Knowledge and Perceptions on Menstrual Hygiene Management Among School-Going Adolescent Girls in South Sudan

This article draws on grounded theory and ethnographic fieldwork approaches and applies a political ecology of adolescent health (PEAH) framework to examine how school-going adolescent girls and their communities perceive sexual and reproductive health education (SRHE) and menstrual hygiene management (MHM) in the region. Three young girls were purposefully selected from each of 10 government-run mixed primary schools in Juba, South Sudan, as peer research evaluators (PREs) and key informants (N = 30). Each PRE interviewed and reported on three of their peers about how they talk about and manage menstruation. The findings show that political, socioeconomic, and cultural factors do influence adolescent girls’ and their communities’ perceptions about puberty and menstruation. In general, MHM was culturally constructed, but the results show a disproportionate emphasis on social norms rather than on SRHE, which could have long-lasting health implications for adolescent girls. There is a need for all stakeholders in education to come together to better grasp and address the obstacles young girls face in their communities and school environments. There is also a need to develop relevant training materials to assist care providers and adolescent girls to openly talk about and address sexual and reproductive health issues.


Introduction
Menstruation is a biological phenomenon that happens every month to healthy reproductive age females.In recent years, researchers have gained interest in studying menstrual hygiene management (MHM) and sexual and reproductive health education (SRHE) among young girls in low-and middle-income countries (LMIC) (Bharadwaj & Patkar, 2004;Sommer, Hirsh, et al., 2015).This is partly because poor MHM negatively affects young girls' school enrollment and retention compared with their counterparts (Biddlecom et al., 2009).SRHE is a program that teaches girls what to expect as they grow up, what menstruation is, and how to safely navigate these natural biological changes into adulthood (Allotey et al., 2011).Proper MHM provides young girls with appropriate physical and emotional skills to manage their monthly periods with confidence.Culturally appropriate SRHE coupled with good MHM will enable girls to take greater charge of their lives, feel positive about themselves and their bodies, and mitigate health problems (Allotey et al., 2011;Biddlecom et al., 2009).Despite increased research interest, SRHE and MHM receive little to no attention in public education and policy discourses in LMIC countries like South Sudan.This study aims to address this gap by exploring how school-going adolescent girls and their communities perceive SRHE and MHM in Juba, the capital of South Sudan, one of the world's most war-ridden countries.
Like many LMICs, South Sudan has many school-aged girls, but not all have the liberty to go to school.Discussions about school opportunities for girls in South Sudan go beyond the scope of this article.This study focuses only on adolescent girls who are able to attend school, referenced here as school-going girls.This study will help us to better conceptualize how SRHE and MHM are constructed and practiced among young adolescents in educational institutions where they are supposedly assisted with relevant information to improve their health and livelihood.

Literature Review
Menstruation characterizes the onset of puberty among girls (Eccles, 1999;Jones et al., 2009).Puberty is a period of physical, psychological, and cognitive changes that occur naturally in both healthy girls and boys (Brooks-Gunn, 1987;Harris, 2014;Sommer, 2009a) and when gender norms and identities are shaped (Kettaneh et al., 2014).In most cases, young girls are afraid, anxious, ashamed, and confused by the onset of their menstrual periods because they lack clear comprehension of what is happening in their bodies (Aniebue et al., 2010;Kane et al., 2016;Mason et al., 2013;Sommer et al., 2014;Sumpter & Torondel, 2013).Hence, changes during puberty may have overreaching social and cultural implications for girls' physical and emotional well-being, making many of them more vulnerable to early marriages and dropping out of school (Herz et al., 2004;McMahon et al., 2011;Sommer, 2009b).This is partly because with menarche young girls are regarded as potential child bearers.Some of the challenges mentioned above arise from cultural taboos and norms around menstruation, a lack of discussion on sexual maturation, and misinformation from a variety of unreliable sources, including peers, parents, and teachers (Sommer et al., 2014;Sumpter & Torondel, 2013).Therefore, it is paramount that every young girl should be properly educated about menstruation, why it occurs, and how to deal with it prior to menarche.The onset of menstruation could provide a natural entry point to educate girls about their reproductive capacities and health choices.Hence, SRHE and MHM are very important to ensure young girls receive the practical support (e.g., sanitary menstrual materials and washing facilities) and emotional guidance (e.g., encouragement) they need to handle their monthly periods (Allotey et al., 2011).
Some entrenched negative social norms about puberty might deepen stigma around SRHE and MHM, and exacerbate the sufferings of adolescent girls who are already among the most victimized in conflict regions like South Sudan (Allotey et al., 2011;Human Rights Watch, 2013;Kane et al., 2016;Mkandawire et al., 2019).Puberty has been identified (Bastien et al., 2011;Biddlecom et al., 2008;Blake et al., 2018;Kirby, 1999;World Health Organization [WHO], 2007) as a window of opportunity to reach adolescent girls and boys with appropriate SRHE before they get involved in high-risk sexual behaviors and to reduce injuries, unplanned pregnancies, and health problems such as sexually transmitted diseases (STDs) (Dixon-Mueller, 2010;Gallant & Maticka-Tyndale, 2004;Kirby, 2001;Sommer, 2009a).For instance, while examining school-based HIV prevention programs for African youth, researchers (Gallant & Maticka-Tyndale, 2004) found that programs aimed at young adolescents who were yet to become sexually active provided unique and effective opportunities to avoid STDs.On the contrary, analysis of adolescents aged 12 to 19 years in Burkina Faso, Ghana, Malawi, and Uganda found that girls were more vulnerable to dropping out of school once they became sexually active than their male counterparts.
Unfortunately, the majority of adolescent girls (66%) in South Sudan had very limited or wrong knowledge about MHM, whereas many had zero knowledge about menstruation before it happened to them (Tamiru et al., 2015).Other studies conducted in low-income countries such as Nepal (Jothy & Kalaiselvi, 2012), Kenya (McMahon et al., 2011), and India (Suhasini & Chandra, 2017) found similar results.These findings point directly to a need for intervention programs before adolescent girls become sexually active (Biddlecom et al., 2008).Despite these enlightening studies, no research has yet explored similar contextual experiences in South Sudan.

