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<strong>FINAL</strong> <strong>REPORT</strong><br />
1
A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
2
A STUDY ON MENSTRUAL HYGIENE<br />
MANAGEMENT IN MONGOLIA:<br />
Understanding practices and impacts on<br />
adolescent schoolgirls’ education and health<br />
<strong>FINAL</strong> <strong>REPORT</strong><br />
Ulaanbaatar 2016
A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
Supported by Global Affairs Canada<br />
Programme Division/WASH<br />
3 United Nations Plaza<br />
New York, NY 10017 USA<br />
www.unicef.org/wash/schools<br />
Commentaries represent the personal views of the authors and do not necessarily reflect the positions<br />
of the United Nations Children’s Fund (UNICEF). The designations employed in this publication and<br />
the presentation of the material do not imply on the part of UNICEF the expression of any opinion<br />
whatsoever concerning the legal status of any country or territory, or of its authorities or the<br />
delimitations of its frontiers.
<strong>FINAL</strong> <strong>REPORT</strong><br />
TABLE OF CONTENTS<br />
ACRONYMS<br />
ACKNOWLEDGEMENTS 1<br />
EXECUTIVE SUMMARY 2<br />
INTRODUCTION 3<br />
METHODOLOGY 9<br />
Preparatory work 9<br />
Study design/scope 9<br />
Research process 10<br />
FINDINGS 14<br />
Social and environmental context 15<br />
Contextual factor 1. Poor community-level access to water and shower facilities in<br />
rural and suburban areas 15<br />
Contextual factor 2. Poor WASH facilities in urban, provincial and rural schools 16<br />
Contextual factor 3. Parental support 16<br />
Contextual factor 4. Age of girls at menarche 17<br />
Contextual factor 5. Rapidly increasing access to information and the media 17<br />
Challenges girls face 18<br />
Being unprepared 18<br />
Hiding menstruation from boys 18<br />
Fear of leaks, stains and odour 19<br />
Difficulty in asking for help 19<br />
Biological challenges 19<br />
Determinants and Contributing Factors 20<br />
Determinant 1. Inadequate WASH facilities in schools and dormitories 20<br />
Determinant 2. Knowledge, information and education 27<br />
Determinant 3. Access to emergency materials to manage menstruation 32<br />
Determinant 4. Supportive psychosocial environment 34<br />
Determinant 5. Biological factors 36<br />
Impacts on and risks to education and health 37<br />
Voiced impacts 37<br />
Potential risks/potential health impacts 39<br />
RECOMMENDATIONS 42<br />
1. Recommendations from participants 42<br />
2. Recommendations from researchers 43<br />
REFERENCES 45<br />
ANNEXES 46<br />
ii<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
ACRONYMS<br />
CSWE<br />
FGD<br />
GDP<br />
IDI<br />
JMP<br />
KII<br />
MDGs<br />
MICS<br />
MHM<br />
MNT<br />
MoECS<br />
MoF<br />
MoHS<br />
NGO<br />
NSO<br />
PE<br />
SISS<br />
UNICEF<br />
UNFPA<br />
WASH<br />
WinS<br />
Centre for Social Work Excellence (a Mongolian NGO)<br />
Focus Group Discussion<br />
Gross Domestic Product<br />
In-Depth Interview<br />
Joint Monitoring Programme<br />
Key Informant Interview<br />
Millennium Development Goals<br />
Multiple Indicator Cluster Survey<br />
Menstrual Hygiene Management<br />
Mongolian Tugrug<br />
Ministry of Education, Culture and Science<br />
Ministry of Finance<br />
Ministry of Health and Sports<br />
Non-governmental organization<br />
National Statistics Office<br />
Physical Education<br />
Social Indicator Sample Survey<br />
United Nations Children’s Fund<br />
United Nations Population Fund<br />
Water, Sanitation and Hygiene<br />
Water, Sanitation and Hygiene in Schools<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
ACKNOWLEDGEMENTS<br />
This first qualitative study of Menstrual Hygiene Management (MHM) in Mongolia was commissioned<br />
by UNICEF Mongolia with funds from Global Affairs Canada through the project ‘WASH in Schools<br />
for Girls: Advocacy and Capacity Building for Menstrual Hygiene Management through WASH in<br />
Schools Programmes’ (WinS4Girls Project); with technical guidance from Emory University (Bethany<br />
Caruso, Anna Ellis, Gauthami Penakalapati, Gloria Sclar, Candace Girod and Matthew Freeman) on<br />
the study design, qualitative data analysis and final report; and with the active participation and<br />
support of the Ministry of Education, Culture and Science and the Ministry of Health and Sports.<br />
The authors would like to express their gratitude to the Water, Sanitation and Hygiene (WASH) team in<br />
UNICEF Headquarters, New York, particularly Murat Sahin, Lizette Burgers, Maria Carmelita Francois,<br />
Sue Cavill and Yodit Sheido. The authors also appreciate technical guidance from Columbia University,<br />
particularly Marni Sommer, the UNGEI Advisory Group, and the Gender, Adolescent Development<br />
and Participation, and Education Advisers in UNICEF Headquarters, New York. Sincere thanks to the<br />
UNICEF country office team: Roberto Benes, Representative, Judith Bruno, Deputy Representative<br />
and Batnasan Nyamsuren, Water and Environmental Sanitation Officer, Odgerel Myagmar, C4D<br />
Officer and Robin Ward and Uranchimeg Budragchaa, WASH Consultants for managing various<br />
processes in undertaking the study.<br />
Special thanks go to the research team of CSWE of Mongolia: Erdenechimeg Ts., Research Team<br />
Leader and Principle Researcher, and field researchers: Naranchimeg Ja., MPH (researcher/editor of<br />
the report), Oyuntugs S., MA, Altantsetseg B., MSW, Amarjargal T., PhD, Gerelmaa, Ch., BSW, and<br />
Batsuuri G, BSW.<br />
Special thanks to all the school authorities, students, teachers and key interviewees, who took part in<br />
the study and shared their experiences, ideas and thoughts on this sensitive topic.<br />
1
A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
EXECUTIVE SUMMARY<br />
UNICEF Mongolia and the Centre for Social Work Excellence (CSWE), a Mongolian NGO, with technical<br />
support from Emory University and the financial support of Global Affairs Canada, conducted the<br />
first qualitative study on menstrual hygiene management in Mongolian schools from February to<br />
June 2015. The aim was to understand, from the girls’ perspective, how well schools and dormitories<br />
meet their needs when they are menstruating; and to gather evidence to inform key stakeholders for<br />
future actions to ensure a supportive school environment for girls.<br />
The study identified challenges that limit the ability of girls to manage menstruation hygienically and<br />
with dignity, especially while in school. These challenges include shame and fear of being teased by<br />
boys; feeling discomfort; feeling unable to actively participate in class; distancing themselves from<br />
classmates; distraction during classes; and inadequate water and sanitation facilities in schools where<br />
girls can manage their menstrual hygiene needs in private. These challenges contribute significantly to<br />
girls’ reduced participation in class and school and even absenteeism, thus affecting their academic<br />
performance, as well as impacting on their physical and emotional well-being.<br />
Broader social and environmental factors that contribute to these challenges include poor communitylevel<br />
access to water and shower facilities in rural and suburban areas, and often a lack of parental<br />
support for girls staying in dorms and with host families. Other factors include the quality and<br />
availability of psychosocial and physical support for girls at home and at school, the affordability and<br />
availability of sanitary pads at local stores; and access to information via TV and the internet.<br />
These key recommendations are intended to guide programming for menstrual hygiene management:<br />
1. Access to safe water and proper sanitation and hygiene facilities is a basic requirement for<br />
girls in managing their menstruation in school and in dormitories. It is important to strengthen<br />
the implementation of the “Norms and Minimum Requirements for WASH in Kindergartens,<br />
Schools and Dormitories” which was approved by the Government in 2015.<br />
2. Plan, develop and introduce programme interventions to improve the knowledge, attitudes<br />
and practice of girls and boys, parents and teachers (and particularly male teachers) on<br />
menstruation and its proper management. This could include developing information materials,<br />
mini guidebooks and online learning materials, training school doctors and revisiting the work<br />
responsibilities of teachers, doctors and dormitory teachers, and janitors.<br />
3. Create a more favourable environment so that schoolgirls have better access to sanitary pads<br />
during school hours and can get physical and emotional support from teachers, school doctors<br />
and other school personnel, including boys.<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
INTRODUCTION<br />
Assessment background<br />
There is a growing global focus on menstrual hygiene management (MHM), with several assessments<br />
conducted in Africa, Asia and Latin America (including Rwanda, Bolivia, the Philippines and Sierra<br />
Leone), as well as recent international conferences on MHM. However, no research or study on MHM<br />
has ever been carried out in Mongolia. For these reasons, UNICEF and Emory University decided in<br />
2015 to conduct this current research.<br />
MHM research from the other countries shows that menstruation poses several common challenges<br />
to girls: fear, stress, and embarrassment because of different factors, such as inadequate WASH<br />
facilities in schools and poor knowledge and understanding of MHM, which may have a negative<br />
impact on girls’ learning, leading to absenteeism, low levels of participation in class, distraction and<br />
long-term health consequences.<br />
The aim of this report is to provide information on the challenges girls face in school when<br />
menstruating, to examine the determinants of these challenges and to provide recommendations for<br />
decision-makers, school managers and other relevant stakeholders.<br />
Country and development context<br />
Mongolia is a large landlocked country located in North-East Asia, bordering the Russian Federation<br />
to the north and the People’s Republic of China to the south (Figure 1). It is the second-least densely<br />
populated independent territory in the world, occupying 1,564,900 km 2 with a population density<br />
outside the capital of less than two persons per square km 1 . The population stands at three million,<br />
of whom more than a half live in cities and provincial urban centres, and particularly in the capital,<br />
Ulaanbaatar.<br />
Figure 1. Map of Mongolia<br />
1 NSO, Year book 2015.<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
Mongolia has a harsh continental climate, and a prolonged winter with an average temperature of<br />
minus 15–30°C.<br />
The country has a decentralized system of government and is divided administratively into 21<br />
aimags (provinces); each aimag is divided into soums (rural sub-provinces) and baghs (the smallest<br />
administrative unit in rural areas). There are 330 soums and 1,592 baghs. The capital, Ulaanbaatar, is<br />
divided into 9 districts (urban districts), and 152 khoroos (urban sub-districts) 2 .<br />
The rate of urbanization is very rapid in Mongolia. According to 2014 estimates, urban residents make<br />
up 66.4 per cent of the total population (with 45.5 per cent or 1.31 million in Ulaanbaatar) and 65.3<br />
per cent of total households. Internal migration towards cities and urban settlements has increased<br />
since 2000, mainly because herders who have lost their livestock in severe winters (‘dzud’) have<br />
migrated to urban areas in search of alternative livelihoods.<br />
Universally, population migration is considered to have a positive influence on economic development<br />
and to reduce regional imbalances. However, urbanization in Mongolia is accompanied by many<br />
negative impacts, such as over-population in Ulaanbaatar and urban areas, making it difficult to<br />
provide services including a water supply 3 . Most of those who have migrated to urban areas live in<br />
the underserviced ger areas that have limited access to the modern infrastructure enjoyed by their<br />
city-centre counterparts, such as sanitation and piped water.<br />
Figure 2. Unplanned ger districts on the outskirts of Ulaanbaatar<br />
Source: Asia Foundation<br />
2 NSO, Yearbook 2014.<br />
3 Achieving the Millennium Development Goals: Fifth National Progress Report, 2013.<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
Mongolia is a youthful country, with 36 per cent of the population under the age of 19.<br />
Figure 3. Mongolia, population pyramid, 2014 4<br />
Achieving the Millennium Development Goals: Fifth National Progress Report 2013 gives the<br />
employment rate in 2009 as 88.4 per cent, which increased to 91.8 per cent in 2012. The target for<br />
labour force participation is 70 per cent and the actual unemployment rate for 15–24-year-olds is<br />
2.5 per cent.<br />
Water, Sanitation and Hygiene<br />
There is growing political recognition and public<br />
awareness of the importance of water and<br />
sanitation as a prerequisite for the country’s<br />
development, with the Government sitting on<br />
the Sanitation and Water for All (SWA) steering<br />
committee from 2015. However, progress in<br />
this sector remains limited.<br />
Mongolia’s highly variable and challenging<br />
environmental and living conditions are<br />
illustrated by the country’s progress and<br />
performance in achieving WASH Millennium<br />
Development Goal (MDG) indicators and<br />
targets, where sanitation lags behind water.<br />
Mongolia loses an estimated 35.5<br />
billion Mongolian Tugrugs (MNT),<br />
or US$26 million per year, because<br />
of poor sanitation and hygiene,<br />
equivalent to approximately 0.5 per<br />
cent of gross domestic product (GDP).<br />
UNICEF, Economic Impacts of Sanitation<br />
in Mongolia (2011)<br />
4 https://populationpyramid.net/mongolia/2016/.<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
National-level water and sanitation indicators show stagnation, with the use of improved drinking<br />
water sources increasing from 65.2 per cent in 2010 to only 68.1 per cent in 2013, and the use of<br />
improved sanitation increasing from 54.3 per cent to only 58.3 per cent during the same period 5 .<br />
According to WHO/UNICEF Joint Monitoring Programme (JMP) on Water and Sanitation (http://<br />
www.wssinfo.org/documents/?tx_displaycontroller[type]=country_files), trend on access to<br />
improved water and sanitation coverage in Mongolia from 2010 to 2015 is showing a slight increase,<br />
but almost stagnant (Water: 63% - 64%, Sanitation: 57%-60%). The JMP collects all available<br />
national survey results (National Census, Multiple Indicator Cluster Survey (MICS), Reproductive<br />
Health Survey, Pilot Household Survey, Household Income and Expenditure Survey etc.) and estimates<br />
projections in each year. By the MICS surveys (http://mics.unicef.org/surveys), trend on access to<br />
improved water and sanitation coverage since 2010 is also slightly increased (Water: 65% - 68%,<br />
Sanitation: 54%-58%). However, by country specific definition, sanitation coverage is decreased<br />
considerably (from 83 to 27 %), which explains that ordinary household pit-latrines was considered<br />
as un-improved in the last survey.<br />
Table 1. Improved water and sanitation coverage<br />
Trend 2005 2010 2013/2014<br />
Improved water coverage, % 71.6 65.2 (77.9*) 68.1 (84.8*)<br />
Improved sanitation coverage, % 77.2 54.3 (83.1*) 58.3(27.3*)<br />
Note: *-by country specific definition<br />
Mongolia is a hugely challenging context for WASH service delivery. Constructing, operating and<br />
maintaining WASH infrastructure in remote areas is very expensive because of permafrost and<br />
a lack of local service providers, among other factors. Given these constraints, the vast majority<br />
of households at the rural and sub-urban district level have pit latrines and inequities for use of<br />
sanitation are highly pronounced by household location.<br />
There do not appear to be any strong disparities in terms of gender norms and roles in relation to the<br />
use of (or exclusion from) improved water and sanitation, and generally adult men bear the burden<br />
of water collection from off-premises water sources. 6<br />
In summary, for use of improved water sources and sanitation facilities, there are consistently<br />
correlated and negative disparities for rural households (especially those outside permanent<br />
settlements) and poorer households.<br />
Education in Mongolia<br />
Mongolia has made great progress in delivering education services for children, with schools becoming<br />
more child-friendly, and has achieved a high rate of adult literacy and school enrolment.<br />
