The Zimbabwe Formative Research on Menstrual Hygiene Management
Final Report for every child
ZIMBABWE
The Zimbabwe Formative Research on Menstrual Hygiene Management
Final Report 13.12.2019
for every child ii Formative Research on Menstrual Hygiene Management Final Report, December 2019
Acknowledgement
The Zimbabwe Formative Research on Menstrual Hygiene Management was commissioned by UNICEF and the Government of Zimbabwe. It was financed by DFID through the Rural WASH Program and by the Education Development Fund.
The research team would like to express their sincere gratitude to staff of UNICEF in the Water, Sanitation and Hygiene section. Specific mention goes to Moreblessing Munyaka and Aidan Cronin for their support during the research process.
Our gratitude also goes to the government technical committee which comprised of staff from the Ministry of Women Affairs, Gender and Community Development, Ministry of Primary and Secondary Education (MoPSE), Ministry of Health and Child Care, Ministry of Public Service, Labour and Social Services, ZIMSTAT, the National Coordination Unit and other UNICEF departments who took time from their busy schedules to participate in the research study and tools review workshop.
The team would like to recognise and appreciate all those that participated in the study as key informants and in group discussions. We express special gratitude to schools and communities visited in all the ten provinces of the country for the warm reception and their consent to participate in the study. Special mention goes to all the school staff and students that participated in the research.
Research Team of Muthengo Development Solutions
Prof Julie Elliot Stewart (Team Leader) Prof Marni Sommer (Technical Adviser) Dr Nyasha Madzingira (Quantitative Research Expert) Monica Mandiki (Social Behaviour Change and Communication Consultant) Remembrance Mashava (WASH Consultant) Walter Vengesai (Male Involvement – Gender Consultant) Vasco Chikwasha (Biostatistician) Shepherd Chikomo (Data Manager) Kudzai Tinago (Videographer) Tariro Mukupe (Project Manager)
Contact Details
Contact all authors on [email protected] Formative Research on Menstrual Hygiene Management Final Report, December 2019 iii
Definition of Key Concepts
Adolescents: UNFPA/WHO/UNICEF’s standard definition of adolescents is people between 10 and 19 years old. In addition the World Health Organisation (WHO) defined adolescence as progression from appearance of secondary sexual characteristics to sexual and reproductive maturity, development of adult mental process and identity, and transition from total socioeconomic dependence to relative independence. For the purpose of this study adolescence will be divided into two subgroups (10-14 and 15-19 years) to capture experiences around menstruation.
Confidentiality: The right of an individual to privacy of personal information, including health-care records (in this study). This means that access to personal data and information is restricted to individuals who have a reason and permission for such access. The requirement to maintain confidentiality governs not only how data and information are collected (e.g. a private space in which to conduct a consultation), but also how the data are stored (e.g. without names and other identifiers) and how, if at all, the data are shared. ’Privacy’ and ‘confidentiality’ are distinct and complementary concepts. Privacy is ‘the right and power to control the information (about oneself) that others possess’. Confidentiality is “the duty of those who receive private information not to disclose it without consent”. Thus, confidentiality ensures privacy.
Constrictions and Restrictions: In the context of this study, reflecting on the use of the word taboo was considered as a descriptor that limits discussion and interventions on sexual maturation issues, mainly for females. It seemed more appropriate to use the term constrictions and restrictions to describe these limits as it appeared to open up the possibilities of dialogue around such issues in contrast to the possibility of the term taboo closing down dialogue opportunities.
Culture: Culture is a way of life of a group of people--the behaviors, beliefs, values, and symbols that they accept, generally without thinking about them, and that are passed along by communication and imitation from one generation to the next. Culture broadly subsumes beliefs, values, attitudes, meanings, hierarchies, religion, notions of time, roles, spatial relations, concepts of the universe, and material objects and possessions acquired by a group of people in the course of generations
Curriculum: UNESCO defines a curriculum as the planned programme of objectives, content, learning experiences, resources and assessment offered by a school. iv Formative Research on Menstrual Hygiene Management Final Report, December 2019
Disability: The WHO defines disability as an umbrella term, covering impairments, activity limitations, and participation restrictions. An impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a participation restriction is a problem experienced by an individual in involvement in life situations.
Disability is thus not just a health problem. It is a complex phenomenon, reflecting the interaction between features of a person’s body and features of the society in which he or she lives. Overcoming the difficulties faced by people with disabilities requires interventions to remove environmental and social barriers.
Drop Outs: School drop outs fall into a variety of categories and given the problems of determining school going age the research focuses on girls who drop out before completing O Level which coincides with the current minimum entry levels into a variety of post-secondary training programmes. It also roughly reflects the assumed average age for completion of O Levels at 16 years. In this study therefore a dropout is anyone who is of school going age, intellectually capable of attending school, under 16 but not in school.
Gender: According to UNFPA (2005), the term gender refers to the economic, social and cultural attributes and opportunities associated with being male or female. In most societies, being a man or a woman is not simply a matter of different biological and physical characteristics. Men and women face different expectations about how they should dress, behave or work. Relations between men and women, whether in the family, the workplace or the public sphere, also reflect understandings of the talents, characteristics and behaviour appropriate to women and to men. Gender thus differs from sex in that it is social and cultural in nature rather than biological (UNFPA, 2005). It refers to personality traits, attitudes, feelings, values, behaviors and activities that society attributes to the two sexes on a differential basis. The social construct varies from society to society and changes overtime. Gender determines roles, responsibilities, opportunities, privileges, expectations and limitations within a specific context.
Information Education and Communication: The WHO operational definition of “IEC” refers to a public health approach aiming at changing or reinforcing health-related behaviours in a target audience, concerning a specific problem and within a pre-defined period of time, through communication methods and principles. Information, education and communication initiatives are grounded in the concepts of prevention and primary health care. Largely concerned with individual behaviour change or reinforcement, and/or changes in social or community norms, public health education and communication seek to empower people vis-à-vis their health actions, and to garner social and political support for those actions. IEC is multidisciplinary and client-centred in its approach, drawing from the fields of diffusion theory, social marketing, behaviour analysis, anthropology, and instructive design. IEC strategies involve planning, implementation, monitoring and evaluation. When carefully carried out, health communication strategies help to foster positive health practices individually and institutionally, and can contribute to sustainable change toward healthy behaviour (WHO, 2001). Formative Research on Menstrual Hygiene Management Final Report, December 2019 v
Improved Sources of Drinking Water: An improved water source (or improved drinking-water source or improved water supply) is a term used to categorize certain types or levels of water supply for monitoring purposes. It is defined as a type of water source that, by nature of its construction or through active intervention, is likely to be protected from outside contamination, in particular from contamination with faecal matter (WHO-UNICEF, 2012). The term was coined by the Joint Monitoring Program (JMP) for Water Supply and Sanitation of UNICEF and WHO in 2002 to help monitor the progress around water supply. The opposite of “improved water source” has been termed “unimproved water source” in the JMP definitions.
In 2017, JMP defined a new term: “basic water service”. This is defined as the drinking water coming from an improved source, and provided the collection time is not more than 30 minutes for a round trip. A lower level of service is now called “limited water service” which is the same as basic service but the collection time is longer than 30 minutes (WHO-UNICEF, 2017). Include piped water, public taps, standpipes, tube wells, boreholes, protected dug wells and springs, and rainwater. Because the quality of bottled water is not known, households using bottled water for drinking are classified as using an improved source only if their water source for cooking and hand washing are from an improved source. (Zimbabwe Demographic Health Survey 2015).
Improved Sanitation: Sanitation services refer to the management of excreta from the facilities used by individuals, through emptying and transport of excreta for treatment and eventual discharge or reuse. Improved sanitation facilities are those designed to hygienically separate excreta from human contact. There are three main ways to meet the criteria for having a safely managed sanitation service (SDG 6.2). People should use improved sanitation facilities which are not shared with other households, and the excreta produced should either be:
●● treated and disposed in situ, ●● stored temporarily and then emptied and transported to treatment off-site, or ●● transported through a sewer with wastewater and then treated off-site (WHO and UNICEF, 2018).
Improved toilet facilities include any non-shared toilet of the following types: flush or pour flush into a piped sewer system, septic tank, or pit latrine; ventilated improved pit(VIP) latrines or Blair toilets; and pit latrines with a slab. Although developed for emergencies and based on availability of funding there is a design that is adaptable for more routine MHM in the form of a “female friendly toilet” in the MHM in Emergencies Toolkit (Columbia University and International Rescue Committee, 2017; WaterAID, WSUP, UNICEF 2018),
Menstruation: A period or menstruation is a process of shedding of the lining of the womb, the endometrial tissue, through the vagina. This happens approximately every 28 days, however, there is some variation in this cycle. Most girls start menstruation between 10 and 15 years and it may take a few years for the menses to become regular. The beginning of menstruation is referred to as menarche and when menstruation ceases the period is referred to as menopause. Menopause usually occurs between the ages of 45 and 55 years. Menstruation vi Formative Research on Menstrual Hygiene Management Final Report, December 2019
occurs when an egg is released alternately and monthly from one of the ovaries throughout the reproductive years and when this egg does not get fertilized. The pituitary gland in the brain releases hormones that stimulate production of oestrogen in the follicles of the ovaries. Oestrogen causes maturation of eggs in the ovaries and thickening of the lining (endometrium) in the uterus. The lining is shed off when there is no fertilized egg embedded and oestrogen and progesterone hormone levels drop. The menstrual flow therefore consists of blood and the endometrium as fine blood vessels within the womb breakdown and the lining detaches itself. The detachment causes pain and discomfort which is severe for some. Bleeding generally lasts 3-5 days and is usually heavy in first 2 days. In total 5-12 teaspoons of blood are lost during each period. This is around 30-60 millilitres which has to be managed (Planned Parenthood Federation of America, 2019). Amenorrhea is when menstruation is absent during the reproductive years, between puberty and menopause. It is not a disease, and it does not mean that a person is infertile, but it can be a sign of a health problem that needs some attention.
Endometriosis is a disorder and can be cause for pain during menstruation. In this disorder endometrium tissue that normally lines the inside of your uterus grows outside the uterus and may cover ovaries, fallopian tubes and the tissue lining pelvis.
Menstruation is considered as part of sexual maturation when girls grow to reach adult height and weight and undergo puberty. Kakavoulis (1998) notes that sexual development leading to sexual maturation (for both boys and girls) is a complex process of biological physiological and behavioural changes starting from conception and continuing through the life cycle. The timing and speed with which these changes occur vary and are affected by both heredity and environment. However when sexual maturation begins, it typically occurs in the same order. Education on sexual maturation usually addresses biological changes to the body and how to interpret these changes, issues of hygiene and reproductive health, relationships and problems associated with sexual maturation.
Menstrual Hygiene Management: The UNICEF global guidance on MHM attached as follows; menstrual hygiene management refers to management of hygiene associated with the menstrual process. The World Health Organization (WHO) and UNICEF Joint Monitoring Programme (JMP) for drinking water, sanitation, and hygiene has used the following definition of MHM: Women and adolescent girls are using a clean menstrual management material to absorb or collect menstrual blood, that can be changed in privacy as often as necessary for the duration of a menstrual period, using soap and water for washing the body as required, and having access to safe and convenient facilities to dispose of used menstrual management materials. They understand the basic facts linked to the menstrual cycle and how to manage it with dignity and without discomfort or fear. In this regard Menstrual materials are the products used to catch menstrual flow, such as pads, cloth, tampons or cups. Menstrual supplies are other supportive items needed for MHM, such as body and laundry soap, underwear and pain relief items. Menstrual facilities are those facilities most associated with a safe and dignified menstruation such as toilets and water infrastructure and Menstruator is a term for a girl/ woman who experiences menstrual periods.
Religion: A set of fundamental beliefs concerning the cause, nature, and purpose of the universe Formative Research on Menstrual Hygiene Management Final Report, December 2019 vii
especially when considered as the creation of a superhuman agency or agencies usually involving devotional and ritual observances and often containing a moral code governing the conduct of human affairs.
School Going Age: School going age does not appear to be defined in the current Education Act but is set by the National Education Advisory Board in terms of s28 of the Education Act. However, the Children’s Act Chapter 5:06 section 2 defines “school-going age”, in relation to a child or young person, means a child or young person between the ages of five and a half years and sixteen years.
Whereas the 2013 Constitution Section 81(1) (f) provides that every boy and girl under eighteen years has the right to education, this may require alignment of the education policy and the provisions of the Children’s Act in relation to school going age. By way of clarification such contradictions in different pieces of legislation are not uncommon but arguably the constitutional provision should prevail.
Sexual Maturation: During adolescence (usually considered age 10 to the late teens or early 20s), boys and girls reach adult height and weight and undergo sexual maturation (puberty). The timing and speed with which these changes occur vary and are affected by both heredity and environment. Sexual maturity often begins earlier today than a century ago, probably because of improvements in nutrition, general health, and living conditions (Graber). For example, the average age that girls begin menstruating has decreased by about 3 years over the past 100 years. However, whenever sexual maturation begins, it typically occurs in the same order. Kakavoulis (1998) notes that sexual development is a complex process of biological physiological and behavioural changes staring from conception and continuing through the life cycle. Education on sexual maturation usually addresses biological changes to the body and how to interpret these changes, issues of hygiene and reproductive health, relationships and problems associated with sexual maturation.
WASH: The WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation agreed on the following definition for MHM: Women and adolescent girls are using a clean menstrual management material to absorb or collect menstrual blood, that can be changed in privacy as often as necessary for the duration of a menstrual period, using soap and water for washing the body as required, and having access to safe and convenient facilities to dispose of used menstrual management materials (JMP;2012). This definition focuses on four aspects of MHM interventions:
●● ‘Hardware’, in the form of gender-specific, safe, clean and accessible sanitation facilities and water sources. ●● ‘Software’, in the form of puberty and hygiene education and support systems. ●● Operations and maintenance systems, to ensure that facilities are well kept. ●● Continual availability of consumables, with particular attention on soap, water and culturally appropriate MHM materials.
In the context of this research the role of teachers and educational administrators is an important consideration in implementing WASH initiatives (Sommer et al, 2017). viii Formative Research on Menstrual Hygiene Management Final Report, December 2019
Table of Contents
Acknowledgements...... ii Definition Of Key Concepts...... iii Table Of Contents...... viii List Of Figures...... x List Of Tables...... x Acronyms And Abbreviations...... xii Executive Summary...... xiii
1 Introduction...... 1 1 Background...... 1 1.1 MHM In Zimbabwe...... 2 1.1.1 Key Issues In Mhm In Zimbabwe...... 2 1.1.2 Status Of Water, Sanitation And Hygiene (Wash) In Zimbabwe...... 4 1.1.3 Institutional Arrangements For MHM And Wash In Schools (Wins)...... 7 1.1.4 Key Issues In The Education Sector...... 8 1.1.5 Key Gender-Related Issues Or Inequities...... 9 1.1.6 Legal And Policy Framework...... 10
2 Study Approach And Methodology...... 11 2.1 Purpose And Scope Of The Study...... 11 2.1.1 Scope Of The Study...... 11 2.2 Approach...... 12 2.3 Study Design...... 16 2.3.1 Quantitative Survey ...... 16 2.3.2 Qualitative Survey...... 20 2.4 Ethical Considerations...... 23 2.5 Limitations...... 25
3 Study Findings...... 29 3.1 MHM Information Sources...... 31 3.1.1 MHM Information Sources For Girls In And Out Of School...... 32 3.1.1.1 School Based Sources...... 35 3.1.2 Mhm Information Sources For Boys...... 39 3.1.3 Barriers And Constraints To Accessing Mhm Information...... 43 3.1.3.1 Barriers Within The Education Sector...... 44 3.1.3.2 Religious, Cultural And Gender Related Barriers To Information Sharing On MHM...... 44 3.1.3.3 Limited Cross-Sectoral Approach To Mhm Information Dissemination...... 47 3.2 Knowledge, Attitudes And Practices On MHM...... 47 3.2.1 Girls Knowledge, Attitudes And Practices On MHM...... 47 Formative Research on Menstrual Hygiene Management Final Report, December 2019 ix
3.2.1.1 Menstrual Hygiene Management Practises Among Girls...... 50 3.2.2 Boys’ Knowledge, Attitudes And Practices On Mhm...... 50 3.3 Social Norms, Myths And Taboo (Constrictions/Restrictions) That Surround Menstruation...... 52 3.3.1 Gender, Culture And Religion: Positive And Negative Constrictions And Restrictions...... 52 3.3.2 Involvement Of Man And Boys In MHM...... 56 3.3.3 What Benefits Do Those Traditions, Beliefs, Restrictions And Constrictions, Serve?...... 57 3.3.4 Creating Positive Social Norms...... 57 3.4 Facilities To Support MHM...... 58 3.4.1 Appropriateness Of Facilities...... 59 3.4.1.1 Challenges Faced In Ensuring Standard Hygiene Practices In Schools ...... 61 3.4.2 Access To Clean Safe Water For MHM...... 62 3.4.2.1 Access To Clean And Safe Water In School...... 62 3.4.3 Wash In Public Spaces...... 64 3.5 Services Available To Women And Girls On Mhm In The Communities Or Supportive Institutions...... 65 3.5.1 Perceptions Of Stakeholders - Interviews With Key Personnel...... 67 3.6 Access, Acceptability And Disposal Of Sanitary Materials...... 70 3.6.1 Materials And Percieved Safety Of Materials...... 70 3.6.1.1 Available Sanitary Materials...... 71 3.6.1.2 Sources Of Sanitary Materials...... 72 3.6.1.3 Manufacturing Of Sanitary Materials...... 74 3.6.1.4 Effectiveness Of Sanitary Materials...... 75 3.6.1.5 Quality Of Sanitary Materials...... 76 3.6.1.6 Safety Of Sanitary Materials...... 77 3.6.2 Acceptability Of Sanitary Materials...... 77 3.6.3 Affordability Of Sanitary Materials...... 78 3.6.4 Disposal Of Used Sanitary Materials...... 78 3.7 Experiences Of Menstruating Girls, In And Out Of School...... 80 3.7.1 Positive And Supportive Experiences...... 80 3.7.2 Negative Experience For Girls...... 81 3.7.2.1 Menarche Experiences...... 81 3.7.2.2 Experiences Of Girls With Disability...... 82 3.7.2.3 Shortage Of Sanitary Materials And Facilities...... 83 3.7.2.4 Bullying And Harassment...... 83 3.7.2.5 Pain, Self-Confidence, Stigma And Stress...... 84 3.7.2.6 Embarrassing/Humiliating Experiences...... 86 3.8 Legal And Policy Framework And Stakeholder Perceptions On Mhm...... 87 3.8.1 Legal Framework...... 87 3.8.2 Policy Framework...... 90 x Formative Research on Menstrual Hygiene Management Final Report, December 2019
4 Conclusions And Recommendations...... 92 4.1 Conclusions...... 92 4.2 Recommendations...... 95 4.2.1 Long Term Recommendations...... 95 4.2.2 Short Term Recommendations...... 95
5 References...... 98
6 Annexes...... 105 Annex 1: Sample Coverage...... 104 Annex 2: List Of Tables...... 109 Annex 2.1: Mhm Information Received By Girls In School...... 109 Annex 2.2: Mhm Information Sources For Boys...... 111 Annex 2.3: Social Norms, Myths And Taboos That Surround Menstruation...... 112 Annex 2.4: Appropriateness Of Facilities...... 114 Annex 2.5: Challenges Faced In Ensuring Standard Hygiene Practices In Schools.....115 Annex 2.6: Access To Clean And Safe Water In School...... 115 Annex 2.7: Experience Of Menstruating Girls In And Out Of School...... 117 Annex 3: Ethical Approval Letter...... 118
List Of Figures Figure 1: Reasons For Dropping Out In Primary School...... 9 Figure 2: Reasons For Dropping Out In Secondary School...... 9 Figure 3: Key Elements For MHM...... 13 Figure 4: Map Of Sample Distribution For The Quantitative Survey...... 18 Figure 5: Map Of Provinces And Districts Covered In The Qualitative Survey...... 21 Figure 6: Mhm Iec Materials In Urban Schools...... 32 Figure 7: Mhm Iec Materials Rural Schools...... 32 Figure 8: Number Of Schools By Type Of Toilet...... 57 Figure 9: Availability Of Water And Soap By Rural/ Urban Location Of School...... 58 Figure 10: Percentage Of Girls Receiving School Support During Menstrual Period...... 64 Figure 11: Types Of Sanitary Materials Used By In - School Girls...... 69 Figure 12: Samples Of Reusable Pads...... 72 Figure 13: Effectiveness Of Sanitary Material Urban...... 73 Figure 14: Effectiveness Of Sanitary Material -Rural...... 73
List Of Tables Table 1: Who/Unicef Jmp Wash Service Levels For Zimbabwe...... 5 Table 2: Quantitative Questionnaires Used...... 19 Table 3: Summary Of Data Collection Tools For The Qualitative Survey...... 22 Table 4: Socio- Demographic Characteristic Of The In -School Girls...... 27 Table 5: Socio-Demographic Characteristics Of The Out Of School Girls...... 28 Formative Research on Menstrual Hygiene Management Final Report, December 2019 xi
Table 6: Source Of Mhm Information For In School Girls...... 30 Table 7: Information On MHM Received Before Menarche By In School Girl...... 31 Table 8: Responses For True Or False Statements On Menstruation...... 46 Table 9: Girls’ Understanding, Myths And Misconceptions On Menstruation...... 47 Table 10: Common Myths And Taboos Related To MHM...... 50 Table 11: Dietary Restrictions During Menstruation...... 54 Table 12: Challenges Do You Face In Ensuring Standard Hygiene Practices In Schools....59 Table13: Entity Responsible For Operation, Maintenance And Repair Of The School Sanitation And Hygiene Facilities...... 60 Table 14: Main Water Source By Rural /Urban Location...... 61 Table 15: Distribution Of Public Spaces Observed By Province...... 62 Table 16: Summary Of Stakeholder Perceptions On MHM...... 67 Table 17: Provider Of Sanitary Materials By Area Provider Of Sanitary Materials By Area..70 Table 18: Source Of Sanitary Materials By Outlets...... 71 Table 19: Types Of Sanitary Materials Used By In School Girls...... 74 Table 20: Methods Of Disposal Of Sanitary Material...... 77 Table 21: Summary Of Girl’s Menstruation Related Experiences...... 85 Table 22: Mhm Information Received At School...... 109 Table 23: Additional Information On MHM Required By Girls In School...... 110 Table 24: Additional Information On MHM Required By Girls In School...... 111 Table 25: Recommended Methods Of Information Delivery...... 112 Table 26: Main Drivers Of Restrictions And Constrictions...... 112 Table 27: When Boys Know That Girls Are In Menstrual Periods, How Do They Treat...... Girls?...... 113 Table 28: How Does Your Family Treat You During Menstrual Periods?...... 113 Table 29: Specific Toilet Observations National Statistics...... 114 Table 30: School Waste Disposal And Drainage Observation By Rural/Urban Location....114 Table 31: Observed Characteristics Of Public Places...... 114 Table 32: Challenges Faced In Ensuring Standard Hygiene Practises As Per Guidelines In Schools- School Health Heads...... 115 Table 33: Water Sources By District...... 115 Table 34: Persons Primary Responsible For Fetching/ Collecting Water For All Water-Related Activities By District...... 116 Table 35: Status Of Water Storage Containers...... 116 Table 36: Challenges Do You Face In Ensuring The Availability Of Clean Safe Water In This School?...... 117 Table 37: Problems Faced By Girls At School During Their Menstrual Period...... 117 xii Formative Research on Menstrual Hygiene Management Final Report, December 2019
Acronyms and Abbreviations
AFM Apostolic Faith Mission AIDS Acquired Immunodeficiency Syndrome ASRH Adolescent Sexual and Reproductive Health CAMFED Campaign for Female Education CAPI Computer Assisted Personal Interview System CRC Convention on the Rights of the Child CSPRO Census and Survey Processing System DREAMS Determined, Resilient, Empowered, AIDS-free, Mentored and Safe DWSSC Water Supply and Sanitation Collaborative Council FGDs Focus Group Discussions HIV Human Immunodeficiency Virus IDI In-Depth Interviews KII Key Informant Interview MRCZ Medicines Research Council of Zimbabwe MDS Muthengo Development Solutions MHM Menstrual Hygiene Management MoEWC Ministry of Environment Water and Climate MoPSE Ministry of Primary and Secondary Education MoHCC Ministry of Health and Child Care MWAGCD Ministry of Women Affairs, Gender and Community Development NAC National AIDS Council NGOs Non-Governmental Organisations ODK Open Data Kit PMS Premenstrual Syndrome PMT Pre Menstrual Tension PSI Population Services International PSZ Population Services Zimbabwe SDGs Sustainable Development Goals SRH Sexual and Reproductive Health UN United Nations UNESCO UUnited Nations Educational, Scientific and Cultural Organization UNICEF United Nations International Children’s Emergency Fund WAG Women’s Action Group WASH Water, Sanitation and Hygiene
Formative Research on Menstrual Hygiene Management Final Report, December 2019 xiii
Executive Summary
Background and Context This study was commissioned by UNICEF with the aim of consolidating and documenting the status of menstrual hygiene management (MHM) for in and out of school girls aged 10-24 years in Zimbabwe. The findings are intended to direct initiatives to more effectively address girls’ and young women’s MHM needs in Zimbabwe in line with global standards and trends. This is especially important as communities are not homogenous and MHM solutions need to be tailor made to suit different socio-economic, cultural and religious considerations. Furthermore, much MHM-related research has been carried out in Zimbabwe, and the relevance of prior recommendations proposed might no longer suit today’s requirements and socio-economic, cultural and religious environments. Thus, this formative study was carried out in all the 10 provinces of Zimbabwe.
The study aimed to address the following specific objectives:
i. Investigate and understand the range of challenges faced by in and out of school girls during menstruation as well as the determinants of those challenges across a range of settings and cultural contexts, encompassing both rural/ urban Zimbabwe; ii. Identify positive deviants and their strategies around managing menstruation; iii. Understand the socio-economic, cultural and religious norms and practices around menstruation in Zimbabwe; iv. Unpack the drivers of social taboos and stigma surrounding MHM in Zimbabwe v. Compare the varied challenges and determinants across cultural contexts to identify points of intervention that may ameliorate the challenges of menstruation for girls, with a primary focus on girls in schools.
Approach and methodology The study was grounded in a Life Cycle Approach, which embraced ecological, environmental concerns and strategies to enable deeper understanding of MHM focused on a particular life stage of a female. The overall approach facilitated the mapping of the environmental influences on behaviour and attitudes towards menstruation at the critical life trajectory stage of adolescence and that of young adulthood. This then fits into a broader methodological and analytical framework which that investigates the status of main key element of MHM.
The MHM Formative Research used a mixed-methods approach, qualitative and quantitative research, to collect data from diverse sources and to facilitate analysis of data collected. The approach allowed researchers to conduct exploratory research, respond and reformulate the research thrust as issues emerged during the field research. Triangulation of data collected from various sources provided insight into the fundamental issues that affect effective MHM for in and out of school girls in Zimbabwe, allowing for formulation of realistic and implementable recommendations for effective MHM. xiv Formative Research on Menstrual Hygiene Management Final Report, December 2019
The Qualitative study was carried out in four (4) Provinces, namely Matabeleland North, Midlands, Mashonaland Central and Mashonaland East, which were selected to capture minority and hard to reach populations, perceived hotspots for early marriages and other SRH challenges, which have been underrepresented in other MHM related studies. The qualitative survey was rolled out at four levels: national, provincial, district and community levels and in four selected districts namely: Mt Darwin (Mashonaland Central); Marondera (Mashonaland East); Binga (Matabeleland North) and Gokwe South district (Midlands province).
Key Informant Interviews, Focus Group Discussions, In-depth interviews, Observation checklist (for public facilities) were used to collect data from the various target groups and stakeholders. Consolidation of qualitative data was done in Excel with analysis undertaken with Atlas ti and Excel utilising key themes to answer specific questions. Thematic areas were then identified and key questions answered by reference to specified questions.
The Quantitative data showed the distribution of different determinants to MHM challenges across a range of geographical settings and socioeconomic contexts in Zimbabwe. Data was collected using internet based ODK data collection software running on Android tablets to relay data from various locations to a central server. The data collection tools included the Girls in school Questionnaire, Girls out of school and Observation checklist for sanitary facilities in school. Common Application Programmer’s Interface (CAPI) software allowed real-time data quality control and reduced the time lag between data collection and data analysis. Quantitative data collected was analysed using SPSS and results were integrated with the qualitative narratives which dealt with the issues in depth. Multi-stage sampling strategy was employed to select 2 schools (one primary and one secondary) from each of the 2 selected districts in every province. A minimum sample size of 2130 of 10-24 year old girls calculated using Dobson’s formula was found sufficient. The actual sample size exceeded this minimum as 2,620 girls of 10-24 years were reached.
