RESEARCH ARTICLE Open Access

‘The girl with her period is the one to hang herhead’ Reflections on menstrual managementamong schoolgirls in rural KenyaShannon A McMahon1,2, Peter J Winch2, Bethany A Caruso1*, Alfredo F Obure3, Emily A Ogutu3, Imelda A Ochari3

and Richard D Rheingans4

Abstract

Background: The onset of menstruation is a landmark event in the life of a young woman. Yet the complicationsand challenges that can accompany such an event have been understudied, specifically in resource-poor settings.As interventions aim to improve female attendance in schools, it is important to explore how menstruation isperceived and navigated by girls in the school setting. This research conveys rural Kenyan schoolgirls’ perceptionsand practices related to menstruation

Methods: Data were collected at six rural schools in the Nyanza Province of Western Kenya. Using focus groupdiscussions, in-depth interviews, and field notes from observations, researchers collected information from 48primary schoolgirls and nine teachers. Systematic analysis began with a reading of transcripts and debriefing notes,followed by manual coding of the narratives.

Results: Focus group discussions became opportunities for girls to share thoughts on menstruation, instruct oneanother on management practices and advise one another on coping mechanisms. Girls expressed fear, shame,distraction and confusion as feelings associated with menstruation. These feelings are largely linked to a sense ofembarrassment, concerns about being stigmatized by fellow students and, as teachers explained, a perception thatthe onset of menstruation signals the advent of a girl’s sexual status. Among the many methods for managingtheir periods, girls most frequently said they folded, bunched up or sewed cloth, including cloth from shirts ordresses, scraps of old cloth, or strips of an old blanket. Cloth was reported to frequently leak and cause chafing,which made school attendance difficult particularly as the day progressed. Attitudes and practices of girls towardmenstruation have been arranged into personal, environmental and behavioural factors.

Conclusion: Further research on menstrual management options that are practical, sustainable and culturallyacceptable must be conducted to inform future programs and policies that aim to empower young girls as theytransition into womanhood. Stakeholders working within this and similar contexts must consider systematicmechanisms to explain to young girls what menstruation is and how to manage it. Providing sanitary supplies orguiding girls on how to create supplies serve as critical components for future interventions.

BackgroundMenstruation is managed differently according to cul-tural, social and economic contexts. For young girls inpoor, rural settings who often receive minimal instruc-tion on what menstruation is and how it can be managed,

the experience has been described as frightening, confus-ing and shame-inducing [1]. At the same time, the onsetof menstruation - with its accompanying physical devel-opment, its hygienic requirements and its increasedsocial pressure to move into adulthood - has implicationsfor young girls’ academic performance, school attendanceand self- esteem [1-5]. It is therefore important to under-stand how girls cope with menstruation in settings whereaccess to water, latrines and sanitary products is poor

* Correspondence: bcaruso@emory.edu1Emory University Center for Global Safe Water, Rollins School of PublicHealth, 1518 Clifton Road, Room 767, Atlanta, GA 30322, USAFull list of author information is available at the end of the article

McMahon et al. BMC International Health and Human Rights 2011, 11:7http://www.biomedcentral.com/1472-698X/11/7

© 2011 McMahon et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.

and discussions concerning menstruation are consideredinappropriate, unnecessary or forbidden.This study examines knowledge and practices sur-

rounding menstruation and menstrual managementamong primary schoolgirls in the Nyanza Province ofWestern Kenya.Researchers have explored menstrual management

among schoolgirls in resource-poor settings includingIndia, Nigeria, Tanzania and Pakistan [5][4][1][3], butwe are not aware of other studies that have addressedthe issue in this setting. For this reason, questions ofhow primary schoolgirls in rural Kenya perceive andnegotiate their periods in the school setting and barriersthey face in the process of menstrual management wereexplored.This study was prompted by research carried out in

2009 as part of the Sustaining and Scaling School Water,Sanitation and Hygiene Education Plus CommunityImpact (SWASH+) Project in schools in Nyanza Province,Kenya. SWASH+ is an applied research project that seeksto identify, develop, and test approaches to school-basedwater, sanitation and hygiene in Nyanza Province, Kenya.The partners that form the SWASH+ consortium areCARE, Emory University, the Great Lakes University ofKisumu, the Government of Kenya, the Kenya Water forHealth Organisation, and http://Water.org (formerlyWater Partners International). Using qualitative methods,a rapid assessment found that girls viewed menstruationas the most significant social stressor and barrier toschooling. Specifically, girls discussed limited access tomenstrual supplies, confusion on biological aspects ofmenstruation and limited knowledge of the logisticalimplications of menstruation [6].

Literature reviewMenstruation, or the monthly shedding of uterine lining,is the most outwardly visible portion of a woman’s men-strual cycle. Occurring once every four weeks, menstrua-tion typically lasts 3 to 5 days. Using an average of fourdays per period, most girls have their periods 52 days ofevery year, totalling 13 cycles per year. Menarche, or theonset of menstruation, marks a significant turning pointin the life of a young girl [7]. It alters her perception ofherself and the perceptions or pressures that society mayplace on her [8-10][1][11]. In her study on schoolgirls inTanzania, Sommer found that the onset of menstruationalso meant the onset of new restrictions on movement.Girls’ abilities to pursue an education or a career, shenoted, became obstructed [11]. In Kenya, Thomas foundthat reproductive health issues - a term that emphasizesmarriage, pregnancy and female circumcision butincludes menstruation- were the leading cause of dropoutamong primary school girls [8].