One remarkable success is that girls are not disadvantaged in the education system. They have higher<br />
enrolment and net attendance rates than boys, and lower dropout rates (35 per cent for girls, 65 per<br />
cent for boys). The student gender ratio is approximately balanced, but there is a higher percentage<br />
of girls in secondary schools. 7<br />
5 Multiple Indicator Cluster Surveys (MICS)/Social Indicator Sample Survey (SISS), Mongolia 2013.<br />
6 SISS(2013, Social Indicator Sample Survey, Mongolia)<br />
7 NSO, Statistical Year Book, 2014.<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
The country has a 12-year free basic education system, which consists of five years of primary<br />
education, four years of lower secondary (completing the nine-year compulsory education cycle) and<br />
three years of upper secondary. The age of admission to primary education is six.<br />
The education system includes preschool (kindergartens and nursery schools) and general secondary<br />
schools (primary, lower and upper secondary). Primary, lower and upper secondary levels generally<br />
do not exist separately. Schools up to grade 12 are mainly found in larger towns and cities. Primary<br />
and secondary education services are available in all areas including rural districts. 68 per cent of all<br />
schools are in Ulaanbaatar city and other provincial centres, 31 per cent are in rural soums and the<br />
remaining 1 per cent are in bagh centres.<br />
Boarding schools or school dormitories are a special feature of Mongolian primary and secondary<br />
education, enabling large numbers of herders’ children – who usually live in remote areas outside<br />
permanent settlements – to be enrolled in school. As the academic school year (September to May)<br />
unavoidably coincides with Mongolia’s harsh winter, when average temperatures drop to as low<br />
as -20°C, living permanently in a dormitory is the best way for children to continue their schooling<br />
without having to travel long distances. Dormitories are most commonly found in rural district schools<br />
but there are also some in provincial capitals and (rarely) in cities.<br />
60 per cent of all schools have dormitories and accommodate 6.5 per cent of the student population,<br />
of whom 51.7 per cent are girls.<br />
It should be noted that many children also stay with host families (mostly relatives) who are close to<br />
school, so that they can attend school more easily.<br />
Health education in schools<br />
In September 2015, at the beginning of the academic year, the Government of Mongolia decided to<br />
drop health as a separate and dedicated subject in the school programme. Instead it is working to<br />
integrate health into other subjects, requiring all subject teachers to include relevant information on<br />
health in their lessons, with a particular focus on physical education (PE) and biology classes.<br />
The Education Research Institute takes the lead in developing and revising health curricula for<br />
secondary schools and secondary school teacher training colleges. The previous health curriculum,<br />
delivered through a dedicated subject on health, was introduced to lower secondary schools about<br />
20 years ago; all school children from grades 5 to 12 had dedicated lessons on health, aimed at<br />
improving their life skills. The curriculum mainly aimed to reduce risky adolescent sexual behaviour<br />
and its consequences, including teen pregnancy and the spread of sexually transmitted infections<br />
and HIV/AIDS, by providing children and young people with comprehensive and age-appropriate sex<br />
education and information.<br />
At present, the future of health education in schools is uncertain. MHM was barely addressed in<br />
the previous curriculum and it is still not known whether it will be addressed in the new integrated<br />
curriculum for PE, biology and health, which is not yet in place. School doctors mainly focus on<br />
cleanliness, sanitation and hygiene in school and do not have sufficient resources to provide sanitary<br />
napkins for girls in emergency situations.<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
WASH in schools and MHM<br />
Despite significantly increased focus and the Government’s commitment to WASH in schools (WinS),<br />
children currently do not receive coordinated health education and continue to face challenges<br />
because of a lack of child-friendly WASH facilities in schools, especially in rural village (soum) schools<br />
and dormitories. Location is the main determinant of the standard of school WASH facilities, just as it<br />
is for households. Although a comprehensive national baseline for WASH in schools is unavailable and<br />
WASH is not currently included in the Education Management and Information System or national<br />
educational statistics, a 2007 UNICEF study found that 78 per cent of schools had outdoor latrines.<br />
WHO’s Global School-based Health Survey (2010), which had a nationwide sample, found that “One<br />
in ten students (9.7%) said there was no toilet or sink at their school and 35.4 per cent said there<br />
were not enough toilets or sinks at their school”.<br />
There have been some improvements since UNICEF’s 2007 study, although these are unquantified,<br />
but many rural schools and dormitories still have open pit latrines and inadequate WASH facilities,<br />
particularly given Mongolia’s harsh weather conditions. For children in rural schools and those living<br />
in school dormitories, having to go outside to use WASH facilities during the extremely cold winter<br />
months presents real challenges, and many younger children or boys don’t use the pit latrines but<br />
defecate outside. In most cases, open pit latrines do not have lighting and are located far away<br />
from school and dormitory buildings. Open defecation in the school environment is likely to be partly<br />
behavioural, but also partly due to the poor conditions, particularly smelly, dirty or slippery pit latrines<br />
in winter. In urban areas, although pupils from the ger districts of Ulaanbaatar are likely to use an<br />
outdoor shared or private pit latrine at home, the schools that they attend will have indoor flushing<br />
toilets. In rural villages (soum centres), there is sometimes only one public shower block and showers<br />
may not be available in the school complex.<br />
Many governmental and non-governmental organizations (NGOs) at national and sub-national levels<br />
play a crucial role in creating healthy and hygienic conditions in schools. Though very active, the WASH<br />
in Schools movement is a relatively small sector in terms of the number of actors and funding. The<br />
main Government duty-bearers include the Ministry of Education, Culture and Science (MoECS), The<br />
Ministry of Health and Sports, the Ministry of Construction and Urban Development, the Mongolian<br />
Agency for Standardization and Metrology and the National Water Committee.<br />
National, international and multilateral organizations, such as WaSH Action, a local NGO, the Asian<br />
Development Bank, UNICEF, Save the Children Japan, and the Government of Japan, have been<br />
supporting government efforts to improve the learning environment for children, to implement<br />
WASH-related projects, to invest in building and renovating school and dormitory buildings and<br />
school and kindergarten sanitation facilities, as well as integrating hygiene education into the school<br />
curriculum. WASH in Schools infrastructure projects tend to focus on rehabilitating or constructing<br />
indoor washrooms in urban and rural areas.<br />
The Government has adopted many laws and regulations relating to WASH in order to fulfil its<br />
obligation to create a favourable environment where children can obtain a quality education. Most<br />
notable and relevant are the Norms and Minimum Requirements for Water, Sanitation and Hygiene<br />
(WASH) in Kindergartens, Schools and Dormitories that were developed by MoECS, the MoHS and<br />
the Ministry of Finance (MoF), with UNICEF coordinating sector-wide support and advocacy. They<br />
were approved by an official decree in June 2015. The Norms and Minimum Requirements reflect<br />
the experiences of adolescent schoolgirls who were interviewed about these issues, and the insights<br />
gained from consultation with WASH stakeholders, international and national governments and<br />
NGOs.<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
2015 was a milestone year, which saw the start of a coordinated national programme on WASH in<br />
schools, driven by the adoption of the Norms and Minimum Requirements and led by MoECS. MoECS<br />
is developing a mid-term plan for implementation of the standards and the first WASH in Schools<br />
network meeting was recently convened. At this initial meeting, a school self-monitoring checklist for<br />
the Norms and Minimum Requirements was discussed, a positive development which will hopefully<br />
see the first government-led national baseline on WASH in schools and routine annual monitoring.<br />
In summary, although there have been positive developments in recent years, the current WASH<br />
situation in schools and dormitories remains unsatisfactory in many cases, with significant<br />
improvements needed. Schools and dormitories are often too crowded and unhygienic, and are still<br />
far from reaching the national Norms and Minimum Requirements. The challenge of providing WASH<br />
services in schools is potentially undermining the positive hygiene behaviours that children have<br />
learned. The start of the WASH in Schools National Programme led by MoECS provides an excellent<br />
opportunity and vehicle for advancing the MHM agenda for the ultimate benefit of Mongolian<br />
schoolgirls.<br />
METHODOLOGY<br />
Preparatory work<br />
• A working group was established, including officials and relevant staff from the cooperating<br />
ministries, MoECS and MoHS.<br />
• Staff from key ministries, UNICEF and other national stakeholders including NGOs participated<br />
in an e-course on MHM led by Emory University’s Centre for Global Safe Water and UNICEF. 8<br />
• Ethical approval to conduct the study was obtained from the National University of Mongolia’s<br />
Ethical Clearance Committee for Social Studies, which is under MoECS. Copies of the ethical<br />
approval were then sent to city district and aimag education directors requesting their<br />
assistance with the research. School directors and administrators of the selected schools were<br />
also sent copies, along with a detailed description of the research objectives and goals, the<br />
process and the timeline for data collection.<br />
Study design/scope<br />
The study used both qualitative and quantitative research techniques such as in-depth interviews<br />
(IDIs), focus group discussions (FGDs), key informant interviews (KII)s and observations; in addition,<br />
girls wrote short stories about their own experience of menarche.<br />
8 This course was designed to equip practitioners and policymakers with the skills to investigate and understand the challenges<br />
girls in school face during menstruation, through qualitative research. It was invaluable in enabling this research to be carried<br />
out in Mongolia.<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
The Socio-Ecological Framework (Figure 4) was used for data analysis.<br />
Figure 4. Socio-Ecological Framework for MHM research activities and themes 9<br />
Research process<br />
Face-to-face training<br />
Tools for FDGs, IDIs, KIIs and observations developed by Emory University and UNICEF 10 were translated<br />
into Mongolian, pretested in two schools and then revised. Researchers advised including a tool for<br />
dormitory girls so that they could compare their experiences with those of schoolgirls living at home.<br />
All researchers had three weeks’ training led by the research manager from Emory University. The<br />
first course, conducted over two weeks, covered the tools and how to adapt them, as well as data<br />
collection. Topics 11 included WASH, menstruation, research ethics, qualitative data collection methods<br />
and techniques, and research logistics. The second course focused on data analysis and analytical<br />
techniques.<br />
Data collection<br />
Data collection was completed in May 2015. Due to the dispersed location of schools, three satellite<br />
teams of researchers were organized to collect data. Researchers collected data together at the first<br />
location; then subsequently, in three locations at the same time. Each satellite team covered three<br />
schools and consisted of three researchers: a researcher–facilitator, a note-taker and a local research<br />
assistant who was mainly responsible for logistics.<br />
Data collection started after written consent was obtained from school directors, who approved the<br />
research activities with schoolchildren and staff. Before starting interviews or discussions, signed<br />
written consent was obtained from each participant to ensure their voluntary participation and<br />
confidentiality. School directors and teachers provided consent on behalf of parents, who were<br />
informed by the schools.<br />
9 WASH in School: Empowers Girls’ Education in Rural Cochabamba, Bolivia, An Assessment of Menstrual Hygiene Management<br />
in Schools.<br />
10 ‘WASH in Schools Empowers Girls’ Education, Tools for Assessing Menstrual Hygiene Management in Schools’.<br />
11 Modules 1–8 of the UNICEF- and Emory University-facilitated online training course, ‘WinS for Girls’ on MHM.<br />
10
<strong>FINAL</strong> <strong>REPORT</strong><br />
Selection of schools<br />
The CSWE research team, in consultation with UNICEF Mongolia and Emory University, selected<br />
11 schools in total. Four were from aimags (in the aimag/province centre) and four from soum<br />
centres (rural villages) representing Western, Khangai, Central and Eastern regions. Three schools<br />
were selected in Ulaanbaatar: one in the centre, and two from suburban districts. The purpose<br />
was to identify the similarities and differences in girls’ MHM experiences, and the challenges and<br />
needs encountered in geographical locations that vary in terms of environment, WASH infrastructure<br />
development and the girls’ living conditions. Schools with dormitories were deliberately selected to<br />
explore the specifics of this sub-population of schoolgirls.<br />
Table 2. School sampling categories, by location<br />
Region/aimag or UB district Ulaanbaatar or aimag/soum & school code Boarding<br />
Urban<br />
Suburban<br />
UB: Chingeltei S1 No<br />
UB: Songinokhairkhan S2 No<br />
UB: Nalaikh S3 Yes<br />
Aimag centre<br />
Soum centre<br />
Central: Dundgobi S4 S5 Yes<br />
Eastern: Dornod S6 S7 Yes<br />
Western Khovd S8 S9 Yes<br />
Khangai: Khuvsgul S10 S11 Yes<br />
Figure 5. Areas selected<br />
Ulaanbaatar<br />
11
A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
Selection of participants<br />
Teachers were informed of the research and selected students from specific age groups based on the<br />
research objectives. Two groups of girls – aged 12–13, and 14 and above – were made up of girls<br />
who had been menstruating for a few years at the time of the research. The group of boys were<br />
aged 14–16 and had attended health classes. Children were asked if they wanted to participate in the<br />
research and only those who expressed a willingness to do so were involved.<br />
Parents were invited to take part, divided into groups and invited to share their ideas and thoughts<br />
with the researchers.<br />
Participants and activities<br />
A total of 300 people took part in the study, including teenage girls and boys who attend day<br />
schools, girls living in dormitories, school administrators, teachers, parents of adolescent girls, and<br />
school/dormitory workers/janitors. In addition, WASH facilities at 11 schools were observed.<br />
Table 3. Summary of study activities<br />
Tool Participants/location No. of discussions,<br />
interviews<br />
No. of participants<br />
FGD Girls aged 12–13 (school and dormitory) 11 81<br />
Girls aged 14–16 (school and dormitory) 11 81<br />
Boys aged 14–16 6 47<br />
Mothers of teenage girls 3 16<br />
Teachers from middle and secondary classes 3 14<br />
IDI Girls in school and/or aged 12–13 11 11<br />
Girls from dormitories and/or aged 14–16 11 11<br />
KII Health teachers 11 11<br />
School administrators 11 11<br />
Short interview Janitors 7 7<br />
Story writing<br />
Girls’ stories<br />
Total 85 300<br />
Stories from girls in soum and aimag schools<br />
from Eastern and Western regions<br />
10 10<br />
Table 4. Observed WASH facilities<br />
Observed WASH facility<br />
11 Schools Handwashing facilities<br />
Indoor toilets<br />
Outdoor toilets<br />
7 dormitories Handwashing facilities<br />
Indoor toilets<br />
Outdoor toilets<br />
Number<br />
129<br />
124<br />
64<br />
40<br />
23<br />