Ethical considerations were central part of the study. To ensure the study adhered to ethical standards the following were undertaken: seeking ethical approval from a recognised international research board; training of enumerators on ethical standards; development and supervision of the implementation of ethical safeguards protocols that ensured: 1) protection of research participants, 2) did not violate local laws and traditions; and 3) protection of field teams.
There were some limitations to the study including: 1) the timing of the field work coinciding with June examinations which meant some age groups could not be accessed in all schools; 2) in some schools there were fewer pupils than anticipated which led to over sampling in some schools and increase in the number of schools; and the sample size was sufficient to provide only national level conclusions.
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Summary of Key Study Findings The study noted the following key issues pertaining to MHM for girls in and out of school:
Legislation, policies, strategies and guidelines: The study found that Zimbabwe has a comprehensive legal framework to support MHM particularly in schools. However, implementation is affected by lack of specificity and reference to MHM or prioritisation of MHM by implementers.
MHM information sources, knowledge and attitudes: Over 60% of girls in school, have received some basic MHM information. Majority of these have received it before menarche (95.6% in urban areas and 88.9% in rural areas). Mothers and teachers were the major sources of this information. However more than 50% of the girls in urban (68.2%) and rural (66.9%) areas felt that mothers should be the prime providers of MHM education before menarche than the teachers urban (19.7% rural 14.9%). While girls receive information on menstruation, information provided was cited as inadequate. Learner-targeted Information education and communication materials on MHM are generally not available for girls in and out of school (76.3%). In addition, there is a general lack of a comprehensive and cross- sectoral approach to addressing MHM resulting in a piece-meal approach to information dissemination. There are untapped sources of MHM that include women influencers as well as women religious leaders that are underutilised because of cultural beliefs that girls could be bewitched and that mothers are the best trusted source of information.
Services and Support: Challenges relating to MHM services and support in schools pertain mainly to inadequately equipped providers, inadequate support by experts and perception of MHM as a female issue (45.4% urban girls and 40.6% rural girls said they received no support). Girls still suffer discrimination on the basis that they menstruate. There are significant unjustifiable restrictions placed on girls, rooted in discriminatory traditional, cultural, religious practices and outdated views of menstruation as “unclean”.
Materials: Disposable sanitary pads are commonly used and preferred for sanitary hygiene as they are considered by majority of girls as highly effective (59.4%) with a slightly higher use in urban (94.7%) than rural areas (85%). The cost however has become prohibitive with many relying on less user friendly and unacceptable sanitary materials such as old pieces of cloth (3.3% urban, 11.7% rural), tissue paper (0.1% urban and 0.4% rural) and cotton wool. (0.6% urban, 1.7% rural areas)
Facilities: Findings show that maintaining good sanitary hygiene is affected by general lack of private spaces for changing, inadequate clean water supply (13.7% urban, 70.3% rural), lack of incinerators, cultural beliefs that menstrual blood may be used to bewitch someone and lack of sanitary materials for emergencies in schools. xvi Formative Research on Menstrual Hygiene Management Final Report, December 2019
Pain was listed as the main reason for missing school by girls who had missed school during menstruation (90.3% urban and 68.2% in rural areas), as few schools have clinics, sick bays for rest or stock pain killers in their first aid kits. Majority those that have missed school missed 1 day per month (54.9% and 34.4% in urban and rural areas) and 2 days per month (29.2% and 33.8% in urban and rural areas). Approximately 13.2% and 27.9% in urban and rural areas miss 3 or more days of school. Severe pain, lack of sanitary ware, discomfort, and tiredness were the main reasons for missing school. However, the extent of contribution of these reasons differed between girls in urban and rural schools. Lack of sanitary ware was a major reason for missing school in rural (32.5%) than urban areas (8.9%). Missing school due to severe pain was prevalent in urban areas, where almost all that missed school gave this reason (90.3%), than rural areas (68.2%). Tiredness (8.3% in urban areas and 10.4% in rural areas) and discomfort (13.9% and 19.5% in urban and rural areas) were other contributors. Lack of private changing was not a contributor to missing school as this a reason for only 0.7% of the respondents in rural areas and 0% in urban areas.
Disability: Girls with disabilities are the most affected as mainstream schools do not have appropriate sanitation facilities for them as over 60% of schools visited for the study had no disability friendly latrines or washing areas. However, there was strong evidence that girls with severe disabilities were not in ordinary schools with reports that they were either in specialized institutions or not attending school at all. Girls in institutions seem to cope better with menstruation and receive free donations of sanitary materials.
Recommendations The following recommendations are made based on the realisation that human rights and development goals will not be attained without considering MHM. No intervention or programme across the main sectors of education, health, humanitarian etc., will be inclusive and ensure full participation of women without ensuring women and girls have adequate access and information to appropriate MHM thus the need to:
Long term recommendations
1. There is need for mainstreaming and targeted approaches for MHM within all interventions which address women’s and girls’ issues as well as resilient families and societies; (Responsibility: NGOs, UN, Government). This should be accompanied by a systematic and cross-sectoral capacity building approach for: 1) policy makers; 2) programme managers; and 3) programme implementers. (Responsibility: NGOs, UN, Government) 2. The entry point for social behaviour change on MHM should be gender equality in its totality. (Responsibility: NGOs, UN, Government). Entry points should also be on sexual maturation (the “female body”) and life skills. (Responsibility: NGOs, UN, Government) 3. Men and boys should be especially targeted to dispel myths and misconceptions on MHM and increase their support for MHM. (Responsibility: NGOs, UN, Government) Formative Research on Menstrual Hygiene Management Final Report, December 2019 xvii
4. Consider supporting a cotton value chain that would create jobs, and increase availability of suitable organic and locally produced sanitary materials. (Responsibility: Government of Zimbabwe, Ministry of Finance and Ministry of Industry) 5. Support local manufacturing of sanitary materials. This requires that there be no monopoly in the industry and support should be provided to 2-3 attested and large manufacturing companies. Effective and efficient distribution systems need to be supported basing on proven supply chains to reach remote areas. (Responsibility: Government of Zimbabwe, Ministry of Finance)
Short-term recommendations
1. Strengthen inter-sectoral coordination of MHM interventions. To do this a desk for addressing MHM should be created to strengthen coordination of the multisectoral players. Stakeholders can agree on where best to place the coordination desk however, as MHM needs to be addressed from a broader gender lense, the Ministry of Women Affairs is better suited for this role. (Responsibility: Government of Zimbabwe) 2. Establish a sustainable and rights based social movement on MHM to ensure MHM challenges are tackled regardless of numbers affected as its mismanagement infringes on other rights for the child such as education, play, good health, dignity etc. (Responsibility: UNICEF, National Association of non-Governmental Organisations (NANGO)) 3. Develop national MHM guidelines that can be mainstreamed in sectors that include components of MHM to ensure standardisation in approaches. (Responsibility: Government of Zimbabwe; UNICEF) 4. Develop national MHM guidelines that can be mainstreamed in various sectors that interact with MHM issues to ensure standardisation in approaches. (Responsibility: Government of Zimbabwe; UNICEF) 5. Develop a comprehensive and standardised age appropriate MHM information package for women, community influencers, programme implementers and volunteers, teachers etc. to enable them to engage in one on one and group conversations around MHM with girls and boys paying special attention to facts on menstruation, pain management, use and disposal of sanitary materials. (Responsibility: UNICEF; Government of Zimbabwe) 6. Every school to keep pads for emergencies at all-times. Support for this should be skewed towards rural schools. The schools, through the schools development association, need to identify the most appropriate way of funding these sanitary materials. Ministry of Education should support this by finding a way of making availability of sanitary materials for emergency at every school a performance standard to encourage adherence. (Responsibility: MoPSE) 7. Establish sustainable mechanisms for schools to provide emergency painkillers for girls and places of rest during severe pain. (Responsibility: MOPSE)
Formative Research on Menstrual Hygiene Management Final Report, December 2019 1
1 Introduction
This report presents findings of a national survey on Menstrual Hygiene Management (MHM) in Zimbabwe. The study aimed to gather information that will direct initiatives to effectively address girls’ and young women’s menstrual hygiene management (MHM) needs in Zimbabwe, in line with global standards and trends. UNICEF managed the study with Government stakeholders providing technical support throughout the process.
The report begins with a background section that details the context of the survey, a synopsis of the MHM situation from literature review and a presentation of the research objectives, all in Chapter 2. Chapter 3 provides details of the methodology used in undertaking the study. Findings drawn from the various methods used are presented in Chapter 4 followed by the main conclusions and recommendations in Chapter 5.
1.1 Background The study was implemented on the backdrop of an economic crisis characterised by deterioration of social services. Annual inflation was 60% in January 2019 with month on month inflation increasing to over 30% in August 2019 (ZIMSTAT, 2019). Linked to this deterioration of economic and social sectors, poverty levels have been increasing since 2012. Proportion of the population living in poverty increased from 70.5% to 72.3%. Prevalence of extreme poverty increased from 22.5% in 2011/12 to 29.3% in 2017. More than double the rural than urban population is poor (76.9% compared to 30.4%) of the poor live in rural than in urban areas (ZIMSTAT, 2018). 2 Formative Research on Menstrual Hygiene Management Final Report, December 2019
At the same time, the country was also grappling with a crippling drought with 7 million people (about 60% of the population of Zimbabwe) estimated to require food assistance. In rural areas, an estimated 5.5million of the population required food assistance (Reliefweb, 2019).
1.2 MHM in Zimbabwe According to Zimstat population estimates, Zimbabwe, as at 1 January 2019, had 4,801,104 female adolescents and young people in the age group 10-24 years. Puberty and adolescence, which occurs in this period, can be challenging for any girl. Although it may occur at different ages for different girls, adolescent girlhood is always a critical time of identity formation and a period of transition from childhood to womanhood (Sommer & Sahin, 2013). That period also comes with socio economic implications including needs and responsibilities that can be determinant towards girls’ equal access to key child development requirements. These include access to education, personal dignity, and proper health among other key development facets. For women and girls the world over, challenges related to menstruation are a common feature when it should be a straightforward issue of privacy and reproductive health. Pads and other safe menstrual management supplies may be unavailable or unaffordable, they may lack access to safe sanitary facilities with clean water where they can attend to their hygiene in privacy. Furthermore, they face discriminatory cultural norms or practices that make it difficult to maintain good menstrual hygiene. Together, these challenges may result in women and girls being denied basic human rights which turns a simple biological fact into a barrier to gender equality.
1.2.1 Key issues in MHM in Zimbabwe A significant amount of literature is available in Zimbabwe but majority is predominantly of an academic nature and not of national scale. However, it provides evidence of the problems related to the management of menstruation in schools in Zimbabwe. Several challenges are pointed out. Managing discomforts, pain, and access to safe sanitary materials and stigma associated with menstruation were commonly referred issues. Manyara (2014) found that the girl child’s participation in school is affected by failure to manage pain, affording sanitary wear and stigma. These experiences lead to poor attendance during menstruation and increased vulnerability to harassment (Manyara, 2014). Apart from the associated abdominal pain, girls experience shame, low self-esteem, and lack of confidence due to fear of mismanagement of menstruation. Selamawit, et al (2015) found that girls who were fearful of soiling their clothes and of a bad smell associated with not washing properly found concentrating during class difficult.
Despite these challenges, a limited number of Zimbabwean schools offer some relief for girls. A 2012 Ministry of Education survey found that only 24% of the 212 schools surveyed had provisions for medication for period pains (MoPSE, 2012). Further, Ndhlovu and Bhala (2016) found that in general, most schools were unable to provide appropriate sanitary wear for girls to handle their periods and painkillers for those who experience dysmenorrhea. This was resulting in some girls choosing to absent themselves from school to avoid loss of self- esteem, discomforts and stigma from schoolmates. Formative Research on Menstrual Hygiene Management Final Report, December 2019 3
Stigma associated with menstruation violates human rights, especially human dignity but also the right to non-discrimination, equality, bodily integrity, health, privacy and the right to freedom from inhuman and degrading treatment, abuse and violence. However, infrequent bathing and inadequate change of menstrual materials may lead to an odour or foul smell that may result in avoidance of closeness and isolation and result in self-stigma. Several studies have identified stigma related to menstruation as an issue (Selamawit et al, 2015), (Seymour, 2009), (Nahar and Ahmed, 2006).
A study across 5 countries (Ethiopia, Uganda, South-Sudan, Tanzania, and Zimbabwe) identified menstruation hygiene materials ranging from nothing to cloths/rags, commercial sanitary pads (disposable and re-usable), toilet paper, magazines, cotton, pieces of mattress, natural materials (leaves, tree bark), goat skin, cow dung, ash, and sand. The study reported usage of ash, sand, and cow dung in Masvingo (Selamawit, 2015). However, an earlier study done in Zimbabwe in 2003 noted cotton wool, pads, tampons, cloths/rags, tissue paper, newspapers and pads being commonly used in urban areas (Stewart et al 2003). A survey by Ndhlovu and Bhala (2016) highlighted that the materials used during menstrual periods were a major cause of concern since in a quarter of the schools girls used pieces of cloths during menstruation. The efficacy, safety and hygiene of these pieces of cloths were questionable and increased health risks for girls. Due to girls’ and women’s incapacity to access reusable sanitary ware, promotion of reusable sanitary materials has taken hold in Zimbabwe with reusable pad and the menstrual cup most promoted. Evidence on the acceptability, safety and efficacy of these reusable materials is yet to be generated in Zimbabwe. A study by Madziyire et al (2018) on the acceptability of using a reusable menstrual cup was conducted in a Harare suburb of Epworth in Zimbabwe in 2018 but larger scale studies are still outstanding.
Failure to appropriately manage menstruation has been associated with challenges in attending school and in worse cases dropping out of school. Evidence on this has largely been anecdotal in the case of Zimbabwe. One study that provides an indication of the challenge is Ministry of Education Schools Survey in 2012 focused on Masvingo province. Of the 212 schools in Masvingo Province, 41% (83) of the schools reported some girls missed school because of menstruation. In 58 of these schools (69%), girls missed school for one to two days per month, three to four days in 21 schools (25%), and over five days in five of the schools (6%). The most affected classes were Grades 5 to 7 in 47 schools (57%) and Forms 1 to 6 in 43% (of the 24 secondary schools). The main reasons for missing school were period pains (49% of the schools) and stigmatisation (9% of the schools). 4 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Information dissemination in school: In the early millennium several studies identified weaknesses in the appropriateness of the school curriculum to provide information on Life Skills, Sexual Maturation and Sanitation (Stewart et al, (2004); Khatete, (2003); Shumba et al, (2003)). The present-day Ministry of Primary and Secondary Education Guidance and Counselling Teacher’s manual reveals that some of the recommendations from these studies were taken up. While this is the case, a survey by Ministry of Education (2012) in Masvingo Province revealed that although lessons relating to menstrual hygiene were given in some schools, most girls (92%) highlighted that the contents of the lessons were so varied, indicating the lack of a standard approach in designing the lessons. A study by World Vision (2015) on WASH in schools found about 31.9% of the schools had trained personnel in menstrual hygiene management. An earlier study in Chitungwiza schools (Dube and January, 2012) had also noted availability and accessibility of learning materials on hygiene and maintenance of the hygiene enabling facilities as associated with the children’s predisposing factors i.e. knowledge and attitude on use and maintenance of hygiene in schools. These resource materials for children lacked in the life skills training approach of the school curriculum. Such scenarios limit access to adequate information on MHM by girls and boys alike. For example, Selamawit et al, (2015) find that on average 66% of girls had not known about menstruation before it started. Similarly, Sommer et al., (2012) and UNESCO (2014) found that more than 80% of girls have knowledge about puberty in general; they know the stages of body change but have limited know-how on handling the changes including menstruation.
1.2.2 Status of Water, Sanitation and Hygiene (WASH) in Zimbabwe The most obvious enabling condition for personal hygiene is the availability of water and sanitation facilities. However, the status of WASH in Zimbabwe is on the decline since 2004 contributing to an unprecedented cholera epidemic which affected over 100 000 people and caused over 4,000 deaths between June 2008 and August 2009 and the resurfacing of cholera in 2018. Table 1 provides a summary of key WASH coverage statistics in Zimbabwe between 2000 and 2015. The population with access to only unimproved sanitation facilities increased significantly from 3.49% to 11.10% in 2015. In absolute terms, due to population increase, this population increased four-fold. In general, even when slight improvements are seen such as the reduction of the population with “limited service” or “basic service” in sanitation and drinking water the absolute population has actually increased. Formative Research on Menstrual Hygiene Management Final Report, December 2019 5
Table 1: Who/Unicef Jmp Wash Service Levels For Zimbabwe
Service Type Service Level % % Population Population (2015) Population Population (2000) coverage coverage (2000) (2015)
Sanitation At least basic 41.73 38.58 5,216,511 6,020,886.11
Drinking water At least basic 70.38 66.56 8,798,159 10,385,674.96
Hygiene Basic service NA 30.73 NA 4,794,797.32
Hygiene Limited service NA 47.43 NA 7,401,060.65
Sanitation Limited service 25.43 23.72 3,179,030 3,701,614.51
Drinking water Limited service 10.15 9.56 1,269,683 1,492,918.78
Hygiene No hand NA 21.83 NA 3,406,893.03 washing facility
Sanitation Open 29.34 26.48 3,667,634 4,133,076.01 defecation
Drinking water Surface water 5.56 7.33 695,138 1,143,956.22
Sanitation Unimproved 3.49 11.19 436,804 1,747,174.37
Drinking water Unimproved 13.89 16.53 1,737,000 2,580,201.05
6 Formative Research on Menstrual Hygiene Management Final Report, December 2019
In relation to school-based WASH, a study by World Vision (2015) in a sample of 18 districts and the 2014 Rural WASH Baseline Survey found that:
●● 55% of schools did not have access to adequate sanitation facilities; ●● Average squat hole ratio for girls was 35.7 and 26.4 in primary and secondary schools1 ●● Average squat holeratio for boys was 37.9 and 26.8 in primary and secondary schools; and ●● 38% of schools did not have access to hand washing facilities.
They also found that more than 55% of the schools had no sanitation infrastructure that provided appropriate facilities for menstrual hygiene for girls and female teachers. More importantly 45% and 35% of Primary and Secondary schools respectively had toilets whose designs were not supportive of MHM2 with only 2.4% of girls having access to lockable latrines.
There are huge disparities in the provision of WASH between schools. The heavy reliance on community support for infrastructure development at schools has created a bottom up school financing system, which unfortunately disadvantages schools in poorer communities. This has resulted in deep rooted inequity in school investments with children in rural and remote areas being most affected with poor learning outcomes and pass rates3. A study by Tarisayi (2016) noted that while there was an apparent need for funds to build toilets, classrooms and teachers’ accommodation, efforts were being hampered by lack of resources at the satellite schools4. Because communities are poor, they are unable to meet these infrastructure demands. All schools sampled in the study had no reliable water supply and toilets for both students and teachers.
Another study, SNV (2012)5, demonstrated the inequity in provision of WASH between urban and rural areas with the latter more affected. It also noted that there was limited investment in WASH at schools with the major draw-back being the lack of a clear cause and effect in the Zimbabwe context for the lack of WASH in schools and education outcomes. Schools infrastructure development plans do not prioritise investment in WASH infrastructure when compared to education materials and classrooms, etc. This drawback is despite a clear support for WASH in schools in the legislation and policies for the education sector. The Education Act, amended in 2006, requires every school to have two blocks of toilets, one for boys and the other for girls, the ratio of the toilets to school enrolment. The recently launched, March 2018, Zimbabwe School Health Policy, provides broad based support for WASH in schools by providing a framework to equip learners with comprehensive life skills for healthy living and reduction of health barriers to learning.
1The standard squat hole to children ratio for Zimbabwe is 1:20 for boys and 1:15 for girls. 2One concern that needs to be carefully considered is whether separate facilities for MHM may deter girls and women from using them because of the attention such facilities might attract, the emphasis probably needs to be on incorporation of facilities into general female sanitation and ablution infrastructure. 3This is confirmed by the Zimbabwe Early Learning Assessment (ZELA) that has been undertaken annually at the end of Grade 2 since 2012, and by pass rates at Grade 7 and ‘O’ level. 4Tarisayi K. (2016) An Exploration Of The Challenges Encountered By Satellite Schools In Masvingo District, Zimbabwe. https://internationaljournalofresearch.com/2016/11/28/an-exploration-of-the-challenges-encountered-by-satellite- schools-in-masvingo-district-zimbabwe/ 5SNV (2012) Masvingo Schools WASH Report. http://www.snv.org/public/cms/sites/default/files/explore/download/ masvingo_-_wash_in_schools_-_2012_.pdf Formative Research on Menstrual Hygiene Management Final Report, December 2019 7
1.2.3 Institutional arrangements for MHM and WASH in Schools (WinS) There is no one specific institutional structure for addressing MHM in Zimbabwe. Responsibilities for MHM are spread between the education, WASH, health and gender sectors. There is however an overlap between the WASH and education sectors as MHM responsibilities converge at the school level. The Education sector addresses MHM through life skills lessons as well as promoting MHM appropriate WASH in schools. The WASH sector through the National Action Committee (NAC) supports MHM in schools through construction of appropriate WASH facilities in poor and vulnerable schools as well as current initiatives to improve the design of school girls’ toilets to enhance their responsiveness to MHM needs. NAC does this through decentralised WASH coordination structures. At district level WASH is coordinated through the Rural District Council’s inter-ministerial subcommittee, the District Water and Sanitation Sub-Committee (DWSSC). The Ministry of Primary and Secondary Education is a member of the DWSSC and provides access to schools WASH interventions. At school level, WASH is coordinated through school structures such as the School Development Committees (SDCs) and school health clubs. The SDCs provide the linkage between the school and community WASH structures that include Ward Water and Sanitation Sub-Committees (WWSSC).
Within the health sector, MHM is addressed through the National Adolescent and Youth Sexual and Reproductive Health Coordination Forum (NCF) (headed by the Reproductive Unit in the Family Health Department) and Environmental Health Department. The NCF provides guidance on all sexual and reproductive health related interventions for adolescents and young people in Zimbabwe. With regards MHM, a Comprehensive Training Manual on Sexual and Reproductive Health for Adolescents and Young People was developed and is operational. Information on MHM is also included the manual targeted at both in and out of school girls. Through EHTs, the MOHCC supports safe water, sanitation and hygiene health promotion in communities and schools including MHM. 8 Formative Research on Menstrual Hygiene Management Final Report, December 2019
1.2.4 Key issues in the education sector Zimbabwe has near parity enrolment between girls and boys in both secondary and primary schools but enrolment decreases for both sexes with form and grade and with less females enrolled than males (MOPSE (2019)). Girls constituted 50.86% of total enrolled in Form 1 for secondary schools in 2018 and reduced to 48.52% in Form 4 and 47.33% in Form 6 (MOPSE, 2019). In 2018, more males (54.2%) than females (45.8%) dropped out of school at primary level. This reversed in secondary school where more females (55.7%) than males (44.3%) dropped out (MOPSE, 2019). For the five years (2014-2018), the number of dropouts decreased by 30.4% in primary school but increased by 12.8% in secondary school. According to MOPSE (2019), over the four years (2014-2018) more girls are dropping out of school at secondary level. The number of females dropping out at secondary school level increased by 14% compared to 12% for males during this period. Inversely less girls (13982 in 2014 compared to 9330 in 2018) were dropping out at primary school than their male counterparts (15 316 in 2014 compared to 11070 in 2018) (MOPSE, 2019). Absconding school and inability to pay school fees are the major reasons for dropping out of school for both females and males dropping out in primary and secondary school (Figure 1 and Figure 2). However, at secondary school an increasing number of girls drop out as a result of pregnancy (13.8%), and marriage (17.2%) (Figure 2).
School Survival rates in primary school decrease with grade with gender parity in favour of females. In 2018, Grade 2 Survival Rate was 95.56% (95.19% - Males; and 95.94% - Females) which decreased to 83.21% (80.67% – Males; and 85.83% - Females) in Grade 7. This trend repeats for secondary school with the Survival Rate decreasing from 94.94% when learners move to Form 2 to 79.83% and 19.3% when they move to Form 4 and Upper 6. In both cases gender parity favours males (MOPSE, 2019)). At primary school level the Completion Rate is 77.57%, with gender parity in favour of females (MOPSE, 2019). At lower secondary level the Completion Rate is 63.12%, with gender parity in favour of males. The Completion Rate at the upper secondary level is 14.94%. Formative Research on Menstrual Hygiene Management Final Report, December 2019 9
Figure 1: Reasons For Dropping Out In Primary School
50.0 47.2 42.6 45.1 40.0 33.7 32.2 32.93 30.0
20.0 10.61 10.4 10.8 10.0 5.4 5.9 3.15 5.66 3.5 2.9 2.3 0.5 0.6 0.55 0.1 1.13 1.6 0.3 0.88 0 Absconded Death Expulsion Illness Marriage Other Pregnancy Financial
Female Male Total
Figure 2: Reasons For Dropping Out In Secondary School
60.0 55.4 50.0 46.57 39.6 40.0 33.9 30.0 27.8 23.0 17.2 20.0 13.8 10.34 7.85 10.0 3.8 5.3 4.46 1.2 1.9 1.49 0.2 0.6 0.38 1.1 1.01.09 1.7 0.3 0 Absconded Death Expulsion Illness Marriage Other Pregnancy Financial
Female Male Total
Source: MOPSE (2019)
1.2.5 Key gender-related issues or inequities Child marriages: With one in four teenage girls being married, Zimbabwe, as with most countries in the region, has a child marriages problem (UNICEF, 2015). It is largely a female and rural phenomenon with rural female teenagers 1.5 times more likely to be married than their urban counterparts. The challenge increases with age. The highest proportion of teenage girls who are married is in the 18-19 years age range followed by 15-17 and then 10-14 years old (UNICEF, 2015).
Gender Based Violence: The National Baseline Survey on Adolescents’ Life Experiences in Zimbabwe (NBSLEA) of 2013 found that over a third of girls experience sexual violence before their 18th birthday. For a majority of these girls (78%) the perpetrator was either a boyfriend or partner. This is almost double that of similar countries for which data is available (Cambodia (24%), Haiti (29%), Malawi (33%), eSwatini (36%), Nigeria (40%), and Kenya (47%)) (Fry, et al, 2016). 10 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Sexual maturation, age of consent, initiation ceremonies and rights: In cultures that practice initiation or rite of passage (transformation from a girl to womanhood) this occurs after menarche. These cultures include the VaRemba of Mberengwa, in Southern Zimbabwe and BaTonga of Binga in South Western Zimbabwe (Shoko, 2009)6. A girl’s first menstruation is a sign of her sexual maturity and must therefore be equipped for adult life. While both initiation cases involve Female Genital Mutilation (FGM) and orientation on being an adult woman in the house and community that of the VaRemba provides main teachings that help the girls understand the process of menstruation and what it entails in terms of hygiene (Shoko, 2009) . Other teachings imparted to VaRemba women include skills of life.
According to the Zimbabwe Demographic Health Survey (ZDHS) of 2016 about 5.3% females and 4.5% males in the ages 15-24 had their first sexual intercourse before the age of 15 (ZIMSTAT and ICF, 2016). Other studies have found the median ages for first sex and first marriage to be 18.5 year and 18.5 years for men and 18.2 years and 18.5 years for women respectively for women aged 15-54 years (Cremin et al, 2008).
Access to SRHR: In general adolescents and youth have poor access to SRH services and information in Zimbabwe (Marimo, 2018). Access is undermined by low coverage of youth friendly SRH services, information and weak coordination of SRHR interventions aimed at adolescents (MOHCC, 2016).
1.2.6 Legal and policy framework Zimbabwe has policies and laws in place that have an influence on MHM. The Constitution of Zimbabwe obligates the Government of Zimbabwe to ensure the rights women and girls are upheld. The Education Act, as amended in 2006, provides provisions for promulgation of regulations that safeguard the health of learners. The Act further provides minimum WASH standards for schools that ensure the dignity and health of boys and girls in school. An Education Amendment Bill, under discussion at the time of the study, mandated Government to provide facilities to enhance MHM for girls. Further, the Zimbabwe School Health Policy 2018 provides a broad frame of reference to guide the implementation of a number of health related interventions pertaining to the welfare of learners in the school system, such as water, sanitation and hygiene, sexual and reproductive health (SRH) concerns. Revisions to the School Curricula for Primary and Secondary School provides opportunities for improving the coverage of Life Skills and Sexual Maturity (which includes MHM) education.
6 Also refer to https://www.thepatriot.co.zw/old_posts/female-initiation-among-the-batonga/ Accessed 2 January 2020 Formative Research on Menstrual Hygiene Management Final Report, December 2019 11
Study Approach and 2 Methodology
This section provides details of the methodology beginning with a description of the overall approach and conceptual framework followed by details of the study design: tools, sample size calculation, sampling strategy, data collection, collation and analysis. It ends with a list of limitations of the study.
