Schoolgirls’ experiences of changing and disposal of menstrual hygiene items and inferences for WASH in schools
Cliff Oduor | Kelly T. Alexander | Kelvin Oruko | Elizabeth Nyothach | Linda Mason | Frank O. Odhiambo | John Vulule | Kayla F. Laserson | Penelope A. Phillips-Howard
Menstrual hygiene management (MHM) challenges during changing and disposal of menstrual items are important in low-income countries (LICs) where schools lack sufficient water and sanitation. Changing in poorly maintained latrines may expose girls to excrement and infection. We examine the frequency of dropping menstrual items and disposal of waste by schoolgirls in a menstrual solutions feasibility study in western Kenya. Drops when changing were reported in 17 per cent (20 per cent <16 years; 16.5 per cent 16 years plus; p=0.04) of girls’ reports overall. Differences by socio-economic status were not evident. Fifty-four per cent of girls dropped at least once. A quarter of girls using pads and cups reported drops in the first few months, reducing to 10 per cent over time, compared with ~30 per cent among traditional item users. One in four accidental drops occurred at school during the study. When dropped at school, most girls swapped the dropped item for a new one, but 24 per cent brushed/washed the item and reused it. While no clinical events occurred during this study, data suggest dropping within latrines could place girls at potential risk of exposure to infection. Disposal of items, or emptying cups, was mostly into the latrine. We conclude that accidental dropping of menstrual items while changing is common, including at school. Prevention will be helped by improving poorly constructed sanitation facilities, shelving, privacy, and staggering/increasing break time for girls to change. Provision of special garbage bins to prevent clogging and overflow of latrines is recommended.Alexander, K.T., Dreibelbis, R., Freeman, M.C., Ojeny, B. and Rheingans, R. (2013) ‘Improving service delivery of water, sanitation, and hygiene in primary schools: a cluster-randomized trial in western Kenya’, Journal of Water and Health 11: 507–19 <http://dx.doi.org/10.2166/wh.2013.213>.
Alexander, K., Oduor, C., Nyothach, E., Laserson, K., Amek, N., Eleveld, A., Mason, L., Rheingans, R., Beynon, C., Mohammed, A., Ombok, M., Obor, D., Odhiambo, F., Quick, R. and Phillips-Howard, P. (2014) ‘Water, sanitation and hygiene conditions in Kenyan rural schools: are schools meeting the needs of menstruating girls?’ Water 6: 1453–66 <http://dx.doi.org/10.3390/w6051453>.
Blanton, E., Ombeki, S., Oluoch, G.O., Mwaki, A., Wannemuehler, K. and Quick, R. (2010) ‘Evaluation of the role of school children in the promotion of point-of-use water treatment and handwashing in schools and households: Nyanza Province, Western Kenya, 2007’, American Journal of Tropical Medicine and Hygiene 82: 664–71 <http://dx.doi.org/10.4269/ajtmh.2010.09-0422>.
Boyatzis, R.E. (1998) Transforming Qualitative Information: Thematic Analysis and Code Development, London, New Delhi: SAGE Publications.
Cohen, D. and Atieno-Odhiambo, E. (1989) Siaya: The Historical Anthropology of an African Landscape, London: James Currey.
Crofts, T. and Fisher, W.A. (2012) ‘Menstrual hygiene in Ugandan schools and investigation of low-cost sanitary pads’, Journal of Water, Sanitation and Hygiene for Development 2: 50–8 <http://dx.doi.org/10.2166/washdev.2012.067>.
Dreibelbis, R., Greene, L.E., Freeman, M.C., Saboori, S., Chase, R.P. and Rheingans, R. (2013) ‘Water, sanitation, and primary school attendance: a multi-level assessment of determinants of household-reported absence in Kenya’, International Journal of Educational Development 33: 457–65 <http://dx.doi.org/10.1016/j.ijedudev.2012.07.002>.
Garg, R., Goyal, S. and Gupta, S. (2012) ‘India moves towards menstrual hygiene: subsidized sanitary napkins for rural adolescent girls – issues and challenges’, Maternal and Child Health Journal 16: 767–74 <http://dx.doi.org/10.1007/s10995-011-0798-5>.