Analytical Framework
This study is situated within the political ecology of adolescent health (PEAH) framework, a subset of political ecology (PE), which is concerned with analyzing interactions between social processes and physical environments (Bryant, 2017;Robbins, 2020).Using the PEAH analytical framework helps us to understand how SRHE and MHM are perceived among schoolgoing adolescent girls and their communities, and how both social and physical environments shape such perceptions.PE acknowledges that health and well-being are not entirely products of our physical bodies, but involve many factors operating at different scales outside our corporeal selves (Bryant, 2017;De Francisco et al., 2007;Kane et al., 2016;Mkandawire et al., 2019;Robbins, 2020).Consequently, health and well-being are produced discursively and historically within the context of individual, family, kinship, and community; political institutions; power structures; and political or religious ideologies (Blum et al., 2012;Correa & Petchesky, 2007;De Francisco et al., 2007;Smyth, 2002).With a PEAH framework, we can better comprehend how access to, or lack of, relevant SRHE and MHM practices may influence adolescent girls' capacities to make decisions that impede or enhance their own and others' sexual and reproductive health and rights (Blum et al., 2012;Correa & Petchesky, 2007;De Francisco et al., 2007).As mentioned above, SRHE and MHM are important factors that shape girls' health directly, and ultimately their education and community participation (Blake et al., 2018;Care International, 2014;Kettaneh et al., 2014).
Evidence (Bastien et al., 2011;Biddlecom et al., 2008;Blake et al., 2018;Kirby, 1999;WHO, 2007) suggests that improved parent-child communication on SRHE contributes to reductions in risky sexual behaviors among adolescents.However, many parents and trusted adults are uncomfortable or uninformed about SRHE and MHM and tend to avoid addressing such important societal issues (Biddlecom et al., 2009;Biddlecom et al., 2008;Muhwezi et al., 2015;Sommer, 2011).On the contrary, it is worth noting that for many girls and young women, sexually related decision-making is constrained by contextual social and economic circumstances beyond their control (Bankole et al., 2007), especially in poor countries like South Sudan (Amnesty International, 2016;Care International, 2014;Human Rights Watch, 2013;Mkandawire et al., 2019).For example, a survey (Tamiru et al., 2015) conducted in Ethiopia, South Sudan, Uganda, Tanzania, and Zimbabwe by the SNV 1 Netherlands found that two thirds of school-going adolescents in South Sudan use unhygienic materials to manage their menstruation due to unaffordability.In addition, 78% of young girls miss a considerable number of school days during menstruation due to the lack of affordable sanitary pads and 56% due to the lack of private changing rooms in their schools.The survey also found that about 80% of schools in South Sudan have no MHM facilities on their premises, a situation that minimizes the importance of general body hygiene among young adolescent girls (Bharadwaj & Patkar, 2004;Sommer, 2011) and further entrenches negative attitudes toward SRHE and MHM in the region.
To achieve universal primary education, there were increased efforts in research, programing, and policymaking within private and public institutions to enhance school enrollments and the success of girls in South Sudan (South Sudan Ministry of Finance and Planning, 2017;South Sudan National Bureau of Statistics, 2013;WHO, 2000) and in many LMICs (Blake et al., 2018), in general.However, inadequate governments and intuitional supports undermined such development initiatives for SRHE and MHM (Blake et al., 2018;Mensch et al., 2001;Tamiru et al., 2015).This was partially due to insufficient understanding of how perceptions and some ideologies, mentioned above, influence SRHE, and MHM in particular, as subjects of strict taboo, shame, and revulsion in many LMIC countries (Kettaneh et al., 2014).
To our knowledge, our study is the first to present qualitative research from South Sudan that explores how school-going girls and their communities perceive SRHE and MHM, and how they handle real and/or perceived challenges related to MHM in their communities and school environments.Context-specific knowledge generated from this research will aid in the development of training, behavioral changes, and communication materials for SRHE and MHM for South Sudan.Such training materials will dispel some of the myths and misconceptions that impede effective SRHE and MHM (Blake et al., 2018;Sommer, Sutherland, & Chandra-Mouli, 2015).Understanding SRHE (e.g., puberty) and MHM (e.g., use of sanitary pads) will underscore the contextual perceptions of communal recognition of sexual maturation and expectations, and the unwarranted pressures for sexual initiation among young girls (Jimenez et al., 2007;Mkandawire et al., 2019) in South Sudan and in similar war-prone and/or LMIC countries.

