girls are old to be in primary, and most of them even know it --- some of their parents will definitely marry them off”

This Finding is in agreement with EMIS data (2011) revealing that over-age children make up 85% of all primary school enrolees, and 90% in secondary school and this has a negative effect on

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completion rates56. The average recommended age range for completion of primary cycle in South Sudan is estimated at 14 years and Secondary 18. The Net Enrolment Rate for at-age children (below 14 years) in the primary system is only 42.9%57 implying that 57.1% of children in primary schooling are over age.

The enrolment age of the children in this assessment shows that more than half of the children are over aged (over 14 years, the recommended age of being in primary with the context of South Sudan)

3.2.4 Teachers:

Across all the schools visited, the number of male teachers compared to female teachers was observed and reported to be higher. Some schools did not even have a female teacher and this was noted to greatly affect management of menstrual hygiene in those schools. Though some schools had female teachers, the majority were untrained and also very few numbering about two per school. The assessment noted that the male teachers either trained or untrained were completely ignorant on menstrual hygiene management issues and had no clue on how it affects girls and learning. This observation calls for concerted efforts to capacitate teachers on issues WASH and menstrual hygiene.

56EMIS Data 2011 57 EMIS Data 2011 25 | P a g e

Figure 5: Primary School girls of Lofus Primary school, Ikwoto County during focus group discussions

Table 2; Number of trained and untrained teachers by gender

Primary Secondary Minimum Maximum Average Minimum Maximum Average Male trained staff 0 13 5 0 22 8 Female trained staff 0 2 2 0 5 2 Male untrained staff 1 9 8 0 10 6 Female untrained staff 0 6 2 0 2 1

3.2.5 Reasons for dropping out of school Fifty two percent ( 52.9%) of head teachers and teachers cited early and forced “One of the parents impregnated some girl in the marriages as a major contributing factor to village…; he forced his 17 year old Primary Six girls dropping out of school. Twenty two daughter studying in this school to get married so (22.4%) identified early unwanted that he pays off the cows his in laws wanted”. Head Teacher, Primary School, Kapoeta South pregnancies while 16.5% cited lack of parental care as other major factors contributing to school dropout.

The reason for early forced marriages by parents was cited in FGDs and it came out very clearly that girls are generally viewed as a source of wealth and as such all measures should be done to protect her.

Only 3.5% teachers identified menstruation as one the contributing factors to girls dropping out of school while poor performance in school and poverty was cited by 3.5% and 2.4% of the teachers respectively.

Table 3; Showing reasons why girls drop out of school

Reasons for dropping out Frequency Percentage Early and forced marriage 45 52.9 Pregnancy 19 22.4 Lack of parental care 14 16.5 Lack of school fees 11 12.9 Cultural belief of girls not going to school 7 8.2 Menstruation periods 3 3.5 Poor performance 3 3.5 Poverty 2 2.4 Too much domestic work 1 1.2

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Other factors identified during the FGDs for girls dropping out of school included; lack of awareness among parents on the value education and therefore the do not adequately provide for girls in school, lack of appropriate guidance and counselling about education from both teachers and parents, teachers using in appropriate child friendly teaching techniques like abusive language, and a heavy reliance on parents on girls on domestic issues.

The findings of this assessment relate with the findings of UNICEF (2008) which cited that girls’ lack of access to educational opportunity has been exacerbated by certain cultural practices as well as widespread insecurity and conflict. The report shows that poverty, insecurity, early marriage and pregnancy have been identified across the States as key causes of drop out from schools58. Morrison (2010) further builds on this argument by stating that ‘each percentage point increase in poverty reduces a girl’s chance of being enrolled at “… if I have four girls, I send one to school and keep three at a primary school by 0.3 home so that I may also get something” (something meaning cows). Local Chief, Kapoeta South County percentage point’59.

The cultural norms that give girls not a chance of going to school is common in many communities. This assessment supports similar findings by DIFD (2012) who showed that a cattle culture and economy is predominant in South Sudan and in many communities women are viewed as a household resource, commonly valued by the number of cows they would bring as dowry; and as a tool for domestic chores60. These social views and the economic realities that underpin them result in further barriers for girls’ education. Communities fear that girls will be ‘spoilt’ by going to school, mixing with boys and men un-chaperoned, and that educated girls’ will not respect their men folk and thus their future husbands and therefore they will be harder to marry off61. In relation to this view, the PTA chairperson at one of the primary schools in Torit County is quoted saying “People here value cattle so much that they can give away their daughter even at a young age just to get cows. So they will not take the girl to school but instead marry her off”.

“In our culture, if a girl gets married, someone can pay something like 70 cows, the brothers, uncles and unties are also given a share. So if your daughter is still in school, they tell you “you prefer sending your girls to school and yet you enjoy receiving the cows of our daughters, so when shall we enjoy yours also?” Female Parent, Kapoeta South County

Another parent is quoted saying “when you take a girl to school, she will end up “Parents do not budget for their girls. The girls are neglected and in the end they just drop out of school” learning a bad culture and forget about our culture, this girls become prostitutes, and ---PTA Chairperson, Primary School, Torit County they lose respect for others. We do not

58Unicef, 2008. A Study on Socio-economic and Cultural Barriers to Schooling in South Sudan

59 Michael Morris, 2010. Analysis of Provincial Education Statistics of South Sudan. Un published. DFID Sudan 2010 60 DFID, Business Case for the Girls Education South Sudan (GESS) Programme, December 2012 61DFID, Business Case for the Girls Education South Sudan (GESS) Programme, December 2012 27 | P a g e

want our culture to be distorted by this girls moving away from the community in the name of education”…..male parent, Hiyala, Torit county

“… Our problem is that our

Senior Woman Teacher does not talk to us, we need her to talk to us on this issues of MHM” ---Female Pupil, AIC Primary School, Ikwoto County

3.3 MENSTRUAL HYGIENE MANAGEMENT

3.3.1 Knowledge on menstruation:

The assessment revealed that on average 69.9% of the respondents felt that old women do not menstruate, 28.4% claimed that menstruation is a disease with Lopa-Lafon having 62.9% of its respondents asserting this claim. 19.2% of respondents said that pregnant women menstruate, while 63.7% agreed that menstrual blood comes from the uterus/womb. 48.7% of the respondents claimed that menstrual blood is harmful to the body with Lopa-Lafon having the highest claims at 82.3% followed by Kapoeta South at 62.7%. On the other hand, 59.9% of the respondents argued that “But where did this painful thing called menstruation come from pain during menstruation and for what reason? Female pupil, Primary School, Kapoeta East means that someone is County unhealthy with Lopa-Lafon having the highest claims at 80.6% followed by Kapoeta South at 70.6% and Torit at 64.4%. When asked on whether women are dirty during menstruation periods, 74.2% of the respondents from Lopa-Lafon agreed with this assertion followed by 65.8% from Torit and 62.7% from Kapoeta South.

Overall, 86.1% of the respondents agreed that menstruation is something that is normal and natural as indicated in the table 4 below.

The underlying reason for lack of knowledge is that pupils/students are not adequately provided with information if any when growing up. Information is either got from peers and by first time experience without an preparation and hence it creates a sudden shock.