Greene, L.E., Freeman, M.C., Akoko, D., Saboori, S., Moe, C., and Rheingans, R. (2012) ‘Impact of a school-based hygiene promotion and sanitation intervention on pupil hand contamination in Western Kenya: a cluster randomized trial’, American Journal of Tropical Medicine and Hygiene 87: 385–93 <http://dx.doi.org/10.4269/ajtmh.2012.11-0633>.
Mason, L., Nyothach, E., Alexander, K., Odhiambo, F.O., Eleveld, A., Vulule, J., Rheingans, R., Laserson, K.F., Mohammed, A. and Phillips-Howard, P.A. (2013) ‘“We keep it secret so no one should know”: a qualitative study to explore young schoolgirls attitudes and experiences with menstruation in rural Western Kenya’, PLoS One 8: e79132 <http://dx.doi.org/10.1371/journal.pone.0079132>.
Mason, L., Laserson, K., Oruko, K., Nyothach, E., Alexander, K., Odhiambo, F., Eleveld, A., Isiye, E., Ngere, I., Omoto, J., Mohammed, A., Vulule, J. and Phillips-Howard, P. (2015) ‘Adolescent schoolgirls’ experiences of menstrual cups and pads in rural western Kenya: a qualitative study’, Waterlines 34(1): 15–30 <http://dx.doi.org/10.3362/1756-3488.2015.003>.
Mcmahon, S.A., Winch, P.J., Caruso, B.A., Obure, A.F., Ogutu, E.A., Ochari, I.A. and Rheingans, R.D. (2011) ‘“The girl with her period is the one to hang her head”: reflections on menstrual management among schoolgirls in rural Kenya’, BMC International Health and Human Rights 11: 7 <http://dx.doi.org/10.1186/1472-698X-11-7>.
Migele, J., Ombeki, S., Ayalo, M., Biggerstaff, M. and Quick, R. (2007) ‘Diarrhea prevention in a Kenyan school through the use of a simple safe water and hygiene intervention’, American Journal of Tropical Medicine and Hygiene 76: 351–3.
Ministry of Public Health and Sanitation (MOPHS) (2010) Republic of Kenya National School Health Strategy Implementation Plan 2011–2015, Nairobi: Ministry of Public Health and Sanitation, and Ministry of Education, Republic of Kenya.
Montgomery, P., Ryus, C.R., Dolan, C.S., Dopson, S. and Scott, L.M. (2012) ‘Sanitary pad interventions for girls’ education in Ghana: a pilot study’, PLoS One 7: e48274 <http://dx.doi.org/10.1371/journal.pone.0048274>.
Mugo, J., Kaburu, A., Limboro, C. and Kimutai, A. (2012) ‘Are our children learning?’ in Annual Learning Assessment Report, Nairobi, Kenya: Uwezo Kenya.
Odhiambo, F.O., Laserson, K.F., Sewe, M., Hamel, M.J., Feikin, D.R., Adazu, K., Ogwang, S., Obor, D., Amek, N., Bayoh, N., Ombok, M., Lindblade, K., Desai, M., Ter Kuile, F., Phillips-Howard, P., Van Eijk, A.M., Rosen, D., Hightower, A., Ofware, P., Muttai, H., Nahlen, B., Decock, K., Slutsker, L., Breiman, R.F. and Vulule, J.M. (2012) ‘Profile: the KEMRI/CDC Health and Demographic Surveillance System: Western Kenya’, International Journal of Epidemiology 41: 977–87 <http://dx.doi.org/10.1093/ije/dys108>.
Omwami, E. and Omwami, R. (2009) ‘Public investment and the goal of providing universal access to primary education by 2015 in Kenya’, International Journal of Education Development 30: 243–53 <http://dx.doi.org/10.1016/j.ijedudev.2009.09.002>.
Oster, E. and Thornton, R. (2012) ‘Determinants of technology adoption: peer effects in menstrual cup up-take’, Journal of the European Economic Association 10: 1263–93 <http://dx.doi.org/10.1111/j.1542-4774.2012.01090.x>.
Phillips-Howard, P. (2013) ‘Menstrual solutions in adolescent schoolgirls in western Kenya: an acceptability, feasibility and safety study (tools and instruments), 21 November 2013’, in M. Sommer and M. Sahin (eds), 2nd Virtual Conference on Menstrual Hygiene Management in Schools ‘Exploring MHM in Countries: MHM Tools and Instruments’, 2013, New York: UNICEF.