Research Setting
This study was conducted in Juba, the capital city of South Sudan, a nascent country, which seceded from Sudan in 2011 after a referendum.The city was chosen because it enjoyed the relative peace and security needed to perform the research.After its separation from Sudan, much of South Sudan is still waiting for the peace dividends and the provision of basic social services, such as water, sanitation, and hygiene (WASH).Currently, about 54% of the country's Central Equatorial State's (CES) schools have some form of drinking water, 63% latrines, 6% electricity, and 7% health care amenities within their facilities (Tamiru et al., 2015).More than half of the population of South Sudan still live under the poverty line.Nonetheless, peace dividends might not be realized for years to come, because, only 2 years after its independence (South Sudan National Bureau of Statistics, 2013), South Sudan fell into another civil war due to power struggles among its leadership.A peace accord was signed in 2015 but violated in 2016, after this study's data had been collected.Currently, the country has another shaky peace agreement, signed in 2018.
South Sudan has an estimated area of 640,000 km 2 with a population of about 12 million people.About half (49%) of its population is women, more than 70% of whom are illiterate (South Sudan National Bureau of Statistics, 2013).Estimates show that the country has less than one health worker per 1,000 people, which is significantly below the average density of the health workforce (3.2) throughout Africa.Approximately 45% of women in the country marry before their 18th birthday, whereas 7% marry before they turn 15 years old.This figure is higher (10%) in the CES, where Juba is located (South Sudan Ministry of Health and National Bureau of Statistics, 2013), further emphasizing the need to better understand SRHE and MHM in the region.Polygyny is widespread in South Sudan, with 41% of men having more than one wife (South Sudan Ministry of Health and National Bureau of Statistics, 2013;Stern, 2015).The country has 10 States, with the CES having an estimated population of 368,400 people.
In South Sudan, the social status of women and adolescent girls continues to worsen due to widespread civil and tribal wars and the availability of small arms, coupled with problems of alcoholism that fuel domestic violence, rape, physical abuse, and economic deprivation (Bubenzer & Lacey, 2013;Kane et al., 2016;Mkandawire et al., 2019).After many years of civil war with the government of northern Sudan, questions linger about the meaning of peace and liberation for women and young girls in South Sudan.It is worth noting that adolescent girls between the ages of 10 and 19 years constitute around 11% of the South Sudanese population (Southern Sudan Centre for Census, 2010).They are an important age group that the new nation must reckon with and understand their experiences of SRHE and MHM.However, with no clear government policies, these young women will continue to suffer from discrimination, coercion, and violence (Cook & Dickens, 2000;UN High Commissioner for Human Rights, 2000), which are prevalent in South Sudan due to high rates of illiteracy and disregard for basic human rights (Care International, 2014;Human Rights Watch, 2013).
Currently, South Sudan primary education consists of 8 years, followed by 4 years of secondary school and 4 years of university or tertiary education.Although the country acknowledges the importance of UN Sustainable Development Goal #4 to ensure inclusive and equitable quality education and promote lifelong learning opportunities for all, it struggles to explicitly address these challenges (South Sudan Ministry of Finance and Planning, 2017).For example, in 2012, the ratio of girls to boys in primary schools was relatively high (59% girls to 41% boys), but got inverted drastically at the secondary school level.The situation might have worsened due to several ongoing conflicts and civil wars in the region.In addition, many young girls were likely to drop out of school due to limited SRHE and MHM support.Finally, adolescent girls were more likely to assume roles as care providers and supporters for relatives who were aged or sick during conflict and food crisis (South Sudan National Bureau of Statistics, 2013), who are everywhere in the nascent country.

