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• (Article) Schoolgirls’ experiences of changing and disposal of menstrual hygiene items and inferences for WASH in schools

  01.10.2015
  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.

• (Article) Why do some behaviours change more easily than others? Water-use behaviour interventions in rural Nepal

  01.10.2015
  Water-sector development is inevitably based on changes in people’s behaviour. We analyse why some types of domestic water-use behaviours change more easily than others. Our case study is a water supply and sanitation intervention in remote and rural Nepal. We found that collective opportunities, degree of individual freedom, and individual incentives influenced the ease of the promoted behaviour changes. The enhanced individual opportunities, incentives, and collective tolerance enabled behaviour changes that were regarded as beneficial by the people themselves, whereas the existing social traditions in our case-study context often restricted those changes. Often, the individual agency and the collective traditions confronted one another. We suggest that this study can provide a design for predicting possible opportunities and challenges regarding behaviour changes in field operations, and for enhancing joint operation of individual and collective capabilities at local levels in the development intervention context.

• (Article) Strengthening behaviour change communication in western Nepal: how can we do better?

  01.10.2015
  The Government of Nepal aims to achieve full water and sanitation coverage by 2017. The bilateral Rural Water Supply and Sanitation Project in Western Nepal (RWSSP-WN) works with local governments in 14 districts, aiming to declare them open defecation free. This behaviour change communications evaluation explored how to improve RWSSP-WN’s present practices to reach the diverse target population in the Terai districts, where more than 1 million people still defecate in the open. The study reviewed RWSSP-WN’s present behaviour change triggering tools and related communications strategies. Our findings suggest that availability of subsidies seems to change how people think about sanitation and tends to eliminate willingness to pay for a latrine. We recommended strong advocacy for a no-subsidy policy, and more attention paid to alternative financing options with targeted support to the poorest of the poor. The present behaviour change triggering tools do work as intended, but there is a need to develop pre-triggering and post-triggering strategies to increase the overall impact. The pre-triggering strategy would ensure that potential barriers to change are identified and addressed before the actual triggering event, and that the key stakeholders are prepared for the actual triggering event. The post-triggering strategy is needed to continue motivating households to change via messages that tap into the drivers of change, addressing also the barriers which may keep each household from changing behaviour. This paper provides a number of recommendations applicable for those working with local governments and communities to increase the scope and scale of behaviour change triggering.

• (Article) Measurement of handwashing behaviour in Multiple Indicator Cluster Surveys and Demographic and Health Surveys, 1985–2008

  01.10.2015
  With this paper, we aim to describe handwashing worldwide, as measured in Multiple Indicator Cluster Surveys (MICS) and Demographic and Health Surveys (DHS) in low- and middle-income countries between 1985 and 2008, and to explain the strengths, weaknesses and evolution of this data collection to inform future survey development. We searched reports of DHS and MICS conducted before 2009 and analysed data on handwashing measurements. We examined data according to geographic region, as well as demographic characteristics such as wealth quintile, education of the household head, and rural/urban location. Before 2009, eight MICS and 40 DHS included handwashing-related measurements, using a variety of self-reports and rapid observations. Internal triangulation of findings from surveys that collected multiple types of measurement shows that self-reports to closed questions overestimate behaviour. Observation-based data suggest low handwashing rates in many low- and middle-income countries with high prevalence of water and sanitation-related diseases, and high inter- and intra-country disparities. However, due to the widely disparate nature of the pre-2009 handwashing-related measurements, much of the data cannot be compared between countries, and only an incomplete picture of global rates can be formed. Efforts to increase the prevalence of handwashing with soap and water need to be strengthened in many low- and middle-income countries, especially among poorer, rural populations and where the household head has less formal education. Closed questions asking for self-reports of handwashing behaviour should be avoided. Findings support instead the inclusion of uniform observation-based measurements, as were integrated as core modules of MICS and DHS in 2009.