2.1 Purpose and Scope of the Study In line with its Terms of Reference, the study sought to address the following objectives:
i. Investigate and understand the range of challenges faced by in and out of school girls during menstruation as well as the determinants of those challenges – across a range of settings and cultural contexts, i.e. rural/ urban Zimbabwe; ii. Identify positive deviants and their strategies; iii. Understand the socio-economic, cultural and religious norms and practices around menstruation in Zimbabwe; iv. Unpack the drivers of social taboos and stigma surrounding MHM in Zimbabwe; and v. Compare the varied challenges and determinants across cultural contexts to identify points of intervention that may ameliorate the challenges of menstruation for girls with a focus on girls in schools but also those not in school.
2.1.1 Scope of the study This was a national study covering all ten provinces of Zimbabwe: Bulawayo, Harare, Manicaland, Mashonaland Central, Mashonaland East, Mashonaland West, Matabeleland North, Matabeleland South, Masvingo, and Midlands provinces. 12 Formative Research on Menstrual Hygiene Management Final Report, December 2019
The main target group were adolescent girls and young women at pre-menarche and those already menstruating from the age of 10 years to 24 years across all study areas. The study focused on understanding the MHM situation for both in and out of school girls for the target age range.
2.2 Approach The MHM formative research followed a mixed-method approach encompassing qualitative and quantitative research methods. The approach allowed researchers to conduct exploratory research, respond and reformulate the research thrust as issues emerged during the field research and to triangulate data collected from various sources. Moreover, mixed methods provided the study with the ability to validate information from various sources ensuring the findings were grounded on strong evidence. Data collection was guided by the key elements of MHM depicted in Figure 3. Formative Research on Menstrual Hygiene Management Final Report, December 2019 13
Figure 3: Key Elements For MHM
accessible water available, hygiene supply, sanitation and affordable and hygiene sanitary protection facilities, private matarials place to change safe, discete knowledge and and hygienic information on disposal of menses and good sanitary protection menstrual hygiene materials Creating a practises supporting environment for MHM advocay, creative positive communication, social norms, policies, strategies breaking down and guidelines myths, sensitization integrate menstrual of leaders, women, hygiene girls, men and boys key professionals (health, education, WASH, protection, gender, community, development) knowledgeable on MHM 14 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Key research questions were then drawn from these elements of MHM as follows:
Box 1: Key Research questions
1. What sanitary materials are being worn by women and girls? a) safety of materials b) affordability c) accessibility d) acceptability 2. What are the knowledge, attitude and practices related to menstruation and menstrual hygiene? 3. What are the social norms, myths and taboos that surround menstruation? a) What are they? b) Whom are the drivers? 4. What are the experiences of menstruating girls in and out of school? 5. What services are available to women and girls on MHM in the communities or supportive institutions? 6. What policies, strategies, guidelines are available on MHM and who are the key national stakeholders and duty bearers? 7. What facilities are available to support MHM? a) appropriateness b) accessibility c) acceptability
Source: Terms of Reference for the Formative Study
Life cycle approach: Since this is a formative study upon which the design of interventions will be anchored, the life cycle approach helped in identifying the interconnectedness of menstruation and other reproductive health issues. Ensuring availability of education about MHM and puberty which is available to students in and out of school was considered an important platform for introduction of comprehensive sexuality education. Such education provides a wide range of information and knowledge about sexual and reproductive health, including HIV prevention, contraception, pregnancy and sexual and gender-based violence. Such approaches would empower young girls with skills and intellectual capacity to make informed decisions and engage in decision-making that affects their lives during adolescence and through other phases of womanhood. The life cycle approach allowed an assessment of the inter-connectedness of the various stages of a woman’s life and how these relate to each other and ultimately affect menstrual health management practises, decisions and challenges. Using the life cycle approach, made it easy to identify where specific interventions and programmes should be introduced in the various stages of the life cycle of the girl child.
Socio–ecological factors determine issues of access to MHM materials, the information and support available within communities and organisations, also facilities available within these organisations and communities and policies around these issues. Thus the ecological approach allowed for interrogation of relationships from the levels of individual, family and social networks, social institutions, organisations and communities right up to public policy formulation entities and how MHM regulation is addressed. This also facilitated understanding as to how all of these entities interplay to ultimately shape MHM practises for girls and young women between 10 -24 in different spaces in Zimbabwe. Formative Research on Menstrual Hygiene Management Final Report, December 2019 15
The socio-ecological framework presents multiple factors that affect menstruating girls and should be considered when exploring MHM practices at a national level7.
Societal factors - Policy, tradition, cultural beliefs
Desk Review - School/gender WASH policies, curriculum and teacher training standards , reports Klls - National and community level - government officials; UNICEF and non- governmental organisation staff FGDs and IDIs - Solicitation of norms, beliefs and local knowledge from girls, boys, teachers and mothers
Environmental factors - Water, sanitation and resource availability
Observations in schools and communities - WASH conditions, availability and cost of MHM supplies Klls with teachers - Availability of resources and support for WASH; teachers’ role in educating girls FGDs with girls - Perceptions of school environment, use of WASH facilities
Enterpersonal factors - Relationships with family, teachers, peers
FGDs with girls, boys and mothers - Perceptions of changes in gender roles post-menarche, relationshipswith family, peers and teachers; access to support for information, practical guidance and supplies Klls with teachers - Role of teachers in supporting girls; changes in girls’ interactions with others
Personal factors - Knowledge, skills, beliefs
FGDs and IDIs with girls - Biological knowledge about menstruation and practical knowledge about menstrual hygiene management; coping mechanisms and behavioural adaptations; needs attitudes and beliefs about menstruation; self-efficacy regarding management
Biological factors - Age, intensity of menstruation, cycle
IDIs with girls - Severity of pain, including headaches and cramps, and influence on behaviour and school experience, intensity of flow and ability to manage menstruation in school setting, ability to concentrate, fatigue
7Module 1: Understanding the Social Ecological Model (SEM) and Communication for Development (C4D) 2014 16 Formative Research on Menstrual Hygiene Management Final Report, December 2019
2.3 Study Design
2.3.1 Quantitative survey This section presents the design of the quantitative survey including methods, questionnaires and target groups, sample sizes, sampling approach, data collection, data management and analysis.
The quantitative study was undertaken in all ten province of Zimbabwe covering both rural and urban areas. The study population was principally all in-school and out of school girls aged 10 – 24years. To reach out to this population, primary and secondary schools were used to determine the sampling frame.
In-School Girls: At school level, the target population was girls aged 10-24 years; however, the main age grouping was adolescents 10 -19. The 20-24 year age grouping was designed to capture late school entrants and out of schools females. Based on experience of the study team on the challenges of 10-13 year olds to respond to MHM survey questions in other countries and from the pilot a deliberate decision was made to have a lower proportion of this group in the sample compared to those in higher age groups of the target population. Girls were selected from Grades 4-7 in primary schools, while those in Forms 1-6 were selected in secondary schools.
Out of School Girls: Out of school girls were sought through a grounded process of enquiring about their presence in an area from schools, clinics, churches and identified youth groups.
Sample size calculation and sampling strategy The sample size for 10-24 year old girls who face some MHM challenges in their everyday life was calculated using Dobson’s formula (see Box 2). Based on the formula a minimum sample size of 2134 was found adequate at 95% confidence level and 3% precision. Since a clustered sample was adopted, with the school being the sampling unit, a design effect of 2 was incorporated to address intra-cluster correlation. Further, to determine response distribution, proportion of girls facing MHM challenges was selected as an appropriate indicator. Because there was no nationally representative data on MHM experiences by adolescents and young girls, this indicator was estimated to be 50% based on small-scale studies by SNV (2012), World Vision (2015) and MoPSE (2012) in Zimbabwe. Formative Research on Menstrual Hygiene Management Final Report, December 2019 17
Box 2: sampling parameters
2 ( 1 − ) = × ∆2
Where the different input parameters are:
the required minimum sample size the standard normal value at a given level of confidence (=1.96 at 95% confidence level) the proportion of girls who face some MHM challenges in their everyday life (assuming 50%) ∆ the absolute precision (set at 3%) design effect (set at 2)
The sample was distributed equally across all provinces (216 in each province). As the study was carried out in both rural and urban/peri-urban schools in the 10 provinces, two (2) districts were randomly selected representing an urban and rural district. Within these districts, two schools (one primary and one secondary school) were selected making a total of four schools per province. Primary and secondary schools were clustered according to the school profiling system of P1/S1, P2/S2, and P3/S3. This Poverty Based Grading system was used to enable the study to reach out to all socio-economic classifications both in Urban and Rural settings8. By using this categorisation, the study was able to reach out to the different wealth classes/ communities of both rural and urban districts.
Based on this stratification, the sample of 216 respondents was distributed equally between urban and rural districts – 108 each in a selected province. The equal distribution transcended to the school level with 54 girls enrolled in each school. Table 1.1 in Annex 1, provides details of the sample sizes. In all, 2,610 girls were reached by the survey. Figure 4 shows the distribution of the targeted schools across Zimbabwe.
7P1/S1 schools are attended by children from the highest wealth quintile (ordinarily schools in low-density urban residential areas), while P3/S3 schools are in the most disadvantaged, rural areas. P2/S2 schools are located in the less privileged high-density urban residential areas. 18 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Figure 4: Map Of Sample Distribution For The Quantitative Survey
It was realized during fieldwork that some schools that were selected in the sample as urban schools were in effect rural schools. After adjusting the sample to cater for the gap that had been identified for urban schools, the sample of schools assessed increased from 40 to 50 (24 urban and 26 rural) as shown in Table 1.2 in Annex 1.
Out of school girls: As the sampling frame for out of school girls was determined by the selected schools, at each school a minimum of 5% of the 54 in-school girls sample constituted the out of school girls enrolled for the study. Thus, at least three (3) out of school girls were to be enrolled in the study for each selected school. One hundred and eight (108) out of school girls were covered by the survey. The target sample size of 150 out of school girls could not be reached as finding them was more difficult than anticipated. More time was required in the field than could accommodated by the available budget therefore a trade-off had to be reached.
Girls with disability: Twenty-five in-school girls with disability were interviewed for the study (10 urban and 15 in rural areas) representing 1% of the sample. Six of the girls were deaf and hard of hearing (hearing impaired); 9 were blind and low vision (visual disability); 2 had a mental disability (mentally retarded); 4 had motor and physical disability (physically disabled); and 3 had multiple disabilities. Formative Research on Menstrual Hygiene Management Final Report, December 2019 19
In each school, students were stratified by grade or form. In Grades 4 to 6, ten students were selected while double the number was selected for grade 7 in line with the sampling approach highlighted above where more girls were enrolled in higher age groups. In secondary schools, the sample was distributed equally for each class with 9 girls selected.
Data collection tools Four structured questionnaires were used for the quantitative survey as detailed in Table 2 which translated to the three languages: Shona, Ndebele and Tonga. These translations were back translated to English to verify the translation by the team of survey supervisors. Further verification was undertaken during training and the pilot survey.
Table 2: Quantitative Questionnaires Used
Tool Target Administration Issues
Face to In school face Knowledge, attitudes, perceptions and girls 10-24 practices; years Effect of menstruation while at school; Length of period school is missed when Student Out of Face to face menstruating; questionnaire school girls interview Impact of menstruation on girls; 10-24 years Provision of menstrual materials; and Infrastructure and facilities available at school.
School assessment School Observation Quality and gender-responsiveness of WASH questionnaire/ WASH infrastructure checklist on MHM infrastructure Adherence to minimum sanitation and hygiene standards for MHM o toilets’ design o construction o operation, maintenance o privacy and access for girls with disabilities Quality of water supply infrastructure, infrastructure maintenance and functionality Extent to which water supply addresses menstrual hygiene Disposal system for sanitary products
Public/ private Public Observation Availability of WASH facilities assessment WASH Adequacy of the facility for MHM purposes. questionnaire/ infrastructure o availability of water and disposal bins checklist on MHM (bus termini, for instance. clinics, Support and information system available for market MHM for young and adult women in places and communities. shopping malls)
20 Formative Research on Menstrual Hygiene Management Final Report, December 2019
A total of 25 enumerators were recruited for the survey and underwent training. A surplus of 3 enumerators were trained as a pool to cover for any dropouts during the survey. Female enumerators were tasked with interviewing girls. A four day training was undertaken which included: two days of classroom based training on interviewing techniques, the questionnaires and filed procedures; one for the pilot survey undertaken in four schools of Seke district of Mashonaland East; and one day for feedback and finalisation of fieldwork plans. More details on the training can be obtained from the Field Report.
Data collection Data was collected by five teams of trained researchers. Structured questionnaires and observation checklists were used to collect quantitative data. Five data collection teams composed of 5 persons each carried out fieldwork for 15 working days with each province covered in 5-7 working days. Among the five working team members, one was the Supervisor in charge of monitoring data collectors’ performance. The core team of study experts provided overall oversight on data collection. Each team collected data from two provinces.
Data collection used ODK®, a Computer Assisted Personal Interview (CAPI) software running on tablet computers. Data collection teams were able to upload completed interviews real time. Using this approach enabled the study team to also undertake real-time data quality checks. The data was stored in a secure central database and accessible only with the right permissions. To maintain confidentiality of data, personal identifiers were removed from the dataset.
Data analysis Quantitative data cleaning was done by creating a series of syntax in STATA. Data analysis was conducted in the same software. The tables include summaries of demographic information, MHM practices, MHM challenges, school absenteeism, MHM sources, attitudes and infrastructure. The analysis comprised mainly descriptive statistics.
2.3.2 Qualitative survey The qualitative study was carried out in four (4) Provinces, namely Matabeleland North, Midlands, Mashonaland Central and Mashonaland East. These were purposively selected with the participation of stakeholders in MHM and considered the following variables: 1) presence of minority and hard to reach populations; 2) hotspots for early marriages and other SRH challenges; and 3) underrepresentation in other MHM related studies. The qualitative survey was also undertaken at national level (Harare based stakeholders).
Sample size and sampling strategy In each of the four provinces, a district was selected for the qualitative survey. These were:
1. Mashonaland Central – Mt Darwin; 2. Mashonaland East – Marondera; 3. Matabeleland North – Binga; and 4. Midlands – Gokwe South district.
Kwekwe district in Midlands was added during data to increase the coverage of urban schools in the qualitative survey as all schools in Midlands were rural. Thus, five districts Formative Research on Menstrual Hygiene Management Final Report, December 2019 21
Figure 5: Map Of Provinces And Districts Covered In The Qualitative Survey
were eventually covered. Two (2) schools (that were visited for the quantitative survey) were enrolled in the qualitative study.
In each province, interviews were conducted at the school, community, district and provincial level. At the school level, interviews and discussions were held with 1) school heads; 2) teachers; 3) guidance and counselling teachers; 4) girls; and 5) boys. Traditional and religious leaders, environmental health technicians (EHTs), men and women, women influencers or leaders, out of school girls and shopkeepers or traders were the main respondents at the community level. District stakeholders that included governmental members of the District Water and Sanitation Sub-Committee (DWSSC) and Rural District Councils were included in the survey while members of the Provincial Water and Sanitation Sub-Committee (PWSSC) were also incorporated at the provincial level.
Respondents at national level included government ministries, Non-Governmental Organisations (NGOs), manufacturers and distributors of sanitary wear, Standards Association of Zimbabwe (SAZ), United Nations (UN) agencies.
Table 1.3 in Annex 1 summarises the number of respondents reached by the qualitative survey. All respondents in the qualitative survey were purposively selected with exception of girls in and out of school and boys. For girls in primary school, two groups were established according to class, that is, grade 4-5 and grade 6-7. The same approach was adopted for secondary schools with one group being of Form 1-2 students and the other of form 3-6 students. Teachers were tasked with randomly selecting girls in these groups. Eight girls were selected for each group. In schools where the evaluation coincided with exams 22 Formative Research on Menstrual Hygiene Management Final Report, December 2019
and an adequate number of girls could not be mobilised, only one group was selected. This occurred in three schools. For boys one group in each of primary and secondary was selected comprising all classes. Selection of out of school girls was based on convenient sampling – those that could be located and were able to participate at the time of the visit.
Data collection tools Several qualitative tools and techniques were used for the survey including focus group discussions (FGDs) and key informant interviews (KIIs). Table 3 provides a list of respondent categories, key techniques used and the main issues investigated.
Table 3: Summary Of Data Collection Tools For The Qualitative Survey
Respondent Tool and Issuesa Technique Girls in school knowledge attitudes and practice on MHM information sources myths and misconceptions on MHM for primary school: experiences of early menarche especially considering that menstruation might not be a very common phenomenon in primary schools for secondary school: experiences with menstruation and Topic effects on schooling Boys in Guides knowledge attitudes and practice on MHM school FGDs information sources myths and misconceptions on MHM Girls out of challenges faced in MHM support and also school whether MHM was a cause of and contributing factor to school dropout Boys out of knowledge attitudes and practice on MHM school views regarding MHM perceived roles in supporting girls with MHM Women and establish their views on MHM, men- key their knowledge, attitudes on MHM influencers on sources of information on MHM MHM participation in raising knowledge on MHM Shopkeepers stocking of sanitary wear sales and trends in purchase of sanitary Manufacturers production of MHM materials and how this affects accessibility of sanitary materials in the country challenges experienced in manufacturing and distribution of Topic sanitary wear Guides opportunities in enhancing manufacturing and distribution of KIIs sanitary wear Licencing and establish involvement in regulating the production and quality control distribution of sanitary materials in the country and any bodies opportunities Community level of MHM support rendered to girls health WASH in schools and the community in relation to MHM institutions Teachers insights on the quality of education and the MHM support learners receive at school
aThe list of issues is not exhaustive. More information can be obtained from the tools in the inception report. Formative Research on Menstrual Hygiene Management Final Report, December 2019 23
Data collection Ten research assistants in two teams of five were trained over four days and tasked with data collection. As with the training of the quantitative team the training for qualitative research assistants included techniques for facilitating FGDs, note taking, training on the tools and role plays and one day pilot survey in two schools in Seke District of Mashonaland East. All qualitative tools were translated to Shona, Ndebele and Tonga and with verification undertake as per similar procedure with the quantitative tools. Two research assistants, a facilitator and notetaker, facilitated FGDs. Each FGD was recorded and later transcribed in Microsoft Excel. The core team members conducted KIIs at community, district and provincial level while research assistants focused on FGDs and interviews at the school level.
Data analysis All the interviews were transcribed into excel spreadsheets and data banks as appropriate. Further consolidation of data was done in Excel and exported to Atlas ti for analysis. This was followed by coding and establishment of networks in the data. The coding was undertaken by two data analysts. Based on the uploaded data, thematic areas were then formulated to which key questions governing the collected data were allocated. Data was then run again in Excel to produce spreadsheets for each thematic area. Further analysis including merging the qualitative and quantitative data was done.
2.4 Ethical Considerations Ethical clearance for this study was provided by the Medical Research Council of Zimbabwe (MRCZ). To ensure child protection, several safeguards were employed. Researchers and everyone participating in the study was bound by the UNICEF Child Protection Protocol. All members of the research teams, both quantitative and qualitative were expressly advised about and trained to appreciate the need for compliance with the highest ethical standards in all the study processes, with particular emphasis on the protection of the rights of children.
Permission and clearances to conduct the study were obtained from all accessed Ministries and institutions involved in the study. An informed consent process where children were involved in the study was utilized either through direct parental or guardians consent for those under 18 years of age. All consent involved signed consent forms as per the Ethical approval requirements. In relation to schools and institutions where there were children under 18 the in loco parentis, substitution on the part of school or institutional authorities was invoked. Further, even with such permission in place, all respondents, including children, were asked for their individual consent regarding participation in interviews.
Each participant, whether individually interviewed or a participant in a focus group discussion participated after being advised of the purpose of study and the issues to be covered during their engagement in the study. All participants were made aware that they were free to opt out at any time during the interview/discussion should had they feel uncomfortable or uneasy about any aspect of the interview or discussion. All reporting in the study was made with careful attention to the anonymity of all respondents, unless being adults they had consented to their identity being revealed. 24 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Further the following protocols were put in place for these issues:
●● Identification of ethical issues and mitigation measures: the inception report identified risks and potential ethical issues that the research needed to address. Risk mitigation plan was developed and implemented and an ethics protocol was developed and approved by the Medical Research Council of Zimbabwe (MRCZ) – see attached letter of approval, Annex 3. ●● Methods to ensure the avoidance or minimization of harm and stress to participants: the field protocol required enumerators to interview respondents in private but open space to ensure no abuse occurred. Secondly, enumerators were trained to identify signs of distress and discomfort by the respondent and how to ensure they were comfortable and in worst case scenarios to stop the interview altogether. In cases where abuse was reported or suspected the interviewer would inform the headmaster or senior teacher available at the time of the visit to the school. Lastly, all interviews were done during school time to enable participants to leave with their peers. ●● Security matters and protection protocols utilized - both for enumerators and people interviewed: To guarantee protection of enumerators and respondents the field protocol required all the field teams to receive authorisation from administrative and security authorities in the provinces and targeted districts. Schools were made aware of the survey prior to arrival through their respective District Supervision Inspectorate (DSI) allowing them to inform local authorities about the impeding visit of the team and the research. Once at the school, the field teams ensured that community leaders were made aware of the survey. ●● Protection of privacy of participants, confidentiality and anonymity of data collected: First no names or nay details that could identify the respondent were obtained. Further, all data shared is anonymised ensuring no case is linked to a particular school. ●● Absence of benefit or compensation offered to interviewees: The study did not offer any benefits to participants of the quantitative survey. However, refreshments were offered to participants in FGDs due to the long period the interviews took. ●● Respect of local religious and cultural beliefs and practices: before community level meetings, the supervisor would meet the traditional leaders to gain authorisation for field work and in the process receive information on how the team should conduct itself including dressing etc.
2.5 Limitations There are some limitations for the study as follows:
1. Timing of fieldwork: Fieldwork coincided with June 2019 national examinations. This meant that students in exam classes, Form 4 and Form 6, in some schools could not be enrolled for the study. However, this did not affect the survey as in most schools FGDs were timed to coincide with completion of examinations. Only three school were affected with field teams able to interview less than the required number of students. Over sampling was done in other schools to overcome this shortfall. Formative Research on Menstrual Hygiene Management Final Report, December 2019 25
2. In some schools there were fewer pupils than anticipated. This meant the establishment of sub-groups for FGDs was not possible. This affected mostly P3 schools in rural areas. However, this was not a widespread challenge. 3. Sample size used has restrictions. The sample size for the research is sufficient to provide national level statistics and the rural urban divide but is of insufficient power to provide provincial level conclusions. 26 Formative Research on Menstrual Hygiene Management Final Report, December 2019
3 Study Findings
This section presents the findings of the study beginning with description of the study sample. The findings are organized by theme, using the framework provided in the terms of reference as illustrated in the study methodology section. Study findings depict the context, challenges, determinants, voiced impacts and potential risks identified around MHM in Zimbabwe. Following the framework provided in Figure 1, Key Elements of MHM, the section begins by discussing the MHM information sources for girls and boys. Building on the information sources, the section provides details on the findings on knowledge levels of MHM among girls and boys, and key professionals’ capacity. Social norms including gender and cultural constrictions and restrictions on MHM are further discussed, as are the facilities (including disposal) and services available for MHM in school and public spaces. The last two sections discuss experiences of girls in managing menstruation from pre-menarche to during menarche and the legal and policy gaps.
Description of the study sample
In-School Girls The study had a sample size of 2,620 girls age 10 -24 years between grades 4-7 and forms 1 to 6. Most of the girls interviewed are in secondary school (54.2%) with the remainder in primary school. Categorisation of the girls by age shows that 64.6% were in the 10-14 age group; 34.9% aged 15-19 years and 0.6% aged 20-24 years. There was an equal distribution in number between urban and rural areas (49.7% in urban; 50.3% in rural areas. Of the 1,302 girls in urban schools, 37.6% follow Pentecostal churches, 25.2% are Protestants, while 18.7% are Apostolics. For the 1,318 from rural schools, the majority 43.9% are Apostolics, 23.6% Protestants and 19.2% are Pentecostal. Table 4 presents a detailed breakdown of the characteristics of the sample. Formative Research on Menstrual Hygiene Management Final Report, December 2019 27
Table 4: Socio- Demographic Characteristic Of The In -School Girls
Characteristic Urban (N=1,302) Rural (N=1,318) Total Number Percent Number Percent (N=2,620) Age (years), mean±sd 13.3±2.3 13.8±2.5 13.6±2.4 Age (years) 10-14 893 68.6 799 60.6 1,692(64.6) 15-19 409 31.4 504 38.2 913(34.9) 20-24 0 0 15 1.1 15(0.6) Level of Education Primary 648 54.0 522 46.0 1,200 Secondary 654 46.1 766 53.9 1,420 School Class Grade 4 92 41.8 128 58.2 220 Grade 5 145 54.3 122 45.7 267 Grade 6 197 57.8 144 42.2 341 Grade 7 214 57.5 158 42.5 372 Form 1 153 43.7 197 56.3 350 Form 2 156 47.6 172 52.4 328 Form 3 140 43.6 181 56.4 321 Form 4 125 48.1 135 51.9 260 Form 5 56 57.7 41 42.3 97 Form 6 24 37.5 40 62.5 64 Province Manicaland 101 34.5 192 65.5 293 Mashonaland Central 98 37.1 166 62.9 264 Mashonaland East 110 36.5 191 63.5 301 Mashonaland West 169 75.1 56 24.9 225 Matabeleland North 101 35.4 184 64.6 285 Matabeleland South 102 32.4 213 67.6 315 Midlands 112 43.4 146 56.6 258 Masvingo 56 24.8 170 75.2 226 Harare 233 100.0 0 0 233 Bulawayo 220 100.0 0 0 220 Religion Roman Catholic 107 55.7 85 44.3 192 Protestant 329 51.4 311 48.6 640 Pentecostal 489 65.9 253 34.1 742 Apostolic sect 243 29.6 578 70.4 821 Other Christian 90 59.6 61 40.4 151 Islam 15 100.0 0 0 15 Traditional 3 60.0 2 40.0 5 Other religion 14 70.0 6 30.0 20 No religion 12 35.3 22 64.7 34
28 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Out-of-School Girls
One-hundred and eight out-of-school girls were reached by the study aged 15 -21 years. Most of the girls interviewed have secondary school (75%), i.e. 81 of the 108 out of school girls. On assessing reasons for leaving school none mentioned lack of sanitary material nor lack of facilities for changing sanitary materials in both rural and urban areas. Reasons cited for leaving school were lack of fees and long distances to the school. Sixty-one percent of the out of school girls have never married, while 28% are married and living with spouse. Table 5 presents a detailed breakdown of the characteristics of the sample including by province and by religion.
Table 5: Socio-Demographic Characteristics Of The Out Of School Girls
Characteristic Urban (N=54) Rural (N=54) Total Number Percent Number Percent (N=108) Level of Education No education 2 100.0 0 0 2(100.0) Primary 6 27.3 16 72.7 22(100.0) Secondary 44 54.3 37 45.7 81(100.0) Tertiary 2 66.7 1 33.3 3(100.0) Main Reason why you left School No sanitary materials 0 0 0 0 0 No facilities for changing sanitary materials 0 0 0 0 0 Lack of school fees 35 64.8 24 24 59(54.6) Long distance to school 1 1.9 1 1 2(1.9) Other 18 33.3 29 29 47(43.5) Marital Status Married and living with spouse 14 25.9 16 29.6 30(27.8) Married but not leaving with spouse 2 3.7 4 7.4 6(5.6) Divorced/separated 1 1.9 5 9.3 6(5.6) Never married 37 68.5 29 53.7 66(61.1) Province Manicaland 6 33.3 12 66.7 18(100.0) Mashonaland Central 5 55.6 4 44.4 9(100.0) Mashonaland East 6 66.7 3 33.3 9(100.0) Mashonaland West 5 62.5 3 37.5 89100.0) Matabeleland North 7 53.9 6 46.2 13(100.0) Matabeleland South 6 40.0 9 60.0 15(100.0) Midlands 6 35.3 11 64.7 17(100.0) Masvingo 3 33.3 6 66.7 9(100.0) Harare 4 100.0 0 0 4(100.0) Bulawayo 6 100.0 0 0 6(100.0) Religion Roman Catholic 8 14.8 4 7.4 12(11.1) Protestant 15 27.8 9 16.7 24(22.2) Pentecostal 17 31.5 13 24.1 30(27.8) Apostolic sect 13 24.1 23 42.6 36(33.3) Other Christian 0 0 3 5.6 3(2.8) No religion 1 1.9 2 3.7 3(2.8)
Formative Research on Menstrual Hygiene Management Final Report, December 2019 29
About 53.8% of girls in urban areas and 52.6% in rural areas had started menstrual periods.