Participant Selection
In March 2016, three young girls were purposefully selected from each of 10 government-run mixed primary schools in Juba to be peer research evaluators (PREs).Public schools were chosen because of infrastructure similarities among them and chronic insufficient government financial support (South Sudan Ministry of Finance and Planning, 2017) compared with private schools that might have additional amenities due to different support systems.Due to financial difficulties, many parents enroll their children in public or government schools.The PREs (N = 30) were selected as key informants based on their leadership skills (e.g., chair of a club) and/or as active members in their school communities (e.g., club members, athletes).
The PREs received 3 days of intensive participatory training on how to develop conversational prompts and the confidence to guide one-on-one interviews with their peers.Before data collection, an additional 1-day workshop was organized for the PREs to test the interview guidelines and their conversational abilities and confidence for collecting the relevant study data.Each PRE conducted three in-depth conversational interviews with peers in their school network in English or Arabic.
The PREs were required to remember their conversations or record keywords to remind themselves of the discussions.After interacting with their interviewees, the PREs reported their key findings to the research team, one at a time, and were audio recorded.The PREs were encouraged to report on what and how their peers (i.e., others like them) talk about and manage menstruation, but not to talk directly about themselves to maintain confidentiality.In total, the PREs reported on 90 interviews with their networks.
This innovative data collection approach was taken for several reasons.First, delegating PREs to talk with their peers was an effective way of getting information from participants without the risk of breaking cultural norms.Second, peers are more likely to talk freely to one another than to researchers.Third, PREs are more likely to report (more plausibly) on the experiences of others than of themselves.Last, PREs are more likely to help in the analysis and interpretation of qualitative data collected.
The study was conducted with the assistance of staff from BRAC, an international development organization dedicated to alleviating poverty among the poorest in society.BRAC is one of the very few international nongovernmental organizations (NGOs) from the Global South to make a name for itself on the global humanitarian development stage.It works in many developing countries in Asia, the Middle East, and Africa.In South Sudan, BRAC worked in hard-to-reach communities across different counties, including in Juba.The organization provided after-school programs to school-going girls in the region.It helped with the selection of PREs, facilitated their training, and reported them to the research team.However, in July 2016, BRAC scaled down its operations in South Sudan due to countrywide insecurity.
Ethics clearance was obtained from the South Sudan Ministry of Health.All the PREs and their interviewees were asked for their informed consent to participate in the oral conversation and were promised confidentiality.The PREs were asked for additional consent to record their reports and exchanges with a research team member.The PREs purposefully selected three peers to interview and briefed them on the study's objectives outlined in the consent form.Interviews were conducted in private during school time (e.g., lunch break) or during after-school programs on school premises.They lasted between 45 and 60 minutes.

Interview Checklist
The interview guideline was developed based on themes and constructs related to adolescents' knowledge of SRHE (e.g., puberty and menstruation), MHM (e.g., use of menstrual pads and hygiene), and how they dealt with real or perceived challenges.The guidelines were open-ended to stimulate conversation.The research team reviewed and pretested the checklist at least once with the PREs for flow, clarity, length, and to ensure interviewers were comfortable asking required and follow-up questions.The checklist was designed to be flexible enough to allow PREs and the researchers to follow up on issues raised by participants that were not specifically included.The authors used the same checklist to interview and collect data from the PREs.

Data Analysis
Given the limited previous research conducted on SRHE and MHM in South Sudan, the study draws on ethnographic fieldwork (Price & Hawkins, 2002) and grounded theory (Corbin & Strauss, 2014) methodologies for its analysis.These approaches are appropriate for examining understudied phenomena embedded in broad social, political, and economic contexts (Glaser, 1992) and are widely used in a number of social science disciplines (Bryant & Charmaz, 2019).The anthropological approach accentuates the importance of building a relationship of trust and rapport with the community as a prerequisite for researching social life, advanced in this case by BRAC's after-school programs.Grounded theory is a qualitative data analytical approach, which helps us to better understand how social or biological phenomena are perceived among individuals and their communities.
All data collected in Arabic were translated into English, and all audio recordings of the PREs were transcribed verbatim and entered into NVivo qualitative software for thematic analysis (Jackson & Bazeley, 2019).The data were analyzed based on the key themes outlined above.Thematic categories were identified through line-by-line coding, a common strategy in deductive qualitative research that draws heavily on grounded theory (Corbin & Strauss, 2014).Group consensus was used to categorize emerging themes based on a number of criteria, including relevance to the research objectives, frequency (themes with the greatest number of mentions were considered important), universality (how predominant the same theme was across research participants), differences between research participants, relative importance of the themes within interviews, and emphasis (e.g., emphatic speech).Threats to qualitative research rigor were minimized using member checking and researcher triangulation by allowing research team members to analyze and interpret sections of the data (Baxter & Eyles, 1997).The quotes reproduced here were inductively generated from the interviews to illustrate the themes that emerged from the conversations conducted by the PREs with their interviewees and reported to the authors of this article.The direct quotations maintain respondents' voices to ensure credibility and dependability of the results (Baxter & Eyles, 1997;LeCompte & Goetz, 1982).Where illustrative quotations are presented, pseudonyms, age, and generic school names are provided.

Findings
The findings presented below demonstrate the complex ways school-going adolescent girls and their communities perceive SRHE and MHM within the PEAH analytical framework in South Sudan.The results fall under five major themes: knowledge about puberty and menstruation; perceptions about menstruation; MHM; challenges of menstrual management; and coping mechanisms among adolescent girls.Both PREs and their interviewees ranged in age between 14 and 17 years.

