A TOOLKIT FOR INTEGRATING MENSTRUAL HYGIENE MANAGEMENT (MHM) INTO HUMANITARIAN RESPONSE THE FULL GUIDE ACRONYMS
ACKNOWLEDGEMENTS CCCM Camp Coordination Camp IRC International Rescue Committee Management KAP Knowledge Attitude This research project is funded by Elrha’s CFS Child Friendly Spaces And Practices Research for Health in Humanitarian Crises (R2HC) 4 Cs Coordination, Consultation, KII Key Informant Interviews Programme, which aims to improve health outcomes Culture, Communication by strengthening the evidence base for public health M&E Monitoring And Evaluation CTP Cash Transfer Programming interventions in humanitarian crises. The R2HC MHM Menstrual Hygiene Management Disabled Persons Organizations programme is funded equally by the Wellcome Trust DPO NFI Non-Food Item FGD Focus Group Discussion and the UK Government. Visit www.elrha.org/r2hc NRC Norwegian Refugee Council FGM Female Genital Mutilation for more information about Elrha’s work to improve PDM Post Distribution Monitoring humanitarian outcomes through research, innovation, HWF Hand washing facility SRH Sexual And Reproductive Health and partnership. IDP Internally Displaced Person UNFPA United Nations Population Fund IEC Information Education UNHCR United Nations Refugee Agency Communication UNICEF United Nations Children’s Fund IFRC International Federation Of The Red Cross WASH Water Sanitation And Hygiene INEE Inter-Agency Network for WHO World Health Organization Education in Emergencies WRA Women Of Reproductive Age
© 2017, Columbia University and International Rescue Committee. All rights reserved. This material is under copyright but may be reproduced by any method for educational purposes by anyone working to improve the lives of displaced girls and women in emergency and development contexts, as long as the source is clearly referenced. It should not be reproduced for sale or commercial purposes.
First edition, 2017 CONTENTS
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INTRODUCTION TRAINING CONDUCTING PROVIDING MHM MHM AND MHM AND MHM AND WATER STAFF A NEEDS MATERIALS AND TRANSIT SHELTER AND SANITATION ON MHM ASSESSMENT SUPPLIES FACILITIES
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MHM, DISPOSAL MHM AND HYGIENE MHM AND MHM AND MHM AND MHM AND MONITORING AND WASTE PROMOTION & VULNERABLE EDUCATION HEALTH PROTECTION AND MANAGEMENT HEALTH EDUCATION POPULATIONS EVALUATION ACTIVITIES
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1 Introduction The Menstrual Hygiene Management (MHM) in Resource Format: The MHM in emergencies Emergencies toolkit aims to provide streamlined toolkit is comprised of 2 main sections, serving The resource has been collaboratively produced 2 Training staff on MHM guidance to support organizations and agencies different functions: by David Clatworthy (International Rescue seeking to rapidly integrate MHM into existing Committee), Margaret Schmitt (Columbia 3 Conducting a needs programming across sectors and phases. This toolkit University, Mailman School of Public Health) assessment MHM IN EMERGENCIES TOOLKIT: was informed by an extensive desk review, qualitative and Dr. Marni Sommer (Columbia University, THE FULL GUIDE. This document serves assessments with a range of humanitarian actors 4 Providing MHM as a more extensive guidance resource. The Mailman School of Public Health) with inputs Materials and Supplies and organizations, and direct discussions with girls chapter structure follows the same structure from displaced adolescent girls and women and and women living in emergency contexts and directly as the sections in the mini-guide, providing humanitarian practitioners and organizations affected by this issue. 5 MHM and Transit deeper discussion on each topic, including key (see acknowledgements).* Toolkit audience: The toolkit was designed to assessment questions, case studies from around 6 MHM and Shelter Please contact Dr. Marni Sommer with any support a range of humanitarian actors involved the world, design considerations, resources for in the planning and delivery of emergency responses. gathering monitoring and feedback, and links to concerns or insights you would like to share 7 MHM and Water and The guidance is therefore aimed to support additional resources. with the MHM in emergencies toolkit team at: Sanitation Facilities 1) program staff directly delivering services; [email protected] 2) program supervisors and country-level staff 8 MHM, Disposal and • MHM IN EMERGENCIES: THE MINI GUIDE. responsible for designing, coordinating and Preferred citation: Sommer, M., Schmitt, M., Waste Management This complementary document provides a monitoring field activities, and 3) technical staff, Clatworthy, D. (2017). A toolkit for integrating brief summary of the key actions necessary for focused on providing technical support and Menstrual Hygiene Management (MHM) 9 MHM and Hygiene addressing MHM during emergencies. It serves Promotion & Health developing standards. into humanitarian response. (First edit). Education Activities as a quick read to gain a basic understanding New York: Columbia University, Mailman but it is advised to review the complete guide School of Public Health and International 10 MHM and Vulnerable when designing programs or developing Populations Rescue Committee. response activities.
11 MHM and Education
12 MHM and Health PUBLISHED BY:
13 MHM and Protection
14 Monitoring and Evaluation
4 BACK TO CONTENTS
1 Introduction CO-PUBLISHED BY:
2 Training staff on MHM
3 Conducting a needs assessment
4 Providing MHM Materials and Supplies
5 MHM and Transit
6 MHM and Shelter
7 MHM and Water and Sanitation Facilities
8 MHM, Disposal and Waste Management
9 MHM and Hygiene Promotion & Health Education Activities
10 MHM and Vulnerable Populations
11 MHM and Education
12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation
5 JUST THE FACTS: UNDERSTANDING MENSTRUATION
WHY IT MATTERS? WHAT IS MENARCHE? THE BASICS • Girls who get blood on their clothes are • Menarche is the onset of menstruation. MENSTRUATION IS NORMAL! often teased by teachers, boys or other girls. Girls generally get their first period between ages 11–15, although some can be IT IS THE MONTHLY • Social norms may lead women and girls younger or older. SHEDDING OF BLOOD AND to feel that menstruation is dirty, UTERINE TISSUE AND AN • The first period is generally a surprise! shameful or unhealthy. IMPORTANT PART OF THE Sometimes girls are scared or worried they are sick. They may not know who to REPRODUCTIVE CYCLE. • Without access to good menstrual materials ask for advice. TYPICALLY, IT LASTS... and private toilets or washrooms for changing, girls and women may not want • Information about menstruation is 2-7DAYS to go far from home. Teachers may miss frequently passed on from mothers, friends, school, health workers may miss work, and sisters or aunts, and is often a mixture of girls and women may not attend school, go cultural beliefs, superstition and practical THE AMOUNT OF BLOOD to the market or wait in line for supplies. information that is sometimes helpful and IS USUALLY BETWEEN sometimes not. Menstruation is very personal. • In many cultures mothers may feel Women and girls often do not want uncomfortable to talk to their daughters others to know they are menstruating – about periods because it is linked AND even other women and girls. 1 6 to sexuality. TABLESPOONS EACH . MONTH AND CAN BE MESSY. WHAT DO THEY NEED?
ABDOMINAL CRAMPS, • A range of materials can be used to • Menstrual periods are irregular and can • Even when using good menstrual NAUSEA, DIARRHEA catch the blood, including a sanitary pad catch girls and women by surprise. This materials, women and girls may be AND HEADACHES (disposable or reusable), a tampon, causes anxiety about finding a bathroom worried about blood stains on their and materials quickly! clothes. ARE COMMON or a piece of cloth in their underwear. BEFORE AND • Menstruation can be messy! Women • Women and girls need access DURING A PERIOD. and girls need a private space with to a private, clean space (toilet or water and soap to clean themselves washroom) to change materials and soiled materials. throughout the day and night and to hygienically dispose of menstrual waste. 1 INTRODUCTION BACK TO CONTENTS
1 Introduction Managing menstruation in resource-poor MHM CHALLENGES FACING GIRLS AND WOMEN IN EMERGENCIES settings is often challenging, especially when 2 Training staff on MHM away from home all day. Such challenges are increased by societal taboos, secrecy and 3 Conducting a needs embarrassment around menstruation. Lack of sanitary assessment During emergencies, girls and women face materials, 4 Providing MHM even greater barriers managing menstruation including Materials and Supplies given the loss of privacy and safety often underwear associated with living in emergency contexts 5 MHM and Transit and the transitory nature of displacement. Lack of private Cultural taboos female friendly 6 MHM and Shelter Menstrual Hygiene Management (MHM) and restrictions toilets and programming in emergencies involves adjustments related to MHM 7 MHM and Water and and improvements to a range of sectoral interventions bathing spaces Sanitation Facilities including Water Sanitation and Hygiene (WASH), Protection, Reproductive Health, Education, 8 MHM, Disposal and Waste Management Non Food Items (NFIs) and Shelter. While some components are specific to menstruation (such as 9 MHM and Hygiene the provision of sanitary pads), most components Promotion & Health Education Activities of MHM programming are concerned with improving the safety, privacy and dignity with which women Overcrowding Lack of 10 MHM and Vulnerable and girls can live in emergency contexts. Therefore, and severly Populations knowledge on they are helpful for overall quality of service provision diminished mensuration and lead to improved outcomes which are expected privacy 11 MHM and Education for all the aforementioned sectors. 12 MHM and Health
Anxiety and 13 MHM and Protection embarassment around leakage 14 Monitoring and and discomfort Evaluation
7 THE 4 Cs OF EFFECTIVE MHM PROGRAMMING:
BACK TO CONTENTS COORDINATION CULTURE
1 Introduction • At the onset of an emergency, generate consensus on • Understanding cultural sensitivities and social norms
U n 0 lo 02 ck 2 Training staff on MHM $1 by 2 0 bi ear MHM by promoting dialogue through presentations llion a y around MHM in the beneficiary population is crucial at meetings (i.e. interagency, camp coordination and for developing an appropriate response. 3 Conducting a needs management, cluster) and discussions with field staff. assessment • Culture may have direct implications for selection of materials, design of • Partner with other agencies, including government entities, to maximize 4 Providing MHM facilities, disposal methods, waste management, and washing, drying and impact and minimize gaps, overlaps and misunderstandings. Materials and Supplies privacy needs. • The WASH sector is usually tasked with leadership on MHM programming. 5 MHM and Transit Many staff, including women, may be uncomfortable discussing MHM. However, a strong partnership between WASH and Protection actors, • Assess staff comfort levels and sensitivities on menstruation to inform and engagement of other sectors, is more effective. 6 MHM and Shelter capacity building trainings. • Delegate MHM focal person(s) from WASH and Protection to track 7 MHM and Water and Sanitation Facilities mainstreaming across relevant sectors. • Trainings can promote the mainstreaming of MHM across sectors.
8 MHM, Disposal and CONSULTATION COMMUNICATION Waste Management
9 MHM and Hygiene Promotion & Health • MHM is private and personal but women and girls are • An effective MHM response requires on-going Education Activities usually willing to talk about it if given the opportunity and communications with MHM focal person(s) and working appropriate environment. groups across relevant sectors. Update partners on 10 MHM and Vulnerable Populations programming, beneficiary feedback, lessons learned, • Appreciate that one-size-fits-all solutions are not ideal for something and challenges.
11 MHM and Education so personal. • Communicate directly with beneficiaries about MHM, ensuring they
12 MHM and Health • Consult girls and women on MHM programming, including materials and understand how to use MHM supplies, dispose of menstrual waste and supplies, facilities, and information needs. have access to basic education on menstrual health and hygiene. 13 MHM and Protection • Share learning from consultations across sectoral actors. • Target communication towards other relevant stakeholders such as 14 Monitoring and caregivers, partners and boys. Evaluation • Continue consultation throughout implementation (i.e. Post Distribution Monitoring (PDM), interviews, Focus Group Discussion (FGD). 8 THE HIERACHY OF MHM NEEDS
BACK TO Providing an MHM response requires a range of sectors to identify which elements CONTENTS or activities may fall within their mandate. Figure 1 depicts the range of MHM considerations (e.g. basic materials and supplies, information, facilities, safety, Protection privacy and dignity) and how these may fall within the responsibility of various 1 Introduction sectoral actors. Effective coordination and communication across sectors is critical. Sectoral responsibility may vary considerably from one context to another. Education 2 Training staff on MHM
Health 3 Conducting a needs DIGNITY assessment Harmful cultural norms addressed; a supportive environment; WASH access to information about puberty and reproductive health; 4 Providing MHM Materials and Supplies engagement with boys & men NFI Non-food items
5 MHM and Transit Shelter PRIVACY 6 MHM and Shelter Ability to privately manage menstruation including to wash, NFI Camp Coordination dry and/or discretely discard disposable materials. Camp Management 7 MHM and Water and (CCCM) Sanitation Facilities
8 MHM, Disposal and SAFETY Waste Management A secure environment; ability to access facilities of choice throughout the day and night 9 MHM and Hygiene Promotion & Health Education Activities
FACILITIES Private female friendly toilets and washrooms 10 MHM and Vulnerable at home and in public & institutional spaces Populations
11 MHM and Education
INFORMATION 12 MHM and Health Practical information on wearing, washing NFI and disposing provided materials 13 MHM and Protection
14 Monitoring and BASIC MATERIALS AND SUPPLIES Evaluation NFI Pads, underwear and soap 9 THREE ESSENTIAL COMPONENTS OF A COMPLETE MHM HUMANITARIAN RESPONSE BACK TO CONTENTS MHM is a cross-sectoral issue. In order to deliver an effective response, the various sectors must coordinate to ensure that the three central components are addressed.
1 Introduction
2 Training staff on MHM
3 Conducting a needs assessment MHM MATERIALS MHM SUPPORTIVE
4 Providing MHM & SUPPLIES FACILITIES Materials and Supplies 1 2 • Appropriate menstrual materials • Safe and private toilet and bathing facilities with water for 5 MHM and Transit (pads, cloths, underwear). changing, washing and drying • Additional supportive materials menstrual materials. 6 MHM and Shelter (e.g. soap, bucket) for storage, washing and drying. • Convenient and private disposal 7 MHM and Water and options for menstrual waste. Sanitation Facilities • Demonstration on how to use MHM materials. • Waste management systems in 8 MHM, Disposal and place for menstrual waste. Waste Management
9 MHM and Hygiene Promotion & Health Education Activities
10 MHM and Vulnerable Populations
11 MHM and Education
12 MHM and Health
MHM and Protection MHM INFORMATION 13 3 • Basic menstrual hygiene promotion and education. 14 Monitoring and Evaluation • Basic menstrual health education (especially for pubescent girls).
• Address harmful cultural or social norms related to menstruation. 10 RELEVANT SECTOR SECTIONS BACK TO CONTENTS BRIEF SUMMARY OF SECTORAL ROLES RELEVANT CHAPTERS IN SUPPORTING MHM RESPONSE
1 Introduction WASH • Ensure access to gender-sensitive water and sanitation facilities; Ch 2: Training Staff on MHM
• Provide appropriate MHM materials (NFIs) and demonstrate Ch 3: Conducting a needs assessment 2 Training staff on MHM their use; Ch 4: Providing MHM Materials and Supplies 3 Conducting a needs assessment • Provide MHM promotion; Ch 5: MHM and Transit • Develop disposal and solid waste management systems to support 4 Providing MHM Materials and Supplies MHM through coordination with Protection. Ch 6: MHM and Shelter
5 MHM and Transit Ch 7: MHM and Water and Sanitation Facilities
6 MHM and Shelter Ch 8: MHM, Disposal and Sanitation Facilities
7 MHM and Water and Ch 9: MHM and Hygiene Promotion and Health Education Sanitation Facilities
Ch 10: MHM and Vulnerable Populations 8 MHM, Disposal and Waste Management Ch 14: MHM and Monitoring and Evaluation 9 MHM and Hygiene • Ensure that shelter structures and public facilities provide Ch 2: Training Staff on MHM Promotion & Health SHELTER Education Activities adequate privacy for girls and women who may need to change their Ch 3: Conducting a needs assessment menstrual materials there. This includes adequate lighting, privacy 10 MHM and Vulnerable partitions, and doors with locks (on the inside). Populations Ch 6: MHM and Shelter
11 MHM and Education Ch 14: MHM and Monitoring and Evaluation
12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation
11 BACK TO CONTENTS BRIEF SUMMARY OF SECTORAL ROLES RELEVANT CHAPTERS IN SUPPORTING MHM RESPONSE 1 Introduction CCCM • Facilitate access to female friendly water and sanitation facilities Ch 2: Training Staff on MHM 2 Training staff on MHM • Monitor availability of MHM materials and supplies and advocate for the Ch 3: Conducting a needs assessment provision of appropriate MHM materials and demonstration of their use. 3 Conducting a needs assessment Ch 6: MHM and Shelter • Advocate for the design of and/or monitoring of available MHM services and
4 Providing MHM where to access them. Ch 7: MHM and Water and Sanitation Facilities Materials and Supplies Ch 14: MHM and Monitoring and Evaluation 5 MHM and Transit HEALTH • Provide health education on MHM (general & schools); Ch 2: Training Staff on MHM 6 MHM and Shelter • Support distribution and demonstration of MHM materials; Ch 3: Conducting a needs assessment
7 MHM and Water and Sanitation Facilities • Ensure access to gender-sensitive water and sanitation facilities (at health Ch 4: Providing MHM Materials & Supplies posts and clinics);
8 MHM, Disposal and Ch 9: MHM and Hygiene Promotion and Health Education Waste Management • Distribute MHM materials (especially for specific clinical conditions). Ch 10: MHM and Vulnerable Populations 9 MHM and Hygiene Promotion & Health Education Activities Ch 12: MHM and Health
10 MHM and Vulnerable Ch 14: MHM and Monitoring and Evaluation Populations EDUCATION • Ensure access to gender-sensitive water and sanitation facilities at schools; Ch 2: Training Staff on MHM 11 MHM and Education • Train staff on MHM and provide MHM to pubescent girls; Ch 3: Conducting a needs assessment 12 MHM and Health • Provide of appropriate MHM materials. Ch 4: Providing MHM Materials & Supplies
13 MHM and Protection Ch 9: MHM and Hygiene Promotion and Health Education
14 Monitoring and Evaluation Ch 11: MHM and Education
Ch 14: MHM and Monitoring and Evaluation 12 BACK TO CONTENTS BRIEF SUMMARY OF SECTORAL ROLES RELEVANT CHAPTERS IN SUPPORTING MHM RESPONSE 1 Introduction PROTECTION • Ensure access to gender-sensitive water and sanitation facilities; Ch 2: Training Staff on MHM 2 Training staff on MHM • Provide appropriate MHM materials (NFIs) and demonstrate their use; Ch 3: Conducting a needs assessment
3 Conducting a needs • Provide MHM hygiene promotion; Ch 4: Providing MHM Materials and Supplies assessment
• Develop disposal and solid waste management systems to support Ch 5: MHM and Transit 4 Providing MHM MHM through coordination with WASH. Materials and Supplies Ch 6: MHM and Shelter 5 MHM and Transit Ch 7: MHM and Water and Sanitation Facilities
6 MHM and Shelter Ch 8: MHM, Disposal and Sanitation Facilities
7 MHM and Water and Ch 9: MHM and Hygiene Promotion and Health Education Sanitation Facilities
Ch 10: MHM and Vulnerable Populations 8 MHM, Disposal and Waste Management Ch 14: MHM and Monitoring and Evaluation 9 MHM and Hygiene Promotion & Health NFIs • Provide appropriate MHM materials; Ch 2: Training Staff on MHM Education Activities
• Develop private and safe methods to distribute and demonstrate use of Ch 3: Conducting a needs assessment 10 MHM and Vulnerable MHM materials (link with the Health, WASH and Protection Sectors). Populations Ch 4: Providing MHM Materials & Supplies 11 MHM and Education Ch 10: MHM and Vulnerable Populations 12 MHM and Health Ch 14: MHM and Monitoring and Evaluation
13 MHM and Protection
14 Monitoring and Evaluation
13 THE 4 Cs IN PRACTICE
BACK TO In a large-scale emergency, interventions should CONTENTS
ideally be planned based on joint assessments, U 0 nlo 2 c 0 k $ y 2 1 r b 0 billion a yea and coordinated across agencies. Assessments AIM AND MISSION of recent emergencies suggest that different OF TOOLKIT 1 Introduction organizations will respond independently in the Coordination The objective of the MHM in Emergencies toolkit early stages, often distributing different products, is to provide streamlined guidance to support 2 Training staff on MHM having overlapping beneficiaries, and having organizations and agencies seeking to rapidly and less focus on disposal, washing facilities and appropriately integrate MHM across programming, 3 Conducting a needs the impact of products on infrastructure and assessment sectors and phases for a more cohesive response. the environment.
4 Providing MHM Although there are many competing priorities Materials and Supplies While this piecemeal approach is not ideal, Consultation inherent to an emergency response, a minimum level it may expose beneficiaries to more than one of MHM standards and programming can and should 5 MHM and Transit option, and help to inform the strengths and be introduced at the immediate onset and continued weaknesses of the different interventions. throughout an emergency to ensure that basic 6 MHM and Shelter The humanitarian community should move standards of dignity, safety and health are ensured to evaluate these interventions early in the 7 MHM and Water and for all girls and women. Sanitation Facilities emergency, collect feedback, and agree on a set of best practices that reflects the culture and
8 MHM, Disposal and circumstances of the emergency context, and Culture Waste Management enables full coverage of the population.
9 MHM and Hygiene Promotion & Health Education Activities
10 MHM and Vulnerable Populations
11 MHM and Education Communication
12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation
14 2 TRAINING STAFF ON MHM BACK TO CONTENTS
1 Introduction Regardless of gender, all staff should be knowledgeable and comfortable discussing THE TRAINING OBJECTIVES ARE TO 2.1 2 Training staff on MHM MHM. Although male staff in most contexts ENSURE ALL STAFF BECOME: should not be directly discussing MHM with 3 Conducting a needs the female beneficiaries, male staff can be • Knowledgeable on the basics of MHM TRAINING CONTENT assessment involved with planning and implementing • Capable of speaking professionally about MHM. An MHM training should make sure to cover 4 Providing MHM MHM activities (i.e. dignity kit distribution, Materials and Supplies water supply, sanitation and bathing facilities, • Versed in the cultural specifics of MHM for a a range of key topics related to menstruation and its management. It is essential to become solid waste management, etc.). given emergency context. 5 MHM and Transit familiar with the local beliefs and taboos surrounding A brief MHM training should be conducted to menstruation prior to conducting the sessions. In 6 MHM and Shelter sensitize all program staff on MHM and to provide addition, it is important to become familiar with the guidance on how to appropriately and confidently language and terms used locally when describing 7 MHM and Water and discuss it with both the target population and menstruation. This information should be integrated Sanitation Facilities colleagues. CULTURAL into the training sessions. 8 MHM, Disposal and Training of more senior staff can help ensure that SENSITIVITY Waste Management MHM is mainstreamed into program planning and In some cultures, it might be necessary to have coordination while training of field staff helps to 9 MHM and Hygiene separate male and female MHM staff trainings. Promotion & Health ensure effective day to day programming. Staff at all Education Activities In some environments, men may be more willing levels could benefit from MHM training. This includes to ask questions and discuss issues related at the Inter-agency level, clusters, ministries, camp 10 MHM and Vulnerable to MHM when females are not present and Populations management and field staff. vice versa. Therefore, it should be assessed 11 MHM and Education beforehand whether these sessions should be held collectively or separately. Over time the 12 MHM and Health team should become comfortable discussing MHM as a mixed gender team. 13 MHM and Protection
14 Monitoring and Evaluation TRAINING IS THE SINGLE MOST EFFECTIVE TOOL FOR MAINSTREAMING MHM INTO MULTISECTORAL EMERGENCY RESPONSES. 15 2.2 BACK TO CONTENTS Familiarize staff with menstrual hygiene materials: KEY TOPICS TO COVER: ADDITIONAL A few basic samples of MHM supplies should be RESOURCES brought to trainings to increase staff familiarity with the 1 Introduction • Menstruation basics, including: What is items. This includes: menstruation? How long is a menstrual period? Additional resources to support 2 Training staff on MHM • Samples of menstrual hygiene supplies relevant to • What are the symptoms of menstruation? the process of training and the context (i.e. disposable pads, reusable pads, sensitizing staff on MHM include: 3 Conducting a needs At what age does it start? At what age does cloth, cotton squares, ties/belts and underwear). assessment it end? • Just the Facts: Understanding menstruation • Waste bins (with lids) 4 Providing MHM • How do girls and women manage their (link). Materials and Supplies menstruation in this context? • Laundry soap, body soap, a designated • Sample facilitator’s note for Menstrual Hygiene MHM bucket with a lid. 5 MHM and Transit • What are the challenges experienced by Management - Staff Training (link). girls and women when managing their • Information Education Communication (IEC) • Sample presentation for Menstrual Hygiene 6 MHM and Shelter menstruation? materials on the menstrual cycle, menstrual Management Staff Training (link). waste disposal, etc. 7 MHM and Water and • What are the local cultural taboos and Sanitation Facilities • Menstrual Hygiene Matters Practitioner’s myths that exist around the management These materials should be passed around so guide (link). of menstruation? How do these impact 8 MHM, Disposal and that participants can touch and feel the materials. Waste Management girls and women? It may also be useful to provide demonstrations on how the menstrual materials are used as some staff, 9 MHM and Hygiene • What are the full spectrum of MHM needs of especially males, may not know this information. Promotion & Health girls and women living in emergencies? Education Activities For example, it is useful to demonstrate: • What are the different sectoral roles in 10 MHM and Vulnerable • How to insert menstrual pads into underwear; Populations supporting MHM? • How the sanitary pads absorb blood; and • What are the operational impacts and/ 11 MHM and Education or restrictions for girls and women when • How to wash and dry reusable pads. accessing basic services while menstruating 12 MHM and Health (e.g. access to NFIs)?
