Improving Menstrual Health Literacy Through Life-Skills Programming in Rural Ethiopia

"After we got information and knowledge about menstrual hygiene management there is nothing we are afraid of...we tell other friends that missing school because of this is foolishness." - 11-year-old girl from Community D

In Ethiopia, lack of knowledge and the stigma around menstruation create challenges for adolescent girls, particularly in the context of broader restrictive gender norms that often keep girls home from school and limit their mobility. Talking about menstruation is seen as socially unacceptable in many contexts, making it difficult for girls to access information. This paper describes a cluster-randomised controlled trial (cRCT) that was conducted to assess the impact of a gender-transformative life-skills intervention called Act With Her-Ethiopia (AWH-E) on the menstrual health literacy and menstrual hygiene management (MHM) practices of very young adolescents in two diverse regions of Ethiopia.

The paper begins by providing context on the meaning of menstrual health literacy in low- and middle-income countries (LMICs) and in Ethiopia, in particular. Several studies find that most girls do not learn about menstruation until they begin menarche. However, previous interventions that have emphasised improving knowledge have often been unable to address the structural norms that make menstruation such a challenging experience for girls, even when they do have better menstrual health literacy. Implementing gender-transformative approaches to menstrual health is complex because of the multiplicity of factors involved.

As detailed here, AWH-E involves a 10-month safe spaces curriculum-based group programme for girls aged 11-13, with additional programming for boys and others who influence adolescents' lives (including parents, schools, community leaders, and other community members), as well as system-strengthening initiatives (in some communities). AWH-E was designed to facilitate adolescent transitions to adulthood via improvements across the six Gender and Adolescence: Global Evidence (GAGE) capability domains (education, bodily integrity, health, psychosocial wellbeing, voice and agency, and economic empowerment). AWH-E developed project-specific curricula for boys and girls, which comprehensively address key topics across the six GAGE domains, along with a parents' guide. The programme aims to help girls and boys build skills and a supportive network to help them navigate the transition from childhood to adulthood, while supporting enabling environments for gender norm transformation. One of the programme's focus areas is tackling gender norms around menstruation and improving menstrual health literacy.

Specifically, in early 2019, Pathfinder (in South Gondar, Amhara) and CARE (in East Hararghe, Oromia) launched AWH-E programming in communities allocated to the appropriate study treatment arms: communities that were randomly allocated to the control group and/or one of the treatment arms (those that received the full AWH-E programme, and those that received a slightly simpler version of this programme, which was focused on adolescents and their families. Project activities fell into three main categories: All AWH-E communities received (i) weekly curriculum-based programming with girls and boys aged 11-13 and six group meetings for their parents over 10 months, and (ii) facilitated community conversations on discriminatory gender norms and how to tackle them; a subset of communities also received (iii) interventions, lasting up to 24 months, to strengthen community-level systems, including the construction of MHM facilities in school. (Click here to learn more about the interventions.)

Ninety-seven communities (kebeles) were randomly assigned to receive the intervention: 58 kebeles assigned to treatment and 39 assigned to control. The evaluation employs a longitudinal mixed-methods design, with baseline data collected in late 2017/early 2018 and midline data collected in late 2019/early 2020. Quantitative surveys were undertaken with 2,492 very young adolescents and their primary female caregivers (or male caregiver if no female was available for the survey) and were complemented by qualitative interviews with 291 adolescents and their caregivers, as well as 96 key informants at community and district levels (including programme mentors, health extension workers, community leaders, and public health officials).

The quantitative findings highlight large and statistically significant improvements on norms around menstruation, knowledge about menstruation and biological function, and knowledge and behavior related to menstrual hygiene management. For example, adolescent girls in AWH-E communities were significantly more likely to report talking to their mothers about menstruation (22 percentage points over a base of 14.5%, p < 0.001). This impact is large - corresponding to a 151% increase. Adolescent girls in AWH-E communities were 15.8 percentage points (or 27%; the mean in the control group is 58.4%) more likely to be able to answer a question about menstruation frequency correctly compared to those in control communities.

The intervention in one area had a significant quantitative impact on knowledge among boys. For example, boys in treatment group were 11.6 percentage points (20.6%) more likely to know that menarche means a girl can get pregnant. Girls were 10.2 percentage points (29%, p < 0.001) more likely to know the frequency of menstruation and 9.0 percentage points (15.4%, p < 0.05) more likely to know that menarche allows for pregnancy.

Qualitative findings further unpack gender and regional differences, highlighting the importance of adapting programming to the local context and, where possible, connecting to other health and gender initiatives. For instance, a significant number of girls emphasised that stigma around menstruation had reduced as a result of AWH-E programming. However, a number of adolescent girls and female mentors underscored that this norm change process has also led to backlash in some communities and that discussions around adolescent puberty changes and sexual and reproductive health have prompted insults toward AWH-E programme participants from some community members.

In short, the findings "suggest that shifting norms around menstruation happened relatively quickly given synchronized programming with adolescent girls, boys and caregivers, and that there was good uptake of information about MHM practices. However, curriculum content about the biological facts of menstruation changed much more unevenly, and girls' ability to practice their new knowledge on MHM depended on the extent to which programme implementers and community leaders engaged directly with male students to construct separate latrines and changing facilities for girls. Where community leaders were actively engaged in the process, as in South Gondar, the impacts appeared transformational, but this required a high level of community buy-in, which was not always possible within the 2-year programme timeframe...Indeed, as observed elsewhere..., changes in norms, knowledge and behavior related to MHM can only be attained with the active involvement of all stakeholders."

In conclusion: "This analysis helps fill the evidence gap on 'what works' to improve menstrual health literacy in rural low- and middle-income contexts."