Girls with Disability
Twenty-five in-school girls’ interviews had a disability (10 urban and 15 in rural areas) which is 1% of the sample. Six of the girls were deaf and hard of hearing (hearing impaired); 9 were blind and low vision (visual disability); 2 have mental disability (mentally retarded); 4 have motor and physical disability (physically disabled); and 3 have multiple disabilities.
3.1 MHM Information Sources This section discusses the sources of the information and how it is delivered, including the significance of MHM being a subject for study, albeit not for examination in schools in Zimbabwe. 30 Formative Research on Menstrual Hygiene Management Final Report, December 2019
3.1.1 MHM information sources for girls in and out of school Based on the overall statistics from the study, over 60% of girls in school in both urban and rural areas stated that they received information on how to care for themselves during their menstrual periods. The information was received before menarche (95.6% in urban areas and 88.9% in rural areas). Over 80% (88.3% urban and 83.6% rural) agreed that the time they received the information was the right time to prepare for the onset of menstruation. The average age of menarche was 12.9 years for girls in urban areas and 13.6 years for their rural counterparts. Asked about their sources of MHM information, urban girls commonly reported the school (teacher) followed by the mother. On average, more urban girls received information on MHM from both the school and their mothers than their rural counterparts. More rural girls than urban girls receive information from relatives, friends, and school health clubs (See Table 6).
Table 6: Source Of Mhm Information For In School Girls
Source Urban Rural
Number Percent Number Percent Mother 223 51.2 184 34.9 Father 4 0.9 7 1.4 Sister 72 16.5 76 14.8 Relative 70 16.1 92 18.0 Teacher 247 56.7 263 51.4 Friends 28 6.4 47 9.2 Books/newspapers 4 0.9 0 0 Radio 1 0.2 0 0 NGO representative 7 1.6 7 1.4 School Health Club 17 3.9 24 4.7 Other 19 4.4 39 7.6
Formative Research on Menstrual Hygiene Management Final Report, December 2019 31
The trend is the same with out-of-school girls. Thirty four girls responded to the question on where they get or got information on MHM. A majority of out-of-school girls who cited two or more information sources mentioned that they got MHM information from either their mother, sister or teacher in addition to other sources. Thus, most girls out of school got information on MHM from their mothers and teachers (at some point during their school career, before dropping out or completing their studies.) in both urban and rural areas and a few from friends and relatives across the board.
Most general information on menstruation that prepares girls for the onset of menses is received before menarche. Ninety-two percent of in school girls interviewed indicated that they had received MHM information before the onset of menarche. This finding was consistent in both urban and rural school with 95% and 89% respectively. In and out of school girls in both rural and urban areas noted that the general information shared was on what menstruation is, materials to use, importance of regular baths, disposal of sanitary materials and linkage between menstruation and pregnancy as presented in Table 7 for in school girls. Fewer girls from both groups received information on cultural beliefs and practices related to menstruation; discomforts and disorders that may occur in relation to menstruation and how to manage them; and managing menstruation for people living with disabilities.
Table 7: Information On Mhm Received Before Menarche By In School Girls
Information received before menarche Urban Rural
Number Percent Number Percent
What menstruation is 181 43.4 219 48.1 Signs and manifestation 48 11.5 87 19.1 Normal and abnormal periods 28 6.7 55 12.1 Importance of regular baths 298 71.5 322 70.8 Materials to use 271 65.0 340 74.7 Disposal of materials used 214 51.3 265 58.2 How to manage pain 16 3.8 48 10.6 Linkage between pregnancy and menstruation 116 27.8 184 40.4 Cultural beliefs and practices related to menstruation 7 1.7 15 3.3 (What were they?) Discomforts and disorders that may occur in relation to 10 2.4 20 4.4 menstruation and how to manage them. Managing menstruation for people living with disabilities 2 0.5 1 0.2 Other 1 0.2 2 0.4
32 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Those who did not receive any information before menarche noted the same areas above as some of the information they would have wanted to receive. Asked who they preferred to get information on MHM from, in-school girls noted that the information should be provided by the mother (68.2% urban and 66.9% rural), by relatives (28% and 26.6%), and by the teacher (19.7% and 14.9%). Out-of-school girls noted the same information providers.
When girls in school were asked whether the information they received was according to their needs, 82% responded in the affirmative. For the 18% (253 girls) that felt they needed more information, the following information were top priority for them:
a. Sanitary materials to use (23.3%); b. How to manage pain (21.7%); c. Normal and abnormal periods (17.0%); d. What menstruation is (15.8%); e. Disposal of sanitary materials used (14.2%); f. Signs and manifestation of menarche (13.0%); g. Importance of regular baths (12.25%); h. Linkage between pregnancy and menstruation (11.0%); and i. Discomforts and disorders that may occur in relation to menstruationUrban and how to 4.8% manage them (11.0%). 1.7%
Annex 2, , provides a full list of additional information required by in school girls. Table 23 19.1% Pamphlets 0.5% Books The study also sought to understand the availability of IEC materials on MHM to supportPosters learning on the subject. MHM learning materials received at school include pamphlets,None books, and posters (see Figure 4 and Figure 5). The majority76.3% of schools (76.3%) in Obothther urban and rural localities had no IEC materials on MHM. About 19.1% of urban schools and 17% rural schools had books with information on MHM while only 0.5% and between 1.1 – 1.7% in both urban and rural localities had posters or pamphlets on MHM. Thus, a majority of girls do not have access to additional learning materials on MHM making verbal communication with teacher the only source of information at the school.
Figure 6: MHM IEC Materials In Urban Figure 7: MHM IEC Materials Rural Schools Schools
Urban Rural 4.8% 1.7% 1.1%
8% Pamphlets 17% 19.1% 0.5% Pamphlets 0.5% Books Books Posters Posters None None 76.3% Other 76.3% Other
Rural
1.1%
8% 17% 0.5% Pamphlets Books Posters None
76.3% Other
Formative Research on Menstrual Hygiene Management Final Report, December 2019 33
3.1.1.1 School based sources Guidance and Counselling lessons from the MoPSE are supposed to be taught from early childhood learning, primary and secondary school levels, and one lesson per week of 25 minutes in primary and 35 minutes in secondary school. However, when school heads were asked about their preparedness to disseminate this SRH information on menstruation and MHM, majority of school heads indicated that they did not have material to support dissemination of SRH information on menstruation. This supported by the fact that in over 70% of schools there were no IEC materials on MHM (see Figure 4 and Figure 5).
It was also evident that not all teachers were comfortable to provide MHM information in the classroom. In many classes, mostly with male teachers, any issue regarding menstruation was referred to the school health or female guidance and counselling teacher.
“It’s not a must to teach MHM we only teach when there is need that is when we see soiling of dress or toilets”. Primary school head
“MHM covered mostly in guidance and counselling which also deals with sexual health, 20 minutes per session run twice a week and emergency programme meetings for girls when a girl spoiled their uniform or was not prepared for beginning of menstruation”. Primary school head
The responses of school heads and class teachers on the issue of teaching MHM in schools revealed that the new guidance and counselling curriculum covered menstruation but there was no uniformity in interpretation and implementation within and across schools and district. The non-prioritisation of SRH including MHM in schools is also a result of the subject area not being examinable as highlighted by some class teachers:
The syllabus has all what is required to be taught on menstrual hygiene management and sexual maturation. There are hand-outs and pamphlets on menstrual hygiene management. The scheme is what indicates that the teacher has taught the topic. These scheme books are checked twice a month and this is the monitoring method used. As teachers taking Guidance and counselling we have refresher courses with the Ministry of health. Guidance and Counselling Teacher
“I do not focus on anything that is in the syllabus but is not examinable as there is a lot of pressure already to make children pass”. Primary class Teacher 34 Formative Research on Menstrual Hygiene Management Final Report, December 2019
The education directorate seemed to be aware of the related challenges as they said there was advanced progress to make the guidance and counselling curriculum an examinable area: “As a ministry [MoPSE] we have noted some of the challenges with the teaching of Guidance and Counselling in schools especially for subjects that may not be included in exams. We are in the process of reviewing how we can make all components examinable.” MoPSE official.
Capacity/willingness to deliver MHM education by teachers: The study found that school health and guidance and counselling (G&C) teachers were mostly involved in MHM within the school. To determine capacity in delivering MHM education, school health and G&C teachers were asked whether they had received training to teach life skills including MHM. Only 7 out the 18 interviewed had received some form of training to teach life skills including MHM. While there are differences in capacity, there was acknowledgement that teachers lacked adequate skills to articulate MHM.
“Training is required across the board. Our society remains a closed society. Guidelines are available and MHM education starts in the classroom and is teacher centred where some are articulate and can mainstream (the) subject and others are not very competent to articulate the subject” (Provincial Education officer).
While there is some effort to raise awareness in primary schools, responses from teachers generally indicated that MHM was not being addressed at secondary level. Asked who teaches menstrual hygiene responses of secondary school teachers pointed mostly to Ministry of Health officials, NGOs, Female teachers, Senior lady teacher. Asked on whether Formative Research on Menstrual Hygiene Management Final Report, December 2019 35
they provide MHM and SRH lessons, most (6 out of 8) secondary school teachers indicated that they are more focused on the examinable subjects assigned to them and MHM is not one of them.
“No, I have a lot of work on my desk, so I have no time for this. I only teach when necessary.” Secondary School Teacher
“Not as such, I don’t because of the nature of the subject I teach” Secondary School Teacher
The absence of structured classroom teaching at secondary school could be attributed to assumptions that learners are now fully aware of MHM and can manage on their own. Another likely reason is the fact that in secondary school, teachers are assigned to specific examinable subjects such that no one is solely responsible for teaching MHM. Findings demonstrate that the biology of menstruation is well taught in science classes however, menstrual hygiene and management are being overlooked.
Role of Health sector as a source of information: Community health programmes in Zimbabwe have a responsibility to support school health programmes including MHM. This was confirmed in interviews with community health nurses. There are varying extents of engagement with schools mainly influenced by availability of both financial and human resources. In Marondera, the community health nurses revealed that prescribed targets 36 Formative Research on Menstrual Hygiene Management Final Report, December 2019
could not be attained by health personnel as usually 40 schools are reached per quarter against a target of reaching each school per quarter (there are approximately 140 schools in the district). In Mt Darwin, there were reports of Ministry of Health and Child Care getting an hour once a month or a quarter for teaching SRH in schools. EHTs from Marondera district and the Binga Town Council, confirmed supporting school health clubs, peer education, and hygiene education programmes for out of school. Provincial ASRH coordinators interviewed in all three provincial offices visited for the qualitative survey (Mashonaland East, Mashonaland Central, and Matabeleland North) reported they had no links with MHM programmes at provincial level.
The extent of engagement can be reflected in the responses of province and district level Adolescent Sexual and Reproductive Health Focal persons of the Ministry of Health and Child Care (MOHCC) as follows:
“I provide my clinical support visit to their health clubs and equip them with accurate information and correct areas that they think they need help/ provide the youth out of school with information and knowledge”. Adolescent Sexual and Reproductive Health Focal persons, MOHCC
“At province we are not very involved in MHM…. It is the responsibility of the Headmaster or the school health coordinators”. Adolescent Sexual and Reproductive Health Focal persons, MOHCC
“Only support health staff with ASRH related clinical support”. Adolescent Sexual and Reproductive Health Focal persons, MOHCC
“The clinic nurse educates the girls on Menstruation and menstrual hygiene they are well informed”. Children’s Home Harare
“The teachers and not clinic health staff educate pupils on MHM. We understand it is the teacher’s mandate according to the new curriculum”. Centre for Children With Disability. Formative Research on Menstrual Hygiene Management Final Report, December 2019 37
These statements bring to the fore the challenges in coordinating MHM both within the MOHCC and between MOHCC and other stakeholders. While there are challenges at provincial level, EHTs through the DWSSC do provide support for MHM in the form of supervising construction of appropriate facilities and health promotion in school health clubs.
3.1.2 MHM information sources for boys It is important for boys to receive correct and comprehensive information on MHM to limit stigma that can be associated with it. The sources of information and type of information received is important in this regard. Boys in school were asked about their information sources on MHM during FDGs. In all four districts, teachers were the most common source of information on MHM with most boys receiving it in primary school from Grades 5 onwards (from age 11). Some however, mentioned they do get information from as young as 9 years old and in grade 3. Some boys only receive information on MHM as late as at 18 years. Only four groups out of 16 highlighted, have received information on MHM while in secondary school. At the secondary level, the source of information widens to include girlfriends. However, in order of the most mentioned sources, boys receive information on MHM from: 1) teachers; 2) friends; 3) brothers; other girls in the school; uncles; parents; school health clubs; sisters; grandmother; and community health nurse visiting the school. The following excerpts from discussions with boys provide a reflection of the boys’ experiences with information on MHM:
“We got this information from uncles, brothers and teachers. I came to know about MHM while I was 14 years old… 18 years old and when I was in secondary.” Boys in secondary School.
“We heard it from the teachers.” Boys in secondary school
“I heard it from my girlfriend” Boys in secondary school 38 Formative Research on Menstrual Hygiene Management Final Report, December 2019
“Our parents, both my mother and my father. I think they just saw my age and saw it necessary to discuss with me”. Boys in primary school
“I was in grade 7 at 13…I first heard about it when girls were discussing and I was in form 2 and then did it later on in science lesson”. Boys in secondary school
“At grade 3, was 9 years and was taught by my teacher…At grade 5, I was 11 years and was taught by my madam….” Boys in primary school
Most boys highlighted that neither girls nor their parents were willing to talk to them about menstruation indicating that their parents only talked to girls about it. That leaves the discussion of menstruation during peer discussions mainly after it has been taught in class or when there is a girl that has spoiled. In one of the FGDs with boys, one participant had this to say,
“If you ask parents, they will ask you, why do you need such information, are you a girl?” Boys in secondary school
Sources without correct information have the risk of passing on incorrect information and myths to boys. There are indications that information obtained from informal sources such as friends, brothers, uncles, sisters, girlfriends etc is not correct:
“My uncle taught me if you indulge in sex with her while in her period, you may acquire STIs.” Boys in secondary school
“Parents don’t say it clearly, but I heard my sister saying she is going to the hospital to collect pads.” Boys in primary school
“Heard it from elders [that] menstruation is when the female egg bursts when it is due for fertilisation” Boys in primary school Formative Research on Menstrual Hygiene Management Final Report, December 2019 39
“I heard it from my girlfriend as well that egg from horns of the uterus bursts and comes out as blood.” Boys in secondary school
As with girls, the teacher is the main source of information on MHM for boys. There are inconsistencies between schools on when, what and how the subject is taught. For some schools, MHM is limited to school health clubs, in others it is taught as part of the guidance and counselling lessons, while for others special times are created to teach the subject. In other schools, boys receive MHM information separate from girls while in others they receive joint lessons on the subject. Such approaches have the possibility of reinforcing stigma on MHM.
“We learn in groups, boys on their own and girls on their own when it comes to Sexual Reproduction.” Boys in primary school
“Yes, we learn together with girls about menstruation.” Boys in secondary school
“We learn about sexual and reproductive health mixed with girls.” Boys in primary school
“We learnt about it in health clubs.” Boys in primary school
Boys strongly feel that it is a female’s responsibility to teach about menstruation and to handle issues related to MHM. Asked if they would grow up to discuss menstruation issues with their own daughters, the majority of boys denied this responsibility, indicating that females are better placed to do so.
“It’s a taboo, daughters won’t respect you if you talk about that…” Boys in secondary school 40 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Based on their interaction with boys with regards menstruation, girls were asked what they would want boys to be taught. Most of the in school girls in urban and rural areas picked two main areas to be focused on i.e. what menstruation is (34.6% in urban areas and 33.6% in rural areas); and linkage between menstruation and pregnancy (11.7% and 13.6%, respectively). A worrying number of in-school girls; however, felt that there was no need to educate boys on menstruation (34.4 in urban areas and 28.3% in rural areas).
When boys were asked whether they would like to know more about menstruation, a majority of boys in FDGs felt they needed to know more about menstruation. Boys in four groups out of the 21 FDGs expressed reservations for learning about menstruation and felt that learning about menstruation should be for girls as they are the ones that experience menstruation. In three out of 21 of the FDGs, boys were not in agreement on whether they should learn about menstruation.
“We as boys are not concerned much about information since we are not the ones who menstruate. More information should be given to girls.” Boys in secondary school
“No because it’s the girl who will be menstruating and not me… I don’t want to know much because I am not the one who goes there (to the moon).” Boys in secondary school
“Yes I will have to know so I can explain to my sons in the future when they ask me”. Boys in primary school
“Yes I need to know so that I don’t sleep with a girl during her period.” Boys in secondary school
“I want to know because I want to know why she does that whilst I am not doing such.” Boys in primary school Formative Research on Menstrual Hygiene Management Final Report, December 2019 41
Excerpts below provide information that boys would like to know on MHM. There seems to be convergence with what girls think boys should be taught on menstruation and what boys expressed as their need (See Annex 2, Table 25). Review of this information also demonstrates the lack of information on MHM among boys as majority of the information border on ignorance or misinformation:
1. Sex and pregnancies: a. I want to know about menstruation so that I do not impregnate or get a swollen penis or testicles; b. when is it safe to have sex with a girl; c. how to avoid pregnancies when a girl is on periods; d. I need to know so that I do not sleep with a girl during her period; and e. I need to know what happens if you sleep with her while on her period.
2. Causes and reasons for menstruation: a. why do girls go on periods? b. why it happens and how because girls at times lie and are shy; c. how long does menstruation cycle take, benefits of periods; d. days of which girls menstruate; and e. symptoms of menstruation, advantages and disadvantages of menstruation.
6. Effects of menstruation: a. I want to know what really causes the pain and if it is something that is normal; b. I am not satisfied with what I know. I want to know if that bleeding reduces blood levels; c. does the girl feel any pain when she is on period? and d. I want to know the behaviour of girls when they are on periods and the feeling when she is on periods.
5. MHM: a. we want to know if there is anything that can be done to stop the bleeding; and b. what can girls use besides pads during menstrua
3.1.3 Barriers and constraints to accessing MHM information
3.1.3.1 Barriers within the education sector As indicated earlier in this report, there are misconceptions about the operationalization of MHM related programmes in schools. At managerial level, there is a strong assumption that implementation of MHM programmes was in place.
“All school heads and coordinators are trained and provided with syllabi for training. The teaching of guidance and counselling is timetabled, 25 and 35 minutes for primary and secondary school per week respectively”. District Education Officer
“Teachers in district were all oriented on Guidance and counselling teaching in 2015”. District Remedial Officer 42 Formative Research on Menstrual Hygiene Management Final Report, December 2019
However, this was not always the case at school level as demonstrated by inconsistencies in implementation of the new curriculum, limited prioritisation of sexual and reproductive health especially MHM as it is not examinable, limited cross-sectoral engagement in MHM (community health, environmental health, education and gender).
As noted in earlier sections, the study found that girls do not always access accurate and timely information on MHM despite policies and curriculum to guide implementation of SRH programmes.
Lack of learner-targeted information, education and communication materials was cited as barrier by all stakeholders. Learning materials on the subject were found to be unavailable in 76% of the schools visited for the survey. A class teacher in Binga said he had never come across any information, education and communication material on MHM and SRH. Another class teacher in Mt Darwin said teaching MHM and SRH was affected by lack of provision of teaching resources including books, media to teach and providing resources such as projectors so that the children visualise what is being taught.
Therefore, and arguably, making the subject examinable, even as a component in another subject would encourage resourcing, more active interest in and concern over the subject at all levels from the pupil through to the highest echelons of government.
3.1.3.2 Religious, cultural and gender related barriers to information sharing on MHM There were varying views by parents on their children receiving sexuality education including MHM. In some discussions, attitudes of parents were reported to be problematic, as they at times refused to have their children taught on sexuality and MHM by any community member without their approval. While others reported that some parents just ignore educating children on MHM and expect the school to tackle the issue.
As a way of balancing male and female views from community leaders, the study considered the role of women who could influence social norms around menstruation in communities. These included older women, pastors’ wives, traditional leaders’ wives or traditional birth attendants. From the qualitative study, it emerged that women influencers seemed to provide information to girls only after menarche citing that before menarche it is the responsibility of a parent or relative. In an interview, one women influencer said that she educated her own family members and makes them understand that when they get premenstrual tension, and other signs that include nausea, abdominal discomfort or pain, then the girl must expect a menstruation related bleeding in 3-4 days. According to the elderly woman who was also an elder in the Apostolic Church:
“…the signs in addition to knowing their cycle should alert the girls of when to carry a pad in the bag”. Formative Research on Menstrual Hygiene Management Final Report, December 2019 43
The information that these women had on menarche and menstruation was in general accurate and would be very useful within communities as a resource. They therefore are a potential resource on MHM particularly in rural areas and can be incorporated into MHM information dissemination activities. It is however key to provide them with additional information where appropriate. Yet, they remain an underutilised resource in communities as girls mainly receive information from their social networks: either their mother, teacher, sister, friends or relative. Further, due to cultural beliefs and mistrust of other peoples’ involvement and possibly their motives, many parents seemed to reject any education offered to their children outside the school or formal education sessions unless requested.
The view that MHM education was the responsibility of women was held by both men and women despite their position in the community. All traditional leaders interviewed, who were all male, regarded educating girls on MHM a woman’s role and responsibility. As highlighted earlier, male teachers’ negative attitudes on teaching MHM relegates the subject to female teachers, increasing their work burden disproportionately. Therefore, students in classes led by males are less likely to receive information on MHM. However, the study is not able to provide conclusive evidence as disaggregated data on female and male teachers was not available from the participants in FGDs and survey questionnaire with school children.
Further, according to education personnel, girls were not very comfortable to discuss or disclose the way they manage their menstruation which presents a barrier to the free flow of information.
“We can’t implement MHM in schools and let it be a taboo at home. We need to change mind sets of the people if we continue to bind MHM to traditional thinking we are bound to fail”. Provincial Education officer 44 Formative Research on Menstrual Hygiene Management Final Report, December 2019
More religious than traditional leaders and more females than males, address MHM within their communities and families. Although content and emphasis on various aspects of SRH and MHM is not consistent for example:
“MHM is discussed at big gatherings when there are many girls around however emphasis is on keeping virginity than managing hygiene”. Johanne Marange, Church Elder - Male
“I discuss with my children boys and girls together. See I grew with my granny who used to talk about these issues and it helped me to appreciate and empathise with the women folk during this period”. AFM Church Pastor - Male
“Not so often. This is purely a duty discussed by women. It also covers fornication. These are introduced when girls start menstruating and during conferences “,Church Pastor - Male. Formative Research on Menstrual Hygiene Management Final Report, December 2019 45
3.1.3.3 Limited cross-sectoral approach to MHM information dissemination MHM is part of the Comprehensive Sexuality Education manual for Zimbabwe. The manual provides a standard approach to educating adolescents and young people on SRH including MHM as a subject. Implementation of the manual is decentralised with multiple stakeholders concerned with adolescent health using contents of the manual in their information dissemination activities. While the MoHCC has made efforts in training nurses, peer educators and other community level stakeholders on the manual, its use across all localities is not consistent with other issues concerning safe sex, STIs and HIV taking precedence over the entire content. As highlighted earlier, ASRH focal persons of the MoHCC have varying engagement with issues of MHM although it was clear that at lower levels MoHCC through the EHTs work with health clubs and schools on MHM. Others relegate MHM information dissemination to schools (see Section 4.1.1.1).
In the WASH sector, MHM in schools is a priority including progress in designing girl-friendly latrines. However, no comprehensive package of support for schools is available to enhance MHM information dissemination.
In addition to the Guidance and Counselling curriculum the MoPSE approved new School Health Club training manuals that include MHM. There are therefore several materials available in the school environment to deliver lessons on MHM but it was not clear how these will be coordinated.
In other public service entities, it seemed that potentially available resources and assistance were not being deployed in MHM. The officers from Ministry of Women’s Affairs interviewed reported that they were not involved in any activities around MHM and felt that it was an anomaly that they were not addressing the issue in compliance with their directorate and job descriptions.
The lack of a comprehensive and cross-sectoral approach to addressing MHM results in a piece-meal approach to information dissemination. Multi-sectoral platform will greatly aid in this regard.
3.2 Knowledge, Attitudes and Practices on MHM
3.2.1 Girls knowledge, attitudes and practices on MHM The study assessed girls’ knowledge and understanding of menstruation. Most girls interviewed professed knowledge of what menstruation is with 82% of in-school girls in urban areas and 77.9% in rural areas, indicating that they know what menstrual periods are.
Further assessing the girls’ knowledge on menstruation, True or False statements were read out to the respondents. The data indicates that most girls involved in the study are knowledgeable of menstruation. For example, only 8.4% in urban areas and 13.9% in rural areas agreed with the statement that menstruation is a disease while 75% from both areas agreed that menstrual blood comes from the uterus/womb. The trend is the same in the qualitative study. 46 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Table 8: Responses For True Or False Statements On Menstruation Numbers recorded are for each question when respondents answered True
Statement Urban (N=1,302) Rural (N=1,318) Number Percent Number Percent Menstruation is a disease 109 8.4 183 13.9 Menstrual blood comes from the uterus/womb 982 75.4 994 75.4 Menstrual blood is harmful to the body 273 21.0 347 26.3 The duration of a period can be 3, or 7, or 10 1,011 77.7 1,069 81.1 days? A menstrual cycle can be 21 days, 26 days or 35 796 61.1 823 64.4 days? Pain during menstruation means that someone is 253 19.4 393 29.8 unhealthy Women are dirty during menstrual periods 383 29.4 527 40.0 Menstruation is normal and natural 1,184 90.9 1,170 88.8
For out of -school girls, 94.4% (98.2% in urban areas and 90.7% in rural areas) understood what menstrual periods are. However, all girls had started menstruating which could have been the reason for the higher knowledge levels as compared to the mixed group of in- school girls (53.8% of in urban areas having started their menses, while the proportion was 52.6% of those in rural areas) which may point to lower knowledge levels pre-menarche.
The terms used to refer to menstruation were linked to understanding or perceptions about menstruation expressed metaphorically sometimes and related experiences such as required more frequent baths, regular occurrence of menstruation and linkage to the moon phases, or blood flow likened to flowing of a river. Some of the several names in vernacular included;
●● Kugeza meaning to wash (majority of Shona speaking areas); ●● Chamuitikila meaning it has happened for her (Bemba areas border with Zambia); ●● Ukudzwi meaning she is on; ●● Mulonga wazula meaning the river is full; ●● Uyavuza meaning she is leaking (Ndebele speaking areas); ●● Kumwedzi meaning she is on the monthly cycle (Majority of Shona speaking); and ●● Kutevera meaning following.
However, during FGDs, it was noted that regardless of their display of basic knowledge on menstruation, some incorrect information on the subject is still prevalent amongst the girls. There exists a knowledge gap on the understanding of the physiology of menstruation as responses ranged from accurate, fairly accurate to misleading information as rated in Table 8. For example, in Mount Darwin, Marondera and Gokwe, rural primary and secondary school girls generally understood menstruation as the breaking of the egg that causes women to bleed through the vagina. They understand that the coming out of the blood is a sign of the vagina being cleaned10. There was no linking of hormones to menstruation in any of the discussions. Formative Research on Menstrual Hygiene Management Final Report, December 2019 47
The inadequacy of MHM knowledge is also evident in that the girls were not mentioning key aspects of menstruation that include pre-menstruation tension sometimes referred to as premenstrual syndrome (PMS) or premenstrual tension (PMT). Furthermore, based on the qualitative research, the study revealed that most girls were not aware of the signs indicating that the onset of a period was close. Girls were also not aware of the broad ways to manage severe pain (dysmenorrhea) during menstruation including engaging in activities that remove attention to the pain and taking a light pain relief tablet with medical attention sometimes necessary for severe pain.
During FGDs, myths and misconceptions around menstruation demonstrating inadequate knowledge of menstruation, were observed. These included that: menstrual pain arose from wearing other people’s clothes; whether bleeding becomes heavy or not was linked to eating too many eggs, or chilli and, the bleeding was in some instances linked to being sexually active.
Table 9: Girls’ Understanding, Myths And Misconceptions On Menstruation
Misconception Myths
Its blood coming out of the vagina. The egg Menses is when a girl gets “pricked by an cracks and that is how the blood comes out injection” and they start bleeding. Primary of the vagina. school girls.
The girls with big eggs bleed more than When one starts bleeding that means they have those with small eggs. Menstruation done naughty things with boys. Also when normally starts from the age of 13. Primary someone sleeps with a person with HIV, they school girls start bleeding from the vagina and they need to go to the clinic and get an injection to make the The woman's egg when it is not fertilised by bleeding stop. Bleeding only starts at the age of a sperm it cracks and it comes out as blood. 20. Primary school girls. Secondary school girls
Period when women start bleeding through Whether bleeding becomes heavy or not was the vagina. The blood comes from the ovary linked to sometimes eating too many eggs and then passes through the vagina. This chilli (Marondera), the bleeding was in some process only takes place when the egg is instances linked to being sexually active. not fertilized. Secondary school girls Secondary school girls
Menstruation happens when the pregnancy To shorten the period you use some herbs. hormone is not fertilized and then the egg (Kubhutsura matutu enhuta), bath only once, will explode making blood come out. sexual Secondary school girls. intercourse during period avoids pregnancy (Darwin). Secondary school girls.
