Menstrual Hygiene Management in School Setting in Two Secondary Schools in the Bamako District, Case of the School “La Chaine Grise” and the School Cheick Modibo Diarra

This study on Menstrual Hygiene Management (MHM) was carried out in two secondary schools in the Bamako district, “Chaine Grise” and “Cheick Modibo Diarra” located respectively on the right bank and the left bank depending on the geographic position of the Niger river. This work took place over a period of 6 months from January 2019 to June 2019. The objective of this study was to study menstrual hygiene management in school setting for girls aged 16 to 18 in two secondary schools in Bamako. It was a transversal and qualitative description. The study population consists of girls aged 16 to 18 years enrolled in one of the selected secondary schools. At the end of this study, we arrived at the following results: *50% of the girls in our study have poor knowledge about we conclude that, in our context, menstruation remains a taboo and shameful subject for girls. In addition, some of their menstrual hygiene practices are a real danger to their health.


Introduction
Menstrual Hygiene Management (MHM) concerns all the strategies set up for women during menstrual periods to stay clean and healthy during menstruation. Menstrual hygiene is an important part of basic hygiene, sanitation and reproductive hygiene to which every woman and girl are entitled. It is fundamental to the health, dignity and well-being of women and girls [1] [2]. It indeed requires that women and adolescent girls use clean material to absorb or collect menstrual blood, that they can change in privacy and as often as necessary for the entire duration of the menstrual cycle, with soap and water to wash as needed, and have access to adequate and safe infrastructure. They understand the basic facts of the menstrual cycle and how to manage it with dignity and without feeling embarrassed or afraid [1] [2] [3]. Menstruation affects girls' participation and performance in school. The majority of girls were shy or stressed at school during menstruation and participated less because of shame, fatigue or pain [4] [5].
The education and training of girls have helped improve the quality of human resources. They have made it possible to eliminate socio-cultural practices unfavorable to women, to predispose girls to behavioral changes and to increase their support for development ambitions [6]. Although menstruation is part and parcel of human life, talking about it remains taboo in societies in Mali, even greater than talking about defecation. Thus, the populations-men and women, girls and boys-lack understanding of the subject out of ignorance. Despite the lack of reliable figures for Mali, expert sources agree that many girls drop out of school or miss school at their first period due to a lack of appropriate sanitation [2]. Analysis of this situation has shown a causal link between the occurrence of menstruation and the absenteeism or girls' dropping out of school, hence an increased need to intervene for the improvement of MHM in secondary schools in Bamako. As a matter of fact, this study aims to identify the obstacles linked to menstrual hygiene management and the impact of menstruation on school. It will sum up the recommendations made by girls for better menstrual hygiene management in secondary schools. We chose these two secondary schools in the Bamako district, one on the right bank of the Niger River and the other on the left bank because they receive students from the public and private sectors. The other public and private schools were on strike during the study period. These two secondary schools were functional during the period of our study, and the school authorities of these two schools were also willing to accept us. The informed consent of the students in these two secondary schools for the investigation was favorable. The objective of this work was to study the management of menstrual hygiene in the school setting of Bamako.

Study Setting
This study was conducted in two secondary schools in the Bamako district: "La Chaine Grise" school and the "Cheick Modibo Diarra" school located respectively on the right bank and the left bank of the Niger River.

Type and Period of Study
This was a descriptive cross-sectional and qualitative study on the management of menstrual hygiene in girls aged 16 to 18 years. The study was carried out over a six-month period, from January to June 2019.

Study Population
The study population is made up of pupils enrolled in the secondary schools of La Chaine Grise and Cheick Modibo Diarra.

Inclusion Criteria
Any girls aged 16 to 18 and who consented to participate in the study were included.

Exclusion Criteria
Were excluded from this study, Schoolgirls who did not belong to the age group indicated and those who did not wish to participate in the study.

Data Collection and Analysis
Data was collected following an interview with the students or in group discussions or questionnaires which were handed out to the students. The questions focused mainly on menstruation, menstrual hygiene, absenteeism and the various obstacles to the practice of menstrual hygiene. The questionnaire was designed as part of a master's degree in public health. It has been validated by the research director. Data were entered and analyzed with SPSS.20 software.

Ethical Aspects
Anonymity and confidentiality have been respected. The results will be made available to researchers to improve women's health.

Characteristics of Schoolgirls
This work was carried out in two schools in the city of Bamako, the school "La Chaine Grise" and the school "Cheick Modibo Diarra" located respectively on the right bank and the left bank of the Niger river, over a six-month period, from January to June 2019. These were mixed schools where girls and boys lived together.
The numbers of the two selected schools is shown in Table 1.
In these schools, according to the inclusion criteria, one hundred girls aged 16 to 18 were selected. The proportion of 16 -18-year-old schoolgirls was 12.99% of girls (100/770) and 3.96% (100/2524) of all students. The average age of the girls selected for the study was 17 years see Figure 1.

Girls' Knowledge of Menstrual Hygiene
 Access to information on menstruation and menstruation hygiene Of the 100 girls in the study sample, 50% of the girls had no real knowledge of female genital physiology and menstruation. Table 2 summarizes the knowledge of young girls on menstruation.

