Improving Menstrual Hygiene Management knowledge and practices as part of the Sahel Women Empowerment and Demographic Dividend Project

Component 1: School safe spaces:
One of the main features of the SWEDD project is the safe spaces, where adolescent girls can interact with their peers and mentors and develop socio-emotional skills during a critical period in their development. Safe spaces can be implemented at the community level or at the school level. In this pilot intervention, they will be implemented at the school level for in-school girls. The safe spaces curriculum contains 28 modules divided into four chapters, two chapters on life skills, one on gender and human rights, and one on sexual and reproductive health. The chapter on sexual and reproductive health contains a module on menstruation and MHM. The module lasts 1 hour and 40 minutes and covers topics such as: i. Menstruation and the menstrual cycle; ii. Menstrual symptoms and how to manage pain; iii. Myths and facts about menstruation; iv. Recommended hygiene practices, v. Protection methods available. The training in the safe spaces will take place over the academic year (i.e., 9 months) and is delivered to groups of approximately 25 adolescent girls 11 to 19 years of age.

Component 2: Hygiene kits:
The hygiene kits have been designed and customized based on the dignity kits designed by the United Nations Population Fund (UNFPA). They contain three sets of reusable sanitary pads, three sets of underwear, soap, buttons, and needles. Kits will be distributed once to all the girls enrolled in the school Safe Spaces, following the safe spaces module on menstruation and MHM.

Component 3: Social and behavioral change and communication intervention:
The SBCC intervention will be targeted at adolescent girls and their parents, as well as to key community members in the girl’s direct environment, such as school and koranic teachers, and designed to address the barriers and needs around MHM. Two animation and two live action films were produced and scripted to appeal to girls, their parents, and other key community members. The duration of each video is short (approximately 3 minutes), with the objective that girls and other people targeted by the intervention can watch them multiple times. The videos will be loaded onto cards and distributed to the school Safe Spaces, where mentors will facilitate screening sessions with the girls and their parents, followed by a discussion on the key messages represented in each of the animated videos. Koranic teachers and other community members targeted will be reached through the community campaign planned by the program to increase awareness and buy-in of the population on program activities. The first video will describe the biological process of menstruation and convey the message that menstruation is part of the process that creates life. This will aim to improve biological understanding of menstruation and menstrual blood’s role and re-frame menstruation and menstrual blood in a positive light. The second video will convey the message that adolescent girls can wash their body and their pads during menstruation to stay healthy and comfortable and to reuse their pads. This will aim to improve the knowledge of MHM strategies and address perceptions that menstrual blood is impure and the belief that girls and women should not wash their body during their menstruation. The third and fourth movies will convey the message that mothers (film 3) and fathers (film 4) can support their daughters to manage their menses with comfort and dignity. It will aim to increase discussion, support, and problem-solving between mother and daughter (film 3) and between father and wife or daughter (film 4). This component will be implemented throughout the school year, for approximately eight months.

2023-10-02

2024-06-30

Educational outcomes:
- Absenteeism will be assessed through school and class attendance both self-reported, school reported, and measured through random attendance checks; self-perceived school engagement (Austrian et al. 2021); and school retention at endline.
- Attainment will be assessed by a short math and language test administered during the survey. We will also try to measure attainment assessed by test scores, either in the exams that take place at the end of each trimester in key topics (e.g., math, French, Arabic) or in the
national exams that take place at the end of each cycle.

Health outcomes: self-reported symptoms indicative of urinary tract infection or reproductive tract infection.

Psycho-emotional well-being:
- Measures of general well-being, such as the WHO well-being Index.
- Measures of generalized anxiety, such as the Generalized Anxiety Disorder by Spitzer et al. (2006).
- Measures of depression, such as the Center for Epidemiological Studies Depression CESD-10 by Andresen et al. (1994)
- Adapted measures of menstruation-related anxiety.

Socio-emotional skills: assessed by measures such as the General Self-Efficacy Tool (Gourlay et al., 2022), the Rosenberg Self Esteem Scale (Rosenberg, 1965) and self-esteem during menstruation (Shah et al., 2019).