If one sleeps with a girl, she doesn’t get pregnant. Secondary school girls.
For girls menstruation means they have The bleeding is a sign of vagina being cleaned. grown up and it symbolizes that they are Primary school girls. fertile, they will have children. Secondary school girls
10Although this description was not further probed in the field one explanation for this interpretation of what takes place is probably that girls visual a hen’s egg, and relate this to the process of triggering menstruation. Not realizing that the ovum is extremely small at this point of the menstrual cycle. 48 Formative Research on Menstrual Hygiene Management Final Report, December 2019
3.2.1.1 Menstrual hygiene management practises among girls The proportion of girls that had started their menstrual periods in urban and rural areas was almost the same: 53.8% of girls in urban areas and 52.6% in rural areas. The mean number of days of menstruation is 4.3 days in urban areas (interval 26.1 days) and 4.0 days in rural areas with an interval of 26.7 days. One hundred and six out-of-school girls (106), out of 108 interviewed, had started having their period with an average of 4.7 days for out-of-school girls in urban areas and 4.0 for those in rural areas.
Many would try to keep menstruation as much a secret as possible while ensuring they do not spoil their uniforms or attract attention of boys, some of whom would jeer them if they found out. Girls indicated that when they have periods they wash twice a day to get rid of the smell of the menstrual flow. Some expressed they wash out the pads and throw them in the sanitary bins whereas in rural areas the practice was usually to throw used materials in the toilet as highlighted above.
Due to inaccurate information on calculating the menstrual cycle, girls carry an extra uniform and pads to school for days in case they spoil themselves. Participation in extra curricula activities such as sports were dependent on the confidence of the learner and availability of appropriate and effective sanitary materials.
3.2.2 Boys’ knowledge, attitudes and practices on MHM The study showed that boys have limited knowledge of MHM, but do have an appreciation of what it involves. In a majority of the FGDs, boys were able to relate to issues of girls bleeding during menstruation but the reasons given for the bleeding varied and were mostly based on myths and misconceptions.
“menstruation is about girls bleeding; another (someone) was told that one should not have sex with a girl who is on as his penis will be eaten.” Boys in secondary school
“menstruation happens to virgins. A virgin has a broken egg which then cause bleeding for 3 to 4 days.” Boys in secondary school
“They bleed from the anus, this is when a girl child starts to grow and can give birth, Girls are the ones who menstruate” Boys in primary school
The boys who displayed knowledge and more detailed understanding of menstruation were those who had learnt about the topic in school. Formative Research on Menstrual Hygiene Management Final Report, December 2019 49
Boys’ attitude on menstruation The research also identified negative attitudes amongst boys in relation to menstruation. It was established that boys usually tease menstruating girls especially if they soil their clothes. This negative attitude is related to stigma associated with menstruation as well as the prevalence of myths and misconceptions about it. This is highlighted by some of the reasons given by boys as to why they tease girls,
“Boys tease girls because of where the blood is coming from.” Boys in primary school
“She was bleeding blood with particles.” Boys in primary school
“She was in grade 7 and we laughed at her, we thought she is no longer a virgin. We thought she slept with a man. That’s what I also thought.” Boys in primary school
“It happened last year when a certain girl messed up and boys started laughing at her and she reported to the teacher and the teacher explained to boys that it’s normal and its part of life.” Boys in primary school
However, there were some boys who reflected a positive attitude, showing concern and sympathising with girls currently menstruating. Asked about their perception of girls who had reached menarche, these boys showed sympathy and highlighted that menstruation is a period when girls and women need assistances with chores. They further added that they should not be left to do hard work during their menses as they will not be comfortable. 50 Formative Research on Menstrual Hygiene Management Final Report, December 2019
“If it’s my sister I will not allow her to do household chores. I will do everything for her except washing her clothes.” Boys in secondary school
“Yes because I don’t want her to feel embarrassed when she messes her dress.” Boys in primary school
“I will tell her so that she will stay smart because poor menstrual hygiene practices cause diseases. I will tell her because I don’t want her to feel lonely.” Boys in secondary school
3.3 Social Norms, Myths and Taboo (Constrictions/Restrictions) that Surround Menstruation This section discusses the positive and negative constrictions and restrictions related to gender, culture and religion and how these have shaped social norms on MHM. It further discusses male involvement in MHM and its importance.
3.3.1 Gender, culture and religion: positive and negative constrictions and restrictions The study identified several myths and taboos related to MHM presented in Table 10 while specific details are provided in the discussion that follows.
Table 10: Common Myths And Taboos Related To Mhm
Common Restrictions and Constrictions
●● After menses girls are not allowed to play with boys as it exposes them to early marriages through early pregnancy. ●● No one should see a girl/woman’s menstrual flow because it is considered dirty and sometimes the blood can be used to bewitch a person. ●● Some churches and traditional leaders feel that women who are menstruating should not participate in religious or cultural rituals to prevent defiling the ceremonies or weakening the spiritual and prophet’s powers. ●● Because menstruation is considered dirty, girls are not allowed to cook in some families. ●● Sexual intercourse is prohibited during menstruation. ●● Should not bath in the river during menstruation. ●● Should not cook or add salt in the food. ●● Wearing someone’s clothes especially tying someone else‘s belt believed to cause period pain. ●● Eating too many eggs was reported as increasing menstrual flow. ●● Should not water the garden or tend to crops as they will dry up or not yield as expected. Formative Research on Menstrual Hygiene Management Final Report, December 2019 51
Women and girls are still suffering discrimination on the basis that they menstruate. In some parts of Zimbabwe, especially in rural areas, women and girl’s activities and mobility are still restricted or constricted during the time of their menstrual cycle. There are numerous restrictions that are placed on women and girls which are not supported by scientific evidence. The restrictions are mainly based on limited understanding of MHM and are rooted in discriminatory traditional, cultural and religious practices.
Women and girls suffer restrictions more when they do not have appropriate sanitary materials. In most FGDs conducted with females in communities covered in the study, it was noted that menstrual hygiene is not prioritised in household financing partly because it is an issue that affects women and girls, and not men who are the budget holders. When a woman or a girl does not have the appropriate sanitary wear and the underpants that hold the pads or cloth in place, their freedom of movement and association with others is limited . In Mashonaland Central, there were reports that some young girls did not have access to sanitary materials and only relied on non-governmental organisations working through schools to access them.
“Boys should also be engaged so that they support girls in issues of menstrual hygiene management” Environmental Health Technician
“Both parents should be educated on menstrual hygiene management, especially the fathers”. DWSSC Chairperson
Women and girls’ right to be treated with dignity, as provided for in section 51 of the Constitution is infringed as the study revealed that religion and culture prescribe limitations to what women and girls can and cannot do during menstruation. In some areas, it was noted that women and girls are not allowed to be in contact with their male counterparts when they are menstruating based on being considered “unclean”. The burden of “avoiding men” is placed on women who are expected to “find ways of getting away from men”. This restricts girls and women in such situations from full participation in public life.
The so called “unclean” women are not allowed to attend traditional ceremonies or functions. The practice humiliates girls and places barriers on what they can do. The argument that they will be unclean could not be backed by any evidence clearly relegating it to the realm of misinformation in essence making it unjust and discriminatory.
In the districts covered in the quantitative and qualitative study, it emerged that some faith- based organisations prohibit women and girls to worship during the time of their menstruation using the same argument that they will be unclean. Others even go further by stating that if menstruating women and girls are allowed in places of worship or have pastors laying their hands over them, their congregations will be weakened and even their “prophets” will lose their prophetic power.
“Here in Binga in some white garment churches, girls who are menstruating are not allowed to attend church service”. Non – Governmental Organisation in Binga 52 Formative Research on Menstrual Hygiene Management Final Report, December 2019
“The menstrual blood and materials should never be seen because its messy and dirty and may cause diseases. Also menstruating women should not go to places of worship as this weakens the congregation”. Apostolic influential Female Church Member Mt Darwin. About 17.5% of in-school girls highlighted restrictions with attending church and participating in church activities because they were considered unclean and likely to stop the work of the Holy Spirit. This was prevalent in rural areas (21.4%) than in urban areas (13.6%) with apostolic sect being the main drivers. There are some restrictions to attending social gatherings (beside church or cultural events) although not prevalent as 4.3% of girls face these restrictions. These include not allowed to go to mainly weddings, and funerals. Even when they attend, they are not allowed to cook, dance, or do other activities because they are unclean or might likely stain themselves which can be an embarrassing moment.
Further, because of this uncleanliness, some menstruating girls were not allowed to cook by their families. For example, 19.7% of girls highlighted restrictions to cooking by their families with the greater proportion being in rural (24.1%) than urban areas (15.3%) (Table 28). In situations where there will be no one to assist, the situation becomes very difficult for the women and girls.
“A girl child on her menses should not cook for her father for health purposes. This is because at times there is no soap.” Female Apostolic Woman Mount Darwin
From information collected around the country, restrictions and constrictions are not necessarily religiously influenced but also influenced by other social norms within societies. Further to the above mentioned, the girls also highlighted that they were also not allowed to water vegetables (they will dry up), enter the cattle kraal (will affect volume of milk), go in the field (groundnut shells will pop before time), should pick fruits (they will dry up while on the tree), etc. However, given that less than 2% of girls experience these restriction means they are not widespread. Formative Research on Menstrual Hygiene Management Final Report, December 2019 53
In all areas, there is a belief that menstruation-related “uncleanliness” is contagious. It was said that when someone comes into contact with a female who is menstruating, they also become unclean and would need cleansing. Such practices places stigma on a normal and natural process. It restricts women and girls’ ability to act to their full potential during menstruation period.
Beliefs on bewitching from menstrual blood makes the unavailability of appropriate disposal facilities for used sanitary wear a challenge. Yet, nothing or very little is done to assist women and girls in terms of making proper disposal facilities available. The fact that women are a minority in leadership and decision-making positions, both at household and community level, makes it difficult for MHM to be prioritised. Used sanitary wear is also supposed to be hidden as a way of preventing those with bad intentions from using Juju (witchcraft) or evil portions against the girls. This was a belief most prevalent in rural areas.
Menstruating women may in some areas and cultural settings be restricted from eating certain food. Fifteen percent of in-school girls had some diet restriction during menstruation (13.2% in urban areas and 16.8% in rural areas). According to the main restrictions were milk and other dairy products, egg and egg products, salty food, tea and cold food and liquids. The main reasons for restrictions on these foods were that they increased pain and the menstrual flow. There were other smaller and less frequently mentioned restrictions categorised as “Other” which include: not allowed to vegetables; beetroot; sweet food; cereals; liver; groundnuts; pork; some fruits; oily foods; toasted bread etc. In Binga, women and girls who are menstruating are prevented from eating mice12 during this period. The reason given was that if they eat mice, they would not be able to have children. No evidence was given to support the validity of the claims. Slaughtering of any animal while menstruating was prohibited as it is believed that this would contaminate the spirit of the deceased animal (unosvibisa denga remhuka iyoyo).
12 Mice are a protein delicacy in many rural communities in Zimbabwe. 54 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Table 11: Dietary Restrictions During Menstruation
Urban Rural Total N % n % n % Tea 16 9.30 7 3.15 23 5.84 Salt 9 5.23 26 11.71 35 8.88 Egg and Egg products 18 10.47 27 12.16 45 11.42 Milk 23 13.4 68 30.6 91 23.10 Cold food and liquids 14 8.14 9 4.05 23 5.84 Other 92 53.49 85 38.29 177 44.92
About 6.2% of girls reported facing some restriction related to bathing with 5.6% in urban areas and 6.7% in rural areas. Most mentioned restrictions were that girls menstruating should not bath in warm or hot water, should only concentrate on washing the bottom half of the body, and should not use soap. Other less mentioned restrictions include: one should bath only once as not doing so could lead to the person menstruating twice in the same month; one should not share bathing materials with others, etc. Prohibitions on bathing in rivers are also placed on menstruating women and girls. As a result, they are forced to seek alternative areas to take their bath during those days. Although the reason that is given to justify the practice is that they will be unclean, several other entities are allowed to use the river, for example, animals and whether domestic or otherwise. The sanctity of blood seems to drive this prohibition.
Similarly, in all districts where the qualitative study was conducted it was reported that sex during menstruation is prohibited. Although there is no scientific evidence that having sex during menstruation is harmful, it is presented as something that is harmful to both the female and the male.
Arguably, these constrictions and restrictions can be linked to male dominance and the unequal gender relations between men and women. Although it is women themselves who monitor and impose these strictures and inculcate such beliefs and fears in girls. When girls were asked who passes the information on do’s and don’t’s to them, the aunt (30.7%) and mother (63.2%) were the main imposers of the restrictions (See Table 26, Annex 2). Fathers were mentioned by only 0.99% of the girls. Aunties (23.6%) and mothers (62.0%) were the main enforcers of these restrictions (See Table 26, Annex 2).
3.3.2 Involvement of man and boys in MHM In most of the areas covered by the study, MHM is considered a “female affair” thus excluding men in the discussions on MHM yet restrictions and constrictions discussed above have their root in gender relations and the unequal power men have over women. Resultantly, efforts to improve MHM are undermined. For example, as discussed earlier, male teachers view discussing menstruation a female teacher responsibility and therefore put less priority Formative Research on Menstrual Hygiene Management Final Report, December 2019 55
to the subject. Hence, in some schools visited, there were calls for the capacitation of male teachers to enable them to assist with MHM issues.
Because of their control of household financial resources, required for purchase of sanitary wear and supplies to ameliorate the effects of menstruation, male engagement was highlighted in focus group discussions and key informant interviews as very important. If fathers or male caregivers understand MHM they are likely to provide resources that enable girls to access hygiene kits.
Engagement of boys in menstruation is equally important as a way of creating a stigma-free and supportive environment for girls. For example, when girls were asked how boys treated them during menstruation, 73.5% highlighted some form of negative experience as follows:
●● 15.1% of girls are humiliated by boys; ●● 6.7% are given nicknames; ●● 40.9% are laughed at; ●● 7.3% are isolated; and ●● 2.2% are solicited for love or sex.
About 1.3% of girls say they have been abused when they were menstruating.
It was argued that boys would be more supportive of their female counterparts, in case one of them “spoils” her dress, if they have a better understanding of menstruation as noted by 9.8% of girls. However, in the majority of cases, it was discovered that when girls are being engaged on MHM, whether in school or other venues, boys are asked to leave thus limiting their access to knowledge on MHM.
3.3.3 What benefits do those traditions, beliefs, restrictions and constrictions, serve? Some communities were of the opinion that the imposed restrictions should be retained as they preserve “Hunhu or Ubuntu” (discipline and identification). The respondents holding these views were mainly traditional and religious leaders who did not seem to put much importance on the rights of women and girls. Many stakeholders (including teachers), felt that there were no serious restrictions and constrictions around MHM within the school which concurs with the findings above as most constrictions and restrictions are home and community bound. As noted earlier, restrictions to cooking, and bathing in rivers, and beliefs such as risk of being bewitched if menstrual blood is seen by others etc, are intended to enhance hygiene during menstruation around the home and the community however this is sometimes at the expense of the girls’ comfort and personal hygiene.
3.3.4 Creating positive social norms Provision of accurate information on MHM is important to dispel myths and misconceptions within communities in order to promote positive thinking, practices and behaviours. According to many of the stakeholders, girls as well all sources of information need to know the facts: 56 Formative Research on Menstrual Hygiene Management Final Report, December 2019
“No one really benefits from restrictions and constrictions but all they do is to continue to perpetuate the oppression of women” NGO Staff Member
One of the biggest menstruation-related challenges girls faced is the demeaning and humiliating behavior of boys to girls. Reports of this happening was very common (see Section 4.7.2.4 for scale of the challenge). Exceptions were: (1) schools with strong programmes addressing menstruation which included boys and girls (15%) and (2) schools where reports of jeering and chiding girls about menstruation was a punishable offence (3%).
Despite the restrictions and constrictions imposed on girls during menstruation, majority do receive support from their families. About 51.5% of girls in rural areas and 45.1% in urban areas receive support through less work while 16.9% and 20.0% in urban areas are offered painkillers. Outside the home, girls receive little to no support during menstruation with communities reinforcing restrictions and prohibitions. At least 45.0% of girls in urban areas and 40.6% in rural areas do not receive any support from the school during menstruation (see further discussion in Section 4.5).
3.4 Facilities to Support MHM The WASH aspects of the study involved in-depth interviews and discussions about Water, Sanitation and Hygiene issues in relation to MHM. The results of the qualitative research in the four districts are presented together with summaries of the quantitative nationwide data collection from the surveys administered in schools and from the observations carried out by enumerators. Formative Research on Menstrual Hygiene Management Final Report, December 2019 57
3.4.1 Appropriateness of facilities One persistent problem that besets menstruating girls is a need for suitable, accessible and hygienic WASH facilities to be available within the school environment and public spaces. In the section below, the results of the observation on WASH issues across the districts where the qualitative study was held are presented.
Figure 8: Number Of Schools By Type Of Toilet
25 22 20 20 Urban 15 Rural 10 4 4 5 3 2 1 1 0 % Flush/pour flush Pit latrine with Pit latrine without Ventilated improved slab slab/open pit pit latrine
Sanitary ware disposal bin in urban latrine
All 4913 schools observed in the study had toilets exclusively for girls, for boys and for teachers. Of the 24 urban schools, 22 had flush/pour flush toilets; four with ventilated Improved Pit Latrine; two had pit latrine with slab and one had a pit latrine without slab/ open pit. In the 25 rural schools, 20 had pit latrines with a slab, four had Ventilated Improved Pit Latrines, three had flush/pour flush toilets, and one a pit latrine without a slab/open pit (Figure 8).
13 While a total of 50 cases were observed one case was dropped due to poor quality data after review. 58 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Toilets at 20 of the 24 urban schools were clearly marked while only 14 of the 25 rural schools were clearly marked. Seven schools in urban areas had 11-20 functional toilet compartments while 17 had more than 20. In rural areas, three schools had 10 or less functional toilet compartments; 11 had 11-20 while another 11 had more than 20. Students visit toilet facilities individually, except for two urban schools and one rural school that had a group arrangement with lines observed during the visits. From observations, girls do not visit toilet facilities with backpacks. Only two schools in urban areas and three in rural areas noted that girls carry their backpacks to the toilet. Most rural and urban schools do not have lockable toilet compartments, no containers for disposing napkins, no supplies for cleaning after toilet use and are not accessible to girls with disabilities. However, those schools using pit latrines may not necessarily need to have containers for napkin disposal as they are thrown into the pit. Table 29, Annex 2 presents additional observations done on the toilets.
Figure 9: Availability Of Water And Soap By Rural/ Urban Location Of School
80 70.3 70 61.4 60
50
40
30 Urban 15 25 22.6 Rural 20 13.7 7.1 10
0 % water only water and soap nothing
Most schools do not have a separate changing room for girls to change sanitary materials as noted by 77% of girls from both rural and urban schools. A further assessment of the availability of water and soap in the toilet/washroom in urban schools showed that 61.4% have water only, 25% water and soap and 13.7% with neither “water only” nor “water and soap”. The scenario is reversed in rural areas where 22.6% have water only, 7.1% have water and soap while 70.3% have neither water nor water and soap (Figure 9). Formative Research on Menstrual Hygiene Management Final Report, December 2019 59
Disposable menstrual hygiene materials are mainly used as indicated by 96.3% of in-school girls in urban areas and 89.8% in rural areas. About 3.7% and 10.3% were using re-usable materials. At the time of the study, most of the schools visited did not have overflowing or full waste pits/composting chambers/septic tanks (17 of 24 urban schools; and 17 of 25 rural schools) as presented in Table 30, Annex 2.
Cleaning of the school sanitation and hygiene facilities for urban school is done by either the caretaker or support staff hired by the school. However, for rural schools cleaning is mostly done by learners.
Washing area, girls’ toilet in an urban secondary school in Kwekwe
3.4.1.1 Challenges faced in ensuring standard hygiene practices in schools Teachers in charge of health face challenges in ensuring standard hygiene practices in schools. These are centred on maintenance of facilities rather than the availability of facilities. For schools located in urban centres, challenges include improper disposal of sanitary towels, dysfunctional flush toilet system and lack or insufficient cleaning materials. In rural areas, the major challenge is the unavailability of water due to distance to water source as well as lack of cleaning materials. Table 12 summarises the challenges by rural and urban areas.
Table 12: Challenges Do You Face In Ensuring Standard Hygiene Practices In Schools 60 Formative Research on Menstrual Hygiene Management Final Report, December 2019
District What challenges do you face in ensuring Total Mt standard hygiene practices in schools Marondera Binga Gokwe Kwekwe Darwin Improper sanitary disposal by girls 0 0 1 0 1 2 Non-functional flash systems 1 0 1 0 0 2 Distance to water source 0 2 0 2 0 4
Lack of cleaning materials and 2 2 0 0 0 4 detergents None 0 0 1 2 1 4 Total 3 4 3 4 2 16
School Heads identified three major causes of the challenges contributing to schools’ failure to adhere to set standard hygiene practices as per guidelines in schools: (1) lack of finances due to parents not paying their levies; (2) insufficient ablution facilities; and (3) insufficient water and shared borehole facilities with the community. Table 32, Annex 2, outlines the response by location whether rural or urban.
Table 13: Entity Responsible For Operation, Maintenance And Repair Of The School Sanitation And Hygiene Facilities
Ward Ministry of Local Government and School Total Public Works
Urban 2 5 7 Rural 0 8 8 Total 3 13 16
The responsibility of operation, maintenance and repair of school sanitation and hygiene facilities lies mostly with school. In rural schools, the responsibility lies 100% with the school, while for urban schools it also lies with the Ministry of Local Government and Public Works as indicated by the three respondents, see Table 13. Some of the challenges associated with maintenance of sanitation and hygiene facilities, are poor responsiveness by relevant authorities as well as lack of finance.
3.4.2 Access to clean safe water for MHM Clean and safe water is a critical requirement for appropriate MHM. This section details findings on access to clean and safe water in schools. Formative Research on Menstrual Hygiene Management Final Report, December 2019 61
3.4.2.1 Access to clean and safe water in school
Table 14: Main Water Source By Rural /Urban Location
Main source of water Urban Rural N=24* N=25* 1. Piped water into school building 12 4 2. Piped water into schoolyard/ plot 11 2 3. Public tap/ standpipe 3 5 4. Tube well / borehole 5 19 5. Protected dug well 1 2 6. Bottled water 0 3 7. No water available in/near school 1 2 8. Other 1 3
*Number of schools does not tally with N because some schools used more than one source of water At the wider national level, eighty-one percent of girls from urban schools 75% from rural schools indicated that they have a reliable source of water at school. Of the 49 schools that were observed, 24 are urban and 25 in rural areas14. Most schools in urban areas indicated that their main source of water was piped water into school building (12 schools); piped water into school yard (11 schools); tube well/borehole (5 schools) see Table 14. Of the 25 rural schools, 19 use tube well/borehole; five use public tape/standpipe, while four have piped water into the school building.
Boreholes are the main sources of water for the sampled schools in Mashonaland East and Midlands. All the respondents from Mashonaland East indicated that they rely on borehole water, while in Midlands all four schools had a combination of borehole and local council water and only one school sources water from a well. Midlands’ tap water is also readily available and is said to be of good quality.
Respondents from sampled urban schools in Binga district indicated that they largely rely on water from the local council tapped water. Of the rural school in the district, one school collects water from a spring which is very reliable and as it is always available. Table 33, Annex 2, summarises survey responses by district.
In schools without own water sources, collection of water is mostly done by students, especially in the rural areas as indicated by nine out of 16 respondents. Four respondents indicated this is done by the caretaker or support staff hired by the school see Table 34, Annex 2. Having students collect water may reduce their learning time, or be strenuous to them.
Water for MHM for both female facilitators and learners is generally adequate as evidenced by the majority of respondents (10 school health teachers from 5 primary and 5 secondary
14 Data from one school was discarded due to inconsistencies in the data. 62 Formative Research on Menstrual Hygiene Management Final Report, December 2019
schools). Four respondents from secondary school and two from primary school indicated that their schools do not have adequate water for MHM purposes. The study assessed if the main water sources were functional or not. Most schools in both rural and urban areas had functional water sources (18 of 24 urban schools; and 21 of 25 rural schools). To ensure availability of water at the schools at all times, 12 schools in urban and 19 in rural areas have drinking water storage containers. Most of the schools in both urban and rural areas have between 1-4 drinking water storage containers, with a few having more than four. At the time of the survey, 9 of the 12 urban schools had water in the containers, likewise seven of the nine rural schools. All water containers at schools in urban areas were properly covered while two of the nine rural schools were not (Table 35, Annex 2).
Challenges faced in ensuring the availability of clean safe water in school: Responses from the school health teachers indicate that the main challenges affecting the availability of water in schools are associated with the school’s location, rural or urban area, as well as geographical conditions. Rural school respondents cited lack of (i) electricity, (ii) own source and (iii) borehole drying up. Whereas in urban centres, it is mostly power cuts. Five respondents cited no challenges.
Three rural based schools heads, drawn from two secondary and one primary school, indicated lack of own water source as their main challenge to the availability of clean safe water in their schools. One primary school head (rural) and one secondary school head (urban) cited power cuts as their main challenge. Lack of finances to timeously fix broken down boreholes is also another challenge.
3.4.3 WASH in public spaces
Table 15: Distribution Of Public Spaces Observed By Province
Province Public Spaces N=49 Percent Manicaland 7 14.3 Mashonaland Central 5 10.2 Mashonaland East 6 12.2 Mashonaland West 4 8.2 Matabeleland North 6 12.2 Matabeleland South 4 8.2 Midlands 5 10.2 Masvingo 3 6.1 Harare 4 8.2 Bulawayo 4 8.2
Forty-nine public spaces15 from the ten provinces were observed by assessing availability and source of water, toilet facilities, washrooms and availability of both water and soap in the facilities. The distribution is presented in Table 15. Of these public spaces 79.6% were shopping centres, 16.3% market places and 4.1% being bus ranks.
15These included shopping centres, market places and bus terminus. Formative Research on Menstrual Hygiene Management Final Report, December 2019 63
Of the 49 public spaces, 44 (89.8%) had toilets/latrines and five (10.2%) did not have. Seventeen (38.6%) had toilets with 1-5 compartments, twelve (27.3%) ranged from 6 to 10 compartments, and 15 (34.1%) had more than ten. Nineteen public places had toilets with urinals for boys/men. Further observations of sanitary facilities are presented in Table 31, Annex 2.
The study also observed waste disposal and drainage system at the public places. All 49 public places observed did not have an incinerator for burning used sanitary materials. Of the 49 public spaces observed, only six had a drainage system for removing waste water from its grounds, four had a partial or incomplete drainage system, while 39 did not have.
Only 12 (24.5%) of the 49 public places had hand-washing facilities. Of the 12 public places with hand-washing facilities, four had running water from a piped system or tank (faucet & sink/stand post /rainwater tank & faucet/bucket & spigot); one had a hand-poured water system (e.g., bucket or ladle); three had basin/ bucket (handwashing done in the water and is not running or poured); one had bottles of water; and four used other methods. At the time of the visit, four public places had water available for handwashing in all facilities; three places had in more than 50% of the facilities; with no water available in the remaining five public places. Only two of the 12 public places with water available for hand washing, had soap at the hand-washing basin. Accessibility of the hand-washing facilities and the soap or ash was restricted for girls with disabilities and for children.
3.5 Services Available to Women and Girls on MHM in the Communities or Supportive Institutions More than half of the girls in school in urban (54.6%) and rural areas (59.5%) had received support from school during their menstrual period. However, the number of those not receiving support is of concern 45.5% in urban and 40.65% in rural schools (Figure 10). 64 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Figure 10: Percentage Of Girls Receiving School Support During Menstrual Period
120
100
80 45.4 40.6 60 No 40 54.6 59.5 Yes 20
0 % Urban Rural
On assessing who provides the support at school, girls from schools in urban indicated the following sources: female friends (53.1%); senior woman teachers (35.9%); class teachers (9.7%); and school health teacher (7.9%). Asked who they are comfortable with to support them, girls from schools in urban areas noted the female friends, followed by senior woman teacher, and the school teacher. Girls from schools in rural areas noted that support was mainly received from senior woman teacher (49%); female friends (29.6%); school health teacher (16%) and matron (10.9%). The support received in both settings included sanitary materials, counselling and advice, protection from humiliation and educational materials. Some schools have an arrangement for girls to access sanitary materials in case of an emergency while at school. In urban areas, 66.9% of in-school girls confirmed that they received emergency support of sanitary materials and 55% of the girls in rural areas.
