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«TEACHING MENSTRUAL HEALTH AND HYGIENE TO YOUNG WOMEN IN EASTERN UGANDA WITH REUSABLE MENSTRUAL PADS By Stacey L. Frankenstein-Markon A REPORT ...»

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TEACHING MENSTRUAL HEALTH AND HYGIENE TO YOUNG WOMEN IN

EASTERN UGANDA WITH REUSABLE MENSTRUAL PADS

By

Stacey L. Frankenstein-Markon

A REPORT

Submitted in partial fulfillment of the requirements for the degree of

MASTER OF SCIENCE

In Applied Science Education

MICHIGAN TECHNOLOGICAL UNIVERSITY

© 2013 Stacey L. Frankenstein-Markon This report has been approved in partial fulfillment of the requirements for the Degree of MASTER OF SCIENCE in Applied Science Education.

Department of Cognitive and Learning Sciences Report Advisor: Dr. Bradley Baltensperger Committee Member: Dr. Shari Stockero Committee Member: Dr. Casey Huckins Department Chair: Dr. Bradley Baltensperger To Betty Adio and Linda Baum Table of Contents List of Tables…………………………………………………………………………… ix Definitions……………………………………………………………………………… xi Abstract………………………………………………………………………………...xiii Chapter 1 – Introduction ………………………………………………………………... 1 Chapter 2 – Research Questions……………………………………………………….. 19 Chapter 3 – Methods …………………………………………………………………...21 Chapter 4 – Results…………………………………………………………………….. 27 Chapter 5 – Discussion ………………………………………………………………... 31 Appendix 1 – The Reusable Menstrual Pads Project…………………………………...39 Appendix 2 – Preliminary and Post Surveys…………………………………………... 45 Appendix 3 – Answer Coding of Survey Responses…………………………………...49 Appendix 4 – Data …………………………………………………………………….. 55 References ……………………………………………………………………………...65 vii List of Tables Table 3.1: Results of participant demographic information…………………………… 24 Table 3.2: An example of answer codes for participants' survey responses to the question "what is sex?"………………………………………………………………....25 Table 4.1: Preliminary (pr) and post (po) survey counts and Chi-Square statistical analysis results for questions about being nervous around others during a menstrual period…………………………………………………………………………………...29

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MP: Local acronym used to describe menstrual period NGO: Non-government organization acronym PIASCY: The Presidential Initiative on AIDS Strategy for Communication

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UPE: Universal Primary Education acronym USE: Universal Secondary Education acronym χ2 : The symbol for the Chi-Square statistical analysis value

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In order to identify the impact of teaching menstrual health and hygiene with reusable menstrual pads on knowledge retention and school attendance, qualitative and quantitative data was collected from three rural schools in three districts of eastern Uganda: Amuria, Bukedea, and Ngora. Research techniques employed were preliminary and post surveys of 85 young women; average age 16.9 years. Findings include positive and negative results. Participants’ feelings of normalcy and comfort increased and participants had improved understanding of sexual climax and appropriate menstrual management strategies. There was no statistically significant impact of teaching on topics of sexual intercourse or pregnancy. The impact of reusable menstrual pad sanitary technology on school attendance was negative as more young women reported missing up to a full day of school during their menstrual period (χ2 (3, 73) = 7.81, p = 0.05). Study limitations are discussed and future work is suggested.

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Adolescent girls in Uganda face many challenges that impact their academic and lifetime success. Cultural and societal norms push girls to be submissive to men who can expose them to sexual risks (Burns, 2002; Koenig et al., 2004; Wagman et al., 2009). Schools’ inadequate health education programs make it difficult for girls to make informed health decisions about personal hygiene, menstrual management, entering into sexual relationships and pregnancy (Bankole, Biddlecom, Guiella, Singh, & Zulu, 2007; Burns, 2002; Cohen & Tate, 2006; De Walque, 2007; Ndyanabangi, Kipp, & Diesfeld, 2004).

These factors along with poverty, poor sanitation, and embarrassment seem to influence school attendance (Bharadwaj & Patkar, 2004; Crofts & Fisher, 2012; Kirk & Sommer, 2006; Scott, Dopson, Montgomery, Dolan, & Ryus, 2009; Sommer, 2010).

