Transnational Engagement: Designing an Ideal Menstrual Health (MH) Curriculum—Stories from the Field


This transnational exchange captures the diverse voices of those working in the menstrual health field to provide insight on the current state of menstrual education. The discussions in this chapter suggest that menstrual education has moved far beyond the confines of schools, and as such, beyond the limitations of traditional models of a relatively limited, short-term intervention given only to girls in a traditional educational setting. Instead, those working in the field specify that menstruators are taught about menstrual health and menstrual decision-making outside of school, with emphases on health literacy and education through a human-rights or justice-based learning experience. These pieces explore just some of the current integrated approaches to menstrual health that draw upon new technologies, new modes of education, and new kinds of curriculum and learning.

First and foremost, the dialogues in this chapter suggest that menstrual education has moved far beyond the confines of schools, and as such, beyond the limitations of traditional models of a relatively limited, shortterm intervention given only to girls in a traditional educational setting. Instead, menstruators are taught about menstrual health and menstrual decision-making outside of school, with emphases on health literacy and education through a human-rights or justice-based learning experience. These dialogues explore just some of the integrated approaches to menstrual health that currently exist which draw upon new technologies, new modes of education, and new kinds of curriculum and learning.
With renewed attention to body literacy, menstrual health education has expanded to include more nuanced understandings of menstrual experiences paying particular attention to the connection between how education can, and does, impact health decision-making over a women or girls lifetime. In such a context, menstrual education is no longer simply focused on the need to "manage menstruation" hygienically and periodically, rather menstruation as an opportunity to increase bodily autonomy and as central to closing the gender gap. As a result, doctors work in tandem with public health officials. Community organizers work in partnership with schools. WASH actors work together with menstrual activists. The public sector works together with the private sector. These fusions and overlaps have resulted in alliances and collaborations that reflect exciting new models for social change that draw from the strengths of each of these entities while minimizing their weaknesses. For example, businesses get to innovate, while activists get to ensure access to those typically ignored or excluded. Doctors relay important health information and people in local communities have increased ownership over translating these messages to meet their needs and contexts. Most importantly, these new models of menstrual education ensure that we continue to see menstrual health as central to the ability of women and girls to exercise their human rights. We enlist the support of all genders in all parts of the world in these efforts. ShapIng the dIalogue: clue'S approach to MenStrual health educatIon -Anna Druet Clue is a menstrual health app that uses science and data to help users discover the unique patterns in their individual cycle. It reminds users about their period, PMS and fertile window.

Explain your approach and intervention toward menstrual health? How do you implement your menstrual health curriculum?
The menstrual tracking app is, above all, a tool. It allows people to create a record of their menstrual cycles and periods, to track their health and identify cycle-related patterns. It facilitates connections with others and enables individualized healthcare. These are active elements of the tool itself, however it also has a variety of equally valuable passive elements, particularly education and learning. At Clue, we aim to enable learning as people use it, resulting in topics that are often taboo to become normalized, neutral, and reframed. Our approach to menstrual health is actually quite zoomed-out from the period. The period is viewed as a gateway into the rest of the cycle. Often, people start using our app as a period tracker alone however by interacting with the app and reading content, we aim to instill in our users an understanding of their cycle as much more than just the period. Promoting body literacy is an important value for us.
I sometimes think of the period as an (easily overlooked) black box. The contents of this box can go relatively unnoticed, or adversely perceived, until something happens that triggers a person to look deeper. Maybe they've had trouble becoming pregnant, or maybe they have symptoms of a reproductive health condition. By opening it, they learn what has been sitting there all along-a fifth vital sign, a signal of health, a process that can connect a person to their body, or to others. People suddenly learn that their cycle may influence their acne, pain tolerance, headaches, or social lives. It may give them a better idea of their risk level for pregnancy if a condom breaks and they are considering emergency contraception. It may play into their muscle-building capacity and influence their workout routine. It may influence how a certain sex position feels on a given day. Learning about the cycle can go far beyond fertility and bleeding. At Clue, we have found people are surprised and excited to unleash the potential of this new information!

What makes your approach unique?
Our communication style is very important to our approach. We follow a carefully selected, ever evolving set of goals and rules to create the Clue tone and feel. Normalizing taboo topics is an overall goal, but the approach can shift from topic-to-topic. We aim to make things approachable and easily understandable, while also communicating the importance of complexity in some instances. We know that oversimplified statements about health, a research finding, treatment, or a little-understood disease, can be harmful. This approach is shaped by our research, academic collaborators, and the people who use our app. We receive hundreds of emails each month from people asking questions about their cycle, health concerns, and basic anatomy. These questions help us understand what is most concerning for people, and where gaps might be in our own materials.

How did you develop your curriculum and who did you consult?
Our menstrual curricula is designed collaboratively. We work directly with some of the world's top clinical researchers on menstrual health via our medical board and research partners. We use services like Uptodate, which incorporate new peer-reviewed research (when sufficient) into current clinical gold standards of practice. We do internal literary reviews, of varying depths, and have extensive research and fact-checking protocol to ensure rigor and accuracy.

What kind of impact have you had?
Our approach has resonated with people. Today we have over ten million active users in 190+ countries. Our app has been translated into 15 languages and counting. We have seen shifts in the questions sent to our support team as we have incorporated certain educational goals into the app and content more broadly. Our dedicated users have led to the development of an unprecedented dataset on cycles and health, which we use in collaboration with academic partners for menstrual health research. We are conscious to choose research topics that can benefit the people who give access to their (amalgamated, anonymous) data for our carefully selected research collaborations. Our website, where we publish weekly content on menstrual and reproductive health topics, gets 2 million readers each month, most of whom are coming to the site after searching for health info in a search engine. We learned that people in areas with higher gender inequality are more likely to use their mobile devices to access sexual health information.
What languages do you use and are there any tensions or conflicts about the language you use for menstrual health education? Challenges for us have been in getting language right. Our app is not currently localized, meaning the same version of the app is being used globally (translated into different languages). The base and context of knowledge varies dramatically across Clue users, as does the status of evolving language around gender and health.
In terms of language, there are also differences in opinion in where the line sits between approachability and euphemisms-fluid vs. mucus, for example. We are grateful to have so many engaged Clue-users who give us a lot of feedback and have an ongoing process where we work with consultants to help in the development of our language.
Communicating on under-researched topics and bridging the gap between diverse menstrual-health spaces can also be challenging. We support access to comprehensive, reputable healthcare services, and information for all. However emerging dialogues on women's health have also brought voice to considerable and important disciplinary gaps. These include: the impact of female physiology being left out of research; the ignoring or minimization of female pain; the dearth of satisfactory answers on how to treat common but complex disorders like Polycystic Ovary Syndrome (PCOS) or endometriosis; the arguably disproportionate under-testing of gynecological medical devices, and undervaluing of female health issues. These facts have led to an important and necessary movement and conversation around women's health. On the other hand, they have also led to the creation of some resources and services using misinformation, a lack of credible research, or entities looking to profit from desperation. For us balancing clinical understanding with new research and evolving trends can be tricky. When writing on evolving health topics, we look out for newer findings and examine the researchers conducting them, to see what recent contributions are being made to burgeoning bodies of knowledge. Sometimes this is all of what is out there. We make it clear when we share any findings which are controversial, unreplicated, or require further validation. It is surprising how much research fits into this category. All sides of these emerging conversations need to take women's health seriously enough to vet and ethically portray the information they are offering to people in vulnerable positions.

What does the future of MH education and curricula look like?
In the future, I would like to see educational initiatives that focus on the cycle overall, cycle phases, and the cycle as a health indicator tool akin to a fifth vital sign. I would like to see boys and men included in menstrual educational initiatives. Like many, I would also like to see a shift in handling of the topic of premenstrual syndrome (PMS)-the 200+ symptoms associated with an inconsistently defined syndrome cover a window of time in the cycle with several hormonal shifts, and diverse experiences. We also need more educational resources dedicated to perimenopause. Ultimately, I believe that more research into hormonal diversity, experiences around the ovulatory phase, and into positive (or perhaps not-only-negative) changes associated with the cycle would be incredibly valuable.