Most of the schools visited by the qualitative team had emergency sanitary wear provisions. The provisions were usually kept by the school health master or the senior woman teacher. One school head reported that the senior lady can request funds to purchase pads for any emergency. While other schools reported stocking donor-funded emergency pads.
“Emergencies are handled by the School Health teacher. They do their best to assist the child before sending her back home, giving her pads if available.” School head in rural Mt Darwin
Pain Management Schools were supportive of learners experiencing pain during menstruation. Most schools would provide pain killers if available. If pain was severe the child would be sent home for parents to continue management.
“The children who have a lot of pain receive painkillers except those with faith that shuns medication.” School head in rural Marondera Support was reportedly through the School Health teacher or Senior Woman teacher. Formative Research on Menstrual Hygiene Management Final Report, December 2019 65
The Ministry of Education Survey (2012), highlighted that out of the 212 schools, medication for period pains was offered in only 24% (48) of the schools. In this study only 28.7% and 18.5% of girls in urban and rural schools respectively receive pain killers from their schools. Therefore in general, most schools are unable to provide pain killers for those who experience dysmenorrhea resulting in some girls choosing to absent themselves from school to avoid loss of self-esteem, discomforts and stigma from schoolmates (Ndhlovu E. and Bhala E, 2016).
4.5.1 Perceptions of stakeholders - interviews with key personnel Stakeholders, including from government ministries, civil society as well as community gatekeepers were probed to identify their perceptions on support required for MHM. The stakeholders expressed a general lack of adequate information and support to address menstruation-related issues in both urban and rural schools. There were calls for provision of emergency sanitary materials in schools with differing views on how this support could be rendered best as shown by the following suggestions proffered:
●● Funds for purchasing emergency pads should come from fees while others felt that fees were already high, and this provision would mean increasing the financial burden for parents. ●● Government should provide the sanitary wear “if government can provide free condoms for people who choose to be unfaithful it should surely provide free pads for the girl child and this natural process.” Government official. ●● Government should fund supply of sanitary materials and schools procure pads from a central government store just as is done with medicines. ●● Pads should be provided in all schools for emergency, “how it’s going to be done I do not know.” Influential female leader.
It was also felt that pain relief tablets should be available and given to students as need arises and that toilets must have privacy and readily available water supply and bathrooms.
There were strong views that if the country was going to succeed in supporting MHM then it should consider supporting 2-3 independent, locally based, accredited and major manufacturing and distribution companies to set up and produce quality and affordable sanitary materials. It was felt that supporting one company would produce monopolistic tendencies, affecting pricing as the company grows and inevitably creates own subsidiaries to become an Oligarchy.
Key informants from the NGO sector were of the opinion that production of reusable pads should also be part of the mix of sanitary ware available on the market, produced at a similar scale to disposable sanitary ware. Accompanying supportive mechanisms are required to guarantee their safety, acceptability, and user friendliness.
Some government sector ministries important in MHM such as; the Ministry of Women’s Affairs, expressed that they were not involved in MHM as the issue was not in their portfolio or reflected in the ministry’s priorities. MHM is not explicit in the Gender Policy, or implementation plan. Information on programmes and related issues on MHM is obtained through interacting with other stakeholders. 66 Formative Research on Menstrual Hygiene Management Final Report, December 2019
“The Ministry of Women’s Affairs should change policy and let us get involved in MHM. We know the needs. Some girls miss school because of menstruation. Some kids do not even have pants”, Ministry of Women’s Affairs
There was another strong call for mothers to get involved in MHM issues of their children at home and buy enough sanitary wear for the children. Many stakeholders expressed that role of education was being left to the teachers who should complement or reinforce the teaching of the parents.
Table 16 provides a summary of stakeholder perceptions regarding MHM gathered through key informant interviews. Formative Research on Menstrual Hygiene Management Final Report, December 2019 67
Table 16: Summary of stakeholder perceptions on MHM
Stakeholder Perceptions
Clinic Nurses The following perception were expressed by clinic nurses: ●● Schools must effectively provide MHM support, however that cannot be adequately provided by clinic nurses “…There must be partners to supply MHM education and resources” ●● Advocate for school health policies that make it possible for sanitary materials to be provided for free in schools ●● It should be mandatory for all schools to have a functional incinerator ●● Teachers need to be trained on menstrual hygiene ●● Information education materials should be made available
Community Community Health Nurses interviewed perceived that: Nurses ●● Community health programming should cover MHM for in and out of school girls ●● MHM generally lacked resources to support education of learners in and out of school ●● Generally very difficult to reach girls out of school for any programmes ●● Open discussion on menstruation should be encouraged among both boys and girls ●● Step up education in and out of school ●● While schools need to stock pain killers there are fears of abuse of medicines by teachers in schools Providers of MHM at district level not always coordinated
School Heads The school Heads generally had the following perceptions: ●● Most mothers, aunties and grandmothers do not provide comprehensive MHM education and sanitary materials including pain killers ●● Religious leaders have no capacity to teach MHM ●● Water provision is generally poor and needs to improve ●● There are no programmes on MHM targeting out of school girls ●● The community, everyone in the family including the father, needs to have MHM information ●● Schools should make it a policy to buy sanitary materials for emergencies. The School Development committees (SDC) are key in supporting such initiatives ●● Ministry of Health and Child Care should be available to support MHM education Staff capacitation in such issues critical ●● Clear cut policies are necessary so that the implementer can religiously follow ●● Prices of pads are high compared to pens which cost just a dollar but you find parents not managing to buy a pen for 1$ let alone a pad. 68 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Education Officials The was a general perception among the education officials that: ●● MHM would be taught separately for boys and girls ●● Mothers are the primary and major source of information on MHM ●● Government should provide experts to equip teachers with adequate training on MHM ●● Government to ensure sanitary materials are available and affordable
Civil Society/ ●● MHM is taught to girls when it should include both NGOs ●● Resources are inadequate to cover all schools ●● Teachers have limited capacity to address MHM
Women’s Affairs ●● The was a perception that policy guidelines for the Ministry requires review so that the officers can participate fully in MHM ●● The community requires adequate information to be able to articulate MHM fully
Religious Leader ●● Religious leaders have no capacity to teach MHM ●● Women pastors are the ones to address MHM in church gatherings ●● Only experts should go into schools and support MHM
Any measures put in place in the school environment and public places in order to enhance WASH and MHM will need to be actively supported by appropriate emphasis on these issues in the classroom and by communities. This observation leads directly to the findings in the qualitative study on the constrictions and restrictions that girls and women experience in relation to sexual maturation and in this study the ostracism and exclusion in both private and public aspects of life. Ostracism and exclusion that is in “direct conflict” with the linkage between menstruation and females’ essential role in the reproduction of the human species. Below the study discusses the findings obtained on this issue.
3.6 Access, Acceptability and Disposal of Sanitary Materials Knowledge, information and education about MHM for girls and women, wherever they are situated, requires support in the form of adequate resources, materials and facilities to ensure that menstruation is as minimally disruptive in female lives as possible.
3.6.1 Materials and perceived safety of materials This section details the sanitary materials commonly used by girls during menstruation including their quality and safety. Formative Research on Menstrual Hygiene Management Final Report, December 2019 69
3.6.1.1 Available sanitary materials The study noted that access to adequate sanitary materials was dependent on several factors including types, effectiveness, availability, ease of access, safety, acceptability and cost.
Types of sanitary Materials available: Both in the quantitative and qualitative study, disposable pads emerged to be the most commonly used sanitary material while pieces of cloth, cotton wool, tissue paper and reusable pads were also used given availability and cost or as an alternative in case of preferred pads not being available. Tampons were not used, and menstrual cups were not mentioned in the discussions, with girls indicating they were not aware of their existence. In urban areas, 94.7% of in-school girls use disposable sanitary pads and 85.0% in rural areas (Figure 11).
Figure 11: Types Of Sanitary Materials Used By In - School Girls
100 94.7 85 80
60 Urban 40 Rural 20 3.3 11.7 1.3 1.2 0.6 1.7 0.1 0.4 0 % Cloth/ Towel Disposable Re-usable Cotton wool Other pad pad 70 Formative Research on Menstrual Hygiene Management Final Report, December 2019
“The senior lady raises a requisition to the Admin for funds to procure the pads or the pads will be provided by the admin. Procurement is done using the school” School Head
“We do have some dresses [to use as emergency uniform when a girl soils her uniform] that were donated by some well-wishers and old school choir uniforms that can be used. The school keeps just a few pads for emergencies, they are procured using sport funds” School Head
“The school makes an effort to provide the pads for emergency. The ones that can be available are for CAMFED sponsored children only” School Head
“Like I said we refer them to them to the School Health Master and they send her back home. We don’t have any sanitary materials for emergency”. School Head
“The learner is given pads and if the situation is tense she is sent home.” School head
“The school has sanitary material which was donated which can last the school for 3 coming years. So, the child is given the material by the senior teacher”. School Head
3.6.1.2 Sources of sanitary materials
Table 17: Provider Of Sanitary Materials By Area Provider Of Sanitary Materials By Area
Urban Rural (N=1,318) Provider of Money/Sanitary (N =1,302) Materials Number Percent Number Percent Myself 11 1.6 18 2.6 Mother 574 82.0 514 74.2 Father 76 10.9 58 8.4 Sister 44 6.3 49 7.1 Friend 0 0 3 0.4 Senior woman teacher 0 0 2 0.3 Traditional Midwives 0 0 0 0 Community Health care 0 0 2 0.3 providers 9 1.3 16 2.3 NGO 72 10.3 77 11.1 Relative 20 2.9 30 4.3 Other
The main source of sanitary materials or provider of resources to buy sanitary materials was the mother in both urban (82.0%) and rural (74.2%) areas. Other providers of sanitary materials highlighted in both urban and rural areas are the father, sister and other relatives (See Table 17) who are all part of the extended family. Formative Research on Menstrual Hygiene Management Final Report, December 2019 71
Table 18: Source Of Sanitary Materials By Outlets
Source of Sanitary Urban Rural Materials N=1,302 Percent N=1,318 Percent Market 44 6.3 19 2.7 Shop 284 40.6 384 55.4 Supermarket 428 61.1 209 30.2 Tuckshop 78 11.1 28 4.0 Clinic 1 0.1 2 0.3 Home 17 2.4 79 11.4 School 1 0.1 11 1.6 Bush 0 0 0 0 Don’t Know 24 3.4 30 4.3 Other sources 41 5.9 46 6.6
Girls in urban areas noted that the source of sanitary materials is mainly from the supermarket (61/1%), shop (40.6%) and tuckshop (11.1%)16. The sources of sanitary materials in rural areas are the shop (55.4%), supermarket (30.2%) and home (11.4%) as presented Table 18.
Shopkeepers consulted stocked pads dependent on the movement of product type on the shelf as well as availability and cost considerations. The higher priced brands of pads were not available in small and rural shops. There were remote area shops in Binga that reported not stocking pads at all because they were slow moving and those that required them had to purchase from town, some 60 kilometres away. In institutions, both disposable and reusable pads are provided by sponsors and well-wishers and in some shortages sometimes occur. Following acceptability studies, the menstrual cup had limited availability with one NGO in Harare reporting having ordered stocks of the menstrual cup and awaited training from suppliers to be able to distribute.
16In Zimbabwe, a supermarket is a large merchandise outlet where shoppers pick their own merchandise, whereas in a shop, all merchandise are behind the counter and the shopper has to engage a shopkeeper to serve them. A tuckshop is a smaller version of a shop which sells few basic and snacking commodities in a community or neigborhood 72 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Figure 12: Samples Of Reusable Pads
“Pads, cotton wool, rags/cloth. These materials are used to trap blood, these products are accessible for those who use pads they buy them from shops and those who use rags just use any cut off from their old clothes. We don’t know much about the reusable pads costs.” Traditional leader
There were reports of women having been taught to make their own reusable pads and Figure 12 shows samples of locally produced reusable pad kits available. Some had instructions attached and were said to last 3-4 year with good care.
In Binga, there were also reports of reusable sanitary pads being made in Youth centres and in schools. There were initiatives where school girls are asked to bring money and put it together for purchase of sanitary wear in bulk and then share amongst those who would have contributed.
There were shops in Binga and Gokwe that reported having run out of pads. Girls interviewed reported desire to use pads but opt for old cloth if they have no money to buy pads. Cloths and reusable pads were difficult to use because of lack of water. Cotton wool is expensive. Some schools have bins and plastic bags to put in the used sanitary pads.
Another related problem faced by girls in schools is the unavailability of emergency menstrual materials. The problem cut across rural and urban schools. Where they are said to be available at school, they are often inadequate, in numbers and quality.
3.6.1.3 Manufacturing of sanitary materials The study found that manufacturing of sanitary wear was very limited and affected the supply of affordable products on the market as only two major suppliers were in the market with both having reduced distribution at the time of the survey. According to interviews with a supplier of sanitary ware most of the sanitary materials on the shelves (estimated at + 80% according to a recent market survey by a marketing manager) were imported from mostly Asia countries and South Africa. While the exemption of duty on import duty was a welcome Formative Research on Menstrual Hygiene Management Final Report, December 2019 73
development and only started operating in 2018, some companies had already stopped importing because of high import costs. The importation was also affected by the inspection required before importation which some exporting countries do not understand. This makes the process slow and cumbersome, affecting business viability according to some companies. The Standards Association of Zimbabwe, which is not however a governing body, reported that there were no standards governing local manufacture and quality control of sanitary materials and any tests made were on a voluntary basis. The Medicines Control Authority of Zimbabwe, in charge of monitoring quality of medicines, medical equipment and other related materials, did not have sanitary pads on their list of monitored products. Thus, there are no quality standards for sanitary wear and a system for monitoring quality of sanitary wear on the market in Zimbabwe.
“We went to check for standards of sanitary wear but were told there were none.” Distributor of sanitary wear.
3.6.1.4 Effectiveness of sanitary materials In FDGs, most girls said that their preferred sanitary materials were commercially produced pads. They also indicated that there were brands that were considered less effective because of quality and likelihood of leaking. Girls also considered size of pad and shape of the wings of the pads and their ability to keep stable should they be doing activities such as sports. Cloth was considered not only humiliating but linked to challenges such as likelihood to leak, discomfort, cause of rash, difficulty in removal of blood stains and associated challenges with washing and drying in privacy.
Overall, the sanitary materials used have been described by in-school girls as effective (58.7% in urban areas and 52% in rural areas) or very effective (32.4% and 36.4%, respectively) with very few girls describing them as ineffective (Figure 13 and Figure 14).
Figure 13: Effectiveness Of Figure 14: Effectiveness Of Sanitary Material Urban Sanitary Material Rural
3.9% 5% Urban 7.5% Rural 4.2% Very Very effective effective 32.4% 58.7% Effective Effective 36.4% 52%
Neither Neither
A further assessment of the data on effectiveness by the type of sanitary material shows that disposable sanitary pads (59.4%) and re-usable sanitary pads (58.8%) were described as very effective while cotton wool was deemed effective (50%) with most of those using cloth/ towel saying it was ineffective (35.6%) as presented in Table 19. 74 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Table 19: Types Of Sanitary Materials Used By In School Girls
Type of Effective of sanitary materials sanitary Very Effective Neither Ineffective Not material effective effective effective at Total nor all ineffective Cloth/ towel 13(12.5) 32(30.8) 14(13.5) 37(35.6) 8(7.7) 104(100.0) Disposable 743(59.4) 436(34.8) 36(2.9) 36(2.9) 1(0.1) 1252(100.0) sanitary pads Re-usable 10(58.8) 3(17.7) 2(11.8) 2(11.8) 0 17 sanitary pads Cotton wool 5(31.3) 8(50.0) 3(18.8) 0 0 16 Other natural 0 0 1(25.0) 0 3(75.0) 4(100.0) materials Total 771(55.4) 479(34.4) 56(4.0) 75(5.4) 12(0.9) 1,393(100.0)
Ninety-one percent and 81.8% of in-school girls in urban and rural areas did not experience any side effects from the sanitary materials used. The girls that experienced side effects highlighted them as rash (3.6% urban; 6.4% rural); itchiness (3.9% urban and 7.5% in rural areas); skin darkening (2.3% in urban areas and 7.1% in rural areas and other (0.9% urban and 3.5% rural). The main challenges with sanitary materials were the cost, availability, appropriateness, some not easy to use and disposal.
3.6.1.5 Quality of sanitary materials The study found that across all areas, women and girls buy pads that are relatively cheap and take into consideration issues of quality, reliability, comfort and ability to absorb menstrual flow. However, in the harsh economic environment in Zimbabwe, they said they are usually forced to buy what they can afford. Selected representative comments on this are given below:
“These days people don’t really care about quality. They are more concerned about the price and the number of pads inside the packet”. Shopkeeper, High Density Suburb
“Some ask and do not buy. When the women come to buy these things don’t forget they also come for other things”. Shopkeeper
“They look at the quality some have a thin lining and do not absorb a lot of blood (they get fully soaked quickly”. Shopkeeper
“Pads with wings that are more stable and can wrap around pant were preferred”. Ministry of Women’s Affairs Officer Formative Research on Menstrual Hygiene Management Final Report, December 2019 75
“Quality for example these pads that I have here, older ladies will buy these for $6 as they are thicker than the other ones”. Shopkeeper
Not all users have the capacity to choose the form of menstrual material they would wish to use, for example in institutions, such as children’s homes and centres for the disabled, girls used whatever was provided for by well-wishers or by parents.
3.6.1.6 Safety of sanitary materials The study revealed mixed feelings about the sanitary materials available for use. The disposable sanitary pads, being the most preferred, were considered hygienic and safe as they were packaged. Re-usable pads were considered unsafe because of the challenges of availability of water to wash, dry and iron them properly. However, there were many who felt it was a better alternative for those who could not buy pads and are forced to use old cloth. The used cloths were purportedly uncomfortable and caused rash. In Binga, there was confirmation of girls reporting to clinics for treatment of urinary tract infection. The clinic sisters linked this to poor menstrual hygiene and use of menstrual cloth
3.6.2 Acceptability of sanitary materials The study also explored the acceptability of sanitary materials with most girls citing disposable sanitary pads as the most appropriate. In discussions, a few girls preferred reusable pads indicating they were cost effective and comfortable. A large Zimbabwean company used to supply sanitary materials, including tampons and found that tampons were slow moving due to cost and acceptability and the company decided to abandon that aspect of its business.
According to a sanitary wear marketing manager, “Menstrual cups are cost effective but aggressive marketing and education is required to get it accepted […] more like what happened with the condom promotion” Sanitary ware marketing manager
These remarks are consistent with studies conducted by Phillips-Howard, P. et al 2015 that revealed that the menstrual cup was a potential cost-effective alternative to pads as it reportedly lasts for approximately 8-10 years. A study by Madziyire et al 2018 on the acceptability of using a reusable menstrual cup in a Harare suburb of Epworth in Zimbabwe revealed similar acceptance. In the discussions with girls, there was little mention of menstrual cups with many not aware of them and sceptical that the sanitary device is inserted rather than worn. 76 Formative Research on Menstrual Hygiene Management Final Report, December 2019
3.6.3 Affordability of sanitary materials At time of study, the cost of sanitary materials was considered expensive with this remark given by personnel at the Ministry of Women’s affairs:
“Parents can’t afford sanitary materials and children miss school. Sometimes they use tissue. Even me I can’t afford what more the child.” Ministry of Women’s Affairs Officer
Prices of sanitary pads sampled was between 6-12 Zimbabwe dollars, at that time, equivalent of 1.50 to 2 USD average price17.
Cotton wool was considered generally more expensive than pads. Asked on why cotton would be expensive, a sanitary ware distributor marketing manager reported that there were only 2-3 distributors of cotton wool in the country and they subcontract manufacturing of cotton wool. The se distributors have been affected by low production of cotton in the country as well as import of raw materials and chemicals used to produce, clean and sterilise the cotton. Foreign currency availability was a challenge.
“I do not think they are overpricing locally produced goods. The pricing seems to be justified’’. Sanitary ware marketing manager
The other sanitary materials such as menstrual cups, tampons were available through NGOs, pharmacies and other specific private sector outlets. The prices were however prohibitive for wide use.
3.6.4 Disposal of used sanitary materials The study found that disposal of used sanitary materials was dependent on the type of sanitary facilities and presence or absence of incinerators. Girls disposed sanitary pads in pit latrines in rural schools (78% of girls) and bins in urban schools (53.6%). In urban areas, 12% take the used sanitary pad home for disposal compared to 1.3% in rural areas (See Table 20). Such girls indicated that they did not dispose of their pads at school for fear others would see their menstrual blood and bewitch them. In Kwekwe urban, a reason given
17Escalation in the exchange rate means that this Zimbabwe dollar price (ZWL) is constantly increasing but salaries are not keeping pace, exacerbating, no doubt, problems with obtaining MHM materials. Formative Research on Menstrual Hygiene Management Final Report, December 2019 77
for carrying used material home was that all general workers in the school were males and could not be expected to clean the girl’s blood (i.e. taking the rubbish bins away for burning). One class teacher in Mt Darwin said:
“sometimes pupils are shy here at school and on the way, they just throw away along the road, which spoils the environment. To discourage this kind of disposal, they are warned of “concoct”- mix that [takes place through 18] witchcraft when their blood will be taken and can be bewitched.” Mt Darwin, Class Teacher
One respondent indicated that girls take used towels home for disposal as the school has no female teacher to assist in their disposal. In urban schools, they are put in metal or plastic bins in female toilets and the sanitary materials are later incinerated or taken to dump sites. Some respondents did not know how the school is disposing of the used sanitary materials. Table 20 provides a summary of methods of sanitary material disposal.
Table 20: Methods Of Disposal Of Sanitary Material
Common disposal Less common Common disposal Less common method urban disposal method in method rural disposal method schools urban schools schools/rural homes rural homes
Incineration Absorbent gel in Throw in pit latrines Burn pads flushed in toilet
Throw in sanitary Wrap and put in Dig hole and bury bins ordinary bin
Wrap and take home Wrap and take home Throw in bush for disposal for disposal
Blair toilet Wrap and throw into latrine
For some schools, burning was done over weekends. For schools that did not have incinerators, girls either wrap the used materials and dispose of them at home or throw them into ordinary bins. In addition, the incinerator at one of the Provincial hospital visited was also not working for quite some time and waste collection has been dysfunctional for some time. According to the Municipal EHT in this municipality, this has been adding menstruation materials to other solid waste (disposable baby diapers/pampers), littering suburbs. This phenomenon is not restricted to this municipality but can be seen in wasteland in and around other towns and cities. The distributors/sellers of sanitary materials were aware of the need for proper disposal of this waste. According to on sanitary ware distributor, when they were selling pads and tampons the scale was not large enough to warrant developing and implementing disposal mechanisms.
18 Additional words added to enhance clarity 78 Formative Research on Menstrual Hygiene Management Final Report, December 2019
It was evident from the study that there was awareness of the need to practise proper disposal of sanitary waste among town councils, as pronounced in Urban Council Environmental Health by laws Section 73 of the Constitution which provides that:
1. Everyone has the right – a. to an environment that is not harmful to their health or well-being …
One Environmental Health Officer observed that there were challenges with disposal of sanitary waste (including sanitary pads) which according to the urban by laws was supposed to be collected separately from other household waste and incinerated at the Provincial Hospitals . According to the Department, for long periods the Municipality has had no vehicles to do much in this regard. This situation is consistent across the urban councils visited: Mutare, Kwekwe and Harare.
3.7 Experiences of Menstruating Girls, In and Out of School This section highlights the lived experiences of girls in relation to menstruation gathered mainly through FGDs.
These FGDs were constructed around a mini-drama. Dramas provide an opportunity for an apparently third party form of response to the experiences of a fictional girl experiencing her first period while in school. See text box.
These interactive FGDs drawn revealed that girls in school undergo menstruation-related experiences that in some instances were positive and supportive. In other instances, the experiences were either embarrassing or humiliating and could have detrimental or harmful effects if not addressed timely and effectively.
The drama starts with boys giggling and shouting, “wavhiya mbudzi” She has slaughtered a goat. Tatenda realises it is her being laughed at. The other girls rush to call a female teacher who shouts at the boys and sends them out of class. Teacher asks other girls to go home with Tatenda since she lives close by. Tatenda feels embarrassed and the following day she does not go to school again until the teacher visits her at home and tells them that it is not a problem. She also assures her that no one will laugh at her. Tatenda has missed two days at school which means she will have to work harder in class to catch up. FGD Girls’ activity Rural District
3.7.1 Positive and supportive experiences Girls highlighted receiving support during menstruation including MHM-related guidance and counselling. In Marondera, one girl said she was adequately prepared by her mother, a school teacher. The FGD method prompted further discussion as other girls in the group requested her to tell them how it feels when menstruating: Her experience of pain, comfort and discomfort. The discussions among girls in groups also revealed instances of solidarity in relation to management of menstruation-related accidents and management of pain and
19A copy of the relevant by laws was not provided, and such by laws are notoriously difficult to track down. However, subject to verification, it can be assumed that they are drawn from national model by laws on such matters. Formative Research on Menstrual Hygiene Management Final Report, December 2019 79
discomfort. Boys were also seen as sympathetic at times with girls expressing appreciation for the forthcoming support from boys.
“My friend [a boy] used a jersey to cover me and walked me to the school health teacher who assisted me to clean up and get a clean pad.” Girl in School
“My brother saw that I had messed my dress and told my sister to tell me”. Girl in School
3.7.2 Negative experience for girls This section details girls’ negative experiences of menarche as well the lived experience of girls with disability.
3.7.2.1 Menarche experiences The study found that the first menstrual period/ menarche is not usually a good experience for girls. Missing out on school was common for girls after soiling their dress or where they were emotionally unprepared. Bad experiences related to the soiling of uniforms or the onset of menarche were reported to result in loss of confidence. This often manifests in girls becoming quieter and decrease in concentration levels in school. Views provided by school staff on girls’ experiences at menarche were as follows:
“…. generally, it happens at every school, especially with the first-timers and the child will disappear for almost two weeks if not properly counselled” School Head
“Normally this happens at menarche and thereafter we don’t see it” School Health Teacher
“I lost my mother when I was young and when I started bleeding, I cried as I did not know what was happening to me.” Girls in School 80 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Such experiences and their detrimental effects on the life of the girl child are a product of limited pre-menarche awareness on menstruation as highlighted under Section 4.2 on knowledge. Based on the overall statistics from the study, just over 60% of girls in school in both urban and rural areas stated that they received information on how to care for themselves during their menstrual periods. The remaining 40% who have not received any information are a significant number of girls who then face challenges at menarche. Regardless of the fact that most of the 60% who have received information have received it at the right time, before menarche, there still is a glaring lack of adequate information for girls to prepare themselves for menarche. This was evident during FGDs with the junior primary school girls in grades 4 and 5 (average age 9 -11 years). Below are some of their response to their understanding of menstruation:
“Menses is when a girl gets pricked by an injection and they start bleeding.” Girls in School
“When one starts bleeding that means they have done naughty things with boys.” Girls in School
“when someone sleeps with a person with HIV, they start bleeding from the vagina and they need to go to the clinic and get an injection to make the bleeding stop” Girls in School
“Bleeding only starts at the age of 20.” Girls in School
3.7.2.2 Experiences of girls with disability Menstruation is a difficult experience for girls with disability. In addition to discomfort, managing the menstruation process is quite a difficult task for girls with disability since in some instances they require assistance in managing the process.
“…disposal is a bit challenging because I don’t have that much power to remove all the blood and it takes me time for the whole process but I do it because my mother told me to wash first then burn”Girls in School
Without the necessary support, menstruation becomes a very difficult and horrendous task for girls with disability. Some end up soiling their clothes and experiencing further humiliation from other students in the school.
“boys in the community laugh when they know that I am on my time” Girls in School
“Boys laugh when l stain at school but teachers support me at any cost because they understand my condition.” Girls in School
Needs of girls with disability still receive minimal attention in the design and construction of sanitation facilities in schools. Depending on the disability, managing menstrual hygiene can be a challenge which is worsened by failure of schools to provide appropriate facilities for girls with disability. Asked about the challenges they face, some in school girls with disability had this to say: Formative Research on Menstrual Hygiene Management Final Report, December 2019 81
“The toilets are there but not friendly to me. Sometimes there will be no water when there is no electricity. The toilets are always dirty and some flash toilets are not working.”Girls in School
“Due to the fact that I may need much time to use the toilet as I do at home, this leads to harassment by others waiting outside to use the same toilet.” Girls in School
However, it was also discernible that support from family members, teachers and other caregivers can ease the burden associated with menstruation for girls with disability. Such support systems are common for girls attending specialised institutions for children with disabilities.