• (Article) Handwashing for menstrual hygiene management among primary schoolgirls in rural western Kenya

  01.10.2015
  Good hand hygiene contributes to the health and educational attainment of schoolchildren. Poor menstrual hygiene management (MHM) is recognized to impact on girls’ health, education, wellbeing and dignity, particularly in low-income countries. Identifying practical, affordable, and comfortable menstrual products to improve girls’ MHM is needed. One potential cost-effective product is the menstrual cup; however, provision of this insertable MHM product, in schools in low-income countries with challenging water, sanitation and hygiene (WASH) conditions, increases the need for assurance of good hand hygiene. This paper uses data from a randomized controlled feasibility study evaluating the acceptability, use and safety of menstrual hygiene products provided to schoolgirls in rural western Kenya. Here, we explore girls’ handwashing practices in school when using menstrual cups, sanitary pads or traditional items, examining the availability of WASH and the reported frequency of handwashing. Data generated from interviews with adults, girls’ private surveys, narratives from focus group discussions, and observational WASH surveys are explored. Reported presence of WASH was higher than that observed during random spot-checks. Overall, 10 per cent of girls never washed before, and 7 per cent never washed after, emptying or changing their menstrual item at school. Girls in cup schools were twice as likely to wash prior to emptying, compared with girls using other items. Handwashing among girls using traditional items was low, despite the same hand hygiene training across groups and a comparable WASH presence. Data highlight the need for sustained mechanisms to support schoolgirls’ handwashing practices for MHM.

• (Article) Are burial or disposal with garbage safe forms of child faeces disposal? An expert consultation

  01.07.2015
  The importance of safe handling and disposal of child faeces given its potential role in disease transmission are increasingly recognized. Household surveys demonstrate that the burying of child faeces (‘dig-and-bury’) is common in several countries, especially in sub-Saharan Africa and South-east Asia. Disposal with garbage is widely practised in middle- and high-income countries and is becoming increasingly common in urban areas of low-income countries. The safety of these two approaches is difficult to assess given the limited evidence available and we therefore sought the opinion of experts in the field of sanitation to support advocacy around the topic. We report the findings of an anonymous expert (Delphi) consultation on the safety of these two child faeces disposal methods. There was almost unanimous agreement these should be considered neither safe nor improved. A range of arguments was provided to support this position, including proximity of solid waste and burial sites to the home and children’s play areas and that neither practice would be acceptable for adults. The consultation also highlighted gaps in the current evidence base that should be addressed to gain a fuller insight into the risks involved in these two forms of sanitation with a view to providing both programmatic and normative guidance. In particular further work is needed to assess the potential for exposure to faecal matter in solid waste in low- and middle-income countries and to elucidate the predominant practices of child faeces burial including proximity to the home or infant play areas as well as depth of burial.

• (Article) Microfinance for sanitation: what is needed to move to scale?

  01.07.2015
  The sanitation sector is gradually realizing that the effectiveness of approaches such as Community-Led Total Sanitation (CLTS) is limited by inadequate access to finance. Households are not able to construct durable facilities and sanitation services are unable to develop so as to respond to demand. At the same time, there is fierce competition among microfinance services providers that is pushing institutions towards more remote customers and to offer innovative products. In addition, the rise of mobile banking and digital finance has lifted many poor people out of financial exclusion. These factors have created a nexus between microfinance and sanitation with high growth potential. However, the sanitation microfinance market remains small to date. Since 2010, the SHARE research consortium has investigated global experiences and lessons for using microfinance to develop sanitation services. A SHARE action-research in Tanzania triggered selected financial institutions to offer financial products for sanitation and generated lessons for scaling up sanitation microfinance. This article presents the findings from the SHARE research, in the context of broader developments in the microfinance markets and key findings from other donor-led initiatives.