MenStrupedIa: MakIng perIodS Fun and acceSSIble -Carla Giacummo
Menstrupedia is a comic which acts as guide to educate people around the world on menstruation.
Explain your approach and intervention toward menstrual health? How did you implement your menstrual health curriculum? I began working on menstrual health while running Eco-Ser in 2010, an NGO which increases women's knowledge of menstrual cups as a healthy product option for women. Within this project we worked with Mooncup Ltd., to educate and distribute cups to girls in rural areas or from disadvantaged backgrounds. After interacting with hundreds of women, I realized there was a clear lack of resources to talk about periods with girls aged 9 and up in the Latin America region, as well as tools for parents and educators to generate natural and easy interaction around the menstrual cycle. When I met Aditi Gupta, the Founder of Menstrupedia India, I realized that Menstrupedia was exactly the resource I was looking for to enable my own work in Latin America. Therefore I worked to translate Menstrupedia for a Spanish-speaking audience with sensitivity to the local context.

What makes your approach unique?
Within an Indian context, girls are often in a very vulnerable situation regarding the menstrual cycle and puberty related changes. The Menstrupedia comic contents captures different experiences to address all that a girl or a boy should understand regarding this time in a very easy, clear, and funny way. I recognized that cartoons are helpful to address complex concepts which through storytelling help young people grow up with positive messages around puberty and changes in their life. Within a Latin America context, there was no material available like this. Most sexual education focuses on contraceptive methods, abortion, and biological differences. Most resources I encountered either skipped the menstrual cycle or failed to acknowledge the importance of menstruation in little girls lives. The work of Menstrupedia in India and now the Spanish translation, connects the biological impact of puberty and menstruation with the emotional, social, and psychological aspects in order to help girls on their journey to womanhood.

What kind of impact have you had?
While working on the Spanish translation, I tested the English version at the biggest ecological event in our country. At this event a variety of different projects, alternative health workshops, and ecological products are presented to the public with approximately 15,000 people in attendance. I was able to sell several of the resources immediately and realized that mothers felt an incredible sense of relief to find a tool to help them start conversations with their daughters. However, there was clearly a need, and demand, for them to be readily available in Spanish. Teachers and midwives also showed interest in using the resource in educational and clinical settings. The first edition in Spanish was available in October 2015.

How did you develop your curriculum and who did you consult?
Menstrupedia's curriculum was developed with input from health and educational experts. The content has been carefully designed and created with expert input, therefore the Spanish version duplicated the content, with minor adjustments for a Latin American context. After the first edition was produced with a positive response from Non-Government Organization's in Latin American countries (as well as Spanish speakers from across Spain, USA, and Europe) I collaborated with Daniel Goldman, CEO of Inmmentor, an expert in innovation. We both understood Menstrupedia as fundamentally an innovative educational tool, which supports an improved understanding of menstrual and reproductive health for girls in rural areas and indigenous communities in Latin America. With high rates of adolescent pregnancy in these populations we worked to increase distribution with the hope that in the long term we would see its impact on these pressing issues, among others. With strong interest from Mexico, Guatemala, Nicaragua, Colombia, Perú, Puerto Rico, Argentina, Chile, and Brazil we have worked to toward internationalization of Menstrupedia including adding several companion resources such as audiovisual, and trainers guide.
What languages do you use and are there any tensions or conflicts about the language you use for menstrual health education? While there are nuances across different Spanish-speaking countries, Menstrupedia was translated into neutral or the most common form of Spanish with minimal colloquialisms. We have found few tensions or conflicts, as the content of the book is already culturally sensitive. Regardless of a readers beliefs or context, those who use the resource are not made to feel uncomfortable.
To ensure the accuracy of the translation we worked with Dana Riensi, Spanish Teacher, Library and Educational Technology Specialists (Oregon) as well as NGO partners from Guatemala, México, and Perú. This helped to translate and implement not only the text, but the audiovisual guides.
What do you wish could be included in future curricula about menstrual health? After two years of working with different international and national organizations, as well as school teachers, social educators, and health professionals, I believe that there is a need for the development of a menstrual health workshop for adults. Menstrual health knowledge remains a gap in a variety of adult populations therefore those implementing our resources, also require capacity building regarding the importance of integrated menstruation health education. We have received many requests for further guidance beyond the audiovisual and trainers guide. This resource would need to be tailored to the needs of those working in rural areas, where populations are being affected by a broader lack of resources, hygienic products, and access to water, sanitation and hygiene. I also hope one day to be able to create a Portuguese and sign language (LSU) version of Menstrupedia What does the future of MH education and curricula look like? I believe MH education and curricula should be simple and easily accessible by all. Governments seem unaware of the importance of MH education in spite of its social, economic, and cultural impact. There is a strong need for improved puberty-related education delivered at a younger age. It will enable girls to feel more confident and help boys to understand what happens not only in their own bodies, but also those of girls. I hope to see plenty of information available that looks at the great biological and emotional changes that occur at this time.
I believe that early MH education is an opportunity for girls' interaction with their bodies and cycle. Menstrual dignity has to do with their own confidence, self-esteem, and healthy growth. However, it is also an opportunity for greater awareness and respect for human beings and their right to make decisions over the bodies and lives. We cannot express with words what we do not know. So, MH education is a great opportunity for adults and children to learn about their emotional and physical health and how they can talk about it.