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Table 4; Showing perception of pupils/students on menstruation

P Perception on Menstruation COUNTY Ikwoto Kapoeta Kapoeta Lopa- Magwi Torit Average % East % South % Lafon % % % % Old women do not menstruate 64.6 62.1 92.2 56.5 69.9 70.1 69.9 Menstruation is a disease 17.2 18.2 21.6 62.9 20.7 32.9 28.4 Pregnant women menstruate 28.1 20.0 13.7 11.3 16.3 24.7 19.2 Menstrual blood comes from the 66.2 61.5 70.6 74.2 46.7 71.2 63.7 uterus/womb Menstrual blood is harmful to the body 43.1 37.9 62.7 82.3 40.2 35.6 48.7 Pain during menstruation means that 49.2 47 70.6 80.6 53.3 64.4 59.9 someone is unhealthy Women are dirty during menstruation 50.8 50 62.7 74.2 50 65.8 58.2 Menstruation is normal and natural 66.2 84.8 88.2 96.8 89.1 90.4 86.1

It is evident from the results of this assessment that girls are less informed about menstruation and this is in line with Shannon et al (2011) argument that young girls in developing countries often receive minimal instruction on menstrual hygiene management62.There is therefore an urgent need to provide girls before and during adolescence with adequate information on puberty and practical ways of managing menstruation in a hygienic and discrete way.

“The issue of menstruation is not meant for men, women are the one who face it and therefore they are the best people who can deal with it and even help girls” -- Male Parent, Kerepi, Magwi County

” ---Female Pupil, AIC Primary School, Ikwoto County

3.3.2 Information on Menstrual Hygiene Management:

62Shannon A, Peter J, Bethany A, Alfredo F, Emily A, Imelda A and Richard D (2011). The girl with her period is the one to hang her head. Reflections on menstrual management schoolgirls in rural Kenya, BMC International Health and Human Rights Journal, 11(7): 689-698 29 | P a g e

Assessment findings revealed that 22% of the girls from Lopa-Lafon County had never heard information on how to care for themselves during menstrual periods followed by Ikwoto County at 20% and Kapoeta South at 19%. Torit County had the highest number of girls (98%) who have ever heard information on how to care for themselves during menstrual periods and this could have been influenced by the fact that being a relatively urban town, parents are generally literate and as such are able to offer advice on MHM in addition to availability of various media platforms including radios, TVs, and newspapers.

Figure 6; Percentage of girls that have ever heard information on menstrual hygiene care

3.3.3 Source of information on Menstrual Hygiene Management: The results showed that mothers were the major source of information on Menstrual Hygiene Management at 83.4%, followed by sisters at 82.3% and friends at 71.8%. Fathers on the other hand were the least identified as source of information used by girls on issues of MHM. It was established that issues of menstruation are generally a big secret and that men are not “What assistance do you need from your supposed to know it and it’s the sole father or mother for you to defecate? --- responsibility of women to provide such that’s how menstruation is --- it’s something information to girls at all circumstances. normal” Local Chief, Kapoeta South County

In fact other parents both men and women in the communities of Kapoeta South and Kapoeta East asserted in the FGDs that there was completely no need of providing MHM information to

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girls as they compared it to defecating as something that is normal and natural. It was noted that 64.6% of the girls had ever heard information on how to care for themselves during menstrual periods from School Health Clubs as shown in table 5 below though some schools did not have School Health Clubs.

Girls only feel free to discuss with the mothers and the elder sisters. The men do not even get to know sometimes if his daughter or wife is menstruating. In our culture, we men are not even supposed to talk about menstruation---Male Parent, Pageri p/s, Magwi County

Table 5; Showing sources of information on MHM:

Source of information Frequency Percentage Mother 322 83.4 Father 62 16 Sister 318 82.2 Relative 202 52.3 Teacher 216 56 Friend 278 71.8 Books/newspaper 167 43.2 Radio 141 36.4 Community leader 116 30 NGO representative 195 50.4 School health club 250 64.6

3.3.4 Materials used during Menstruation:

The materials used by many girls’ during menstruation were found to be highly diverse and varied from county to county. 23.3% of girls from Ikwoto County use pieces of mattress, 21.6% and 24.3% of girls from Kapoeta East and South dig holes on the ground respectively, while 20.8% of girls from Lopa-Lafon use natural materials like leaves and skins of animals especially goats. In Torit and Magwi Counties, 21.6% and 21.9% of the girls respectively use purchased sanitary pads like Always with 26.2% and 12.9% relying on pieces of cloth especially rags.

Unbelievably, 42.9% of the girls from Ikwoto County and 22.2% from Kapoeta East completely use nothing and this view was shared by some “For us here we don’t care… we don’t use anything, parents during FGDs. even if it comes (periods) when you are walking, you just continue, for there is no problem”. FGD female parents, Kapoeta South County

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Table 6; Showing materials and approaches used during menstruation:

Material used COUNTY Ikwoto Kapoeta Kapoeta Lopa-Lafon Magwi Torit % East South % % % % % Cloth 15.2 12.5 15.2 17.9 26.2 12.9 Purchased sanitary pads 9.2 17 11.4 19 21.9 21.6 Toilet paper 20 8.2 12.9 30.6 18.8 9.4 Cotton 17 12.5 11.5 21 24 14 Pieces of mattress 23.3 7.8 9.7 26.2 23.3 9.7 Natural materials 20.8 25 12.5 20.8 4.2 16.7 (leaves,tree back) Digging a hole 18.9 21.6 24.3 8.1 24.3 2.7 Ash or sand 16.7 16.7 10.4 29.2 18.8 8.3 I use nothing 42.9 22.2 11.1 11.1 7.9 4.8

Focus group Discussions with girls and parents revealed a number of approaches and methods used by girls and women during menstruation periods including among others; 1) Making sanitary pads using goats skin and oil, 2) Doubling underwear’s or skirts, 3) use of backcloth, 4) Traditional herbs like “bene” which is popular among the Lotuko tribe and is used for controlling blood flow.

3.3.5 Use of sanitary pads in the last 3 months When asked on whether they had used sanitary pads like always in the last 3 months, 71% of girls from Lopa-lafon acknowledged not to have used them completely, with Kapoeta South at 70.6%, Ikwoto at 67.7%, 65.2% from Magwi, 54.5% from Kapoeta East and only 43.8% of girls from Torit had not used a sanitary pad.

Figure 7; showing whether girls had used sanitary pads in the last 3 months:

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3.3.6 Reasons for not using sanitary pads:

Seventy two (72%) of respondents in secondary schools and 68% from primary schools said they did not have money for buying sanitary pads, 27% from primary acknowledged that sanitary pads were generally not available in their areas, 12% was comfortable with local materials while 10% were not comfortable with use of sanitary pads. The study further revealed that 9.8% of respondents in primary schools do not completely what know what sanitary pads are and have never seen or touched them.

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Figure 8; Showing reasons for not using pads in the last 3 months:

3.3.7 Usage of Knickers/underwear:

Being a crucial factor in management of menstrual hygiene, surprising 42.7% of all respondent do not put on underwear. Overall, Lopa-lafon “Women here are not allowed to put on had the highest rates of girls not wearing underwear estimated at 90%. knickers…..” This was closely followed by Magwi at 64% while 59%, 57% and 51% of girls from Kapoeta East, Ikwoto and Kapeta South never put on Local Chief, Kopeata underwear. The underlying reasons for this trend included; cultural East County beliefs against wearing knickers, un

“A woman can only be affordability, and some girls are generally comfortable moving allowed to put on freely without underwear. knickers when her husband has died”. However, in Torit County 72% of girls were found to be wearing Local Chief, Kopeata underwear and this could have been influenced by the fact that it’s East County an urban town.

The assessment further revealed that even at secondary school level, 53.5% of female students do notLocal put Chief,on knickers Kopeata despite their advancement in education level attainment. East County

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Figure 9; Showing percentage of girls who put on knickers

3.3.8 How boys react to girls during menstrual periods

The assessment revealed that, 52.6% of boys laugh at girls during their menstrual periods and 35.2% abuse them. 26.4% of the girls however reported being approached for love and sex since they have a high attraction to the opposite sex during that time. Boys however refuted the assertion of laughing at girls during FGDs on grounds they even do not when girls experience their periods since they secretly protect themselves.