13 MHM and Protection
14 Monitoring and Evaluation
16 3 CONDUCTING A NEEDS ASSESSMENT BACK TO CONTENTS
1 Introduction 3.2 Training staff on MHM
3 Conducting a needs Adolescent girls’ and women’s strategies for KEY ASSESSMENT AREAS: assessment managing menstruation vary greatly across countries and cultures. Understanding local 4 Providing MHM MHM practices is essential for integrating MATERIALS & FACILITIES INFORMATION Materials and Supplies MHM effectively into the emergency response. SUPPLIES 5 MHM and Transit At the onset of an emergency, the addition of a few key MHM questions can serve as 1 4 6 6 MHM and Shelter a quick and informative tool for guiding PREFERENCES? FACILITIES? KNOWLEDGE GAPS? programming. More comprehensive What are girls’ and women’s What do girls and women Are girls and women familiar 7 MHM and Water and MHM assessments are advised in later preferences for menstrual want or need in terms of with the MHM materials and Sanitation Facilities phases of an emergency response. materials? What is feasible facilities for dealing with supplies, disposal options in this context? Any specific menstruation? and good hygiene practices? 8 MHM, Disposal and Waste Management type/brand? 3.1 5 9 MHM and Hygiene 2 DISPOSAL AND WASHING? Promotion & Health Education Activities TARGET POPULATION? How can women and girls TRAIN STAFF ON MHM Who should receive MHM privately dispose of or wash 10 MHM and Vulnerable materials and supplies and dry used materials? Populations Regardless of gender, all staff should be (identify scale of need)? knowledgeable and comfortable discussing 11 MHM and Education MHM. See Chapter 2 for more information 3 on training staff on MHM. DISTRIBUTION? 12 MHM and Health How should MHM materials For definitions of MHM materials and supplies, and supplies be safely and 13 MHM and Protection see Chapter 4. privately distributed to the target population? 14 Monitoring and Evaluation
17 3.3 BACK TO CONTENTS ASSESSMENT METHODS
Several methods can be used to determine the MHM A needs assessment can include both qualitative and quantitative methods: 1 Introduction practices and needs of adolescent girls and women in a given emergency. It is essential to gather this QUALITITATIVE METHODS Training staff on MHM information directly from adolescent girls and women. Focus Group Age segmented groups of girls or Qualitative methods are used to 3 Conducting a needs assessment Important information can also be obtained from Discussion (FGD) women (8-10 participants per FGD) explore beliefs or perceptions, program staff, key individuals, existing population led by a female facilitator. Recommend specific aspects of a program segmenting age groups (15-19; 20- and to capture beneficiaries’ 4 Providing MHM based surveys (i.e. access to WASH), multi-sectoral Materials and Supplies or rapid assessments and institutional knowledge. 25; 26-49). Younger girls may be direct voiced experiences. uncomfortable or shy discussing MHM. These methods provide in-depth 5 MHM and Transit It is important to protect confidentiality when information and are useful when interviewing girls and women, especially those Structured interviews This can include female WASH committee discussing sensitive topics. 6 MHM and Shelter deemed underage. with key individuals members, girls and women from the target population, or program staff.
7 MHM and Water and Sanitation Facilities Discussions with local This method is most useful when staff are staff from the same population as the female 8 MHM, Disposal and beneficiaries, as in the case of Internally Waste Management Displaced Persons (IDP), or have worked with the population before. 9 MHM and Hygiene Promotion & Health Education Activities QUANTITATIVE METHODS
10 MHM and Vulnerable Populations Checklists/ This can include physical inspections Quantitative methods are used walk-throughs of existing WASH facilities (communal, to measure extent of coverage,
11 MHM and Education family and schools) and can utilize changes in impact, and to obtain CONSULTATION AND RESPECT FOR qualitative methods as well. statistical data on knowledge CULTURE ARE KEY TO DESIGNING 12 MHM and Health and perceptions, such as of AN EFFECTIVE ASSESSMENT Surveys (i.e. PDM or This can be useful for assessing NFIs usefulness or satisfaction.
13 MHM and Protection Knowledge, Attitude and identifying gaps in MHM knowledge and Practices (KAP) and access.
14 Monitoring and Evaluation Market assessment Explore availability of products in local markets to inform existing norms (and 18 consider vouchers). 3.4 BACK TO CONTENTS ASSESSMENT QUESTIONS
Additional sector specific assessment questions can be found in sector chapters. 1 Introduction
KEY QUESTIONS WHEN ESTABLISHING AN MHM RESPONSE: SHARING ASSESSMENT Training staff on MHM Overarching Questions Information FINDINGS CAN 3 Conducting a needs STRENGTHEN EACH assessment 1. What challenges exist for girls and women when 9. What taboos or cultural beliefs exist around SECTOR’S RESPONSE managing their menstruation here? menstruation in your community? What beliefs 4 Providing MHM exist around disposal of materials? Materials and Supplies 2. In what ways are girls and women’s access to public spaces and services restricted by Facilities 5 MHM and Transit menstruation? 10. Where do girls and women prefer to change 6 MHM and Shelter 3. How did adolescent girls and women from your their menstrual materials?
community manage their menstruation before this 7 MHM and Water and emergency (or being displaced)? (i.e. materials, 11. How do girls and women prefer to dispose Sanitation Facilities where they changed) of their menstrual materials? Are there any taboos in their culture around disposal? 8 MHM, Disposal and Waste Management Materials 12. In what ways could toilets be designed better to support girls and women managing their 9 MHM and Hygiene 4. What materials do they now use? How are these Promotion & Health materials disposed of? If reusable, how are these menstruation? (For example, distance from Education Activities materials washed and dried? their shelter, lighting, locks). 10 MHM and Vulnerable Populations 5. What types of menstrual materials do adolescent 13. In what ways could bathing facilities be girls and women prefer? designed to support girls and women 11 MHM and Education washing their used menstrual materials? 6. How would you prefer to receive menstrual (For example: household versus communal, 12 MHM and Health materials? private spaces, screens, hooks, close water sources). 7. At what age do girls in your community typically 13 MHM and Protection reach menses (see Box 3A)? 14. In what ways could shelters be designed to support girls and women who may be 14 Monitoring and 8. Are men and boys aware of and/or supportive Evaluation changing or managing their menstrual of MHM? materials in these locations? 19
3.5 BACK TO CONTENTS TIPS TO ASSESS ADDITIONAL AGE OF MENARCHE RESOURCES 1 Introduction The range of age of menarche may differ in Additional resources in the Training staff on MHM various populations. The below can assist with reference supplement may be guesstimating to assure MHM response is useful for the design of needs 3 Conducting a needs appropriately targeted. assessment materials, including: assessment • Conduct FGD with older adolescent girls to ask • Sample MHM Needs Assessment Focus Group 4 Providing MHM when they started as they are more likely to be Materials and Supplies Discussion Guide (link). menstruating and more comfortable discussing the topic. • Sample MHM Needs Assessment Key 5 MHM and Transit Informant Discussion Guide (link). • Conduct FGDs with mothers or caregivers 6 MHM and Shelter (Note: Only useful if girls in the local culture tell • Oxfam’s Rapid MHM Focus Group Discussion their mothers about menstrual onset). Guide (link). 7 MHM and Water and Sanitation Facilities • Conduct interviews with adolescent girls and
8 MHM, Disposal and compare to FGD feedback. Although girls may Waste Management be less shy in a group discussion, there may be peer pressure to be seen as “normal” and 9 MHM and Hygiene they may answer to be like the other girls. Promotion & Health Education Activities • Alternative approach when girls are literate: Summary of Key Actions from Chapter 3: Conducting a needs assessment 10 MHM and Vulnerable If working with groups of girls who are literate, Populations the facilitator can ask the girls to write down 1. Determine the key areas relevant for an MHM response to assess. on a piece of paper (with no name on it) their 11 MHM and Education age at their first period. The facilitator should 2. Select assessment method(s). explain the answers are confidential and there 12 MHM and Health is no right/wrong answer. The girls should then 3. Train all male and female program staff to be confident and knowledgeable discussing and fold the papers for collection, and the facilitator planning MHM activities. 13 MHM and Protection walks around with a bag to collect them. 4. Conduct the needs assessment. 14 Monitoring and Evaluation Note: If conducted with several groups, the average should give a reasonable estimate 5. Communicate relevant learning across your organization, with cross-sectoral partners and relevant working groups. 20 of the lower end age. 4 PROVIDING MHM MATERIALS AND SUPPLIES BACK TO CONTENTS
1 Introduction Although an MHM response is more than supplies, the MHM Needs Assessment (Chapter 3) informs BOX A: BEYOND PADS: THE RANGE OF 2 Training staff on MHM the procurement and distribution of MHM materials SUPPLIES NEEDED BY GIRLS AND WOMEN and supplies (see Box A). 3 Conducting a needs Menstrual Materials Menstrual Supplies assessment Menstrual material preferences are influenced Refers to the materials used to catch blood. This Refers to the other items needed by culture, environment, access to funds, water, could be a pad, piece of cloth, tampon, cup or any to support the management of 4 Providing MHM and privacy. other preferred method. menstruation. Materials and Supplies
When selecting menstrual pads or cloths, it is 5 MHM and Transit important to consider the life cycle of usage (procurement, distribution, usage, washing/drying, 6 MHM and Shelter disposal, and waste management). 7 MHM and Water and When procuring and planning distribution, it is Sanitation Facilities important to consider the emergency phase, the emergency type (conflict, natural disaster), climate 8 MHM, Disposal and Waste Management (dry/rainy), population and setting (camps, urban areas, informal settlements). For example, in many 9 MHM and Hygiene settings, finding private spaces for washing and drying Promotion & Health Education Activities reusable materials can be a significant challenge.
10 MHM and Vulnerable Populations MENSTRUAL MATERIALS 11 MHM and Education
12 MHM and Health
MENSTRUAL 13 MHM and Protection SUPPLIES 14 Monitoring and Evaluation THROUGHOUT THIS TOOLKIT WE DIFFERENTIATE BETWEEN MHM MATERIALS AND MHM SUPPLIES. 21
4.1 4.2 BACK TO CONTENTS TRAIN DISTRIBUTION SELECT MENSTRUAL STAFF CASE STUDY MATERIALS
1 Introduction All staff, regardless of gender, should be Although a diverse range of sanitary materials are In a set of camps valuable insights were knowledgeable and comfortable discussing MHM. used around the world, the table below provides a 2 Training staff on MHM gathered from girls and women following a See Chapter 2 for more information. brief summary of the most commonly used materials large distribution of reusable pads. Many girls in emergency contexts, and specifically those 3 Conducting a needs and women indicated challenges related to assessment currently being used in low-income settings. KEY CONSIDERATIONS WHEN the color of the pads and their long drying
4 Providing MHM SELECTING MENSTRUAL times, the latter due to the pad’s extra A more extensive list of menstrual material options can Materials and Supplies MATERIALS: absorbency. The distinctive color made it difficult be found in Menstrual Hygiene Matters in Module 3: to discreetly dry them on top of tents, on clothing sanitary protection materials and disposal (see link). 5 MHM and Transit • Preferences of adolescent girls lines, and on hooks inside the house. One and women solution was to cover them with other clothing 6 MHM and Shelter and blankets, which further lengthened the • Comfort, speed of drying, and drying time. Thus, many girls and women 7 MHM and Water and absorbency (likelihood of leakage?) Sanitation Facilities would reuse the pads while they were still damp, resulting in discomfort and irritation. • Affordability and availability 8 MHM, Disposal and When possible, it is important to consult girls Waste Management • Do they need underwear? How many and and women using actual samples of various what sizes? options of available sanitary pads/cloths before 9 MHM and Hygiene Promotion & Health large procurements. Such discussions can yield Education Activities • How much or many (cloth/disposable or important insights on concerns related to color, reusable pads) are needed for each texture, and drying times and may minimize the 10 MHM and Vulnerable menstrual period? Populations challenges which arise with select materials.
• Washing, drying, storage 11 MHM and Education • Disposal options (collection, transfer 12 MHM and Health and final disposal)
13 MHM and Protection
14 Monitoring and THE TYPE OF MATERIAL SELECTED HAS IMPLICATIONS FOR OTHER Evaluation ASPECTS OF THE MHM RESPONSE SUCH AS WASH FACILITIES, DISPOSAL AND WASTE MANAGEMENT SYSTEMS, NFIs, HYGIENE PROMOTION, 22 SHELTER AND CASH ASSISTANCE. BACK TO CONTENTS TABLE 1. BENEFITS AND CONSTRAINTS OF MOST COMMON MHM MATERIALS USED IN EMERGENCIES
TYPE OF CLOTH DISPOSABLE SANITARY PADS REUSABLE SANITARY PADS 1 Introduction MATERIAL (STRIPS OF CLOTH) (COMMERCIALLY PRODUCED) (COMMERCIALLY PRODUCED) 2 Training staff on MHM BENEFITS • Available in local markets. • Generally easier to procure rapidly. • Cost effective. • Re-usable. • Perceived as ‘easier’ to manage in privacy- • Re-usable. 3 Conducting a needs assessment limited situations (i.e. camps). • Maintains traditional practices. • May be procured locally. • Easier to dry in open discreetly. 4 Providing MHM Materials and Supplies
CONSTRAINTS • Requires a private space for washing and • Environmental implication regarding disposal. • Requires a private space for washing and 5 MHM and Transit drying cloth and access to water. drying pads and access to water. • Need disposal system (immediate, transfer 6 MHM and Shelter • Requires an additional (separate) bucket and endpoint). • Requires an additional (separate) bucket and soap. and soap. • Sustainability challenges (in protracted 7 MHM and Water and • A clothesline and clips may need to be contexts). • A clothesline and clips may need to be Sanitation Facilities provided for drying. provided for drying. • Poor disposal practices result in clogged • Poor final disposal practices result in clogged latrines and other sanitation challenges. • Poor disposal practices result in clogged 8 MHM, Disposal and latrines and other sanitation challenges. latrines and other sanitation challenges. Waste Management • Washing facilities.
9 MHM and Hygiene OTHER • Color, size, and absorbency of the cloth can • Provision of disposable pads must be • May require additional cotton or cloth Promotion & Health Education Activities CONSIDERATIONS influence its acceptability. accompanied with appropriate disposal inserts. and waste management systems. • Considerations for end-point disposal and • Considerations for end-point disposal and waste management systems. • Underwear should also be provided. waste management systems. 10 MHM and Vulnerable Populations • Underwear or supportive ties should • Underwear should also be provided. be provided. 11 MHM and Education
SECTOR • WASH sector needs to provide and maintain • WASH sector needs to provide disposal • WASH sector needs to provide and maintain 12 MHM and Health IMPLICATIONS private washing/drying spaces. mechanisms and waste management systems. washing/drying spaces. • Sectoral actors need to ensure adequate • WASH/Health/NFI sectors needs to ensure • WASH/Health/NFI sectors needs to ensure 13 MHM and Protection soap (laundry & bathing) and dedicated demonstrations on use are provided during demonstrations on use are provided during MHM bucket provided. distributions. distributions. 14 Monitoring and • Sectoral actors need to ensure adequate Evaluation soap (laundry & bathing) and dedicated MHM bucket provided. 23 4.3 BACK TO CONTENTS SELECT MHM SUPPLIES
Although many organizations and agencies design their own kits, there are essential MHM supplies to include in the various kits being distributed (i.e. dignity kits, 1 Introduction hygiene kits, core relief items). The below examples illustrate the range of MHM-supportive NFI items needed for reusable and disposable options.
2 Training staff on MHM SAMPLE A: MHM SPECIFIC KIT CONTENTS (REUSABLE)
3 Conducting a needs assessment Item Specifications Quantity Other information
4 Providing MHM Soap Laundry and bathing soap 200g of each Will need to continue to distribute monthly. Materials and Supplies Bucket With a lid 1 Must be a separate container, as many women may not feel comfortable using communal 5 MHM and Transit family washing containers.
6 MHM and Shelter Reusable menstrual pads At least 4-5 pads or inserts for Commercial manufacturers often provide complete sets of pads and inserts which can be rotating. distributed one set per female. Quantity estimates generally take into account drying times.
7 MHM and Water and Sanitation Facilities Underwear Size options should be available. 3 pairs Redistribute every 6 months.
Safety Pins 6-8 8 MHM, Disposal and Waste Management Storage bag for used cloths/ Should be non-transparent, 1 These bags may be used to carry used menstrual materials and therefore must be leakproof pads washable and leakproof. and discreet. 9 MHM and Hygiene Promotion & Health Education Activities Carry bag for all menstrual Should be non-transparent and Bags are intended for discreetly holding menstruation supplies for girls and women while they supplies able to hold the storage bag, are not in their households. 10 MHM and Vulnerable extra pads and underwear. Populations
Cloth (when appropriate) Culturally acceptable forms Ensure that the texture and color are acceptable to target population. Cloth may be used 11 MHM and Education could include a kanga, sarong, as a backup method, to cover stained clothes or for covering pads/underwear drying on a etc. clothesline to enhance privacy. A minimum of 4 square meters should be provided. 12 MHM and Health Torch With batteries or solar 1 Should be designated for female household members for safer passage to toilets at night.
13 MHM and Protection IEC pamphlet on MHM Providing useful information on how to use pads, wash and dry them, and eventually dispose of them. Consider local languages and culture. 14 Monitoring and Evaluation Clothes lines and pegs 1 set 24 BACK TO CONTENTS
1 Introduction
2 Training staff on MHM SAMPLE B: MHM SPECIFIC KIT CONTENTS (DISPOSABLES)
3 Conducting a needs Item Specifications Quantity Other information assessment
Underwear Size options should be available. 3 pairs Redistribute every 6 months. 4 Providing MHM Materials and Supplies Soap Laundry and bathing soap 200g of each 5 MHM and Transit Bucket With a lid 1 Although pads will not be washed, will still need separate bucket to wash soiled underwear or
clothing. 6 MHM and Shelter
Sanitary pads 12-15 pieces Estimated amount for a monthly menstrual period; may need to continue distribution. 7 MHM and Water and Sanitation Facilities Carry bag for menstrual Should be non-transparent. 1 Bags are intended for discreetly holding menstruation supplies for girls and women while they supplies are not in their households. 8 MHM, Disposal and Waste Management Cloth (when appropriate) Culturally acceptable forms Ensure that the texture and color are acceptable to target population. Cloth may be used
could include a kanga, sarong, as a backup method or to cover stained clothes. A minimum of 4 square meters should 9 MHM and Hygiene etc. be provided. Promotion & Health Education Activities
Torch With batteries or solar 1 Should be designated for female household members for safer passage to toilets at night. 10 MHM and Vulnerable Populations IEC pamphlet on MHM Consider local languages and pictures.
11 MHM and Education
12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation
23 4.4
BACK TO INNOVATION CASE STUDY CONTENTS PROCURE MHM MATERIALS
In environments with seasonal water shortages, In a Norwegian Refugee Council (NRC) & SUPPLIES 1 Introduction it can be useful to consider a mixed kit, which warehouse in southern Ethiopia that was Key considerations when developing a contains both reusable and disposable options. supplying sanitary pads to schools in the Dollo procurement plan: 2 Training staff on MHM For example, if girls and women prefer a Ado camp, there were found to be serious reusable method, periodic lack of water access distribution delays. It was soon determined that • Specific items need monthly re-supply 3 Conducting a needs assessment may make washing difficult. In such situations, the reason was that many of the Somali men (i.e. soap, disposable sanitary pads). providing a disposable option might also be working in the warehouse were refusing to touch • Procure locally when possible. 4 Providing MHM necessary, along with essential education on or move the sanitary pads. This resulted in Materials and Supplies usage and disposal practices to girls and women. female teachers, already busy with their teaching, • Account for the total number of females of The local sanitation actors should also be to have to make extra trips to local markets to reproductive age in each household. 5 MHM and Transit informed of material shifts in order to adapt the ensure they had supplies for their students. It waste management system. is crucial that all staff, regardless of gender and • Check samples of products with beneficiaries 6 MHM and Shelter position, are sensitized and supportive to MHM before large-scale procurement. The quality may programming needs (NRC/Columbia University not be adequate or acceptable (color, absorbency, 7 MHM and Water and Sanitation Facilities Teacher’s College, 2014). or texture).
8 MHM, Disposal and • Conduct routine updates of household Waste Management demographics to account for newly menstruating girls. 9 MHM and Hygiene Promotion & Health Education Activities • Expiration dates may be required on menstrual materials due to government regulations. In
10 MHM and Vulnerable general, menstrual materials last at least 10 years if Populations not exposed to sun and moisture.