Mobility restrictions and general social restrictions during periods:
- Mobility restrictions will be assessed by indicators such as self-reported ability and permission needed to travel to certain places.
- Social restrictions will be assessed by permission to perform certain tasks and activities
during periods, such as mobility-related activities (going to school, going out of the house
alone), social activities (attending social functions), religious activities (attending religious
functions), and activities that relate to control over one’s body (washing the body).

Intermediate outcomes for girls (MHM):
- MHM knowledge: score of knowledge and beliefs about menstruation (based on Austrian et al., 2021 and Shah et al., 2019)
- Attitudes towards menstruation: score of positive attitudes towards menstruation (Austrian et al., 2021)
- Individual attitudes and perceived injunctive and descriptive norms around menstruation practices, social and school related behaviors during menstruation.
- MHM Practices (based on Hennegan et al., 2020; Austrian et al., 2021 and Shah et al., 2019)
- Use of effective pain management methods: proportion of girls reporting using at least one effective pain relief method during their last menstrual period if they reported pain (Kansiime et al., 2020).

Intermediate outcomes for mothers:
- Individual attitudes and perceived norms around menstruation practices
- Social and school related behaviors during menstruation.

58 secondary schools where a Safe Space will be implemented, and 3,196 adolescent girls aged 13 years old or more and having expressed willingness to participate in the Safe Spaces, will be selected to evaluate the impact of the pilot intervention. These 58 secondary schools will be randomly allocated to two treatment arms:
(i) School Safe Spaces
(ii) School Safe Spaces plus Hygiene Kits plus a social and behavioral change and communication (SBCC) intervention

Not available

Randomization will be done in office by a computer.

Randomization will be done at the school level.

Yes

58 schools

3,196 students

29 schools in control (receiving school safe spaces only), 29 schools in treatment (receiving school safe spaces, the kits, and the SBCC intervention)

We have conducted power size calculations using different scenarios based on two main outcome variables related to absenteeism and MHM beliefs. For absenteeism, we use the baseline data collected in 2017 for the impact evaluation of the first phase of SWEDD in Mauritania. Based on these data, we constructed a dichotomous variable identifying whether a girl 15-19 years of age was absent from school at least 3 days over the past month. For the power size calculations using this outcome variable, we assume one baseline survey, two follow-up surveys, an intra-group correlation of 0.25, autocorrelation of 0.5 and power of 80%. Calculations assume an ANCOVA specification. For beliefs, we use the midline data collected in 2021 for the impact evaluation of the first phase of SWEDD in Niger. Based on the data, we constructed a dichotomous variables indicating whether an adolescent girl 12-19 years old thinks that when a girl is menstruating, she should not go to school or only go partially. For the power size calculations, we assume one baseline survey, one follow-up survey, an intra-group correlation of 0.15, autocorrelation of 0.5 and power of 80%. Calculations assume an ANCOVA specification. For our power size calculations, we use as a reference the impact found by Benshaul‐Tolonen et al. (2019) on absenteeism. Authors found that girls that received sanitary pads were 5.4 percentage points less likely to be absent at endline, with a reference value of 14%, which would imply a decrease of 38%. In order to detect a 12pp (percentage points) decrease in absenteeism (i.e., whether a girl 15-19 years of age was absent from school at least 3 days over the past month), we would need 29 secondary schools and 1,516 adolescent girls per arm (accounting for 15% attrition and 80% take-up). To detect a 15pp decrease in absenteeism, we would need a sample of 19 secondary schools and 993 adolescent girls, per arm. In terms of the outcomes related to MHM beliefs, to detect a decrease of 15pp in the likelihood that a girl thinks that when menstruating, a girl should not go or should only go partially to school, we need a sample of 24 secondary schools and 1,255 adolescent per arm (accounting for a 15% attrition and 80% take-up). These results show that with a sample of approximately 28 secondary schools and 1,598 girls per treatment arm, we will be able to detect a decrease in absenteeism of 12pp to 15pp, and a decrease in misbeliefs about menstruation of 15pp.