10<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
In-depth interviews<br />
The objective of the IDIs was to learn about girls’ personal experiences of menstruation, specifically<br />
what they knew about it, where their information came from and who they trusted. They were also<br />
asked to describe their first experiences.<br />
Focus group discussions<br />
Figure 6. Girls’ FGD<br />
Separate FGDs were conducted with girls aged 12–<br />
13, and 14 and above; with boys aged 14–16; and<br />
with mothers. Each session involved up to eight<br />
participants. The aim of the girls’ FGDs was to<br />
discover girls’ typical experience of menstruating<br />
at school, as well as their typical behaviour,<br />
coping mechanisms, level of understanding of<br />
menstruation and the availability of support.<br />
The facilitator and note-taker led discussions and<br />
took notes, as well as recording them.<br />
In the girls’ FGDs, several techniques were used,<br />
including group discussion, drawing and role<br />
play. Girls were asked to draw the experiences<br />
Source: CSWE<br />
of a typical girl to give researchers a more indepth<br />
understanding of how they cope and manage menstruation-related issues at school, and the<br />
challenges and issues to be addressed. FGDs with mothers and boys focused on the same themes,<br />
providing researchers with a different standpoint to the girls’ challenges and experiences. After<br />
the FGDs the two-person teams discussed key notes and the process, coded the work and checked<br />
records.<br />
Girls’ stories<br />
Twelve girls from schools in different locations (urban, rural and suburban areas) were asked to write<br />
a short story about their experiences of menstruation and to seal it in an envelope, without writing<br />
their names on the envelopes. The aim was to gain a deeper understanding of the challenges and<br />
impacts that may affect girls’ school performance and other areas of their lives.<br />
Key informant interviews<br />
The objective of the KIIs with school staff was to investigate hygiene, sanitation, what students were<br />
taught about menstrual hygiene, menstruation-related challenges at school and budget- and supplyrelated<br />
questions. KIIs were conducted with teachers, principals/school administrators and school/<br />
dormitory workers/janitors. The interview content was informed by UNICEF’s WASH in Schools<br />
Monitoring Package. 12<br />
School/dormitory observations<br />
In order to understand the challenges faced by Mongolian school children and those whose school<br />
experience extended beyond the traditional school day, all school and dormitory WASH facilities were<br />
observed. Tools/checklists were used that were informed by the UNICEF WASH in Schools Monitoring<br />
Package and adapted to research purposes.<br />
12 United Nations Children’s Fund, ‘WASH in Schools Monitoring Package’, UNICEF, New York, April 2011.<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
Recording and transcribing<br />
All activities were recorded with prior permission of the participants. All recordings were listened to<br />
and transcribed verbatim.<br />
Data analysis<br />
The CSWE research team completed data analysis in Mongolian, following technical training by Emory<br />
University on qualitative data analysis. While transcripts of the interviews and discussions were being<br />
completed, researchers developed a codebook. Each transcript was cleaned by researchers and deidentified<br />
to maintain interviewees’ anonymity.<br />
The main codes were identified using the Socio-Ecological Framework and sub-codes were identified<br />
in the process of analysis. Predefined codes for life changes, knowledge and practice, support,<br />
context, WASH hardware, WASH software, challenges, consumables, home, school, dorm, impacts,<br />
risks, and recommendations were used.<br />
Several people worked on coding a single transcript so that no bias was introduced to ensure the<br />
quality and credibility of the research analysis. Main themes were developed after consolidating<br />
coded data and verified by the research team.<br />
Data gathered through observation was summarized in tables and notes from self-observations were<br />
reflected in the data analysis to illustrate the context more broadly.<br />
FINDINGS<br />
This section analyses the social and environmental context in which the research is situated and the<br />
challenges girls face at school. The determinants of these challenges are then explored, as well as<br />
their impact and the potential risks within the Socio-Ecological Framework (see earlier).<br />
Table 5: Schematic of the research findings<br />
CONTEXT:<br />
• Poor community-level access to water and shower facilities in rural and suburban areas<br />
• Poor WASH facilities in urban, provincial and rural schools<br />
• Parental support<br />
• Age of girls at menarche<br />
• Rapidly increasing access to information and the media<br />
DETERMINANTS<br />
CHALLENGES<br />
VOICED IMPACTS<br />
POTENTIAL RISKS<br />
Inadequate school and<br />
dormitory WASH facilities<br />
Knowledge, information<br />
and education<br />
Access to emergency<br />
materials to manage<br />
menstruation<br />
Supportive psychosocial<br />
environment<br />
Biological factors<br />
Being unprepared<br />
Hiding menstruation<br />
from boys<br />
Leaks, stains and<br />
odour<br />
Difficulty in asking<br />
for help<br />
Biological challenges<br />
Physical symptoms of<br />
menstruation<br />
Taking time off from<br />
classes<br />
Reduced<br />
concentration<br />
Withholding urine<br />
Threat of harassment<br />
Lower academic<br />
and sporting<br />
achievements<br />
School dropout<br />
Negative impact on<br />
girls’ physical and<br />
emotional well-being<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
Social and environmental context<br />
Girls’ experiences during menstruation and the challenges they face are explored within the broader<br />
social and environmental context. This includes their physical and psychosocial environment, the<br />
culture they were raised in, and the groups they interact with that have had and continue to have a<br />
great influence on their past, current and future physical and emotional well-being and behaviour.<br />
There are five key contextual factors:<br />
• Poor community-level access to water and shower facilities in rural and suburban areas<br />
• Poor WASH facilities in urban, provincial and rural schools<br />
• Parental/family support for girls<br />
• Age of girls at menarche<br />
• Increasing countrywide media access, particularly to the internet<br />
Contextual factor 1. Poor community-level access to water and shower facilities in rural and<br />
suburban areas<br />
In rural and suburban areas, particularly in rural soums, access to adequate WASH facilities was limited<br />
because of water scarcity and poor infrastructure development because of the cost implications of<br />
such a vast territory. Households were not connected to a piped water supply system and most rural<br />
soums had only one or two public shower/bath houses. If they were closed for some reason, local<br />
people had to wash at home, using a bath tub, where facilities were often limited. Rural households<br />
had no separate shower rooms, making it difficult for girls who are menstruating to wash themselves<br />
and their clothes.<br />
“We have only one public shower in the whole soum. So there is always a long<br />
queue, so we (as girls) are not always able to go there.” (RuralS9_ GirlsIDI_2)<br />
Herders living in remote places collect water from wells, springs and rivers, and some families use<br />
snow or ice from the river for drinking and cooking in winter.<br />
In suburban districts of Ulaanbaatar, people often have to queue to collect water from water<br />
distribution kiosks. (See Figure 7).<br />
According to the Social Indicator Sample Survey 2013 (NSO, UNFPA, UNICEF, 2014), it is mostly adult<br />
men (62 per cent) and boys under the age of 15 (7.3 per cent) who fetch water for their families.<br />
Figure 7. A water distribution kiosk in a<br />
suburban area of Ulaanbaatar<br />
Figure 8. Boys fetching water in a rural area<br />
Source: B.Mungunkhishig, UNICEF<br />
Source: B.Mungunkhishig, UNICEF<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
While this relieves women and girls from this burden and time commitment, it can create difficulties<br />
when they use more water than other members of the household.<br />
Contextual factor 2. Poor WASH facilities in urban, provincial and rural schools<br />
In urban areas, although most schools had flush toilets, access was limited because schools were<br />
overcrowded. In some schools, three children sat at a table for two and other schools ran three shifts<br />
a day. For example, the first shift or primary grades have classes from 8 a.m. till 11 a.m., the next<br />
group of grades (e.g. lower secondary) have classes from 11.a.m. till 4 p.m. and classes for the third<br />
shift or higher grades are from 4 p.m. till 8 p.m. School time depends on the number of classes each<br />
grade has, which is usually four or five classes a day, each lasting 45 minutes.<br />
Researchers found that two of the urban schools had more than 2,000 students and the children<br />
attended in three shifts, but there were no provincial or rural soum schools with a three-shift system<br />
during the time of their visit.<br />
Provincial schools had both indoor flush toilets and outdoor pit latrines. The condition of indoor flush<br />
toilets was the same as those in the Ulaanbaatar or suburban schools, but the outdoor pit latrines<br />
were in a similar condition as those in the rural schools.<br />
Most rural schools had only outside open pit latrines and children felt reluctant to use them because<br />
of poor sanitary conditions, a lack of privacy, as often toilets had no doors (either broken or not<br />
installed at all), no locks, no lights and no rubbish bin inside the toilet cubicle, etc.<br />
According to girls and other research participants, there was usually no toilet paper in the urban and<br />
rural school toilets. Children are asked to bring a number of toilet rolls to school at the beginning of<br />
the school year, which are kept in the classroom; when students need to use the toilet, they take a<br />
toilet roll with them. Children reported using toilet rolls in most cases, but it is difficult to say whether<br />
this arrangement worked well every single time.<br />
Contextual factor 3. Parental support<br />
In Mongolia, girls are traditionally strongly encouraged to pursue an education. Generally, most<br />
parents give priority to their daughters’ education rather than their sons, as was noted in the girls’<br />
statements. Girls reported being well supported by family members such as mothers and sisters as<br />
well as fathers and grandmothers. Particularly in herder families, parents tend to ask their sons to<br />
help with herding rather than their daughters, therefore the school dropout rate is higher among<br />
boys than girls.<br />
“In rural areas where we live, people pay a lot of attention to a girl child.”<br />
(RuralS9_ GirlsFGD_1)<br />
However, for those girls who didn’t live with immediate family members or didn’t have an elder sister<br />
nearby, there was less support on managing menstruation. Girls in rural areas lived in the school<br />
dormitory during the academic year and those who couldn’t because of limited dorm spaces stayed<br />
with host families.<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
Girls who lived in school dormitories for the whole school year might need special attention and care<br />
as they are away from their parents but still need the help and support of someone close to them in<br />
practical terms, for example pads or cash, as well as advice and encouragement.<br />
Girls in FGDs in different locations told researchers that when dorm girls needed information and<br />
support, they could turn to their dorm teachers and older girls; but girls who stayed with host families<br />
didn’t have this option. However, this is an area for further exploration and was not adequately<br />
addressed in the research design. (See Annex 1 for information on dormitory children.)<br />
Contextual factor 4. Age of girls at menarche<br />
Younger schoolgirls, under the age of about 13, face more challenges than their older counterparts<br />
because their scant experience and knowledge is compounded by a lack of information and support<br />
at school both before and at menarche. Parents, particularly mothers, in many cases do not brief their<br />
daughters beforehand, assuming that it is too early, or provide very vague information. Therefore,<br />
the younger girls are when they begin to menstruate, the more fearful and shocked they feel, and<br />
are too embarrassed to ask for help on such a sensitive topic.<br />
Contextual factor 5. Rapidly increasing access to information and the media<br />
Currently, all districts, both rural and urban, have internet connections and electricity. TV was the<br />
most common media channel that rural children use, mostly to watch movies; there were a few<br />
health programmes tailored to children. In urban areas, children used the internet more than any<br />
other media channel; according to a government report, 13 84 per cent of internet users are in the<br />
capital.<br />
“There are almost no children in the school who do not have a smart phone and they<br />
use it all the time getting connected to the internet. With this, children have access<br />
to different information faster than us and learn new things more quickly than us.”<br />
(RuralS7_TeachersFGD)<br />
Until 2016, people living in rural areas, who make up half of Mongolia’s total population, paid four or<br />
five times more for internet access. For example, Ulaanbaatar residents paid 13,000 MNT per 1 MBs<br />
of data, while rural residents paid 55,000 MNT for the same access. Recently the Government has<br />
tackled this inequality with a policy to improve rural internet access. According to the girls, internet<br />
access is widely available and is a source of useful information. They felt it would be good for<br />
information on MHM to be available online; this could be a more equitable means of disseminating<br />
information and sharing knowledge.<br />
13 The Government orders to charge equal tarrifs for internet service nationwide.<br />
See more (in Mongolian language) at: http://zasag.mn/news/view/12341.<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
Challenges girls face<br />
Challenges were identified through discussions and interviews with girls on their experiences of<br />
menstruating. Girls also shared stories with researchers, including how they felt physically and<br />
emotionally, and how their attitudes and behaviour changed as a result of menstruating. These<br />
challenges are related to education, psychosocial support and the availability of materials or the<br />
condition of the physical environment, such as WASH facilities. Girls reported how they felt and<br />
behaved during menstruation, which might be different if they were in a more supportive environment<br />
(for example, “I wash my cloth when no one is around”; “I feel ashamed”).<br />
Being unprepared<br />
Young girls mostly felt stressed at menarche. They had some information, but when it happened,<br />
they were still scared and felt shocked. Most girls heard about menstruation before menarche, but<br />
some did not know anything about managing it.<br />
• “The first time I had my period, I got scared thinking that I might be dying and<br />
cried.” (Sub-urbanS3_GirlsFGD_2)<br />
• “When I had a period for the first time, I was frightened, I felt disgusting and<br />
worried that someone might notice my period.” (AimagS8_GirlsFGD_2)<br />
• My period is changeable, with irregular intervals, so I don’t carry sanitary pads.”<br />
(RuralS9_Girls FGD_1)<br />
Some girls said they were sometimes unprepared because their menstruation was irregular, and no<br />
sanitary pads were available.<br />
Hiding menstruation from boys<br />
Talking about menstruation with or in front of fathers, brothers and other males is still taboo. Therefore,<br />
at school, boys’ teasing made it stressful and embarrassing for girls to manage menstruation. They<br />
worried about leaks and stains on their clothes or that boys would notice that they carried pads with<br />
them. Keeping pads out of sight from boys was a serious concern for girls.<br />
• “Our biggest fear was that boys would notice we were menstruating.” (AimagS8_<br />
GirlsFGD1_2)<br />
• “Our teacher told us if there’s a stain on the chair, you should clean it before<br />
boys notice it.” (AimagS6_Girls FGD_2)<br />
• “We know one case when boys from another class teased a girl who had stains<br />
on her clothes and the girl looked embarrassed as she was put in a humiliating<br />