3.7.2.3 Shortage of sanitary materials and facilities Girls in- and out-of-school sometimes find it difficult to manage their menstrual hygiene due to the complete lack of or inadequate sanitary material and facilities. Without the relevant sanitary materials and facilities, practicing menstrual hygiene can become a challenge. Below are some insights on experiences girls go through each month:
“Shortage of pads, no privacy in the toilets since they are open to an extent that one can notice that someone is menstruating and spread the news to the whole school although she is also a girl. Bathrooms are not functioning; they were closed long time ago due to mis-use by students.” Girls in School
“The school have a special toilet though there is no water near the toilet.” Girls in School
School health teachers confirmed both the experiences highlighted by girls such as the non- availability of sanitary materials including pads, soap and buckets or bathing facilities. When a girl spoils her uniform, there is not much that the teacher can do but to send the girl home.
Particularly with reusable pads, some girls experience difficulty in washing off the blood stains in the absence of soap, detergents, adequate water and a private space to dry them. Additional adverse experiences emanated from failure to participate in routine school activities and sports due to restrictions in accessing appropriate sanitary materials. Using cloth was reported to cause health problems such as “burning of the skin” (causing a rash around the thighs) which was embarrassing for the girls. Some girls wanted to use commercially produced pads but could not afford them.
3.7.2.4 Bullying and harassment Girls also reported experiencing bullying and harassment by boys during their menstrual period. At one school in Marondera, it was mentioned that boys sometimes open girls’ satchels to search for menstrual hygiene materials and when they think a girl is having a period, they “chide”/harass her. Girls and boys were reported to sometimes “chide” at menstruating girls 82 Formative Research on Menstrual Hygiene Management Final Report, December 2019
accusing them of possessing a foul smell. Lack of bath soap, detergents and deodorants to maintain hygiene were cited as causes of such comments and harassment. Discussing their experiences in school, the girls indicated that:
“Boys laugh at the girls and sometimes spread the news to the whole school that a certain girl is on her menses.” Girls in primary school
“Boys usually laugh at girls when they know that they are on their periods.” Girls in secondary school
The quantitative survey confirmed these findings where the girls reported that when menstruating boys laugh at them (40.9% urban and 42.6% rural), humiliated (15.1 % urban and 14.6% rural) . However, there are boys who were reported to offer support (9.8%).
3.7.2.5 Pain, self-confidence, stigma and stress During FGDs, school going girls reported that during their periods they participate poorly, lacked concentration, had wandering minds in class and mood swings, felt lonely and out of place and generally had low self-esteem. Table 37 in Annex 2 provides girls’ responses on the challenges they face during menstruation at school. Inability to concentrate (22.2% in rural areas and 13.3% in urban areas); feeling physically weak (22.2% in rural areas and 18.0% in urban areas); experience discomfort (28.0% and 24.4% in rural and urban areas) and affected by pain (24.4 and 22.7% in rural and urban areas) were the main challenges that girls experienced at school. Lack of privacy to change sanitary wear (4.8% and 3.4% rural and urban areas) was not a considered a big challenge by girls.
A strong sense of self-stigmatization was evident driven by social norms around menstruation. During discussions, girls opened up about the beliefs around menstruation that drained their confidence contributed to self-stigmatization:
“you are not allowed to touch or plait someone’s hair as it is believed that it leads to great hair loss.” Girls in School
“not allowed to put salt in food that is to be eaten by male counterparts as it is said their anus will be swollen.” Girls in School
“Not allowed to pick green vegetables as they will dry up.” Girls in School
“Sharing clothes is prohibited as it is believed they transfer period pains.” Girls in School Formative Research on Menstrual Hygiene Management Final Report, December 2019 83
Most of these beliefs construct menstruating girls as dirty or having a bad omen. Having been socialised in communities with these beliefs, the girls are prone to lose confidence and are entrenched in self-stigma during menstruation.
For girls who experienced pain during menstruation (24.4% and 22.7% in rural and urban areas) majority use nothing to manage pain (56.6% and 46.3% in rural and urban areas). Higher proportion in urban areas modern medication (42.9%) compared to rural areas (31.4%). Traditional methods of pain management are used by 12.0% and 10.9% of girls in rural and urban areas. Other girls who have experienced dysmenorrhoea indicated that they use either herbal or OTC medicines to ease the pain. The most common form of treatment cited was hot water either taken orally or used to dab the womb area to relieve pain. However, the severity of pain differs and for those who suffer from a lot of pain, they sometimes miss school as indicated below:
“They go home if they are at school. At home they sometimes go to the hospital if the pain is severe.”
“They do not go to school if they have period pain. At home they use hot water to ease the pain. They are sometimes given brufen and paracetamol at home”
“go home if they are at school. At home they drink hot water, they use herbs like ginger (tsangamidzi)”
This was also confirmed by one school health teacher who indicated that some girls who experience heavy menstrual flows usually do not come to school during this period. Such experiences thereby become detrimental to their schooling. The quantitative data further corroborates these sentiments. About 22.2% and 20.6% of girls in rural and urban areas have missed school due to menstruation. Majority those that have missed school missed 1 day per month (54.9% and 34.4% in urban and rural areas) and 2 days per month (29.2% and 33.8% in urban and rural areas). Approximately 13.2% and 27.9% in urban and rural areas miss 3 or more days of school. Severe pain, lack of sanitary ware, discomfort, and tiredness were the main reasons for missing school. However, the extent of contribution of these reasons differed between girls in urban and rural schools. Lack of sanitary ware was a major reason for missing school in rural (32.5%) than urban areas (8.9%). Missing school due to severe pain was prevalent in urban areas, where almost all that missed school gave this reason (90.3%), than rural areas (68.2%). Tiredness (8.3% in urban areas and 10.4% in rural areas) and discomfort (13/9% and 19.5% in urban and rural areas) were other contributors. Lack of private changing was not a contributor to dropping out as this a reason for only 0.7% of the respondents in rural areas and 0% in urban areas.
Study findings were consistent with previous studies which have shown that child participation in school is affected by failure to manage pain which leads to poor school attendance during menstruation and increased vulnerability to harassment …” Manyara (2014). According to UNFPA (2017), a systematic review of 50 studies, found that dysmenorrhea was a major gynaecological complaint of adolescents, that many do not seek medical care, and that it causes diminished quality of life including poorer school attendance, girls experience shame, low self-esteem, and lack of confidence due to fear of mismanagement of menstruation. 84 Formative Research on Menstrual Hygiene Management Final Report, December 2019
3.7.2.6 Embarrassing/humiliating experiences From the study, it is evident that menstruation is not a subject for public discussion and is shrouded in secrecy and silence. Interviews conducted confirmed that it is generally believed that no one should see a girl/woman’s menstrual flow because it is considered dirty and that sometimes the blood can be used to bewitch a person. Therefore, when a girl shows any visible signs of being on her menses, they are embarrassed and other children can further humiliate them which results in distress. During an FGD with boys, the boys confirmed these humiliations suffered by girls during menstruation saying,
“A girl was playing when her bloody stained cloth fell. The boys teased her and she had to miss her grade seven exam because of that.” Boys in School
“I saw it when a girl had a smudge of blood on her dress and the boys teased her. she reported to the teachers and went to the homestead next to the school where she bathed and went home.” Boys in School
Girls interviewed responded that the fear of soiling their clothes and of a bad smell associated with not washing properly prevents them from concentrating on their education (Selamawit, et al 2015). Below is a tabulated summary of the girls experiences faced during menstruation as gathered by the study. Formative Research on Menstrual Hygiene Management Final Report, December 2019 85
Table 21: Summary Of Girl’s Menstruation Related Experiences Category of Girls Experiences Effects of the different experience Positive/Supportive Embarrassing/Humiliating experiences on the girls Restrictions Receiving Clumsy walking and Where there were no related to mobility appropriate and even peers (male pads at school for including going to timely MHM related and female) chiding emergencies girls school regularly guidance and that someone was would go home to counselling in not walking properly deal with the preparation for because of the pad situation. menarche or cloth worn during menstruation Emergency/ Provision of Soiling uniform/dress Missing out Menarche emergency school/dropout / sanitary material Discontinuing of schooling, absenteeism/dropout Self Confidence, Sympathetic Inability to participate Mood changes, felt Stigma and management of in routine school lonely, out of place, Stress menstruation activities because of had low self-esteem, related inappropriate felt loss of freedom accidents, pain menstrual and discomforts management materials Experienced a Using reusable cloth Loss of confidence, supportive instead of a pad becoming quieter environment within the school i.e. menstruation understood as a natural phenomenon by both boys and girls. Support of teachers and peers Bullying Boys searching girls Concentration levels satchels for evidence drop “wandering of menstrual hygiene minds” materials and drawing attention to them Health Problems Body changes Unrelieved period making them pain and discomfort uncomfortable and have to go home
3.8 Legal and Policy Framework and Stakeholder Perceptions on MHM
3.8.1 Legal framework The government is obligated to ensure equal enjoyment of human rights for all including girls through the facilitation of MHM in- and out-of-schools20. Through a long list of international human rights instruments, Zimbabwe is mandated to respect, promote and fulfil the right to
20Zimbabwe has expressed provisions in the Constitution of Zimbabwe Amendment Act (No. 20) Act 2013 (hereinafter referred to as the 2013 Zimbabwe Constitution ), section 2 provides: The obligations imposed by this Constitution are binding on every person, natural or juristic20, including the State and all executive, 86 Formative Research on Menstrual Hygiene Management Final Report, December 2019
education. These instruments articulate international concepts of rights and guide states as to the focus they need to have in the delivery of rights-based entitlements for their citizens and in some cases permanent residents and other persons living within the bounds of the state21.
Within Zimbabwe, the import of the above articles in international instruments has been to some extent incorporated into the 2013 Zimbabwe Constitution by way of Sections 56, 75(1), 76(1), 81(f). Although none of the above international instruments have been formally domesticated as per section 34 of the Constitution, they are indirectly applicable to the interpretation of Zimbabwean legislation in terms of s327 (6)22 . Based on the 2013 Constitution and international instruments, the government is accountable for schools lacking adequate MHM as they are violating the girls’ rights to equality and non-discrimination on the basis of sex and gender.
Section 45 in the Declaration of Rights, requires all laws, and government policies to be aligned with the provisions of the 2013 Zimbabwe Constitution. Although s19 falls under the National Objectives rather than being a right, it creates obligations that fall under governments’ obligation to create and enforce. Most importantly in relation to MHM in schools, section 19(2) provides:
The State must adopt reasonable policies and measures, within the limits of the resources available to it, that ensure that children - (d) have access to appropriate education and training.
As this report reveals, without attention to MHM and its effect on school attendance and participation for girls, this becomes an arena of gender discrimination, perpetuating gender disparities in education. This section intersects with section 27 which requires that the State promotes education. Most significantly the section with the most ‘weight’ is s75 on the right to education.
In terms of the Declaration of Rights, s83 places special emphasis on enabling those with disability to be self-reliant and thus change the model from a welfare approach to one of human rights entitlements for the disabled.
In relation to women and girls and the need to cater for their full participation and life cycle needs, Section 80(3) actively addresses the need to eliminate all discriminatory practices against women, regardless of where they are situated and what their needs and actual experiences may be23 .
The right to water and sanitation: The right to water entitles everyone to have access to sufficient, safe, acceptable, physically accessible, and affordable water for personal domestic use (United Nations Committee on Economic, Social and Cultural Rights in General
legislative and judicial institutions and agencies of government at every level and must be fulfilled by them 21The right to education is variously described and prescribed in the following: Article 13 International Covenant on Economic, Social and Cultural Rights (ICESCR); Article 28, 29 Convention on the Rights of the Child (CRC); Article 10 Convention on the Elimination of All Forms of Discrimination against Women (CEDAW); Article 17 African Charter on Human and Peoples’ Rights (ACHPR: AU Charter); Article 12 African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (Maputo Protocol); Convention on the Rights of People with Disabilities; Article 26 Universal Declaration of Human Rights (UDHR). 22s327(6) provides that,” When interpreting legislation, every court and tribunal must adopt any reasonable interpretation of the legislation that is consistent with any international convention … which is binding on Zimbabwe, in preference to an alternative interpretation inconsistent with that convention.” 23More detailed consideration of specific laws is covered as appropriate in relation to the issue being discussed. Formative Research on Menstrual Hygiene Management Final Report, December 2019 87
Comment 15 drafted in 2002). The right to sanitation entitles everyone to have physical and affordable access to sanitation, in all spheres of life, that is safe, hygienic, secure, socially and culturally acceptable, and that provides privacy and ensures dignity. Access to water and sanitation facilities that meet the definition above, in all spheres of life, including at home, work, school, or in institutions, are necessary to enable women and girls to practice good MHM in schools. This definition of the rights to water and sanitation as components of the right to an adequate standard of living was recognized by all UN Member States in 2015 in UN General Assembly Resolution 70/169. Article 25 of the UDHR and 11 of the ICESCR guarantee the right to an adequate standard of living.
The human right to health: Absence of good MHM in schools violates girl’s right to health. The human right to health is guaranteed in Article 12 ICESCR and, specifically for women, in Article 11 CEDAW. The UN Committee on Economic, Social and Cultural Rights, General Comment No. 14, “The Right to the Highest Attainable Standard of Health” para. 11 interprets the right to health, as defined in article 12.1 (ICSECR), as an inclusive right extending not only to timely and appropriate health care but also to the underlying determinants of health, such as access to safe water and adequate sanitation. Thus, lack of adequate private clean toilets, hygienic menstrual pads, medical stocks such as pain killers to assist in pain management during menstruation, lack of knowledge on MHM resulting in unhygienic menstrual practices which can lead to reproductive tract infections.
According to Section 29 (1) and (3) in the National Objectives in the 2013 Zimbabwe Constitution, the State is obligated to;
a. take all practical measures to ensure the provision of basic, accessible and adequate health services throughout Zimbabwe b. take all preventive measures within the limits of the resources available to it, including education and public awareness programmes, against the spread of disease. 88 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Section 64 (1) of The Education Act, as amended in 2006, stipulates that the Minister of Primary and Secondary Education in consultation with the Minister responsible for Health shall make regulations for the purposes of safeguarding the health of learners. The Zimbabwe School Health Policy 2018 provides a broad frame of reference to guide the implementation of a number of health related interventions pertaining to the welfare of learners in the school system, such as water, sanitation and hygiene, sexual and reproductive health (SRH) concerns, and the care and support provisions including guidance and counselling services for all learners.
In light of all these provisions and policies as read together with sections 2, 45, 56, 80, 81 and 83 of the 2013 Zimbabwe Constitution, the state is obligated to enforce good MHM standards in schools for the protection of girl’s human rights to health, education, adequate standards of living, dignity and privacy.
All the above legislative sections set the tone for a conducive legislative environment for litigation for provision of adequate and comfortable MHM environment and facilities for girls in and out of school. However, most of these provisions are not met to ensure that MHM in schools is adequately addressed. Absence of good MHM in schools particularly affects girls’ education. Menstruation creates a set of physical, socio-cultural and economic challenges that may interfere with a girl’s or young woman’s ability to attend school or to participate fully in classroom activities as demonstrated in earlier sections.
3.8.2 Policy framework The Zimbabwe School Health Policy launched in 2018 aims to provide a comprehensive framework for school-based health but fails to mention MHM as one of the key issues to be addressed. This leads to inconsistencies in addressing MHM in practice at school level. The policy mentions reproductive health but does not at any point refer specifically to menstruation and MHM (GoZ, 2018). With regards to facilities, the Education Act, amended in 2006, requires every school to have two blocks of toilets, one for boys and the other for girls, the ratio of the toilets to school enrolment. However, there still is lack of adequate policy guidance on standards. There are policy gaps that still need to be addressed to enhance WASH and Menstrual Hygiene Management in schools including: 1) the package of support for MHM in schools including nationally approved national designs for girl friendly toilets; 2) hygiene education and related child friendly materials; and 3) ensuring schools especially satellite schools are established in places with easy access to water. At the time of the research, proposed girl friendly toilet designs were developed and awaiting approval.
MoPSE was given a mandate to introduce Life Skills, HIV and AIDS Education in 1992. Thereafter, the Chief Education Officer’s Circular Number 16 of 1993 was formulated making Life Skills, HIV and AIDS education mandatory. Policies were formulated and amended emphasising the Ministry’s mandate for implementation of Life skills, HIV and AIDS Education and Guidance and Counselling as non-examinable study areas. A teacher’s manual with content partitioned into sections for infants, junior level (primary schooling)24 was produced. The Provincial and District level Ministry of Education officials all confirmed that schools through the School Health Policy (2018) and the Guidance and Counselling new curriculum were sources of information on SRH including menstrual hygiene management.
24In the context of Zimbabwe primary schooling runs from what is often known as pre-schooling (3+-5) known now as EDC A and B through to Grade 7. The normal age on which the project is predicated for Grade 5 is 10, 14 year olds are normally expected to be in Form 2, the second level in High School. Ages do vary in each level but the average assumed age for a level informs the study and the age ranges for materials and other inputs that should be available in schools. Formative Research on Menstrual Hygiene Management Final Report, December 2019 89
It is mandatory to implement Health programmes based on the Zimbabwe School Health programmes 2018, Directors’ circular 23 of 2005, 6.2, Zimbabwe School Health Policy (2018). Sexuality and HIV/AIDS related topics are part of the multipronged approach of providing Guidance and Counselling as a learning area which was confirmed by provincial and district primary and secondary education level supervisors. Guidance and Counselling lesson is supposed to be taught from early childhood learning, primary and secondary school levels, one lesson per week of 30 minutes in primary and 35 minutes in secondary school.
Further, the content of teaching materials for the new curriculum are graded according to the needs of learners and addresses 2 levels - infant and juniors. At infant level, the content covers issues of self-identity as an individual, within family and community, Ubuntu and values, relationships and family life education. At junior level healthy living, relationships, human growth and development, health, values and beliefs are covered. The manual speaks to issues of sexuality, puberty, personal hygiene. There is no specific mention of MHM.
At the higher levels of management within the Ministry, there was a belief that:
“All school heads and coordinators are trained and provided with syllabi for training. The teaching of guidance and counselling is timetabled, 25 and 35 minutes for primary and secondary school per week respectively”. District Education Officer.
“Teachers in district were all oriented on Guidance and counselling teaching in 2015”. District Remedial Officer.
Provincial and District Education Officers were confident that the schools were disseminating SRH information that included MHM. This confidence was built on the premise of the existence of the curriculum and syllabus, the training of School heads and school health masters to implement it; and the institution of Guidance and Counselling core teams in schools to articulate health programmes. However, when trained school heads were asked about their preparedness to disseminate information not all heads acknowledged preparedness to address MHM. It was common across the schools visited and as reported by school heads that MHM was specifically addressed when there was a specific MHM related incidence in the school.
The Adolescent and Youth Sexual and Reproductive Health Strategy 2016-2020 does not provide explicit reference to MHM however, the product of this strategy – the comprehensive sexuality education training manual provides an information package for MHM. 90 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Conclusions and 4 Recommendations
4.1 Conclusions General conclusions: The study has brought to the fore challenges experienced by girls during menstruation and their impact on the quality of life at school, in the home and community. The main conclusions from the study include that:
●● For the in-school and out of school girls included in the study there was no difference in access to services and support for MHM. There is little to no service provided in schools to girls for appropriate MHM. ●● Poor MHM is not a contributor to dropping out of school in Zimbabwe but rather affects the quality of education and life for girls - through missing some school days, lack of concentration during class, and loss of dignity and confidence. ●● The main driver for missing school is pain, discomfort while other factors play a minor role but do improve the quality of MHM for girls and confidence building.
Knowledge and information on MHM: About 40% of girls never received information on MHM at all. Of the 60% that received some information on MHM a majority 95.6% (urban) and 88.9% (rural) received it before menarche. Despite such high proportion of girls receiving some information on MHM the information was incomplete, incorrect and skewed towards personal hygiene. This reflects the sources of information which are inadequately equipped to provide enough information on MHM to girls during pre- and post-menarche phases. Majority of these sources include their Mother (51.2% urban and 34.2% in rural) and Teacher (56.7% urban and 51.4% in rural). Their mothers pass on information they received from a combination of other relatives, their own mothers and their own experiences with menstruation when growing up which is usually inadequate. There are no specific alternative Formative Research on Menstrual Hygiene Management Final Report, December 2019 91
sources of information to equip women in communities with appropriate and complete MHM information.
Despite the availability of Guidance and Counselling curriculum and accompanying teacher training, a comprehensive training manual on adolescent sexual and reproductive health the school does not provide adequate information on MHM to girls and boys. Gendered views of MHM which undermine male teachers’ involvement; lack of incentive for teachers to deliver the full guidance and counselling curriculum; limited cross-sectoral coordination in information dissemination on MHM; and unavailability of IEC materials on MHM all combine to limit access to MHM information within the school environment.
For girls out of school the sources are narrower with mother and relatives being primary sources. Limited availability of community-based initiatives that incorporate MHM further limit their access to appropriate and comprehensive information on MHM. Limited coordination, cross-sectoral working and inadequate involvement of key constituents such as the Ministry of Women Affairs undermine efforts of delivering appropriate and comprehensive MHM packages in the community.
Misconceptions, and taboos are prevalent at home, in the community and at school and reinforce self-stigma, and undermine confidence building of being a woman which affects other spheres of life and growing up.
The study found that boys remain a forgotten group in information dissemination of the MHM yet their attitudes towards menstruation reinforces stigma surrounding menstruation which lead to embarrassing experiences for girls and loss of self-confidence among girls. This limited targeting of boys in both formal and informal environments (school community and the home) leads to misinformation and incorrect knowledge of MHM which are the drivers of negative attitudes towards menstruation.
Social norms and myths surrounding MHM: Myths, taboos and misconceptions surrounding MHM are driven by a lack of adequate knowledge on the issue but more importantly negative gendered social norms that place significant restrictions on menstruating girls and women.
Key professionals: All available materials for service providers are devoid of attention on the gendered aspects of MHM. This has inadvertently limited knowledge of key professions and the information they disseminate to the biology of menstruation, personal hygiene and appropriate sanitary ware, safe disposal of sanitary ware and management of pain and discomforts. There is limited cross-sectoral collaboration various professionals in education, health, WASH, gender, protection, gender, community development, etc., which undermines the targeting of various constituents (in the family, community, and school) and the provision of comprehensive knowledge on MHM. Dispelling gendered notions on MHM will enhance participation of male key professionals on the subject.
Safe and discrete disposal of sanitary protection materials: The study concludes that the disposal of sanitary ware is mixed but the general trend is standards are required in schools and public spaces to enhance safe, hygienic and private disposal. 92 Formative Research on Menstrual Hygiene Management Final Report, December 2019
WASH facilities and safe place to change: A majority of urban and rural schools had separate boys and girls toilets. In both urban and rural areas, with rural areas most affected, sanitation facilities do not provide sufficient support for privacy and dignity for menstruating girls. Poor school hygiene in schools, particularly in urban schools also undermining appropriate hygiene management. Across all urban and rural areas sanitation infrastructure is poorly managed. Inadequate, non-functional and poorly maintained sanitation facilities in public spaces undermines MHM. Therefore, in general sanitation facilities were not appropriate to meet girls’ needs.
Available sanitary materials: Disposable sanitary protection ware the most used and most preferred by in and out of school girls. Cloths are used by 11% as an alternative to disposable sanitary ware. Despite the disposable sanitary ware being the most preferred and used, the increasing costs and availability particularly in remote areas, are undermining their consistent use by girls. The unavailability of manufacturers of disposable sanitary protection materials in Zimbabwe (as all companies import and distribute) is driving both the price and availability due to the shortage of foreign currency. Further, the absence of quality standards for sanitary ware introduces risks for low health safeguards.
Reusable sanitary ware is still a new phenomenon in the country with only 1.2% (urban) and 1.3% (rural) using them. However, the study concludes that their promotion should consider the following challenges:
●● poor WASH conditions in schools, in public spaces and the home; ●● privacy and safety of disposal and use; and ●● that they are the least preferred.
