Menstrual Health and Hygiene and Adolescent Pregnancy in the Rorya District: A Case Study of Two Health Education Interventions in Rural Tanzania

In 2009, I volunteered in Shirati, a rural community in the Rorya District of the Mara Region of Tanzania. Over the next several years, I made numerous visits and developed strong ties to Shirati. Through discussions with local health and education professionals I became aware of the negative consequences of insufficient menstrual health and hygiene (MHH) and adolescent pregnancy for school-aged girls. In 2019, I turned these concerns into praxis and founded the Gender Respect Project at a primary school run by a non-governmental organization called REACH Shirati. Sparked by my work experience and the professional relationships built over a decade, I started a PhD project in 2020 that developed into a case study about two health education interventions with MHH education in the Rorya District: my own Gender Respect Project and the Hygiene Programme by the Maji Safi Group. My literature review highlights the relationship between insufficient MHH and adolescent pregnancy that poses a risk to girls’ educational aspirations as well as their sexual and reproductive health. However, there is limited research about country-specific programming of educational programmes that incorporate MHH. To respond to this gap, I conducted a qualitative study in the Rorya District in Tanzania between March 2022 and December 2022. My overarching research question explores how the two education programmes focused on MHH—the Gender Respect Programme and the Hygiene Programme—address issues regarding menstrual health and hygiene of adolescent girls in the Rorya District, and to what extent they address the concerns regarding the link between MHH and adolescent pregnancy. My study raises sub-questions focused on three areas: the design and implementation of the interventions, their effect on participating adolescent girls, and possible improvements to enhance MHH education in the Rorya District. The research analyses views from participants of the programmes, staff, adolescent girls in the community who did not participate in the programmes, and MHH experts. The capability approach serves as the theoretical lens of this study. This approach focuses on human functionings and capabilities. In this study, functionings refers to adolescent girls having the in-depth knowledge needed to properly practice menstrual health and hygiene. Capabilities refers to adolescent girls possessing the ability to apply sufficient MHH and pursue their educational aspirations. The manifestation of the functionings and capabilities of adolescent girls in the Rorya District is tied to the social norms around MHH that influence the decisions the girls can make and the ambitions they can hold. Furthermore, the ability of adolescent girls to enjoy such functionings and capabilities correlates to the interplay between structure and agency. Structure is understood in terms of the social characteristics of the living environment of the adolescent girls. For my study, agency refers to the perceptions held by adolescent girls with respect to their ability to make choices regarding MHH. The capability approach provides a perspective for delving deeply into that interplay between structure and agency which gives rise to a conceptual framework connecting the three focus areas of my research questions stated above. The design and implementation of the two interventions are associated with structure, the effect is related to agency, and needed improvements are correlated with both structure and agency. The data collection, consisting of interviews and focus group discussions, included 64 individuals and paid particular attention to my positionality as the founder of the Gender Respect Project and a foreign male researcher. Awareness of the unequal power of individuals from the Global North while conducting research and working in the Global South shaped the design of my study. The interviews with adolescent girls, both participants and non-participant in the intervention programmes, were conducted by local health and education professionals from the Rorya District fluent in both Swahili and Luo. The focus group discussions with staff were primarily conducted by local collaborators, and I facilitated the interviews with the MHH experts. A co-thematic data analysis ensued in which I first identified themes based on the sub-research questions and review of transcripts and then engaged with collaborators to get feedback. Accompanying this co-thematic analysis was a multi-step approach to coding that involved creating Excel codebooks prior to analysing transcripts using MAXQDA. Returning to my overarching research question, my findings indicate that the Gender Respect Project by REACH Shirati and the Hygiene Programme by the Maji Safi Group tackle known issues regarding MHH and also indirectly address concerns regarding the link between MHH and adolescent pregnancy. As one of the first of its kind in the Rorya District, the study provides new, localized, and context-specific evidence about MHH education initiated by non-local founders but administered by local implementing partners. Evidence suggests that locally inspired holistic teaching methods and wider community engagement activities encourage participants to acquire actionable knowledge about MHH and a community that is receptive to the programmes implemented by the two interventions. Concurrently, the interventions help shift social norms. By raising awareness about MHH, the interventions reduce myths about menstruation, make menstruation less of a taboo, and lower the stigma girls face at school, at home, and in their communities. Such developments increase the sense of empowerment among participating girls as menstruation is slowly normalized among community members, including critical male members such as fathers, brothers, and male classmates. However, ongoing challenges remain at both an operational and systemic level. Participants responses indicate that teaching methods about the nature of the menstrual cycle lack clarity and need to be modified in a contextually informed manner. MHH programming needs to be led by health education professionals from the Global South who are most knowledgeable about the context. Lastly, there are three critical, interconnected issues—scalability, financing, and sustainability—that require greater attention.