Researchers from Ghana and Tanzania have discovered that when girls have their menstrual period they are likely to stay home from school (Scott et al., 2009; Sommer, 2010). Absence can lead to girls falling behind their classmates and many risk dropping out of school (Kirk & Sommer, 2006).





While education is a key to success for boys and girls, this paper investigates the potential opportunities present in health education workshops to help keep girls in school. By addressing health education and taboo topics with sensitivity, it was hoped that girls would be better able to understand and integrate their science knowledge into their daily lives. Additionally, with the introduction of reusable menstrual pads, it was hoped that girls would be better able to manage their personal hygiene with confidence.

Social Norms and Sexual Risk Sexual relationships in Uganda are complex, with men and women likely having multiple, concurrent partners (Koenig et al., 2004; Nyanzi, Nyanzi, Kalina, & Pool, 2004; Stephenson, 2010). A man could have a wife raising children in the village and a second wife in town; some men could even have additional lovers and one-night-stands (Nyanzi et al., 2004). The number of partners and frequency of sexual interactions vary. In a study by Koenig et al. (2004), it was found that approximately one in three women reside in polygamous unions and almost 50% of women do not know about their male partner’s other sexual partners. A study by Biraro et al. (2009) found that the proportion of married men with two or more partners in the past year increased between 1996 and 2002 while simultaneously there was an increased prevalence and incidence of Human Immunodeficiency Virus infection / Acquired Immunodeficiency Syndrome (HIV/AIDS). Although risks of HIV/AIDS, sexually transmitted infections (STIs), and pregnancy are present today, it is culturally acceptable and encouraged for men to have extramarital intercourse as a sign of masculinity and to fulfill ‘uncontrollable’ sexual needs (Burns, 2002; Koenig et al., 2004; Rujumba & Kwiringira, 2010; Stephenson, 2010; Wagman et al., 2009).

These cultural and societal norms greatly impact adolescent girls. The median age for sexual debut of young men and women is 18.1 and 16.4 years old, respectively, with 49% of men and 74% of women becoming sexually active by age 18 (Koenig et al., 2004; Uganda Bureau of Statistics & Macro International Incorporated, 2007;

Wagman et al., 2009). In a study by Wagman et al. (2009), half of their participants experienced sexual coercion during their sexual debut, including physical force, threats of abuse, and inducement in the form of promises of money, gifts, or marriage. Overall, 87.5% reported experiencing sexual coercion during adolescence. Sexual partners of adolescent girls vary and consist of lovers, boyfriends, husbands, authority figures (including teachers), older male friends of the family, or relatives (Kinsman, Nyanzi, & Pool, 2000; Nyanzi et al., 2004; Wagman et al., 2009).

These potentially polygamous partners put young women at risk of HIV infection and pregnancy. A Demographic Health Survey found that women who had their sexual debut before age 16 have the highest HIV prevalence (Burns, 2002; Madise, Zulu, & Ciera, 2007). New HIV infections for boys versus girls is a ratio of one to six in the 15-19 year old age bracket (Burns, 2002; Madise et al., 2007). In Uganda the median age for women having their first child is 18.6 years old; by age 20, 74% of women are married, compared to only 26% of men (Uganda Bureau of Statistics & Macro International Incorporated, 2007).

The reasons that adolescents enter into sexual relationships vary: curiosity, unwarranted trust in the relationship, desire for respect and proof of maturity, peer pressure, and the expectation of gifts and money (Burns, 2002; Madise et al., 2007;

Wagman et al., 2009). In Uganda, “(a) continuity from traditional society lies in the man’s role of giving [a] gift, and the woman’s role of receiving [it] and in turn offering sexual service to the man” (Nyanzi et al., 2004, p. 251). These gifts include cash, food, school books, household items, clothing, toiletries and services such as rides into town (Nyanzi et al., 2004; Wagman et al., 2009). Culturally, gifts are not considered payment for sexual services but are viewed as providing household necessities (Nyanzi et al., 2004). Nevertheless, there is a blatant power exchange with gift giving that makes women practically unable to negotiate for condom use or frequency of sex (Koenig et al., 2004; Madise et al., 2007; Nyanzi et al., 2004; Wagman et al., 2009).