While studies of girls’ school attendance and men-struation have stated that drop-out rates among school-girls accelerate at the onset of puberty and menstruation[12], evidence-based research on the link betweenabsenteeism and menstruation is lacking. Documentedinterventions addressing the issue of menstrual manage-ment in schools have found contradicting results.An analysis of the Chinese Health and Nutrition Sur-

vey found that among girls who had not yet had theirperiods, a lack of sufficient water had no effect onabsenteeism. Following menarche however, a lack ofwater could result in a 13% reduction in the probabilityof enrolment and a two-year fall in the amount of timea girl attends school [13]. A pilot intervention in Ghanafound that after six months of free sanitary pad provi-sion, girls missed significantly less school, and theyreported an improved ability to concentrate in school,higher confidence levels and increased participation in arange of activities despite menstruating. Negative experi-ences related to soiling and embarrassment declined;measures of well-being, as measured using questions onsadness or shame, improved [2]. In Nepal, a randomizedcontrolled trial found that schoolgirls who received andwere instructed on the use of menstrual cups (reusable,silicone devices inserted during menstruation) were nomore likely to attend school during their periods. TheNepal study also found no significant effects on testscores, self-reported measures of self-esteem or gynaeco-logical health [14].

Research SettingNyanza Province lies on the shores of Lake Victoria inWestern Kenya. Household economies in the provinceare supported by farming and fishing. Kenya’s currentdrought has posed increased financial strain on familiesin this region as they rely heavily on subsistence agricul-ture. In the region, 94.9% of homes have no electricityand 73.8% of homes have floors made of earth, mud,dung or sand [15].Nyanza is most heavily populated by the Luo, the sec-

ond largest ethnic group in Kenya. Household and com-munity arrangements among the Luo have beensignificantly altered in recent decades due to the AIDSepidemic, scarce employment opportunities and malelabour migration [16]. Nyanza Province has the coun-try’s highest overall HIV prevalence at 15% amongadults aged 15 - 49, with 16.0% of women and 11.4% ofmen infected [15,17]. In Nyanza Province, 13.4% offemales have never received education and of those whoenrol in school, 49.3% do not complete primary educa-tion [17]. Among males, 8.9% have no education and48.4% who enrol in school do not complete primaryeducation [15,17].

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In 2003, Kenya introduced free primary school educa-tion. Many educators interviewed for this research notedan uptick in older students, particularly female students,which they attribute to the free education policy. Thereturn of older students to school has, in some cases, ledto classrooms where classmates are not age mates.English is the language of instruction starting in Stan-

dard 4, when children are typically 10 or 11 years old.Techniques for enforcing the English-only policy rely onpeer oversight wherein students report to teachers if theyhear others speaking Dholuo, the language of the Luo. Inother settings, however all students and teachers speakDholuo. This has implications for researchers as childrenoften feel pressured to speak English at the risk of beingpunished by authorities or peers.

MethodsThis study employed in-depth interviews, focus group dis-cussions and observation activities. The study designincluded an initial phase of data collection and a potentialsecond phase, in the event that saturation was not reached.The second phase was deemed necessary and took place2 months after the first phase. In total, focus groups with48 girls ages 12-16 in six groups allowed researchers toexplore social norms as perceived and described by girlsrelated to menstruation. In-depth interviews with nine tea-chers focused on observations or interactions teachersrecalled with girls who were successfully or unsuccessfullymanaging their periods. An observation tool was used tocollect data on the cost and availability of menstrual sup-plies in each of the six localities.Only girls who had started menstruating were included

in the discussion. Selection of girls was done in collabora-tion with a female teacher from the school (when possible)or any school staff member who could discretely helpidentify girls who had started menstruating. All head tea-chers (or other responsible party) were explained the pur-pose of the study and all gave permission to speak withgirls.Once identified, students went with a focus group mod-

erator and a note-taker (both female) to a private settingon the grounds of the school. At the outset of focus groupdiscussions, the moderator explained the purpose of theresearch and girls provided informed consent. The lan-guage used in focus group discussions was Dholuo. Girlswere assured that they would not be reprimanded by mod-erators or by one another for speaking Dholuo.A tape recorder was used during focus group discus-

sions. Students were asked open-ended questions on howthey felt about their periods and how they managed theirperiods. Interview instruments provided to the moderatorincluded probes and follow-up questions. All data collec-tors in this study had previous training and experience inqualitative research and have a professional background

in health or social sciences. Data collectors were familiarwith the iterative nature of qualitative research andallowed the flow of conversation to be controlled byparticipants. Copious note-taking took place throughoutdiscussions by a trained note-taker who was seated neara circle of girls. Note-taking allowed for effective debrief-ings, which took place off-site after all discussions indebriefing sessions among the discussion’s moderator,note-taker and the study’s lead researcher. Note-takingprovided a means to record valuable, yet unspoken,aspects of the discussions such as girls showing oneanother how to fold cloth into a menstrual pad.The lead researcher (who is not Kenyan and does not