Knowledge of Puberty and Menstruation
The study participants acknowledged puberty as a normal biological and physiological phenomenon that signals profound progression from childhood to adolescence among boys and girls.PREs, like Papiti and Nakuru, clearly articulated how their interviewees defined puberty: Puberty is when a girl is getting ready to become a woman and a boy to [become a] man.(Papiti, 15, Malakia Primary School) It's a period of change in the body of both male[s] and female[s] that every part of the body will develop from small to big.(Nakuru,17,Gudele Basic School) When asked how they defined menstruation, some of the study participants reported different but correlated understandings.Like many of the adolescents, Papiti discussed how her colleagues conceptualized menstruation as " . . . the coming of blood from the place where a girl produces urine" (Papiti, 15, Malakia Primary School).Furthermore, some of the study participants described menstruation as a monthly blood flow from the body of a woman or an adolescent girl who was matured enough to have babies.The adolescent girls acknowledged menstruation was different among women; it happened to those who were between 12 and 55 years old, and it could last 2 to 7 days.
During menstrual periods, many PREs like Ihisa and Pita and their peers reported painful experiences that sometime resulted in school absenteeism: . . .normally get sick, feel body weakness, and even breast becomes big and pains a lot during my period.(Ihisa, 17, Buluk A Primary School) . . .I get back pain, stomach pain, fever, headache, dehydration, tiredness, feel sleepy, loss of appetite, weight loss, don't move outside and remain out of school . . .(Pita, not stated, Gudele Primary School) To get relief from these painful experiences, many of the adolescent girls took herbs like alome, a traditional medicine that is white in color and has a bitter taste.Alome is also used to cure stomachache.When they were able, the respondents visited hospitals or clinics to consult with health practitioners.Others just went to pharmacies or corner stores to buy pain remedies like paracetamol to alleviate their discomfort.In some cases, they just drank hot water or tea and/or took a bath with hot water and slept.Other girls mentioned exercising and eating enough good food to relieve the agony.
When asked where and when they get information about puberty, the PREs answered that many of their peers learned from their teachers, mothers, sisters, and senior girl friends at school.Because of the different and sometimes contradictory sources of information, many PREs like Alek and their adolescent peers only actualized puberty when they experienced menstruation and physiological changes: Many of the study participants recognized physiological (e.g., voice changes) and physical changes in their bodily appearance, including having pimples, development of breasts and buttocks, and growth of hair in their armpits.With these physiological changes, many participants felt happy that they were growing up and could take care of their own bodies, prepare materials for menstruation, and keep some special outfits like bras and panties.
However, some of the adolescent girls did not know about menstruation beforehand due to insufficient information.They explained their discomfort when it first happened to them.Some of the young girls thought they were going to die because they were bleeding.Many of the interviewees acknowledged they were scared, frightened, and ashamed to move around the community or even go to school, and cried from their menstrual experiences.Fortunately, some of the PREs, like Mary and Salwa, and their peers got parental reassurances: When I received my first period I was very ashamed and hide inside the room, but I was relief from the shame when my mother explained it better to me.(Mary, 14, Munuki Primary School) I first got my period at night when I was sleeping.Suddenly I woke up and thought someone had broken my virginity.I started crying when my mother heard this she asked what happened.I told her that someone had injured my vagina but the door was closed.Then my mother told me no my lovely daughter, it is what I said last time to you about the period in a woman.(Salwa,17,Buluk Primary School) Despite this support, many respondents felt ashamed when they started buying their own personal hygiene products at public venues like shops and pharmacies.Happily, the sense of shame gradually disappeared as they embraced the new reality of growing up.As Poni argued, the new life experience brought her and her peers to a new social position among their families and communities."I am very happy because all my family members respect me that now I am a big person.I feel responsible to my family . . ." (Poni,16,Hai Malakal School).Some of the adolescent girls admitted that their mothers become more interested in them and advised them on how to take care of themselves, be more responsible to family issues, and avoid early pregnancy.Many argued that their parents advised them to stay home and not to associate with boys.If they went outside, they were required to be home before dusk.
Some parents provided monetary assistance to their adolescent girls to purchase personal items such as sanitary pads, bras, panties, clothes, soaps, and different cosmetics during menstruation.Like Susan, many of the respondents claimed that the purpose of increased parental attention was to make them more responsible as individuals and important members of their families and society, in general: My parent [mother] tells me that I should not play with boys and I should learn how to prepare good food.Even sometimes they [parents] buy good clothes for me so that I look responsible.(Susan, 15, Gudele Primary School) Twenty-three out of 30 PREs confirmed that their peers knew about menstruation before it happened to them.These study participants knew about it from their sisters, mothers, aunties, and grandmothers.Although the experience of menarche intrigued them, many wished they had had more information before it happened to them.Nonetheless, many of the participants were very appreciative of the assistance, advice, encouragement, and guidance they received from their friends and family members on how to handle their periods and use pads.

Perceptions About Menstruation
Twenty-two out of 30 PREs reported that their peers regarded themselves as unclean or/and impure during menstruation.Although such views varied among the research participants, they express a common sentiment.Like many of the PREs, Kaku, Sadia, and their interviewees believed their parents and community members perceived them as unclean during menarche and they were forbidden from cooking and even going to school or church: Some parents think that a girl who is experiencing menstruation . . .should not cook and get out from the compound.(Kaku,16,Gudele Primary School) . . .some parents restrict [us from going] outside the house until the period is over.All the girls are not even allowed to go to church.(Sadia,18,Atlbara Primary School) Despite the negative perceptions, some of the study's participants emphasized that they were clean.Like some of the PREs, Naponi and her peers believed God's creations are always clean."Period was made by God and anything made by God is clean or pure" (Naponi, 17, Atlabara Basic School).

