Menstrual hygiene management practices among primary school girls from a pastoralist community in Kenya: a cross sectional survey

Introduction pubescent girls from developing countries are confronted with diverse menstrual hygiene management (MHM) challenges, especially at school. Girls from rural pastoralist communities experience insurmountable MHM barriers. Inadequate coping strategies adopted result in sub-optimal school performance, absenteeism and physical problems. We conducted a study to assess MHM practices among primary school girls from a pastoralist community in Kenya. Methods a cross sectional survey was done among primary school girls in Kajiado County, Kenya. Accent was sought. We administered structured questionnaires which sought information on socio-demographics, knowledge, perceptions and practices. Results we enrolled 320 girls; with mean age of 14.9 years. Their parents were mostly (69.4%) self-employed pastoralists. Good menstruation knowledge was observed in 51.6%, while 45.5% reported diverse perceptions about menstruation. Majority, (80.9%) used sanitary towels as absorbents, but 40.3% delayed changing by > 6 hours. Poor MHM practices were documented in 28.8% and 32.2% kept the issue secret. Factors associated with poor MHM practices on univariable analysis were age (p=0.016), religion (p=0.037), non-discussions (p=0.001), lack of sanitary pads (p<0.0001), lack of latrine privacy (p=0.031), lack of water (p=0.001) and teasing by boys (p=0.016). On logistic regression, factors that independently influenced MHM practices were inadequate latrine privacy (p=0.031) and fear of teasing by boys (p=0.016). Conclusion a third of pubescent pastoralist girls had poor MHM practices largely determined by inadequate latrine privacy and fear of teasing by boys.


Introduction
Pubescent girls from developing countries, especially those from rural settings face diverse "Menstrual Hygiene Management" (MHM) challenges [1][2][3][4]. Many rural schools are not attuned girls' menstruating needs. Girls from pastoralist communities face insurmountable MHM barriers [5,6]. MHM is defined as use of clean menstrual material to absorb or collect blood that can be changed in privacy as often as necessary for the duration of menstruation, using soap and water for washing the body as required and having facilities to dispose of used menstrual management materials [7].
Unfortunately, many rural schools have inadequate water, sanitation and hygiene facilities (WASH) for girls [2][3][4][5][6][8][9][10] Besides, menstruation is surrounded by divergent religious beliefs and cultural perceptions that impact on MHM practices [5, 6, 10]. It is considered a taboo by various communities and even by the teachers; hence they do not provide information and guidance on the meanings and management of menses [4]. Unable to cope with this physiologic process and to avoid suffering shame, girls adopt diverse coping strategies that vary across regions, based on personal preferences, resources available, knowledge and cultural beliefs [4]. This affects their rights, social and mental well-being, resulting in sub-optimal school performance, school absenteeism, and drop outs [12][13][14]. On average, adolescent girls miss at least 6 weeks of school per year due to menses [13,15]. Further to, many suffer diverse reproductive health problems, especially urogenital infections arising from unsafe unhygienic practices [6,16]. This has worsened existing gender disparities observed across regions on access, retention, transition and achievements on education [13]. To mitigate its effects, in 2009, the Government of Kenya increased the budgetary allocation to schools to improve WASH facilities and to provide subsidized sanitary pads for needy girls [17][18][19]. We conducted a study to assess the MHM practices and challenges among primary school girls from a rural pastoralist community in Kenya.

Methods
Design, setting and study population: we conducted a schoolbased cross-sectional survey in Mashuru Sub-county, Kajiado County, Kenya. Ten out of 47 primary schools in the county were randomly sampled. The schools were stratified by classes, and only girls in classes 4-8 were included. Boys and girls that had not attained menarche were requested to leave the classrooms. Systematic random sampling was done, using a sampling frame generated from class lists. Girls absent on the interview day and those non-residents in the area in the preceding 3 months were excluded.

Results
Subjects' enrollment and participants: out of a total of 648 eligible girls, 247 were pre-menarche and 45 were absent from school on day of interview. We sampled 356 girls, but 24 girls declined participation, while 12 were excluded based of non-residency, hence 320 girls were enrolled in the study. Recycled absorbents should be made of materials that are low cost, easy to clean and are quick to dry, in order to prevent genital infection [25]. Knowledge on causation and origin of menstrual blood was low, but overall knowledge level did not independently influence poor MHM practices. Other African studies documented lack of scientific knowledge of menstruation and puberty among school girls [26,30,[34][35][36].
In Kenya, very few girls were able to describe menstruation in biologic terms [29]. Inadequate school support leaves many girls preferring to be absent from school during menstruation [4,39]. In study done in Western Kenya, lack of resources for menstruation led to disengagement from school and stigma [2]. In another Kenyan study, done in Nairobi (Urban) and Garisa (rural) schools observed that 86% and 53% respectfully, of girls missed ≥ 1 day of school every 2 months [24].
Similar findings were observed Ethiopia, where 40% girls missed school because of stress related to menstruation [22]. The girls were constantly alert for leakages, foul smell and discomforts and had poor concentration in class, which contributed to teasing by boys [4].
Teasing humiliates girls by causing stress and embarrassment, stripes their dignity, leaving them withdrawn and lowering their self esteem.
In our study, teasing by boys was independently associated with poor MHM practices. In our settings, men/boys often lack facts on menstruation, hence cannot support the women/girls around them.
It was suggested by 5.8% of the girls that educating boys on the matter, would help them cope better during such times. This concurs with findings made from a study done in South Sudan, where 43.8% girls reported that they were afraid of being made fun of by boys [8].
Likewise, in a Tanzanian study, many respondents suggested need to educate boys on menstruation [2,46]. Adolescence is a crucial developmental stage characterized by heightened self-awareness and actualization, and this could be totally deranged by menstrual accidents, leading to reduced self confidence and emotional wrecks.   *Respondents had more than one response