KEY FINDINGS AND DISCUSSION

From the varied and complex data, three key themes were identified: (1) understanding/learning about the menstrual cycle; (2) pain, discomfort and coping with menstrual symptoms; and (3) stigma, fear and embarrassment surrounding menstruation.  Throughout the lessons, the participants indicated a strong desire to learn about the full menstrual cycle, changes in their bodies and what is “normal” menstrual health. In the first lesson, they were given an open-ended question: what is your biggest question about menstruation? Of the 70 responses, most of them, 46 (66%), were focused on understanding various aspects of the menstrual cycle, from practical questions about periods to understanding why they happen.

The second most common group of responses was about pain and menstrual symptoms (n=13, 19%) (see next section). Other questions/entries centered on approaches to learning about menstruation (n=4, 6%), talking to others about menstruation (n=3, 4%), managing menstruation (n=2, 3%), and general questions about what to do during menstruation (n=2, 3%). Participants were also asked to select from a menu of questions about menstruation (Table 1). Again, concerns about understanding their cycle, other people knowing about their period, and coping with pain appeared to be prioritized over questions about MHM and menstrual products.

Table 1 – Participant responses to questions about menstruation (as selected from diary options)

1) Understanding and learning about the menstrual cycle

What are periods and why do they happen?

Many participants asked practical questions about the physical experiences of the menstrual cycle.  For example, when should periods begin (at what age), how long should menstruation last, can I play sports on my period, is it normal to get two periods per month etc. Many of these questions began with the words “is it normal,” which is how we coded this type of question. Additionally, some participants asked about why periods happen and how it begins.  For example, they asked where the blood comes from, why menstruation happens (to girls and not to boys) etc.

Better to learn earlier. One of the most critical findings was that most of the participants did not understand what was happening to them when they experienced menarche (n= 46 of 72, 63.9%). In total, 41 of 79 (51.9%) of the participants did not learn about menstruation until after their twelfth birthday yet believed that girls should learn before the age of 12. This is a key finding as 12 was the median age for menarche, with 44 out of 69 (63.4%) reporting their first period before age 13. The preferred answer to when girls should learn about menstruation was before age 12 (n=65 of 79, 82.3%), with 10 as the median age. Their responses stress the importance of learning about menstruation at an early age in order to avoid the shock, fear, confusion, and embarrassment described in many of the stories about first period experience.

Discussion on understanding and learning about the menstrual cycle. Examining these responses, we gain an understanding of how the conversion factors in the CA in SFD model impact the capability these participants have to understand menstrual health and well-being. Namely, age (personal factor) is key to enabling greater understanding and reducing fear about menstruation. Access to menstrual health education, in this case through an SFD program designed for adolescent girls, is a key social factor.

2) Pain and coping with menstrual symptoms

Concerns about pain

Many participant’s diary responses reflected concerns about coping with common period pain and physical symptoms: “Sometimes when (I) am on my period, I develop menstrual pain and can’t even walk,” (Participant, age 15). Questions about coping with pain were the second most common “biggest question” about the menstrual cycle (n=13 of 70, 18.6%). The topic of pain and pain relief figured widely in their stories (n=11 of 49, 22.4%, Table . The girls wanted to know more about why they felt pain and cramps, how to cope with the pain and in particular if medication was good.

Breathing and stretching for pain reduction. The final lesson of the program was about using stretching and breathing exercises to cope with menstrual pain and focus on “listening to your body.” We consider this an “embodied” approach, one that connects understanding of menstrual health concepts with how our bodies feel, move and are related to our emotional selves. Participants were taught exercises and how to pay attention to the sensations in their body (pain, relief from pan, breathing process, muscles stretching, etc.). The response to this lesson was very positive. Of the 77 responses to “how did the breathing activity and stretches make you feel?” they selected “relaxed” (n=70), “calm” (n=48), and “energized” (n=10) above all other options (stressed (n=0), tired (n=3), embarrassed (n=2), happy (n=2), fun, (n=1), and focused (n=1). On a follow up item, all 70 respondents said they would try the exercises at home. The breathing and stretching activity was also the second most popular choice of lessons that “should be taught in school” (n=58 of 78, 74.4%). However, further questions such as how often the exercises should be done and how effective they were at reducing pain were raised. Some participants felt “embarrassed” doing the exercises (n=2).