Menstrual Hygiene Management
Regarding bodily hygiene, almost all the participants recognized the lack of WASH facilities and resources to help them maintain proper body hygiene during their menstrual periods at schools, in the public spaces, and sometimes even at home.Some participants, the PREs reported, used dirty materials (e.g., cartons, leaves, and dirty pieces of clothes) because they could not afford sanitary pads.In addition, some adolescent girls did not take regular baths due to a lack of sufficient water and changing clothes.Consequently, they stink.Where there were facilities (e.g., toilets), they had no disposal stations, disinfectants (e.g., soap), and/or running water.In general, study participants argued that inadequate WASH facilities in their communities hindered their ability to properly manage their menstruation, fight disease, and reduce infections and contaminations.
Although some of the study participants whose families had financial resources bought and used sanitary pads, many of the girls used local pads made from pieces of cloth, cardboard, 2 cotton wool, and/or tree leaves to manage their periods.Based on interactions with her peers, Kaku verbalized the study participants' concerns, clearly stating, I always use pieces of clothes and sometimes when there is no money, I use cardboard, I cut the box into pieces and put it in my private part and wear underwear on it.(Kaku,16,Gudele Primary School) Of the 30 PREs, 20 shared the fact that most of their peers used reusable materials during their menstruation cycles.Those who did so cleaned their reusable materials by washing them with warm water and soap and drying them in the sun, ironing them regularly before they reused them.However, some of the PREs like Susan and their peers acknowledged the problem of not managing reusable pads properly: If I don't wash and dry my materials for a period, very well, the vagina will itch a lot.(Susan,15,Gudele Primary School) With inadequate MHM skills, many of the PREs like Agur and her peers were scared, disgusted, sickened, and afraid of using reusable pads: . . .blood has bad smell . . .blood is dirty and it carries diseases.(Agur, not stated, Libya Primary School) Most of the respondents used sanitary pads 2 to 3 times a day.Most of the adolescent girls who utilized reusable pads wash and dry them for reuse.However, they tended to dry them indoors.If they were drying them outdoors, they hid them with other clothes so that nobody would notice them.Unfortunately, due to a lack of financial resources, some of the peers utilized their reusable materials for longer than recommended.On the contrary, study participants who used disposable pads wanted assurance of their safety.
When asked how they knew how to calculate the timing of their next period, more than half of the adolescent girls said it was from their mothers, sisters, friends, and peers.Depending on the availability of resources and knowledge level, they used different techniques.Some of the interviewees used calendars, sticks, and/or counting after every 28 days for the next period.However, some PREs like Agum and their interviewees used self-awareness to determine when their next period will happen: I do not know but when my body starts being weak, then I know my period is about to come.(Agum, 17, Juba 1 Primary School)

Challenges of Managing and Coping With Menstruation
During the interviews, study participants highlighted many challenges of managing and coping with their menstrual experiences.This section discusses three key challenges outlined by the adolescent girls and the coping mechanisms they used: lack of facilities, shaming and bullying, and negative public perceptions about menstruation in their communities and school environments.
Lack of facilities.One of the biggest obstacles faced by participants was the lack of basic facilities for WASH in almost all the government schools studied.Many of the schools do not have basic WASH facilities or dumping stations, changing rooms, or emergency sanitary pads.Consequently, many respondents usually threw their used pads on the roadsides, into toilets, rubbish pits, and/or buried them, if convenient.Only four out of 10 schools studied had some form of WASH facilities such as water and soap in their toilets.However, when the urgent need for assistance to clean up and change arose because of unexpected menstruation, young adolescent girls often mobilized themselves and sought assistance from homes in the school's vicinity.
Shaming and bullying.Another outstanding challenge was shaming and bullying from male students.Like Marua and Mary, many of the study's participants argued that boys in their schools shamed them when they accidently or unknowingly had traces of menstrual blood on their school uniforms.Because of name-calling, many PREs reported that their peers would abstain from school for days, change schools if possible, or drop out of school to avoid the taunting: Boys laugh at us if suddenly blood comes out and appear on clothes.It is very shameful.(Marua, 14, Munuki East Primary School) They nickname us.Many times, it results in absenteeism and even drop out from school.(Mary,14,Munuki East Primary School) In cases of bullying, the first line of support for adolescent girls were their female teachers.However, many schools had few or no female teachers.When teasing continued, the adolescent girls returned home with the support of some of their close friends.Many of the study participants lamented the lack of support from their male teachers, school communities, and administrations to punish the bullies.Many of them did not go back to school because of the harassment.Unfortunately, both male and female teachers had no moral authority to refuse the girls to freely leave the school premises and be absent from school due to menarche, because many of the schools had no basic WASH facilities.
Public perception.Another challenge was public perception, for example, that having sex causes menstruation among young girls.Study participants were perceived as "immoral" if they had an early menarche.To avoid negative perceptions, many adolescent girls hid their menstrual experiences and did not seek help from family members or peers.