11 MHM and Education
12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation
26 BACK TO CONTENTS FIGURE 1: PROJECT CYCLE FOR MHM DISTRIBUTION
1 Introduction Select 2 Training staff on MHM Assess the menstrual situation material & 3 Conducting a needs MHM supplies assessment
4 Providing MHM Materials and Supplies
Procure 5 MHM and Transit Monitoring MHM & Feedback 6 MHM and Shelter supplies
7 MHM and Water and Sanitation Facilities
8 MHM, Disposal and Waste Management
9 MHM and Hygiene Continue Distribute Promotion & Health distribution & demonstrate Education Activities of supplies MHM supplies 10 MHM and Vulnerable Populations Conduct review
of acceptability 11 MHM and Education
12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation MAKE SURE TO DETERMINE THE AVERAGE AGE OF MENARCHE FOR THE TARGET POPULATION PRIOR TO PROCUREMENT. 27
4.5
BACK TO CONTENTS • Unintended consequences with distribution: DISTRIBUTE AND Potential safety and privacy risks related to kit DEMONSTRATION IS DEMONSTRATE MHM distribution should be identified. For example, ESSENTIAL! 1 Introduction SUPPLIES females may be at risk for harassment or humiliation when picking up kits containing Staff should not assume that beneficiaries know 2 Training staff on MHM Kits that include MHM contents should be MHM supplies. Use strategies to minimize such how to use the sanitary supplies in kits. distributed by women so they can describe risks, such as using discreet packaging and Recommendation: Include a sanitary pad 3 Conducting a needs the function of kit contents and minimize the ensuring private, safe, meeting spaces. assessment potential for embarrassment. demonstration activity during the distribution. • Special considerations for girls and women with Additional demonstration activities may be 4 Providing MHM Distributions are good opportunities for health needed and can be supported by the Health, Materials and Supplies special needs: It can be more difficult to reach education and hygiene promotion, and for answering girls and women with special needs, such as girls Protection, and Education sectors. beneficiary questions about menstrual health. 5 MHM and Transit and women with physical or mental disabilities, during routine distributions due to their limited Key considerations for a distribution plan: 6 MHM and Shelter visibility and movement within communities. In • Targeted distributions: The needs assessment such cases, it may be necessary to use community 7 MHM and Water and findings guide the distribution of MHM contents networks (i.e. women’s groups), leaders, and other Sanitation Facilities to the target population. It is important to try to sectors (i.e. Protection) to identify vulnerable girls CULTURAL achieve maximum coverage across the population. and women and target them with supplies. For SENSITIVITY 8 MHM, Disposal and Waste Management additional information, see Chapter 9. • Collaborate across sectors: Any distribution plan In some cultures, there are strong opinions about • Establish feedback mechanisms: It is important to 9 MHM and Hygiene including MHM contents should be shared with all strictly adhering to expiration dates on goods. Promotion & Health provide girls and women with information on how Education Activities relevant sectors (WASH, NFI, Education, Protection When a shipment of sanitary pads was provided and Camp Management) to avoid duplication. and to whom they can share feedback or criticisms to Somali refugees in Ethiopia without expiration about kit contents and the distribution practices. 10 MHM and Vulnerable dates, a few women noticed and refused to use Populations • There are risks of partial coverage if embedding them. Soon enough, all of the women refused • Distribution frequency: Experience suggests that distributions into existing sectoral activities: (i.e. to use the pads as well. Demonstration and monthly distributions reduce likelihood of resale of 11 MHM and Education health clinic outreach activities, women’s groups education while distributing MHM supplies disposables as compared to larger quantities for and schools. can be used to provide education and address extended time periods. 12 MHM and Health these types of misinformation issues. Routine • In some cases, it may be feasible for men to also monitoring can also enable the quick detection 13 MHM and Protection be involved in distributions. Consult first. and resolution of such challenges. (Norwegian Refugee Council (NRC)/Columbia University 14 Monitoring and Evaluation Teacher’s College, 2014).
28 4.6 BACK TO CONTENTS MONITORING AND IMPORTANT FEEDBACK TO COLLECT INCLUDES: FEEDBACK
Reusables: Relevant to both reusables 1 Introduction A plan for monitoring the provision of MHM and disposables: materials should be introduced immediately 2 Training staff on MHM (see Chapter 14). This can be done through a • Are the numbers of re-usable pads adequate • Did the distributions provide a sufficient quantity combination of the following methods: to be washed and dried in-between use for all of MHM-related NFIs for the number of females 3 Conducting a needs members of a household? Was there enough in their household? This includes sanitary assessment fabric for a full menstrual cycle? materials, underwear, soap, and other MHM- QUALITATIVE METHODS supportive supplies. 4 Providing MHM Materials and Supplies • Is the fabric provided comfortable, absorbent, Focus Group Age segmented groups of girls and does it dry fast enough? • Were there any barriers or problems with Discussion or women (8-10 participants 5 MHM and Transit the distribution? Were all households able to (FGD) per FGD) led by female Disposables: participate? facilitator to inquire about 6 MHM and Shelter things like the acceptability of • Are there enough disposable pads materials and appropriateness provided to cover their full menstrual cycle 7 MHM and Water and Sanitation Facilities of distribution methods. (for that month)?
8 MHM, Disposal and Key informant This can include female Waste Management interviews WASH committee members,
(KII) girls and women from the 9 MHM and Hygiene Promotion & Health target population, or Education Activities program staff.
10 MHM and Vulnerable QUANTITATIVE METHODS CULTURAL SENSITIVITY Populations
Post- This can be useful for 11 MHM and Education distribution assessing the acceptability A key consideration when adding MHM questions to an existing PDM survey is that male survey data monitoring of materials, coverage, and collectors may skip MHM related questions due to embarrassment (or girls/women may be hesitant to 12 MHM and Health (PDM) knowledge gaps. respond to a male surveyor). When appropriate, male surveyors should be partnered with a female to Surveys assist, or a brief separate MHM focused PDM can be implemented using exclusively female surveyors. 13 MHM and Protection
14 Monitoring and Evaluation
29 4.6 4.7 BACK TO CONTENTS CASH ADDITIONAL TRANSFERS RESOURCES
1 Introduction There is growing interest and evidence of the • Sample MHM PDM survey effectiveness of cash transfers to support affected 2 Training staff on MHM template (link). populations in acquiring supplies directly. Cash
3 Conducting a needs increases choice and can be one option to enable • UNICEF WASH and Dignity Response Kits assessment access to goods or services, however the use of Guidance (link). cash transfer programming for addressing MHM 4 Providing MHM • Considerations for selecting sanitary protection Materials and Supplies needs of adolescent girls and women has not been studied. If opting to use this approach, specific and incontinence materials for refugee contexts by S. House on behalf of UNHCR, 2016 (link). 5 MHM and Transit considerations need to be taken into account and adequately weighed before employing cash transfers.
6 MHM and Shelter Concerns remain about who controls the cash within a household and if women, who may be managing 7 MHM and Water and the household budget, will use these funds for their Sanitation Facilities personal hygiene needs. Girls and women may Summary of Key Actions from Chapter 4: also have restricted access to local markets and 8 MHM, Disposal and Providing MHM Supplies Waste Management shops, with men and boys possibly uncomfortable purchasing menstrual products. There is a need 1. Consult girls and women on their preferences. 9 MHM and Hygiene for increased evidence on whether CTP is useful to Promotion & Health 2. Train staff on the basics of MHM. Education Activities support MHM. 3. Select appropriate MHM materials and supplies. It is important to consider the following aspects if 10 MHM and Vulnerable Populations implementing a CTP: 4. Coordinate with other sectors to ensure effective distribution achieving maximum coverage without overlap. 11 MHM and Education • For unrestricted cash distributions, agencies should try to monitor through PDM’s and household 5. Rapidly procure MHM-related contents for kits, with an emphasis on finding materials locally.
MHM and Health surveys whether adolescent girls and women are 12 6. Distribute MHM contents in kits (or NFIs) through safe and private means, embedded within able to use these funds to support MHM. existing appropriate activities and always include demonstrations on the use of materials. 13 MHM and Protection • For voucher systems, agencies should check with 7. Provide continuous monitoring of MHM supplies through utilizing existing PDMs and the use
14 Monitoring and the selected vendors to ensure these funds are of qualitative methods (FGDs and structured interviews). Evaluation used to support MHM. 8. Communicate key learning gathered across your organization, crosssectoral partners and 30 working groups. 5 MHM IN TRANSIT BACK TO CONTENTS
1 Introduction
5.1 2 Training staff on MHM
3 Conducting a needs During an emergency, girls and women may need RESPONDING TO MHM IN • Infrastructure: Ensure that female friendly water assessment to walk or travel long distances over a sustained TRANSIT NEEDS and sanitation facilties are available in transit period of time. Upon fleeing their homes, they where possible, and at border points, reception 4 Providing MHM Materials and Supplies are oftentimes unable to bring many important When girls and women arrive at their next destination centers, temporary shelters, etc. as girls and personal belongings, including menstrual materials. (e.g. a border point, railway station, transit center, women will need a place to change their materials, 5 MHM and Transit In addition to a lack of materials, it may also be etc.), they may experience shame if their clothing clean themselves or clothing and in some cases, difficult to find a safe, private space for changing has been spoiled by blood while traveling. They help restore their basic hygiene and dignity after 6 MHM and Shelter or cleaning themselves. This can result in girls and may be in urgent need for a safe and private space their journey. women heading off roads into forests, alleyways for dealing with their menstruation and leaks. In 7 MHM and Water and or others places in search for private spaces response, it is important for response staff receiving Sanitation Facilities to discreetly change, which can create safety beneficiaries to be both sensitive and supportive to concerns. Water access while on the road may also 8 MHM, Disposal and their MHM concerns. Waste Management be a problem. See Figure 1 for review of MHM in transit challenges. Young girls may be separated A few suggested key actions include: 9 MHM and Hygiene from their families and thereby lack their usual Promotion & Health access to materials, supplies and information. • Materials: Provide contingency menstrual materials Education Activities (pads, underwear, soap) for menstruating girls and women. As it can be challenging or insensitive to 10 MHM and Vulnerable Populations directly ask girls and women about their menstrual material preferences immediately upon arrival, this 11 MHM and Education information can also be gathered from longer-term
camp populations or beneficiaries who have been 12 MHM and Health waiting at the transit center/border point for
a longer duration of time. 13 MHM and Protection
14 Monitoring and Evaluation RATHER THAN A BLANKET DISTRIBUTION, MHM IN TRANSIT OFTEN AIMS TO TARGET GIRLS AND WOMEN MOST IN NEED OF MENSTRUAL MATERIALS. 31
FIGURE 1: MHM CHALLENGES FACED BY GIRLS AND WOMEN WHILE IN TRANSIT BACK TO CONTENTS
1 Introduction
2 Training staff on MHM UPON LEAVING THEIR WHILE BEING UPON ARRIVAL UPON ARRIVAL AT HOMES AND WHILE PROCESSED AT THE NEXT TO TRANSIT OR A CAMP OR NEW 3 Conducting a needs assessment TRAVELING, THEY MAY… DESTINATION/ BORDER RECEPTION CENTERS, ACCOMMODATION POINT, THEY MAY… THEY MAY… THEY MAY… 4 Providing MHM Materials and Supplies • Lack of materials for managing • Experience shame if their • Need continued provision of • Need to be consulted on their blood. clothing has been spoiled basic menstrual materials (i.e. MHM preferences and needs. 5 MHM and Transit by blood or be at risk for pads, underwear, soap). • Lack toilets or washrooms for • Need longer term solutions exploitation in exchange for 6 MHM and Shelter changing materials or cleaning • Need access to private female for sustaining access to basic goods. themselves friendly toilets and bathing MHM materials (i.e. providing • Need basic menstrual hygiene spaces for changing reusable materials, maintaining 7 MHM and Water and • May have to go into forests or Sanitation Facilities supplies (i.e. pads, underwear, and cleaning themselves. frequent distributions of alleyways to find discreet places soap) disposables, etc.). to change, creating safety 8 MHM, Disposal and Waste Management concerns. • Need access to private female • Need new toilet and bathing friendly toilets and bathing infrastructure that integrates the • May be unable to clean 9 MHM and Hygiene spaces for changing and minimum standards for private Promotion & Health menstrual materials, clothing Education Activities cleaning themselves. female friendly toilets and or find water. bathing spaces. 10 MHM and Vulnerable Populations
11 MHM and Education
12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation
32 5.2 BACK TO CONTENTS ENSURING GIRLS AND WOMEN IN NEED RECEIVE MATERIALS 1 Introduction
A variety of methods can be used to quickly assess 2 Training staff on MHM who may need assistance most urgently. Discretion CASE STUDY CASE STUDY and sensitivity are essential, especially considering 3 Conducting a needs that girls and women may be tired from the journey assessment and feel embarrassment about their menstruation. A rapid assessment conducted in refugee camps On Lesvos Island in Greece, staff realized that in Tanzania identified a range of menstruation a comprehensive MHM kit was not needed 4 Providing MHM A few possible methods for identifying girls and Materials and Supplies women include: challenges experienced by girls and women or possible due to the transitory nature of the while traveling from the Democratic Republic of refugees. They found that when providing 5 MHM and Transit • Incorporate a menstruation question into existing Congo and Burundi to Tanzania. This includes a hygiene kits, there was a lot of wastage as many health or protection screenings upon arrival at lack of sanitary materials, poor access to water, products were too heavy to be carried across 6 MHM and Shelter border points, reception centers. and challenges finding safe and private spaces Europe. The response adapted to provide for changing or diposing materials. A few women smaller hotel-sized hygiene items that could be • Female protection actors can organize small 7 MHM and Water and expressed feelings of extreme embarrassment distributed at hygiene kiosks and to enable the Sanitation Facilities women’s circles to discuss menstruation (among upon arrival at the border, as there were blood provision of individual items (not entire kits). other protection related discussion items such as stains on their clothing. In response, a small pilot Each refugee was then able to select what items 8 MHM, Disposal and GBV). Waste Management project was introduced, led by the health sector. they needed, including disposable menstrual
• If a displaced population is literate, informative Health staff were trained on how to sensitively pads and underwear (International Rescue 9 MHM and Hygiene screen menstruating girls and women during Committee, Greece, 2016). Promotion & Health signs can be put up instructing girls and women Education Activities on where they can request or discreetly pick up routine health screenings. Girls and women identified were then provided a basic menstrual menstrual hygiene materials. 10 MHM and Vulnerable hygiene kit comprised of reusables pads, a Populations bucket, underwear, soap and a clothesline. In addition, WASH actors also worked towards 11 MHM and Education improving existing toilets and washing spaces at the border points, including adding new doors 12 MHM and Health and latches (International Rescue Committee, Tanzania, 2017). 13 MHM and Protection
14 Monitoring and Evaluation
33 BACK TO CONTENTS Summary of Key Actions from Chapter 5: MHM in transit
1 Introduction 1. Procure basic contingency menstruation materials and supplies for girls and women arriving and in need of assistance.
2 Training staff on MHM 2. Develop an appropriate method for screening or identifying girls and women needing menstrual materials. 3 Conducting a needs assessment 3. Ensure that female friendly toilet and washing facilties are available for girls and women in 4 Providing MHM transit, and upon arrival at border points/transit centers etc. Materials and Supplies
5 MHM and Transit
6 MHM and Shelter
7 MHM and Water and Sanitation Facilities
8 MHM, Disposal and Waste Management
9 MHM and Hygiene Promotion & Health Education Activities
10 MHM and Vulnerable Populations
11 MHM and Education
12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation
34 6 MHM AND SHELTER BACK TO CONTENTS
1 Introduction 6.1 2 Training staff on MHM
Overcrowding in urban areas, camp situations 3 Conducting a needs assessment or informal settlements can intensify the challenges KEY MHM CONSIDERATIONS for adolescent girls and women to find safe, FOR SHELTER 4 Providing MHM private spaces for managing menstruation. Materials and Supplies Shelter actors, including camp management, This can be more difficult when living in tents, Consult first: This information can be quickly should consider including some basic MHM-related multi-household dwellings, unfinished buildings gathered through the use of FGDs and KIIs with 5 MHM and Transit questions into assessments for programs. or communal spaces. adolescent girls and women. When possible, these
can be added to existing Shelter related consultations 6 MHM and Shelter Girls and women have different preferences about WHAT TO LEARN: and assessments with girls and women. Please see where to change menstrual materials. Some prefer Guidance Note B: Assessment Methods for more 7 MHM and Water and Sanitation Facilities toilet facilities and others prefer to change in bathing 1. Where do girls and women change their menstrual information on available methods. or sleeping spaces. Such preferences may be materials? (i.e. toilets, bathing spaces, rooms) 8 MHM, Disposal and influenced by cultural practices, a lack of privacy (i.e. Waste Management absence of walls, doors), poor safety conditions (i.e. 2. Do they feel safe or comfortable managing their menstruation there? lack of lighting) and restricted mobility within their 6.2 9 MHM and Hygiene Promotion & Health community or camp (due to gender norms). In many 3. How do girls and women dispose of used sanitary Education Activities contexts, shelters and facilities are not designed to materials? meet these needs, are made from transparent or TRAIN SHELTER STAFF MHM and Vulnerable flimsy materials that do not offer protection, and lack 4. Is this supported by the waste management system? Populations privacy partitions. All Shelter staff, regardless of gender, should be 5. (If reuseables) How and where are sanitary materials knowledgeable and comfortable discussing MHM. MHM and Education washed, dried, or stored? Please see Chapter 2 for more information on 12 MHM and Health 6. Is there adequate privacy for washing and drying? training staff.
7. In what ways could shelter structures be designed 13 MHM and Protection to better support girls and women with managing menstruation? (For example, privacy partitions, 14 Monitoring and Evaluation lighting, locks, etc.).
35 6.3 BACK TO CONTENTS
IMPROVING INFRASTRUCTURE FOR MHM
1 Introduction Water and sanitation structures: As the development Privacy partitions: Where appropriate for gender, age of WASH facilities is often a collaborative effort or cultural reasons, family and/or gender segregated CASE STUDY 2 Training staff on MHM between WASH and Shelter actors, it is important partitions should be installed. These should be made for both sectors to recognize a few specific MHM from non-transparent materials to help improve girls 3 Conducting a needs To respond to the influx of Burundian refugees assessment considerations (see Chapters 6 and 7 for information and women’s ability to privately change menstrual coming through the Tanzanian border on WASH facilities, disposal and waste management). materials within their shelter structures. crossings, mass transition shelters were 4 Providing MHM Materials and Supplies Shelter Structures: Given that a range of types Mass Shelters: Special consideration should be constructed for these populations to sleep in of structures and living situations are found in given to the privacy needs of girls and women staying upon arrival. These shelters, although very 5 MHM and Transit emergencies, a few important MHM measures in mass shelters. For example, providing a small, large, lacked any partitions inside the should be considered when developing or improving partitioned area designated for changing clothes or structures and had no doors. Many girls and 6 MHM and Shelter these spaces. These improvements are essential for menstrual materials may be necessary. women shared their discomfort changing their improving the safety of girls and women. clothing or menstrual materials inside these 7 MHM and Water and Lighting: Provide internal and area lighting. Upon spaces, explaining that other women, children Sanitation Facilities Considerations should include: consultation with beneficiaries, lighting should and sometimes men could easily see them. be provided in context as needed for improved The border staff decided to explore if providing 8 MHM, Disposal and Building materials: Use strong, non-transparent Waste Management safety. Flashlights or torches should be provided for partitions that would create small changing building materials to ensure that girls and women individual use; ensure these are available to female areas inside the structure would help enable (especially while changing menstrual materials) are 9 MHM and Hygiene household members as needed. girls and women to change more privately. It is Promotion & Health not visible from outside the structure. Education Activities important to directly consult girls and women Allocation of shelter: Avoid overcrowding and regarding their privacy concerns and determine Safety measures: Provide doors and windows with consider placement as related to sanitation and 10 MHM and Vulnerable if some small improvements can be introduced Populations inner locks. water access. to increase their comfort, dignity and safety while residing in mass shelters (International Rescue 11 MHM and Education Committee (IRC) - Tanzania, 2017).
12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation
36 6.4
BACK TO CONTENTS MONITORING AND FEEDBACK
1 Introduction It is advisable to add on a few MHM related questions To be informed by discussions with girls and to any existing shelter and settlement management women: 2 Training staff on MHM checklist and inspection activities. An example of key • Do girls and women feel that their shelters are questions to include: private and safe spaces? (Why or why not?) 3 Conducting a needs assessment To be informed by direct observations of • Do girls and women feel comfortable changing shelter structures: 4 Providing MHM their menstrual materials within their shelters (why Materials and Supplies • Are structures built from strong, non-transparent or why not?) building materials? 5 MHM and Transit • Do girls and women feel comfortable drying their used menstrual materials within or around their • Do doors and windows (when installed) have 6 MHM and Shelter interior locks? shelters (why or why not)?
7 MHM and Water and • Are privacy partitions installed within family or For a WORD version of the checklist, see link. Sanitation Facilities multi-family dwellings (when gender, age and culturally appropriate)? 8 MHM, Disposal and Waste Management • Is both internal and area lighting provided? 9 MHM and Hygiene Promotion & Health • Are shelters located within safe access to water Education Activities and sanitation infrastructure? 10 MHM and Vulnerable *See Chapters 7 and 8 for WASH infrastructure Populations monitoring guidance. 11 MHM and Education
12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation
37 BACK TO CONTENTS Summary of Key Actions from Chapter 6: MHM and Shelter
1 Introduction Consult girls and women, including their preferences of locations for changing, disposing and washing of menstrual materials.
2 Training staff on MHM Train Shelter staff on the basics of MHM.
3 Conducting a needs assessment Build female friendly water and sanitation facilities in collaboration with WASH actors.
4 Providing MHM Construct shelter structures the ensure that girls and women have adequate privacy and safety Materials and Supplies for managing their menstruation.
5 MHM and Transit Monitor and gather feedback on the acceptability and challenges experienced by girls and women in managing their menstruation within shelter structures. 6 MHM and Shelter
7 MHM and Water and Sanitation Facilities
8 MHM, Disposal and Waste Management
9 MHM and Hygiene Promotion & Health Education Activities
10 MHM and Vulnerable Populations
11 MHM and Education
12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation
38 7 MHM AND WATER AND SANITATION FACILITIES BACK TO CONTENTS
1 Introduction 7.1 2 Training staff on MHM
Women and girls require more privacy for 3 Conducting a needs assessment sanitation than men and boys, especially KEY CONSIDERATIONS: TRAIN WASH STAFF when dealing with menstruation. Maintaining All WASH staff, regardless of gender or personal • ‘Look before you leap.’ Rapidly building 4 Providing MHM safety and dignity while accessing sanitation beliefs, should be knowledgeable and comfortable Materials and Supplies infrastructure without determining the needs facilities remains a widespred challenge in discussing MHM. Please see Chapter 2 for more and preferences of girls and women can result humanitarian contexts. information on training staff. 5 MHM and Transit in future delays and costly modifications.
Most MHM requirements for women and girls are 6 MHM and Shelter • Minimal new implications. A well-designed similar to basic hygiene and sanitation needs. This sanitation response should already address includes the following: 7 MHM and Water and most MHM needs when assuring the safety, Sanitation Facilities • A safe, private place to change their menstrual privacy and dignity of women and girls. Only materials (at least 3 times daily), including during a few components are additional and specific 8 MHM, Disposal and Waste Management the night. to MHM.
• Broad staff consensus is key. All staff, 9 MHM and Hygiene • A place to privately wash their hands with soap and Promotion & Health water after changing menstrual materials. regardless of gender, should be familiar and Education Activities comfortable discussing MHM. • A safe, private place for bathing typically once 10 MHM and Vulnerable Populations a day.