Saboori, S., Mwaki, A., Porter, S., Okech, B., Freeman, M. and Rheingans, R. (2011) ‘Sustaining school handwashing and water treatment programmes: lessons learned and to be learned’, Waterlines 30: 13 <http://dx.doi.org/10.3362/1756-3488.2011.040>.
Sibiya, J.E. and Gumbo, J.R. (2013) ‘Knowledge, attitude and practices (KAP) survey on water, sanitation and hygiene in selected schools in Vhembe District, Limpopo, South Africa’, International Journal of Environmental Research and Public Health 10: 2282–95 <http://dx.doi.org/10.3390/ijerph10062282>.
Sinha, S. and Singh, A. (2013) ‘Adolescent health-tackling menstrual hygiene issue through social marketing’, Journal of Postgraduate Medicine, Education and Research 47: 127–30 <http://dx.doi.org/10.5005/jp-journals-10028-1069>.
Sommer, M. (2010) ‘Where the education system and women’s bodies collide: the social and health impact of girls’ experiences of menstruation and schooling in Tanzania’, Journal of Adolescence 33: 521–9 <http://dx.doi.org/10.1016/j.adolescence.2009.03.008>.
Sommer, M. and Sahin, M. (2013) ‘Overcoming the taboo: advancing the global agenda for menstrual hygiene management for schoolgirls’, American Journal of Public Health 103: 1556–9 <http://dx.doi.org/10.2105/AJPH.2013.301374>.
Sommer, M., Kjellén, M. and Chibesa Pensulo, C. (2013) ‘Girls’ and women’s unmet needs for menstrual hygiene management (MHM): the interactions between MHM and sanitation systems in low-income countries’, Journal of Water, Sanitation and Hygiene for Development 3(3): 283–97 <http://dx.doi.org/10.2166/washdev.2013.101>.
Stewart, K., Greer, R. and Powell, M. (2010) ‘Women’s experience of using the Mooncup’, Journal of Obstetrics & Gynaecology 30: 285–7 <http://dx.doi.org/10.3109/01443610903572117>.
Sumpter, C. and Torondel, B. (2013) ‘A systematic review of the health and social effects of menstrual hygiene management’, PLoS One 8: e62004 <http://dx.doi.org/10.1371/journal.pone.0062004>.
WHO (2014) ‘Dioxins and their effects on human health’, WHO Fact Sheet 225 [online] <www.who.int/mediacentre/factsheets/fs225/en/> [accessed 20 June 2014].
Alexander, K.T., Dreibelbis, R., Freeman, M.C., Ojeny, B. and Rheingans, R. (2013) ‘Improving service delivery of water, sanitation, and hygiene in primary schools: a cluster-randomized trial in western Kenya’, Journal of Water and Health 11: 507–19 <http://dx.doi.org/10.2166/wh.2013.213>.
Alexander, K., Oduor, C., Nyothach, E., Laserson, K., Amek, N., Eleveld, A., Mason, L., Rheingans, R., Beynon, C., Mohammed, A., Ombok, M., Obor, D., Odhiambo, F., Quick, R. and Phillips-Howard, P. (2014) ‘Water, sanitation and hygiene conditions in Kenyan rural schools: are schools meeting the needs of menstruating girls?’ Water 6: 1453–66 <http://dx.doi.org/10.3390/w6051453>.
Blanton, E., Ombeki, S., Oluoch, G.O., Mwaki, A., Wannemuehler, K. and Quick, R. (2010) ‘Evaluation of the role of school children in the promotion of point-of-use water treatment and handwashing in schools and households: Nyanza Province, Western Kenya, 2007’, American Journal of Tropical Medicine and Hygiene 82: 664–71 <http://dx.doi.org/10.4269/ajtmh.2010.09-0422>.
Boyatzis, R.E. (1998) Transforming Qualitative Information: Thematic Analysis and Code Development, London, New Delhi: SAGE Publications.
Cohen, D. and Atieno-Odhiambo, E. (1989) Siaya: The Historical Anthropology of an African Landscape, London: James Currey.
Crofts, T. and Fisher, W.A. (2012) ‘Menstrual hygiene in Ugandan schools and investigation of low-cost sanitary pads’, Journal of Water, Sanitation and Hygiene for Development 2: 50–8 <http://dx.doi.org/10.2166/washdev.2012.067>.