Discussion and Conclusion
This study developed a better understanding of how school-going adolescent girls and their communities in South Sudan perceive SRHE and MHM using the PEAH framework.The focus was on school-going adolescents because not all school-age girls are able to attend schools in South Sudan.The findings show that adolescent girls' perceptions of SRHE and MHM are embedded in cycles of influences including personal characteristics, family, kinship and community values, political institutions, power structures, and/or religious ideologies (Correa & Petchesky, 2007;De Francisco et al., 2007;Mkandawire et al., 2019).In general, these factors influenced adolescents' specific health behaviors and outcomes both at the individual (e.g., knowledge and attitudes or perceptions about menstruation) and at the community or environment levels (e.g., availability of school sanitation facilities, presence of female teachers, or understanding community members).
At an individual level, the findings show that many adolescent girls experienced puberty and menstruation as social positioning in the family and the community at large.Many of the study participants acknowledged some social norms reinforced by their parents, such as how to be more responsible to family, avoid early pregnancy, and take care of themselves during menstruation.However, the results show a disproportionate emphasis on social norms rather than a holistic focus on SRHE, which could have long-lasting health implications for young girls over their life courses.
The findings give no indication that parents and schools were engaged in more comprehensive MHM for girls and SRHE for all adolescent boys and girls.However, the results support the misconception that parents or guardians (Sommer, 2011) pay attention to the SRHE of their adolescent children and highlight the importance of and need for SRHE and MHM if adolescent girls in Juba, and South Sudan in general, are to grow to their full potential.Often, sexual and reproductive illnesses are imperceptible to health care providers and sometimes even to the individuals experiencing them (Roudi-Fahimi et al., 2008).Many cultural traditions and norms contribute to the relative invisibility of many sexual and reproductive health problems (Kettaneh et al., 2014;Roudi-Fahimi et al., 2008;Sommer, 2011).For example, with insufficient SRHE, curable reproductive health problems such as irregular or missed menstrual periods, abnormal discharges, and sores in the genital area due to infections may not be detected and treated in time (Roudi-Fahimi et al., 2008), resulting in more serious future health problems.With insufficient SRHE and the poor health care system of South Sudan, many sexual and reproductive health problems will remain unknown and unattended to.
On the contrary, the results indicate that some adolescent girls learned about menstruation from family members, friends, and older girls in school before it happened to them.School-going girls who knew about menstruation before it happened to them seemed to manage well with the assistance of family members and friends.Nonetheless, the first-day experience of menstruation for many of the participants was very traumatizing and scary.In general, all study participants experienced some form of trauma during their first menstrual experience due to insufficient knowledge and support, and wished they knew more about menstruation before they experienced it.Studies show (Bastien et al., 2011;Biddlecom et al., 2008;Dixon-Mueller, 2010;Kirby, 2001) that although young girls and boys of preadolescent ages (8-14) might exhibit no health risks, they are in a critical age group when intervention strategies could have profound lifetime benefits.Hence, there is a need to train adolescent girls in advance of their menarches so that they are prepared for the unknown.The literature (Ruble & Brooks-Gunn, 1982;Short & Rosenthal, 2008;Williams & Currie, 2000) shows that if young girls start their menstruations in ignorance and fear, their sense of self-confidence and competence may weaken.Not knowing about menstruation before it starts might compromise girls' future ability to assert their sexuality and maintain their sexual and reproductive health (Mason et al., 2013;Schooler et al., 2005).
At an institutional level, lack of political will may partly explain the absence of public health attention paid to SRHE and MHM in South Sudan.The region's predominantly male politicians seem to lack the political will to address such pertinent female issues in the country (Kane et al., 2016;Mkandawire et al., 2019).As mentioned above, this could be due to the assumption that family members (Sommer, 2009a;Sommer, 2011) will carefully attend to puberty and early adolescence.However, the evidence suggests that many young girls and boys do not receive adequate guidance from family during this transition to adulthood.Girls in particular lack sufficient information on how to manage their menses in everyday environments (Biddlecom et al., 2009;Sommer, 2009a).Consequently, young adolescent girls receive insufficient educational support to effectively understand and manage menstruation both at home and in their community (Kettaneh et al., 2014).In addition, due to the connotations of sexuality and disgust around menstruation, and the negative perceptions about this natural phenomenon, it is taboo for girls to raise issues of SRHE and MHM with their male teachers (who might be the only authorities available) and even with their mothers.
In general, a strong political will is required to develop culturally sensitive SRHE and MHM curricula that address negative community perceptions about menstruation and build better understanding of this biological phenomenon.Hence, the government, especially the ministries of Education and Health, should try to encourage national and international NGOs, community-based organizations, school administrations, parents, teachers, student bodies, and local communities to develop more comprehensive SRHE and MHM programs that address the challenges that young adolescents girls face in their daily experiences in community and school environments.Proper SRHE and MHM education programs will help to train adolescent girls in advance of their menarches and prepare them for the experience, and teach the community to better comprehend what reproductive-age women go through during their periods.We were not able to explore the mental health impacts of bullying on the study's participants.