Explain your approach (SRHR, WASH, gender), and intervention?
WoMena has a broad view on menstrual health including physical, mental, social, and structural aspects, which we translate into a set of intervention activities: 1. Menstrual health facility assessments to understand local logistical challenges. 2. Menstrual health training (and if we have time, SRHR training) with a comprehensive curriculum including: puberty, female anatomy, vaginal coronas, menstrual cycle, menstrual hygiene, nutrition, pain management, and methods (pros/cons, use, disinfection and storage). 3. Creating support structures for example involving parents, community members, teachers, training of trainers, health workers, and political/ local leaders in communities. 4. Educating local rights bearers on advocacy tools aimed at encouraging local duty bearers to effectively manage water and sanitation facilities. 5. Emphasizing male involvement for example fathers and male community members, male teachers, and boys in schools. 6. Monitoring the use of the products and evaluating the acceptability and following up to address the challenges in relation to the use of the product. 7. Scaling up projects by designing pilots with the next steps in mind (for example, cost-efficiency). 8. Educating at the top through national advocacy. 9. Effective knowledge management including active review of scientific literature to enable internal learning.
To do this, we employ both paid local and international staff and volunteers, which contributes to a richness of perspectives and energy to implement our programs, and achieve social impact.

What makes your approach unique?
WoMena's educational approach is unique in several ways. Our approach is context based, and our standard curriculum is usually tailored to the needs of the local population. We also use locally available materials, for easier accessibility and affordability of the menstrual management materials we distribute. We believe that when something is so new, like the menstrual cup, and knowledge is so low, you need to go into the fundamentals, personal stories, as well as a lot of honesty, to build people's trust, such as: how many holes women have, pros and cons of cups, and how difficult it is when you take out your cup the first time. Furthermore, we believe in a life-skills based educational approach. Such an approach recognizes that different people learn in different ways-therefore we like to make our trainings interactive, with lots of questions, physical props that people can touch, illustrations, energizers, learning through movement, friendly competitions and time for participant demonstrations.
We train trainers and educate many groups in the community, so that everyone feels included. We are conscious that men and communities have a role to play so that the new user has a supportive environment. We do preand post-training tests to see whether our training has had an impact and monitor how well we are doing. Last, but not least, we have also designed a whole training module with different training methods, as this is an essential part of quality training at WoMena.
WoMena's five training principles include:

What kind of impact have you had?
Our approach has had many layers of impact. The projects we support measure 75-94% uptake and 82% long-term continued use of menstrual cups among girls/women receiving our education and programming. Through our community involvement model we have seen considerable break down of taboos about menstrual health, opening up new avenues for important discussions in communities, while catalyzing change to male participants' perceptions of menstrual health (WoMena 2018a; Gade and Hytti 2017). Through our impact evaluations we know that thousands of women and girls have expressed increased feelings of freedom and comfort during their periods after starting to use the products, which research demonstrates can have a positive, trickle-down effect on girls' school performance (WoMena 2018b; Gade and Hytti 2017).
We also work at a systemic level to address menstrual equity issue including effectively advocating for the inclusion of menstrual cups in a Uganda's national menstrual hygiene management curriculum in 2018 training manual drafted by the Ministry of Education, as well as the waiver of value-added tax for menstrual cup importation. We have built the capacity of ten NGOs to deliver MHM trainings around cup-related projects. We have also partnered to develop training materials for AFRIpads, which led to us has a potential reach of 1 million girls and women. We are currently completing similar work and developing educational materials for Ruby Life. Lastly, we have built capacity and provided meaningful learning experiences for +100 volunteers from Denmark, Sweden, Iran, Finland, Uganda, US, UK, Lithuania, Germany, and Spain.

How did you develop your curriculum and who did you consult?
WoMena's training curriculum was developed in 2012 with the Red Cross and further improved upon through research and project testing in 2013 and 2014. However, our first official comprehensive curriculum was produced and implemented in 2015 based on examples from organizations working with similar environments and target groups. This included resources produced or used by the Red Cross, school readers from Uganda, Kenya, and Tanzania, menstrual cup supplier user materials, group participation materials, as well as expert materials on specific topics such as hymens from the Swedish Association for Sexuality Education. The initial draft was developed for an internal training of trainers by a group of six volunteers in consultation with actors in the field of reproductive health, such as Ruby Life, Menstrual Cup Uganda, and Reproductive Health Uganda. As a relatively new area of research and programming, we consulted with our internal volunteer Medical Advisory Team on particular topics to ensure it met the highest quality standards. We ensured our educational materials were useful in a variety of settings, so we designed the material to be user friendly and flexible, with suggestions on how the content could be tailored for different contexts.
Later updates to our main curriculum included lessons learned and questions from the field, brainstorms and curriculum development projects with partners such as AFRIpads, and updates based on new publications of relevant curriculum from the Uganda Ministry of Education and Sports. We also further developed our material on hymen and virginity with inputs from experts dedicated to this topic. Now, when we implement new projects, our training curriculum is tailored to the specific context by involving community health professionals and local leaders as part of the design process. Also, as education is not limited to training, our knowledge management team prepares FAQ sheets to answer in depth questions asked by implementers, women/girls, and community leaders on topics such as Toxic Shock Syndrome, hymens, menstrual irregularities, and infections.

What languages do you use and are there any tensions or conflicts about the language you use for menstrual health education?
Our main curriculum is in English, although we have almost finished developing a Danish curriculum for Danish contexts. We are also finalizing the translation of our training tool designed for northern Uganda humanitarian contexts into Juba Arabic. In Uganda, we have different trainers who speak various local languages. In most cases they are able to deliver the training in the local language, though we sometimes use translators to deliver our trainings. Local trainers (such as teachers or other community members) are always trained to deliver the training and are also provided with menstrual products for their personal use so they are personally familiar with how the products work. WoMena's trainers then support the local trainers in teaching beneficiaries with teachers sometimes translating the content of the training where necessary.
We rarely experience tensions related to the language we use, although people are often surprised to hear others speak so openly about menstruation and vaginas. Usually when we experience hesitancy around product use, we engage in open dialogue regarding the products (and any issues around its use) and ensure that all beneficiaries understand that uptake is totally optional.

What do you wish could be included in future curricula about menstrual health?
There is a need to increase the focus of MH education on other parts of women's bodies especially myths around hymens, vaginal coronas, and virginity. This must first focus on increased knowledge around basic female anatomy by health professionals as well as the social connotations surrounding it. All training curricula should ensure versatile activities and active participation of beneficiaries, and move toward explanations through illustrative means, rather than simply text and words. Lastly, it would greatly improve implementation to have the best training curriculums translated into different local languages.