Dreibelbis, R., Greene, L.E., Freeman, M.C., Saboori, S., Chase, R.P. and Rheingans, R. (2013) ‘Water, sanitation, and primary school attendance: a multi-level assessment of determinants of household-reported absence in Kenya’, International Journal of Educational Development 33: 457–65 <http://dx.doi.org/10.1016/j.ijedudev.2012.07.002>.
Garg, R., Goyal, S. and Gupta, S. (2012) ‘India moves towards menstrual hygiene: subsidized sanitary napkins for rural adolescent girls – issues and challenges’, Maternal and Child Health Journal 16: 767–74 <http://dx.doi.org/10.1007/s10995-011-0798-5>.
Greene, L.E., Freeman, M.C., Akoko, D., Saboori, S., Moe, C., and Rheingans, R. (2012) ‘Impact of a school-based hygiene promotion and sanitation intervention on pupil hand contamination in Western Kenya: a cluster randomized trial’, American Journal of Tropical Medicine and Hygiene 87: 385–93 <http://dx.doi.org/10.4269/ajtmh.2012.11-0633>.
Mason, L., Nyothach, E., Alexander, K., Odhiambo, F.O., Eleveld, A., Vulule, J., Rheingans, R., Laserson, K.F., Mohammed, A. and Phillips-Howard, P.A. (2013) ‘“We keep it secret so no one should know”: a qualitative study to explore young schoolgirls attitudes and experiences with menstruation in rural Western Kenya’, PLoS One 8: e79132 <http://dx.doi.org/10.1371/journal.pone.0079132>.
Mason, L., Laserson, K., Oruko, K., Nyothach, E., Alexander, K., Odhiambo, F., Eleveld, A., Isiye, E., Ngere, I., Omoto, J., Mohammed, A., Vulule, J. and Phillips-Howard, P. (2015) ‘Adolescent schoolgirls’ experiences of menstrual cups and pads in rural western Kenya: a qualitative study’, Waterlines 34(1): 15–30 <http://dx.doi.org/10.3362/1756-3488.2015.003>.
Mcmahon, S.A., Winch, P.J., Caruso, B.A., Obure, A.F., Ogutu, E.A., Ochari, I.A. and Rheingans, R.D. (2011) ‘“The girl with her period is the one to hang her head”: reflections on menstrual management among schoolgirls in rural Kenya’, BMC International Health and Human Rights 11: 7 <http://dx.doi.org/10.1186/1472-698X-11-7>.
Migele, J., Ombeki, S., Ayalo, M., Biggerstaff, M. and Quick, R. (2007) ‘Diarrhea prevention in a Kenyan school through the use of a simple safe water and hygiene intervention’, American Journal of Tropical Medicine and Hygiene 76: 351–3.
Ministry of Public Health and Sanitation (MOPHS) (2010) Republic of Kenya National School Health Strategy Implementation Plan 2011–2015, Nairobi: Ministry of Public Health and Sanitation, and Ministry of Education, Republic of Kenya.
Montgomery, P., Ryus, C.R., Dolan, C.S., Dopson, S. and Scott, L.M. (2012) ‘Sanitary pad interventions for girls’ education in Ghana: a pilot study’, PLoS One 7: e48274 <http://dx.doi.org/10.1371/journal.pone.0048274>.
Mugo, J., Kaburu, A., Limboro, C. and Kimutai, A. (2012) ‘Are our children learning?’ in Annual Learning Assessment Report, Nairobi, Kenya: Uwezo Kenya.
Odhiambo, F.O., Laserson, K.F., Sewe, M., Hamel, M.J., Feikin, D.R., Adazu, K., Ogwang, S., Obor, D., Amek, N., Bayoh, N., Ombok, M., Lindblade, K., Desai, M., Ter Kuile, F., Phillips-Howard, P., Van Eijk, A.M., Rosen, D., Hightower, A., Ofware, P., Muttai, H., Nahlen, B., Decock, K., Slutsker, L., Breiman, R.F. and Vulule, J.M. (2012) ‘Profile: the KEMRI/CDC Health and Demographic Surveillance System: Western Kenya’, International Journal of Epidemiology 41: 977–87 <http://dx.doi.org/10.1093/ije/dys108>.
Omwami, E. and Omwami, R. (2009) ‘Public investment and the goal of providing universal access to primary education by 2015 in Kenya’, International Journal of Education Development 30: 243–53 <http://dx.doi.org/10.1016/j.ijedudev.2009.09.002>.