• A method for discreetly disposing of menstrual 11 MHM and Education waste, or if reusable materials, privately and hygienically washing and drying them. 12 MHM and Health
There is not one universal approach used by all 13 MHM and Protection girls and women. Managing menstruation is very ENGAGE BENEFICIARIES EARLY IN A RESPONSE TO DEVELOP SOLUTIONS AND personal, and adolescent girls and women will 14 Monitoring and PREVENT POOR DISPOSAL PRACTICES THAT CAN LEAD TO BLOCKAGE AND Evaluation make choices based on culture, preference and DAMAGE OF PIPES. perceived safety. 39 7.2
BACK TO CONTENTS MHM AND WASH FIGURE 1: BUILDING MHM Consult girls and women: INTO A WASH RESPONSE SYSTEMS • Consult girls and women directly on the location of sanitation facilities. 1 Introduction Water and sanitation systems are established during the acute phase of the emergency, including 1 • Discuss proposed plans for toilets with girls and 2 Training staff on MHM measures for supporting MHM. These may need to CONSULT GIRLS AND WOMEN women, highlighting MHM considerations, based be updated if an emergency becomes protracted. What are their privacy concerns? What are their on description and visual depictions. 3 Conducting a needs The needs assessment in Chapter 3 will inform assessment safety concerns? Are there any cultural taboos on the appropriateness of the MHM measures to be • Once the first facilities are built, female staff should this topic? introduced. 4 Providing MHM conduct walk-throughs with beneficiaries and elicit Materials and Supplies feedback from users. It is important to continue dialogue with both 5 MHM and Transit adolescent girls and women as systems are 2 Equip facilities with female friendly measures: established, to reduce the risk of costly errors BUILD FEMALE FRIENDLY FACILITIES 6 MHM and Shelter in infrastructure provision. Basic sanitation infrastructure will need to adopt a few Where should the washing and toilet facilities be basic female friendly measures in the development or
7 MHM and Water and located? Gender segregated? Where should water rehabilitation process (see Figure 2). See the MHM Sanitation Facilities be located? How should they be designed? minimal requirements for household, communal and public toilets and bathing spaces in Table 1. 8 MHM, Disposal and Waste Management 3 9 MHM and Hygiene Promotion & Health ENABLE WASHING AND DRYING OF Education Activities REUSABLES MATERIALS
10 MHM and Vulnerable Do they need seperate buckets? How much Populations additional soap to provide? Are there private spaces for washing and drying? 11 MHM and Education
12 MHM and Health MAKING MODIFICATIONS EARLY IS FAR 4 13 MHM and Protection PROVIDE MENSTRUAL EASIER THAN CORRECTING ERRORS HYGIENE PROMOTION
14 Monitoring and AFTER INFRASTRUCTURE IS BUILT. Evaluation Do they know where to appropriately use the materials provided? Do they know how to 40 dispose of menstrual waste? BACK TO FIGURE 2: EXAMPLE OF A FEMALE FRIENDLY TOILET CONTENTS
Adequate numbers of safely located 1 Introduction toilets separated (with clear signage) FEMALES FEMALES FEMALES FEMALES from male facilities. 2 Training staff on MHM Safe and private toilets with inside FEMALES FEMALES 3 Conducting a needs door latch assessment
FEMALES Clear signs instructing girls and 4 Providing MHM women to dispose of menstrual Materials and Supplies waste in the trash bin 5 MHM and Transit
FEMALES A shelf and hook for hygienically storing 6 MHM and Shelter belongings during usage. 7 MHM and Water and Sanitation Facilities Night time light source both inside and outside of the toilets 8 MHM, Disposal and Waste Management Easily accessible water (ideally inside the cubicle) for girls and 9 MHM and Hygiene Promotion & Health women to wash themselves and Education Activities menstrual materials. 10 MHM and Vulnerable Trash bins (with lids) to dispose of Populations used menstrual materials 11 MHM and Education Walls, door and roof are made of non-transparent materials with no 12 MHM and Health gaps or spaces. 13 MHM and Protection Some units should be accessible to 14 Monitoring and people with disabilities. Evaluation
41 TABLE 1: MINIMUM REQUIREMENTS FOR FEMALE FRIENDLY FACILITIES BACK TO CONTENTS HOUSEHOLD COMMUNAL TOILETS PUBLIC TOILETS BATHING SPACES TOILETS (e.g. schools, public spaces) 1 Introduction 1. Access to water
2 Training staff on MHM Tippy tap or handwashing Handwashing Handwashing Water source close to or at station station station the facility
3 Conducting a needs assessment Also consider means to carry water into the cubicle for hygiene needs
2. Access to soap Soap should be provided Soap provided to households Soap should be provided 4 Providing MHM Materials and Supplies to households during during distributions may be to households during distributions used distributions 5 MHM and Transit Soap is needed to be able to wash blood off hands or menstrual materials. In public facilities, soap should be provided.
6 MHM and Shelter 3. Adequate privacy
7 MHM and Water and This includes a door, an internal lock/latch, sufficiently high walls/windows, privacy screens and no gaps or holes Sanitation Facilities in the structure.
8 MHM, Disposal and 4. Sufficient number of Household toilets are not Waste Management gender segregated facilities generally gender segregated
9 MHM and Hygiene Male and female facilities should be physically separated, with clear and appropriate signage. Promotion & Health Education Activities 5. Sustainable, acceptable Based on consultation, and appropriate menstrual household toilets may or may 10 MHM and Vulnerable Populations waste collection, transfer not need in-cubicle waste and disposal system.* disposal 11 MHM and Education This mechanism should be informed by direct consultation from girls and women as there are cultural sensitivities surrounded menstrual waste. Females should be provided with adequate education and materials if required regarding the available disposal mechanisms 12 MHM and Health 6. Provision of a light 13 MHM and Protection source to ensure (if facility is open at night) accessibility at all times 14 Monitoring and Evaluation Where electric lighting is not feasible, handheld torches are an alternative. When electric lighting is not feasible, hand held torches are an alternative with a sustainable power source.
42 * Provision should be considered to make the actual footprint of the cubicle slightly larger than male only facilities to accommodate the MHM disposal design. BACK TO CONTENTS HOUSEHOLD COMMUNAL TOILETS PUBLIC TOILETS BATHING SPACES TOILETS (e.g. schools, public spaces) 1 Introduction Additional improvements can also include:
2 Training staff on MHM 1. Water access inside the cubicles 3 Conducting a needs Direct access to water inside the stall can enhance privacy and comfort during MHM. assessment
2. A hook or shelf inside 4 Providing MHM Materials and Supplies the cubicle
This enables girls and women to hygienically place their bags and personal items while using the facility 5 MHM and Transit
3. A mirror inside the 6 MHM and Shelter cubicle or facility
7 MHM and Water and A mirror, located at a low position, ensures that girls and women can check their clothing to confirm there are no blood stains, Sanitation Facilities enhancing their confidence and dignity.
8 MHM, Disposal and Waste Management
9 MHM and Hygiene Promotion & Health Education Activities
10 MHM and Vulnerable Populations
11 MHM and Education
12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation
43 Other key things to consider: BACK TO CONVENIENT WATER ENABLE PRIVACY FOR WASHING CONTENTS • Both the design of waste bins and end-point SOURCE IN TOILETS OF MENSTRUAL MATERIALS: disposal systems should be developed in Considerations for washing can be either for consultation with girls and women. Taboos and communal private washing places or the provision 1 Introduction fears may exist of boys and men, or other girls and In discussions with girls and women, they almost of MHM supplies for washing at home (buckets, women seeing used materials. See Chapter 7 universally prefer for a water source to be located laundry soap, and clothes line.) It is important to 2 Training staff on MHM on MHM disposal. directly inside the toilet cubicle. However, it is note that washing used menstrual cloths (or related recognized that this is not a standard practice 3 Conducting a needs • It’s important to ensure that all designs for bathing materials such as underwear) is not something girls but something that should be introduced when assessment facilities take into account provision for access by and women are comfortable doing in the presence of possible. In addition, in some cultures it may disabled persons (i.e. access ramp, supports on others, even females. 4 Providing MHM already be common practice to bring water Materials and Supplies internal walling, low level Hand Washing Facilities into the toilets for anal washing and thus an The following things should be addressed after (HWF), spacious room to allow for maneuvering additional water source may not be necessary. consultation with girls and women: 5 MHM and Transit etc.) See Chapter 9 for more information. • If public laundry spaces are introduced, private • If adequate lighting is not feasible, provide torches 6 MHM and Shelter cubicles may be needed for this task, or or solar lamps, to support use of toilets during washrooms may need washing slabs. the nighttime. CASE STUDY 7 MHM and Water and Sanitation Facilities • Bathing or laundry spaces should have discreet • If possible, design the water supply network to drainage (leading to soakaways), so any water with 8 MHM, Disposal and allow for connection to sanitation facilities either Displaced girls and women living in camps in Waste Management menstrual blood cannot be seen outside the unit. during initial installation, or at a future date, Myanmar were uncomfortable using toilets at and also arrange for water supply to all relevant night due to security fears and discomfort. Lights 9 MHM and Hygiene ENABLE PRIVACY FOR DRYING OF Promotion & Health institutions in the settlement. were installed directly around the toilets to make Education Activities MENSTRUAL MATERIALS (REUSABLE them more accessible. However, as these lights • If water is not available in the cubicle itself, women PADS, UNDERWEAR, CLOTHS, ETC.): were the only continuous light source throughout 10 MHM and Vulnerable and girls will need to carry it in with them. In areas Populations the night, groups of men began gathering at the where anal washing is the norm, this will need to Drying menstrual cloths or pads poses challenges lit female toilets in the evening to discuss politics. be addressed in any case, but where toilet paper is given taboos and privacy limitations. Girls and 11 MHM and Education Girls and women felt even less comfortable used, ways of collecting and carrying water to the women often seek to hide them (i.e. hanging cloths using toilets than before. Camp staff responded toilet are needed (see chapter on NFIs). under other cloths on the line or drying them under 12 MHM and Health however, and soon installed additional lights the bed). Although it is ideal for cloths to be dried in elsewhere in the camp and convinced men to the sunlight and fully dried before use, limited space 13 MHM and Protection move their discussions there. It is important to and privacy fears make this a challenge. Private constantly monitor safety measures and to be screened areas in households or communal bathing 14 Monitoring and responsive to the unanticipated consequences of Evaluation facilities for hanging menstrual cloths may address new infrastructure or programming. (Focus Group these challenges. Discussion, Rakhine State, Myanmar 2015). 44 A drying hanger useful for drying BACK TO reusable pads CONTENTS and underwear indoors (see case
U 0 nlo 2 c 0 k $ y 2 1 r b study below). CASE 0 billion a yea STUDY 1 Introduction
In camps in northern Uganda, south Sudanese 2 Training staff on MHM girls and women were provided washable pads 3 Conducting a needs and underwear. The organization distributing the assessment pads was different than the responsible WASH
actor. In this case, girls and women were not 4 Providing MHM Materials and Supplies consulted on how they would wash and dry the reusable cloth pads, and were not provided 5 MHM and Transit MHM-RELATED NFI CASE STUDY with a bucket for washing pads (and most CONSIDERATIONS TO SUPPORT women only had one large cooking pot). Thus 6 MHM and Shelter THE WASHING AND DRYING OF women and girls would wash the pads in a In the Bwagariza refugee camp in Burundi, when nearby river and hang them to dry briefly on MATERIALS: 7 MHM and Water and girls and women left their washed pads outside nearby bushes. The cloth pads rarely had a Sanitation Facilities • Provision of MHM-designated buckets or to dry (which they only did when they were also chance to fully dry, as women and girls worried basins with lids (as girls and women will not outside doing washing or chores), the pads were that men might see them. Therefore many 8 MHM, Disposal and Waste Management want to use the same buckets for cooking and frequently stolen. This deterred many of them were forced to regularly re-use damp pads. In other laundry activities). It can also be used for from drying pads outside, despite knowing that addition, the river washing spot was only 50 9 MHM and Hygiene soaking and storage when not in use. this was the best method. Instead, they would meters upstream from the main intake of the Promotion & Health Education Activities hang their pads indoors, but this lengthened camp’s water supply, possibly contaminating the • Additional laundry soap for girls and women to the drying time needed. Thus, many girls and drinking supply. This example indicates 10 MHM and Vulnerable wash menstrual materials women were found to be re-using damp pads, the importance of consulting girls and women Populations causing skin irritations. It is important that girls on the full spectrum of MHM, including washing • A clothesline and clips to ensure girls and and women are provided with enough reusable and drying needs. It also highlights the critical 11 MHM and Education women can dry materials separately. pads to allow for drying time of used pads. role of coordination in supporting MHM. Indoor drying was also found to be improved Improved communication between actors could 12 MHM and Health • In some contexts, women may want a piece of when girls and women were supplied with locally have mitigated or prevented the contamination cloth to privately cover these materials while procured plastic hangers with pre-existing pegs of the water source. (International Federation 13 MHM and Protection drying. See Chapter 3 for more information. and a hook on the top. (International Red Cross of the Red Cross and Red Crescent Societies, and Red Crescent Societies, Burundi) East Africa) 14 Monitoring and Evaluation
45
7.3 BACK TO CONTENTS INTEGRATE MENSTRUAL HYGIENE MONITORING AND • Are there locks in the inside of all toilets? INTO ROUTINE HYGIENE FEEDBACK • Are there waste bins with lids located inside the 1 Introduction PROMOTION ACTIVITIES: A plan for monitoring the water and sanitation female toilets?
2 Training staff on MHM facilities should be introduced immediately and done To ensure that girls and women understand the • Is there a water source inside or nearby the continuously (see Chapter 13). This can be done intended usage and management of the water and female toilets? 3 Conducting a needs through a combination of the following methods: assessment sanitation facilities provided, including the MHM- • Is there a maintenance system in place? supportive measures, educational campaigns should • Discussion with key informants, community 4 Providing MHM be designed and integrated into routine hygiene members, and relevant staff (WASH, CCCM, Materials and Supplies promotion activities. Educational messages should be Protection). consistent with the menstrual materials and supplies 5 MHM and Transit and WASH facilities being provided. See Chapter 8 • Focus Groups Discussions for more information 6 MHM and Shelter • Environmental inspections
7 MHM and Water and • Direct observations (with checklists) Sanitation Facilities To be informed by discussions with girls and WASH SYSTEMS – OBSERVATION women: 8 MHM, Disposal and Waste Management CHECKLIST • Do girls and women feel that toilets are private and safe? (Why or why not?) 9 MHM and Hygiene Add a few MHM related questions to any existing Promotion & Health Education Activities water and sanitation management checklist and • Do girls and women think that the toilets are inspection activities. Example questions to include: appropriately located? (Why or why not?) 10 MHM and Vulnerable Populations To be informed by direct observations: • Do girls and women feel comfortable changing their materials in the toilets provided? • Have provisions been made to separate toilets by 11 MHM and Education (Why or why not?) gender (including signs, painting, and education)?
12 MHM and Health For a WORD version of the checklist, see link. • Are beneficiaries following the gender segregation mandates? 13 MHM and Protection • Is there a light source available for girls and women 14 Monitoring and Evaluation using toilets during the night?
46 7.4
BACK TO CONTENTS MHM INDICATORS FOR WATER AND ADDITIONAL SANITATION SYSTEM RESOURCES
A few sample indicators have been developed to 1 Introduction support the monitoring of WASH programming. • Screened Toilet, Bathing and 2 Training staff on MHM This includes the following: Menstruation Units for the Earthquake Response in NWFP, Pakistan from Oxfam-GB (link). 3 Conducting a needs assessment
• Mainstreaming Menstrual Hygiene INDICATORS 4 Providing MHM Management in WASH: Guidance Materials and Supplies Note for Oxfam in Nepal (link). 5 MHM and Transit • Percentage of population living within 50 meters of an improved sanitation facility. • Examples of drying methods from Menstrual 6 MHM and Shelter Hygiene Matters (Module 3: Menstrual • Proportion of female-only sanitation blocks hygiene – sanitary protection materials and disposal, Page 94) (link). 7 MHM and Water and Sanitation Facilities • Proportion of female toilet cubicles/stances at institutions (i.e. schools, protection spaces, 8 MHM, Disposal and Waste Management health clinics) with access to water and soap.
9 MHM and Hygiene • Women/girls of reproductive age (12-49 Promotion & Health years of age) are comfortable using sanitation Education Activities facilities for MHM during the daytime and 10 MHM and Vulnerable nighttime.* Populations
• Proportion of sanitation facilities (toilets/ 11 MHM and Education bathing spaces) which incorporate the female friendly minimum requirements (see Table 1). 12 MHM and Health
*Note, some girls under 12 may also be menstruating. 13 MHM and Protection
14 Monitoring and Evaluation
47 BACK TO CONTENTS Summary of Key Actions from Chapter 7: MHM and Water and Sanitation Facilities
1 Introduction Consult women and girls on the location and design of water and sanitation facilities
Train all sanitation staff (male and female) on MHM. 2 Training staff on MHM
Build female friendly toilets including gender segregation, locks, lights, disposal options, hooks 3 Conducting a needs assessment and shelves.
4 Providing MHM Ensure girls and women have private spaces (or mechanisms) for privately hanging menstrual Materials and Supplies cloths to dry.
5 MHM and Transit Regularly consult with women and girls regarding safety, access and convenience of sanitation facilities and disposal mechanisms. 6 MHM and Shelter Share relevant learning from consultation across your organization, sector and relevant working 7 MHM and Water and groups. Sanitation Facilities
8 MHM, Disposal and Waste Management
9 MHM and Hygiene Promotion & Health Education Activities
10 MHM and Vulnerable Populations
11 MHM and Education
12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation
48 8 MHM, DISPOSAL AND WASTE MANAGEMENT BACK TO CONTENTS
1 Introduction
8.1 2 Training staff on MHM
• Disposal directly into toilets provides a convenient 3 Conducting a needs Used menstrual materials make up a TRAIN SANITATION STAFF assessment significant waste flow in camps or other and immediately available option for the user. For any toilets other than direct-drop pit toilets, this contexts. In the absence of effective All sanitation staff, regardless to gender, should be 4 Providing MHM disposal mechanisms, women and girls may knowledgeable and comfortable discussing MHM. is likely to cause frequent blockages. Sanitary Materials and Supplies dispose of used materials directly in toilets See Chapter 2 for more information on training staff. materials in pits, cesspits and septic tanks increase or by other means. the rate at which these fill and make it harder to 5 MHM and Transit de-sludge, as equipment becomes clogged. Menstrual waste is often seen as embarrassing or 6 MHM and Shelter distasteful, and strong taboos may exist. 8.2 • Ad hoc disposal is also common where people do not understand or trust the waste disposal method 7 MHM and Water and Girls and women often do not want anyone in place. This may consist of burying pads near Sanitation Facilities (including other girls and women) to see their MHM DISPOSAL METHODS the home, or discarding used pads in alleys, fields 8 MHM, Disposal and used menstrual materials. or rivers. When widespread, this can lead to an Waste Management Depending on the waste management systems set unsanitary environment. Strong taboos may exist around burning or handling up in the context, and the preferences of the local 9 MHM and Hygiene of menstrual waste by other people, limiting the • Disposal into household solid waste streams Promotion & Health community, used menstrual materials (including Education Activities usefulness of incinerators or collection systems. pads and cloths) are likely to be disposed of in is a common practice. Waste is collected different ways: and disposed of with other household waste. Disposal mechanisms must be discreet if they are 10 MHM and Vulnerable Generally this system works fine where there is a Populations to be used, and consultation with girls and women functioning disposal system, but in some cases the is essential to achieving an effective waste waste may end up on unsightly piles in the local 11 MHM and Education management system. environment. This may cause problems with local taboos or perceptions, especially those of men in 12 MHM and Health the household. 13 MHM and Protection • Disposal into provided trash bins, especially at
BE ADAPTIVE! IT IS ESSENTIAL TO WORK WITH A COMMUNITY TO DEVELOP public toilets and washrooms. 14 Monitoring and A SOLUTION WHICH IS ACCEPTABLE TO THE POPULATION’S DISPOSAL Evaluation PREFERENCES AND ADDRESSES THE WASH STANDARD FOR WASTE MANAGEMENT IN THE CONTEXT. 49
8.3
BACK TO CONTENTS Solid waste disposal should be established during CASE STUDY MHM & WASTE MANAGEMENT SYSTEMS the acute phase of the emergency, including consideration for disposal of menstrual waste. 1 Introduction The key components of a waste management Consult with local female staff and girls and women In the Rahkine State of Myanmar, internally system are: to inform the selection of systems for managing 2 Training staff on MHM displaced girls and women living in camps lacked menstrual waste (See Chapter 3: Conducting a Needs convenient options for disposing of menstrual • Provide disposal points, such as covered waste Assessment). 3 Conducting a needs waste. Furthermore, prior to displacement, assessment bins, in public toilets, washrooms and at they were familiar with burying used menstrual household level Additional notes: materials. This practice was increasingly difficult 4 Providing MHM Materials and Supplies however in the overcrowded living conditions of • Establish a waste collection and transportation • Girls and women using reusable materials (pads the camps. In response, many girls and women system that includes menstrual waste or cloths) will also require options for end point 5 MHM and Transit would get up very early, at 4 or 5 am to go bury disposal, although less frequently than those using • Identify or establish suitable endpoint disposal sites these items discreetly. However, going out at disposable materials. 6 MHM and Shelter this hour, and without proper lighting, put them • Ensure that toilet cleaners and waste handlers are • It is also common that a variety of disposal at serious risk of danger for attacks or sexual properly trained, suitably equipped with protective methods (i.e. bury, drop in pit) are used by girls 7 MHM and Water and violence. It is essential for Protection and Sanitation Facilities clothing and containers and regularly scheduled. and women within the same communities. WASH actors to coordinate on how to ensure appropriate disposal options for girls and women 8 MHM, Disposal and • Ensure that the public understands how the system Waste Management that will minimize their risk. (IRC/Columbia works, and create systems for gathering feedback University, 2015) from women and girls 9 MHM and Hygiene Promotion & Health Education Activities
10 MHM and Vulnerable Populations CULTURAL BELIEFS ON DISPOSAL 11 MHM and Education
12 MHM and Health Myths and taboos may influence how women and girls dispose of menstrual materials. In some cultures, it is believed that if an enemy is able to obtain some of your blood, they can place a curse on you. Others 13 MHM and Protection believe burning/incineration of menstrual blood will make them sick. Cases have been reported of women washing the blood out of disposable pads before disposing of them. It is important to understand these 14 Monitoring and Evaluation cultural beliefs when designing appropriate waste and sanitation management systems.
50 FIGURE 1: A MENSTRUAL WASTE SYSTEM
BACK TO CONTENTS
1 Introduction 1 2 Training staff on MHM
3 Conducting a needs assessment
2 4 Providing MHM Materials and Supplies
5 MHM and Transit
3 6 MHM and Shelter
4 7 MHM and Water and Sanitation Facilities
8 MHM, Disposal and Waste Management WOMEN’S TOILET 9 MHM and Hygiene Promotion & Health Education Activities
10 MHM and Vulnerable Populations
1 3 5 11 MHM and Education
WASTE BINS, CHUTES DESIGNATED END POINT 12 MHM and Health OR OTHER METHODS 2 COLLECTION POINT 4 DISPOSAL 13 MHM and Protection • HOUSEHOLD TOILETS Household caregivers and • A COLLECTION POINT IS Sanitation workers • LANDFILLS, BURY PITS, toilet cleaners regularly SERVICED BY SANITATION regularly clear waste INCINERATORS ETC. • PUBLIC TOILETS 14 Monitoring and empty bins, and deliver WORKERS collection point, and Evaluation • INSTITUTIONAL TOILETS waste to a designated transport waste to final waste collection point disposal point 51 BACK TO CONTENTS Provide covered waste bins in public toilets, Figure 2: Toilet with covered sanitary pad Figure 3: A design for a lined bin attached to the washrooms, and at household level (when disposal basket and water source inside of wall (Oxfam-Nepal, 2015). Note, it must also be appropriate). The provision of immediate waste stall (Oxfam-Myanmar, 2015). easy to empty to prevent the cleaner from handing 1 Introduction disposal points is the responsibility of the sanitation pads directly. actor. Provision of waste bins should be in parallel 2 Training staff on MHM with toilet and washroom construction.
3 Conducting a needs • In public and communal toilet and washroom assessment cubicles, covered waste bins should be provided.
4 Providing MHM • Visual signs may be posted in the cubicle about Materials and Supplies appropriate disposal behaviors.
5 MHM and Transit • Discussions with girls and women will inform whether it is appropriate and useful to provide 6 MHM and Shelter covered waste bins at the household level.