What does the future of MH education and curricula look like?
In Uganda and many other countries, the future for MHM education is bright. For example, MHM and menstrual cups are now included in the national curriculum in Uganda. There is more advocacy work being done by implementers of MHM with government and local leaders receiving more information regarding menstrual health issues. Male involvement in MHM education is also increasing, with the participation of men and boys in educational and advocacy initiatives at the grass root levels. Last but not least, WoMena is concentrating more on low-literacy populations in its curricula development which helps us to meet the needs of the most vulnerable populations. We can't wait!

Srhr aFrIca truSt: IntegratIon and MaInStreaMIng
MenStruatIon Into health prograMMIng -Vicci Tallis

Explain your approach (SRHR, WASH, gender), and intervention?
We work with communities, regional Non-Governmental Organizations (NGOs) and activists working for universal sexual and reproductive health and rights (SRHR) focused on girls, adolescents and young women to promote inclusive, equitable systems for health. We work in communities, districts, countries, and the region, while also having a global footprint in the policy and advocacy space.
Why menstrual health? We believe MH is a major concern for adolescent girls, and young women in the ESA region who lack access to adequate materials which restricts their choices and impacts negatively on their school attendance. We believe that contributing to the improved MH of girls and young women can reduce the risk of HIV infections. Evidence suggests that a lack of access to proper water and sanitation during menstruation and using non-appropriate materials for absorbing menstrual blood, can lead to vaginal imbalances and infections which have been associated with an increased risk of acquiring HIV, human papillomavirus as well as adverse pregnancy outcomes. At the SRHR Africa trust, we see MH as core to women and girl's health more broadly.
What makes your approach unique? How did you develop your curriculum and who did you consult? Our programming around menstrual health happens in different ways: (1) #TheGirlPlan; (2) Supporting local community based organizations; and (3) Youth hubs.

#TheGirlPlan
We developed #TheGirlPlan to address the unmet needs of adolescent girls and young women and to improve the trajectory of their lives. #TheGirlPlan has six key, interlinked elements: keeping girls in safe schools, ending child marriage, addressing gender based violence, universal access to SRH services including modern contraception, comprehensive sexuality education and menstrual health.
We aim to promote adequate menstrual health through advocacy, capacity building and improvement of menstrual health facilities as critical parts of #TheGirlPlan. We have developed tools to equip learners and teachers to implement #TheGirlPlan in schools. These tools include booklets, posters and a YouTube video. The Menstrual health curriculum covers the following areas: (1) Education about girls' bodies and puberty; (2) Facilities and commodities needed for menstrual health-clean water, safe spaces et cetera; (3) Menstrual Products; and (4) Stigma and Discrimination.
As a result of this innovation, an increased number of schools now have emergency sanitary pads available and school attendance registers also report an increase of female school attendance. Girls also report that promoting menstrual hygiene has boosted their confidence and ability to participate in sports, despite having their period.

Support for organizations
Production of reusable sanitary pads is supported in three countries. SRHR Africa Trust (SAT) Zimbabwe was the pioneer, and designed and developed the reusable pad together with adolescent girls and young women through a participatory process. The reusable pad has passed scientific tests of the Standards Association of Zimbabwe which checked for the safety of materials used and microbiological activity after use, washing and drying. Since then, Chiedza and SAT Zimbabwe have become part of the technical committee of the Standard Association of Zimbabwe.
It is important to support community partners with the provision of materials for making reusable sanitary pads in rural areas where levels of poverty contribute to a lack of access to menstrual products including pads. In Malawi, organizations have created mothers groups and identified male champions to create an enabling environment for menstrual health. These groups are usually comprised of mothers, fathers, sisters and brothers of the girls who access the pads. Community based organizations are also involved in raising awareness regarding menstrual health through creative means. For example, Chiedza, our partner in Zimbabwe who is based in Manicaland, works with young people to express their menstrual concerns through drama, dance and music which provides a platform for young people to discuss different issues they encounter and create community-based solutions in response.