Oster, E. and Thornton, R. (2012) ‘Determinants of technology adoption: peer effects in menstrual cup up-take’, Journal of the European Economic Association 10: 1263–93 <http://dx.doi.org/10.1111/j.1542-4774.2012.01090.x>.
Phillips-Howard, P. (2013) ‘Menstrual solutions in adolescent schoolgirls in western Kenya: an acceptability, feasibility and safety study (tools and instruments), 21 November 2013’, in M. Sommer and M. Sahin (eds), 2nd Virtual Conference on Menstrual Hygiene Management in Schools ‘Exploring MHM in Countries: MHM Tools and Instruments’, 2013, New York: UNICEF.
Saboori, S., Mwaki, A., Porter, S., Okech, B., Freeman, M. and Rheingans, R. (2011) ‘Sustaining school handwashing and water treatment programmes: lessons learned and to be learned’, Waterlines 30: 13 <http://dx.doi.org/10.3362/1756-3488.2011.040>.
Sibiya, J.E. and Gumbo, J.R. (2013) ‘Knowledge, attitude and practices (KAP) survey on water, sanitation and hygiene in selected schools in Vhembe District, Limpopo, South Africa’, International Journal of Environmental Research and Public Health 10: 2282–95 <http://dx.doi.org/10.3390/ijerph10062282>.
Sinha, S. and Singh, A. (2013) ‘Adolescent health-tackling menstrual hygiene issue through social marketing’, Journal of Postgraduate Medicine, Education and Research 47: 127–30 <http://dx.doi.org/10.5005/jp-journals-10028-1069>.
Sommer, M. (2010) ‘Where the education system and women’s bodies collide: the social and health impact of girls’ experiences of menstruation and schooling in Tanzania’, Journal of Adolescence 33: 521–9 <http://dx.doi.org/10.1016/j.adolescence.2009.03.008>.
Sommer, M. and Sahin, M. (2013) ‘Overcoming the taboo: advancing the global agenda for menstrual hygiene management for schoolgirls’, American Journal of Public Health 103: 1556–9 <http://dx.doi.org/10.2105/AJPH.2013.301374>.
Sommer, M., Kjellén, M. and Chibesa Pensulo, C. (2013) ‘Girls’ and women’s unmet needs for menstrual hygiene management (MHM): the interactions between MHM and sanitation systems in low-income countries’, Journal of Water, Sanitation and Hygiene for Development 3(3): 283–97 <http://dx.doi.org/10.2166/washdev.2013.101>.
Stewart, K., Greer, R. and Powell, M. (2010) ‘Women’s experience of using the Mooncup’, Journal of Obstetrics & Gynaecology 30: 285–7 <http://dx.doi.org/10.3109/01443610903572117>.
Sumpter, C. and Torondel, B. (2013) ‘A systematic review of the health and social effects of menstrual hygiene management’, PLoS One 8: e62004 <http://dx.doi.org/10.1371/journal.pone.0062004>.
WHO (2014) ‘Dioxins and their effects on human health’, WHO Fact Sheet 225 [online] <www.who.int/mediacentre/factsheets/fs225/en/> [accessed 20 June 2014].
Alexander, K.T., Dreibelbis, R., Freeman, M.C., Ojeny, B. and Rheingans, R. (2013) ‘Improving service delivery of water, sanitation, and hygiene in primary schools: a cluster-randomized trial in western Kenya’, Journal of Water and Health 11: 507–19 <http://dx.doi.org/10.2166/wh.2013.213>.
Alexander, K., Oduor, C., Nyothach, E., Laserson, K., Amek, N., Eleveld, A., Mason, L., Rheingans, R., Beynon, C., Mohammed, A., Ombok, M., Obor, D., Odhiambo, F., Quick, R. and Phillips-Howard, P. (2014) ‘Water, sanitation and hygiene conditions in Kenyan rural schools: are schools meeting the needs of menstruating girls?’ Water 6: 1453–66 <http://dx.doi.org/10.3390/w6051453>.
Blanton, E., Ombeki, S., Oluoch, G.O., Mwaki, A., Wannemuehler, K. and Quick, R. (2010) ‘Evaluation of the role of school children in the promotion of point-of-use water treatment and handwashing in schools and households: Nyanza Province, Western Kenya, 2007’, American Journal of Tropical Medicine and Hygiene 82: 664–71 <http://dx.doi.org/10.4269/ajtmh.2010.09-0422>.