• (Article) Learning, acting, and learning (LAL) research on schools' menstrual hygiene management (MHM): Pakistan

  01.01.2015
  UNICEF Pakistan adopted a conceptual framework for global qualitative research to advance their ongoing exploratory research work on menstrual hygiene management (MHM) in 2013-14. The findings of qualitative research informed the design of certain interventions in schools to improve MHM. These interventions were implemented as action research so that the benefits of these interventions can be studied. Qualitative research gave an in-depth understanding of girls' needs and their preferences to address MHM-related issues. Data analysis of qualitative research helped a team of sanitation practitioners and social scientists in understanding different factors influencing MHM in girls' schools. A few simple and focused interventions were hence designed and implemented. Six weeks after the implementation of hard and soft activities on the ground the results were studied. Results showed significant improvement in MHM conditions in girls' schools. Girls and teachers welcomed the initiatives and there were indicators for future sustainability. Areas of improvement were also noted by UNICEF before taking these interventions to scale. This research was documented as ‘learning, acting, and learning’ (LAL: literally meaning ‘Red’ in the local language, Urdu) research.

• (Article) Towards a sustainable solution for school menstrual hygiene management: cases of Ethiopia, Uganda, South-Sudan, Tanzania, and Zimbabwe

  01.01.2015
  African schoolgirls face considerable challenges as a result of the real biological phenomenon of menstruation and its management. Menstruation is seen as a secret and is regarded as taboo. As a result girls are not receiving adequate support from home, schools, or the community. They are left on their own to address the challenge which consequently affects their school performance. Development interventions that deal only with the supply of materials cannot resolve the problem in a sustainable manner. We need to have a comprehensive approach that can improve: knowledge, attitude, and practice of girls, parents, and the community; sanitary materials supply; the policy environment; and the physical infrastructure. The issue of menstrual hygiene management is gaining recognition as part of the development agenda for improving girls' school participation. But there is little research and few practical case studies have been conducted to inform policy and practice. SNV Netherlands Development Organization is addressing menstrual hygiene under its WASH in School programme in Asia, Africa, and Latin America. This article highlights baseline survey findings of the current menstrual hygiene management practices in the project areas of Ethiopia, South Sudan, Uganda, Tanzania, and Zimbabwe and recommends the approach piloted.

• (Article) Unpacking the policy landscape for menstrual hygiene management: implications for school WASH programmes in India

  01.01.2015
  Menstrual hygiene management (MHM) relates to how girls and women manage their monthly period, and require access to information about menstruation, clean and safe menstrual absorbents, and amenities and facilities such as toilets and water, and waste management to maintain hygiene. In general MHM is poor in India, with low levels of knowledge and many misconceptions, varied use of menstrual absorbents, and unhygienic practices among adolescent girls. With almost 50 per cent of school age girls enrolled in schools, creating a conducive environment in schools to promote MHM is imperative. This policy scoping exercise examines how select policy initiatives implemented by the Government of India address MHM, especially in the context of schools. This document review found that adolescent girls are a focus of most policy initiatives addressing MHM, with a focus primarily on the hardware (i.e. infrastructure, sanitary napkins) or software (i.e. health education) components. Most programmes are implemented at the school level, though guidelines for implementation are not always explicit. Programmes suggest convergence with other government programmes, yet operationalization of convergence mechanisms is lacking.

• (Article) Developing games as a qualitative method for researching menstrual hygiene management in rural Bolivia

  01.01.2015
  The onset of menstruation has proven challenging for girls in school, with absenteeism, missed class time, reduced participation, teasing, fear, shame, and risky adaptive behaviours among the most commonly noted impacts in many settings. In 2012, Emory University and UNICEF conducted a multi-country formative study to gain a global perspective of girls' experiences. A compendium of tools was created to ensure investigation of common themes across all settings. This paper describes the process of adapting the focus group discussion (FGD) tool for Bolivia into a board game as a method to ease girls' discomfort discussing menstruation and elicit richer data. We describe the development of the menstrual hygiene management game, including structure and strategies for adapting FGD questions that increased interaction, stimulated detailed responses, and diversified participatory activities. A discussion of lessons learned will highlight elements of success and areas for improvement in future game adaptations. The paper discusses games as a research method for other topics and their applications for programme design, monitoring, and skills-based learning.