speak Dholuo) did not attend discussions as this hadserved as a distraction in previous data collection activities.Focus group discussions and interviews with girls wereinitially expected to last 40 minutes but grew longer asgirls shared and critiqued one another’s coping mechan-isms, vented frustration and requested guidance from themoderator and one another. The moderator was carefulnot to instruct girls during the focus group and insteadwould repeat questions that were initially posed to themoderator to others in the discussion.The lead researcher on this project interviewed nine

teachers during data collection. The language in thosediscussions was English. Each interview lasted approxi-mately two hours and took place on the grounds of theschool in a private location.At the outset of data analysis, there were no pre-defined

codes. However because feelings toward menstruation arethe product of personal and situational factors, there wasan expectation that an interplay among influences wouldbe identified during the coding process. Systematic analy-sis began with a reading of transcripts and debriefingnotes, followed by manual coding of the narratives. Pas-sages of text were written on notecards, and assigned aprovisional code. These codes were then organized and re-organized into broader categories related to how girlsrespond to, manage and are affected by menstruation.Authors 1 and 2 had a series of discussion about how todefine the broader categories, and reviewed a number ofmodels and theories to see which could most accuratelysummarize the findings.This research was approved by The Emory University

Institutional Review Board in Atlanta, GA and by theGreat Lakes University of Kisumu Ethical Review Com-mittee, in Kenya.

ResultsData were collected in six localities and included 6focus group discussions with young girls, 9 interviewswith teachers and 6 observation tools from each local-ity that contained information on menstrual suppliesin the community. Results from this study have been

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arranged into three broad categories: personal feelingstoward menstrual management, environmental factorsthat affect menstrual management and behavioursundertaken to address menstrual management. Duringfocus group discussions, students echoed one another,expounded on opinions of their peers and, in one case,began an impromptu demonstration on how to sew ahomemade pad. A mention of sex and/or sexualityarose in nearly all discussions. Despite the sensitivenature of this topic, there was no apparent orexpressed tension or mistrust of the moderator or notetaker. Following each focus group discussion, at leastone student approached the female moderator or notetaker to ask specific questions about menstruation andpregnancy. Many girls remarked that this was theirfirst opportunity to discuss menstruation withoutembarrassment or guilt.

Personal FeelingsWhile at times girls expressed neutrality about their peri-ods, saying it is normal or “something that all womenhave”, the topic is often associated with negative feelingssuch as shame, fear, distraction, confusion and powerless-ness. Two notable exceptions include one instance inwhich a Standard 7 girl said, “When I have my period Iam happy because I know I have no pregnancy” andanother instance in which a Standard 8 student describedmenstruation as “part of God’s plan for all females to passthrough a stage together”.The most commonly described feeling toward men-

struation is shame. Girls had difficulty articulating thesource of their shame, but often mentioned unwantedattention from classmates and a general feeling that thesecrecy surrounding the topic of menstruation is inter-twined with a collective understanding that menstrua-tion is somehow bad.

“The girl with her period is the one to hang herhead.” (Standard 7)“Why would she hang her head?” (moderator)(silence)“Children and boys will make fun of her.” (Standard 7)(silence)“The children have never seen this and they will startsaying that she is dirty and people will start talkingabout her.” (Standard 8)

Along with teasing from male students and youngerstudents, which was discussed and confirmed acrossdata collection activities - and directly observed in oneschool - several girls noted a societal expectation tomaintain secrecy about menstruation. When probed onwhy periods should not be discussed, girls would often

say, “Because that’s the way it is” or “That’s how ithas always been.” At other times girls were more forth-coming:

“Why can’t you know that your friend is carryingAlways™?” (moderator)“It is normally kept secret, you would not allow theother people to know this.” (Standard 8)“Why do you keep it like that?” (moderator)“You don’t want other people to see this.” (Standard 7)“Others should not know this.” (Standard 7)(others agree)“Why is this? Is it bad when somebody sees you withAlways™?” (moderator)“It is only that it brings you shame.” (Standard 8)“Why does it bring you shame?” (moderator)(silence)“There are some people when they realize that youare in the periods, they take the story around evenwith children and you know this is shameful.” (Stan-dard 7)(others agree)“Others should not know about this.” (Standard 8)

Shame overlapped with feelings of fear and distraction.Girls fear getting their periods while at school or inpublic. They fear having blood stains on their uniformsand being looked at “differently” or being stigmatized bypeers.

If a period comes while a girl is in class, “she will bescared. Her whole mind will be centred there.”(Standard 7)“You will not be free even when you are in class, youwill be thinking about your period and not payattention to the teacher.” (Standard 8)

Girls often said that they feel - or they believe othersfeel - incapable of managing an unexpected onset oftheir period:

“Sometimes a girl might not know that she is in herperiod until someone tells her that she is dirty onher hind and she will be frightened because... maybeit’s her first time or maybe she doesn’t know what todo about the blood.” (Standard 8)“When it comes, I don’t feel good because some-times it comes when I don’t have pads and there isnothing I can do.” (Standard 8)

In one school, girls reported that male teachers beganlooking at them “differently” when they started menstru-ating and would tease them upon returning to school

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after a 2 or 3-day absence in which they attended totheir periods.