Figure 10: Showing how girls are treated by boys during menstrual periods:

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3.3.9 How the community treats girls during menstrual periods

In the assessment, 52% of the girls cited being restricted from movement by the community during their menstrual periods, 25% on the other cited said that cleansing and rituals are usually performed while 23% identified being seen as unclean by the community.

Figure 11; how girls are treated by the community during menstruation

The head teachers and senior women teachers and teachers in schools however identified the following beliefs and perceptions surrounding menstruation in their communities.

Table 7; Showing perceptions and beliefs associated with menstruation

Perceptions and beliefs associated with menstruation

If a witch comes across your sanitary materials, she will make you barren Isolation of menstruating girls from peer groups Ladies are not supposed to use the latrine during their menstrual periods Menstruation should be kept a secret Menstruation shows maturity and therefore ready for marriage No bathing in the river during menstruation because they will lose their womb No bathing till the flow is over Performing rituals if the girl is experiencing her first periods by grand mothers Women are not allowed to sit amongst men during menstruation Women are not supposed to visit a certain big tree

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3.3.10 Channels of ensuring availability of sanitary materials

The assessment established, School “… the best way of ensuring that all women and Health Clubs and Senior Women girls get sanitary pads is by using women groups Teachers were identified as the main and senior women teachers in schools and channels through which girls can receive allowing girls collect pads for free on certain sanitary pads and appropriate education particulars days of the month and we women on MHM in all Counties as shown in the paying at least 3 pounds for each in order to figure below. ensure sustainability”. FGD parents, St. Mathew P/s, Ikwoto County However, during focus group discussions with parents, women groups were also identified as channels through which both girls in school and women can access sanitary pads local type. They argued that if only school girls and Local Chief, Kopeata East County teachers are trained on making pads, they women will not be able to access pads. They therefore proposed all the stakeholders i.e. women, girls and female teachers to be involved in this process.

Figure 12; most accessible channels of ensuring availability of sanitary materials

3.3.11 Menstruation and school attendance:

Findings of the assessment revealed that on average girls miss an average of four (4) days during menstruation periods as shown in the table 8 below. Shocking, some girls reported staying home for up to 8 days and this was attributed to a number of factors like heavy bleeding and parents advising them to completely stay home during periods.

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Table 8; Average number of school days missed by girls during menstruation

Descriptive Statistics N Minimu Maximu Mean Std. m m Deviation Number of school days 277 1 8 3.69 1.401 missed in a month during menstruation Valid N (list wise) 277

3.3.12 Why menstruation makes girls miss school

The opinion of girls on why menstruation makes girls’ miss school was sought and 73.7% of the girls cited lack of sanitary pads as the major hindrance to school attendance. Other issues cited included feeling severe pain at 72.5%, lack of a private changing room in school 56.6%, afraid of being made fun of 43.8%, feeling dirty 43.6%, discomfort due to tiredness 43.6% and not allowed by parents at 21.1% as shown the figure 12 below.

Figure 13; Showing why menstruation makes girls miss school

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Focus group discussions with girls also re- “When these periods come, I feel like dying affirmed that lack of sanitary pads; severe pain because it pains a lot”. Female pupil, and lack of private places in schools were Primary School, Kapoeta East County contributing factors to school attendance.

3.4 WASH:

3.4.1 Presence of changing rooms for girls in school:

Of all schools visited in the study, changing rooms were only observed in Kapoeta East and Kapoeta South and these were mainly girls’ dormitories that were available as changing rooms. In regard to availability of sanitary materials, “When am in school and periods come, I just only 6 schools in the selected 49 were at least go back home and bathe because I can’t bathe providing sanitary kits with only two schools from school”. Female Pupil, Primary School, in Torit and Magwi respectively and one Kapoeta South County school in Ikwoto and Kapoeta East as shown in the table 10 below.

Table 9; Availability of changing room and materials in schools:

Changing room Sanitary Basins/buckets Washrooms next to for girls materials available girls changing room available available available Ikwotos 0 1 0 0 Kapoeta East 1 1 1 1 Kapoeta 1 0 1 1 South Lopa-Lafon 0 0 0 0 Magwi 0 2 2 0 Torit 0 2 2 0

The findings in this assessment relate well to the findings of Ezra et al (2014) who show that a Lack of soap, hand wash facilities, emergency pads and privacy are important determinant for proper practice of menstrual hygiene and school attendance and have been identified as main problems63in many schools in developing countries. Mahon and Fernandes (2010) show, that, MHM is neglected but there is an awareness that the problem exists but few have attempted to address it64 while Devrain and Mathias (2011) state that Inadequate access to WASH impacts significantly on girls’ learning opportunities65

63Ezra Guya, Aloyce W. Mayo, Richard Kimwaga, Menstrual Hygiene Management in Secondary schools in Tanzania, International Journal of Science and Technology, January 2014 64Mahon T, &Fernandes M (2010); Menstrual hygiene in south Asia, a neglected issue for WASH programs, gender &development 18 (1) 99-113 65DevnarainA&Sarkar M (2008); How hygienic is the adolescent girl? Indian Journal of community medicine, 33 (2), 77-80 5 | P a g e

3.4.2 Presence of Latrines:

Observation was made on the availability of latrines in schools visited during the assessment and the findings revealed that, 1 school in Ikwoto County, 2 in Kapoeta East, 1 in Kapoeta South, 3 in Lopa-Lafon and 1 in Torit completely lacked school latrines. A cross examination of the whether there were separate latrines maintained for girls, boys and teachers also revealed that 2 schools in Ikwoto, 3 in Kapoeta East, Kapoeta South, Lopa-Lafon and 1 in Torit lacked separate latrines for girls, boys and teachers.

On whether the Latrines were in good condition and functional, only 4 in Ikwoto, 3 in kapoeta East, 4 in Kapoeta South, 3 in Lopa-Lafon, 6 in Magwi and 3 in Torit were effectively functioning. In respect to whether the available Latrines are in regular use, only 3 in Ikwoto, 4 in Kapoeta East, 6 in Kapoeta South, 5 in Lopa-Lafon, 9 in Magwi and all the 10 in Torit were regularly used.

Table 10; Showing presence and state of latrines

County School Separate latrines Latrines in good Latrines in Faeces on latrines not for girls, boys and condition and regular use the floor of available teachers functioning the latrine unavailable Ikwotos 1 2 4 3 2 Kapoeta East 2 3 3 4 2 Kapoeta 1 3 4 6 3 South Lopa-Lafon 3 3 3 5 0 Magwi 0 0 6 9 4 Torit 1 1 3 10 5

The findings of UNICEF Esaro(2010) are not different from the findings of this assessment. Studies in Sub-Sahara African (SSA) countries show that the lack of adequate toilet facilities is a common feature in many schools where the child-toilet ratios is on average 1:10066. In this study, more than a quarter of the schools visited in this study do not have separate latrines for girls and boys. This is in agreement with the findings of UNICEF south Sudan (2013) who stated that 17 of percent of schools have adequate sanitary latrines for both girls and boys67 meaning that a greater percentage (83 percent) do not have separate latrines for girls and boys. They further show that even the few 17% that exist in schools have unfriendly environments for girl’s management of menstrual hygiene. This happens in many schools of South Sudan though it has been stressed that school toilets, are built to accommodate menstruating girls’ specific needs for privacy, space, washing facilities and correct disposal or cleaning of menstrual pads68.

66Unicef ESARO, “Impact of puberty and feminine hygiene on girls’ participation in education –Kenya and Malawi”, 2010 67Unicef, South Sudan “ Water, Sanitation and Hygiene”, 2013 68 UNICEF, Raising clean hands: Advancing learning, health and participation through WASH in schools, UNICEF, New York, 2010 6 | P a g e

3.4.3 Presence of water in schools:

The assessment of the 49 schools revealed that generally, most schools had a water source available and functioning with the exception of 1 school in Kapoeta East, 1 in Kapoeta South, 3 in Lopa-Lafon, 1 in Magwi and 1 in Torit. The majority of schools had the water source within the school compound or within 1 km as shown in the table 12 below with the exception of 1 school in Ikwotos, 2 in Kapoeta East, 1 in Kapoeta South, 2 in Lopa-Lafon and 3 in Magwi which had the water source more than 1km from the school.

