Pakistan: Menstrual Hygiene Management (MHM) Research Project

A significant body of research demonstrates the relationship between girls' education and improved population health. Despite the proven public health impacts of schooling, three quarters of all eligible girls are out of school, and 77% of those attending school will drop out before graduation. Many barriers prevent young women from attending or completing school but one of the most under-researched is menarche.

The intersections between menarche and education in Pakistan are still poorly understood. Nonetheless, existing reports suggest the dominance of male students in middle and high schools, and the absence of other “girl friendly” supports in the schooling environment are causes, e.g. water is rarely available in rural schools in Pakistan, with 75% of hand pumps and 28% of latrines being non-functional. Furthermore, female students lack separate, private latrines, and they often are attacked, sexually harassed, or shamed when waiting to use lavatory services, posing yet another barrier to school attendance. Female students may also have difficulty accessing sanitary materials owing to their high cost, especially if male family members make most major household purchases, as is the case in the majority of households in Pakistan. Given that menarche may be jeopardizing young women’s schooling and health in Pakistan, it is both timely and important to better understand the relationship between menstruation, education, and health for young Pakistani women, and to improve pubertal transitions.

Professor Dr. Marni Sommer of Columbia University, in collaboration with Real Medicine Foundation, and with funding from Grow N Know Inc (G&K), has launched a research study in early 2015 to explore the knowledge gap of how the onset of menstruation and puberty influences the Pakistani girls’ school-going experiences, including school retention, and to develop the Pakistan girls’ puberty book in line with G&K’s model of similar puberty books in low and middle-income countries, with the aim to promote young women’s health and education during pubertal transitions. This project is an adaptation to Pakistan of a similar research methodology previously utilized in studies conducted in Tanzania, Ghana, Ethiopia and Cambodia which also developed context-specific, culturally sensitive girls’ puberty books; all above studies were conducted by the same PI.

The research design of this study is a comparative case study in rural and urban Punjab, aimed at exploring the relationship between the onset of menses and young women's schooling experience. The specific aims of the study are:

1. To describe local cultural understandings and meanings of menarche in urban and rural Pakistan through the use of ethnographic observations, interviews and participatory activities with adolescent young women and the adults who play key roles in the lives of school-aged young women.
2. To explore, through comparative case studies of young women’s lives, the ways in which local cultural meanings about menarche and menstruation interact with sanitary technology, school design, and peer group relations, to create intolerable menstrual-related stigma that leads to young women dropping out of school.
3. To utilize adolescent young women’s own recommendations for improving the pubertal and menstrual management related guidance adolescent girls receive through the development of a girls’ puberty book in Pakistan.

The participatory design of this study will inform the development of the girls’ puberty book in Pakistan. In addition, the descriptive nature of this study will fill gaps in the research literature by providing information on cultural understandings and meanings of menstruation, young women’s lived experiences of menstruation and schooling, and the role of menstrual-related stigma in creating feelings of shame in post-pubescent young women in Pakistan.

Research Methodology: Three data collection methods will be adopted; ethnographic observations; key informant interviews with adults and participatory group activities with adolescent young women aged 10-19. The urban setting will be in Dhoke Sayedan in Rawalpindi and the rural field site will be Nara Mughla village in Chakwal. The data collection will be split between school going girls and young women in vocational training centers.

Project Progress Update:
Having obtained ethics clearance from the Pakistan Board of Ethics, Real Medicine Foundation Islamabad began the process of launching the research study by first taking clearance and NOCs from the Ministry of Health, Punjab Province. This meant several visits to Lahore to introduce the research protocols to key stakeholders which was successful and armed with the NOCs from all the relevant government departments, including the district education offices and TEFTA (Technical Education and Vocational Training Authority).

Data collection will take place in two phases. In phase 1 of the study, the rural school data collection was conducted.  RMF selected the ‘Government Girls’ High School’ in Mulahal Mughla, District Chakwal as the rural school. Data collection for rural school is complete and includes participation observations with nearly 60 girls aged 15-18 over 19 working days. Four informal interviews with teachers were also conducted. In-depth interviews were conducted with four key stakeholders within the community.

The urban school selected is the ‘Government Girls’ Higher Secondary School’ in Morgah, Dhoke Saydan, Rawalpindi and data collection is currently underway, expected to reach completion within 2 weeks.

The vocational training schools’ data collection will be carried out in the second phase. For the rural, the ‘Government Vocational Institute for Girls’ in Mulalhal Mughla has been selected as the center of choice. The urban vocational training center has yet to be selected.