7 MHM and Water and Types of disposal containers: Sanitation Facilities • Waste bins: Basic waste bins should be made of 8 MHM, Disposal and Figure 4 and 5: Direct disposal to a storage bin from a chute inside the cubicle (Oxfam-Nepal, 2015) Waste Management a waterproof (plastic/metal) washable material, or lined with plastic bin liners. To reduce the
9 MHM and Hygiene likelihood of theft or usage of bins for other Promotion & Health uses, it is advised to puncture holes in the Education Activities containers or physically attach the bins (see Figures 2 and 3). 10 MHM and Vulnerable Populations • Chute disposal system. A chute disposal system
11 MHM and Education is an alternative disposal mechanism where pads can be deposited directly into a locked covered 12 MHM and Health bin or deep covered pit outside the toilet. Figures 4 and 5 show a modified toilet with a chute to 13 MHM and Protection deposit pads to a covered collection point adjacent to the toilet. 14 Monitoring and Evaluation
52 BACK TO CONTENTS ESTABLISH A WASTE COLLECTION AND IDENTIFY OR ESTABLISH ENDPOINT CASE STUDY TRANSPORT SYSTEM THAT INCLUDES DISPOSAL SITES
MENSTRUAL WASTE 1 Introduction In the Somali refugee camps located in Ethiopia’s • Ensure that residents and institutions such as If municipal waste disposal sites are available, Dollo Ado region, it was learned through FGDs 2 Training staff on MHM schools (where girls and female teachers may have these are usually used for all solid waste, including that girls and women preferred to bury their menstrual waste) are included in waste collection menstrual waste; otherwise dedicated waste disposal menstrual waste, a practice done prior to 3 Conducting a needs systems and there is understanding on where to sites (such as landfill or waste pits) must be planned assessment displacement. However, that was not a feasible place waste, and when waste will be collected. and constructed for all solid waste. Where pits are option in the confined camps. A new system was close to or within settlements, people may not want to 4 Providing MHM introduced in which women were provided with Materials and Supplies • Generally menstrual waste will be collected see used pads in pits, and may avoid using them for 10-liter bins with lids (and pierced bottoms) in together with other waste streams. There is no menstrual waste. their households for putting household waste, need to keep menstrual waste separate. 5 MHM and Transit including used menstrual materials. The bottoms were pierced to ensure they could not be used 6 MHM and Shelter for other things. In addition, black bags were Considerations around incinerating waste Considerations around burning waste at the final disposal point: provided to accompany the bins. Girls and on site: 7 MHM and Water and Sanitation Facilities women were instructed to leave the bags with If menstrual materials are incinerated on site, Menstrual waste is generally commingled their waste outside their homes (with other the World Health Organization (WHO) with other waste, and treated (often burned) 8 MHM, Disposal and garbage) for pick up by the sanitation worker. Waste Management recommends incinerating all health-related collectively. It is important to recognize that Oftentimes girls and women would remember waste only at temperatures over 800 degrees menstrual materials (disposable and some the sanitation worker’s schedule and bring it out 9 MHM and Hygiene to avoid release of toxic and irritant chemicals reuseable pads) contain polymer liners, which Promotion & Health only once he was arriving for the pick up of the Education Activities into the atmosphere. Some single-chamber when burned at lower temperatures typically communal waste. (WASH Adviser, International incinerators may not consistently achieve this release asphyxiant and irritant gases into Medical Corps) 10 MHM and Vulnerable standard; chosen incineration methods should the atmosphere. Further, the biodegradable Populations be evaluated carefully. Incinerators also require components, such as cellulose, wood-pulp,
electricity or fuel sources, trained operators, cotton in disposable pads often contain furans 11 MHM and Education and a regular burn schedule. and dioxins. Similar emissions can be expected from various other waste streams as well, 12 MHM and Health and these issues are not unique to menstrual materials. It is important to carefully assess 13 MHM and Protection the location of waste pits relative to human populations so that smoke and emissions do 14 Monitoring and Evaluation not blow across settlements. 53 BACK TO CONTENTS
ENSURE THAT TOILET AND WASHROOM CASE STUDY 1 Introduction CLEANERS AND WASTE HANDLERS ARE PROPERLY TRAINED, SUITABLY 2 Training staff on MHM EQUIPPED, AND REGULARLY In refugee camps located in Syria, women SCHEDULED. indicated strong discomfort in putting their used 3 Conducting a needs assessment sanitary pads directly into trash bins located In order to ensure facilities are properly maintained, ENSURE THAT THE PUBLIC inside the toilet stalls. This was due to fears that the following considerations should occur for public 4 Providing MHM UNDERSTAND HOW THE SYSTEM toilet cleaners would see their menstrual waste Materials and Supplies and institutional (school, health facility, etc) toilets WORKS, AND CREATE SYSTEMS FOR which was considered shameful but also because and washrooms: GATHERING FEEDBACK FROM GIRLS the cleaners may use the blood for witchcraft. 5 MHM and Transit In response, some of the women would sneak • Consult with staff to identify any hesitancies to AND WOMEN. out of the camp at night to dispose of the pads 6 MHM and Shelter handle menstrual waste and address. Information on how to manage waste, collection in bins on the edge of the camp, creating safety • Designated staff or volunteers assigned to empty times, etc, should be integrated into hygiene concerns. Other girls and women would put the 7 MHM and Water and Sanitation Facilities waste bins together with cleaning duties on a daily messaging and other IEC activities. Once the solid used disposable pads directly down the toilets. basis. waste management system is up and running, it This resulted in many pour flush toilets frequently 8 MHM, Disposal and is important to continue the consultation process, being clogged up and eventually shut down. In Waste Management • A regular cleaning schedule to ensure that they using FGDs, KIIs, observations and walk-throughs the latrines, the disposable pads also created remain hygienic and usable. in order to ensure that the waste disposal system is challenges with the desludging process. Despite 9 MHM and Hygiene Promotion & Health appropriately meeting the needs of girls and women. attempts to try and prevent these practices Education Activities • Cleaning staff must be trained and monitored on through targeted IEC materials, these disposal the clearance of waste receptacles on a daily basis challenges continued (International Medical 10 MHM and Vulnerable and provided protective clothing including gloves. Populations Corps, Syria). • Male cleaners are generally not suitable for 11 MHM and Education facilities used by women, as they are often more reluctant handle menstrual waste, and women are 12 MHM and Health reluctant to discard waste if they know it will be handled by a man. 13 MHM and Protection • Cleaners and waste handlers may need to be 14 Monitoring and sensitized to these roles and the waste they are Evaluation managing, as menstrual waste often has many taboos associated with it. 54 8.4
BACK TO Waste Management Systems – Observation CONTENTS MONITORING & FEEDBACK Checklist. It is advisable to add on a few MHM Methods for Monitoring Waste Management related questions to any existing waste management Systems. Monitoring of waste management systems checklists and inspection materials. Sample 1 Introduction should occur continuously and utilize a combination questions could include: of methods (see Chapter 14): 2 Training staff on MHM To be informed by observation:
3 Conducting a needs METHODS • Are there waste bins available to girls and women assessment inside or near all female-designated toilets? Direct observations (with This can include household and communal toilets, waste disposal 4 Providing MHM Materials and Supplies checklists) sites, and other relevant locations. • Are waste bins being used and not overflowing?
Walk-throughs Walk-throughs are a type of direct observation, and can be • Do sanitation personnel have protective gear 5 MHM and Transit conducted together with a few users to collect their perceptions (gloves and boots) for managing menstrual waste? and opinions. 6 MHM and Shelter • Are menstrual waste disposal bins emptied twice a week? Environmental inspections This can include female WASH committee members, girls and 7 MHM and Water and Sanitation Facilities women from the target population, or program staff. • Are menstrual waste materials being disposed of in the latrine hole or elsewhere than the provided 8 MHM, Disposal and KIIs This can include girls and women from the target population, Waste Management disposal points (waste bins)? or program staff (WASH, CCCM, Protection). • Are there signs or visuals inside the stalls that 9 MHM and Hygiene FGDs Age segmented groups of girls or women (8-10 participants Promotion & Health inform girls and women on the proper menstrual Education Activities per FGD) led by a female facilitator to inquire about things waste disposal practices? like the acceptability of the disposal options and waste 10 MHM and Vulnerable management system. • Is end point disposal conducted in a manner Populations and place that avoids creating health, safety or environmental problems for the host and affected 11 MHM and Education populations? 12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation
55
To be informed by discussions with women and girls:
BACK TO • Do girls and women feel comfortable putting their CONTENTS menstrual materials in the provided immediate disposal points (i.e. waste bins)? • Have girls and women been educated on the waste 1 Introduction management process in place for managing their Summary of Key Actions from Chapter 8: MHM, Disposal and Waste Management 2 Training staff on MHM menstrual waste? • Do girls and women feel comfortable with the end- Consult female beneficiaries before the setup of the waste management system. 3 Conducting a needs assessment point disposal process being used for menstrual waste (for example burning or burying)? Provide suitable covered waste receptacles in all female communal toilet and washroom cubicles.
4 Providing MHM Materials and Supplies To be informed by program records: Ensure that cubicle waste receptacles are emptied daily. • Has a cadre of female sanitation workers been 5 MHM and Transit Ensure that waste collection points are cleared bi-weekly for transportation and final disposal. trained and sensitized to managing menstrual waste?
6 MHM and Shelter For a WORD version of the checklist, see link. Determine a culturally appropriate end-point menstrual waste system and ensure it is communicated to beneficiaries. 7 MHM and Water and Sanitation Facilities Provide cleaners and solid waste handlers with protective equipment (minimum gloves and boots).
8 MHM, Disposal and Train cleaners and solid waste handlers on proper waste handling procedures. Waste Management MHM INDICATORS FOR WASTE MANAGEMENT 9 MHM and Hygiene SYSTEMS Promotion & Health Education Activities Indicators should be introduced and integrated
10 MHM and Vulnerable into existing monitoring and evaluation (M&E) Populations frameworks. Example indicators include:
11 MHM and Education • Proportion of institutions [i.e. schools, protection spaces, clinics] with functional 12 MHM and Health mechanisms for menstrual waste.
• Women/girls of reproductive age (12-49 13 MHM and Protection years of age) are comfortable disposing
14 Monitoring and menstrual waste with the available methods. Evaluation • Proportion of toilets which incorporate the female friendly minimum requirements. 56 MHM AND HYGIENE PROMOTION 9 BACK TO & HEALTH EDUCATION ACTIVITIES CONTENTS
1 Introduction
9.1 2 Training staff on MHM
3 Conducting a needs Cultural beliefs influence the materials that TYPES OF MENSTRUAL A variety of communication channels can be used assessment girls and women use to manage menstrual HYGIENE PROMOTION & to provide women and girls with accurate, safe flow, their privacy concerns around water and information about MHM. Consult with adolescent girls 4 Providing MHM sanitation facilities, how they dispose of used HEALTH EDUCATION and women to determine what the gaps are in their Materials and Supplies materials and may even limit their mobility current knowledge or the types of messaging that 5 MHM and Transit within their community. KEY TOPICS TO COVER: will be useful to them and the appropriate methods for dissemination. Where cultural beliefs around 6 MHM and Shelter Most of these beliefs can be assessed through the MENSTRUAL Education and demonstrations menstruation are assessed to be harmful, it will be use of FGDs and interviews with adolescent girls and HYGIENE PROMOTION on hygienic practices for necessary to develop a strategy to address them. women. It is important to recognize that some girls 7 MHM and Water and managing menstruation Sanitation Facilities and women may never have discussed the issue (cleaning, changing, openly before. washing etc) 8 MHM, Disposal and CASE STUDY Waste Management Staff working in emergencies also need to identify Information and demonstration appropriate approaches for sharing basic menstrual on washing and drying materials 9 MHM and Hygiene Promotion & Health health education and menstrual hygiene promotion In refugee camps in Ethiopia, staff learned that Education Activities with adolescent girls and women. This information Information and demonstration South Sudanese women and girls had never should be integrated into existing hygiene promotion on hygienic disposal of seen reusable pads before. They needed to be 10 MHM and Vulnerable and health education activities. Information, menstrual materials educated on how to use them, including how Populations education and communication (IEC) materials can to fasten the holder into the underwear, how to 11 MHM and Education be adapted to address the knowledge gaps of the MENSTRUAL Education on puberty and change the inserts, and how to properly wash and HEALTH target community. menstrual cycle basics dry the pads. It is important to provide education and demonstration on how to use and care for 12 MHM and Health Information and demonstration menstrual materials, in addition to menstrual on healthy menstrual hygiene promotion. Providing IEC materials 13 MHM and Protection management practices with MHM supplies that have simple, pictorial 14 Monitoring and instructions on use, care, and hygiene can also Evaluation DEMONSTRATION OF USE OF Education to dispel any harmful be useful to girls and women. (International MENSTRUAL MATERIALS IS KEY cultural myths and taboos Federation of the Red Cross (IFRC) - East Africa) TO ASSURING PROPER USE. 57
9.2
BACK TO CONTENTS DEVELOPING AND DESIGNING IEC
U 0 nl 02 oc 2 k by $10 ear 1 Introduction MATERIALS billion a y
2 Training staff on MHM When developing or adapting IEC materials: • Be wary that public campaigns and dialogue on menstruation may make girls and women CASE STUDY • Use needs assessment findings (Chapter 3) to 3 Conducting a needs uncomfortable and embarrassed in some contexts. assessment identify MHM knowledge gaps or cultural taboos Consultation will help determine the appropriate In North Western Pakistan, the International within the community. methods. 4 Providing MHM Rescue Committee (IRC) faced challenges in Materials and Supplies • During the acute phase, due to the need for rapid • Due to the sensitive nature of MHM, it is important reaching women and adolescent girls in disaster- IEC materials to accompany the distribution of kits to conduct a session with girls and women affected communities. A conservative culture 5 MHM and Transit with menstrual supplies, materials may be modified separate from men and boys who may be present limited women and girls’ access to information from existing resources, through brief consultations during hygiene promotion. Only female staff should and to outside information sources. IRC’s 6 MHM and Shelter with local female staff or existing women’s and conduct menstrual hygiene promotion for women hygiene promotion staff found that it was effective girls’ groups. See additional resources at the end and girls. to work with female religious scholars, who ran 7 MHM and Water and Sanitation Facilities of the Chapter. village-level religious schools for adolescent girls, particularly those who were not in the formal • During the chronic phase, participatory Note: It is important to find out whether 8 MHM, Disposal and school system. Many of these religious scholars Waste Management methodologies conducted with adolescent girls adolescent girls and women are comfortable attended information sessions and trainings and women can be used to develop more culturally receiving this information together, or if it is hosted by IRC, and then incorporated sessions 9 MHM and Hygiene appropriate education materials, visual aids, preferred to separate the females into age groups Promotion & Health (adult women and adolescent girls). about menstruation into their classroom teaching, Education Activities community drama, or films to raise issues acting as a trusted source of information and around MHM. support, in an environment where discussion of 10 MHM and Vulnerable Populations • Targeted IEC materials with clear pictures on menstruation was taboo (WASH Advisor, IRC). MHM-related care and practices can be posted 11 MHM and Education inside female toilets, distributed with NFIs, and used as teaching aids during information sessions. 12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation EARLY FEEDBACK WITH BENEFICIARIES SHOULD BE GATHERED TO ENSURE THAT THE EDUCATIONAL MATERIALS ARE CLEAR, 58 USEFUL, AND APPROPRIATE TO THE CONTEXT.
BACK TO 9.3 CONTENTS
MENSTRUAL HYGIENE 2. Safe spaces for women and girls. Women’s TYPES OF DEMONSTRATION: 1 Introduction PROMOTION community centers, child friendly spaces, youth centers or other safe spaces provide opportunities • Demonstrations on how to use the sanitary 2 Training staff on MHM MHM is an important component of routine hygiene for MHM hygiene promotion. They provide materials. Girls and women may not know promotion programming for adolescent girls and opportunities: how to use the MHM items provided in 3 Conducting a needs women. Hygiene Promoters should work closely with distributions. For example, some females may assessment • To disseminate information about MHM WASH hardware staff to ensure that: have never used disposable pads or underwear • To hear directly from women and girls about their prior to the emergency or may have had their 4 Providing MHM • Health promotion messages use context-specific Materials and Supplies MHM needs first period during the emergency. Girls and information (e.g. MHM materials available, cultural women may also never have used reusable preferences, design of sanitation and washing 5 MHM and Transit • To solicit feedback on the appropriateness of the pads, and may need support learning how to facility, etc.) MHM response. insert pads into their underwear, store them 6 MHM and Shelter between use, and information on how to best • WASH preferred behaviors or hygienic practices Note: In addition, safe spaces for women and girls wash/dry them. (such as disposal methods for used menstrual 7 MHM and Water and can provide an alternative way for distributing Sanitation Facilities materials) are conveyed to girls and women. MHM materials when blanket distributions are • Demonstrations on how to dispose of the not feasible. sanitary materials. Girls and women may 8 MHM, Disposal and Opportunities for conducting Menstrual Hygiene Waste Management not be familiar with the preferred methods Promotion include: 3. Existing girls or women’s community groups. for the disposal of menstrual materials in the Informal groups within communities usually exist 9 MHM and Hygiene 1. NFI distributions. Distributions that include emergency context. Demonstrations should Promotion & Health prior to a crisis. These groups may continue to Education Activities MHM materials are good opportunities for MHM be given on how materials should be wrapped function during an emergency; or as communities are promotion. Ideally: or disposed. Explanations should be provided displaced new groups may form. Hygiene promoters 10 MHM and Vulnerable on the waste management process, including Populations can link with these existing groups and use them as • All distributions should occur in private safe spaces assurances on how girls and women’s privacy for girls and women safe spaces providing MHM promotion will be maintained. 11 MHM and Education
• Only female staff should be involved to ensure that Note: Girls and women have taboos and fears 12 MHM and Health girls and women feel comfortable asking questions about used materials being seen by others. This about the items or hygiene issues. will deter them from following preferred disposal 13 MHM and Protection methods if privacy is not adequately assured. • Demonstrations should ensure girls and women 14 Monitoring and know how to use and properly dispose of the Evaluation supplies being provided. 59 9.4
BACK TO CONTENTS CASE STUDY HEALTH EDUCATION 3. Health education in schools. Menstruation can ON MENSTRUATION be addressed through the regular health education curricula at schools in collaboration with Education 1 Introduction Menstruation should be included in Sexual and actors, or special sessions can be conducted. Protection actors supporting Syrians refugees Reproductive Health (SRH) Education activities Schools are ideal for reaching girls. Health staff 2 Training staff on MHM living in Lebanon realized that adolescent girls provided to girls and women. Similar to other SRH can support school-based health education by were not always reached by existing hygiene topics, menstruation education should be led by partnering with schools and providing health 3 Conducting a needs distributions and often had their own unique assessment female staff and provided in private spaces where education on menstruation, including tackling materials and education needs. In response, men and boys are not present. menstrual taboos and myths. Educating boys on dignity kits were developed that were tailored 4 Providing MHM menstruation and their own pubertal changes can Materials and Supplies to adolescent girls. They had specific items Note: Although traditional methods for sharing diminish the teasing girls experience in schools. targeting girls, including several MHM items like menstrual information may have existed in a culture See Chapter 10 for more information. 5 MHM and Transit appropriately sized underwear (generally smaller prior to the crisis, these systems may no longer be in sizes), disposable pads, and body cleanser/wash. place. This is especially important for pre-pubescent 6 MHM and Shelter The kits were provided to girls while attending girls who may lack any knowledge on menstruation. girl’s empowerment sessions and each item in 7 MHM and Water and the kit was introduced and discussed to ensure Opportunities for providing health education on Sanitation Facilities girls knew how to use the menstrual items and menstruation include: maintain healthy menstrual hygiene practices. 8 MHM, Disposal and 1. Health outreach or clinics. As health workers Waste Management Basic health education, with an emphasis often directly visit communities to provide health on first menarche, was also provided. outreach, their sessions should include menstrual 9 MHM and Hygiene (IRC-Lebanon, 2015). Promotion & Health Education Activities health. Health education provided in clinical waiting rooms can also include menstruation and
10 MHM and Vulnerable MHM as a key topic. See Chapter 11 for more Populations information. These can be a collaboration by Health and WASH actors. 11 MHM and Education 2. NFI distributions with menstrual materials. 12 MHM and Health A health staff member can attend menstrual hygiene NFI distributions to answer questions that 13 MHM and Protection may arise during hygiene promotion demonstration MAKE SURE THAT ALL MENSTRUATING activities. They can also provide menstrual health 14 Monitoring and GIRLS, INCLUDING YOUNGER AND education lessons during these activities. These Evaluation UNACCOMPANIED ONES, ARE PROVIDED can be conducted in collaboration with WASH, MHM INFORMATION. camp management, or NFI actors. 60
9.5
BACK TO CONTENTS ADDITIONAL RESOURCES
1 Introduction
Grow and Know puberty 2 Training staff on MHM Find below links to existing books are example CASE STUDY resources to support hygiene resources for educating promotion and hygiene 3 Conducting a needs girls about puberty assessment education activities, including: and menarche. In a camp in Tanzania Burundian refugee men complained, in reference to menstrual hygiene kits, 4 Providing MHM Menstrual hygiene promotion materials: that their wives were receiving more supplies than they Materials and Supplies were. In response, a hygiene promotion specialist • Menstrual Hygiene Flip Chart (link). held a sensitization session with the men. During the 5 MHM and Transit session she asked for 5 men to volunteer to stand in • Oxfam Menstrual Hygiene Flip Charts front of the group. She then passed out two 500 mL (Oxfam-Jordan) (link). bottles filled with water to each of the 5 men, directing 6 MHM and Shelter them to hold one under each armpit. Some of the water • Guidance Flyer on reusable pads (IFRC) bottles had small holes in them, resulting in water 7 MHM and Water and Sanitation Facilities (link). leaking onto the men. The men started to become wet and asked, “what is going on?!” but she instructed them • Guidance Flyer on disposable pads (IFRC) to keep standing. As the men continued to stand with 8 MHM, Disposal and the water dripping out, the hygiene leader asked them: Waste Management (link). “did you expect to be getting wet right now?” She then explained that women are often unaware when their 9 MHM and Hygiene Menstrual health education Promotion & Health menstruation will start, and frequently lack supplies Education Activities on menstruation materials: they need to manage the blood. She explained that this was the reason they gave the supplies to their 10 MHM and Vulnerable • My Safety, My Wellbeing Guide: Chapters wives, and that it helps both the women and their Populations 10: Reproductive Part 1: My body, puberty, families. Many of the men admitted that they had not been aware of this challenge and asked the organization hygiene, reproductive health (includes 11 MHM and Education to continue to provide menstrual hygiene supplies. for ages 11-13; 14-18) (link). It may be important to directly sensitize boys and men on menstrual hygiene to ensure that they 12 MHM and Health • Grow and Know Puberty books (education are supportive, respectful and aware of the needs resources for adolescent girls and boys) (link). of girls and women. (Hygiene Promotion Actor, 13 MHM and Protection Northwest Tanzania)
14 Monitoring and Evaluation
61 BACK TO CONTENTS Summary of Key Actions from Chapter 9: MHM and Hygiene Promotion & Health Education Activities
1 Introduction 1. Consult girls and women to identify information gaps and areas of need.
2 Training staff on MHM 2. Develop context appropriate IEC materials and curriculum for integrating MHM into hygiene promotion and health education. 3 Conducting a needs assessment 3. Provide menstrual hygiene promotion, including demonstrations on how to use menstrual materials, at NFI distributions, Women’s Safe Spaces and/or existing Women’s Groups, at Child 4 Providing MHM Materials and Supplies Friendly Spaces, schools and other safe spaces.
4. Provide menstrual health education at health clinics, protection spaces, and during NFI 5 MHM and Transit distributions.