Table 11; Showing presence and condition of water sources

County Water source Water source Water source Water source Water source available and available and within the within 1km more than not functioning school 1km functioning compound Ikwotos 0 6 2 1 1 Kapoeta 1 6 4 1 2 East Kapoeta 1 6 6 0 1 South Lopa-Lafon 3 5 4 2 2 Magwi 1 5 4 5 3 Torit 1 10 9 1 0

The findings of this assessment in regard to water accessibility are not different from the findings of recent surveys cited by UNICEF South Sudan which show that more than 30 per cent of people in South Sudan do not have access to safe water supplies with only 13 per cent having access to adequate sanitation facilities69

It is further argued that only 45 per cent of South Sudan’s 3,349 basic primary schools have access to safe water70. In this assessment only half of the schools visited have access to water either, being from its own water source or a community water source. The safety of this water varies since different schools and communities have different water sources. The most common water sources available in school are boreholes and water tanks while the communities access water from the boreholes, rivers and unprotected shallow wells. However the environment around most of these water sources was observed to be dirty and some are non-functional. 2 in 8 schools in each county have a non-functional water source. This finding is not far different from the findings of the Ministry of Water Resources and Irrigation (MWRI), UNICEF 2013 showing that 30-50 percent of water facilities are non-functional at any point in time due to the lack of spare part supply chains, weak maintenance capacity, poor management and/or inappropriate choice of technology71. Thus, the actual level of access to an improved water source in rural areas

69Unicef, South Sudan “ Water, Sanitation and Hygiene”, http://www.unicef.org/southsudan/WASH.pdf

70Unicef, South Sudan “ Water, Sanitation and Hygiene”, 2013 71 USAID, Draft Water Sanitation and Hygiene Programme, 2013 7 | P a g e

is estimated to be only 34 percent – which affects most of the country as over 80 percent live in rural areas, representing 90 percent of those living in poverty72.

The findings in the focus group discussion further build on these findings. One of the girls is quoted saying; “I cannot come to school during my menstrual periods because we do not have water at school that I can use to wash my body”….Primary six girl, St.Marys P/S Eboni. While a teacher stated that “sometimes also finds problems when I also experience my periods because there is no water at school. I prefer to remain at home. I cannot help myself at school”….Senior woman teacher, Lohutok girls P/S, Lopa-Lafon county

This is further supportedby findings of this assessment that established that access to water and sanitation is one major reason why girls are kept out of school and improved access to water and sanitation at schools has been shown to increase school attendance among girls73

72 USAID, Draft Water Sanitation and Hygiene Programme, 2013 73 USAID, Draft Water Sanitation and Hygiene Programme, 2013 8 | P a g e

3.5 DISCUSSION OF RESULTS

3.5.1 EDUCATION: Education in South Sudan has been recited as being in the catch-up phase by many scholars and organizations including the World Bank (2012) citing massive enrolments in schools with key challenges being overcrowding and lack of qualified teachers. However adult literacy rates are still low at only 27 per cent with 70% of children aged 6–17 years never setting foot in a classroom and with only 33 per cent of girls in schools74.

The findings of this study however revealed that in Eastern Equatoria state, enrolment of both boys and girls is mainly concentrated at lower classes (P.1 – P.4) with upper classes (P.5 – P.8) having fewer pupils. Detailed analysis of class enrolment by gender revealed that, the number of girls in per classes (P.5 – P.8) including secondary is unbelievably very low with most schools in Kapoeta East, Kapoeta South and Lopa-Lafon having no girls completely in some for these classes. Findings further exposed that there are only 705 girls enrolled in primary eight compared to 1,263 boys meaning that there is one girl in every six boys in primary eight. This results are closely related to the findings of World Bank (2012) that there is one girl in every seven boys and in South Sudan there are , only five hundred (500) girls in the last grade of secondary school (Senior four) and only one in four girls enrols in primary school and a mere one in ten completes primary education.75

The low level of enrolment of girls in upper classes of primary including secondary has largely been attributed to early forced marriages and pregnancies. It’s dreadful to note that in South Sudan, girls are regarded as a major source of wealth in many tribes who can raise as many as 50 – 200 cows upon marriage equivalent to approximately $ 23,584 – $94,200 perhaps one the highest dowry rates in the whole world in the 21st century.

Despite some communities slowly becoming aware of the benefits of education both girls and boys to school completion, a lot of community awareness campaigns on value of education still need to reemphasized coupled with appropriate policing on issues of child early marriage.

Availability of trained teachers in schools was also revealed by the study as some the major challenges surrounding education. All most all schools visited had at least 1 untrained teacher with the number of untrained teachers surpassing the trained once with the exception of secondary schools. Male teachers in all schools were the majority in both primary and secondary with some schools completely lacking a female teacher. The level of knowledge on MHM among teachers and support extended to girls during menstrual periods was found to be very low and non-existing in some case. It’s therefore not surprising that, 62.9% of girls in one Lopa-Lafon cited menstruation as being a disease and 59.9% citing pain during menstrual periods meaning that someone is unhealthy.

Measures should

74Unicef South Sudan, Basic Education and Gender Equality, http://www.unicef.org/southsudan/Education.pdf 75World Bank, Education in the Republic of South Sudan – Status and Challenges for a New System , 2012 9 | P a g e

The low level of enrolment of girls in the upper classes that was revealed in the study is in agreement with DFID, GESS programme (2012) that shows demand for education in South Sudan far outstrips supply with few children and youth able to complete the full primary cycle – let alone go on to complete secondary and post-secondary studies76.

The drop out of girls could also be attributed to the age at which they enrol for primary. Findings in the study reveal that the average age of girls in primary stands at 16 years with most of the girls of this age being in primary five. Figure 3.xx below shows the minimum and maximum age of pupils per class in the schools reached in this study

3.5.2 MENSTRUAL HYGIENE MANAGEMENT:

Despite the fact that many developing countries have a number of challenges in management of menstrual hygiene in schools as identified by many scholars, according to the findings of this study, South Sudan has one of the worst menstrual hygiene management approaches in the whole world. The study findings reveal that girls in school, both primary and secondary level are ill informed on what menstruation is about. 62.9% of girls in one of the Counties (Lopa- Lafon) cited menstruation as being a disease an assertion that is completely very wrong. 59.9% of the 842 girls involved in the study also claimed that pain during menstrual periods means that someone is unhealthy.

In one of the focus group discussions, a Primary eight girl was quoted asking, “… but where this painful thing did called menstruation come from and for what reason?” This therefore implies that girls in general receive minimum or no instruction in school or at homes on issues of puberty and menstrual hygiene management.

These study findings are in agreement with Shannon el at (2012) argument that girls in many developing countries often receive minimal instruction on menstrual hygiene management because menstruation is seen as taboo by many communities, which makes it extremely difficult for adolescent girls to acquire necessary information and support from parents and school teachers77.

Study findings revealed that Fathers were the most unsought source of information on menstrual hygiene and issues of menstruation are generally regarded as a big secret in their culture and men are not completely supposed to know anything about it and it’s the sole responsibility of women to provide such information to girls since men do not menstruate.

There is therefore an urgent need of ensuring that girls in school receive relevant and adequate knowledge on puberty as well menstrual hygiene management from all existing possible channels including teachers (both male and female), school health clubs as well as parents.