Teachers Perspectives on Girls’ Personal FeelingsTeachers’ insights served as a rich source to triangulatedata reported by students. Teachers reported that theydid not tease their students. They did confirm teasingparticularly from small children and boys toward girls.Teachers added that many girls engage in teasingamong one another and will sometimes join with boysto taunt a girl and “get back” at her. Common teasesinclude “go make a home”, “go get married”, “you havevisitors” or calling the menstruating girl an “upmooner,”a derogatory term that indicates that a girl is menstruat-ing (moon or “dwe” is the word for period in Dholuo).One teacher emphasized that shame expressed by girlsand teasing observed in her peers is linked to the “sex-ual dimension” of menstruation, which underpins thetopic’s forbidden nature.

“When she starts to menstruate, there is a percep-tion in our culture that she has left childhood andnow she may get jumpy jumpy,” (Teacher, referringto girls generally)“Please tell me what you mean by jumpy jumpy.”(Interviewer)“I mean in our culture, when a girl begins attending(menstruating) others may view her with new eyes,as she may view others with new eyes.”“Which others?” (Interviewer)“The men. And then the family may then worry that‘This girl may need to be dehorned. She maybecome horny’.” (Teacher)

In general, teachers were less focused on teasing andemotions such as fear and shame, and emphasized themore pragmatic concern of menstruating girls being dis-tracted or unfocused while in class.

“It’s like you can see that she is thinking something,that she has something urgent to share, but she willsay nothing.” (Teacher)“Do you ask her what she is thinking? Do you askwhy she’s distracted?” (Interviewer)“I know why she is distracted. This is something(teachers) know... when the session ends, she willnot leave the room (until she is the last to leave)and then when she leaves, she will wrap sweatersaround her middle and she will say, ‘Teacher I amso sick’ and then she will go from school and notcome back all day or many days.” (Teacher)

When this teacher was probed, he outlined a recurringpattern observed among many of his Standard 6

students. At first, girls will try to cope with menstrua-tion while in school. Later, they will miss school routi-nely - being absent for three to five days each month “inanticipation of menstruation”. While the teacher’s enrol-ment ledger showed regular absences for several femalestudents, it was not possible to know if the absenceswere attributed to menstruation or another cause.Across all schools, teachers confirmed this patternsometimes stating that instead of being absent for sev-eral days, girls will come to school but refuse to wear auniform. Students reported varying levels of understand-ing on behalf of teachers accommodating the needs of amenstruating girl. While some teachers were describedas supportive, others reportedly punish girls who wishto leave school early. In the latter case, girls reportedleaving school “in secret”.

“A girl will be among the most lively in class, shewill participate and make good marks. Then sheturns a corner and she will not partake and she isgone.” (Teacher)

Environmental FactorsEnvironmental factors, here, include both the physicalenvironment and the social environment, but it alsospeaks to a broader reality for girls in this setting:poverty.Poverty prevents girls from effectively managing their

periods. For example, while girls often state that com-mercially-available pads are their preferred method formanaging their periods, a lack of money inhibits themfrom purchasing pads and, in two instances, inhibitedshopkeepers’ or kiosk owners’ ability to stock pads.

“The Always™ costs money, but with cloths you justfind an old piece of cloth and tear.” (Standard 8)“I choose rags because sometimes there is no moneyto buy pads so these help.” (Standard 8)

Girls also stated that families with many orphans espe-cially struggle to afford sanitary napkins.

Physical Environment and Sanitary FacilitiesGirls reported that it is difficult to manage their periodsin school due to a lack of water and an inability tobathe, which is a preferred practice if a girl is menstru-ating while at home. Girls reported that bathing is diffi-cult or impossible because school washrooms are notprivate, lack water, or have cold water.

“It is different at school because at times you are lateto school so you can’t get time to warm your bath-ing water as required. During lunch break, also there

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is often no time for that so you must bathe usingcold water.” (Standard 7)

This student later said she typically goes home atlunch to bathe and does not return to school. Bathing atschool, which is rare in Kenya though available at a fewSWASH+ intervention schools, also involves the risk ofbeing seen by others, which can lead to shame.

“May be when you go bathing there, all of the otherpeople will know that you are in your menstrual per-iod.” (Standard 7)

Others said bathing in school is also difficult as thereis no dry place to lay a sanitary napkin or cloth, andthere is no basin or soap.At one primary school, bathing is practiced in school

washrooms because soap is provided by the school andwater can be discretely accessed. Girls bathe immedi-ately before going home at the end of the day. Embar-rassment was not a concern as many girls engage in thebehaviour regardless of menstrual status.

Social EnvironmentSocial environment here refers to the household andcommunity context in which girls live and the networkof individuals surrounding a girl. In past generations,teachers said, when a Luo girl began menstruating shewas not permitted to lay or sit on her mothers’ bed norcould she sleep in her parent’s house; instead she wassent to live with her grandmother. If the girl’s fatherhad died (implying that the mother was no longer sexu-ally active) a girl could continue to live in her parentalhome. When a girl is menstruating, she is barred fromengaging in a variety of household chores, such as wash-ing the family water pot, and she may not cross thethreshold into her parents sleeping quarters. These ruleswere described by teachers as mechanisms to maintain“respect for mothers and cleanliness in the home”. Alsoin the past, grandmothers - or other non-sexual femaleelders - played an instrumental role in explaining men-struation and discussing menstrual management andreproductive health with young girls. Today, teachersstated that, due to the AIDS epidemic and its dramaticimpact on the lives and livelihoods of individuals,families and communities, grandmothers are often una-vailable to girls.