6 MHM and Shelter 5. Monitor and gather feedback on the appropriateness of content and identify additional gaps in knowledge. 7 MHM and Water and Sanitation Facilities
8 MHM, Disposal and Waste Management
9 MHM and Hygiene Promotion & Health Education Activities
10 MHM and Vulnerable Populations
11 MHM and Education
12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation
62 10 MHM AND VULNERABLE POPULATIONS BACK TO CONTENTS
1 Introduction
10.1 2 Training staff on MHM
3 Conducting a needs Vulnerable girls and women are those IDENTIFY AND CONSULT assessment individuals at heightened risk in a given MHM CHALLENGES FOR GIRLS AND WOMEN WITH DISABILITIES context. This includes girls and women that Given the restricted movement of many vulnerable 4 Providing MHM are very poor, unaccompanied, orphaned, girls and women, it can be difficult to identify and Materials and Supplies Physical disabilties from indigenous or minority groups, or those address their unique MHM-related needs. A key 5 MHM and Transit with physical or developmental disabilities. • May need help changing and washing part of a needs assessment includes tracking menstrual materials. households that have vulnerable individuals. 6 MHM and Shelter MHM challenges for vulnerable populations. This can be done during: household surveys or • WASH facilities may not be accessible Such populations can experience unique MHM PDM, NFI distributions, and discussions with key 7 MHM and Water and challenges during emergencies: informants and women’s groups. Directly engaging Visual disabilities: Sanitation Facilities with community groups (i.e. Disabled Persons • Limited funds for buying menstrual supplies. • Unable to see leaks or extent of blood Organizations (DPOs), Parents Associations (for 8 MHM, Disposal and Waste Management children with disabilities), or religious organizations) • Reduced access to WASH facilities due to location, • May need help changing and washing accessibility, or social restrictions around use. can help to identify (and ultimately support) menstrual materials. 9 MHM and Hygiene vulnerable girls and women and their caretakers, Promotion & Health • Lower literacy and reduced access to written • May not be able to see or read MHM and improve coverage and distribution of Education Activities information on MHM. information. MHM services. 10 MHM and Vulnerable Populations • Potentially increased restrictions to menstrual Developmental disabilities: After identification, direct consultation with hygiene due to traditional or cultural beliefs. beneficiaries and/or their caretakers is essential • May be unable to communicate discomfort 11 MHM and Education to learn about their experiences and challenges • Reduced social support networks. or pain. around managing menstruation. This can be done 12 MHM and Health • Increased risk of exploitation and other forms • May need help changing and washing through informal conversations or interviews. menstrual materials. The learning is essential for informing organizations of gender-based violence. 13 MHM and Protection about how to proactively and effectively address • May change in inappropriate places their unique MHM needs. 14 Monitoring and • May not understand MHM education Evaluation and activities. 63 (WaterAid/Menstrual Hygiene Matters, 2012) 10.2 10.3
BACK TO CONTENTS PROVIDE MHM SUPPLIES CASE STUDY BUILD ACCESSIBLE AND MATERIALS FEMALE FRIENDLY WASH
1 Introduction A key challenge for vulnerable populations may be INFRASTRUCTURE A Burundian male refugee living in a camp in regularly accessing MHM NFI distributions or other 2 Training staff on MHM Tanzania was the sole caregiver for his adult As girls and women with physical disabilities may be MHM-related services. To address this, additional sister with mental disabilities. The man became unable to comfortably and hygienically access WASH supplies of extra sanitary materials (pads, cloth, etc.) 3 Conducting a needs distressed when his sister had her menstrual facilities, alternative support and supplies should assessment and soap (bathing and laundry) should be provided to bleeding, and the neighbors were reluctant be provided. This includes accessible and female them. For the bedridden, the provision of a protective to help due to suspicions of witchcraft by his friendly water and sanitation faciltiies and access 4 Providing MHM bedding layer should also be supplied. It important Materials and Supplies sister. The man sought help from community- to relevant supplies, such as the provision of water to directly consult with the vulnerable individuals to based rehabilitation staff. At the time, the staff storage containers and a household waste bin (for determine their unique needs. It is also important to 5 MHM and Transit did not have any guidelines or protocols for menstrual waste). ensure that distribution centers (or any venues being how to respond. Whenever possible, they would used for distributions) are accessible to people with Efforts should be made to develop facilities that better 6 MHM and Shelter try to provide him with disposable pads. It is physical disabilities or are culturally appropriate for address their unique needs and should be designed important that persons with special needs and marginalizied women to attend. through direct consultation with disabled girls, women 7 MHM and Water and their caregivers are adequately supported with Sanitation Facilities and their caregivers. Modifications can include larger MHM programming, including the provision door width, bigger handles, handrails, increased of menstrual supplies and education. In some 8 MHM, Disposal and space in the toilet (accessible to both a girl/woman Waste Management cases, these services should be directly provided and her caregiver if necessary), chairs or stools inside to caregivers, as they may be responsible for the toilet, slip-resistant floor, and the use of slopes or 9 MHM and Hygiene helping disabled girls and women change their Promotion & Health ramps at the entrances. Education Activities menstrual materials and may not know how to provide this care. Organizations supporting those 10 MHM and Vulnerable with special needs and their caregivers should Populations train their staff on how to proactively detect such cases. This may also include strengthening 11 MHM and Education existing community support mechanisms to assist with these cases, such as women’s groups and 12 MHM and Health COMMUNITY GROUPS CAN IDENTIFY community leaders. (IRC Tanzania, Nyaragusu VULNERABLE GIRLS, WOMEN AND Refugee Camp 2017) 13 MHM and Protection THEIR CARETAKERS.
14 Monitoring and Evaluation
64 10.4 10.5 10.6
BACK TO CONTENTS PROVIDE MHM MONITORING AND ADDITIONAL EDUCATION FEEDBACK RESOURCES
1 Introduction MHM education and hygiene promotion may need to As vulnerable girls and women may not be Additional resources in the be tailored to account for the developmental level of captured through routine monitoring and evaluation reference supplement may be 2 Training staff on MHM vulnerable girls and women. These populations are activities due to limited visibility and movement, useful for the design of needs often excluded from educational opportunities and staff should proactively follow up with them and/or assessment materials, including 3 Conducting a needs may have less knowledge on menstruation, puberty, their caregivers. It is important for response staff to assessment and reproductive health. Note that different education understand any challenges they may be experiencing, • Oxfam Technical Brief: Excreta disposal for formats may be necessary for the same message. including accessing adequate MHM materials, 4 Providing MHM physically vulnerable people in emergencies Materials and Supplies For example, an audio format may support girls and inclusive infrastructure and MHM education. This (link). women who are blind (loud speaker, radio, video with learning can be used to improve programming and to 5 MHM and Transit audio description) while a written format (brochures, advocate for the needs of vulnerable girls and women • Sample MHM training for caregivers for girls posters) or the use of simplified words and pictures (and their caregivers) across organizations, working and women with disabilities (link). 6 MHM and Shelter may prove supportive for girls with intellectual groups and other relevant forums. • Menstrual Hygiene Matters, Module 7: disabilities. Direct outreach by health and hygiene Supporting women and girls in vulnerable, 7 MHM and Water and workers to households of disabled girls and Sanitation Facilities marginalized of special circumstances (link). women may be necessary. It is important to involve vulnerable girls and women in the design of all 8 MHM, Disposal and • Improving the accessibility of water and Waste Management materials and messages. sanitation infrastructure: Menstrual Hygiene Matters, Toolkit 7.2.1: Technical Designs and 9 MHM and Hygiene Girls and women with mental or physical disabilities Promotion & Health Specifications (link). Education Activities may depend on caretakers to help them manage their menstrual hygiene. Education should be directly • UNICEF Accessible Components for the Built 10 MHM and Vulnerable provided to caretakers on the basics of menstruation Environment: Technical Guidelines embracing Populations and how they can safely and sensitively support Universal Design (link). MHM. See a sample training on MHM for caregivers 11 MHM and Education of girls and women with disabilities in the additional • UNICEF Good Practices in the provision of resources below. Accessible and Inclusive WASH services (link). 12 MHM and Health
• UNICEF India: An Inclusive Approach for 13 MHM and Protection School Sanitation and Hygiene Education
Strategy, Norms and Designs (link). 14 Monitoring and Evaluation
65 BACK TO CONTENTS
Summary of Key Actions from Chapter 10: MHM and vulnerable populations
1 Introduction 1. Identify vulnerable girls and women that may need MHM support (through surveys, community leaders or groups, other organizations etc.) 2 Training staff on MHM 2. Consult vulnerable girls, women and their caregivers on the challenges and needs they may
3 Conducting a needs experience related to MHM. assessment 3. Provide supportive MHM supplies. 4 Providing MHM Materials and Supplies 4. Ensure that inclusive MHM infrastructure is available to girls and women with disabilities.
5 MHM and Transit 5. Provide appropriate menstrual hygiene promotion and menstrual health education to vulnerable girls, women and caregivers. 6 MHM and Shelter 6. Conduct follow up and monitoring to ensure that vulnerable girls, women and caregivers are 7 MHM and Water and Sanitation Facilities adequately supported.
8 MHM, Disposal and Waste Management
9 MHM and Hygiene Promotion & Health Education Activities
10 MHM and Vulnerable Populations
11 MHM and Education
12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation
66 11 MHM AND EDUCATION BACK TO CONTENTS
1 Introduction
11.1 2 Training staff on MHM
The introduction of a few basic MHM-supportive 3 Conducting a needs In many resource poor settings, menstruation CONSULT GIRLS AND assessment can negatively impact a girl’s education. This approaches should be integrated into education in FEMALE TEACHERS is especially the case in emergency contexts emergency response activities, including: 4 Providing MHM Materials and Supplies where a lack of private and safe WASH facilities, A brief needs assessment should be conducted to 1. Facilities: Ensuring access to female friendly information about MHM, and adequate menstrual more effectively address the needs and challenges sanitation facilities, in addition to convenient and 5 MHM and Transit supplies may negatively impact a girl’s ability experienced by adolescent girls and female teachers private water and soap plus disposal systems; to participate in school. Coordination with in school settings. This information can be quickly 6 MHM and Shelter WASH, NFIs/camp management and protection 2. Materials: Improving access to menstrual gathered using the following methods: actors in the emergency is essential to materials, including underwear; 7 MHM and Water and developing a response. • Focus Group Discussions can assess MHM Sanitation Facilities 3. Hygiene Promotion & Health Education: practices, cultural taboos, and MHM knowledge Assuring girls have adequate knowledge and and gaps. 8 MHM, Disposal and MHM CHALLENGES Waste Management understanding about MHM. EXPERIENCED BY GIRLS • A WASH Mapping Exercise. A confidential AND FEMALE TEACHERS mapping exercise with female students can help 9 MHM and Hygiene Promotion & Health IN EMERGENCIES: MHM challenges for female teachers. design female friendly toilets. This includes sharing Education Activities Like their students, female teachers and school their opinions on safety, privacy, location, disposal, • Lack of private, safe, gender-segregated toilets and other sensitive topics. 10 MHM and Vulnerable staff may also experience challenges dealing Populations (including disposal mechanisms, locks, water with their menstruation during the school day. • One-on-one discussions can be used to assess sources, etc.); Poor facilities, lack of adequate materials and MHM practices, challenges, and MHM knowledge 11 MHM and Education fear of leaks can prevent them from coming to • Lack of knowledge or information on menstrual and gaps. school to teach. and reproductive health; 12 MHM and Health See Chapter 3 and 14 for more information. • Anxiety and embarrassment around leakage 13 MHM and Protection and discomfort; 14 Monitoring and Evaluation
67
11.2
BACK TO CONTENTS Materials: Schools should have an emergency stock THE ESSENTIAL TRAIN TEACHERS AND EDUCATION STAFF of appropriate menstrual supplies available for girls QUESTIONS who are unprepared for a menstrual period during 1 Introduction All teachers and school staff, male and female, the school day. The needs assessment will inform should be knowledgeable and comfortable discussing the types of materials that girls prefer to use (e.g., 2 Training staff on MHM A few basic questions should be asked to guide MHM. Review Chapter 2 on training staff on MHM. disposable pads, reusable pads, cloth), if they effective MHM programming and services in have underwear, and how they dispose or wash 3 Conducting a needs school settings: assessment used materials.
• What materials do girls prefer to use for Key considerations when preparing materials: 4 Providing MHM Materials and Supplies managing their menstruation? 11.3 • When consulting girls about their menstrual • How do girls dispose of used sanitary 5 MHM and Transit materials preferences (including underwear), it materials while in school? (If reuseables) INFRASTRUCTURE & is useful to bring samples of the various options How are these materials washed, dried, or 6 MHM and Shelter MATERIALS available. This exercise should be completed prior stored while in school? to procuring supplies in larger quantities.
7 MHM and Water and Infrastructure: School sanitation facilities should • What taboos or cultural beliefs exist around Sanitation Facilities promote student and staff privacy, dignity, and • Inventory lists should be maintained to ensure menstruation in their communities regarding safety. When establishing a response, a few basic emergency menstrual materials are stocked 8 MHM, Disposal and menstrual practices and disposal of materials? and used appropriately. The materials should Waste Management infrastructure improvements should be introduced be stored in a locked cabinet managed by staff. • Do girls currently have access to sufficient to existing school facilities or integrated into the As female teachers and staff may also be in 9 MHM and Hygiene supplies of sanitary materials? development or rehabilitation of new facilities. Promotion & Health need of these materials, it is important to Education Activities • How could school toilets be designed Adopting these MHM actions at the onset may carefully monitor inventories. to better support girls with managing prevent difficult or costly modifications later (e.g. 10 MHM and Vulnerable • If blanket distributions to school girls are Populations menstruation? (For example: water inside, toilets may get clogged with used menstrual conducted, it may be necessary to also target lighting, locks, etc.) materials) and enable girls’ immediate access to 11 MHM and Education school. out-of-school girls through: Child friendly spaces • How would girls prefer to learn information (CFS), youth centers and women’s spaces. Essential MHM supportive components include: 12 MHM and Health about menstruation? (For example: In girls’ However, community-wide blanket distributions groups or hygiene clubs after schools? During are preferable to ensure that all adolescent girls • Access to female friendly toilets (see Figure 1) 13 MHM and Protection all-girls classes?) are covered. • A separate, well-located toilet for use by female • At what age or grade-level do girls in • During the chronic phase, the types of supplies 14 Monitoring and teachers, including a water source and disposal Evaluation this population generally have their first available may expand based on increased bins (Inter-Agency Network for Education in menstruation? knowledge about preferences. Emergencies (INEE), 2006) 68 BACK TO FIGURE 1: EXAMPLE OF A FEMALE FRIENDLY TOILET CONTENTS
Adequate numbers of safely located 1 Introduction toilets separated (with clear signage) GIRLS FEMALES FEMALES FEMALES from male facilities. GIRL’S 2 Training staff on MHM Safe and private toilets with inside FEMALES TOILET 3 Conducting a needs door latch assessment FEMALES FEMALES Clear signs instructing girls and 4 Providing MHM women to dispose of menstrual Materials and Supplies waste in the trash bin 5 MHM and Transit A shelf and hook for 6 MHM and Shelter FEMALES hygienically storing belongings during usage. 7 MHM and Water and Sanitation Facilities A light source inside of the toilets. (Note, as they won’t be at schools 8 MHM, Disposal and during the evening). Waste Management
Easily accessible water (ideally 9 MHM and Hygiene Promotion & Health inside the cubicle) for girls and Education Activities women to wash themselves and menstrual materials. 10 MHM and Vulnerable Populations
Trash bins (with lids) to dispose of 11 MHM and Education used menstrual materials
Walls, door and roof are made of 12 MHM and Health non-transparent materials with no 13 MHM and Protection gaps or spaces.
14 Monitoring and Some units should be accessible to Evaluation people with disabilities. 69 11.4
BACK TO CONTENTS CASE STUDY PROVIDE MHM EDUCATION In the absence of female teachers:
Schools can be ideal settings for providing menstrual When no female teachers are available, 1 Introduction and reproductive health education. The introduction appropriate women in the community should In the Dadaab Camp in northern Kenya, the of MHM education in schools may not be possible be identified. These could be health workers 2 Training staff on MHM Norwegian Refugee Council (NRC) supported until the chronic phase of an emergency. If MHM- or female elders who can visit the school and schools in providing Somali girls with sanitary related content does not already exist in a given provide MHM guidance. 3 Conducting a needs kits comprised of pads and underwear. However, assessment education curricula, then basic lesson plans on staff later learned that the girls’ families held menstruation and puberty can be integrated into Sensitize male administrators and teachers conservative religious values and would not allow 4 Providing MHM relevant lessons or in separate sessions. Content can about MHM so they are aware of the issue and Materials and Supplies their daughters to wear the underwear. Many of be adapted from existing MHM educational resources their basic responsibilities and role in supporting the girls were not able to bring the sanitary kits available in the development sector and elsewhere. girls. They can serve to create a safer and more 5 MHM and Transit home and would only use the underwear and Key considerations: enabling environment even if they do not teach pads while attending school. This is an example about the topic. 6 MHM and Shelter of the types of cultural issues that arise in an • MHM education should be organized for groups MHM response, and the need for community of all-girl students and led by female teachers (or 7 MHM and Water and engagement, such as gathering support and hygiene promoters or health clinic staff). Sanitation Facilities understanding among community elders and religious leaders. (Norwegian Refugee Council/ • It should not be assumed that an atmosphere of CASE STUDY 8 MHM, Disposal and Waste Management Columbia University’s Teachers College) comfort and trust exists between girls and female teachers, or that girls will be comfortable receiving 9 MHM and Hygiene MHM guidance from them or that teachers are In refugee camps in Somaliland, girls were Promotion & Health Education Activities Sustaining supplies of sanitary materials. comfortable teaching on this topic. provided with sanitary kits at schools. Boys at During the chronic phase, efforts can be made the school noticed that the girls were receiving • Prior to delivering MHM education, make sure 10 MHM and Vulnerable to create sustainable approaches for including extra packages and became curious about what Populations to gain an understanding of local cultural taboos menstrual health education lessons or hygiene they were. It is important that boys are also surrounding menstruation and how these may clubs that teach girls to make their own pads. educated on the basics of menstruation so that 11 MHM and Education impact female students and their MHM. These Women’s or other community groups can they understand and are supportive of the privacy findings should be integrated into lesson plans. also be encouraged to provide and material needs of their female peers. Such 12 MHM and Health homemade sanitary materials • If possible, education should be provided to boys education should reflect local cultural norms. for girls attending school In some contexts, it may also be appropriate 13 MHM and Protection on puberty (including menstruation) to reduce the (INEE 2010). teasing that girls experience around menstruating to include hygiene kits for boys in schools in while in school. the form of soap and other necessary items 14 Monitoring and Evaluation (Norwegian Refugee Council/Columbia University Teacher’s College). 70 11.5
BACK TO CONTENTS MONITORING AND TOOLS FEEDBACK
A checklist for assessing MHM measures in education programs. A few MHM specific questions should 1 Introduction It is important to continuously collect feedback from be added to any existing WASH checklists or inspection tools used in the school setting. Key questions female students and teachers and to monitor all including the following: 2 Training staff on MHM MHM interventions in order to determine the need for To be informed by direct observation: any further education or improved system. 3 Conducting a needs • Are girls and boys using separate toilet blocks or separate sides of the privacy wall? assessment • Direct observation, individual interviews and FGDs • Are there working locks on the inside of the toilets? with School WASH committees, teachers, and girl 4 Providing MHM students can all be used. • Are there private handwashing facilities? Materials and Supplies • Is there a means for girls to bring water into individual stalls (e.g. a bucket)? • Direct observation of WASH facilities should be 5 MHM and Transit routinely conducted and can be led by teachers or • Is there soap available at the toilet? female students. • Is an emergency stock of menstrual materials (including underwear) available for girls to manage 6 MHM and Shelter their menstruation if it starts unexpectedly or they lack access to materials? 7 MHM and Water and • Are used menstrual materials disposed of in the toilet or through another method of collection Sanitation Facilities and disposal? 8 MHM, Disposal and • Is there a waste bin available for disposal of used menstrual materials? Waste Management
To be informed by project records: 9 MHM and Hygiene Promotion & Health • Are all teachers and school staff (male and female) oriented on MHM needs and education? Education Activities
• Are girls receiving basic MHM promotion and education during or after school? 10 MHM and Vulnerable Populations
To be informed by discussion with girls: 11 MHM and Education • Do girls feel safe and comfortable using the toilets at school? (Why or why not?) • Do girls feel comfortable changing and disposing of materials while in school? 12 MHM and Health • Do girls feel comfortable requesting menstrual materials from school authorities? 13 MHM and Protection • Do girls feel that the MHM promotion and education provided was useful? (Why or why not?) 14 Monitoring and • Do girls feel like their menstruation is effecting their ability to attend school? Why or why not? Evaluation
For a WORD version of the checklist, see link. 71 11.6
BACK TO CONTENTS INDICATORS ADDITIONAL RESOURCES
1 Introduction Additional guidance resources available, include • My Safety, My Wellbeing MHM Indicators for School WASH response. the following: Guide: Chapters 10: 2 Training staff on MHM A few basic indicators should be adopted to Reproductive Part 1: My body, • INEE’s Gender Responsive School Sanitation, assess the MHM response. Find below a few puberty, hygiene, reproductive Health and Hygiene Brief (link). 3 Conducting a needs example indicators, which can be used: health including for ages 11-13 assessment and 14-18 (link). • Menstrual Hygiene Matters, Module Five: Working • Proportion of schools serving any girls older 4 Providing MHM with schools on menstrual hygiene (link). • Grow and Know Puberty books: education Materials and Supplies than 10 years of age that provide contingency resources for adolescent girls and boys (link). MHM materials. • Menstrual Hygiene Management Toolkit in Schools, 5 MHM and Transit Section 7: Activities, Games and Fun by USAID, • Proportion of female toilet cubicles/stances at Ministry of Zambia, and Splash 2015 (link). schools with access to water and soap. 6 MHM and Shelter • Women/girls of reproductive age (12-49 7 MHM and Water and Sanitation Facilities years of age) are comfortable using sanitation facilities for MHM while at school.
8 MHM, Disposal and Waste Management • Proportion of educational spaces with Summary of Key Actions from Chapter 11: MHH in educational spaces functional disposal mechanism for 9 MHM and Hygiene menstrual waste. 1. Consult girls and female staff on their MHM needs, preferences and challenges while Promotion & Health Education Activities managing their menstruation in educational spaces. • Proportion of toilets which incorporate the female friendly minimum requirements 10 MHM and Vulnerable 2. Equip schools with female friendly toilets (with doors, locks, lighting, water and a disposal Populations (see figure 1). method) in collaboration with WASH actors.
11 MHM and Education • Proportion of adolescent girls (12-19 years of 3. Train male and female staff on how to confidently and knowledgeably talk about menstruation age) who have received education on how to and support female students. 12 MHM and Health use MHM materials in school settings. 4. Ensure basic access to contingency sanitation supplies (including underwear) for girls To learn more on M&E and sample indicators, 13 MHM and Protection unprepared for a menstrual period during the school. please see Chapter 14. 5. Provide menstrual hygiene promotion and menstrual health education to adolescent girls. 14 Monitoring and Evaluation *Note, some girls under 12 may also be menstruating. 6. Conduct follow up and monitoring to ensure that vulnerable girls, women and caregivers are adequately supported. 72 12 MHM AND HEALTH BACK TO CONTENTS
1 Introduction
12.1 2 Training staff on MHM
3 Conducting a needs In most contexts, health facilities are viewed as KEY CONSIDERATIONS TRAINING HEALTH STAFF assessment ‘women-friendly’ spaces, where women visit for health services such as contraception, emergency All health staff, including men and women should • Health providers in emergencies often have 4 Providing MHM obstetric care, post-natal care and vaccination and be knowledgeable and professional discussing Materials and Supplies many competing priorities. curative services. Health facilities therefore provide menstruation with girls and women obtaining care. 5 MHM and Transit an important opportunity to reach women and girls • They may be resistant to adding MHM They should also be sensitized to ask clients about with MHM support, materials, and information. responsibilities to their tasks. MHM during clinical encounters. See chapter 2 for 6 MHM and Shelter more information: An MHM response in health settings includes • MHM activities should be integrated into providing female friendly toilets, addressing vaginal existing activities rather than added as 7 MHM and Water and Health supervisors’ considerations: Sanitation Facilities bleeding, maintaining an emergency stock of extra tasks. menstrual materials for unprepared clients who • Distribute brief information and job aids 8 MHM, Disposal and Waste Management experience a menstrual period, and pain medications. to support health staff integrate MHM into MHM challenges for female health staff. consultations Adolescent girls are less likely to seek care at health Like their patients, female health staff may 9 MHM and Hygiene Promotion & Health facilities for reproductive health services out of fear of also experience challenges dealing with their • Provide on-the-job training to health staff Education Activities provider bias and lack of confidentiality. Other access menstruation during the work day. Poor facilities, and regularly supervise them to ensure they points, such as schools (see Chapter 10) or child lack of adequate materials and fear of leaks can know when and how to discuss MHM and 10 MHM and Vulnerable Populations friendly spaces and youth centers (see Chapter 13), prevent them from coming to work. distribute MHM materials. may be more appropriate for reaching girls with MHM 11 MHM and Education services and education. Health sector collaboration Health providers’ considerations: with these sectors can increase adolescent girl 12 MHM and Health engagement and comfort with health sector • Demonstrate to clients how to use MHM resources and staff. supplies when distributed, including how to 13 MHM and Protection dispose and/or wash and dry them.
• Girls and women with clinical indications 14 Monitoring and Evaluation (see 12.2) should be advised at what point they need to return to the health facility if bleeding is too heavy or lasts too long. 73 12.2
BACK TO CONTENTS INFRASTRUCTURE & Provision of Materials: Health providers can play a • Many girls and women experience extreme pain MATERIALS role in assessing whether female clients have sufficient or discomfort during menstruation and request menstrual supplies. Shortages or issues in accessing pain-relief medication. Protocols for managing 1 Introduction Infrastructure: Girls and women may spend long menstrual materials can then be communicated to these requests should be prepared by each hours waiting in health facilities to receive health FEMALESrelevant sectoral partners (NFIs, WASH). health facility. 2 Training staff on MHM care for themselves or their families. A few basic MHM measures can ensure that health facility toilets • The health facility should keep an emergency 3 Conducting a needs assessment address the needs of menstruating female clients and stock of MHM materials (i.e. pads, underwear) health staff (see Figure 1). appropriate for the local context for girls and 4 Providing MHM women who are unprepared for a menstrual Materials and Supplies period while waiting for or receiving services. FEMALES
5 MHM and Transit FIGURE 1: EXAMPLE OF A FEMALE FRIENDLY TOILET
6 MHM and Shelter Adequate numbers of Easily accessible water toilets seperated (ideally inside the cubicle) 7 MHM and Water and FEMALES Sanitation Facilities FEMALES (with clear signage) for girls and women to from male facilities wash themselves and 8 MHM, Disposal and menstrual materials. Waste Management FEMALES
FEMALES Safe and private Trash bins (with lids) to 9 MHM and Hygiene Promotion & Health toilets with inside dispose of used menstrual Education Activities door latch materials FEMALES 10 MHM and Vulnerable Populations Clear signs instructing Walls, door and roof are girls and women to made of non-transparent
11 MHM and Education FEMALES dispose of menstrual materials with no gaps or waste in the trash bin spaces.
12 MHM and Health A shelf (or hook) for Some units should be
13 MHM and Protection hygienically storing accessible to people belongings during usage. with disabilities.
14 Monitoring and Evaluation Night time light source both inside and outside 74 of the toilets
12.3
BACK TO CONTENTS There may be other clinical indications (i.e. excess PROVIDE MENSTRUAL KEY MENSTRUAL HEALTH vaginal bleeding) for which health care facilities HEALTH EDUCATION TOPICS TO COVER: should provide a supply of MHM materials to 1 Introduction adolescent girls and women: Health educators who conduct sessions in the facility • Healthy MHM practices. The importance waiting areas or during regular outreach activities at of healthy MHM practices including the 2 Training staff on MHM • Women who have just delivered a baby camps or service points should integrate MHM into rationale for regularly washing themselves and (post-partum bleeding). (Minimum Initial existing educational activities and/or conduct sessions routinely changing, washing, fully drying and/or 3 Conducting a needs Service Package, 2011). about MHM (see Chapter 8 for more information). assessment disposing of sanitary materials. These can occur during post-natal and immunization • Girls or women taking contraceptive methods that days and for women waiting for curative and • Reproductive health. The important and 4 Providing MHM have breakthrough bleeding as a side effect (i.e. Materials and Supplies contraceptive services. natural role of menstruation within a female’s contraceptive implant or copper-bearing IUD). reproductive health system, including topics 5 MHM and Transit related to menarche, menopause, and • Abortion care clients (post-abortion and safe pregnancy. induced abortion care) treated with manual 6 MHM and Shelter COORDINATION U n 0 lo 02 ck 2 vacuum aspiration, medical abortion or dilation $ by 1 r 0 billion a yea • Healthy diet and exercise. The importance of 7 MHM and Water and and curettage. Note: In some contexts, women a healthy diet, including consuming iron-rich Sanitation Facilities are provided with misoprostol to treat incomplete foods and adequate water and exercise during Collaborating with other sectors can create abortion or misoprostol and mifepristone to menstruation. 8 MHM, Disposal and additional opportunities for MHM and Waste Management safely induce abortion and retained products reproductive health education, such as NFI are evacuated at home. These women should • Dispel other menstruation myths. Ensure that distributions, hygiene promotion women’s groups 9 MHM and Hygiene be provided with extra sanitary materials as the girls and women are informed about harmful Promotion & Health meetings, schools, and child friendly spaces. Education Activities bleeding can be very heavy. misconceptions regarding menstruation within their culture or communities. • Girls or women who may suffer from incontinence 10 MHM and Vulnerable Populations (the lack of voluntary control of urination or Other considerations include: defecation). This includes elderly women and 11 MHM and Education females who have experienced female genital • When possible, MHM should be integrated into mutilation (FGM) or a fistula. health topic calendars or agendas developed by 12 MHM and Health health staff (weekly or monthly).
• In cases where women and men are waiting 13 MHM and Protection together, women (and girls) should be asked to sit 14 Monitoring and away from the men to privately receive and discuss Evaluation information about MHM. 75 12.4 12.5
BACK TO CONTENTS CASE STUDY MONITORING AND ADDITIONAL FEEDBACK RESOURCES
1 Introduction • Proportion of female cubicles at health institutions In Bwagariza refugee camp in Burundi, it was • Additional resources with access to water and soap. 2 Training staff on MHM learned that the shaving of pubic hair was include the following: perceived as a method for promoting cleanliness, • Women/girls of reproductive age (12-49 years of 3 Conducting a needs especially during menstruation. Razors were age) are comfortable using sanitation facilities for • Menstrual Hygiene Flip Chart (link). assessment being shared between families and friends for MHM during the daytime and nighttime. • Oxfam Menstrual Hygiene Flip Charts this purpose. The health clinic responded by 4 Providing MHM • Proportion of health institutions with functional (Oxfam-Jordan) (link). Materials and Supplies holding health education sessions to discourage menstrual waste disposal mechanisms. the sharing practices, warning about the spread • Guidance Flyer on reusable pads (IFRC) (link). 5 MHM and Transit of HIV and other diseases. It is crucial for • Women/girls of reproductive age are comfortable • Guidance Flyer on disposable pads (IFRC) health providers to both explore and respond to disposing menstrual waste with the available 6 MHM and Shelter (link). cultural practices that may have serious negative methods. health consequences. MHM demonstration 7 MHM and Water and and education sessions provide important • Proportion of toilets which incorporate the female Sanitation Facilities opportunities for addressing these types of issues friendly minimum requirements (see Figure 1). and promoting key menstrual health messages. 8 MHM, Disposal and See Chapter 13 for more on indicators. Waste Management (WASH Advisor, International Federation of the Red Cross (IFRC) East Africa) 9 MHM and Hygiene Promotion & Health Education Activities
Summary of Key Actions from Chapter 12: 10 MHM and Vulnerable Populations MHM and Health
11 MHM and Education Consult girls and women to assess existing knowledge and gaps on menstrual health
12 MHM and Health Conduct trainings for health supervisors and health staff on integrating MHM.
Provide and regularly re-supply a reserve of MHM materials in health facilities. 13 MHM and Protection
Equip health clinics with female friendly toilets for girls and women using the clinic and female staff. 14 Monitoring and Evaluation Provide menstrual health education at health facilities or during outreach activities, in coordination with other sectoral actors (i.e. education, protection, WASH). 76 13 MHM AND PROTECTION BACK TO CONTENTS
1 Introduction Protective spaces in emergencies are often the safest FIGURE 1: MHM CHALLENGES FOR A GIRL OR entry point for women and girls to access some kinds WOMAN LIVING IN AN EMERGENCY CONTEXT 2 Training staff on MHM of MHM services and information. As described in Chapter 1, menstruation impacts women and girls’ 3 Conducting a needs ability to comfortably move within an emergency assessment Lack of sanitary setting (see Figure 1). Such challenges can deter materials, women and girls from using supportive resources 4 Providing MHM including Materials and Supplies and programming, including the services available underwear through women’s safe spaces and Child-Friendly 5 MHM and Transit Spaces (CFS). Lack of private Cultural taboos 6 MHM and Shelter Adolescent girls (10-17 years of age), in particular, female friendly & restrictions face significant barriers to accessing MHM toilets and related to MHM 7 MHM and Water and resources and information in emergencies. In some bathing spaces Sanitation Facilities contexts, this population may seek support through women’s spaces. In others, adolescent girls may 8 MHM, Disposal and Waste Management be best reached through CFS and youth centers. Unaccompanied girls and women may need 9 MHM and Hygiene specific attention. Promotion & Health Education Activities A few basic MHM-supportive measures should be provided in women’s safe spaces, CFS and youth Overcrowding 10 MHM and Vulnerable Lack of Populations and severly centers to better address these needs. This includes: knowledge on diminished mensuration 11 MHM and Education Facilities: Ensuring access to female friendly privacy sanitation facilities, in addition to convenient and 12 MHM and Health private water and soap plus disposal systems;
Materials: Improving access to menstrual materials, Anxiety and 13 MHM and Protection including underwear; embarassment around leakage 14 Monitoring and Hygiene promotion and health education: Assuring & discomfort Evaluation girls have adequate knowledge and understanding about MHM. 77 13.2 13.3
BACK TO 13.1 CONTENTS CONSULT GIRLS MHM INFRASTRUCTURE TRAINING PROTECTION AND WOMEN & MATERIALS 1 Introduction STAFF A brief needs assessment should occur to more Infrastructure: Sanitation facilities at CFS, youth effectively address adolescent girls’ and women’s centers or women’s safe spaces can accommodate 2 Training staff on MHM Train protection staff working in women’s safe needs while using protective spaces (see Chapter 3) the MHM-needs of girls, women and female workers spaces, CFS and youth centers on the basics of for more information. Many girls and women may be by integrating a few minimal improvements into the 3 Conducting a needs MHM and puberty to ensure they are confident and assessment more comfortable sharing information on MHM in development or rehabilitation of facilities: knowledgeable in discussing these topics with girls protective spaces than in other forums. Other sectors 4 Providing MHM and women. See Chapter 2 for more information. (WASH, Education, NFIs) can benefit if protection This includes the following: Materials and Supplies staff proactively share learning on MHM practices. • Access to female friendly toilets. Note: In CFS, MHM challenges for protection staff. Like their The following questions provide essential information: 5 MHM and Transit if It’s not possible to provide separate toilets, clients, female staff and outreach workers may arrangements should be made to avoid girls and also experience challenges dealing with their 6 MHM and Shelter boys using the toilets at the same time (INEE menstruation while at work. Poor facilities, lack THE ESSENTIAL QUESTIONS: 2010). See Figure 2 for an example female of adequate materials and fear of leaks can 7 MHM and Water and friendly toilet design. Sanitation Facilities prevent them from coming to work to deliver 1. What materials do girls and women prefer to programming and outreach. use for managing their menstruation? Are these • Where possible, protection spaces should have a 8 MHM, Disposal and Waste Management materials locally available or being provided? separate, well-located toilet for use by female staff which includes a water source and disposal bins 2. (If reusables) How do girls and women wash, 9 MHM and Hygiene (INEE 2006). Promotion & Health dry and store their menstrual materials? Education Activities Provision of Materials: Both CFS and women’s safe 3. In what ways could toilets be designed to spaces should have emergency stocks of menstrual 10 MHM and Vulnerable better support girls and women with managing Populations materials (including underwear) available for girls their menstruation? (Disposal, privacy, safety, and women who lack access to supplies or are 11 MHM and Education access to water, etc.). unprepared for a menstrual period while visiting these spaces. 4. What menstrual-related challenges do girls 12 MHM and Health and women experience visiting child-friendly or women’s safe spaces during menstruation? 13 MHM and Protection 5. What type of information or education would 14 Monitoring and Evaluation girls and women like to learn about managing their menstruation? How would they like to learn this information? 78 Key considerations include: BACK TO • When consulting girls about their menstrual • Inventory lists should be maintained to ensure • Both CFS and women’s safe spaces can also be CONTENTS materials preferences (including underwear), emergency menstrual materials are stocked and used as venues for distributing MHM supplies it is useful to bring samples of the various options FEMALESused appropriately. The materials should be stored (or kits with menstrual materials) especially available. This exercise should be completed prior in a locked cabinet managed by staff. As female when targeting vulnerable populations such as 1 Introduction to procuring these supplies in larger quantities. staff may also be in need of these materials, it is adolescent girls, including those not in school. important carefully monitor inventories. However blanket community wide distributions 2 Training staff on MHM are preferable to ensure all adolescent girls and women are covered. 3 Conducting a needs assessment FEMALES
FIGURE 1: EXAMPLE OF A FEMALE FRIENDLY TOILET 4 Providing MHM Materials and Supplies
Adequate numbers of Easily accessible water 5 MHM and Transit toilets seperated (ideally inside the cubicle) FEMALES FEMALES (with clear signage) for girls and women to 6 MHM and Shelter from male facilities wash themselves and menstrual materials. 7 MHM and Water and FEMALES Sanitation Facilities
FEMALES Safe and private Trash bins (with lids) to 8 MHM, Disposal and toilets with inside dispose of used menstrual Waste Management door latch materials FEMALES 9 MHM and Hygiene Promotion & Health Clear signs instructing Walls, door and roof are Education Activities girls and women to made of non-transparent
FEMALES dispose of menstrual materials with no gaps or 10 MHM and Vulnerable waste in the trash bin spaces. Populations
A shelf (or hook) for Some units should be 11 MHM and Education hygienically storing accessible to people belongings during usage. with disabilities. 12 MHM and Health
Night time light source 13 MHM and Protection both inside and outside of the toilets 14 Monitoring and Evaluation
79 13.4
BACK TO CONTENTS Supporting the MHM needs of girls and women PROVIDING MENSTRUAL Reaching women at CFS. CFS are not only with special needs. Some girls and women may HYGIENE PROMOTION useful for reaching adolescent girls, but can also have restrictions on their access to services due serve as safe entry points for women – mothers 1 Introduction AND MENSTRUAL to a disability that makes movement challenging and other female caretakers – who often remain HEALTH EDUCATION close to the CFS while children take part in 2 Training staff on MHM or from strict cultural and family norms that activities and therefore could have opportunities do not allow them to attend school, protective Women’s safe spaces, CFS and youth centers can to access information sessions. However, these 3 Conducting a needs spaces, or otherwise move freely. Find out if be useful settings for providing basic MHM assessment sessions should be separate from those targeting households or communities have any individuals information, hygiene promotion and health girls, as they may not be comfortable asking living with them who may have special needs. education to women and girls. See Chapter 8 4 Providing MHM questions or discussing menstruation in front of Materials and Supplies A tailored MHM response may be needed to for details on content to include. reach them with MHM supplies and education. adult women.
5 MHM and Transit See Chapter 10 for more information. Key considerations for protection spaces:
• All sessions should be led by females. 6 MHM and Shelter • All sessions should be conducted in a safe and 7 MHM and Water and private space (with no men or boys present) Sanitation Facilities CASE STUDY CULTURAL • Conduct sessions when women and girls are free SENSITIVITY 8 MHM, Disposal and Waste Management from family responsibilities and not when attending In post-earthquake Nepal, women participating will put them in danger. The provision of MHM health education can in mother’s groups supported by Oxfam asked provide an opportunity to discuss other culturally 9 MHM and Hygiene for assistance in teaching their daughters Promotion & Health • Explore if sessions should be conducted separately sensitive topics, such as the link between Education Activities about menstruation. Prior to holding a session, or together with adolescent girls and women. menarche and early marriage. In some cultural questions and challenges experienced in contexts, a menstruating girl is considered ready 10 MHM and Vulnerable managing menstruation were collected from • If female staff are not available, arrange for a Populations for marriage. This can be exacerbated during girls and women. An MHM informational session health care worker or hygiene promoter to emergencies, where resource scarcity and safety was then developed by health promoters and provide this instruction to women and girls 11 MHM and Education concerns may increase the risk of early marriage. protection staff. The session’s discussion drew in the protective space.
12 MHM and Health upon the questions already provided to minimize any embarrassment or discomfort by girls and
13 MHM and Protection women. This example shows the importance of cross-sectoral collaboration to address MHM and
14 Monitoring and the importance of tailoring an MHM response to Evaluation meet the specific information gaps in a culturally sensitive manner. (Oxfam-Nepal, 2015). 80
13.5 BACK TO CONTENTS MONITORING & FEEDBACK TOOLS Protective spaces can be an entry point to 1 Introduction understanding and monitoring whether women A checklist for assessing MHM measures in protection programs. and girls’ MHM-needs are being addressed more A few MHM specific questions should be added to any existing WASH checklists or 2 Training staff on MHM broadly by the response. This can occur through inspection tools used in protection spaces. Key questions including the following: discussions with women, girls and female staff. In 3 Conducting a needs the case of mixed-gender environments, like CFS, To be informed by direct observation: To be informed by discussions with girls and assessment direct observations of WASH facilities (accompanied women: • Are males and females using separate toilets? with checklists and led by both staff and adolescent 4 Providing MHM • Do girls feel safe at all times and comfortable Materials and Supplies girls themselves) can also be useful to ensure the • Is there water at the hand-washing station and is using the toilets at protection spaces? (Why or infrastructure supports girls in meeting their MHM it private? why not?) 5 MHM and Transit needs safely. • Is there a means for girls and women to bring • Do girls feel comfortable changing and disposing water into individual stalls (e.g. a bucket)? 6 MHM and Shelter of materials while at protection spaces? • Is there soap available at the toilet? 7 MHM and Water and Sanitation Facilities • Is an emergency stock of menstrual materials (including underwear) available for girls and To be informed by program records: 8 MHM, Disposal and women to manage their menstruation if it starts • Are all program staff oriented on MHM needs Waste Management unexpectedly or they lack access to materials? and education? 9 MHM and Hygiene • Are used menstrual materials disposed of in the Promotion & Health • Are girls and women receiving basic Education Activities toilet or through another method of collection and MHM promotion and education while at disposal? protection spaces? 10 MHM and Vulnerable • Is there a waste bin available for disposal of used Populations menstrual materials? 11 MHM and Education
12 MHM and Health
13 MHM and Protection
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13.6 BACK TO CONTENTS ADDITIONAL RESOURCES 1 Introduction Existing MHM curricula from 2 Training staff on MHM the education sector can be adapted for these lessons. 3 Conducting a needs assessment Summary of Key Actions from Chapter 13 – MHM and Protection Menstrual hygiene promotion materials: 1. Consult girls and women on their menstrual hygiene preferences, behaviors, and cultural 4 Providing MHM • Menstrual Hygiene Flip Chart (link). Materials and Supplies beliefs. • Oxfam-Jordan’s Menstrual Hygiene Flip Charts 5 MHM and Transit 2. Train and sensitize protection staff on how to confidently and knowledgably discuss (link). menstrual health and hygiene with girls and women. 6 MHM and Shelter Menstrual health education on menstruation materials: 3. Equip protection spaces with female friendly toilets for adolescent girls, women and 7 MHM and Water and female staff. Sanitation Facilities • My Safety, My Wellbeing Guide: Chapters 10: Reproductive Part 1: My body, puberty, 4. Ensure that CFS and women’s safe spaces have a basic emergency reserve of appropriate 8 MHM, Disposal and menstrual materials (including underwear). Waste Management hygiene, reproductive health (includes for ages 11-13; 14-18) (link). 5. Provide basic education to adolescent girls and women on menstrual health and menstrual 9 MHM and Hygiene Promotion & Health hygiene. Education Activities
10 MHM and Vulnerable Populations
11 MHM and Education
12 MHM and Health
13 MHM and Protection
14 Monitoring and Evaluation
82 14 MONITORING & EVALUATION BACK TO CONTENTS
1 Introduction
14.1 2 Training staff on MHM
3 Conducting a needs To ensure that MHM programming is TYPES OF METHODS Qualitative Methods: Beyond the needs assessment appropriately designed, sustained and assessment, qualitative methods can be used to improved upon, continuous Monitoring An M&E plan should use a combination of qualitative gather continuous feedback from girls and women 4 Providing MHM and Evaluation (M&E) activities should be and quantitative assessment methods. Please about their perceptions of the response, challenges Materials and Supplies conducted. M&E plans should begin with the reference Table 1 below for a summary of available and barriers, and opportunities for improvement. 5 MHM and Transit design and implementation of MHM activities, methods. Possible methods include: and be expanded once conditions stabilize. 6 MHM and Shelter Whenever possible, integrate MHM M&E into • Focus Group Discussions on-going M&E activities. • Key informant interviews 7 MHM and Water and Sanitation Facilities KEY M&E LEARNING QUESTIONS • Semi-structured interviews 8 MHM, Disposal and Waste Management 1. Were the approaches used for distributing and 5. Do girls and women feel safe and comfortable • Pocket or voting charts demonstrating the use of MHM materials and washing their reusable menstrual materials in • Social Mapping (safe-scaping) 9 MHM and Hygiene supplies effective in reaching all girls and women? existing washing facilities or their homes/shelters? Promotion & Health Education Activities (Why or why not?) (Why or why not?) Quantitative Methods: MHM questions should be built into existing M&E activities or introduced as a 2. Were the menstrual hygiene materials acceptable 6. How are girls and women drying reusable 10 MHM and Vulnerable new activity if necessary. This can provide explicit Populations in design and adequate in quantity? menstrual materials? learning on the quantity, quality and reach of 11 MHM and Education 3. Do all girls have access to suitable facilities for 7. How are girls and women disposing of used response activities. Possible methods include: managing their menstruation (toilet, bathing space menstrual hygiene materials? • Observational surveys 12 MHM and Health or space in their homes)? 8. Were girls and women provided with MHM • Household surveys 4. Do girls and women feel safe and comfortable education? Was the information useful to them? In 13 MHM and Protection managing their menstruation in the existing what ways could it be improved? • Post Distribution Monitoring (PDM) surveys 14 Monitoring and sanitation or bathing facilities available to them? Evaluation (Why or why not?) • Pre-and post-test knowledge assessments 83
TABLE 1: ASSESSMENT METHODS BACK TO CONTENTS ASSESSMENT METHODS
FGDs are an ideal method for discussing sensitive topics such as MHM. 1 Introduction FOCUS GROUP DISCUSSIONS Key considerations include: 2 Training staff on MHM • Gather groups of 8-10 female participants in a safe and private space.
3 Conducting a needs • Deliver (if culturally appropriate) to segmented age groups (i.e. girls (12-18 years) and women assessment (19-45 years). Further segmentation may be needed.
4 Providing MHM • Female staff should conduct, partnered with someone from the local context, in a safe and Materials and Supplies private space.
5 MHM and Transit • Use purposive sampling or selective sampling during the acute phase. Selection criteria should represent both the norm (average response) and most vulnerable cases (i.e. adolescent girls, 6 MHM and Shelter disabled, impoverished). As conditions stabilize probability sampling may be used.