76DFID, Business Case for the Girls Education South Sudan (GESS) Programme, December 2012 77Shannon A, Peter J, Bethany A, Alfredo F, Emily A, Imelda A and Richard D (2011). The girl with her period is the one to hang her head. Reflections on menstrual management schoolgirls in rural Kenya, BMC International Health and Human Rights Journal, 11(7): 689-698 10 | P a g e

Based on these findings, it’s therefore not surprising that 20% of girls had never heard any information on how to care for themselves during menstrual periods. 80% of those who had hoverer heard also relied heavily on friends, sisters and mothers who are also inadequately informed about puberty and menstrual hygiene management. It was shocking to hear during focus group discussions with the parents that some women do not completely use anything, for they just let the menstrual blood flow and they continue with their work as it will eventually dry. This kind of act exists in the community because menstruation is regarded as something normal and compared it to defecating as thus girls in school do not need any support or guidance on menstruation. This claim was further reaffirmed by 42.9% of the girls from Ikwoto County and 22.2% from Kapoeta East who asserted that during their menstruation periods, they completely use nothing.

The materials and approaches used by many girls and women for menstrual hygiene management in Eastern Equatoria state, South Sudan were found to highly diverse, traditional, unhealthy and perhaps the worst in the whole world.

In the 21st century, some women and school going girls in South Sudan still use goat’s skin, bark cloth, soil, digging holes on the ground, leaves of trees and traditional herbs like “bene” popular among the Lotuko tribe used for controlling blood flow because even a mere piece of cloth or rag can be extremely very difficult to find in some villages. Despite scholars like Doinimirski (2013)78 and Sumpter&Torondel (2013)79 citing use of materials like pieces of cloth/rags as being unhealthy and can result into serious health complications, little is yet known on the level of health complications that women and girls in South Sudan are exposed as a result of using such traditional menstrual hygiene methods.

However, taking on averages, findings revealed that 12.9% of respondents use cloths/rags, only 21.6% use sanitary pads influenced by the over 15 schools visited in the study were urban, 16.7% use natural materials like leaves, 9.7% use pieces of mattress and 4.8% completely use nothing.

Accessibility and affordability of modern sanitary pads like Always is a huge challenge to many to many girls in school. When asked on whether they had used sanitary pads like always in the last 3 months, 71% of girls from Lopa-lafon asserted having not used them completely, closely followed by from Kapoeta South at 70.6%, Ikwoto at 67.7%, 65.2% from Magwi, 54.5% from Kapoeta East and only 43.8% of girls from Torit had not used a sanitary pad. The reasons for this trend was that pads are generally expensive and unavailable with some girls reporting to be comfortable with current materials like cloth and skin while 9.8% of the girls had completely never heard or seen a sanitary pad.

Use of knickers/underwear among school going girls in both primary and secondary schools in Eastern Equatoria state, South Sudan is generally very low and probably the worst in Africa. 42.7% of the 410 of 842 girls involved in the study do not wear underwear, and this is greatly

78 Donimirski, M (2013). Health Effects of Menstruation and Birth Control Pills http://serendip.brynmawr.edu/biology/b103/f00/web2/donimirski2.html.Retrieved on October 23rd 2013. 79 79Sumpter C and Torondel B (2013). A systematic review of the health and social effects of menstrual hygiene management, PLOS One 11 | P a g e

attributed to the cultural factors surrounding underwear among the tribes like the Toposa. Women are by culture not allowed to wear underwear whether educated or not and it’s believed that if a woman wore underwear, her husband would die. She is therefore only allowed to put on underwear when her husband has died. This cultural factor surrounding wearing underwear needs to be strongly addressed by any actor intending to implement MHM project in Toposa and Lotoku tribe.

52.6% of Girls in the study complained being laughed at and 35.2% reported being abused by boys in school during their menstrual periods. This happens in addition to a number of beliefs and perceptions surrounding women and girls in menstruation including; girls and women are unclean during menstruation, if a witch comes across your sanitary materials, she will make you barren, performance of rituals to a menstruating woman or girl, and Women are not allowed to sit amongst men during menstruation among others.

This has therefore contributed to low school attendance during menstrual periods with girls missing up to four days in a month. This findings are in agreement with World Bank (2005) argument that girls miss up to 4 days80 and SNV Uganda Menstrual Hygiene Management (MHM) survey conducted in 120 schools across six Districts that indicated that girls are more likely to remain at home from school during their period due to a lack of facilities for and embarrassment about menstrual hygiene81.

However, we tested relationship between menstruation and missing school, in order to establish if a statistically significant relationship existed between girls’ menstruation and missing school during their menstruation. The hypothesis was; “There is no significant relationship between girls’ menstruation and their missing school at 0.05 level of significance”

The results revealed that a correlation coefficient of r = 0.092 and p = 0.063 using Pearson Product Moment Correlation Coefficient. This correlation shows a positive weak and statistically non-significant relationship between menstruation and missing school due to menstruations meaning that the relationship between the two variables was not by chance, however not entirely conclusive on menstruation.

It was therefore found that menstruation contributes only contributed only 1% to their missing school. This implies that the other 99% is being contributed by other factors that need to be established

School Health Clubs and Senior Women Teachers were identified as channels through which girls can receive sanitary pads and appropriate education on MHM in all Counties of the study. However, parents especially women proposed inclusion of women groups or mothers in the supply chain since they are in close contact with the girls and as means of forging sustainability strategies.

80 World Bank, “Toolkit on Hygiene Sanitation & Water in Schools: Gender Roles and Impact," 2005 81 SNV Uganda, Keeping girls in school with improved menstrual hygiene management, June 2013 12 | P a g e

4.0 CHAPTER FOUR RECOMMENDATIONS AND CONCLUSIONS

4.1 RECOMMENDATIONS:

4.1.1 Menstrual Hygiene Management:

1. Teachers, especially male, should be capacitated on MHM issues and adolescence education so as to empower them in supporting pupils when needed. 2. Massive community awareness campaigns need to be undertaken on;  Role of parents both male and female in MHM issues  Breaking barriers, practices and taboos surrounding MHM like no wearing underwear’s for women and performance of rituals 3. Efficient and cost effective methods of making re-usable sanitary pads need to be explored with due consideration on design, availability of materials, cultural diversity and acceptability of each state. Pre-testing of sample sanitary materials in each state need to be undertaken in order to further assess absorptive ability, comfort, cost and sustainability.

4. Support for the availability of sanitary pads should be done with consideration that girls would inevitably need proper underwear to secure the pad in place and that for some families may not afford to buy girls any/adequate underwear as 42.7% do not put on underwear. Sanitary Pads that double as underwear should therefore be explored if success is to be realised.

5. Training of girls on puberty, menstrual hygiene management, personal hygiene in all schools needs to under-taken with due consideration on girls who have not yet started menstruating and are about to begin. Some of the possible approaches that can be used include; menstrual hygiene manuals, use of drama and use posters among others.

6. Overall, there is need to have MHM integrated into existing health and WASH surveillance systems in the community and schools like the PTA’s and SMCs 7. MHM needs to be implemented with due consideration that there is inadequate supply of detergents like soap. Training of women and girls in school in making of sanitary pads and soap should be explored so that there is a sustainable supply of pads and soap in schools and communities. 8. Sharing, lobbying and advocacy with relevant stakeholders including, Government and CSOs needs to be undertaken for inclusion of MHM in school curricular and development of MHM and child friendly school aspects. 9. Need to mainstream MHM issues into the normal school teaching programmes that should be untaken by both male and female including school health clubs 10. MHM interventions in schools should integrate senior women teachers, school health clubs and women groups/ mothers in promotion of MHM, puberty education towards realisation of sustainability. 11. In areas where there is ample supply of rain, MHM interventions should be linked to agricultural production in order to address issues of raw materials like cotton.