situation.” (Peri-urbanS3_BoysFGD)<br />
• “Girls worry that boys will search their bags and if they find pads, they will tease<br />
them, so they try to hide them in a very secure place in their bags or do not bring<br />
them to school at all.” (RuralS9_ Girls FGD_1)<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
Fear of leaks, stains and odour<br />
Girls from urban and rural areas, regardless of whether they lived in dormitories or at home, all<br />
experienced emotional stress through fear of leaks, stains and possible bad odour while they were<br />
menstruating at school.<br />
• “I worry that bad odours will come, therefore I always avoid sitting next to my<br />
boyfriend in class.” (Peri-urbanS3_GirlsIDI)<br />
• “There was a case that one day one of the girls asked the teacher for permission<br />
to take time off from class, but as it was exam term, the teacher did not let her<br />
go out and all of a sudden, boys started pointing to her and saying that she peed<br />
in her pants . . . embarrassing.” (Peri-urbanS3_GirlsFGD_2)<br />
• “When boys were cleaning the classroom after class, they were pushing a chair<br />
to each other. Then I noticed there were bloodstains.” (RuralS5_Teachers FGD)<br />
Difficulty in asking for help<br />
Due to the existing taboo in the community about not talking about menstruation, girls found it<br />
difficult to ask anyone about anything related to menstruation, except very close friends. They felt<br />
they could not ask permission to leave the class if teachers was male, or buy pads in a shop if the<br />
shopkeeper was male or men were present.<br />
• “Usually we look for support from our teachers, but if the teacher is male, then<br />
it would be difficult to ask for help.” (AimagS6_GirlsFGD_1)<br />
• “It’s especially difficult to tell male teachers and ask permission to use the toilet.”<br />
(RuralS11_Girls FGD_2)<br />
• “Usually girls approach the school doctor for pads, but the doctor’s budget is very<br />
limited and not enough to buy three packets of pads, and therefore sometimes<br />
we buy them with our own money.” (Peri-urbanS3_TeacherFGD)<br />
Biological challenges<br />
There were also biological challenges. These include lower abdomen and back pain, headaches and<br />
sometimes dizziness, though some girls said they didn’t experience any pain. Girls try to ignore the<br />
pain by wearing tight underwear or by concentrating on something else, like reading, watching<br />
movies, or playing games, but they don’t take any medicine.<br />
Irregular periods posed additional challenges for girls, as they came to school unprepared and worried<br />
more about possible leaks and stains.<br />
19
A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
Determinants and contributing factors<br />
Girls and other participants involved in the research identified the main challenges faced by girls who<br />
are menstruating at school through IDIs, FGDs and KIIs. Participants also shared their thoughts on<br />
the reasons why girls face such challenges. These determinants that can be summarized as follows:<br />
1. Inadequate school and dormitory WASH facilities<br />
2. Knowledge, information and education<br />
3. Access to emergency materials to manage menstruation<br />
4. Supportive psychosocial environment<br />
5. Biological factors<br />
Determinant 1. Inadequate WASH facilities in schools and dormitories<br />
Children spend long periods of time at school, and the physical environment and cleanliness of school<br />
facilities can significantly affect their health and well-being. Good school WASH facilities help to<br />
create a safe, healthy and comfortable environment where children can learn and thrive, and can help<br />
to keep them motivated to go to school.<br />
WASH minimum standard for toilets are not met by most schools<br />
The Norms and Minimum Requirements for WASH in Kindergartens, Schools and Dormitories adopted<br />
by the Mongolian Government in early 2015 state that there should be one latrine or toilet available<br />
for every 30 girls; and one latrine or toilet, plus one urinal, for every 40 boys 14 (see Annex 2).<br />
Two of the schools selected in Ulaanbaatar (one in the city centre and one of the suburban schools<br />
in the ger district) had three shifts per day, which means that only one toilet was available for 56–66<br />
girls per shift. Keeping the toilet clean and well-maintained in this situation was very problematic.<br />
Among the participating schools, the standard number was met in one of the suburban schools in<br />
the remote district of Ulaanbaatar and in rural soums where they had smaller numbers of children.<br />
When the number of school children exceeded the capacity of school buildings and classes, including<br />
the number of WASH facilities, it was challenging for children to use the toilets during school hours.<br />
• “The dormitory toilet does not have lights, it’s difficult to think what girls do in<br />
the dark and how they change pads in such conditions.” (RuralS9_MothersFGD)<br />
• “The school toilet is separate for girls and boys. But there is no light, no electricity,<br />
no waste bin, it’s smelly, there’s no door but there are eight cubicles.” (RuralS9_<br />
Girls FGD)<br />
14 Norms and Minimum Requirements for WASH in Schools, Dormitories and Kindergartens, 2015, MoECS, MoF, MoHS.<br />
20
<strong>FINAL</strong> <strong>REPORT</strong><br />
Comparison of toilet facilities in urban, provincial and rural schools<br />
Designation. Around 40 per cent of all toilets were used by girls as well as female teachers.<br />
However, in the rural soum schools, 18 per cent of toilet cubicles were used by both boys and girls.<br />
Few toilets were locked for teachers’ use only. As mentioned above, rural soum schools mostly had<br />
simple open pit latrines. Some toilets were locked or non-functional and have therefore been included<br />
in the ‘unknown’ or ‘not applicable (n/a)’ category (see Annex 3a).<br />
“School toilets are separate for boys and girls, but there is no sign indicating who<br />
the toilet is for, therefore I feel uncomfortable about using them, and nervous that<br />
somebody might come in at any time.” (AimagS8_GirlsFGD_2)<br />
Functionality. According to the study’s observation data, only 42 per cent of all toilets in the selected<br />
schools were fully functional, while 14,5 per cent were either non-functional or their status was<br />
unknown because they were locked. In dorms, only 24 per cent were fully functional, while 15 per<br />
cent were non-functional (see Annex 3a and 3b).<br />
In the rural soum schools, almost 40 per cent of toilets were non-functional, but only around 10 per<br />
cent in the urban schools. So although toilets may exist, they are not fully functional, as they may<br />
have no doors (or the doors have no locks on the inside), no lighting or waste bins and they do not<br />
provide a safe and private environment for children, particularly girls. The location of school toilets<br />
and the availability of window blinds was also critical. Girls from one urban school told researchers<br />
that they did not like using the toilets on the first floor because the window did not have a blind,<br />
allowing anyone to peep in from upper floor windows.<br />
21
A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
Figure 9. Pit latrine in a rural (soum) school (A) compared with flush toilet in an urban school (B) (Figure 10)<br />
Source: CSWE, Ulaanbaatar<br />
Cleanliness. Researchers’ observation data show that 65 per cent of urban school toilets were<br />
hygienic, 15 versus 29 per cent of those in provincial schools, and only 20 per cent of rural schools.<br />
Almost half of the toilets were evaluated as ‘dirty’ because of bad smells, flies, dirty floors and<br />
waste bins or rubbish strewn everywhere because there were no waste bins. Therefore, most children<br />
avoided using school toilets as much as possible and waited until classes were over when they could<br />
go home, or even to the dormitory as dorm toilets were preferable. Many girls said that the dormitory<br />
toilet was much better than school toilets. In some case, insanitary WASH facilities led boys and<br />
younger children to defecate openly.<br />
Janitors worked in all the rural, urban and provincial schools. They were responsible for keeping<br />
toilets clean and free of smells and rubbish. School janitors used different cleaning materials and<br />
disinfectants, including chloramine which is very widespread and commonly used by local people.<br />
Girls and other FGD participants explained that toilets were sometimes not very clean and smelled<br />
because, in most cases, very large numbers of children use them, and the ratio of children per<br />
latrine is high. In addition, janitors locked their designated toilets over the weekend, and sometimes<br />
unlocked them after classes began. First floor toilets were usually left open over the weekend, and<br />
as a consequence were the most dirty.<br />
“The school janitor cleaned the toilet, but it was still not clean because many children<br />
use it. So we usually do not use school toilet.” (AimagS8_GirlsFGD_1)<br />
Lights. Over 75 per cent of the rural school pit latrines had no lighting, compared to 5 per cent of<br />
the urban schools and 25 per cent of the provincial-level schools. This makes it difficult enough for<br />
girls to use the toilet ordinarily, but even more so if they need to change sanitary pads. Toilets could<br />
also be risky to use at night.<br />
15 Defined as in the WASH in Schools Monitoring package as free from smells, visible faeces in or around the facilities, no flies<br />
or litter.<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
“It is dark in the dormitory toilet, there are no lights, that’s why we always ask<br />
somebody to come with us to use the toilet after dark.” (RuralS9_GirlsFGD_2)<br />
An inside lock is very important for ensuring girls’ privacy. In the rural schools, only 26 per cent of<br />
toilets had an inside lock, and only 18 per cent of them were working properly, while in the urban<br />
schools, 81 per cent of toilets had locks, of which 61 per cent were working properly. At the provincial<br />
schools, 69 per cent had inside locks, with 41 per cent worked properly.<br />
Most girls felt anxious about having no private space at school to change and wash their clothes or<br />
change used pads.<br />
• “Because there is no privacy we usually avoid going to the toilet at school.”<br />
(RuralS5 _GirlsFGDs_2)<br />
• “It’s difficult to change napkins because the toilet is open with no lock.”<br />
(AimagS4_GirlsFGD_2)<br />
• “I don’t change it at school. I change it at home in the morning. Then I change it<br />
again when I come back home.” (RuralS9_Girls FGD_2)<br />
Because of a lack of privacy, girls usually asked their friends to accompany them to the toilet. In 76<br />
per cent of toilets in the urban schools, girls did not require a friend to assist or accompany them,<br />
compared with in 44 per cent of the provincial schools.<br />
“If we have to go to the toilet, we go together with friends, not alone, so that one<br />
of us will be holding the door.”( AimagS4_Girls FGD_2)<br />
Rubbish bins are available in 92 per cent of the urban school toilets, 74 per cent of the provincial<br />
school toilets, and 26 per cent of rural school latrines. The lack of bins discouraged girls from<br />
changing their pads at school as there was nowhere to dispose of them, which made girls feel<br />
awkward. From this we can see that children in rural schools and dormitories had no choice other<br />
than to wrap up used pads and throw them into the toilet or onto the cubicle floor. During FGDs<br />
it was reported that although most of the urban school toilets had bins, they were often full and<br />
therefore not usable.<br />
WASH facilities in urban and provincial schools with indoor flush toilets<br />
Table 6 shows that 95 per cent of the urban schools had indoor flush toilets, while almost 90 per<br />
cent of the rural soum schools had simple outdoor pit latrines.<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
Table 6 Types of toilet facilities for urban, provincial and rural schools<br />
Observation Response Urban schools Aimag/provincial<br />
schools<br />
Categories Categories No. of toilets,<br />
N=79<br />
Type of toilet<br />
facilities<br />
% No. of toilets,<br />
N=77<br />
Soum schools<br />
% No. of toilets,<br />
N=65<br />
Flush toilet 75 95% 65 81% 7 11%<br />
Pit latrine 4 5% 8 10% 52 80%<br />
Improved ventilated<br />
pit latrine<br />
0<br />
0%<br />
Unknown/NA 0 0% 1 5% 1 2%<br />
Girls were concerned about water pressure in school flush toilets because if the pressure was low,<br />
they had to wait and flush the toilet several times to ensure all bloodstains disappeared, as they did<br />
not want the next user to notice. This shows that girls also hide from each other the fact that they<br />
are menstruating; or that they fear others blaming them for getting blood on the bowl or being<br />
unhygienic.<br />
In the rural schools, toilets were not always well separated for boys and girls, particularly in rural<br />
areas. Sometimes, outdoor school latrines for boys and girls were separated by a simple plank wall<br />
between toilet cubicles.<br />
Sometimes school toilets were closed in the evening (when girls may be attending extracurricular<br />
activities), which means they had to use whatever other toilets were open, even the boys’ toilets.<br />
3<br />
4%<br />
5<br />
%<br />
8%<br />
“Once we wanted to use the male toilet, there was a male teacher peeing.”<br />
(UrbanS1_Girls FDG+2)<br />
Figure 11. Outdoor pit latrine<br />
Provincial school WASH facilities<br />
The provincial schools had a mixture of indoor<br />
toilets and outdoor latrines. When there were<br />
indoor facilities, handwashing areas were close<br />
to the toilet area which enabled children to wash<br />
their hands immediately after using the toilet.<br />
According to the schoolchildren, indoor latrines in<br />
most cases were locked as the school management<br />
was concerned about the cost of emptying them,<br />
so children were forced to use outdoor latrines. The<br />
condition of outdoor pit latrines in the provincial<br />
schools was almost the same as in rural schools.<br />
Source: CSWE<br />
WASH conditions in rural schools with outdoor simple<br />
pit latrines<br />
Most of the rural schools and dormitories had outdoor open pit latrines, which did not provide privacy.<br />
In most cases cubicles did not have locks or lighting, which meant girls did not feel comfortable<br />
changing their pads there. The girls’ reports confirm this description.<br />
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The condition of school outdoor pit latrines was mostly poor. Often they had no doors to provide<br />
privacy, were not separate for girls and boys, were dirty and smelly, had no lights, and became<br />
slippery during the winter because of snow and because it was not possible to clean them in cold<br />
weather. Figure 11 shows a typical school outdoor latrine. They are easy to use in the autumn, spring<br />
or early summer, but would not be so in winter as most of them were not insulated or heated.<br />
In most of the soum schools and dormitories where there was no water supply system, the boys<br />
were asked to fetch water from wells or reservoirs by truck or yak-drawn cart for both washing and<br />
drinking.<br />
Figure 12. Yak cart for fetching water for rural soum school<br />
Source: CSWE<br />
A critical reason why schools did not have functioning toilets was that school administrators were not<br />
sufficiently aware of the importance of good WASH facilities and therefore made their improvement<br />
a low priority. For example, one soum school celebrated its sixtieth anniversary the year before<br />
the research study and carried out 60 investment projects through the funds they raised. The only<br />
thing they did not spend money on was improving the school toilets, though they needed serious<br />
renovation. In the FGDs, girls said they should be rebuilt, as there was no way to improve the current<br />
latrines.<br />
In some schools, one toilet was locked for teachers’ use only, while all pupils, both boys and girls,<br />
shared the second latrine (see Figure 13).<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
Figure 13. Comparison of (a) the girls’ and boys’ toilet and Figure 14. (b) the teachers’ toilet at an aimaglevel<br />
school<br />
Figures 15, 16: Ideal toilet (Girls’ FGD)<br />
Source: CSWE<br />
Ideal toilets<br />
In all schools, girls shared thoughts on their ideal toilets. There would be separate toilets for boys<br />
and girls, with locks on the inside, mirrors to check their dresses, hooks for bags and a place to put<br />
personal items such as phones. Schools would have operational flushing toilets, with sanitary pads,<br />