Youth Hubs
We develop programs for and with youth, paying particular attention to their voices and experiences. We are focused on growing, nurturing and supporting advocates across the continent in SRHR among the variety of projects and programs that SRHR Africa Trust runs. The primary purpose of our Youth Hubs is to bring together like-minded youth activists to convene, network and collaborate around SRHR advocacy issues in the region. The Hubs operate in Botswana, Malawi, Zambia and Zimbabwe. However, we also understand the need to include all youth and have virtual Hubs which attract young leaders from across the continent including Madagascar, South Sudan and Tanzania. Our Hubs carry out large-scale, out-of-the box thinking initiatives around SRHR and menstrual health issues. As they have grown and evolved their continued impact is seen at the grassroots level as well as in public policy as they advocate for change with their local governments.

What kind of impact have you had?
Young activists from the hubs have lobbied for increased and improved efforts of government and stakeholders to ensure that young girls have clean and safe toilets and washrooms with access to a range of menstrual products. Youth hubs have also engaged in media advocacy to address taboos associated with menstruation and starting conversations that de-mystify menstruation.
These conversations are driven by young people-whether they focus on advocacy around reducing sanitary pad tax, the implementation of hygienic washrooms in primary and secondary schools, inclusion of personal menstrual hygiene discussions in schools, or opening up discussions on the menstrual cycle to include management of menstrual cramps and the myths that the society creates pertaining to the management of menstrual cramps.

What languages do you use and are there any tensions or conflicts about the language you use for menstrual health education?
In most countries, the target audience determines our choice of language. Often discussions are held in multiple languages. Our materials are initially developed in English and then translated into local languages if needed with all materials tested in each country we work in. We also try and encourage discussions across the Southern African region-building regional movements that reflect the diverse voices of young people who demand improved information and services.

What do you wish could be included in future curricula about menstrual health?
The Youth Hubs play an active role in Menstrual Health day where we have adopted an inclusive, leave no-one behind approach. We actively work to reach out to, and raise issues affecting those often left behind-such as prisoners, women living with HIV, trans communities and refugees. We believe they are important to conversations around menstrual health and hope to see them included more in the future of menstrual health programming.
the cup: educatIon WIth a SpecIal FocuS on the boy Methodology

-Steve Nganga Wambui, Camilla Wirseen
The Cup Foundation is a California based non-profit organization founded in 2015 with a mission to empower underprivileged girls worldwide by providing them with sustainable menstrual cups and comprehensive education on sexuality and reproductive rights.
The Cup runs a community empowerment program where underprivileged girls and their needs are at the center. The program is called The Cup Program and targets girls, boys, parents, teachers, elders and informal leaders. Girls are provided with three educational sessions and a menstrual cup while the boys are trained over the course of two sessions. The trainings usually take place in school settings with a focus on the trainers building a relationship with young people through role modelling. Teachers at the school are not allowed to participate in the trainings as they often have a complicated relationship with youths. It is instead young men and women who come from similar backgrounds who are facilitators. Our facilitators are often individuals who will have an easier time to connect with youths and who are able to provide an intimate and safe space.

Explain your approach (SRHR, WASH, gender), and intervention?
The Cup believes there are three core issues facing adolescent girls growing up in challenging environments; poverty, cultural taboos around sex and menstruation, and gender inequality that often are inbedded in their culture. These challenges leave girls alone and with many gaps in basic knowledge putting them at risk for a variety of issues such as: teenage pregnancy, HIV, school dropout, sexual abuse, health infections, unsafe abortions, and low self-esteem. The Cup has developed a holistic manual which has a strong human rights perspective that targets many of the aforementioned challenges facing girls.
We believe that the only way to break down menstrual and sex related taboos taboo is by talking and including boys and men in the conversations around menstruation in order to break the stigma surrounding the issue. Closing girls off into one room and only educating them about menstruation will not challenge cultural taboos which are ingrained in society. During our boy focused sessions, the trainers engage in conversations about puberty and menstruation. We examine how reproduction is a natural part of human development with menstruation as natural, healthy and a normal part of girls and women's lives. We have found that boys are usually very curious, not shy and ask many questions.
We work toward building empathy and greater understanding among boys regarding period pain, discomfort, lack of solutions, leakages, shame, transactional sex, relationships, and parenting. We touch upon other important issues such as human rights, sex education, gender roles, hygiene, abuse, and HIV. We focus on empowering boys to be important allies to the women in their lives as brothers, boyfriends, husbands, and fathers. The boy curriculum also targets challenges that are specific to boys own development and other issues such as drugs and crime.