Uganda’s contraception use is 18% and depends on age, school enrollment, and marital status (Ndyanabangi et al., 2004; Stanback, Otterness, Bekiita, Nakayiza, & Mbonye, 2011; Uganda Bureau of Statistics & Macro International Incorporated, 2007).

Studies have found that unmarried youth use modern contraception (i.e.

pharmaceuticals and condoms) to a greater degree than married adults, but condom use steadily declines with increasing age (Biraro et al., 2009; De Walque, 2007; Madise et al., 2007; Singh, Prada, Mirembe, & Kiggundu, 2005).

It has been found that 75% of men and women believe that “a woman needs her husband’s permission before using a contraceptive” (Stanback et al., 2011, p. 27). Also people believe that it is “unacceptable for a married [woman] to ask her partner to use a condom” (Koenig et al., 2004, p. 789). This would suggest a woman is promiscuous even if her husband has an STI or HIV/AIDS (Koenig et al., 2004; Stanback et al., 2011; Uganda Bureau of Statistics & Macro International Incorporated, 2007).

Regardless of age, women who reported a forced sexual debut were less likely to be currently using contraception (Wagman et al., 2009).

The low use of contraception in Uganda may be explained in part by personal values. It is commonly believed that childbearing is synonymous with marriage and men often state that God decides whether a couple has children (King et al., 2011;

Wagman et al., 2009). Even outside of marriage, childbearing plays a role in new relationships (King et al., 2011). A widow with five children who was pregnant with her boyfriend’s child said, “a man cannot simply give you… help when…you do not [want to] have his kid”(King et al., 2011, p. 5). Nationally, this has led to approximately half of pregnancies being unintended or mistimed and women having two more children than desired (Singh et al., 2005; Uganda Bureau of Statistics & Macro International Incorporated, 2007).

Researchers have found that socioeconomic status in Uganda influences sexual behavior in a variety of ways. Uganda is a low income country with an annual per capita income of US$270 (Singh et al., 2005). While socioeconomic status cannot predict of the risk of coercive sex, there is evidence that low socioeconomic status has a strong association with multiple sexual partnerships, vulnerability to HIV infection, and low use of condoms (Koenig et al., 2004; Madise et al., 2007). Girls with low socioeconomic status have a higher likelihood of initiating sex despite having knowledge of HIV/AIDS in order to have access to gifts (Adamczyk & Greif, 2011;

Madise et al., 2007). In a study by Wagman et al. (2009, p. 2086), participants honestly explained their beliefs about the influence of money on sexual relationships: “Girls in peer groups talk about having sex and how their boyfriends give them money (for sex) which makes the other girls want to start having sex for money.” “Yes, if a girl has friends who have good things like nice shoes she also wants to try her best to fit in the society.” One possible scenario of a sexual exchange relationship is between school girls and motorcycle taxi drivers, known locally as boda boda men (Nyanzi et al., 2004).

Compared to other potential sexual partners, boda boda men have cash on hand due to the nature of their work (Nyanzi et al., 2004). This relationship can develop when a driver is taking a girl to school and sex is exchanged for fare payment or cash gifts are given (Nyanzi et al., 2004). In Uganda, girls attend all types of schools; often girls attend boarding schools in neighboring towns because parents believe that schools can isolate and protect their daughters from sexual predators (Burns, 2002).

Known locally as lovers, boda boda men claim to have sexual access to these girls whenever they wanted without having any moral or social obligation toward them (Nyanzi et al., 2004). Boda boda men said that their lovers consisted mostly of school girls despite the legal consequences of such relationships (Nyanzi et al., 2004).

Additionally, girls may take on sexual risk in relationships if they participate in a practice known as “detoothing” (Nyanzi et al., 2004, p. 250). As long as a man hopes to get sex from a girl he will continue to give her gifts while she will avoid him until the demand for sex becomes unbearable (Nyanzi et al., 2004). Over time, girls can experience sexual coercion in the form of verbal insistence, deception, and threats (Wagman et al., 2009).



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