toilet paper and soap available inside toilet cubicles; and toilets would be clean and smell-free with<br />
sinks for handwashing, waste bins and hand dryers (see Annex 4a, 4b, 4c).<br />
Figure 15, a drawing from a girls’ FGD, highlights that most importantly, toilets should be clean, wellventilated,<br />
and separate for girls and boys (Peri-UrbanS3_GirlsFGD_2). In the top half of the picture<br />
girls drew the current latrine door and in the second half a picture of their dream toilet, highlighting<br />
that there should be enough toilets for the number of children at the school.<br />
Handwashing in rural schools<br />
Urban and aimag centre schools mainly had indoor latrines with modern WASH facilities, including<br />
sinks for hand washing. However, most rural schools and dormitories did not have handwashing<br />
facilities with soap close to the latrine area. After using the toilet, children had to go back to their<br />
classroom or to the dormitory living room and use the simple washstand there.<br />
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Figure 17. Simple wash stand in a rural school<br />
Due to the scarcity of water in rural schools,<br />
schools advised children to use wet tissues<br />
or hand sanitizers, such as Sanitol, to clean<br />
their hands after using the toilet or before<br />
meals.<br />
A lack of water creates additional challenges<br />
for personal hygiene in general.<br />
“There is no space at school<br />
to wash up when [blood] has<br />
leaked through clothes.”<br />
(RuralS11_Girls FGD_2)<br />
Source: CSWE<br />
WASH facilities for dormitory girls<br />
There were no private rooms at school for dorm girls to wash their clothes so they had to use the<br />
communal laundry room where all children do their washing. They could use small basins in the<br />
dormitory to wash smaller items, but had to wait until they went home at the weekend or at the end<br />
of term to wash any bloodstained clothes. The rural school dormitories usually had open pit latrines<br />
that were often inadequate; conditions were similar to rural school latrines. Showers were available<br />
for dormitory children but in some instances there was a schedule and students could only use them<br />
once or twice a week. If they wished, dormitory children could use the community or soum public<br />
bath or shower.<br />
Shower facilities in rural school<br />
All the rural school dormitories (but not the rural schools) were required to have a shower room.<br />
This requirement was followed in most school dormitories, where, on average, children shower two<br />
to four times a month during the school year, following a set schedule. But in one of the four rural<br />
schools the shower wasn’t working due to maintenance problems. In these cases the children used<br />
the community or soum public bath.<br />
Determinant 2: Knowledge, information and education<br />
Throughout the study, researchers asked girls if they knew about menstruation before menarche,<br />
what kind of problems and challenges they faced, and what information and advice they had<br />
received and from whom. Responses varied.<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
Formal school health curriculum does not cover MHM<br />
Ministerial Decree No. 369, dated 28 September 2011, ruled that health education was to be included<br />
in the curriculum from the fifth grade and above as a separate dedicated subject for 34–35 hours<br />
throughout the school year, or one hour per week. There were many topics to cover, but limited time<br />
was allocated.<br />
Recently the Government has overturned this decision and, from the beginning of the academic<br />
year in 2015, health education was integrated into the biology and physical education curricula. For<br />
instance, for primary classes, ‘People and the Environment’ and ‘People and Nature’ classes included<br />
topics on health and exercise, the human body, reproduction and development. Biology classes for<br />
lower secondary students cover human anatomy, biology, the structure of the reproductive organs,<br />
and fertility. The physical education class includes topics related to proper clothing in different<br />
weather condition, healthy living, healthy food, exercise and obesity. 16<br />
As this research was conducted before health was incorporated into the biology and physical<br />
education curricula, both boys and girls said they learned about puberty and other health-related<br />
topics in health education classes. These classes started in the fifth grade, when children were aged<br />
12, and were delivered for one hour per week.<br />
• “It was taught from the fifth grade, given that menarche has shifted to an earlier<br />
age.” (RuralS9_HealthTeacher)<br />
• “The whole topic on puberty was only for one hour. So menstruation was, of<br />
course, not covered in detail.” (RuralS9_HealthTeacher)<br />
Girls confirmed that menarche/menstruation was taught briefly under the topic of ‘puberty’. Many<br />
girls did not remember what they were taught on menstruation, what it was, why it happened and<br />
how to manage it, while the other groups of girls thought that only very general information was<br />
given.<br />
This may have been because boys and girls attended health education classes together, and teachers<br />
did not want to embarrass students by talking openly about it; and also boys and girls may have felt<br />
awkward about talking openly about the issue in front of each other.<br />
• “We get a certain amount of knowledge from health education [classes] such as<br />
communications, decision-making, preventing pregnancy.” (RuralS9_Girl_IDI_1)<br />
• “There’s no independent topic on menstruation in the subject of health<br />
education. It is somehow mentioned generally within another topic. Information<br />
on menstruation is not provided consistently. Sometimes, basically only one hour<br />
is given for that information.” (RuralS9_ Health Teacher)<br />
Some health education teachers noted that it was difficult to teach the subject as time was limited,<br />
and that health education textbooks were of poor quality.<br />
However, as reported by schoolgirls and boys, MHM and puberty-related topics were mentioned<br />
briefly only in the grade 5 curriculum, not in other classes, which had a different focus. Class teachers<br />
16 ‘Is it a reform to integrate Health with Natural Science?’, 6 February 2015, Zuuny medee: www.Zms.mn; http://www.polit.<br />
mn/content/59229.htm.<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
mainly provided information on the biological process of menstruation rather than management and<br />
hygiene-related issues.<br />
Girls’ knowledge and understanding of menstruation<br />
Girls’ knowledge and understanding of menstruation varied. Most young girls learned about<br />
menstruation before menarche, usually from their mothers or health education teachers. The first<br />
information they received was very brief and related only to the biological process, the reproductive<br />
organs and signs of puberty.<br />
Girls had very vague ideas about why women menstruated, what menstruation was, for how long<br />
they would bleed and how often it would happen. When they experienced menarche, they felt<br />
shocked and scared. In some cases, girls were influenced by the traditional beliefs that have been<br />
perpetuated in the community for many years. For example, when some girls in one FGD explained<br />
that menstruation was part of puberty and the physiological changes taking place within the body,<br />
other girls said their mothers and grandmothers had told them that menstruation was “dirty blood”<br />
leaving the body to purify it. These traditional myths may persist because menstruation is a sensitive<br />
topic that mothers felt uncomfortable about discussing openly; or because they did not know a<br />
better way to explain it; or perhaps because this misconception is still very strong.<br />
• “Dirty blood is drained from the body through menstruation and the body is<br />
purified as a result of it.” (UrbanS1_school report)<br />
• “[My mother] said that bad blood is discharged from the body and the period<br />
starts.” (RuralS9_GIRL_IDI_1)<br />
It was clearly seen that age contributed to girls’ understanding of menstruation; older girls were<br />
likely to have more accurate information as they learned how to manage menstruation and shared<br />
experiences with their girlfriends at school. From girls’ perspectives, when they learned about<br />
menstruation during health education classes, they had already acquired good management skills.<br />
Therefore, in their opinion, such education should be given in grades 5 or 6 when menarche might<br />
be expected to occur.<br />
Younger age girls didn’t have a clear understanding of menstruation and there was no sense of them<br />
talking about tracking their periods. Most girls aged 12–13 reported that they did not know how to<br />
use a calendar to track menstruation, while girls over 14 could predict their periods by looking out for<br />
physical signs such as backache or lower abdomen pain. However, they observed that after one and<br />
half or two years of menstruation, their cycle became more regular. For this reason girls preferred<br />
to have sanitary pads to hand.<br />
Girls who didn’t know about menstruation were often were unprepared at school and had to borrow<br />
sanitary pads from friends. Older girls did not feel too embarrassed to ask and to talk about it with<br />
female school doctors, female teachers and their mothers or sisters.<br />
During pretesting of the research, one suburban girl in a girls’ FGD told researchers that before<br />
menarche, she had heard about menstruation and using pads from her mother and sister, but when<br />
it happened, she did not know how to use the pads correctly, though she later found out from<br />
watching TV.<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
Support and information from mothers and sisters<br />
Mothers were the first people girls approached when they needed help or wanted information about<br />
puberty and menstruation, even before menarche. Mothers explained to girls what menstruation<br />
was, at what age it would occur, how to behave, how to take care of personal hygiene and even<br />
about the use of sanitary pads.<br />
As noted above, there were cases where mothers gave misguided information regarding<br />
menstruation, including references like “dirty blood” or “bad blood” to their daughters. A common<br />
reason for this misinformation is that the negative understanding is based on the knowledge and<br />
experiences passed down from their previous generations. As such, some girls made their own<br />
judgements:<br />
• “The bad blood or ill blood comes out of the body [during menstruation] and<br />
women’s blood circulates, refreshing the body, therefore women live longer than<br />
men. Men do not live longer as their blood is not refreshed during their life<br />
time.” (RuralS7_Girls FGD_2)<br />
• “I feel sorry for boys because their body keeps the bad blood, poor boys.”<br />
(piloting FGD in urban school)<br />
Urban schoolgirls said their mothers emphasized personal hygiene, telling their daughters to wash<br />
every day when they were menstruating. However, many rural schoolgirls were advised not to wash<br />
in the river when menstruating (tradition says one should not pollute water in a river, lake or spring<br />
by dropping blood or milk into them), and some were told by their mothers not to shower frequently<br />
to prevent infections.<br />
Girls believed (and were advised by their mothers and sisters) that if they moved about too much<br />
or did any physical work, their menstrual flow would be heavier and cause leaks. But in one case, a<br />
doctor strongly advised a girl not to play sports during menstruation without explaining why. Having<br />
followed this advice for a while, the girl entered a sporting competition, and only then realized that<br />
extensive physical activities causes a heavy blood flow.<br />
Apart from mothers, girls learned about menstruation from their sisters, other female relatives and<br />
friends, and shared this information and their own experiences with friends. Girls with older sisters<br />
were more likely to hear about menstruation first and tell their friends what they knew. Girls in urban<br />
schools also learned about menstruation and puberty from social media, including Facebook.<br />
Boys’ knowledge and support<br />
Boys’ FGDs were conducted at six of the selected schools. Urban, suburban and rural schoolboys<br />
from higher grades had attended health education classes and therefore had some awareness of<br />
menstruation; some had a very scientific understanding because they were studying fertility and<br />
reproduction as part of a health course. However, during discussions, the boys behaved oddly,<br />
laughing, looking sideways, and making fun of each other.<br />
They admitted that they did not know about menstruation when they were younger, and had teased<br />
the girls about it.<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
“We’re used to it now, so we don’t tease the girls anymore. If it had been explained<br />
to us at a younger age, around fifth grade, we would not have teased the<br />
girls.”(RuralS11_ Boys FGDs)<br />
In the boys’ FGDs, researchers conducted an exercise to simulate what girls might experience when<br />
menstruating. Researchers asked boys to imagine how they would feel and react if their elbow<br />
suddenly started bleeding in the middle of class. Afterwards some boys admitted they felt sorry for<br />
teasing girls without knowing how difficult it was for them.<br />
The girls’ greatest fear was that boys would find out that they were menstruating and would tease<br />
them, and that it would be even worse if leaks caused bloodstains on their clothes. But the highergrade<br />
boys said that though younger children might do this, boys in high school wouldn’t. Girls<br />
agreed that by the time boys reached upper grades, they had become more understanding and<br />
stopped bullying and teasing. In addition, some boys in upper grades ignored the issue as they felt<br />
it was none of their business.<br />
“Boys’ attitudes changed when they grew up. They stopped teasing girls and they<br />
became very supportive and ready to help when girls needed help.”<br />
(Peri-urbanS2_ Girls FGD_2)<br />
Support from teachers at school<br />
Female teachers made up the majority of school teachers, comprising 70 to 90 per cent of all teachers<br />
in schools (details in Annex 5).<br />
Therefore, female teachers are the primary adults in the school environment who could provide<br />
support when girls are menstruating. Girls mostly approached their female teachers and received<br />
support, for example when requesting permission to leave the class to use the toilet, or asking for<br />
extra pads.<br />
“Two girls approached me saying that one of them had a serious problem because<br />
she has bloodstains in her pants. I took them to the toilet and gave them a sanitary<br />
pad. And I explained about menstruation and how to use the pad. The second girl,<br />
who was the friend, was so surprised and asked, ‘that means this will happen to me<br />
too?’ They were sixth graders.” (Aimag S10_ Teachers FGD)<br />
Although it was rare, there were a few cases where even female teachers were reluctant to allow<br />
girls to take a few minutes off from the class, because they didn’t want them to miss an important<br />
session. Sometimes girls could not explain the reason they needed to use the toilet in front of whole<br />
class, so teachers assumed it wasn’t serious, and perhaps was just an excuse to leave the class and<br />
have fun outside.<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
“Everybody (every woman) menstruates so it is a normal phenomenon. When<br />
they grow up, as adult women, they cannot be absent from work because they<br />
are menstruating. Similarly, students cannot be absent from class because of<br />
menstruation.” (AimagS_10 Teachers FGD)<br />
Girls thought that unlike most female teachers, male teachers did not understand girls’ situation<br />
during menstruation and they did not feel comfortable approaching them. This attitude, of both male<br />
teachers and the girls themselves, has its roots in the existing taboo around menstruation and the<br />
belief that it should be hidden from all males.<br />
School and dorm support staff’s lack of awareness<br />
The schools’ non-teaching staff, including janitors, dorm guards and dorm teachers, also played<br />
important roles in supporting or not supporting girls during menstruation. Girls of different ages in<br />
the FGDs said that some school staff were unsupportive.<br />
• “At night we go to the toilet all together, and after that the door is locked and<br />
we’re not allowed to go out to pee. The staff member on duty in the dormitory<br />
