Sanitary Care and Girls’ Education

Study of Eco-Friendly Sanitary Options

Jim photographed these lovely girls in Uganda.

November 21, 2013

This week, we are announcing the results of a study completed in Uganda that investigated the acceptability of three cloth pads, a papyrus pad, and an individual-level incinerator. The study was conducted over a five month period in a large secondary school and two primary schools, all in a mountainous rural area. The aim was to determine the pads’ acceptability among school girls, as compared to commercially-available disposable pads, and to see whether they would use a purpose-built, individual level incinerator that could be attached to the toilet stall.

The couple who produce AFRIpads (on left, Paul Grinvalds and Sophia Klumpp) won a prize for their efforts in Paris last summer.

On the basis of the study in the primary schools, we decided to use a cloth pad, called AFRIpads, in the larger, randomized controlled trial we now are running elsewhere in Uganda.  We made this decision with some reluctance because we did find, once again, that access to soap and clean water is a problem for girls in rural areas.  However, of all the primary girls we interviewed (n=110) in this study, only one of them had experience with sanitary pads. That’s because shops that sell disposable pads are a long distance away and most families–especially fathers–do not believe them necessary. (Please see previous reports on the gender aspects of household purchase decisions in this area:  here and here. Households regularly spend twice the cost of a month’s supply of disposable pads on the beer consumed in a single day.)

In the primary schools where we tested the cloth pads, girls very much preferred the designs we introduced to customary methods. We felt that the likelihood of getting disposable pads for these girls was small, so we decided to change our plan for the RCT and use the AFRIpad instead of disposables. It’s important to understand that the cloth designs we were testing offered significant advantages to the “found” cloth girls normally use.  Each had a plastic liner to guard against leakage, each had a secure means to fasten into underwear, and two had inserts that could be added for extra protection.  The AFRIpad is also made of soft, absorbent fleece material that releases soil easily and dries quickly.  We have issued them in the new site along with soap.

Moses Musaazi, an engineering professor at Makerere University, designed the incinerator and produces the MakaPads in the test.

In the secondary school, nearly 100% of the girls were using disposables when we arrived, despite the fact that most of them came from poor rural families. About half reported, after the trial, that they would switch to the cloth pads we provided. However, half continued to use disposables during the trial and said they would not switch, despite the expense.  We continue to feel that the advantages offered by disposables should not be dismissed easily.  And, if girls are determined to continue using disposables even when provided with free, well-designed cloth alternatives, then it is foolish not to plan accordingly. An important option is to develop businesses that produce pads using local labor and sustainable materials, such as the MakaPads we tested.

With the rising numbers of girls in schools in Uganda (because of population increase, rather than improved retention), the cost of latrine replacement is becoming an issue.  Though many secondary schools have central incinerators for burning waste, girls simply will not walk even a short distance with a used sanitary pad, then drop it into an open cage for all to see.  It just won’t happen.  So, we tested an ingenious incinerator that is attached to the wall of the toilet so the girl doesn’t have to leave the stall to dispose of her pad.  The pad falls into an enclosed space, where it can be burned, without fuel and at medical waste temperatures–within emission standards.

However, we found in this study that the girls were subject to a local taboo in which burning menstrual blood is believed to make you sterile.  So, this test did not work out, but I still think the individual incinerator is the way to go in most places.  The cost is $1,000 to install. It sounds like a lot, but latrine replacement is also costly.

These findings and more details are available in the reports.  Lina Rothman has summarized everything in three versions of different levels of detail, all amplified and clarified by the graphic design of Andrew Wicklund.  The reports are here:

A “cheat sheet” for journalists, downloadable here: SustainablePadsCheatsheet

A 7 page report for journalists wanting more detail and for policy people to distribute.  Download here:  SustainablePads7PageReport.

A longer (11 pages) report, intended for academics, practitioners of all sorts, and just generally for those who need to know more. Here: SustainablePads11PageReport

All three publications were supported by the Skoll Foundation.  The study was funded by Green Templeton College, Oxford.

Along the way, I wrote a number of blog posts explaining the set-up and the conditions of use, as well as giving details about each innovation: Makapads, the Mak 1 IncineratorAFRIpadsMwezi Pads, and KMET Pads.

Sanitary care innovation is important to the future of developing countries.  Key needs are: well-designed cloth pads that will actually work in the conditions of use, pads such as the MakaPads tested here that can be locally made from sustainable materials, and incinerators that can be used privately.  Once such technologies are developed and tested, governments and investors need to support them so that they can scale up to service a large population.

I posted a final blog telling the human story behind the study and will follow with some new work about menstrual cups.


Ghana Study (2008/2009)

My colleagues at Oxford and I have been investigating the effects that inadequate sanitary care provisions have on girls’ educational achievements in the developing world. We completed one study in Ghana in 2009, showing an improvement in attendance with free sanitary pads and puberty educaiton

We continue to lookat the relationship between menstruation and education generally, while also investigating various methods for meeting girls’ needs for sanitary care.  Importantly, we are also studying the impact of household purchasing priorities on girls’ access to adequate sanitary provisions.

There are various papers surrounding this project: the initial report, a teaching case, a Plos publication, and a working paper in review at Journal of Consumer Research.  We now have an extension of this study in the field in Uganda.  In addition, we have  undertaken further research in east Africa on environmentally friendly alternatives.  Details of that test are available in six instalments on the blog, but the results have not yet been reported.

Procter and Gamble’s Always campaign in Africa illustrates the problem menstrual care presents for schoolgirls in an upbeat way. In my travels in Africa, I have seen that many people like this spot. Watch the “Check No Stain” advertisement below: