School and Participant Information
Public schools were larger than private schools with fairly even numbers of girls and boys (See Table 1). Private schools were located within the informal settlements and served students from that community, while public schools were located 2 km or less from informal settlements and served students who lived in informal settlements as well as those who did not. Almost all of the Muslim students in this study attended public schools. In two of the three schools with FLTs, only girls in grade 6–8 were permitted to use them. All of the public schools had pour flush toilets, and two of the public schools had Fresh Life Toilets in addition to their pour flush toilets. Private schools had only one type of toilet, either fresh life, pour flush, or pit latrine.
Challenges Posed by Policy, School Infrastructure, and Social Norms
Challenges related to WASH and menstrual management varied based on whether pupils attended a public or private school, girls’ socio-economic status, and their religion. All girls lacked access to complete and accurate information about menstruation, and they faced harassment and risk of sexual assault.
Access to Pads and WASH Infrastructure Based on School Enrollment
There is a broad array of menstrual materials available in Nairobi, including menstrual cups, tampons, disposable sanitary pads, and reusable pads. However, availability of products is variable. Menstrual pads were the most prevalent menstrual material among the women and girls in this study. While many non-governmental organizations provide girls with reusable sanitary pads, including girls at one of the private schools in this study, disposable pads are still far more popular and convenient for girls at school. Girls in this study said that they use disposable menstrual pads, and in an emergency, they use toilet paper if it is available. None of the participants in this study said that they use reusable pads at school. Any mention of pads in this article refers to disposable sanitary pads. Girls in public schools had greater access to pads and WASH facilities. Access largely determined whether girls stayed in school all day during menstruation and how comfortable they felt managing menstruation at school.
The Sanitary Towels Programme Provides Pad Access, but Not for All Girls
Only girls in public schools could expect to receive pads from their teachers when they asked. Public schools were part of the Sanitary Towels Programme sponsored by the Kenyan government. The program, focused on schools in arid parts of the country and in informal settlements, has two primary components: (1) provision of one package of disposable menstrual pads per menstruating girl per month (10 pads, the amount that women and girls typically use during their period), and training for teachers so that they can discuss menstruation with their students appropriately and accurately. When a teacher attends the government sponsored training, their school is eligible to receive menstrual pads for all of the menstruating girls in their school. At private schools, where the program did not apply, girls more frequently reported menstrual stains and missed school than girls in public schools because they lacked money to purchase menstrual pads. While some families could afford to provide disposable pads, girls in every private school discussed their inability to purchase pads as often as they needed. Participants said that non-governmental organizations sometimes donated pads, but the timing was unpredictable, and the quantity was only sufficient for 1 month or less. Consequently, girls in private schools more often expressed fear and anxiety about staining their clothes.
If she [the teacher] sees you, that you have messed bad, she will tell you to go home and shower and wear a pad…[but] you could go home and find no one in the house and then you cannot come back to school because of the sanitary pads. So there are some lessons that you could miss that day.
(FGD, School 1, Private)
Girls had inequitable access to pads even in public schools where they were provided by the government because not all girls felt comfortable requesting them. Additionally, supplies were not consistently available, and no standards existed to identify girls in greatest need. Participants in focus groups said that they were able to access pads, but that some of their peers lacked the confidence to ask their teacher for pads. Public school teachers described rationing the pads by only giving girls half of the number they might typically need because they did not have enough to give to each girl for the duration of her period. They reported that it had been almost a year since the last pad disbursement, and they were not sure when or if the government would distribute more pads. They did not have an objective way to identify needy students, so they distributed based on their knowledge, potentially overlooking some girls in need.
Now, we are fearing to give them a whole packet. Even now if they come, I give them maybe 4. And those ones who are coming from the slums, they are the ones I give a whole packet. Because those ones, will stay home until the period is over.
(Teacher, School 5, Public)
Access to school WASH facilities improves girls’ ability to manage menstruation
Girls in five of the six schools had limited access to WASH facilities they needed. The public schools we visited had one water point per toilet block as per the national standards ; however, the pupil to water point ratio was over twice the ratio in private schools compared to public schools (509:1 public, 232:1 private). The pupil to water point ratio contributed to long lines for handwashing, and participants in one public school reported bullying from older girls in line. Only one school had a private space with access to running water because a former student donated sinks. At that specific public school, girls could ask permission to use the teacher’s toilet block, which had running water, so they could wash their stained clothes or body parts. Girls in this school also had access to extra uniforms if their clothes were stained badly. In every other public and private school, girls went home to take care of stains.
High pupil to latrine ratios at private schools were an obstacle for girls (27:1 public, 88:1 private). Girls in every school felt rushed using the facilities to some degree; however, girls in public school, where the latrine ratio was lower, were less concerned than private school girls. Girls in private school said they felt rushed to finish changing their pads, and they sometimes waited until they could go home.
Participants from both public and private schools were concerned about disposal. FLTs have disposal bins within the stall, so girls in FLT schools (2 public, 1 private) were satisfied. The two private schools without FLTs had either a pit latrine or pour flush toilets. At both places, girls said that they kept their used pads in their pockets instead of putting them in the public trash pile because they did not want others to know they were menstruating. This practice came with other worries:
Since the pad box is not there, if you put the pad in your pocket it may start smelling or it may fall down and you'll get embarrassed and ashamed.
(FGD, School 2, Private)
In traditional toilets at public schools, disposal bins were in one or two toilet stalls. Sometimes girls threw their used pads on the floor if they could not wait for a stall with a disposal bin, scaring younger children who would urinate or defecate on the floor to avoid going near the used pad. At one school, the janitor refused to clean the toilets when girls threw their pads on the floor; his frustration caused fear and stress for girls.