locks us in at 5–6 p.m. in winter and at 7–8 p.m. in summer. And they don’t let us<br />
go out even when we need to go to the toilet.” (RuralS9_GirlsFGD_2)<br />
• “Sometimes the cleaning lady does the cleaning during the break and doesn’t let<br />
children use the toilet.” (UB report)<br />
• “It’s always locked when I try to use it. Sometimes, when it is not locked, the<br />
cleaning lady scolds us and doesn’t let us in. She says: ‘Go to another toilet. I’m<br />
cleaning here, what do you want?’” (AimagC4_GirlsIDI_2)<br />
Determinant 3. Access to emergency materials to manage menstruation<br />
Lack of easy access to commercial pads at school<br />
All participants, including girls, mothers, teachers and health professionals, reported that girls used<br />
exclusively commercial pads during menstruation, except in rare cases when there were none, for<br />
example in remote rural areas, when girls might use whatever materials were at hand. For instance,<br />
one girl described visiting her grandmother in a rural area, who advised her to use a cloth instead of<br />
a pad if she needed one.<br />
“All girls use commercial pads as girls report to us during their routine check-up of<br />
girls’ hygiene at schools.” (KII with rural district Adolescent Health doctor)<br />
School doctors are required to give children a routine health check at least three times a year, including<br />
a dental check-up, as well as looking at the sanitary condition of classes and schools. As part of this<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
process they organize discussions, and provide information and advice for children. Doctors working<br />
with adolescents mention girls’ hygiene here to highlight specific issues related to them.<br />
Commercial sanitary pads were widely available in all urban and rural shops. However, access to<br />
sanitary pads at school varied. Urban schools sold sanitary pads in the school shop, so urban girls<br />
had no problem accessing them, providing they had the money. At the same time, girls confirmed<br />
that pads in the school shop were more expensive than outside. It should be noted that, in general,<br />
pads in rural areas were slightly more expensive than in urban areas. Most rural schools did not sell<br />
pads within the school compound. If girls needed them, they had to leave the compound and buy<br />
pads in nearby shops, providing they could afford it. If they couldn’t, girls borrowed money from<br />
classmates, including boys, or asked for pads from school doctors, female teachers or anybody else<br />
who could help in an emergency.<br />
Younger girls said that they felt embarrassed about buying pads from male shopkeepers or when<br />
men were in the shop, and sometimes went to another store with a female shopkeeper, or waited<br />
until there were no men present. Older girls said that they did not worry about this so much and felt<br />
free to ask for money to buy pads from even their male classmates<br />
In case of emergencies at school, girls either kept pads with them or asked friends, teachers or<br />
doctors for them. In general, girls tried to keep pads secure and well-hidden so they would not fall<br />
out or be discovered; sometimes boys rifled through girls’ bags looking for extra pens and pencils,<br />
and if they found pads, they would laugh and tease the girls (urban schools report).<br />
“In general girls keep pads in their bags for any emergency. In my experience, 80 per<br />
cent of girls buy them from shops, 5 per cent of them get them from teachers, 10 per<br />
cent from friends, 5 per cent from the school doctor.”(AimagS10_ GirlsIDI)<br />
In the girls’ FGDs, some thought that girls staying in dormitories or with host families might not be<br />
able to obtain sanitary pads because they had no money, as they did not see their parents often.<br />
However, it should be noted that none of the girls explicitly said this was the case. This research<br />
included girls in dormitories in the older girls’ FGDs, but because there weren’t separate questions for<br />
dorm girls and they did not offer this information, it has not been possible to examine the situation<br />
of dorm girls in detail within this report.<br />
Also, although girls in FGDs spoke about the challenges that girls with host families might face,<br />
none identified themselves as living with host families, and therefore it was difficult to explore any<br />
specific challenges.<br />
One mother explained that, because of a lack of water or space to wash bloodstained clothes, some<br />
girls were driven to stealing other girls’ clothes.<br />
“Because the children in dormitories have no napkins and have no money to buy<br />
pads, there have been cases where some of them stole and wore my daughter’s<br />
clothes.” (RuralS9_Mothers FGD)<br />
Girls staying in dorms were usually from herder families, and were unable to go home frequently and<br />
therefore lacked parental support. Participants in the mothers’ FGDs thought some parents might not<br />
be aware that their daughters who were staying in dormitories needed money to buy pads.<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
Girls chose thin pads<br />
Girls preferred to wear very thin, small pads, thinking that they were better, more comfortable to use<br />
and most importantly, less noticeable, so others would not realize they were menstruating. However,<br />
it should be noted that if girls experienced leaks and stains, these thinner pads may not provide<br />
enough protection.<br />
“We choose to buy thin and long sanitary napkins, they allow ventilation. Also they<br />
should have deodorizers and good absorption capacity.” (RuralS9_GirlsFGD_2)<br />
Some, but not all girls mentioned using different pads for different purposes. For instance, during<br />
the night and while at school, they used night pads which are thicker and longer; and at other times<br />
used thin ones.<br />
Mother and fathers are willing to buy good quality pads for their daughters<br />
Girls usually kept a supply of pads at home. Mothers offered practical support to their daughters by<br />
buying pads whenever they were needed, and explained the pros and cons of different types. Mothers<br />
confirmed that cost was not the most important factor when buying pads for their daughters.<br />
Some girls reported that fathers did support their daughters by providing money to buy sanitary<br />
pads, and even purchased them themselves, though it was rare for fathers to involve themselves in<br />
these matters.<br />
• “The price isn’t important, but the quality is. Some napkins cause allergic<br />
reactions. The thin ones are for girls. Those small pink ones from China are also<br />
not good. There’s a green one with a very breezy scent. They [the girls] say it has<br />
deodorizers.- Those smaller and narrower ones, you know. Those are for daily<br />
use.” (RuralS9_MothersFGD)<br />
• “Well I didn’t know about these things last year. I was wondering how those<br />
small ones are used, then my daugther said, ‘Mom, these are nice to use, you<br />
should use them’. (RuralS9_MothersFGD)<br />
• “My husband advised me ‘Buy our daughter good quality good pads, I cannot<br />
do it because she would feel embarrassed with me’.” (AimagS10_TeachersFGD)<br />
Determinant 4: Supportive psychosocial environment<br />
School regulations on toilet use<br />
Not all schools allowed children to use the toilet whenever they needed it.<br />
Usually, there was only a five-minute break between classes, which gave children just enough time to<br />
get to the next classroom, but not enough to use the toilet. There was only one longer 10–15-minute<br />
break during the day and if toilets were crowded, or latrines were located a long way from school<br />
buildings, not all girls were able to use the toilet or change their pads.<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
• “We don’t manage to use the toilet during breaks. There is only one toilet for<br />
boys, one for girls and one for teachers indoors, so break-time is insufficient.<br />
There is a pit latrine for girls with two pits outside, but it’s still not enough.”<br />
(AimagS6 Girls FGD)<br />
• “It is far away from the school building. Even if we run to the toilet, we still don’t<br />
manage to use it because there’s a long queue.” (RuralS11_ Girls FGD_1)<br />
Some schools required all children to do physical exercise during the longest 10–15-minute break,<br />
which leaves less time for using the toilet.<br />
• “Since girls are not able to use the toilet during break, they have to ask permission<br />
to go during class. But some teachers let them go to the toilet, some don’t.”<br />
(RuralS9_GirlsFGD_1).<br />
• “We are not able to tell our classroom teacher because our class teacher is a<br />
male” (laughter). (RuralS9_GirlsFGD_2<br />
As girls explained, they believed that physical activity, such as running and jumping would lead to a<br />
heavier flow that might result in leaks and stains. Therefore, they tried their best not to attend PE<br />
classes, giving different excuses and even lying if the teacher was male.<br />
It was also observed that even when latrines were available, some schools opened them in turn, or<br />
during class time, and locked them when classes were over. This may be to reduce work for the<br />
janitor or save funds for maintenance, which also require funds and manpower.<br />
• “The third break time at school lasts 10 minutes, the longest, and so many<br />
children want to use toilets, so we have to wait in a very long queue.” (RuralS9_<br />
GirlsFGD_1)<br />
• “While we wait in the queue, break time finishes and so we have to hurry back<br />
to class. If we are late, the teacher would be angry and ask where we were.”<br />
(RuralS9_GirlsFGD_1)<br />
• “The school toilet is always closed during class and open only during break time.”<br />
(AimagS8_GirlsFGD_1)<br />
Support at home, in dorms and at school<br />
At home, most girls confirmed that they received strong support from female members of the family<br />
and even in some cases from their fathers. This included information, accessing sanitary pads, and<br />
being released from doing heavy physical work around the house, such as fetching water. However,<br />
girls who stayed in dorms or lived with host families had less support. Nonetheless, it should be noted<br />
that girls thought that some might still experience difficulties when menstruating.<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
“In schools on the outskirts of the city, more than 45 per cent of the students are<br />
from low-income families, the children of mine workers, and some parents can’t<br />
afford sanitary napkins for their daughters. Girls from such families are quiet, not<br />
confident, feel weak.” (Peri-urbanS3_Girls FGD_report)<br />
Though nowadays children are becoming more open than older generations, many girls still did not<br />
talk about menstruation-related topics with their fathers and brothers.<br />
Girls living in dormitories received emotional and material support from the classmates, friends and<br />
dormitory teachers. However, as their parents lived far away, these girls lacked cash and found it<br />
difficult to buy pads; girls living with the host families encountered similar problems. In these cases,<br />
girls borrowed money or pads from their friends.<br />
Determinant 5: Biological factors<br />
Biological factors include the age of menarche, frequency of menstruation and painful symptoms.<br />
From the stories girls shared with researchers, the age of menarche ranged from 9 to 14 years of age.<br />
Younger girls were more vulnerable because they had not yet learned about menstruation and were<br />
still learning to care for themselves. First experiences of menarche are described in the girls’ stories;<br />
all shared the same fear, stress and shock.<br />
Irregularity is one of the contributing factors to leaks and stains. Particularly in the early stages, girls’<br />
menstrual cycles are not regular and the flow is also not always consistent. Because girls did not<br />
know when to expect their periods, they went to school unprepared, though older girls reported that<br />
they carried sanitary pads in their bags when their period was due.<br />
Girls reported that they began menstruating between the ages of 10 and 14, but most mothers and<br />
teachers expected it would be later, at 13–15 years of age.<br />
“It has changed nowadays, it [menstruation] begins earlier than in our time. It began<br />
at 14 in my daughter. In our time, it started at 15 and 16.” ( RuralS9_MothersFGD)<br />
In general, physical changes and especially height were different in rural and urban girls. In rural areas,<br />
especially in soums, girls tended to be shorter than urban teens. It would therefore be worthwhile<br />
segregating data and information on adolescents’ growth and the speed of the process into urban<br />
and rural groups, and further studying the issue in depth.<br />
Mothers also assumed that teachers would advise girls on managing menstruation, while teachers<br />
expected mothers to do this. Some mothers did not teach their daughters about sanitary pads<br />
because they assumed they already knew about them from school or elsewhere.<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
Impacts on and risks to education and health<br />
The challenges girls face during menstruation may impact on their health and education and pose<br />
risks. ‘Voiced impacts’ are the impacts that girls, mothers and teachers mentioned during interviews<br />
as negatively affecting girls’ health and education at school, as well as their behaviour, as expressed<br />
in the participants’ own words.<br />
Voiced impacts<br />
Voiced impact 1. Physical symptoms of menstruation<br />
Some of the challenges girls experienced during menstruation included abdominal cramps and back<br />
pain as well as general weakness and lowered levels of activity. They felt uncomfortable and could<br />
not sleep well because they were worried about leaking and staining the bed linen, which meant they<br />
felt exhausted in class the next day.<br />
“Girls worry and can’t even sleep calmly at night. We have to sleep on one side or<br />
another without facing up worrying that it may leak.” (AimagS4_ Girls FGD_2)<br />
Voiced impact 2. Taking time off from classes, particularly PE<br />
Girls and teachers reported that girls frequently left the classroom to use the toilet and that in<br />
particular they missed PE when they were menstruating. Girls said that it was very difficult to<br />
participate in PE when they had their periods, as they feared leaking if they ran, jumped or exercised.<br />
Also, most girls were advised not to run when menstruating.<br />
If PE teachers were male, girls felt embarrassed and avoided asking their permission to leave the class.<br />
• “Girls skip physical training once a month.” (AimagS10_Teachers FGD)<br />
• “If I need to change a pad in the middle of the class, I would request leave from<br />
the teacher and go home.” (Urban school report)<br />
• “Sometimes I have to lie to leave a class to change pads. I would say that I had<br />
something urgent at home.”(RuralS9_GirlsFGD_2)<br />
Girls left classes from time to time, and sometimes even had lie in order to use the toilet, change<br />
their pads or because of abdominal pain.<br />
Voiced Impact 3. Reduced concentration and class participation<br />
When girls were menstruating, they were less inclined to participate in class and less able to concentrate.<br />
They did not like being asked to stand in front of the class to answer teachers’ questions, as they<br />
feared movement might cause leaks or exposing potential stains. Because they were preoccupied with<br />
these anxieties, they found it difficult to pay attention to what was going on in class.<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
• [talking about a hypothetical girl] “All the time at school, she spends worrying<br />
about her trousers. She cannot ask the teacher for time off, and she cannot skip<br />
lessons, so she spends the day just sitting, immovable. This reduces her ability to<br />
concentrate . . . on the subject.” (RuralS9G_FGD_1; S9_GirlsFGD_2)<br />
• “She takes one of the back seats.” (RuralS11_Girls FGDI_1)<br />
• “Unable to concentrate on the topic of the lesson.” (RuralS11_GirlsFGD_2)<br />
• “I worry about leakage so much that I frequently stand up and check if my chair<br />
is stained.” (Peri-urbanS2_GirlsFGD)<br />
• “I once forgot to bring sanitary napkins into school. That day we had seven hours<br />
of classes. During the last hour, I had a terrible feeling that I was about to leak<br />
and stain the chair. . . . Eventually I worried so much that I got up from the chair<br />
from time to time. While walking back home, I was worried all the way, wishing<br />
I wouldn’t leak before I reached home. That day was a dreadful one. That’s a<br />
terrible memory.” (Peri-urbanS2_GirlsIDI)<br />