The input from all three facilitators (in their diaries) aligns with the participants’ responses. They felt the exercises were the “best part” of Lesson 4 and that it was “important to learn new ways of how to deal with the pain and how it helps through during different phases.” Unfortunately, one of the three groups was unable to do the stretching activities for the lack of a suitable room. One group facilitator reported that a number of girls did not participate in the exercises because they felt “uncomfortable” stretching during their period. It is not clear if they meant physically uncomfortable or if they felt embarrassed. Their refusal to participate is noteworthy and important in understanding their hesitation to do physical activity during menstruation. On the other hand, the fact that they shared their menstrual phase with their facilitator demonstrates an openness to discussing this taboo topic.

Discussion on pain and coping with menstrual symptoms. This topic of pain is important for several reasons, but mainly because it negatively impacts their quality of life. Studies from the United Kingdom (Tingle & Vora, 2018; Women in Sport, 2018) and Global South (Bobel, 2019) indicate that menstrual pain may contribute to bad feelings about menstruation and support harmful myths and restrictions. Specifically, they reveal that menstrual pain can be a distraction making it difficult for people who menstruate to focus or fully engage in and/or enjoy activities such as school, sport, dance, etc.

There is evidence in sport science that exercise can help to reduce cramping, stress, fatigue and improve mood (Bruinvels, et al., 2017). Although it is not possible to directly connect these activities to pain reduction, the positive response to this activity is encouraging.  Furthermore, encouraging physical activity throughout menses may dissuade people from quitting sport or skipping physical education lessons during their periods.

In relation to the CA in SFD model, we can see how pain as a personal factor, impacts their lived experience of the menstrual cycle. More specifically, we see that Lesson 4 seemed to enable more understanding of menstrual health and provided practical exercises toward their (ideal) achieved functioning of methods to cope with symptoms. Beyond the practical implications, we note that this lesson focused on how to “listen to your body.” This is an innovative, embodied approach that supports capability development (self-awareness) beyond the specific learning outcomes of the program. For menstrual health-education, this approach might be particularly well-suited for SFD programs, which use physical movement as a key aspect of learning.

3) Stigma, fear, and embarrassment

This theme was the most prevalent across the participant diaries and facilitator feedback. We have organized data from this theme into four sub-themes: Menstruation stigma, fears about leaking, activities and social engagement during periods, talking about menstruation with others.

Menstruation stigma

In our study, the participants discussed aspects of stigma, fear and embarrassment more than any other theme. It is well-documented that the secrecy, stigma and fear of embarrassment about menstruation are problems for people everywhere and lead to negative consequences.  The challenges of menstrual stigma in the Global South explored by Bobel (2019) are reflected in the data from this study, with many girls accentuating feelings of embarrassment and fear regarding menstruation. Most girls, 63.7% (n=44 of 69), “felt embarrassed” because of their periods. In one diary session (Lesson 2), participants were asked to “Tell us about the day you got your first period. Write where you were, how you felt, what you did to stay clean, etc.” Their responses (n=63) were varied and complex, reflecting the three main themes. The participants’ stories of menarche were dominated by feelings of fear, worry, and being nervous to talk about it. One passage from a 14-year-old demonstrates this quite clearly:

“Because I was scared that maybe they (family) would shout at me for telling or not telling them, I was so scared to death. How I felt that day was that I was in so much pain that I can’t explain myself on this piece of paper, right now what I can say is that managed to face my fears of not telling them. I just forgot about them shouting at me, went ahead and told my mom and sister that I have started my periods…”

She went on to describe how her family (mother, sister and aunt) had supported her.  Her fear was expressed by others, although with less intensity. In many cases (n=30), girls described how someone stepped in to tell them they were menstruating, provide a pad and/or offer comfort and explanation. As discussed above, many participants did not understand menstruation before they had their first period, which seems to contribute to confusion and fear.