He is always angry. If he is cleaning and you go there, you'll make him even more angry.
Even you can be beaten.
If you just go to fetch water to drink it, you can be beaten.
(FGD, School 6, Public School)
This janitor also locked the door after he had finished cleaning, preventing girls from accessing the toilets. When this happened, girls would have to wait to use the toilet until a regularly scheduled break time, which occurred halfway through the morning classes, at lunch time, or halfway through the afternoon classes. Alternatively, girls could find a teacher to ask the janitor to unlock the door; however, this was particularly problematic for girls who were too shy to talk to their teachers.
Inequitable Access Based on Religious Practice
Girls experienced inequity when they practiced ablution. The majority of Muslim students in the study attended public schools—only one participant identified as Muslim at the private schools. During focus groups, Muslim girls said that not all classrooms had bottles for girls to carry water for ablution. When they asked teachers to borrow a bottle from another classroom, the teacher sometimes refused. Girls noted that some teachers would say that the classroom did not have bottles, although the bottle was in sight. Girls described feeling angry and frustrated when this happened. Muslim girls in public schools (which had higher pupil to water point ratios in our sample) described frustration with access to water points. They said that lines were often very long. This was particularly troublesome because they needed to get water before and after using the toilet.
Participants referred to the FLTs as the “Christian toilets” because Muslim students were unable to use them. FLT urine containers were too small and girls were not allowed to perform ablution in them. Instead, Muslim girls used older flush toilets with no functional water supply. A janitor flushed the toilets two or three times per day, so they were far dirtier and rarely had private disposal bins or locks on doors. Three stalls out of eight at one public school were designated as “Muslim toilets,” although Muslims made up the majority of the student body. Those toilets had more feces and urine on the ground, creating further inequity.
Challenges to Managing Menstruation at School for All Girls
Girls Do Not Receive Complete Information about Menstruation
Girls at all schools experienced challenges accessing complete and accurate information about menstruation. Teachers at every school said they taught girls about menstruation beginning in grade six or after they reached menarche. Those who reached menarche prior to grade six received no prior information. Girls reported that teachers explained how to wear a sanitary pad and how to clean their bodies during menstruation, coupled with warnings about not getting pregnant and/or not getting raped. Consequently, girls were confused about the relationship between sex, rape, pregnancy, and menstruation.
[The teacher says] You stop playing with boys on your period.
On your period, you can get pregnant.
(FGD, School 3, Private)
When someone is continuing with the period and is raped is there any chance to get pregnant?
(AQS, School 4, Public School)
Girls in every school had fear and anxiety about getting infections. They worried about negative health outcomes due to poor menstrual management, and they believed that “splash back” (urine splattering onto the vulva) could cause urinary tract infections, gonorrhea, or infertility—regardless of menstrual status. Girls reported that teachers said using anything but a disposable pad would cause these ailments:
[She said] our private part is just like a mouth. And if we use tissue paper [instead of a sanitary pad]... [It could get into the vagina], and you may suffer with these diseases. [You may get] the disease that cannot be cured--You may not be able to have a kid.
(FGD, School 1, Private)
Participants also said they were less able to concentrate on their school work because of fear and anxiety about menstrual accidents.
Many Girls Experience Gender-Based Harassment and Assault
Girls indicated that the onset of menstruation introduced new gendered inequities that inhibited their sense of comfort and safety at school. Harassment and assault from boys as well as the threat of rape from classmates and community members hindered the level of safety girls felt in their school.
How do boys tease?
They may say, now you're a mother.
They will say that you will have 15 babies
Or they say you are raining [hurtful slang term for menstruation].
(FGD, School 5, Public)
Girls at every school expressed fear and stress related to boys. In one school, girls stopped using the FLTs even though they were far cleaner than the flush toilets without a water supply because boys were trying to peak into the stall through vents in the doors. Girls and teachers said that boys regularly harass girls. Girls in one focus group described multiple occasions in which boys knew that a girl had a blood stain on her uniform; the boys found ways to make the girl stand up to expose the stain.
They may not let you stay in peace in class...They may take all of [your books] So that you [have to] stand up.
You stand up from your [desk] and you don’t know that you have messed [had a menstrual accident].
(FGD, School 5, Public)
Girls in this focus group also talked about trying to play soccer or run around to divert attention from menstruation. Unfortunately, half of the girls did not feel comfortable playing games because boys touched them inappropriately.
Some boys, they pretend that they're playing with you. Like, playing football. When they're playing, they come, and touch your breast. You think that's it's just a play, but they have...
We would like it to stop
We feel devastated
(FGD, School 5, Public)
While this was the only incidence in which girls discussed a specific incidence of sexual assault, girls in four of the six schools asked questions about boys touching them inappropriately or about boys raping them.
Teachers placed the onus on girls to prevent harassment. They said that girls must either ignore boys when they tease (KII, School 1, Private; KII, School 6, Public), or teachers place blame on girls by saying that teasing happens because girls are “mixed up with boys” (KII, School 2, Private).
Some participants disclosed that they had been raped, and they did not feel safe in their communities, while others were anxious about being raped.
If your father’s friend came and tell you to have sex with him, what would you do?
(AQS, School 4, Public)
Teachers told girls that they needed to be wary of boys and men once they reached menarche and that family members could be dangerous because they might misconstrue friendliness as a sexual advance.
Even hugging your brothers. You should keep away from them
If you're grown up let's say,
Even your uncle, say he has just come from Mombasa, do not run to him and hug him.
Go and greet him with hands. Say hi with words
Don't go and jump
You should not be that close to men. Even if your father has come with a male friend to the house, it is not good to go and greet him.
(FGD, School 5, Public)