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4.1.2 EDUCATION:

1. Facilitate formulation of bylaws: Communities through the PTA’s, Chief’s and other existing local government structures at Counties should be trained and facilitated on development of appropriate bylaws that will put parents into task on education of children. The bylaws will also have to tackle issues concerning forced marriages and early pregnancies among girls contributing to school dropout. 2. Community awareness campaigns on the value of education should be conducted with focus on both parents and children. This can be made more effective through involvement of PTAs, teachers, children in school and women role models in respective areas. Approaches like use of drama, theatre for development, IEC/BCC materials, video documentary and poems need to be explored.

3. Training, couching and mentoring: Schools should be encouraged, trained, coached and mentored on how to organize school festivals (such as parents day) where all stakeholders are invited, entertained while learning through children’s folk songs, poems, skits. This will enable other stake holders learn from the children. 4. Introduction and establishment of a Promotion, advocacy and Girl’s Education (PAGE) clubs. This group of women is elected form the community such that they advocate for girl’s rights among the community members. This will campaign for girls among community members and support girls to acquire special needs 5. Introduction and re-establishment of the Girl’s Education movement (GEM) clubs in schools. These clubs will handle the needs of the girls by availing them a platform to present their issues/challenges to the teachers and other stakeholders.

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4.1.3 WASH:

1. Review of existing schools latrine designs to incorporate wash rooms It’s important to have designs of school latrines especially girls reviewed to accommodate a changing/wash room. The changing/wash room should at least have a regular supply of water, soap and a basin/bucket which can be used for bathing. There should as well be ample washing space with enough water and privacy to wash and dry cloths and rags used during menstruation.

All relevant stakeholders including, Ministry of Education at all levels, Development partners in WASH and Education, Health Departments at state and county level, Chairpersons PTA, Chiefs and Head teachers need to therefore be aware of the need for this component as they are the direct recipients and implementers. 2. Hygiene and sanitation campaigns involving teachers, pupils and parents need to be conducted in view of increasing the level of knowledge and improving their practices. 3. There is need to facilitate schools to establish and strengthen hygiene and sanitation clubs such that they are used as channels of communication to; pupils teachers, parents and community on Menstrual hygiene management and good hygiene and sanitation practices.

4.2 Conclusion:

In conclusion, it can be said that girls in Eastern Equatoria State, South Sudan are greatly challenged in education attainment. The number of girls in school especially upper levels is very low compared to boys in both primary and secondary schools with some schools having a total enrolment of only 9 girls in the whole school. The underlying factors for these include the high cultural orientation that girls are a source of wealth and as such should be jealously protected. Adolescent school girls both in urban and rural areas have limited menstrual knowledge in addition to negative perceptions, poor practices which are not often optimal for proper hygiene in addition to un conducive school environments. Often ignored issues of privacy affect the hygienic practices and daily lives, particularly school attendance, of the adolescent girls. The know-how, availability and affordability of sanitary products to manage menstruation are far from satisfactory. Schools, home, government, society and organizations of reproductive health as well as water, sanitation and hygiene sectors need to be able to break cultural barriers surround girls education and MHM in an effort towards making menstrual hygiene and management better for adolescent population.

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ANNEXES

Annex One: Sample population

Sample population Planned Actual Response Actual Total Total

Ikwoto KEC KSC Lopa Torit Magwi

Head teachers primary school 44 6 5 6 7 9 7 40

Head teachers secondary 6 0 2 1 0 2 1 6 schools Senior woman teacher/other 44 4 6 5 6 5 8 34 teacher primary school Senior woman teacher/other 6 0 2 1 0 1 2 6 teacher secondary Girls for primary 440 57 54 48 67 47 96 369

Female Students for secondary 60 0 14 5 0 16 6 41 school PTA/SMC 50 5 6 4 17 6 6 44

Local/opinion Leaders 50 5 5 1 3 1 2 17

Focus Group Discussions

Parents 500 73 40 36 60 64 33 302

Pupils Primary 528 71 51 68 88 79 50 407

Students secondary 72 0 5 5 0 0 0 10

Total 1800 221 190 180 248 230 211 1280

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Annex Two: List of Selected School per County for MHM Baseline Survey Project

S/N County School Name Days Date Name 1. Magwi Central Primary school Day 1 5th – 9th 2. Magwi Primary school Day 1 May 3. Obbo Primary school Day 2 4. Magwi Pamakong Primary school Day 2 5. Kerepi Primary school Day 3 6. Panyikwara Model Primary Day 3 school 7. Pageri Primary school Day 4 8. Loa Senior Secondary school Day 4 9. OwinykibulCentral Primary Day 5 School

10. Lokutok Girls Primary school Day 1 11. Lopa Lokutok AIC P/S Day 1 17th - 21st 12. /Lafon Ibahore Primary school Day 2 13. St. Mary’s Eboni Primary school Day 2 14. Imehejek Primary school Day 3 15. Mura Lopit Primary School Day 3 16. Lafon Central Primary school Day 4 17. Lofiriang Primary school Day 4

18. Torit E. Primary school 12th –15th 19. Greater Torit Day SS Day 1 May 20. Torit Ileu Primary school Day 1 21. Hilaya P/s Day 1 22. Dr.Garang Memorial SS Day 2 23. Porit Model Primary school Day 2 24. Dumak Primary school. Day 2 25. AIC (Africa Inland Curch) Day 3 Primary school 26. Torit West Primary school Day 3 27. Torit one Primary school Day 3 28. Haramorok Primary school Day 4 29. Kudo Central P/s Day 4

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30. St. Mathew Primary Day 1 th th Ikwoto School 15 – 19 31. AIC Primary school Day 1 32. Momoria Primary school Day 2 33. Ikwoto Primary school Day 2 34. Lofus Primary school Day 3 35. Katire Primary school Day 4

36. Bakhita Senior Secondary Day 1 5th – 8th KapoetaEa school 37. st Bakhita Girls’ Primary Day 1 school 38. Lopoa SS Day 1 39. Narus Mixed Primary Day 2 school 40. Nakwartuum Primary Day 2 school 41. ISTL/Brainstorm Primary Day 3 school 42. Nathapal Primary school Day 3 43. St. Thomas Primary Day 4 schools

44. Kapoeta Kapoeta Day Secondary Day 1 9th – 13th South school 45. Kapoeta Mixed Primary Day 1 School 46. Kotome Primary school Day 2 47. Singaita Primary school Day 2 48. Longeleya Primary school Day 3 49. Hope for South Sudan Day 3 Primary school 50. Kuleo Light Primary Day 4 school.

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Annex Three: Questionnaires

TOOL3: SEMI STRUCTURETED INTERVIEW WITH THE SCHOOL TEACHERS

I wish to appreciate your participation in this very important area of study. This questionnaire is designed to solicit for your responses on the status of WASH and MHM in your school. The output of this study will not only be used to design programs for MHM in schools but the information obtained will be used to facilitate formulation of better policies/recommendations that will enhance WASH and MHM in the school, county, state and the country. The findings will also be distributed and can be used as a stepping stone for further research. Please feel free to express your opinions as all responses will be treated with confidentiality. Instructions  This tool is to be used by enumerators to gather data.  Enumerators are to interview school head.