7 MHM and Water and ONE-ON-ONE Key Informant Interviews: Conduct with individuals such as female WASH Committee members Sanitation Facilities INTERVIEWS or staff members who work extensively with women and girls in the community, and may have insight into the issues that the community faces. 8 MHM, Disposal and Waste Management Semi-structured Interviews: Conduct with a select number of adolescent girls and women who may not feel comfortable discussing MHM in groups, or who may be able to provide deeper 9 MHM and Hygiene insight in a private setting. Promotion & Health Education Activities Key considerations include:
10 MHM and Vulnerable • Conduct with key individuals, such as female WASH committee members, and a select Populations number of girls and women in the target population.
11 MHM and Education • Conduct enough interviews to ensure a range of perspectives are captured (especially if no other assessment methods are used). 12 MHM and Health • Female staff should conduct, partnered with someone from the local context, in a safe and
13 MHM and Protection private space.
A participatory method for assessing peoples’ preferences in a private and interactive format 14 Monitoring and POCKET Evaluation OR VOTING where individuals are asked to ‘vote’ anonymously. This is often used in association with FGDs. When possible, pictures or drawings can be used to depict an activity or item. This technique is CHARTS useful for sensitive topics related to MHM and WASH. 84
14.2
BACK TO CONTENTS ASSESSMENT METHODS M&E INDICATORS A concise set of MHM indicators are A participatory method in which small groups of participants draw maps of their PARTICIPATORY needed for effective monitoring and 1 Introduction communities (including sanitation and washing facilities) and draw where they do and MAPPING evaluation of MHM programming. do not feel safe as well as where they can and cannot access while menstruating on the 2 Training staff on MHM maps. Conduct a discussion directly after a short drawing period, during which participants These indicators can be integrated explain the safety rationale for each of their maps. into existing sectoral monitoring or 3 Conducting a needs surveillance systems. Table 2 (on page 84) assessment OBSERVATIONAL A rapid method for assessing the situational context or whether various components of the provides a few sample MHM indicators, MHM response have been implemented or maintained over time. CHECKLIST how and when to collect this data, and 4 Providing MHM their rationale for use. Materials and Supplies • Add MHM focused checklist questions to existing M&E checklists being used by various
sectors (such as WASH, Education, etc.). 5 MHM and Transit
• Use observational checklists at different phases of the response, including at the onset 6 MHM and Shelter of an emergency to assess the situation or capacity and then later during routine M&E activities. 7 MHM and Water and Sanitation Facilities SURVEYS A method for assessing programming, including Post-Distribution Monitoring (PDM) or Knowledge Attitude and Practices (KAP) surveys. A few basic MHM-focused questions can 8 MHM, Disposal and be added to existing sector survey tools. Waste Management
Key considerations include: 9 MHM and Hygiene Promotion & Health • Consider whether the culture of the population is sufficiently open on MHM that answers Education Activities will be realistic and unbiased. 10 MHM and Vulnerable • When training data collectors, sensitize both men and women on how to professionally Populations ask questions related to MHM. However, it is always preferable for females to ask all MHM-related questions during survey activities. 11 MHM and Education
• Consider whether the venue where the survey takes place provides sufficient privacy for 12 MHM and Health eliciting the information needed.
13 MHM and Protection
14 Monitoring and Evaluation
85 BACK TO CONTENTS TABLE 2: MHM IN EMERGENCIES INDICATOR LIST
KEY PROGRAMMATIC INDICATOR NUMERATOR/DENOMINATOR 1 Introduction AREAS: (DATA SOURCE)
2 Training staff on MHM 1. ACCESS TO During a given distribution round: NUMERATOR: Number of kits women/girls 12-49 years of age receiving a kit (or number of kits distributed) 3 Conducting a needs ADEQUATE AND Proportion of women/girls of reproductive age assessment DENOMINATOR: Total number of women/girls 12-49 years of age in target area SUPPORTIVE MHM (WRA) (12-49 years of age) that receive MHM MATERIALS materials DATA SOURCE: administrative data 4 Providing MHM Materials and Supplies NOTES AND INTERPRETATION: (1) The minimum requirements for MHM materials would be context specific depending on other distributions, but should include disposable 5 MHM and Transit or reusable pads and/or cloths, soap, a bucket and underwear in appropriate quantities for the distribution interval; (2) an estimate of the number of WRA can be used to estimate the
6 MHM and Shelter denominator. Target 100%
During a given distribution round: NUMERATOR: Number of women/girls 12-49 years of age who report materials are 7 MHM and Water and Sanitation Facilities acceptable Proportion of WRA reporting that the MHM Number of women/girls 12-49 years of age who report materials are sufficient materials received are acceptable and sufficient 8 MHM, Disposal and Waste Management in quantity. DENOMINATOR: Total number of women/girls 12-49 years of age surveyed in target area
DATA SOURCE: Post-distribution monitoring survey 9 MHM and Hygiene Promotion & Health NOTES AND INTERPRETATION: If no post-distribution monitoring survey is planned, Education Activities focus group discussions conducted separately with women and girls can help to understand acceptability and whether quantities are sufficient. Target is 100%. 10 MHM and Vulnerable Populations Proportion of schools serving any girls older than NUMERATOR: Estimated number of liters of water used by a household on a daily basis 10 years of age that provide contingency MHM [based on number of containers collected]. 11 MHM and Education materials DENOMINATOR: Total number of households surveyed X average household size 12 MHM and Health DATA SOURCE: Institutional assessment
NOTES AND INTERPRETATION: The minimum requirements for contingency MHM 13 MHM and Protection materials would be context specific depending on other distributions, but should include disposable pads or cloths, soap and underwear. Target is 100%. 14 Monitoring and Evaluation
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KEY PROGRAMMATIC INDICATOR NUMERATOR/DENOMINATOR AREAS: (DATA SOURCE) 1 Introduction
2.ACCESS TO Average water use for drinking, cooking and NUMERATOR: stimated number of liters of water used by a household on a daily basis 2 Training staff on MHM ADEQUATE AND personal hygiene is at least 15 liters per person [based on number of containers collected]. per day 3 Conducting a needs SUPPORTIVE MHM DENOMINATOR: Total number of households surveyed X average household size assessment INFRASTRUCTURE DATA SOURCE: Household survey 4 Providing MHM NOTES AND INTERPRETATION: Sphere specifies 15L/person/day and UNCHR specifies Materials and Supplies 20L/person/day is the minimum standard for access to water supply.
5 MHM and Transit Proportion of households living within 500 meters NUMERATOR: Number of households within 500 meters of an improved water point/ of an improved water point/source source 6 MHM and Shelter DENOMINATOR: Total number of households in catchment area 7 MHM and Water and DATA SOURCE: Administrative data, mapping or household survey Sanitation Facilities NOTES AND INTERPRETATION: Target is 100%. 8 MHM, Disposal and Percentage of population living within 50 meters NUMERATOR: Number of households within 50 meters of an improved sanitation facility Waste Management of an improved sanitation facility* DENOMINATOR: Total number of households in catchment area 9 MHM and Hygiene Promotion & Health * Separates human excreta from human contact, DATA SOURCE: Administrative data or household survey Education Activities i.e. flush toilet, connection to a piped sewer NOTES AND INTERPRETATION: Target is 100%. system or septic system, flush / pour-flush to a pit 10 MHM and Vulnerable latrine, pit latrine with slab, ventilated improved pit Populations latrine, composting toilet (JMP, 2012) 11 MHM and Education Proportion of female-only sanitation blocks NUMERATOR: Number of female-only sanitation blocks
DENOMINATOR: Total number of sanitation blocks 12 MHM and Health DATA SOURCE: Administrative data, facility assessments 13 MHM and Protection NOTES AND INTERPRETATION: Target is 50%.
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1 Introduction KEY PROGRAMMATIC INDICATOR NUMERATOR/DENOMINATOR AREAS: (DATA SOURCE)
2 Training staff on MHM 2.ACCESS TO Proportion of female toilet cubicles/stances at NUMERATOR: Number of institutional female toilet cubicles/stances with access to water institutions [e.g. schools, protection spaces, health and soap 3 Conducting a needs ADEQUATE AND assessment clinics] with access to water and soap SUPPORTIVE MHM DENOMINATOR: Total number of institutional female toilet cubicles/stances DATA SOURCE: Administrative data, facility assessments 4 Providing MHM INFRASTRUCTURE Materials and Supplies (CONTINUED) NOTES AND INTERPRETATION: Target is 100%.
5 MHM and Transit Women/girls of reproductive age (12-49 years of Qualitative information age) are comfortable using sanitation facilities for DATA SOURCE: Focus group discussions conducted separated with women and girls can 6 MHM and Shelter MHM during the daytime and night time. help to understand comfort level.
7 MHM and Water and Proportion of institutions with functional disposal NUMERATOR: Number of institutions with functional disposal mechanisms for Sanitation Facilities mechanisms for menstrual waste. menstrual waste DENOMINATOR: Total number of institutions 8 MHM, Disposal and Waste Management DATA SOURCE: Administrative data, facility assessments NOTES AND INTERPRETATION: Target is 100%. 9 MHM and Hygiene Promotion & Health Education Activities Women/girls of reproductive age (12-49 years of Qualitative information age) are comfortable disposing their menstrual DATA SOURCE: Focus group discussions conducted separated with women and girls can 10 MHM and Vulnerable waste with the available methods. Populations help to understand comfort level.
Proportion of sanitation facilities (toilets1/bathing NUMERATOR: Number of sanitation facilities (toilets1/bathing spaces2) which incorporate 11 MHM and Education spaces2) which incorporate the female-friendly the female friendly minimum requirements minimum requirements. 12 MHM and Health DENOMINATOR: Total number of sanitation facilities DATA SOURCE: Administrative data, facility assessments 13 MHM and Protection NOTES AND INTERPRETATION: Target is 100%.
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14.3
BACK TO CONTENTS IMPROVED DOCUMENTATION KEY PROGRAMMATIC INDICATOR NUMERATOR/ 1 Introduction AREAS: DENOMINATOR There is need for continued innovation and improvement in the provision and response of MHM (DATA SOURCE) 2 Training staff on MHM in emergencies. When possible, document lessons learned and best practices for developing a MHM 3. ACCESS TO Proportion of women/girls NUMERATOR: Number of women/girls of 3 Conducting a needs response. This information will help to build the assessment MENSTRUAL of reproductive age (12-49 reproductive age (12-49 years of age) who years of age) who have have received education on how to use learning on this topic. This includes practical briefs, HYGIENE AND received education on how to MHM materials photo documentation, and anecdotal experiences. 4 Providing MHM Materials and Supplies HEALTH EDUCATION use MHM materials DENOMINATOR: Total number of women/ girls of reproductive age (12-49 years of age) 5 MHM and Transit surveyed
DATA SOURCE: Post-distribution monitoring 6 MHM and Shelter survey
NOTES AND INTERPRETATION: If no post- 7 MHM and Water and Sanitation Facilities distribution monitoring survey is planned, program activities across partners should 8 MHM, Disposal and be reviewed to understand if educational Waste Management activities have been undertaken and with
which populations. 9 MHM and Hygiene Promotion & Health Education Activities Proportion of adolescent girls NUMERATOR: Number of adolescent girls in (12-19 years of age) who school who have received education on how 10 MHM and Vulnerable have received education on to use MHM materials. Populations how to use MHM materials in DENOMINATOR: Number of adolescent school settings girls surveyed. 11 MHM and Education
DATA SOURCE: Sampling survey in schools 12 MHM and Health
1). The minimum requirements for female friendly 2). The minimum requirements for female friendly 13 MHM and Protection toilets include: 1). Access to water 2). Access to soap bathing spaces include: 1). Access to water 2). Access to 3). Adequate privacy 4). Acceptable and appropriate soap 3). Adequate privacy 4). Discreet and appropriate 14 Monitoring and Evaluation menstrual waste disposal mechanism 5). Gender drainage system 5). Gender segregation 6. Lighting where segregation 6). Lighting where appropriate. appropriate.
89 14.4
BACK TO CONTENTS ADDITIONAL RESOURCES
1 Introduction Additional reference documents 2 Training staff on MHM may be useful including:
3 Conducting a needs • MHM Needs Assessment assessment Focus Group Discussion Guide (link). 4 Providing MHM Materials and Supplies • Oxfam’s Rapid MHM Focus Group Discussion Guide (link). 5 MHM and Transit • Sampling: UNICEF”s Rapid Assessment 6 MHM and Shelter Sampling in Emergency Situations (link).
7 MHM and Water and • Pocket or voting charts: The World Bank’s Sanitation Facilities MetGuide – Methodology for Participatory Assessments with communities, institutions 8 MHM, Disposal and Waste Management and policy makers (link).
9 MHM and Hygiene • Participatory Mapping: Safe scaping Promotion & Health participatory safety mapping adolescent Education Activities refugee Somali girls, Ethiopia from the Violence, Gender & Wash toolkit (link). 10 MHM and Vulnerable Populations • Participatory Assessments: UNHCR’s Listen
11 MHM and Education and Learn: Participatory Assessments with Children and Adolescents (link). 12 MHM and Health • IFRC’s Menstrual Hygiene Management (MHM) kits for emergencies (link). 13 MHM and Protection
• Menstrual Hygiene Matters Module 9: 14 Monitoring and Evaluation Research, Monitoring and Advocacy (link).
90 CITATIONS
BACK TO CONTENTS 1. Bishop, E., Dunn, J., Gregory, L., Murphy, E., Retrieved from: https://watsanmissionassistant. 11. Oxfam GB. (2011). Women’s Menstrual Hygiene Romero-Amaya, D., & Spector, A. (2014). Sanitary wikispaces.com/file/view/IFRC MHM+Kits+ Needs in Emergencies. London. Retrieved from Kit Distribution within NRC Education Programs: for+Emergencies_Case+Study_Final.pdf http://policy-practice.oxfam.org.uk/publications/ 1 Introduction Supporting Girls’ Education in Ethiopia, Kenya, womens-menstrual-hygiene-needs-in- Somalia and South Sudan. New York City. 7. International Federation of the Red Cross and Red emergencies-298990 2 Training staff on MHM Crescent Societies (IFRC). (2013). Operational 2. Hayden, T. (2012). Menstrual Hygiene research on menstrual hygiene management 12. Save the Children. (2015). Menstrual Hygiene 3 Conducting a needs Management in Emergencies: Taking stock of (MHM) kits for emergencies. Bwagiriza. Retrieved Management Operational Guidelines. assessment support from UNICEF and partners. New York from: http://www.elrha.org/researchdatabase/final- Retrieved from http://www.savethechildren.
City. Retrieved from: https://www.unicef.org/wash/ report-operational-research-menstrual-hygiene- org/atf/cf/%7B9def2ebe-10ae-432c-9bd0- 4 Providing MHM schools/files/MHM_in_Emergencies-vConf.pdf management-kit-emergencies/ df91d2eba74a%7D/MENSTRUAL_HYGIENE_ Materials and Supplies MANAGEMENT_OPERATIONAL_GUIDELINES. 5 MHM and Transit 3. House, S., Mahon, T., & Cavil, S. (2012). 8. Inter-agency Network for Education in PDF Menstrual Hygiene Matters: A resource for Emergencies (INEE) Gender Task Team. (n.d.). improving menstrual hygiene aound the world. Gender Responsive School Sanitation, Health and 13. Sommer, M., Ferron, S., Cavill, S., House, S. 6 MHM and Shelter (First Edit). London: WaterAid. Retrieved Hygiene. New York City: Inter-agency Network (2014). Violence, gender and WASH: Making from: http://www.wateraid.org/what-we-do/ for Education in Emergencies (INEE). Retrieved water, sanitation and hygiene safer through 7 MHM and Water and Sanitation Facilities our-approach/research-and-publications/view- from http://toolkit.ineesite.org/toolkit/INEEcms/ improved programming and services (A publication?id=02309d73-8e41-4d04-b2ef- uploads/1042/Gender_Strategies_in_Emergencies. practitioner’s toolkit). London: WaterAid. Retrieved 8 MHM, Disposal and 6641f6616a4f PDF from: http://violence-wash.lboro.ac.uk/ Waste Management
4. House (2016). Considerations for selecting 9. Nawaz, J., Lal, S., Raza, S., & House, S. (2006). 14. Sommer, M., Schmitt, M. L., Clatworthy, D., 9 MHM and Hygiene sanitary protection and incontinence materials Screened Toilet, Bathing and Menstruation Bramucci, G., Wheeler, E., & Ratnayake, R. Promotion & Health Education Activities for refugee contexts by S. UNHCR: Geneva. Units for the Earthquake Response in NWFP, 1 (2016). What is the scope for addressing Retrieved from: http://wash.unhcr.org/download/ Pakistan (pp. 514–517). Colombo: 32nd WEDC menstrual hygiene management in complex 10 MHM and Vulnerable considerations-for-selecting-sanitary-protection- International Conference. Retrieved from: humanitarian emergencies ? A global review. Populations and-incontinence-materials-for-refugee-contexts/ http://wedc.lboro.ac.uk/resources/conference/32/ Waterlines, 35(3), 245–264. Retrieved from http:// Nawaz.pdf dx.doi.org/10.3362/1756-3488.2016.024 11 MHM and Education 5. House, S. (2013). Course Report: ToT in
Menstrual Hygiene Management (MHM) in 10. Oxfam GB. (2008). Vulnerability and socio- 15. Tucker, M., & Yamakoshi, B. (2017). MHM for 12 MHM and Health Emergencies for Emergency WASH Trainers. cultural considerations for PHE in emergencies girls with disabilities webinar. New York City:
(April), 1–21. (Vol. 2). London. Retrieved from http://policy- United Nations Children’s Fund (UNICEF). 13 MHM and Protection practice.oxfam.org.uk/publications/vulnerability- 6. International Federation of the Red Cross and and-socio-cultural-considerations-for-phe-in- 14 Monitoring and Red Crescent Societies (IFRC) (2013). Menstrual emergencies-126713 Evaluation Hygiene: What’s the fuss? Piloting menstrual hygiene management (MHM) kits for emergencies 91 in Bwagiriza refugee camp, Burundi. Geneva.
ACKNOWLEDGEMENTS
BACK TO CONTENTS This publication has benefited from the valuable expertise toolkit, including Giorgio Faedo and Paul Timothy Mwebe. Roelandt (UNHCR), Devanna De La Puerte (UN), Meghan and energy of a wide range of humanitarian actors and The pilot, which yielded a great deal of learning and value for Greeley (IMC), Biserka Pop-Stefanija (MSF-B), Jessica researchers. The development of the toolkit came from the final toolkit and research products, would not have been Hjarrand (INEE), Deborah Nicol (IRC) and Patricia Gray 1 Introduction a strong partnership between the International Rescue possible without the tireless efforts of the MHM pilot team, (IRC). Committee (IRC) and Columbia University’s (CU) Mailman especially the Pilot Coordinator, Tom Ogello, and Program 2 Training staff on MHM School of Public Health based on funding from R2HC. Dr. Officer, Magdalena Mark. We would also like to thank practitioners and peer-reviewers Marni Sommer (CU), Margaret Schmitt (CU), and David including: Dominque Porteaud (UNICEF), Murray Burt 3 Conducting a needs Clatworthy (IRC) co-authored the guidelines with input into A special thanks to all the organizations and staff in Tanzania (UNHCR), Colin Rogers (Plan International), Nicholas assessment the research and monitoring and evaluation approaches that supported the pilot and evaluation efforts, including Brookes (CARE), Janet Meyers (IMC), Melissa Opryszko from Ruwan Ratnayake (IRC) and Erin Wheeler (IRC). Burton Twisa (UNICEF), Majaliwa Mabula (TWESA), Noreen (USAID), May Maloney (IFRC), Danielle Spencer, Pema 4 Providing MHM Materials and Supplies A dynamic team from both institutions provided crucial Omondi (DRC), Christina Msonge (IRC), Justine Luinael Lhaki (NFCC-Nepal), Libertad Gonzalez (Netherlands Red support throughout the research and development process, (IRC), Subira Lendaiga (IRC), Hashim Hatibu (Oxfam), Cross), Marion O’Reilly (Oxfam), Helen Hawkings, Anushka Florence Uwineza (Oxfam), Heri Ntoke, (IRC), Violeth Kalyanpur (IMC), Kate Brogan (IMC), Osama Abu Eita 5 MHM and Transit including: Penninah Mathenge (IRC), Nicole Klaesener- Metzner (IRC), Gina Bramucci (IRC), Elisabeth Roesch (IRC), Chihimba (PLAN), Yuseph Bahayuri (Tanganyika Christian (UNFPA), Brian Kae Enriquez (Philippines Red Cross), Refugee Service (TCRS)), Sam Nkola (IRC), Jonia Karuruma Therese Mahon (WaterAid), Brooke Yamakoshi (UNICEF), 6 MHM and Shelter Mobolaji Ibitoye (CU), Samantha Khandakji (CU) and Grace Lee (CU). (IRC), Frank Bigira Kaliyo (IRC), Conchesta Vedasto (TCRS), Bibi Lamond (IRC), Alisa Phillips (WRC), Lara Quarterman and Simon Peche (UNHCR). (DFID), James Robertson (UNICEF), Crystal Stewart (IRC), 7 MHM and Water and Sanitation Facilities The research and pilot activities were made possible through Boram Lee (WRC), Jennifer Rosenberg (WRC), Anna In 2016 a workshop was conducted in New York with a the time and support from the staff and leadership from the Reichenberg (IOM), Nicolas Villeminot (ACF), and Tom IRC Country Offices in Myanmar, Lebanon and Tanzania. group of global cross-sectoral humanitarian practitioners 8 MHM, Disposal and Wildman (USAID). Waste Management We want to thank all of the adolescent girls and women from who provided critical feedback and revisions to the draft both Lebanon, Myanmar and Tanzania who were willing to document. We would like to extend a special thanks to these Our sincere gratitude goes out to Adam Cohen for the design 9 MHM and Hygiene openly discuss this sensitive topic and share their personal individuals including: Sarah House (Independent), Chelsea and layout of the MHM in emergencies toolkit. Promotion & Health Giles-Hensen (IFRC), Benedicte Hafskjold (NCA), Henia Education Activities insights and advice with us. We would also like to thank the numerous humanitarian staff from each of these contexts Daddak (UNFPA), Sandra Krause (WRC), Jenn Schlecht Finally, we would like to give our extraordinary thanks to (across several organizations) who generously provided (WRC), Vinay Sadavarte (IFRC), Jamal Shah (UNICEF), the “MHM pioneers” around the world who have been 10 MHM and Vulnerable Populations their time and sincere feedback despite their demanding Michelle Farrington (Oxfam), Francesca Rivelli (UNFPA), paving the way on this topic for many years now, and whose schedules. We especially would like to express our gratitude Minja Peuschel (Save the Children), Jacquelyn Haver contributions to moving forward this agenda made the 11 MHM and Education to the Tanzania Country Office responsible for piloting the (Save the Children), Claudia Perlongo (UNHCR), Marjolein development of this toolkit possible.
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14 Monitoring and Evaluation
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A TOOLKIT FOR INTEGRATING MENSTRUAL HYGIENE MANAGEMENT (MHM) INTO HUMANITARIAN RESPONSE
Marni Sommer, Margaret Schmitt and David Clatworthy
This cross-sectoral resource on MHM in emergencies provides:
• Strategic guidance on best practices and design considerations for integrating MHM across response activities.
• Key assessment questions, case studies, staff training tools and additional resources for operationalizing MHM into planning and service delivery.
• Evaluation input and sample indicators for ensuring that MHM is integrated into existing monitoring and feedback systems.
The toolkit was designed to support a range of humanitarian actors involved in the planning and delivery of emergency response from a variety of sectors. This includes actors from the water, sanitation, and hygiene (WASH), health, education, protection, camp coordination camp management (CCCM), non-food items (NFI) and shelter sectors.