Sisters, mothers, grandmothers, teachers, aunts, friends and even strangers were all helpers to these girls. Although, many girls (n=16) expressed a negative emotion such as fear, embarrassment, nervousness, sadness, etc., others were more positive, identifying excited or happy amongst their feelings (n=7). Six (n=6) of the participants had trouble understanding what was happening to them and identifying the blood as menstrual blood. Four (n=4) identified it as a painful experience. Three (n=3) were sent home from school. Three others (n=3) had not yet had their periods. Two (n=2) discovered they were leaking during a sport or physical activity session.

The stories below explain their experience more vividly than numbers: “…I was scared and I kept it to myself to avoid embarrassment,” (Age 15), “I was at school first time I started and I was very scared, I then told my teacher as she told me to go home and clean myself,” (Age 14). Other participants stated:

“The day I got my first period was very happy day and nervous at the same time happy because I felt mature and I become a lady or woman nervous because I didn’t know much about it my friend at school taught me how to stay clean and use a pad,” (Age 14)

“I was on a bus going to school then …one of the women I was with on that bus saw that I made my uniform dirty then she called me back and gave me a pad and a chittenge (cloth pad) and asked me to go back home I was scared because I didn’t know what happened,” (Age 13)

“I started my periods this year I did not know what it was its at school when we were playing at the ground and I was in white my one if my classmate came and told me that I had blood on my shorts, she told me to go and see the teacher I went the teacher gave me something to cover myself with I went home and told mom who later called my Grandmother. Grandmother talked to me on how a girl need to take care of herself,” (Age 12)

“When I started I did not tell anyone about it I stayed for two days without me telling but when I saw the blood was not stopping I told my sister about (it) who then she give a pad and told me that I have become a big girl and that is what big (girls) do,” (Age 14).

“My first period was at home when I saw the blood I felt happy about them coming I went to the bathroom after that I got a pad from my sister and she showed me how to put it,” (Age 16).

In the final lesson, the girls were asked the following: People often think the topic of menstruation is taboo – that it is a secret we shouldn’t talk about. Do you agree or disagree? Why?. We later recognized that the disagree/agree option may have been confusing, and therefore did not analyze which box they ticked. However, their written responses were much clearer and we were able to code and analyze all of them. The majority of participants (n=29 of 45, 64%) clearly indicated that menstruation should not be taboo in their written responses.  Of those participants, twenty-two (n=22) wrote that menstruation should be talked about so that people can learn about their bodies, growing up and how to manage their menstrual blood.  A 16 year-old participant said “…when we keep it a secret, no one will help you.” Other responses that supported talking about menstruation included:

“All girls and boys should learn about menstruation so that they can understand.” (Age 14), “…the more we talk about it the more we learn about menstruation.” (Age 14), “… we need to share so that others may learn.” (Age 15), and “… we need to teach our friends about what we have learnt.” (Age 15).

By contrast, five (n=5 of 45, 11%) participants wrote that it was a taboo topic and should be kept secret. Their responses included; “Because if you tell others you will even tell wrong people” (Age 14), “…because it is so embarrassing to girls” (Age 13), and “…it is a secret we should not talk about” (Age 14). Clearly, many participants felt that the taboo should be broken because it was preventing people from learning more about menstruation. Some of the responses were neutral (e.g. “I don’t know”).

Fears about leaking

Many of the menarche stories included discussions about leaking. In many cases, someone noticed a stain on their clothing and offered help (e.g. got them a pad, told them to go home from school, etc.). Most girls had had a leak on their clothes (85.7%, n=60 of 70), worried about leaking (90.1%, n=64 of 71) and felt embarrassed to change menstrual products at school (75.7%, n=56 of 74). Many had been teased by boys (49.3%, n=34 of 69) and others had noted that both boys and girls tease others about their periods (more boys than girls).

Throughout the lessons, fear about leaking or being discovered were common stories. Amongst their open-ended stories, eight (8) of the 49 responses were about concerns of leaking or being revealed publicly revealed to be menstruating. One 12 year-old shared a story about her friend being teased and asked how to cope with the situation: “One of my friends her periods started and everyone started making fun of her, how can one deal with such situation?”  These stories and their questions reflect the larger problem of stigma and shame surrounding menstruation. Although menstrual health education programs, like the present project, do not address larger social and environmental factors from the CA model that maintain the menstrual taboo, they may be valuable in supporting girls at a personal and micro-social level.