1. 1Date of information Date Month Year 1collection 2. Title of Respondent Head Senior Woman Other Teacher Teacher Teacher School Information 3. 2Name of school 4. Level of School Primary Secondary 5. 4County 6. 5Payam 7. 6Boma

8. 7Type of school 1 = Public 2 = Private 3 = Church 4 = Community 9. 1Location 1 = Urban . 2 = Semi-Urban 8 3 = Rural

10. Enrolment - Grade/Form Girls Boys Total Dropped out Boys Girls Nursery 1 2 3 4 5 6 7

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8 Total

11. Why did the girls drop out of school? ………………………………………………………………………………………………………………. .………………………………………………………………………………………………………………

12. Staff Staff Male Female Total Teaching Trained Untrained Non-Teaching Grand Total

13. What type of toilets/latrines do you have in the school? VIP Pit Other

14. Number of stances for students and staff? Category No. stances Ratio Girls Boys Teachers Non-Teaching

15. Latrine usage Are the pupils given lessons on how to use latrine facilities? 1= YES 2 = No Are the pupils monitored/supervised on the use of latrines? 1= YES 2 = No Does the school health teacher/school authority conduct periodic 1= YES inspection of latrines 2 = No Do pupils practise open defecation 1= YES 2 = No Do pupils practise open urination 1= YES 2 = No

16. Has the school had any contact and interaction with any NGO staff, school inspector, in the last 6 month on WASH issues? A. Yes B. No C. Do not remember

17. If yes, what did the staff talk about (remember not to prompt so that we see if they can mention WASH or MHM) Issue talked about Yes No Water sources

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Hand washing Latrine use and maintenance Personal hygiene Menstrual hygiene management Others (specify)

18. On average, how often does this staff visit the school in a year?...... 19. Have these visits increased the school commitment towards WASH and MHM? a. Yes b. No c. not sure 20. a) Does the school have access to a community water system or its own water system a. Yes b. No b) If yes, has it experienced breakdowns? A. Yes B. No C. Not sure c) If yes, is it immediately repaired? A. Yes B. No C. Not sure

21. What is the primary drinking water source for the school?

Water Source YES NO Borehole Protected Well Unprotected Well Treated Truck Water Untreated Truck Water River/Swamp Water Rain harvesting tanks Pumped water Other (Specify) ……………….

22. How far is the water source? Location Within school boundaries Less than 1 km More than 1km

23. Does the school have adequate drinking water storage facilities? A. Yes B. No C. Not sure 24. If yes, what type of drinking water storage facilities are used in school? a. Bucket with a tap b. Water pot c. Jerri cans d. School tank e. Large containers with tap others (specify)......

25. What types of materials are used to clean the water storage facilities? a. Detergent b. Soap c. Chlorine d. Grass e. Ash f. Others specify………………………………………………………………

26. Does the school have access to funds to facilitate purchase of improved water containers? A. Yes B. No C. Not sure

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27. What mechanisms have been put in place to ensure that the water is safe and clean? ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… 28. Do you treat the drinking water? A. Yes B. No C. Sometimes D. Not sure

29. If yes what do you use to treat the drinking water? a. Chlorine b. Boiling c. Water guard d. Othersspecify......

30. What key areas do you teach about sanitation? Knowledge and skill Yes No Personal Hygiene Proper Latrine Use and maintenance Disposal of rubbish Hand washing Sanitation Others

31. What materials do girls use during menstruation periods? Yes No Cloth Purchased sanitary pad Toilet paper Cotton Pieces of Mattress Natural materials (mud, cow dung or leaves) Ash or sand They use nothing I don’t know

32. Which of the above materials would you prefer to be explored further to ensure girls have constant supply of sanitary pads? ...... 33. What actions has the school put in place to help girls deal with their menstrual periods? a. Training girls on MHM b. Providing sanitary materials c. Providing changing room d. Appointing and training a senior woman teacher e. Having separate latrines f. Forming (Girls Education Movement GEM/ Promotion of Advocacy and Girls Education PAGE g. Others (specify)...... 34. Does menstruation make girls miss school? A. Yes B. No 35. If yes, how many days of school do they miss in a month?......

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36. Do you know of any girls who have dropped out of school as a result of menstruation? A. Yes B. No 37. If yes, how many?...... 38. Are there social cultural beliefs surrounding menstruation? A. Yes B. No If Yes List them...... 39. What do you think is the most accessible channels of ensuring availability of sanitary materials to girls? a. School health club b. Senior woman teacher c. Local clinics d. Parents e. Women groups f. Girls themselves g. Boys Others (specify)………………………………………………………………….. 40. Do girls feel free to interact about their periods to the teachers? A. Yes B. No

41. What key areas do you teach about menstruation? Menstruation practice Yes No Proper use of sanitary materials Personal hygiene during menstrual periods Making of local sanitary materials General menstrual periods care Others specify

42. Health Clubs Activities in schools Health Clubs Yes No Is there a school health club Is there a School Health Teacher (Master) Are there regular hygiene educations sessions conducted for all classes by School Health Teacher Are there scheduled hygiene education sessions for the school by Ministry of Health officials? E.g. nurses, Public health inspectors Are there scheduled hygiene education sessions for the school by Ministry of Education e.g. Education Directors and Inspectors

43. In an effort to promote hygiene, sanitation and menstrual hygiene care, what are the gaps that need to be addressed in your school and what are your recommendations? Gaps ...... Recommendations ...... THANK YOU FOR YOUR TIME

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Annex Four: QUESTIONNAIRE FOR GIRLS IN PRIMARY & SECONDARY SCHOOLS

I wish to appreciate your participation in this very important area of study. This questionnaire is designed to solicit for your responses on the status of WASH and MHM in your school. The output of this study will not only be used to design programs for MHM in schools but the information obtained will be used to facilitate formulation of better policies/recommendations that will enhance WASH and MHM in the school, county, state and the country. The findings will also be distributed and can be used as a stepping stone for further research.

Please feel free to express your opinions as all responses will be treated with confidentiality.

Number: Age:…………………… School: Class:……………………….

1. Do you understand what menstruation periods are? A. Yes B. No

2. Have you started your menstrual periods? A. Yes B. No

3. Please indicate whether you think the statements below are true or false.

(Please tick to indicate answer) True False a) Old women do not menstruate (45 years and above) b) Menstruation is a disease c) Pregnant women menstruate d) Menstrual blood comes from the uterus/womb e) Menstrual blood is harmful to the body f) Pain during menstruation means that someone is unhealthy g) Women are dirty during menstrual periods h) Menstruation is normal and natural

4. Please tick what you normally use during menstruation. Yes No a) Cloth b) Purchased sanitary pads c) Toilet paper d) Cotton e) Pieces of Mattress f) Natural materials (mud, cow dung or leaves) g) Digging a hole h) Ash or sand i) I use nothing j) Others (specify)

5. Which locally available materials do you think we can use for making sanitary?

......

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6. Who provides you with sanitary materials? (Tick all that apply) Yes No a) My self b) Mother c) Father d) Sister e) Friend f) Senior woman teacher g) Village women leader h) NGO (specify) i) Relative j) Others (specify)

7. Where do you commonly get sanitary materials from? (only one option) a. Market b. Shop c. Clinic d. Home e. School f. others………………….

8. Where can you get sanitary pads (e.gAlways) from? a. Market b. Shop c. Clinic d. Home e. School f. others………………….

9. What feelings do you develop during menstrual periods? a. Having sex b. Getting married c. Living school d. Having sanitary material e. Others (specify)………………………………………………………………………….

10. How do boys treat girls during their menstrual periods? a. Abuse b. Humiliated c. Nicknamed d. Laugh at girls e. Provide supportive environment f. Isolate girls g. Approached for love/sex offers h. Others (specify)……………………………………………………. 11. How does the community treat you during menstrual periods? a. Restrict movement b. Seen as unclean c. Cleansing/perform rituals

12. Have you used sanitary pads (e.g. always) in the last three months? A. Yes b. No 13. If no, why? a. Lack of money b. Pads not available c. Comfortable with the local materials (specify) d. Not comfortable with sanitary e. Do not know about it f. Others (specify) 14. Do you put on nickers? A. Yes B. No 15. If no, Why? a. Do not have b. They are expensive c. Culture does not allow d. Not comfortable e. Others (Specify) ………………………………………………………………………

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16. Does menstruation make you miss school? A. Yes B. No 17. If yes, how many days of school in a month do you miss?...... 18. Why does menstruation make you miss school?