• (Article) Menstrual hygiene management: education and empowerment for girls?

  01.01.2015
  This paper discusses the recent attention of the water, sanitation, and hygiene (WASH) sector to resolving the menstrual hygiene crisis for young girls in developing countries. Menstrual hygiene management (MHM) interventions, including the use of sanitary pads, education, and awareness, and where possible separate, sanitary toilets, are identified to have far-reaching impacts on the education and empowerment of girls. Field research conducted in Ghana's Northern Region indicates a pronounced socialized, sexualized understanding and experience of menstruation among young girls and their families, school teachers, and local NGOs. Unfortunately WASH initiatives only allow interventions to manage menstrual hygiene, leaving the young girls and others in their social settings to deal with the larger subset of sexuality issues. We argue that opening the dominant discourse of a medicalized concept of menstruation to other meanings and experiences will have significant implications for the education and empowerment of young adolescent girls.

• (Article) Mainstreaming menstrual hygiene management in schools through the play-based approach: lessons learned from Ghana

  01.01.2015
  The study objective was to identify and document the effectiveness of the play-based approach in promoting menstrual hygiene management (MHM) in schools and share lessons learned. The study used a mix of study approaches including qualitative and quantitative techniques. The writer carried out an exploratory evaluation on the promotion of MHM activities as part of WASH in Schools programmes in 120 public schools in Ghana. Comparison was drawn between 60 schools currently using the play-based approach in promoting MHM, and 60 other schools which are not using the play-based approach. Data were gathered through interview, focus group discussions, observation, and from field level reports over a six month period. The study showed that there is much potential in play-based approaches, which could accelerate and sustain the implementation of MHM in schools. More teachers and school children participate in and demonstrated considerable knowledge and were confident discussing MHM. The play-based activities also served as point of attraction for the primary school children. The study indicated positive attitudes in boys towards menstruating girls and improved personal hygiene among adolescent girls.

• (Article) Uncovering the challenges to menstrual hygiene management in schools in Mali

  01.01.2015
  There is limited information on girls' menstrual hygiene practices and experiences at school in francophone sub-Saharan Africa. We conducted qualitative research to determine the challenges faced by school-aged girls in Mali, a culturally diverse and largely Muslim country. Research activities were conducted in eight urban and rural schools across the Sikasso and Koulikoro regions, including in-depth interviews with 26 girls and key informant interviews with 14 teachers and school directors. Results describe girls' practices for managing menstruation at school, their support systems and information channels, and their voiced recommendations for school WASH and education improvements.

• (Article) Adolescent schoolgirls' experiences of menstrual cups and pads in rural western Kenya: a qualitative study

  01.01.2015
  Poor menstrual hygiene management (MHM) among schoolgirls in low income countries affects girls' dignity, self-esteem, and schooling. Hygienic, effective, and sustainable menstrual products are required. A randomized controlled feasibility study was conducted among 14-16-year-old girls, in 30 primary schools in rural western Kenya, to examine acceptability, use, and safety of menstrual cups or sanitary pads. Focus group discussions (FGDs) were conducted to evaluate girls' perceptions and experiences six months after product introduction. Narratives from 10 girls' and 6 parents’ FGDs were analysed thematically. Comparison, fear, and confidence were emergent themes. Initial use of cups was slow. Once comfortable, girls using cups or pads reported being free of embarrassing leakage, odour, and dislodged items compared with girls using traditional materials. School absenteeism and impaired concentration were only reported by girls using traditional materials. Girls using cups preferred them to pads. Advantages of cups and pads over traditional items provide optimism for MHM programmes

• (Article) Putting the men into menstruation: the role of men and boys in community menstrual hygiene management