“In the past, she could talk to her granny about this.The grandmother would take the girl into her placeand explain the way it works. Now grannies are soyoung - they are like age-mates with you - or theyare raising so many orphans or maybe they are even

now dead... Now there is no time. And nobody elseis having this conversation with the girls.” (Teacher)

Teachers mentioned that mothers and teachers alsofeel discomfort while discussing menstruation. Accord-ing to one teacher, the topic of menstruation is firmlylinked with the topic of sex, which is only discussedbehind closed doors and among adults.

“If the parents or neighbours heard me explaining,really explaining, how to manage the issues withattending (one’s menstruation) they may eitherbecome angry or they may think, ‘That man iscrazy.’” (Teacher)

Teachers most often said it is not their role - and it isperhaps beyond their professional authorisation- toexplain menstruation to students. Several teachers addedthat they never received instruction on menstruation inschool as young students or as teachers-in-training inTeacher College, and they therefore felt ill equipped toteach the topic.

“It is very very difficult to discuss menstruation withgirls because then you must also discuss sex. Andhow should we then discuss sex? We are not gran-nies.” (Teacher)

In one school, which is an exception in that it isdominated by female teachers, an older female teachermentioned that she has begun individually counsellingyoung girls on menstruation and menstrual manage-ment. She does this informally on an as-needed basis,such as when a girl has a stained dress or begins com-plaining of stomach aches and asks to go home. Usingpersonal funds, this teacher also procures commercialsupplies and makes them available to students whennecessary. The teacher also loans kanga (cloth) or swea-ters to girls if they have a stained uniform. Withoutprompting, students confirmed this teacher’s statements.

BehaviourGirls described various behaviours for managing theirperiods. Girls discussed several different materialresources that they use (to varying success) to managethe flow of their period. The most frequently citedmaterial used to absorb menstrual blood is cloth, includ-ing cloth from shirts or dresses, or scraps of old towelsor blankets. Cloths were frequently mentioned as inef-fective because blood leaks through the cloth, a bloodiedcloth can slip out of panties and fall on the ground, andbloodied cloth smells “like bad eggs” or feels wet orheavy. Mattress cuttings were also mentioned as a

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material for absorbing blood although sometimes, if amattress cutting gets too saturated, it can stain a girl’suniform when she sits. Commercially-available sanitarytowels are used primarily among girls who have finan-cial means (the minority). In the absence of napkins orcloth, bunches of dry, soft grass are placed in the pan-ties or sat upon at home or girls “go for a walk.”

“When you are at home you can’t tie a sweaterbecause you have to work and walk, you know, andwhen you sit down it can come out to the clothes.But if you go walking, it can’t stain the clothes.”(Standard 7)

Many girls discussed coping mechanisms in theabsence of material resources, namely sanitary pads,which often are referred to as ‘towels’ and occasionallyas ‘a loaf of bread’ or a ‘mud guard’. These mechanismsinclude wearing many layers (including several panties,biker (spandex) shorts, a skirt, and a sweater wrappedaround one’s waist). Girls also report wearing darkclothes or wearing civilian clothes (to avoid ruiningone’s only school uniform). Girls reported that theysometimes try to avoid sitting and instead prefer to “loi-ter”, or stand and wait idly in the back of the class toavoid sitting. Others reported that they try to avoidstanding, which is problematic as many students muststand when participating in class (in order to answer ateacher’s question). Girls added that they often try to bethe last person to leave a classroom in case there is astain on their clothing.

“The cloth may at times smell bad, or it may also falldown so some people put on many panties or manybikers. But blood can pass through the pants becausethey are very light. At times when blood passesthrough your outer clothes, you have to wait untileverybody has left the class and that is when youleave.” (Standard 8)

Sometimes a girl will ask a trusted friend to walk veryclosely behind her so that nobody will see a stain on herclothing. When asked for the most effective mechanismfor coping with menstruation while in school, manygirls said simply “go home.”

“It’s not good to go home during the morning, butsometimes one must do this.” (Standard 8)

Beyond behaviours as they relate to coping mechan-isms and menstrual management, girls also discussedtheir behaviours in terms of seeking guidance fromothers on menstrual management. In this sense, girls’behaviours were largely linked to social pressure to

refrain from asking questions about menstrual manage-ment from family or friends. When one moderator men-tioned to the girls that they seemed at ease discussingthe issue in the focus group, girls explained that it was“okay” to discuss periods in this setting because themoderator was not from their community and the topicwas broached by the moderator rather than the girlsmaking it “safe” for discussion. In contrast, girls in allfocus groups said they rarely or never discussed men-struation with parents, teachers or casual friends. Con-cerning their mothers, statements by girls included:

“You can’t know what your mother does. Her periodis her secret... like you want your period to be yoursalone.” (Standard 8)“(A period) is normal but if your mum is a cruelperson she will not understand you. She will alwaystell you to use cloths... She will say she did not haveAlways™ so why should you.” (Standard 8)

Periods are not typically discussed with teachers or theheadmaster:

“Madams will just talk about you when you walkby.” (Standard 8)“Teachers can sometimes be harsh with you. Shemay have nothing to help you... we are not givenpads at school.” (Standard 8)

Teachers said that on rare occasions they had dis-cussed menstruation with girls, typically in a one-on-one setting and only when the topic is teacher-initiatedif, for instance, a girl has a stain on her uniform.Students said if they must ask questions about men-

strual management, the best person to approach is anolder sister. In the absence of a sister, the next bestoption is to speak with a sister-in-law or a “friend inheart” (best friend). These women are most likely toexplain how to use sanitary napkins and/or give moneyto purchase sanitary napkins or absorbent materials.Periods are not typically discussed with friends

because friends may gossip about your period, or theymay interpret your confession as a veiled request formoney to buy supplies.Another behavioural factor, mentioned by a minority

of girls, was a feeling that with menstruation came newresponsibilities. Menstruation meant a distinct momentin the transition from childhood and child-like beha-viours toward adulthood and its accompanying responsi-bilities. Girls mentioned that menstruation meant theirbodies were “coming alive” and they were “like an adult”in the sense that they could now “mako ich” a Dholuoterm that literally translates as catching a stomach, buthere refers to getting pregnant.

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DiscussionOur grouping into three main themes of interacting setsof factors related to menstruation and menstrual man-agement - personal/individual, environmental and beha-viours - bears similarity to Social Cognitive Theory(SCT- see Diagram A, figure1 ).The inadequate level of information girls conveyed in

interviews speaks to the urgent need for girls to receivemore guidance on menstruation, which has been pre-viously recommended [18][1][11]. The fact that girls inthis study expressed negative feelings such as fear andanxiety is supported by studies conducted in India,Nigeria, Tanzania and Pakistan [4][9][5][19][3][1][11].Several findings in this study were echoed in Som-

mer’s study of schoolgirls’ menstrual experience in Tan-zania [1][11]. Sommer found that while girls in urbanand rural areas of Kilimanjaro express positive feelingsabout growing up, they regarded menstrual onset as amajor drawback to the growing up process [11]. Thestatement among Kenyan girls in this study that one ofthe most effective ways to deal with menstruation is to

“go home” - despite reported guilt about leaving classes- was reflected in Sommer’s earlier study, which alsodocumented that school toilet facilities are inadequateto support optimal menstrual hygiene practices andmany girls could not financially afford the cost of buyingsanitary pads [1]. Specific findings on the shame, guiltand confusion many Kenyan girls reported, the lack ofpragmatic knowledge they demonstrated, and their hesi-tation to discuss the onset of menstruation with theirmothers are echoed by young girls in Tanzania [1].In Pakistan, Ali and Rizvi found that reactions to the

experience of menarche - fear and worry - are similaramong female students in Karachi regardless of a school’sgovernment or private status. The study also found thatamong girls with some prior knowledge about menstrua-tion, most received it mainly from their elder sisters and,contrary to reports from girls in this study, from theirmothers [3].In India, Khanna’s study with grade nine schoolgirls in

Rajasthan reported that girls were frightened to see andfeel blood at menarche. They were worried, they wept

BehaviorAffects and is affected by

personal factors &environment

EnvironmentalFactors

Affect and are affected bybehavior & personal factors

PersonalFactors

Affect and are affected bybehavior & environment

Individual fear or anxiety about menstruation fosters an environment where menstruation is not discussed.

and

A difficult environment contributes to anxiety and low self-efficacy in relation to menstrual management.

The environment, incl. condition of facilities at school, affects what behaviors are possible.

and

Practices by girls create or reinforce aspects of their environment.

Negative behaviors or experiences with menstrual management add to fear and anxiety.

and

Perceptions of menstruation affect how it is managed.

Figure 1 Factors affecting Menstrual Management by Schoolgirls in western Kenya.

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and in response to feelings of fear and shame theybroached the issue with their mothers [5]. Similar tofindings among Kenyan girls, Indian girls reportedrestrictions on engaging in household work while men-struating due to the perceived unclean nature of men-struation [5]. Also consistent with this study, Khannareported that very few girls used sanitary pads duringmenstruation and instead used old cloths [5].

LimitationsThis study prioritized reaching female students duringschool hours, which was unfortunately the same timeparents were farming. For that reason, while researchersinitially intended to engage in data collection activitieswith parents, this proved impractical given financialconstraints and an inability to remain in villages throughthe evening during the rainy season. The study alsosought to engage with school boys, but due to staff lim-itations this proved unfeasible.