Voiced impact 4. Withholding urine<br />
“Because access to the girls’ toilet was poor and it was closed at 17:00, we had to go<br />
to the male toilet. There had been cases [where a girl’s had to face] a male person<br />
there, especially a male student, and gets embarrassed and frightened.” (UrbanS1_<br />
GirlsFGD_2)<br />
Classes usually took place between 8 a.m. and 7 p.m. However, school janitors finished work at<br />
around 5 p.m. and after cleaning the toilets they locked the doors and left. This meant that children<br />
who took part in extracurricular activities did not have access to school toilets until the next morning.<br />
This often happened in urban schools with indoor flush toilets. In some cases, half of the toilets,<br />
either the boys’ or the girls’, were closed while the other half were open during and after school<br />
hours.<br />
“The rural school dormitory outdoor latrine was located far from the dormitory and<br />
in winter time or at night, [girls] asked their friends to go out together or asked the<br />
dormitory teacher to accompany them to the toilet.” (RuralS9_ GFGD_2)<br />
Because of these conditions and to avoid using unhygienic and cold facilities, girls tried their best not<br />
use toilets when needed and withheld urine as much as they could. However, it should be noted that<br />
avoiding urination and defecation while at school seems common for both girls and boys because of<br />
the lack of adequate toilets.<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
How girls felt before and after menarche<br />
Girls participating in the FGDs discussed the changes they had experienced after menarche. They<br />
were organized into groups and after some discussion decided to draw or make a list of the things an<br />
imaginary, ‘ordinary’ girl would experience both before and after menarche (see Figures 18 and 19).<br />
Girls’ experiences before and after menarche<br />
Before menarche:<br />
Happy, friendly and open Active, loved to run, jump<br />
and play sports Liked to travel around with their<br />
families, visited relatives, could stay away from home<br />
Could wear any clothes they liked Were careless, did<br />
not worry about anything, open and straightforward<br />
Could play with boys Did not take care of themselves<br />
Figures 18, 19. Girls before and after<br />
menarche<br />
After menarche:<br />
Felt nervous, uncomfortable and distracted, their<br />
attention only on menstruation Became worried,<br />
irritable, shy, lonely and quiet Avoided interacting with<br />
boys, liked to sit at the back of the classroom Did not<br />
like to make sudden movements, jump or dance with<br />
friends Had back and stomach ache when menstruating<br />
Did not like to travel anymore or spend the night<br />
away from home at a camp or at relatives’ Started<br />
paying more attention to what to wear, how they look<br />
Preferred to wear dark clothes, trousers, rather than<br />
skirts Became more conscious of their appearance<br />
and how they behave and talk to others, esp. boys<br />
Became more open with other girls as they shared the<br />
same experience Cared more about cleanliness and<br />
hygiene, started washing their clothes more frequently<br />
Source: S6_GirlsFGD_1<br />
Potential risks/potential health impacts<br />
Risk 1. Lower academic performance and sporting achievements<br />
Girls’ poor concentration in class when they are menstruating means they miss lesson content. This<br />
could affect how well they perform in exams and lead to lower academic achievements.<br />
Similarly, limiting movement during menstruation and being frequently absent from PE classes could<br />
also reduce their sporting achievements.<br />
Risk 2. School drop out<br />
Boys frequently tease girls when they are menstruating, causing the girls great embarrassment and<br />
feelings of shame, which may even lead to them dropping out of school.<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
“There has been a case where a girl was ridiculed by boys when [blood] leaked<br />
through her clothes and she had to change her school.” (AimagS10_Girls FGD_2)<br />
Boys’ teasing and bullying seems to be a big problem in schools, with girls afraid that boys will notice<br />
they are menstruating or carrying pads in their bags. However, male teachers do not have enough<br />
knowledge or skills to talk to boys or girls about the issue and are even reluctant to support girls<br />
or stop the boys teasing. Unfortunately, if boys don’t understand that this is unacceptable, either<br />
during menstruation or at any other time, there is a danger this behaviour could escalate, making<br />
girls dislike and even drop out of school, lose their self-esteem and self-confidence, and even cause<br />
mental problems.<br />
During boys’ FGDs, they were taken through a simulation exercise and asked to imagine what it<br />
would be like to menstruate. One of the boys said, “I’m embarrassed that I laughed at the girls. Now<br />
I feel sorry for girls” (in a peri-urban area during pretesting). This demonstrates the importance of<br />
making boys more aware of the situation.<br />
Risk 3: Negative impact on girls’ physical and emotional well-being<br />
Hiding menstruation, not being able to discuss it openly with people close to them, constantly feeling<br />
stressed, fearful and anxious can impact on girls’ physical and emotional well-being.<br />
Many girls when menstruating keep themselves apart from others because of their fear of odour,<br />
leaks and stains and that others will notice that they are menstruating. This could affect girls’ selfesteem<br />
and self-confidence and they may end up becoming lonely, isolated and unsociable. In<br />
addition, inadequate, unhygienic toilets can spread infection and disease among children, and in<br />
particular, girls.<br />
As reported, many girls tried their best not to use unsatisfactory sanitation facilities and instead<br />
withheld urine for many hours until they got home. This could also have negative consequences for<br />
girls’ health, leading to Urinary tract infections.<br />
Summary of the key findings<br />
Figure 20. Different socio-ecological levels<br />
The challenges girls faced during menstruation occur at different socio-ecological levels, as grouped in<br />
Figure 20.<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
Societal level: Recently the Government has made tremendous efforts to improve WASH facilities in<br />
schools so that children can learn and reach their full potential in a child-friendly environment. Most<br />
notable is the key policy document, the Norms and Minimum Requirements for WASH in Schools,<br />
Dormitories and Kindergartens, which was approved in 2015 with the active support of three key<br />
Ministries (MoECS, MoHS and the Ministry of Finance). All national and sub-national government<br />
authorities have started working to implement these Norms and Minimum Requirements, and some<br />
provincial and district-level governments have already been allocating funds from national and local<br />
development budgets to improve school WASH facilities. However, not all government good will was<br />
realized in terms of school WASH facilities and the responsible agencies and the local government<br />
were not eagerly allocating funds to this very important sector. Even when funds were allocated, the<br />
amount was often meagre compared to the need.<br />
The existing taboo on menstruation influences people’s perception and behaviour. Many people,<br />
including parents, teachers, community members and schoolgirls themselves, tried their best to hide<br />
anything related to menstruation from others, and particularly from men and boys. Boys teased girls<br />
if they found out that they were menstruating.<br />
Environmental level: Not all school WASH facilities were adequate to meet the needs of girls in<br />
managing menstruation in a private and comfortable environment, without fear and embarrassment.<br />
In particular, rural school WASH facilities were in need of infrastructure improvement and maintenance<br />
through long use.<br />
Interpersonal level: Due to their low level of knowledge about managing menstruation, girls<br />
often felt stressed and isolated themselves from others, sitting at the back of the classroom, not<br />
participating in school activities with other children, and trying to minimize their movements through<br />
fear of triggering heavy bleeding. Girls tried hard to prevent others, particularly boys, from noticing<br />
that they were menstruating and did not talk about it with anyone except their mothers or very close<br />
friends. There was a common understanding that menstruation should be strictly hidden from males,<br />
an understanding was very strong among girls.<br />
Personal level: At a younger age, girls had very little knowledge of menstruation and how to<br />
manage it, relying mainly on their mothers’ and sisters’ advice. Girls became anxious and irritable as<br />
they worried about how to handle menstruation, including their lack of knowledge about the quality<br />
of pads, and they did not sleep well as they worried about staining the bed linen or clothes. Most girls<br />
felt things had been much better before menarche, that they were happier, braver and more active.<br />
Biological level: Girls experienced back pain, stomach cramps and sometimes dizziness and tiredness<br />
during menstruation, but most did not know how to manage these symptoms. Some took medicines,<br />
but most tried to relieve the pain by focusing on other things or wearing tight underwear to minimize<br />
it. The irregularity of menstruation was also quite challenging, particularly for younger girls.<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
RECOMMENDATIONS<br />
1. RECOMMENDATIONS FROM PARTICIPANTS 17<br />
WASH facilities:<br />
• There is a pressing need to install as many indoor toilets as possible on each floor of a school<br />
or dormitory building. They should have locks, good lighting, mirrors, hand dryers, soap, toilet<br />
paper, and a waste disposal bin. In addition, it would be good to set up a drawer in the toilets<br />
containing sanitary pads.<br />
• Handwashing facilities should be close to the toilet so children can wash their hands immediately<br />
after using it.<br />
• A separate space or room in the school compound for emergency use and equipped with a<br />
mirror, chair, shelves and skirts would enable girls to change or wash dirty clothes, and would<br />
really help relieve girls of some of the stress of menstruation.<br />
• Toilets should be clean and well-maintained, and renovated when necessary.<br />
Children’s participation:<br />
• The school administration should encourage the participation of schoolgirls and boys in<br />
planning, implementing and monitoring school WASH activities through organizing school<br />
campaigns or regular child-led activities at school.<br />
Knowledge and information:<br />
• Teachers’ awareness and understanding of the challenges girls face should be increased,<br />
especially that of male teachers, by providing them with special training.<br />
• Male teachers could play an important role by becoming role models for boys, learning and<br />
sharing information with them and talking to them about menstruation related-issues. This<br />
would help boys understand and stop bullying girls.<br />
• Schools could plan and carry out awareness-raising campaigns for teachers, parents, boys and<br />
girls on managing menstruation.<br />
• A crucial step forward would be to develop communications on positive MHM experiences<br />
and MHM support for girls, such as posters, newsletters, online training or video clips, and<br />
to disseminate them to community members, parents, school doctors and education sector<br />
workers.<br />
• As children in all rural schools have access to and use the internet widely, MHM-related<br />
information could be developed and disseminated through this channel.<br />
17 See Annex 6.<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
Access to sanitary pads:<br />
• To improve access to sanitary pads, schools could sell them or establish a system to provide<br />
emergency pads using the school’s internal budget.<br />
School doctors’ and dormitory teachers’ roles and responsibilities:<br />
• School doctors should be actively involved and provide support in improving school WASH<br />
facilities to meet the standard requirements, strengthening the awareness and understanding<br />
of school workers, teachers (including male teachers) and boys, developing the communications<br />
mentioned above, and providing advisory services.<br />
2. RECOMMENDATIONS FROM RESEARCHERS<br />
National level:<br />
• It is important for the Government to prioritize mobilizing all possible efforts to implement the<br />
Norms and Minimum Requirements for WASH in Schools, Dormitories and Kindergartens, along<br />
with other developmental programmes. WASH facilities are a basic human need that relates<br />
closely to the issue of respecting girls’ human dignity and greatly affects their educational<br />
achievements.<br />
• A key developmental issue in coming years would be to carry out a nationwide campaign<br />
to increase the awareness of decision-makers, planners and staff in governmental and nongovernmental<br />
organizations, as well as the general public, of the need to prioritize improving<br />
WASH facilities, particularly in schools, dormitories and kindergartens. This is particularly<br />
important, given the fact that it will help to raise physically and mentally healthy children, vital<br />
for the development and future of Mongolia.<br />
• Based on careful analysis of the content of the previous health curriculum, new content<br />
should be developed and introduced as part of the school curriculum (both in formal and nonformal<br />
settings) focusing on the practical needs of schoolchildren, particularly covering girls’<br />
specific needs (MHM), healthy behaviour, healthy eating and the principles of healthy living.<br />
• Health teachers and school doctors need to be trained and retrained on the health curriculum’s<br />
new content and the correct health messages for children.<br />
• It is crucial to put maximum effort into developing and disseminating information on<br />
menstruation and hygiene to the wider public, including teachers and parents, to increase<br />
awareness. The internet could be a more equitable means to disseminate information and<br />
share knowledge widely, from government officials to local people, including schoolgirls,<br />
boys, teachers and parents.<br />
• Key WASH in school indicators should be included in the Education Management and<br />
Information System (EMIS) reporting system and regularly monitored by stakeholders, involving<br />
the main users at national, sub-national and local levels to improve school WASH facilities.<br />
These indicators could be key criteria for selecting schools for the Best Schools award.<br />
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A study on Menstrual Hygiene Management in Mongolia:<br />
Understanding practices and impacts on adolescent schoolgirls’ education and health<br />
• More women should be promoted to school management positions, in particular to school<br />
director posts. As researchers observed, the condition and maintenance of WASH facilities<br />
were much better in the schools with female directors. This hopefully should not pose any<br />
difficulties in Mongolia, where the majority of teachers are female, though currently, most<br />
school directors are male.<br />
Sub-national level:<br />
• Aimag and soum governments need to prioritize improving WASH facilities in schools,<br />
dormitories and kindergartens and make all efforts to establish model WASH facilities as<br />
per the Norms and Minimum Requirements on Water, Sanitation and Hygiene in Schools,<br />
Dormitories and Kindergartens.<br />
• Aimag and soum governments and members of the citizens’ representative khurals should<br />
prioritize and focus more on planning and allocating the necessary budget from Local<br />
Development Funds or on raising funds by any other means to improve WASH facilities in<br />
kindergartens, dormitories and schools, in consultation with aimag/soum residents.<br />
School level:<br />
• School management teams should focus on improving MHM facilities in schools and increasing<br />
the awareness and understanding of girls’ specific needs among male teachers, boys, and<br />
school support staff (including dorm staff and janitors).<br />
• Teachers and children themselves could be key players in monitoring and reporting the progress<br />
of WASH access in their own schools. Child-led monitoring could play a vital role in this area.<br />
• School management should make sure that in school WASH facilities all toilet doors are lockable<br />
to ensure privacy for children when using toilets, the washroom, and when showering.<br />