Legislation and policy framework: Findings show the presence and availability of supportive legislation and policy provisions to support effective MHM and SRH in schools. However, lack of specificity and reference to MHM; limited cross sectoral working; and a weak social movement derail implementation. Further, sector (education, health, gender, WASH) monitoring tools and reporting are limited in their reporting on MHM status which in turn undermines investments towards addressing MHM. Nonetheless, the new Education Bill strengthens the state’s obligation to support MHM in schools but maybe deficient in addressing the main causes of missing school and quality education in different contexts for example sanitary wear is an issue in rural areas but managing pain, discomfort and tiredness are issues in urban areas. Formative Research on Menstrual Hygiene Management Final Report, December 2019 93
4.2 Recommendations
4.2.1 Long term recommendations 1. All findings point to the fact that the realisation of human rights and development goals will not be possible without considering MHM. No intervention or programme across the main sectors of education, health, humanitarian etc., will be inclusive and ensure full participation of women without ensuring women and girls have adequate access and information to appropriate MHM. ●● Thus there is need to have a two-pronged approach that comprises mainstreaming and targeted approaches for MHM within all interventions which address women and girls issues as well as resilient families and societies; (Responsibility: NGOs, UN, Government) and ●● This needs to be accompanied by a systematic and cross-sectoral capacity building approach for: 1) policy makers; 2) programme managers; and 3) programme implementers. (Responsibility: NGOs, UN, Government)
2. The study found that negative social norms and restrictions around MHM are internalised by society and influence girls’ and women’s perceptions of the embodied experience of being a girl/woman. Negative social norms are a manifestation of deep- rooted gender inequalities and discrimination. a. Hence the entry point for social behaviour change on MHM should be gender equality in its totality. (Responsibility: NGOs, UN, Government) b. Entry points should also be on sexual maturation (the “female body”) and life skills. (Responsibility: NGOs, UN, Government) c. Men and boys should be especially targeted to dispel myths and misconceptions on MHM and increase their support for MHM. (Responsibility: NGOs, UN, Government)
4.2.2 Short term recommendations 1. The challenges girls face in handling menstruation emanate from a broad range of factors. In order to effectively create a supportive environment there is need to harness and amplify the multi-sectoral efforts around MHM, from SRH and Life skills education, advocacy and Lobbying for policy changes around MHM, Girl friendly infrastructure development, WASH and provision of sanitary materials. There is therefore need to: a. strengthen inter-sectoral coordination of MHM interventions. To do this a desk for addressing MHM could be created to strengthen coordination of the multisectoral players. Stakeholders can agree on where best to place the coordination desk however, as MHM needs to be addressed from a broader gender lense, the Ministry of Women Affairs is better suited for this role. (Responsibility: Government of Zimbabwe) b. establish a sustainable and rights based social movement on MHM to ensure MHM challenges are tackled regardless of numbers affected as its mismanagement infringes on other rights for the child such as education, play, good health, dignity etc. (Responsibility: UNICEF, National Association of non-Governmental Organisations (NANGO)) 94 Formative Research on Menstrual Hygiene Management Final Report, December 2019
2. Zimbabwe has an adequate legislative framework to address MHM. This will further be buttressed by new legislation such as the Education Bill that was under consideration at the time of the study. a. Therefore, there is need to advocate for implementation of the existing legislation by government through the rights based social movement on MHM mentioned under recommendation 2b. (Responsibility: NGOs; UNICEF) b. There is need for national MHM guidelines that can be mainstreamed in various sectors that interact with MHM issues to ensure standardisation in approaches. (Responsibility: Government of Zimbabwe; UNICEF) c. A review of all key policies and strategies is required to ensure MHM is a explicitly mentioned and given priority in implementation. (Responsibility: UNICEF, Government of Zimbabwe, NGOs)
4. About 40% of girls do not receive information on MHM before they reach menarche. For those that do, the information is inadequate and skewed towards hygiene management. This emanates from deficiently equipped information sources within the schools, community and family environment. a. There is need to develop a comprehensive and standardised age appropriate MHM information package for women, community influencers, programme implementers and volunteers, teachers etc. to enable them to engage in one on one and group conversations around MHM with girls and boys paying special attention to facts on menstruation, pain management, use and disposal of sanitary materials. (Responsibility: UNICEF; Government of Zimbabwe) b. Develop appropriate IEC materials that enrich MHM conversations in the multisectoral, multimedia and community level spaces and platforms. (Responsibility: UNICEF; Government of Zimbabwe) c. Ensure no child is left behind by ensuring inclusiveness for people with disability by ensuring appropriate infrastructure, facilities and information are made available. (Responsibility: UNICEF; Government of Zimbabwe)
4. Access to suitable and quality sanitary materials for girls, disposable pads being the preferred, is hampered by the inability to pay for preferred and appropriate product. Further, the absence of local manufacturing exposes the country to price volatility and shortages in a country already experiencing multiple economic crises. Failure to create or adopt and implement safe disposal methods is an additional challenge. Hence: a. Consider supporting a cotton value chain that would create jobs, and increase availability of suitable organic and locally produced sanitary materials. (Responsibility: Government of Zimbabwe, Ministry of Finance and Ministry of Trade) b. Support local manufacturing of sanitary materials. This requires that there be no monopoly in the industry and support should be provided to 2-3 attested and large manufacturing companies. Effective and efficient distribution systems need to be supported basing on proven supply chains to reach remote areas. c. Every school to keep pads for emergencies at all-times. The schools, through the schools development association, need to identify the most appropriate way of funding these sanitary materials. Ministry of Education should support this by finding a way of making availability of sanitary materials for emergency at every school a performance standard to encourage adherence. (Responsibility: MoPSE) Formative Research on Menstrual Hygiene Management Final Report, December 2019 95
d. There is need to develop national standards for sanitary protection ware to enhance health safeguards. (Responsibility: UNICEF)
5. Pain and discomfort during menstruation are the main drivers for school absenteeism and limited concentration during school in Zimbabwe. Yet majority of schools have no facilities to provide support for girls. a. establish sustainable mechanisms for schools to provide emergency pain killers for girls and places of rest during severe pain. (Responsibility: MOPSE) 96 Formative Research on Menstrual Hygiene Management Final Report, December 2019
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●● Meredith S (2006), What’s Happening to Me? Usborne, London. ●● Mishra, VK (2015), Social and psychological impact of limited access to sanitation: The link between MHM and reproductive tract infections, and between WASH practices and pregnancy. 38th WEDC International Conference. Loughborough, UK ●● Ministry of Primary and Secondary Education (MoPSE) (2019) 2018 Primary and Secondary Education Statistics Report. ●● Moyo S, Makoni FS, Ndamba J (2004), An evaluation of National Sanitation Policy with an emphasis on sexual maturation needs of girls vis-a-vis menstruation; In: Stewart JE (ed.) Life skills, sexual maturation and sanitation: What’s (not) happening in our schools? 2004: Weaver Press, Harare, Zimbabwe ●● Mpofu (2012), Challenges Faced by Students with Special Educational Needs in Early Childhood Development Centres in Zimbabwe as Perceived by ECD Trainers and Parents. ●● Nahar Q, Ahmed R (2006), Addressing Special Needs of Girls Challenges in Schools: paper presented at the 2nd South Asian Conference on Sanitation, Islamabad, Pakistan, and 19-22 September 2006 ●● Ndlovu E, Bhala E (2016), Menstrual hygiene – A salient hazard in rural schools: A case of Masvingo district of Zimbabwe’, Jàmbá: Journal of Disaster Risk Studies 8(2), Art. #204, 8 pages. http://dx.doi. org/10.4102/jamba.v8i2.204 ●● Nyakanyanga S. (2017), Free Sanitary Pads to Fight School Dropout, Child Marriage in Zimbabwe [Internet]. Women and Girls. 2017 [cited 2017 Nov 25]. Available from: https://www.newsdeeply.com/womenandgirls/ articles/2017/11/09/free-sanitary-pads- to-fight-schooldropout-child-marriage-in-zimbabwe ●● Oruko, K. et al (2015), He Is The One Who Is Providing You with Everything So Whatever He Says Is What You Do: A Qualitative Study on Factors Affecting Secondary Schoolgirls’ Dropout in Rural Western Kenya. ●● Phillips-Howard P A (2015), Menstrual Needs and Associations with Sexual and Reproductive Risks in Rural Kenyan Females: A Cross-Sectional Behavioral Survey Linked with HIV Prevalence, Journal of Women’s Health, Volume 24, Number 10, 2015 DOI: 10.1089/jwh.2014.5031 ●● Phillips-Howard P A et al (2016), Menstrual Cups and Sanitary Pads to Reduce School Attrition, and Sexually Transmitted and Reproductive Tract Infections: A Cluster Randomised Controlled Feasibility Study in Rural Western Kenya BMJ Open 2016;6: e013229. doi: 10.1136/bmjopen-2016-013229 ●● Pillitteri S P (2012), School Menstrual Hygiene Management in Malawi: More than Toilets, ●● Planned Parenthood Federation of America (2019), Health and Wellness. ●● Porter, K.A., (2007), Life Skills, Sexual Maturation and Sanitation: What’s (Not) Happening in Our Schools? An Exploratory Study from Kenya (review). African Studies Review, 50(2007):1. ●● Sahin, M., T. Mahon, A. Tripathy and N.Singh (2015), Putting the men into menstruation: the role of men and boys in community menstrual hygiene management, Practical Action Publishing ●● Sarah House, S., Thérèse Mahon and Sue Cavill (2012), Menstrual Hygiene Matters; A resource for improving menstural hygiene around the world, Water Aid ●● Selamawit T. et al (2015), A sustainable solution for school menstrual hygiene management: cases of Ethiopia, Uganda, South-Sudan, Tanzania, and Zimbabwe, SNV Netherlands Development Organisation, 2015 100 Formative Research on Menstrual Hygiene Management Final Report, December 2019
●● Seymour, K. (2009) Bangladesh: Tackling Menstrual Hygiene Taboos. Sanitation and Hygiene Case Study 10. UNICEF, New York. ●● Seymour, K. 2009 Bangladesh: Tackling Menstrual Hygiene Taboos. Sanitation and Hygiene Case ●● Shangwa, A., 2011 The Girl-Child and Menstrual Management in Zimbabwe, SEI, Sweden ●● Shangwa, A., 2011, the Girl Child and Menstrual Management in Zimbabwe, SEI, Sweden. Shumba, A, J. ●● Shoko, T., 2009 Komba: girls’ initiation rite and enculturation among the VaRemba of Zimbabwe, UZ, Zimbabwe ●● Shumba, O et al 2003 Analysis and Learning Opportunities for Teacher Education Curriculum on Growing UP and Sexual Maturation, University of Zimbabwe and Mary Mount Teachers’ College. ●● Shumba, A, J. Mpofu (2012) ‘Challenges Faced by Students with Special Educational Needs in Early Childhood Development Centres in Zimbabwe as Perceived by ECD Trainers and Parents ‘. The Anthropologist, 14(2012):4. ●● Shumba, A, J. Mpofu (2012), Challenges Faced by Students with Special Educational Needs in Early Childhood Development Centres in Zimbabwe as Perceived by ECD Trainers and Parents ●● Shumba, O et al (2005) Stakeholder Constructions of an Interpretive Framework For a Growing Up Sexual Maturation Oriented Curriculum, University of Zimbabwe and Zimbabwe Open University, Zimbabwe ●● SNV Uganda Country Office. (2014) SNV Menstrual Hygiene Management Baseline Survey Conducted in Lira, Mubende, Dokolo and Mukono Districts. Kampala, SNV ●● SNV. 2012. Masvingo Schools WASH Report. http://www.snv.org/public/cms/sites/ default/files/explore/download/masvingo_-_wash_in_schools_-_2012_.pdf ●● SNV. 2014. Menstrual Hygiene Management (MHM) and WASH in Schools Baseline Survey Report, May 2014. South Sudan – East Equatorial Estate (EES). ●● SNV. 2014. Menstrual Hygiene Management Baseline Survey Conducted in Sengerema, Chato, Magu, Siha, Babati, Karatu, Njombe and Mufindi Districts of Tanzania. ●● Sommer, M 2009 ‘Ideologies of sexuality, menstruation and risk: Girls’ experiences of puberty and schooling in northern Tanzania.’ Culture, Health and Sexuality, vol 11, no 4, pp 383-398. ●● Sommer, M (2010), Integrating Menstrual Hygiene Management (MHM) Into The School Water, Sanitation And Hygiene Agenda, The Future Of Water, Sanitation And Hygiene: Innovation, Adaption and Engagement in a Changing World’ Briefing Paper, 2011, WEDC, Loughborough, UK. ●● Sommer, M (2010), Putting Menstrual Hygiene Management on to the School Water and Sanitation Agenda.’ Waterlines 29, (4) 268-278 Study, #10. UNICEF, New York ●● Steinfeld, E 2005 Education for All: The Cost of Accessibility. Education Notes 38864. The World Bank: Washington ●● Stewart, J.E., ((2008), Why I can’t go to School Today, in Hellum, A, J. E. Stewart, S. Sardar Ali and A. Tsanga, Human rights, legal pluralities and gendered realities. Weaver Press, Harare ●● Stewart, J.E and A. Tsanga, (2011) Women and Law: Innovative Approaches to teaching, research and analysis, Weaver Press, Harare Formative Research on Menstrual Hygiene Management Final Report, December 2019 101
●● Stewart J.E. Do it, then do it again: Practical course and dissertation in Tsanga, A and Stewart, J.E (eds). Women and Law: Innovative Approaches to teaching, research and analysis, Weaver Press, Harare ●● Stewart J.E. (2011) Breaking the Mould: Research Methodologies and Methods in Tsanga, A and Stewart, J.E (eds) Women and Law: Innovative Approaches to teaching, research and analysis, Weaver Press, Harare ●● Stewart, J.E and R Katsande, (2018), The Quest for Safe and Inclusive Cities in Zimbabwe in Salahub, Gottsbacher and de Boer (eds) Social Theories of Urban Violence in the Global South: Towards Safe and Inclusive Cities, Routledge, Oxford ●● Sumpter, C. and Torondel, B., (2013). A systematic review of the health and social effects of menstrual hygiene management. PloS one, 8(4), p.e62004 Taking stock. Mumbai, India, Junction Social. Available at www.mum.org/menhydev.htm (Accessed 6/4/11). ●● Tamiru, S. et al (2015), Towards a sustainable solution for school menstrual hygiene management: cases of Ethiopia, Uganda, South-Sudan, Tanzania, and Zimbabwe. Waterlines, 34(1):92-102. ●● Tarisayi K. (2016) An Exploration Of The Challenges Encountered By Satellite Schools In Masvingo District, Zimbabwe. https://internationaljournalofresearch. com/2016/11/28/an-exploration-of-the-challenges-encountered-by-satellite-schools- in-masvingo-district-zimbabwe/ ●● Ten, V.T.A. (2007), Menstrual Hygiene: A Neglected Condition For The Achievement Of Unicef and World Health Organisation (2008) Progress On Drinking Water And Sanitation Unicef and World Health Organisation ●● The Netherlands Development Organization (SNV)/IRC International Water and Sanitation Centre (2012), Study on Menstrual Management in Uganda ((Arua, Adjumai, Budibugyo, Kasese, Kyenjojo, Lira, and Sorti Districts) ●● UNFPA (2005), Frequently Asked Questions about Gender Equality ●● UNICEF(2011), The state of the world’s children ●● UNICEF(2009), Wash in Schools Manual ttps://www.unicef.org/publications/files/ CFS_WASH_E_web.pdf ●● UNICEF (2013), WASH in Schools Empowers Girls Education Tools for Assessing Menstrual Hygiene Management in Schools ●● UNICEF (2015) Atlas on Child Poverty in Zimbabwe. ●● UNICEF (2017), Gaining Ground: UNICEF Supported Programming on Menstrual Health and Hygiene Now in 46 Countries Around The World ●● WaterAid (2007), ‘Global Cause’ and Effect How The Aid System Is Undermining The Millennium Development Goals. WaterAid ●● WaterAid (2007), Global cause and effect. How the aid system is undermining the Millennium Development Goals, WaterAid, and London ●● WaterAid and Tearfund (2008), Sanitation and Water Why We Need a Global Framework for Action. WaterAid and Tearfund ●● WaterAid in Nepal (2009), Is Menstrual Hygiene And Management An Issue For Adolescent Girls? A Comparative Study of Four Schools In Different Settings Of Nepal, WaterAid in Nepal ●● WaterAid in Nepal (2009), Seen But Not Heard: A Review of the Effectiveness of Gender Approaches in Water And Sanitation Service Provision, WaterAid in Nepal 102 Formative Research on Menstrual Hygiene Management Final Report, December 2019
●● WaterAID, WSUP, UNICEF (2018), Female-Friendly Public and Community Toilets: A Guide For Planners and Decision Makers ●● Watkins K (2006), Human Development Report 2006 Power, Poverty and the Global Water Crisis ●● Weis-Bentzon A et al (1998), Pursuing Grounded Theory in Law: South North Experiences in Women’s Law, Tano, Oslo and Mond, Harare, 1998. [Selected chapters are available at searcwl.uz.ac.zw – SEARCWL web site ●● WHO 2001, Information, Education and Communication: Lessons from the Past; Perspectives for the Future ●● WHO (2009), Water, Sanitation and Hygiene Standards for Schools in Low-cost Settings Edited by: John Adams, Jamie Bartram, Yves Chartier, Jackie Sims ●● WHO/UNICEF (2017), Progress on Drinking Water, Sanitation and Hygiene: Update and SDG Baselines. Joint Monitoring Programme for Water Supply and Sanitation (JMP), Geneva: World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) ●● WHO and UNICEF Definitions of Improved Drinking-water Source on the JMP Website Archived 2012-06-06 at the Wayback Machine, WHO, Geneva and UNICEF, New York, accessed on June 10, 2012 ●● WHO/UNICEF (2014), Progress on Drinking Water and Sanitation, 2015 Update; WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) ●● WHO and UNICEF JMP report (2018), The WHO/UNICEF JMP estimates for WASH in schools, https://washdata.org/monitoring/sanitation ●● Wilbur, J.et (2018), Developing Behaviour Change Interventions for Improving Access to Health and Hygiene for People with Disabilities: Two Case Studies from Nepal and Malawi. Int. J. Environ. Res. Public Health 2018, 15, 2746 ●● Wilbur J, Torondel B, Hameed S, Mahon T, Kuper H (2019) Systematic Review of Menstrual Hygiene Management Requirements, Its Barriers and Strategies for Disabled People. PLoS ONE 14(2): e0210974. https://doi.org/10.1371/journal.pone.0210974 ●● World Health Organisation (2010), Water, Sanitation and hygiene standards for schools in low cost settings. s.l.:John Adams,Jamie Bartram, Yves Chartier, Jackie Sims ●● World Vision (2015), Rural WASH Baseline Survey, Zimbabwe ●● Zimbabwe Government (2019), Education Act [Chapter 25:04, Amendment Bill. ●● Zimbabwe National Statistics Agency and ICF International (2016). Zimbabwe Demographic and Health Survey, Final Report. Rockville, Maryland, USA: Zimbabwe National Statistics Agency (ZIMSTAT) and ICF International ●● ZIMSTAT (218) Poverty, Income, Consumption and Expenditure Survey (PICES). ●● Zimbabwe Government Central Statistical Office (2015), Zimbabwe Demographic Health Survey. Formative Research on Menstrual Hygiene Management Final Report, December 2019 103
6 Annexes 104 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Annex 1: Sample Coverage
Table 1.1: Sampling
Province District School Target Actual Sample Sample size Size Manicaland Urban Primary 54 Secondary 54 Rural Primary 54 Secondary 54 Mashonaland Urban Primary 54 Central Secondary 54 Rural Primary 54 Secondary 54 Mashonaland East Urban Primary 54 Secondary 54 Rural Primary 54 Secondary 54 Mashonaland West Urban Primary 54 Secondary 54 Rural Primary 54 Secondary 54 Matabeleland North Urban Primary 54 Secondary 54 Rural Primary 54 Secondary 54 Matabeleland South Urban Primary 54 Secondary 54 Rural Primary 54 Secondary 54 Midlands Urban Primary 54 Secondary 54 Rural Primary 54 Secondary 54 Masvingo Urban Primary 54 Secondary 54 Rural Primary 54 Secondary 54 Harare Urban Primary 54 Secondary 54 Peri- Primary 54 Urban Secondary 54 Bulawayo Urban Primary 54 Secondary 54 Peri- Primary 54 Urban Secondary 54 Total Sample 2,134 2,620
Formative Research on Menstrual Hygiene Management Final Report, December 2019 105
Table 1.2: Sample stratification
Province District and Schools Number Number of U=Urban, P=Primary, S=Secondary of Schools Districts Urban Rural 1 Bulawayo Khami (U) Reigate (U) 2 4 - Fusi (P) Josiah Chinamano (P) Pumula South (S) Cowdray Park (S) 2 Harare Mabvuku Tafara Warren Park Mabelreign 2 4 - (U) (U) Epworth (P) Haig Park (P) Muguta (S) Dzivarasekwa 2 High (S) 3 Manicaland Mutare (U) Chimanimani (R) 2 2 4 Cross Kopje (P) Nyambeya (P) St Mary’s Mhakwe (S) Chikanga (S)
Mutare (R) Chibiya (P) Zimunya High (S) 4 Mashonaland Bindura (U) Mt. Darwin (R) 2 2 3 Central Trojan (P) Nembire (P) Chipindura(S) Chiswiti (S)
Bindura (R) Wayerera (S) 5 Mashonaland Marondera (U) Goromonzi (R) 2 2 4 East Godfrey Huggins St Francis Udebwe (P) (P) Bosha (S) Nyameni (S)
Marondera (R) Manhoro (P) Mukanganise (S) 6 Mashonaland Kariba (U) Mhondoro Ngezi (R) 2 3 1 West Nyamhunga 1 (P) Mvurachena (S) Mahombekombe (S) Mhondoro Ngezi (U) Waverley (P) 7 Masvingo Masvingo (U) Mwenezi (R) 2 1 3 Ndarama 2 (S) Rushumbe (P) Gukuku (S) Masvingo (R) Muchibwa Primary (P) 8 Matabeleland Binga (U) Tsholotsho (R) 2 2 4 North Binga (P) Sihazela (P) Binga High (S) Nemane (S)
Binga (R) Sianungu (P) Simatelele (S) 9 Matabeleland Mangwe (U) Insiza (R) 2 2 4 South Dingumuzi (P) Gcabayi (P) Phakamani High Mbaulo (P) (S) 106 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Province District and Schools Number Number of U=Urban, P=Primary, S=Secondary of Schools Districts Urban Rural
Mangwe (R) Kahlu (P) Bulu (S) 10 Midlands Kwekwe (U) Gokwe South (R) 2 2 3 Amaveni (P) - Masekesa (P) urban Bengwe (S) Kwekwe (S) – urban
Kwekwe (R) Zvibomvu (S) Total 20 24 26
Formative Research on Menstrual Hygiene Management Final Report, December 2019 107 FGDs Table 2: Summary of Qualitative Interviews and M FGDs I D nt e ata ethod r v co l i e
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108 Formative Research on Menstrual Hygiene Management Final Report, December 2019
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Formative Research on Menstrual Hygiene Management Final Report, December 2019 109
Annex 2: List of Tables
Annex 2.1: MHM information received by girls in school
Table 22: MHM Information Received At School
Information received at School on MHM Urban Rural Number Percent Number Percent What menstruation is 509 39.1 529 40.1 Signs and manifestation 176 13.5 167 12.7 Normal and abnormal periods 99 7.6 78 5.9 Importance of regular hygiene practices 662 50.8 636 48.3 Materials to use and how to use them 588 45.2 540 41.0 Disposal of materials used 561 43.1 477 36.2 How to manage pain 94 7.2 120 9.1 Linkage between pregnancy and menstruation 324 24.9 386 29.3 Cultural belief and practices related to 8 0.6 12 0.9 menstruation 48 3.7 30 2.3 Discomforts and disorders that may occur in relation to menstruation and how to manage 3 0.2 1 0.1 them. 9 0.7 5 0.4 Managing menstruation for people living with 301 23.1 374 28.4 disabilities Stigmatisation None
110 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Table 23: Additional Information On MHM Required By Girls In School
What information did Total you think was missing individuals % from the information With source? Response What menstruation is 40 15.81% Signs and manifestation 33 13.04% Normal and abnormal 43 17.00% periods Importance of regular 31 12.25% baths Sanitary materials to 59 23.32% use Disposal of sanitary 36 14.23% materials used How to manage pain 55 21.74% Linkage between pregnancy and 28 11.07% menstruation Cultural belief and practices related to 21 8.30% menstruation (What were they?) Discomforts and disorders that may occur in relation to 28 11.07% menstruation and how to manage them. Managing menstruation for people living with 9 3.56% disabilities I don't know 11 4.35% Nothing 2 0.79%
Formative Research on Menstrual Hygiene Management Final Report, December 2019 111
Annex 2.2: MHM information sources for boys
Table 24: Additional Information On MHM Required By Girls In School
What information did Total you think was missing individuals % from the information With source? Response What menstruation is 40 15.81% Signs and manifestation 33 13.04% Normal and abnormal 43 17.00% periods Importance of regular 31 12.25% baths Sanitary materials to 59 23.32% use Disposal of sanitary 36 14.23% materials used How to manage pain 55 21.74% Linkage between pregnancy and 28 11.07% menstruation Cultural belief and practices related to 21 8.30% menstruation (What were they?) Discomforts and disorders that may occur in relation to 28 11.07% menstruation and how to manage them. Managing menstruation for people living with 9 3.56% disabilities I don't know 11 4.35% Nothing 2 0.79%
112 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Table 25: Recommended Methods Of Information Delivery
Method of delivery Urban Rural Number Percent Number Percent One to one 131 21.7 105 17.8 Group education 377 62.4 385 65.1 Class lesson 241 39.9 222 37.6 Pamphlets 27 4.5 14 2.4 Radio 27 4.5 17 2.9 Television /films /documentaries 34 5.6 10 1.7 WhatsApp message 21 3.5 4 0.7 Blogs 14 2.3 3 0.5 SMS messages 17 2.8 3 0.5 Ceremonies (initiation ceremonies) 13 2.2 5 0.9 Other means 16 2.7 23 3.9
Annex 2.3: Social norms, myths and taboos that surround menstruation
Table 26: Main Drivers Of Restrictions And Constrictions Urban Rural Total n (%) n (%) n (%) How is the information on do’s and don’ts passed? Auntie 411(31.6) 394(29.9) 805(30.7) Mother 899(69.1) 758(57.5) 1657(63.2) Father 5(0.4) 21(1.6) 26(0.99) Initiation ceremony 1(0.1) 0 1 (0.04) Faith based organisations 28(2.2) 28(2.1) 56(2.1) Other 335(25.7) 414(31.4) 749(28.6)_
Who ensures that the rules are adhered to? Auntie 299(23.0) 319(24.2) 618(23.6) Mother 875(67.2) 749(56.8) 1624(62.0) Father 13(1.0) 33(2.5) 46(1.8) School health teacher 43(3.3) 26(2.0) 69(2.6) School boarding mistress 12(0.9) 0 12(0.5_ Other 254(19.5) 353(26.8) 607(23.2)
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Table 27: When Boys Know That Girls Are In Menstrual Periods, How Do They Treat Girls? What boys do Rural Urban (n=1,318) (n=1,302) n % n % Provide supportive environment 117 8.9 127 9.8 Abuse 9 0.7 17 1.3 Humiliate 193 14.6 197 15.1 Nickname 98 7.4 87 6.7 Laugh at girls 561 42.6 532 40.9 Isolate girls 87 6.6 95 7.3 Approached for love/sex offers 45 3.4 28 2.2 Other 145 11.0 90 6.9
Table 28: How Does Your Family Treat You During Menstrual Periods?
Urban (n=700) Rural (n=693) Restrict movement 14(2.0) 27(3.9) Seen as unclean 22(3.1) 53(7.7) Stop cooking duties 107(15.3) 167(24.1) Support through less work 316(45.1) 357(51.5) Offer pain killers 140(20.0) 117(16.9) Cleansing/perform rituals 1(0.1) 3(0.4) Other 286(40.9) 200(28.9)
114 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Annex 2.4: Appropriateness of facilities
Table 29: Specific Toilet Observations National Statistics
Characteristics observed Urban (N=24) Rural (N=25) All Some None All Some None 1. Girls individual toilet compartments lockable 4 7 13 0 2 23 2. Girls individual toilet compartments with a container 3 5 16 0 2 23 for disposing of napkins 3. Girls individual toilet compartments contain supplies 2 10 12 1 1 23 for cleaning after toilet use 4. 4. Toilets accessible to girls with disabilities 1 6 17 0 6 19
Table 30: School Waste Disposal And Drainage Observation By Rural/ Urban Location
Characteristics observed Urban (N=24) Rural (N=25) Ye No Partially Yes No Partially s 1. School has a pit for burning used sanitary 8 16 - 3 22 - materials 2. School had incinerator for burning used 6 18 - 1 24 - sanitary materials 3. School has drainage system for removing 14 9 1 3 22 - waste water from school grounds 4. Drainage system functional at the time of 12 2 1 3 - - study
Table 31: Observed Characteristics Of Public Places
Observation Accessibility N=49 All Some None Girls’/women’s toilet facilities separate from boys/men’s 20 10 19 facilities. (40.8%) (20.4%) (38.8%) Girls’/women’s individual toilet compartments lockable from the inside. 5 (10.2%) 12 32 Girls’/women’s individual toilet compartments contain a (24.5%) (65.3%) container for disposing of napkins. 0 Girls’/women’s individual toilet compartments contain 2 (4.1%) 47 anal cleansing materials (water, toilet tissue). 1 (2.0%) (95.9%) Toilets accessible to girls/women with disabilities. 7 (14.3%) Toilets available in the public place designed for younger 3 (6.3%) 41 children. 3 (6.1%) 2 (4.2%) (83.7%) 1 (2.0%) 43 (89.6%) 45 (91.8%)
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Annex 2.5: Challenges faced in ensuring standard hygiene practices in schools
Table 32: Challenges Faced In Ensuring Standard Hygiene Practises As Per Guidelines In Schools- School Health Heads
Location Challenge Total Urban Rural Financial (parents not 0 2 2 paying levies) Insufficient Ablution 0 1 1 facilities Erratic Power Supply 1 0 1 Insufficient water 0 1 1 Shared borehole facilities 0 2 2 with the community Total 1 6 7
Annex 2.6: Access to clean and safe water in school
Table 33: Water Sources By District
District Maronder Mt Total Binga Gokwe Kwekwe a Darwin Borehole Urban 3 0 0 0 0 3 Rural 0 0 0 0 0 Urban Water Tap 0 0 3 0 0 3
Rural 0 0 0 0 0 0 Well Urban 0 0 0 1 0 1 Rural 0 0 0 0 0 0 Borehole + Urban Water Tap 0 0 0 0 2 2 Rural 0 0 0 2 0 2
Borehole + Urban well 0 3 0 0 0 3 Spring Rural 0 1 0 1 0 2
Total 3 4 3 4 2 16
116 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Table 34: Persons Primary Responsible For Fetching/ Collecting Water For All Water-Related Activities By District
District Responsible Mt Total Marondera Binga Gokwe Kwekwe Persons Darwin Caretaker/ Urban 2 2 4 School support staff Rural 0 0 0 0 0 Urban 1 0 0 0 0 1 Students Rural 0 4 0 4 0 8 Water Urban 0 0 3 0 0 0 readily available Rural 0 0 0 0 0 3 Total 3 4 3 4 2 16
Table 35: Status Of Water Storage Containers
Schools with water storage Urban Rural containers N=24 Percent N=25 Percent (12 with containers) (9 with containers) 1. Schools with functional main 18 75 21 84 source of water 12 50 9 36 2. Schools with water storage 9 75 7 77.8 containers 12 100 7 77.8 3. Schools with water in 10 83.3 6 66.7 containers 4. Schools with water 10 83.3 7 77.8 containers properly covered 5. Schools with functional water 11 91.7 8 88.9 containers 6. Schools with water containers accessible to girls with disabilities 7. Schools with water containers acc to youngest children in the school
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Table 36: Challenges Do You Face In Ensuring The Availability Of Clean Safe Water In This School?
District
Mt Marondera Binga Gokwe Kwekwe Total Darwin Location Lack of Urban 0 0 0 0 0 0 electricity Rural 1 0 0 0 0 1 Lack of Own Urban 0 0 0 0 0 0 Water Source Rural 0 2 0 0 0 2 Borehole dries Urban 0 0 0 0 0 0 up Rural 0 1 0 0 0 1 Urban 1 0 0 0 1 2 None Rural 0 1 0 2 0 3 Urban 1 0 3 0 1 5 Power cuts Rural 0 0 0 0 0 0 Urban 0 0 0 0 0 0 Other Rural 0 0 0 2 0 2 Total 3 4 3 4 2 16
Annex 2.7: Experience of menstruating girls in and out of school
Table 37: Problems Faced By Girls At School During Their Menstrual Period
Urban Rural (n=700) (n=693) Cannot concentrate 93(13.3) 154(22.2) Feel physically weal 126(18.0) 154(22.2) Negative mood (Mental effects) 105(15.0) 102(14.7) Experience discomfort 171(24.4) 194(28.0) Affected by the pain 159(22.7) 169(24.4) Frustrated by lack of privacy to change sanitary wear 17(2.4) 33(4.8) All of the above 3(0.4) 2(0.3) None 274(39.1) 227(32.8) Other 19(2.7) 19(2.7)
118 Formative Research on Menstrual Hygiene Management Final Report, December 2019
Annex 3: Ethical Approval Letter