  01.01.2015
  This paper examines how men and boys have an essential role in effective menstrual hygiene programmes and describes an initiative to engage men and boys in Uttar Pradesh, India. Cultural norms around menstruation are rooted in gender inequality and compromise women's ability to manage menstruation hygienically and with dignity. While there has been significant progress in developing comprehensive approaches to menstrual hygiene management (MHM), the role of men and boys in supporting menstrual hygiene has been lacking. In India, WaterAid and Vatsalya have targeted men and boys to address this gap in a programme that started in December 2011. Groups of men and boys were established and sensitized. Male teachers and masons were also trained to provide MHM services in school. Regular monitoring of software and hardware components, focus group discussions with male and female community members, and analysis of attendance registers has been undertaken to assess the emerging outcomes of the programme. As a result of the initiative, men and boys have begun to talk about menstruation more freely and are better able to support the MHM needs of women and girls within the household, community, and school.

• (Article) Identification of the potential opportunities, barriers, and threats within the sector in taking up sanitation as a business: rural sanitation in Nkhata Bay District (Malawi)

  01.07.2014
  Private sector participation in sanitation marketing provides a great opportunity to improve rural sanitation access. Although a number of opportunities for private sector participation within the sanitation sector exist, there are numerous barriers and threats to taking up sanitation as a business. This Note from the Field identifies these opportunities, barriers, and threats in Nkhata Bay District, a rural area of Malawi. These insights emerge from a wider research project entitled ‘Private sector participation in the delivery of sanitation and hygiene services’. This note provides background information on the research project on private sector participation and the project location. It goes on to describe the data collection process and present two examples of business activities in the district sanitation sector, before listing the opportunities, barriers, and threats identified and the recommendations that emerge from them.

• (Article) Roads for water: the unused potential

  01.04.2014
  Roads are generally perceived as infrastructure to deliver transport services, but they are more than that. They are major interventions in the hydrology of areas where they are constructed - concentrating runoff and altering subsurface flows. At present, water-related damage constitutes a major cost factor in road maintenance. Using ongoing research from Ethiopia, this article argues to reverse this and turn water from a foe into a friend and integrate water harvesting with road development. Optimized road designs are required - better planning of alignments, making use of road drainage, road surfaces, and river crossings, but also capturing freshly opened springs and systematically including developing storage and enhanced recharge facilities in road-building programmes. Equally important are inclusive planning processes that are sensitive to the multi-functionality of roads but also to the potentially uneven distribution of benefits and the diverse livelihood impacts. There is a need for closer integration of watershed and road-building programmes. With 5.5 million kilometres of roads in sub-Saharan Africa alone, and road building continuing to be one of the largest public investments, the potential of roads for water harvesting is great.

• (Article) Sustaining school hand washing and water treatment programmes: Lessons learned and to be learned

  01.10.2011
  In Nyanza Province, Kenya, a sustainability evaluation of 55 pilot primary schools 2.5 years after the implementation of the Safe Water System (SWS) intervention revealed that programme activities were not successfully sustained in any of the schools visited. The most common criterion met was drinking water provision. We identified six enabling environment domains: financial capacity; accountability; technical feasibility and availability; community support; school leadership and management; and student engagement. While these domains pertain to the sustaining of the SWS activities in schools, they are likely to be applicable in creating an enabling environment and serve as proxy indicators for other school water, sanitation, and hygiene initiatives as well.

• (Article) Is soapy water a viable solution for handwashing in schools?

  01.10.2010
  Despite the known health benefits of washing hands with soap, global handwashing rates are low. In Nyanza Province, Kenya, a follow-up of 55 pilot primary schools three years after the implementation of a safe water and hygiene intervention revealed that only 2 per cent (one school) provided soap for handwashing on the day of the assessment. After identifying barriers to soap provision, SWASH+ partners piloted a handwashing intervention using powdered soap mixed with water to create soapy water in place of bar soap in 11 schools. The first six months of unannounced visits showed high uptake (10 schools). A one-year follow-up visit revealed a decrease of soapy water use (four schools). This paper discusses the soapy water intervention, initial and follow-up monitoring findings, potential sustainability drivers of handwashing programmes in rural primary schools and next steps.