• Schools should set up a system that provides girls with easy access to sanitary pads at school<br />
during school hours. This could be a small shop, the school doctor, or a special room for girls<br />
– whichever is most convenient for girls – and could be organized as a local initiative by dorm<br />
or class teachers.<br />
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<strong>FINAL</strong> <strong>REPORT</strong><br />
REFERENCES:<br />
1. United Nations Children’s Fund, WASH in Schools Monitoring Package, UNICEF New York,<br />
April, 2011<br />
2. Norms and Requirements for Water, Sanitation and Hygiene for Kindergarten, Dormitory<br />
and School, MOECS, MOF, MOHS, 2015, Ulaanbaatgar<br />
3. Monitoring Package of Norms and Requirements for Water Sanitaton and Hygiene for<br />
Kindergarten, Dormitory and School, MOECS, MOF, MOHS, 2015, Ulaanbaatar<br />
4. Analysis of the Situation of Children in Mongolia, UNICEF, 2014, Ulaanbaatar<br />
5. WASH in School: Empowers Girls’ Education in Rural Cochabamba, Bolivia, An Assessment of<br />
Menstrual Hygiene Management in Schools<br />
6. UNICEF, Economic Impacts of Sanitation in Mongolia (2011)<br />
7. SISS (MICS, 2013, Social Indicator Sample Survey, Mongolia<br />
8. Millennium Development Goals Implementation, The Fourth National Report, Summary,2011<br />
9. Achieving Millennium Development Goals, Fifth National Progress Report, 2013<br />
10. https://populationpyramid.net/mongolia/2016/<br />
11. “WASH in Schools, Empowers Girls’ Education, Tools for Assessing Menstrual Hygiene<br />
Management in Schools”, UNICEF, Emory University<br />
12. http://zasag.mn/news/view/12341. 2016-03-02 14:54. http://zasag.mn/news/view/12341<br />
13. Is it a reform to integrate health with Natural Science? 6 Feb,2015. Zuuny medee. www.Zms.<br />
mn&http://www.polit.mn/content/59229.htm<br />
14. WASH in Schools, Empowers Girls’ Education, Proceedings of the Menstrual Hygiene<br />
Management in Schools Virtual Conference, 2013, Columbia University, UNICEF,<br />
15. WASH in Schools, Empowers Girls’ Education: An Assessment of Menstrual Hygiene<br />
Management in Schools, Emory University, Center for Global Safe Water, UNICEF<br />
16. Education, Science Sector Policy Reform, 1999-2014, Ulaanbaatar, 2014<br />
17. Field Guide: The Three Star Approach for WASH in Schools, GIZ, UNICEF, 2013<br />
18. Modules, WinS4Girls E-Course, Emory University, 2015<br />
45
ANNEXES:<br />
ANNEX 1. NUMBER OF STUDENTS IN DORMS IN THE STUDY SCHOOLS<br />
School<br />
code<br />
School location &<br />
region<br />
Total students<br />
of which in dorms<br />
% of students in<br />
dorms<br />
S1 Urban 2,640 n/a n/a<br />
S2 Urban 2,975 n/a n/a<br />
S3 Suburban 1,426 91 6.4%<br />
S4 Gobi aimag 1,057 100 9.5%<br />
S5 Gobi soum 1,100 84 7.6%<br />
S6 Eastern aimag 274 28 10.2%<br />
S7 Eastern soum 584 116 19.9%<br />
S8 Western aimag 1,059 n/a n/a<br />
S9 Western soum 613 110 17.9%<br />
S10 Khangai aimag 760 n/a n/a<br />
S11 Khangai soum 512 110 21.5%<br />
46
ANNEX 2. WASH STANDARDS FOR GIRLS’ TOILETS IN THE SELECTED SCHOOLS<br />
Region Level No.of shifts No. of<br />
students,<br />
categories<br />
No.of students<br />
No. of<br />
toilets<br />
No. of female<br />
students<br />
No. of<br />
toilet seats<br />
for girls*<br />
No. of girls per<br />
toilet per shift<br />
The standard<br />
met or not met<br />
UB city 3 Over 2,001 2,640 19 1,489 6+3/2 66 Not met<br />
UB ger district 3 Over 2,001 2,975 24 1,524 18/2 56 Not met<br />
UB remote<br />
district<br />
2 1,001–2,000 1,426 29 726 23 16 Met<br />
Gobi aimag 2 1,001–2,000 1,057 18 552 9 31 Not met<br />
Gobi soum 2 1,001–2,000 1,100 16 558 6 47 Not met<br />
Eastern aimag 1 Up to 500 274 7 134 3 45 Not met<br />
Eastern soum 2 501–1,000 584 6 280 2 70 Not met<br />
Western aimag 2 1,001–2,000 1,059 12 525 6 44 Not met<br />
Western soum 2 501–1,000 613 15 302 8 19 Met<br />
Khangai aimag 2 Up to 500 380 24 372 11 17 Met<br />
Khangai soum 2 Up to 500 254 18 268 5+8/2 15 Met<br />
* seats for<br />
girls+all student/2<br />
47
ANNEX 3A. SUMMARY OF OBSERVATIONS OF SCHOOL TOILETS AND WASH FACILITIES<br />
Observation Response UB aimag soum<br />
categories categories No. of toilet<br />
seats, N=79<br />
per cent No. of toilet<br />
seats, N=77<br />
% No. of toilet %<br />
seats, N=65<br />
1. Designation For girls 32 41% 34 43% 24 37%<br />
For boys 17 22% 35 44% 23 35%<br />
For all students 3 4% 0 0% 12 18%<br />
For female teachers 1 1% 0 0% 2 3%<br />
For male teachers 1 1% 0 0% 2 3%<br />
For all teachers 5 6% 2 3% 1 2%<br />
Unknown/ n/a 20 25% 6 8% 1 2%<br />
2. Type of toilets Flush toilet 75 95% 65 81% 7 11%<br />
Pit latrine 4 5% 8 10% 52 80%<br />
Improved ventilated pit latrine 0 0% 3 4% 5 8%<br />
Unknown/ n/a 0 0% 1 1 2%<br />
3. Functionality Functional 53 67% 30 38% 13 20%<br />
Semi-functional 17 22% 23 29% 22 34%<br />
Non-functional 8 10% 23 29% 25 38%<br />
Unknown/ n/a 1 1% 1 1% 5 8%<br />
4.Cleanliness Clean 51 65% 23 29% 13 20%<br />
No so clean 16 20% 41 51% 15 23%<br />
Dirty 5 6% 8 10% 31 48%<br />
Unknown 7 9% 5 6% 6 9%<br />
5.Lighting Lit 50 63% 56 70% 8 12%<br />
Not well lit 18 23% 0 0% 2 3%<br />
Dark 4 5% 19 24% 49 75%<br />
Unknown/ n/a 7 9% 2 3% 6 9%<br />
6.Lock inside Yes, can be locked 48 61% 33 41% 12 18%<br />
Yes, but can’t be locked 16 20% 22 28% 5 8%<br />
No locks 8 10% 14 18% 42 65%<br />
Unknown/ n/a 7 9% 8 10% 6 9%<br />
48
Observation Response UB aimag soum<br />
categories categories No. of toilet per cent No. of toilet % No. of toilet %<br />
seats, N=79<br />
seats, N=77<br />
seats, N=65<br />
7. Lock outside Yes, can be locked 74 94% 24 30% 16 25%<br />
Yes, but can’t be locked 0 0% 18 23% 0 0%<br />
None 0 0% 34 43% 47 72%<br />
Unknown 5 6% 1 1% 2 3%<br />
8. Assistance of<br />
friend NOT required<br />
Yes 60 76% 35 44% 42 65%<br />
No 8 10% 38 48% 21 32%<br />
Unknown 11 14% 4 5% 2 3%<br />
9. Rubbish bin Yes 73 92% 59 74% 17 26%<br />
No 6 8% 18 23% 48 74%<br />
10. Toilet paper Yes 2 3% 5 6% 7 11%<br />
No 77 97% 72 90% 58 89%<br />
11. Access for disabled<br />
Yes 0 0% 1 1% 0 0%<br />
No 79 100% 76 95% 65 100%<br />
ANNEX 3B. FUNCTIONALITY OF THE DORM TOILETS SEATS<br />
SchoolCode Fully functional* Semi-functional** Non-functional*** total<br />
3.9_Urban 7 0 0 7<br />
4.9_Provincial 0 8 0 8<br />
5.9_Rural 0 0 4 4<br />
6.9 Provincial 0 8 0 8<br />
7.9_Rural 1 4 1 6<br />
Total 8 20 5 33<br />
24% 61% 15% 100%<br />
49
ANNEX 4A. IDEAL FUNCTIONAL TOILETS COMPARED WITH CURRENT SITUATION AT URBAN SCHOOLS<br />
School Location urban schools<br />
School code School S1 School S2 School S3<br />
FGD age/gender Girls aged 12–13 Girls aged14+ boys Girls aged 12–13 Girls aged 14+ Girls aged 12–13 Girls aged 14+<br />
functional toilet characteristics ideal now ideal now ideal now ideal now ideal now ideal now<br />
1 rubbish bin √ + √ + √ + √ + √ X<br />
2 inside lock √ X √ X √ X √ X<br />
3 separate for boys and girls √ + √ X √ X √ √ X √ +<br />
5 mirrors √ X √ + √ + √ X √ + √ X<br />
6 clean √ X √ X √ X √ X √ X √ X<br />
7 place to put belongings √ X √ X √ X √ X<br />
8 lights √ X<br />
9 hooks √ X √ X √ X<br />
10 no smells √ X √ X √ X √ X<br />
11 air circulation or window opens √ + √ X √ X √ X<br />
12 sanitary pads available √ X √ X √ X √ X √ X √ X<br />
13 chlorine disinfectant √ X<br />
14 handwashing facilities + √ √ + +<br />
15 hand dryer √ + √ + √ √ X +<br />
16 toilet paper and soap √ X √ X √ X √ X √ X<br />
17 info board √ X<br />
18 flush operational √ X √ X √ X √ X<br />
19 available on every floor √ + √ X<br />
50
ANNEX 4 B. IDEAL FUNCTIONAL TOILETS COMPARED WITH CURRENT SITUATION IN PROVINCIAL SCHOOLS<br />
School Location aimag/provincial schools<br />
School code School S4 Gobi School S6 Eastern School S8 Western School S10 Khangai<br />
FGD age/gender Girls 12-13 yrs Girls 14+yrs Girls 12-13 yrs Girls 14+yrs Girls 12-13 yrs Girls 14+yrs Girls 12-13 yrs Girls 14+yrs<br />
functional toilet characteristics ideal now ideal now ideal now ideal now ideal now ideal now ideal now ideal now<br />
1 rubbish bin √ + √ + √ √ X<br />
2 inside lock √ + √ X √ + √ X √ X √ X<br />
3 separate for boys and girls √ X NA NA NA NA NA NA NA<br />
5 mirrors √ √ X √ + √ X √ X √ X<br />
6 clean √ X √ X √ √ X √ X √ X<br />
7 place to put belongings √ X √ X √ X √ X √ X √ X<br />
8 lights √ X √ X<br />
9 hooks √ X √ X √ X √ X √ X √ X<br />
10 no smells √ X √ X √ X √ X √ X<br />
11 air circulation or window opens √ + √ X √ X √ X √ X<br />
12 sanitary pads √ X √ X √ X √ X √ X √ X √ X<br />
13 disinfectant √ X √ X √ √ X √ X √ +<br />
14 handwashing facilities √ + √ X √ X √ X<br />
15 hand dryer √ X √ X √ + √ X √ X √ X<br />
16 toilet paper and soap √ X √ X √ X √ X √ X √ X √ X √ X<br />
17 info board √ X √ X √ X √ X<br />
18 flush operational √ X<br />
19 available at every floor NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA<br />
20 enough space √ X<br />
21 operational all the time √ X<br />
23 with CCTV camera √ X<br />
51
ANNEX 4C. IDEAL FUNCTIONAL TOILETS COMPARED WITH CURRENT SITUATION IN RURAL SCHOOLS<br />
School Location soum level rural schools<br />
School code School S5 Gobi S5 School S7 Eastern School S9 Western School S11 Khangai<br />
FGD age/gender Girls 12–13 Girls aged<br />
14+<br />
Boys Girls aged<br />
12–13<br />
Girls aged<br />
14+<br />
Girls aged<br />
12–13<br />
Girls aged<br />
14+<br />
Girls aged<br />
12–13<br />
Girls aged<br />
14+<br />
functional toilet characteristics ideal now ideal now ideal now ideal now ideal now ideal now ideal now ideal now ideal now<br />
1 rubbish bin √ X √ X √ X √ X √ X<br />
2 inside lock √ X √ X √ X √ X √ X √ X √ X √ X<br />
3 separate for boys and girls<br />
4 inside lining/can’t be seen √ X √ X √ X √ X √ X<br />
5 mirrors √ X √ X √ X √ X √ X √ X<br />
6 clean √ X √ X √ X √ X √ X √ X √ X<br />
7 place to put belongings √ X √ X √ X<br />
8 lights √ X √ X √ X √ X √ X √ X<br />
9 hooks √ X √ √ X<br />
10 no smells √ X √ X √ X √ X √ X √ X<br />
11 air circulation or window opens √ X √ X √ X √ √ X √ X<br />
12 sanitary pads √ X √ X √ X √ X √ X √ X √ X<br />
13 disinfectant √ X √ X √ X<br />
14 hand washing facilities √ X √ X √ X √ X √ X<br />
15 hand dryer √ X √ X<br />
16 toilet paper and soap √ X √ X √ X √ X √ X √ X<br />
17 info board √ X √ X √ X<br />
18 flushing NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA<br />
19 on every floor NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA<br />
20 enough space √ X √ X √ X<br />
52
ANNEX 5. NUMBER OF TEACHERS FOR THE PARTICIPATING SCHOOLS, BY GENDER<br />
School code Region Location Total no. of<br />
teachers<br />
No. of male<br />
teachers<br />
No. of female<br />
teachers<br />
Percentage of female<br />
teachers<br />
S1 Urban city centre 99 12 87 88%<br />
S2 Urban suburban 131 14 117 89%<br />
S3<br />
Urban<br />
remote<br />
district 74 16 58 78%<br />
S4 Gobi aimag 66 15 51 77%<br />
S5 Gobi soum 60 12 48 80%<br />
S6 Eastern aimag 17 4 13 76%<br />
S7 Eastern soum 31 9 22 71%<br />
S8 Western aimag 66 10 56 85%<br />
S9 Western soum 34 6 28 82%<br />
S10 Khangai aimag 52 10 42 81%<br />
S11 Khangai soum 33 7 26 79%<br />
53
ANNEX 6. SUMMARY OF RECOMMENDATIONS FROM THE PARTICIPANTS.<br />
Determinants<br />
Recommendations for schools and school administrators<br />
Girls, aged<br />
12–13<br />
Girls, aged<br />
14+<br />
Boys aged 14+<br />
Teachers<br />
Mothers<br />
School administrators<br />
School<br />
WASH<br />
facilities<br />
improved<br />
Create<br />
supportive<br />
psycho<br />
social<br />
environment<br />
• Sufficient number of toilets segregated for girls and boys<br />
are built, renovated<br />
• Toilets ensured privacy for use by girls<br />
• Each toilet booth had locks from inside, good lighting, mirrors,<br />
hand dryers, soap, toilet paper rolls<br />
• Each toilet booth had a waste bin<br />
• A hand wash stand installed close to toilet area to enable<br />
children wash their hands immediately after use of toilets<br />
• Had a drawer inside the toilet booth that keeps sanitary<br />
pads for girls<br />
• A separate room is established in school and dormitory for<br />
girls to change and wash their clothes in case of need<br />
• Toilets are kept and maintained clean at all time<br />
• Timely renovation of school toilets is ensured<br />
• School campaign, school wide activities on MHM, monitoring<br />
of WASH facilities conducted by child-led organizations<br />
are fully supported and encouraged by school management.<br />
Understanding the girls special needs and the support to them<br />
increased through involving teachers, particularly male teachers<br />
and boys in sensitization training on the topic so that the male<br />
teachers became roles models for boys and boys stop bullying<br />
girls<br />
Teachers should allow girls to use the toilet whenever they need<br />
School budget should include the cost of napkins. The education<br />
sector budget is allocated by budget lines. If some money<br />
is saved on fuel costs, then it would be taken back. Instead<br />
this money should be given to WASH improvements<br />
S4<br />
S1,<br />
S4,<br />
S5,<br />
S9,<br />
S7,<br />
S11,<br />
S10<br />
S1<br />
S9<br />
S1,<br />
S2,<br />
S3,<br />
S4,<br />
S10<br />
S11,<br />
S5<br />
S9,<br />
S7<br />
S9 S11 S10<br />
S9<br />
S9<br />
54
Strengthen<br />
the<br />
knowledge,<br />
information<br />
and<br />
education<br />
of<br />
all<br />
Improve<br />
an access<br />
to emergency<br />
menstrual<br />
management<br />
materials<br />
Biological<br />
factors<br />
Dedicated health subject continued and included in the curriculum<br />
and taught separately to boys and girls. Children are<br />
equipped with scientific knowledge on MHM<br />
Handouts or booklets for girls should be of practical use, not<br />
too much theory, easy to read based on real stories or experiences.<br />
The IEC materials to include how to keep a calendar<br />
and how to deal with menstrual cramps, whether should use<br />
tablets when it is painful, why it disappears for two or three<br />
months and then starts again and if it is possible to stop it<br />
Also handouts for girls should include information about what<br />
napkin is, how to use and how often to change napkins, how<br />
to take care of themselves etc.<br />
Handouts can be prepared as brochures. Recommendations<br />
can be disseminated via the internet and brochures to school<br />
children, boys and girls<br />
Schools should be responsible for providing information on<br />
the menstruation to children on a monthly or weekly basis or<br />
through mail boxes where children could ask questions. There<br />
should be a room for individual meetings.<br />
Peer educators can be used for educating girls. Girls listen<br />
more to the school leader girls and accept their word better<br />
than the teacher and school doctor.<br />
Movies and videos can be used to raise awareness of children<br />
because they like videos.<br />
Janitors should be educated on girls’ situation and be trained<br />
on communication skills<br />
Boys should be educated on the needs of girls in the class and<br />
taught not to tease girls<br />
Parents should be open with their girls and regularly give money<br />
to the daughters to by pads and fathers also should take<br />
care of their daughters<br />
Parents should take care of their girls, particularly in maintaining<br />
personal hygiene, and not let them lift heavy things<br />
Parents should be involved in the training and a brochure,<br />
handbook should be provided to them also<br />
Access to sanitary pads for girls improved through different<br />
measures, like through setting up of a point selling sanitary<br />
pads or establishing other system using school internal<br />
resources.<br />
Female teachers or school doctors should arrange access to<br />
emergency pads by creating funds through collecting money<br />
from girls or at least keep pads available when girls need<br />
them. The cost of sanitary pads could be reflected in the<br />
school budget for use by girls when they are in emergency<br />
need<br />
Timely and relevant, practical guidance are provided to girls<br />
by school doctors, teachers and dormitory teachers on how to<br />
take care of themselves, what to do and not to do and what<br />
sanitary pads to use, ways to relieve uncomfortable feelings<br />
including pains during the menstruation<br />
Health check-ups with a doctor should be arranged for girls at<br />
least once a year<br />
S9,<br />
S2<br />
S11,<br />
S5<br />
S10<br />
S4,<br />
S10,<br />
S9,<br />
S10,<br />
S7,<br />
S11,<br />
S3,<br />
S4<br />
S6,<br />
S6<br />
S4<br />
S2<br />
S10 S6 S6 S8<br />
S4,<br />
S10,<br />
S5,<br />
S11,<br />
S4,<br />
S10,<br />
S5,<br />
S11<br />
S2,<br />
S4,<br />
S7<br />
S5,<br />
S7<br />
S5,<br />
S9,<br />
S7<br />
S2,<br />
S9<br />
S3,<br />
S7<br />
S7 S10<br />
S10<br />
S10<br />
S6,<br />
S11,<br />
S9,<br />
S2,<br />
S3,<br />
S8,<br />
S6,<br />
S9<br />
S2<br />
S9<br />
S6,<br />
S10<br />
S4,<br />
S5<br />
S5,<br />
S3<br />
S10<br />
S2<br />
S6 S3,<br />
S9<br />
55
56