At the community level, the results show that some of the girls were terrified and ashamed to go out or even go to school during their menarches.These feelings led to school absenteeism and dropouts.In addition, many participants reported that many of their male teachers did not comprehend their experiences, which contributed to failures and dropouts from school.Hence, there is a need for culturally sensitive SRHE and MHM in schools targeting both teachers and students to create awareness of the changes that happen during puberty.Such education may help to limit the tendency for these young girls to suffer from sexual and reproductive illnesses in silence rather than live with these conditions, either knowingly or unknowingly (Roudi-Fahimi et al., 2008).SRHE and MHM materials will help to bridge the gap between the adolescents' need for education and their parents' and male teachers' lack of knowledge of how to address sexual and reproductive issues.
The study's participants underlined a dangerous misconception among community members in South Sudan that menstruation happens to those girls who are sexually immoral.Perception is reality to the eye of the perceiver and may lead to unintended consequences.First, due to the shame and fear of being labeled "immoral," many adolescent girls might opt for unhygienic or unconventional MHM, especially in poorer settings.In such unfriendly environments, studies have shown widespread use of unsanitary absorbents and inadequate washing and drying of reusable pads across Africa and in other parts of the developing world (Narayan et al., 2001;Sumpter & Torondel, 2013).Many underprivileged adolescent girls may choose undesirable options instead of humiliation.In a systematic review of the health and social effects of MHM, Sumpter and Torondel (2013) found that social restrictions and taboos made drying reusable pads indoors rather than in sunlight or open air very common.These are real problems that need all stakeholders in education to come together to understand and solve by providing access to girl-friendly facilities in community and school environments in South Sudan.Second, community misconceptions about the causes of menstruation might encourage unsafe health and sexual practices.For example, in Tanzania, Uganda, and South Sudan, a baseline survey conducted by SNV Netherlands (Tamiru et al., 2015) found that boys approached 26% of adolescent girls for love and sex after they knew they had had their menarches.The same study found that many male adults approached young girls for sex in exchange for money.These inappropriate overtures were based on the community perception that young girls who had early menstrual periods were already immoral.
In general, the findings of this study show that school-going girls in Juba, South Sudan, face many MHM challenges and that these are embedded in sociocultural and traditional practices and institutional ideologies better explained within the PEAH framework.First, it was evident that study participants lacked WASH facilities to maintain proper bodily hygiene during their periods.Girls using reusable pads mainly faced these challenges, because clean running water was not readily available in schools and even in some homes.Second, study participants lacked support from their male teachers, school communities, and administrations regarding bullying and shaming during their menstrual periods.Third, the negative public perceptions that young girls who had menstruated were sexually "immoral" caused many adolescent girls to hide their menstrual experiences and pursue no help from family members or peers.Fourth, lack of safety information on the use of disposable sanitary pads inhibited some study participants from utilizing them.Finally, the negative public perception that young girls with periods were unclean restricted their full community participation.
It is worth noting some of the key limitations of this study.First, we were unable to obtain firsthand accounts of adolescent girls' experiences and their perceptions of SRHE and MHM.Due to traditional norms and taboos, adolescent girls in South Sudan are unlikely to talk about and express their own perceptions and experiences of SRHE and MHM to researchers.To address this limitation, we used school girls as PREs in an innovative approach to interviewing participants (as peers in trusted networks) and reporting on the experiences of "others" and not necessarily themselves to the research team.The approach was an effective way of getting information from participants without the risk of breaching cultural norms in the process of gathering relevant information to inform the research objectives.Second, the research team was unable to follow up with key informants on study results and interpretations due to insecurity in the country.Most of the PREs could not be found after the July 2016 war in Juba.The research team is trying their best to locate the PREs and determine their safety after the unrest.Notwithstanding these limitations, the research team includes two South Sudanese members who speak and understand Arabic and cultural nuances in the region.Hence, the team is sure of the quality of the results presented.
In conclusion, the findings suggest the need for all stakeholders to intervene in MHM and SRHE to alleviate and better address some of the challenges that adolescent girls face in their neighborhoods and school environments in South Sudan.Strong political will is needed to develop better SRHE and MHM frameworks that address the infrastructure, WASH problems in schools and public spaces, and accommodate properly the unique needs of adolescent girls and young women.In addition, proper and culturally sensitive SRHE and MHM programs will help to bridge the gap between the adolescents' need to learn and parents' and guardians' lack of knowledge of sexual and reproductive issues, thereby improving the social, emotional, educational, and physical development of South Sudanese girls.Such programs could also assist in creating awareness and community sensitization on how to respect and accommodate females with menstruation, especially among male teachers and adolescent boys in school environments.The use of PREs is an innovative aspect of this study that was helpful for highlighting important sensitive topics and how to address them without the risk of breaching cultural and traditional norms.Hence, we hope the findings of this study will help to initiate discussion about more culturally sensitive SRHE and MHM topics among stakeholders in public education and policymakers in South Sudan.

I
heard from the school.My teacher taught about body changes . . .when I was in P6 [Primary 6].[However], I know puberty when I started seeing my menstruation and big breasts.(Alek, 14, Munuki Primary school)