Boyatzis, R.E. (1998) Transforming Qualitative Information: Thematic Analysis and Code Development, London, New Delhi: SAGE Publications.
Cohen, D. and Atieno-Odhiambo, E. (1989) Siaya: The Historical Anthropology of an African Landscape, London: James Currey.
Crofts, T. and Fisher, W.A. (2012) ‘Menstrual hygiene in Ugandan schools and investigation of low-cost sanitary pads’, Journal of Water, Sanitation and Hygiene for Development 2: 50–8 <http://dx.doi.org/10.2166/washdev.2012.067>.
Dreibelbis, R., Greene, L.E., Freeman, M.C., Saboori, S., Chase, R.P. and Rheingans, R. (2013) ‘Water, sanitation, and primary school attendance: a multi-level assessment of determinants of household-reported absence in Kenya’, International Journal of Educational Development 33: 457–65 <http://dx.doi.org/10.1016/j.ijedudev.2012.07.002>.
Garg, R., Goyal, S. and Gupta, S. (2012) ‘India moves towards menstrual hygiene: subsidized sanitary napkins for rural adolescent girls – issues and challenges’, Maternal and Child Health Journal 16: 767–74 <http://dx.doi.org/10.1007/s10995-011-0798-5>.
Greene, L.E., Freeman, M.C., Akoko, D., Saboori, S., Moe, C., and Rheingans, R. (2012) ‘Impact of a school-based hygiene promotion and sanitation intervention on pupil hand contamination in Western Kenya: a cluster randomized trial’, American Journal of Tropical Medicine and Hygiene 87: 385–93 <http://dx.doi.org/10.4269/ajtmh.2012.11-0633>.
Mason, L., Nyothach, E., Alexander, K., Odhiambo, F.O., Eleveld, A., Vulule, J., Rheingans, R., Laserson, K.F., Mohammed, A. and Phillips-Howard, P.A. (2013) ‘“We keep it secret so no one should know”: a qualitative study to explore young schoolgirls attitudes and experiences with menstruation in rural Western Kenya’, PLoS One 8: e79132 <http://dx.doi.org/10.1371/journal.pone.0079132>.
Mason, L., Laserson, K., Oruko, K., Nyothach, E., Alexander, K., Odhiambo, F., Eleveld, A., Isiye, E., Ngere, I., Omoto, J., Mohammed, A., Vulule, J. and Phillips-Howard, P. (2015) ‘Adolescent schoolgirls’ experiences of menstrual cups and pads in rural western Kenya: a qualitative study’, Waterlines 34(1): 15–30 <http://dx.doi.org/10.3362/1756-3488.2015.003>.
Mcmahon, S.A., Winch, P.J., Caruso, B.A., Obure, A.F., Ogutu, E.A., Ochari, I.A. and Rheingans, R.D. (2011) ‘“The girl with her period is the one to hang her head”: reflections on menstrual management among schoolgirls in rural Kenya’, BMC International Health and Human Rights 11: 7 <http://dx.doi.org/10.1186/1472-698X-11-7>.
Migele, J., Ombeki, S., Ayalo, M., Biggerstaff, M. and Quick, R. (2007) ‘Diarrhea prevention in a Kenyan school through the use of a simple safe water and hygiene intervention’, American Journal of Tropical Medicine and Hygiene 76: 351–3.
Ministry of Public Health and Sanitation (MOPHS) (2010) Republic of Kenya National School Health Strategy Implementation Plan 2011–2015, Nairobi: Ministry of Public Health and Sanitation, and Ministry of Education, Republic of Kenya.
Montgomery, P., Ryus, C.R., Dolan, C.S., Dopson, S. and Scott, L.M. (2012) ‘Sanitary pad interventions for girls’ education in Ghana: a pilot study’, PLoS One 7: e48274 <http://dx.doi.org/10.1371/journal.pone.0048274>.
Mugo, J., Kaburu, A., Limboro, C. and Kimutai, A. (2012) ‘Are our children learning?’ in Annual Learning Assessment Report, Nairobi, Kenya: Uwezo Kenya.