Activities and social engagement during periods

Lessons 2 and 4 included questions about participation and engagement in a variety of school and social activities. In one section (Lesson 2), participants were asked “because of your period, have you ever …” followed by a list of items (Table 2). Most girls (n=43 of 72, 59.7%) reported staying home from school and 39 of 73 (53.4%) avoided standing in front of their classes. They were more likely to skip PE class or sport events than any other activity (n=51 of 72, 70.8%). Twenty seven of 73 quit their sport entirely because of their period (37%). Most girls also skipped other social activities (n=45 of 69, 65.2%) and most had felt embarrassed (n=44 of 69, 63.8%). Clearly, menstrual periods are a significant influence on their decisions to attend and engage in sport, school, and social activities.

Table 2 – Participant responses to diary question about coping with menstruation

A person’s interest and willingness to engage in social activities, school or sport may be influenced by many factors. It is possible pain, discomfort or fatigue were just as or more influential than stigma or fear of leaking. However, this research highlights that their first period stories were about leaking and feeling embarrassed or leaving school/activities to go clean themselves and nearly all the participants worried about leaking at school or in public (n=64 of 71, 90.1%). Other issues relating to girls’ dignity and prevention of embarrassment, such as lack of adequate space with privacy for changing and washing as well as unsuitable clothing may be barriers to participation in sport and PE. It is not uncommon for girls to play sport and physical activity in their uniforms, often skirts or dresses. Therefore, certain activities that involved extensive mobility may be considered risky depending on the menstrual products available.

Talking about menstruation with others

The taboo that surrounds menstruation prevents people from openly discussing this topic. In Lesson 1, participants were asked about who they were talking to about menstruation, which gave better insight as to how they experience menstrual stigma. Most girls relied on older female family members, but many girls also discussed it with friends, making peer education an interesting concept to explore. Program leaders (e.g. Goal facilitators) and teachers were also important sources. In Lesson 4, when questioned if these lessons had prompted them to talk to others about menstruation, 56 of 68 (82.4%) responded that they had spoken to someone “because of these lessons.” In a follow up question, they identified many of the same people (mother (n=11), sister (n=6), grandmother (n=2), etc., but were now much more likely to have talked to a friend (32 of 54, 59.3%). It is possible that they were talking to each other during and after these lessons.

Discussion on stigma, fear and embarrassment

Across each of the sub-themes, shame and embarrassment are woven into the girls’ feelings, knowledge, attitudes, and behaviors. Fears about leaking and reflections on how embarrassed they felt when they had their first period were vividly and frequently expressed in their diaries. These feelings about menstruation appear to be drawn from strong cultural and social norms about gender, modesty, and sexual/reproductive health. Altogether, menstrual stigma functions as an environmental (macro) conversion factor, with menstruation practices (e.g. education, school setting, etc.) functioning at a social (meso, micro) level in the CA model.  For example, menstrual stigma restricts the capability development of understanding menstrual health because it hinders the participants’ willingness and opportunity to openly discuss concerns about menstruation.

Limitations and risks

There were several limitations to this research design. It was difficult to conduct this research with rural communities, as was originally planned. Many of those participants do not attend programs or school regularly enough to complete the diaries, so we did not include them in this study. Life in the rural villages is very different from the urban setting in Lusaka and having input from these participants would have brought valuable insight. Future studies should be expanded to the NOWSPAR rural Goal programs for girls who may or may not be enrolled in schools.

Secondly, with participants ranging from age 10 to 17 and enrolled in grades from 3 to 8, there were clearly vast differences in physical, emotional and mental development. Hence, it is difficult to draw nuanced conclusions from the aggregated quantitative data.  Furthermore, at least one of the questions was unclear (see above). Younger children or participants with learning disabilities may have struggled to understand all of the material. However, these data are still helpful in identifying themes and, in combination with the richer qualitative data.

Finally, as menstruation is such a taboo topic, it may have been difficult for the participants to share their thoughts and feelings openly in the diaries. Some participants may have felt too embarrassed to share their experiences openly in their diaries.