What makes your approach unique?
The Cup Life Education Program is unique because it provides comprehensive education to adolescent boys and girls that goes beyond menstruation in order to tackle challenges that arise from cultural taboos and gender inequality more broadly. The program does not only have a comprehensive curriculum but is also holistic in its nature by including; informational meetings with the parents, teachers, and elders; a youth helpline to provide long-term support; and the links to access medical services and counseling sessions if needed. Our trainers play an important role within our educational program and are trained to communicate sensitively regarding these complex subjects and perform peer counseling. They are often selected based on their similar backgrounds and experiences as the youths they educate which improves the efficacy of the trainings. The manual and methodology is developed so it can be adapted to a variety of cultural contexts.

What kind of impact have you had?
The Cup has trained 20,000 girls and over 10,000 boys in Nairobi slums as well as other parts of Kenya since 2015. The decision to include boys in the training was seen as a necessary step to reach a healthier social environment among girls and boys and a way to challenge gender inequality. The cup has a general user acceptance of 80% and girls who are users express that they feel more comfortable, happy, relaxed and are able to concentrate in school. The female trainers are almost in every session able to identify girls who are in need of counseling or medical attention and the team supports them to get help whenever they can. We have also found that starting a conversation with the menstrual cup makes it is easier to speak about taboo topics that are usually avoided as the cup helps with entering into difficult conversations with parents, teachers, and elders. Lastly, the number of girls missing classes due to lack of proper menstrual solution has gone down with the introduction of menstrual cup program in our intervention areas.
What languages do you use and are there any tensions or conflicts about the language you use for menstrual health education? Our trainers usually use Swahili and English depending on the context. However, they often make a point of talking the local slang called 'sheng' which makes the boys and girls feel relaxed and at home. The trainers are often dressed in a casual and relatable manner with jeans and sneakers. This casual dress code and use of local language helps to encourage the youths and create a safe space.

How did you develop curriculum and whom did you consult?
The Founder of the Cup, Camilla Wirseen, developed the curriculum after having read several health manuals and books on different topics aimed at youths from different origins and after having worked in the field in Kibera for over 8 years with Peepoople, a sanitation solution of which she is the co-founder. Most ideas for the methodology came from interviewing the trainers and women who grew up in similar environments to identify the key relevant problems facing different groups as well as reading and analyzing the many anonymous questions that have been gathered since start of program from the girls and boys that have participated in the program. The manual was developed over a one-year period and is regularly revised and updated to reflect any new learning from the field. The curriculum is leaning on the International technical guidance on sexuality education by UNESCO.

What do you think could be included in future curriculum about menstrual health?
We believe that in the future most menstrual health curriculums and programs will become more holistic as menstruation cannot be separated from sexuality education. We see menstrual knowledge as central to health more broadly. For example, a lack of period is one of the signs of pregnancy. By only giving girls a basic menstrual education and solution, girls are left vulnerable to HIV and teenage pregnancy. Comprehensive and holistic menstrual health education can help to combat these related issues. At The Cup, we hope to men and boys as a central part of the menstrual conversation, and their involvement as key tackling taboos.

What does the future of menstrual education and curriculum look like?
As the founder of The Cup my hope for the future is that all adolescents, whether rich or poor, male or female will be reached with similar programs that provide comprehensive sexuality education with a human rights approach where the MHM is only one of the topics. I would also like to see programs that could be connected to health clinics so children and parents also have access to health care services in their communities. I don't believe that teachers are best equipped to talk to youths about such sensitive subjects wherever they are. Communication and trust is key in this regard. Much like people who are in need of counseling, require support from someone outside their circle and environment where there is no dependency, power relationship, or risk of abuse. I hope all young people have access to networks who can support them through puberty. Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/ by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made. The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.