Odhiambo, F.O., Laserson, K.F., Sewe, M., Hamel, M.J., Feikin, D.R., Adazu, K., Ogwang, S., Obor, D., Amek, N., Bayoh, N., Ombok, M., Lindblade, K., Desai, M., Ter Kuile, F., Phillips-Howard, P., Van Eijk, A.M., Rosen, D., Hightower, A., Ofware, P., Muttai, H., Nahlen, B., Decock, K., Slutsker, L., Breiman, R.F. and Vulule, J.M. (2012) ‘Profile: the KEMRI/CDC Health and Demographic Surveillance System: Western Kenya’, International Journal of Epidemiology 41: 977–87 <http://dx.doi.org/10.1093/ije/dys108>.
Omwami, E. and Omwami, R. (2009) ‘Public investment and the goal of providing universal access to primary education by 2015 in Kenya’, International Journal of Education Development 30: 243–53 <http://dx.doi.org/10.1016/j.ijedudev.2009.09.002>.
Oster, E. and Thornton, R. (2012) ‘Determinants of technology adoption: peer effects in menstrual cup up-take’, Journal of the European Economic Association 10: 1263–93 <http://dx.doi.org/10.1111/j.1542-4774.2012.01090.x>.
Phillips-Howard, P. (2013) ‘Menstrual solutions in adolescent schoolgirls in western Kenya: an acceptability, feasibility and safety study (tools and instruments), 21 November 2013’, in M. Sommer and M. Sahin (eds), 2nd Virtual Conference on Menstrual Hygiene Management in Schools ‘Exploring MHM in Countries: MHM Tools and Instruments’, 2013, New York: UNICEF.
Saboori, S., Mwaki, A., Porter, S., Okech, B., Freeman, M. and Rheingans, R. (2011) ‘Sustaining school handwashing and water treatment programmes: lessons learned and to be learned’, Waterlines 30: 13 <http://dx.doi.org/10.3362/1756-3488.2011.040>.
Sibiya, J.E. and Gumbo, J.R. (2013) ‘Knowledge, attitude and practices (KAP) survey on water, sanitation and hygiene in selected schools in Vhembe District, Limpopo, South Africa’, International Journal of Environmental Research and Public Health 10: 2282–95 <http://dx.doi.org/10.3390/ijerph10062282>.
Sinha, S. and Singh, A. (2013) ‘Adolescent health-tackling menstrual hygiene issue through social marketing’, Journal of Postgraduate Medicine, Education and Research 47: 127–30 <http://dx.doi.org/10.5005/jp-journals-10028-1069>.
Sommer, M. (2010) ‘Where the education system and women’s bodies collide: the social and health impact of girls’ experiences of menstruation and schooling in Tanzania’, Journal of Adolescence 33: 521–9 <http://dx.doi.org/10.1016/j.adolescence.2009.03.008>.
Sommer, M. and Sahin, M. (2013) ‘Overcoming the taboo: advancing the global agenda for menstrual hygiene management for schoolgirls’, American Journal of Public Health 103: 1556–9 <http://dx.doi.org/10.2105/AJPH.2013.301374>.
Sommer, M., Kjellén, M. and Chibesa Pensulo, C. (2013) ‘Girls’ and women’s unmet needs for menstrual hygiene management (MHM): the interactions between MHM and sanitation systems in low-income countries’, Journal of Water, Sanitation and Hygiene for Development 3(3): 283–97 <http://dx.doi.org/10.2166/washdev.2013.101>.
Stewart, K., Greer, R. and Powell, M. (2010) ‘Women’s experience of using the Mooncup’, Journal of Obstetrics & Gynaecology 30: 285–7 <http://dx.doi.org/10.3109/01443610903572117>.
Sumpter, C. and Torondel, B. (2013) ‘A systematic review of the health and social effects of menstrual hygiene management’, PLoS One 8: e62004 <http://dx.doi.org/10.1371/journal.pone.0062004>.
WHO (2014) ‘Dioxins and their effects on human health’, WHO Fact Sheet 225 [online] <www.who.int/mediacentre/factsheets/fs225/en/> [accessed 20 June 2014].
Alexander, K.T., Dreibelbis, R., Freeman, M.C., Ojeny, B. and Rheingans, R. (2013) ‘Improving service delivery of water, sanitation, and hygiene in primary schools: a cluster-randomized trial in western Kenya’, Journal of Water and Health 11: 507–19 <http://dx.doi.org/10.2166/wh.2013.213>.
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