RecommendationsAs more attention is given to improving enrolment ofgirls in schools, it is important to consider evaluationsand interventions that seek to improve the experienceand understanding of menstruation among schoolgirlsand address challenges girls face to attend school whilemenstruating [20,21].Recent evaluations in Nepal and Ghana that included

the provision of menstrual management supplies to stu-dents have reported inconsistent results and have a lim-ited scope [2][14]. There is a need for further researchthat not only involves products that are effective, sus-tainable and culturally acceptable, but also evaluates thephysical environment in which girls are living and looksbeyond absenteeism to measure educational attainment.In terms of physical environment, Oster & Thornton(2010) and Scott et al (2009) did not evaluate the role ofadequate water and soap for washing or the presence oflatrines or washrooms as a private space for girls towash and change their supplies. Yet, in the presentstudy, cleanliness and privacy emerge as important fac-tors for girls. Similarly, Oster & Thornton evaluatedabsenteeism as their primary metric, yet attention, per-formance, participation, and future enrolment may bebetter measures for assessing overall impact on long-term educational attainment [14]. These factors areharder to measure, yet there is a need for the sector tocreate, test, and utilize new instruments that better cap-ture what girls report to be of issue.Using Social Cognitive Theory as a guide, a recom-

mended intervention should take into account environ-mental and individual levels to more comprehensivelyaddress menstrual management.

Environmental interventions emphasize communityorganization around an issue and provision of goods orservices at a community level. In this context, femalehealth groups or “big sister” groups that prioritize femalemenstrual management and promote the production ordistribution of sanitary supplies could be created. Schoolscould be encouraged or supported to provide safe, privatespaces where girls feel capable of attending to theirhygienic needs [22][12]. Families could be incorporatedinto the educational experience as mothers often lackexperience in explaining menstrual management andmany mothers are unfamiliar with limitations that areunique to the school setting. At present, it appears thatteachers do not feel that discussing menstruation iswithin their scope of work. Teachers should be trained inPrimary Teacher Training Colleges on how to teach thissubject and how to pass accurate information to theirstudents. Books aimed at adolescent girls use menstrualstories for content and, in one case, are distributeddirectly to schoolgirls [23,24]; a similar book tailored tothe Kenyan context may prove valuable.Another policy change may involve creating and

enforcing guidelines to ensure that at least one teacheror adult staff member in every primary school is awoman, as many schoolgirls lack a female mentor.At the individual level, girls need to be assured that

menstruation is a natural occurrence and a biologicalreality for women and that it can be managed. Girlsshould be educated on how to select (or make) supplies,how to maintain personal hygiene while menstruatingand how to safely dispose of supplies. They need to beinstructed on how to track their periods so that theycan prepare for their periods rather than fear themwhile in the school setting. This study demonstratedthat menarche and emotions about menstruation impacta girl’s sense of control over her life. Feelings of shamesurround menstruation and may influence how a younggirl sees herself and relates to her own body. When ateacher describes a girl as distanced or “gone” - as tea-chers in this study did - we see that menstruation forsome young girls stretches beyond a biological process;it is hindering the educational ambitions of many girlsas they sit on the cusp of womanhood.

ConclusionsThis study found that young Kenyan girls are not gener-ally taught how to control or manage their menstrua-tion, which is a monthly aspect of their lives and has atremendous impact on the ways a girl views herself andher roles within society. In the absence of guidance,girls appear to internalize a sense that their bodies arebeyond their control. Such a feeling can shape how agirl relates to other situations in her life involving her

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body, namely sex and pregnancy. Menarche, therefore, isa critical moment in a girl’s life that marks an opportu-nity to teach girls that they are the owners of theirbodies. Further research particularly on menstrual man-agement options that are practical, sustainable and cul-turally acceptable must be conducted to inform futureprograms and policies that aim to empower young girlsas they transition into womanhood.

AcknowledgementsThis research was conducted under the umbrella of SWASH+. SWASH+ isfunded by the Bill & Melinda Gates Foundation. The authors wish to thankall girls and teachers who participated in this study and to acknowledgestaff at the Great Lakes University Kisumu who collected this data - KevinOdallo, Fred Okumu and Rosebel Ouda - as well as staff of Emory’s Centerfor Global Safe Water who contributed to the conception of the studyincluding: Leslie Greene, Shadi Saboori, Robert Dreibelbis. Thanks to studentSarah Yerian for EndNote formatting. Finally, the authors wish toacknowledge the career of co-author Alfredo Obure who, before hisuntimely death, engaged in countless endeavours to improve the lives ofchildren in Kenya. He is sorely missed.

Author details1Emory University Center for Global Safe Water, Rollins School of PublicHealth, 1518 Clifton Road, Room 767, Atlanta, GA 30322, USA. 2Social andBehavioral Interventions Program, Department of International Health, JohnsHopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore,MD 21205-2179, USA. 3Great Lakes University of Kisumu P.O. Box 2224 -40100, Kisumu, Kenya. 4Center for African Studies, Department ofEnvironmental and Global Health University of Florida, Box 100188, 101S. Newell Dr, Room 2148, Gainesville, FL 32610, USA.