True False a) I feel severe pain b) Lack of sanitary materials c) Not allowed by parents d) Feel dirty e) Afraid of being made fun of f) Discomfort due to tiredness g) Lack of private changing room at school h) Others (specify)

19. Other than menstruation, what other reasons make you miss school? (Please list them here) ……………………………………………………………………………………………….. ……………………………………………………………………………………………….. ……………………………………………………………………………………………….. ………………………………………………………………………………………………..

20. Does menstruation make girls drop out of school? A. Yes B. No

21. Please mark whether these statements are true for you during your menstrual periods: (tick all that apply) True False a) Not ashamed of myself b) Proud and mature c) Feel less confident than when I am not in my periods d) Feel dirty e) Feel uncomfortable f) Others (specify)

22. Have you ever heard of information on how to care for yourself during menstrual periods? A. Yes B. No

23. If yes, from where? (tick all that apply) Yes No a) Mother b) Father c) Sister d) Relative e) Teacher f) Friends g) Books/newspapers h) Radio i) Community leader j) NGO representative k) School health club l) Others (specify)

24. Do girls have a separate changing room at school during menstrual periods? A. Yes B. No

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25. Does anyone at school support you during your menstrual periods? A. Yes B. No

26. If yes, who supports you Yes No a) Senior woman teacher b) Friends c) Any other teacher d) Health prefect e) Senior man teacher f) Matron g) Head boy h) Head girl i) Others (specify)

27. If yes, how does this person support you? Yes No a) Provide materials b) Counselling/advise c) Protection from humiliation d) Others (specify)

28. Are you comfortable with the person who supports you? A.Yes B. No

29. If no, why……………………………………………………………………………………………………

30. a. Do you have a reliable source of water at school? A. Yes B. No

b. If yes, how has it helped you to improve on menstrual hygiene? …………………………………………………………………………………………………………. …………………………………………………………………………………………………………. c. If no, how do you deal with menstrual periods without water in school?

…………………………………………………………………………………………………………. ………………………………………………………………………………………………………….

31. How best do you feel the issue of menstruation should be addressed to you as a girl in school?

Thank you for your time

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Annex five: OBSERVATION CHECKLIST

NAME OF SCHOOL:………………………………………………………………………… COUNTY:……………………………………………………………………………………..

1. Presence of basic School Structures and facilities; Category YES NO Classrooms available from (P.1-P.8 )/(S.1-S.4) Classrooms in good state and conducive for learning Adequate desks for all pupils/students Office/ staff room available Adequate office furniture Teachers Houses available School Kitchen available with drying rack

2. Menstrual Hygiene Management facilities/materials Category YES NO Changing room for girls available Sanitary Materials available Basins/buckets available Sickbay available Wash rooms next to girls changing room/latrines Water available Soap available in washrooms

3. a. Latrines Category YES NO School latrines available Latrines in good condition and functionality Separate latrines for boys, girls and teachers Latrines in regular use Latrines swept clean Faeces on the floor of the latrine Latrines with cover No Flies and Bad smell Open defecation not practiced

b. type of latrine Type of latrine YES NO Permanent structure with bricks and sand Grass thatched/mud walls Hole no superstructure Latrines made of grass Latrine with wall but no roof

b. Number of latrine stances

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Category Number Boys Girls Teachers/support staff

4. Water source Category YES NO Available but not functioning Available and functioning Water source within school compound Water source within 1KM Water source more than 1KM Water source environment clean

5. Senior man and Senior woman Teachers Category YES NO Appointed by the school Available in school Presence of records in the office

6. Hand washing Category YES NO Hand washing facility available Facility functioning and not damaged Soap/Detergent/ash used

7. Conducive school environment Category YES NO Pupils/students have at least a meal in a school Play materials available Clean environment

8. Record Category YES NO PTA/SMC Files available Visitors Book Duty rosters Enrolment

Thank you

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Annex 6: INTERVIEW SCHEDULE FOR GIRLS AND BOYS (FGD)

1. What do you understand by menstrual periods? 2. What do you feel when we talk about menstrual periods in public? 3. Have you ever been taught anything regarding menstrual hygiene? If yes, what did you discuss? And with who? 4. How do girls feel when they are nearing their menstruation periods? What do they always do in preparation? 5. How do boys treat girls who are in menstruation periods? 6. How does the community treat girls during menstruation periods? 7. What do girls always do when they experience their periods abruptly? 8. Who always helps girls and how, when they are in their periods? 9. What materials do girls always use? 10. Which of the above materials would you prefer to be explored further to ensure girls have constant supply of sanitary pads? 11. Do periods stop girls from coming to school? If yes, why? 12. Do you know of girls who have dropped out of school due to menstruation? If yes, why? 13. If no what other reasons made the girls drop out of school? 14. How best do you think girls can be supported during menstrual periods? 15. What do you think about your school latrines? What do you feel is lacking? How can they be improved? 16. Do you have a school health club? What have you gained out of the school health club? 17. Do you have reliable supply of clean water in your school? If yes, how has it helped you to manage hygiene in the school? 18. What don’t you about menstrual?

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Annex seven: INTERVIEW SCHEDULE WITH LOCAL LEADER, PTA/SMC AND PARENTS

1. What are the reasons for the following; a. Low attendance of girls b. Drop out c. Lack of transition of girls from basic level to other levels of education? 2. Why do you prefer educating boys to girls? 3. What difficulties do children especially girls face at home and school that lead to dropping out of school? 4. What policies or programs are in place to support and promote education, WASH and menstrual hygiene care in communities and schools? 5. How do parents, PTA, Local leaders support girls during menstrual periods? 6. What should be put in place to support and promote education, WASH and MHM in schools? 7. What appropriate channels would you suggest to improve access and availability of menstrual hygiene management facilities in schools? 8. What materials do girls use during menstruation periods? 9. Are menstrual hygiene materials easily available and accessible by the girls at school, home and in the community? 10. Which of the stated materials should be explored further to ensure that girls have constant supply of sanitary materials? 11. How does the community deal with girls/women during menstrual periods? 12. How do girls behave in your community during their menstrual periods? 13. Do girls openly discuss their menstruation problems with you as parents/PTA/Local leaders? If yes, how? If no, why? 14. Do you as parents; discuss issues of menstrual periods with your daughters? If no, why? 15. As a community leader, do you discuss information regarding menstrual hygiene? If no, how do you think you can help your community understand menstrual hygiene? 16. Do you have a reliable source of water in the community and how satisfied are you with its current state? 17. How far from the community is the water point? Time? Distance? 18. In your view, how is your water managed in your community? How can it be improved? What mechanisms have been put in place to ensure that the water is safe and clean?

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Annex eight: List of Enumerators

S/No. Name County Position 1. Justo Thomas County Inspector of schools 2. Loumo Lawrence Magwi Deputy County Education Director 3. Vitale OyyahaOdemi County Education director 4. Kaya Alfred Taban State (EES) SMoE 5. KornelioAdafaBulang Torit Deputy County Director Torit 6. ChristinoGumaSikia Kapoeta East County Education Director 7. Lam Leone Ferem Kapoeta South County Education Director 8. Chandi Pascal S State (EES) Directorate of GESD (MoE)

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Baseline survey Photographs:

Representative from the State Ministry of Education Broken down borehole in Kapoeta East School doing FGDwith children in Torit East P/S County

Communally made latrine in St. Mathew Communally made latrine in Ikwotos County Primary School Ikwotos County

Girls demonstrating on how they use a An example of a locally made “san. Kit” hole during their menstrual periods in used for keeping pads, knickers for girls Kapoeta East in Kapoeta East 33 | P a g e