Authors’ contributionsSM participated in the study design, drafted instruments used in datacollection, trained data collectors, interviewed teachers, debriefed teamsfollowing data collection and drafted this manuscript. PW participated instudy design, edited drafts of data collection tools and was integral indrafting and revising the manuscript critically for important intellectualcontent. BC participated in the study design and coordination, madesubstantial contributions to the acquisition of data, and was integral inrevising the manuscript critically. AO participated in the study design andcoordination, engaged in trainings with data collectors and providedrevisions for this manuscript. EO participated in study design, interviewedstudents and provided revisions for this manuscript. IO participated in studydesign, interviewed students and provided revisions for this manuscript. RRconceived of the study, participated in its design and coordination, andhelped draft this manuscript. All authors read and approved the final scriptwith the exception of author Alfredo F. Obure who died while themanuscript was in draft form.

Competing interestsThe authors declare that they have no competing interests.

Received: 15 December 2010 Accepted: 16 June 2011Published: 16 June 2011

References1. Sommer M: Ideologies of sexuality, menstruation and risk: girls’

experiences of puberty and schooling in northern Tanzania. Cult HealthSex 2009, 11(4):383-398.

2. Scott L, Dopson S, Montgomery P, Dolan C, Ryus C: Impact of ProvidingSanitary Pads to Poor Girls in Africa. University of Oxford; 2009.

3. Ali TS, Rizvi SN: Menstrual knowledge and practices of femaleadolescents in urban Karachi, Pakistan. J Adolesc 2009.

4. Abioye-Kuteyi EA: Menstrual knowledge and practices amongstsecondary school girls in Ile Ife, Nigeria. J R Soc Promot Health 2000,120(1):23-26.

5. Khanna A, Goyal RS, Bhawsar SB: Menstrual Practices and ReproductiveProblems: A Study of Adolescent Girls in Rajasthan. Journal of HealthManagement 2005, 7(1):91-107.

6. Greene L: SWASH+ Application of Lessons Learned to Current andFuture Practice. SWASH+ Programatic Management Group Meeting: 20092009; Tom Mboya Labour College, Kisumu Kenya 2009.

7. Angier N: Woman: an intimate geography New York: Houghton MifflinCompany; 1999.

8. Thomas E: Healthy Futures, Reducing Barriers to Primary SchoolCompletion for Kenyan Girls. In Special Publication No 23. Edited by:Publications C. Baltimore: Johns Hopkins University, Center forCommunication Programs, Population Communication Services;Washington DC: The Academy for Educational Development; 2002:.

9. Irinoye OO, Ogungbemi A, Ojo AO: Menstruation: knowledge, attitudeand practices of students in Ile-Ife, Nigeria. Niger J Med 2003, 12(1):43-51.

10. Sommer M, Kirk J: ’Menstruation is on her mind’: Girl-centered, holisticthinking for school sanitation. WASH in Schools Notes and News VolumeApril IRC and UNICEF; 2008, 4-6.

11. Sommer M: Where the education system and women’s bodies collide:The social and health impact of girls’ experiences of menstruation andschooling in Tanzania. J Adolesc 2010, 33(4):521-529.

12. UNICEF: The State of the World’s Children 2004. 2003 [http://www.unicef.org/sowc04/index.html].

13. Maimaiti Y, Siebert S: The Gender Education Gap in China: The Power ofWater. University of Birmingham Institute for the Study of Labor; 2009.

14. Oster EF, Thornton RL: Menstruation and Education in Nepal. NBERWorking Paper Series 2009, w14853.

15. Central Bureau of Statistics (CBS) [Kenya] MoHMK and ORC Macro: KenyaDemographic and Health Survey 2003. Calverton, Maryland: CBS, MOHand ORC Macro; 2004, 13-25.

16. Grigorenko E, Geissler PWenzel, Prince R, Okatcha F, Nokes C, Kenny D,Bundy D, Sternberg RJ: The organisation of Luo conceptions ofintelligence: A study of implicit theories in a Kenyan village. InternationalJournal of Behavioral Development 2001, 25(4):367-378.

17. Macro I: Kenya Demographic and Health Survey 2008-2009. Calverton,Maryland: Kenya National Bureau of Statistics and ICF Macro; 2010.

18. Eaton L, Flisher AJ, Aaro LE: Unsafe sexual behaviour in South Africanyouth. Soc Sci Med 2003, 56(1):149-165.

19. Dasgupta A, Sarkar M: Menstrual Hygiene: How Hygienic is theAdolescent Girl? Indian J Community Med 2008, 33(2):77-80.

20. Nahar Q, Ahmed R: Addressing Special Needs of Girls: Challenges inschool. SACOSAN II Islamabad, Pakistan; 2006.

21. UNICEF: The State of the World’s Children: Adolescence an Age ofOpportunity. New York; 2011.

22. UNFPA: The state of the world’s adolescents. New York: UNFPA; 2003.23. UNICEF: Sharing Simple Facts.Edited by: UNICEF, Ministry of Rural

Development GoI 2008 [http://www.indiasanitationportal.org/sites/default/files/MHM_Book.pdf], accessed March 15, 2011.

24. Sommer M: The Puberty (Kubalehe) Book. 2010 [http://www.growandknow.org/Grow_and_Know/Puberty_(kubalehe)_book.pdf],accessed December 2, 2010.

Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-698X/11/7/prepub

doi:10.1186/1472-698X-11-7Cite this article as: McMahon et al.: ‘The girl with her period is the oneto hang her head’ Reflections on menstrual management amongschoolgirls in rural Kenya. BMC International Health and Human Rights2011 11:7.

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