 Sources of information on menstruation
Looking at the sources of information on menstruation, the data are shown in Table 3.  The practice of menstruation hygiene and access to hygienic products In this context, the analysis of the data collected has shown that all the girls in the study group practiced menstrual hygiene during their menstruation to different degrees using various products depending on the resources available see Table 4.  Financial sources for the purchase of hygiene products by schoolgirls The financial sources for the acquisition of hygiene products for menstrual hygiene management are summarized in Figure 2.

Impact of Menstruation on School Attendance
Analysis of the data collected shows that one in ten girls drops out of school at the time of menstruation for various reasons expressed in Table 5.     For the 10% of girls absent from school at the time of menstruation, the reasons given to justify these repeated absences are variable. They range from pain during menstruation to the simple discomfort of having menstruation at school, to shame or fear of seeing a stain on one's clothes or an inadequate environment.

Students' Perception of Menstruation and the State of Sanitation Facilities
When students were asked about the condition of the sanitation facilities in the two schools, all stated that they were unsuitable for the practice of menstruation hygiene. The reasons given in this context vary from girl to girl. The main reasons given are as follows: -96% of girls find that the sanitary facilities are not well sanitized.
-100% of the girls mentioned the lack of toilet paper, soap and container allowing using water for the toilet constituted a real handicap. -83% of girls reported lack of privacy. The doors could not be closed tightly.
Finally, other reasons have been raised, such as frequent water cuts or even the toilet position. In addition, all the girls regret the absence of a health facility, in particular an infirmary which can advise or administer care in the event of dysmenorrhea or pain during menstruation.

Social, Cultural, Environmental and Financial Barriers
This study showed that half of the students at the time of their first period had no knowledge of genital physiology and the menstruation that results from it.
For these girls the question remained taboo for socio-cultural or religious considerations, this lack of communication was a major obstacle to the development of young girls. The study found out that 4% of girls used pieces of cloth to contain bleeding during menstruation due to a lack of financial means. It also emerged from the discussions that almost all of the study girls found the washrooms unsuitable for proper menstrual hygiene.

Methodological Approach and Limits
One hundred girls were enrolled in this study. We included all the girls aged 16 to 18 from these two secondary schools who gave their consent for this study. The criterion 16 years to 18 years was made by reasoned choice because it was adolescent girls who provided the precise information and for time and budget constraints of the study.
This study gave an overview of the difficulties encountered by schoolgirls during their menstruation. It raised many relevant questions, including ignorance of the menstrual cycle, menstruation, menstruation hygiene, reasons for school absenteeism, access to products, adequate premises and especially socio-cultural and economic factors which constituted as many obstacles to the practice of correct menstrual hygiene. We carried out a cross-sectional descrip-tive study on a sample of 100 girls. This sample could increase and concern all the girls of the two secondary schools. However, for financial and time constraints we have limited the sample to the age group of girls from 16 to 18 years old in these two secondary schools. Yet, the data received is limited due to the possibility of recall bias and underreporting [6]. Recall bias may have led girls to underestimate or overestimate menstrual absenteeism due to selective memory. For example, they may have based their responses on their most recent menstrual experience, which may have been unusually heavy. It is also likely that there has been underreporting because menstruation is a sensitive subject and taboo to discuss. The questionnaire and response options were translated orally for the girls. One of the limitations of this study is that girls may be absent from school during the survey period or may have dropped out of school for menstrual reasons.

Girls' Knowledge and Perceptions of Menstruation
Typically, menstruation for girls begins at puberty, and it returns once a month until the end of the forties or early fifties when menopause occurs. This gives an average of 3500 days of menstruation, or 10 years of each woman's life [6]. It is a normal biological process that women should know from an early age. Our study found out that half of the girls, 50% did not even know what the period was until they had it for the first time. The same context was confirmed in Burkina Fasso by Traore T et al. He found that in terms of knowledge, it emerged that the girls 'knowledge of menstruation in the various schools is not too good in general and especially it came after the girls' first experiences. In terms of hygienic menstruation management, knowledge was approximate or even often wrong. This was justified by the fact that before their first experiences, girls do not have accurate and complete information on MHM because, menstruation remained a taboo subject in society in Burkina as indeed in many other societies [3] [6]. After their first period, the subject was discussed with their friends or their mothers. These people just limited to show them how to protect themselves from boys so as not to get pregnant. In the family context, therefore, the information provided is always brief and insufficient.
In the school environment, the situation was not favorable either because menstruation was not included in the primary education curriculum. It is from the third class of high schools and colleges, so quite late that the subject is approached. Thus, for lack of information, neither the family nor the school were playing their role. We know that the lack of adequate information on this process between girls and their local community can lead to embarrassment, fear and shame or even the stress of cultural beliefs and superstition transmitted by mothers, friends, sisters or aunts. According to a study by Johnson in 2019 in South Africa, 57% of girls in school did not know what the menstrual periods were before they occurred [7]. However, the family environment should be the main source of information and knowledge about menstrual periods and menstrual hygiene in this study. Thus, 64% of girls obtained this information from their mothers, 24% from a sister and only 12% from another person. The importance of the family in the education of young girls is underlined.

Menstruation Hygiene Practice and Access to Hygienic Products
During their menstruation and the menstrual hygiene, the young student girls need sufficient drinking water, soap, cotton, diapers or sanitary towels and a safe space for washing with privacy and respect for their dignity. As noted in this study, 90% of girls use cotton, 6% use diapers or sanitary towels and 4% use pieces of cloth or fabric. If we take into account the fact that cotton would be cheaper than diapers and sanitary napkins and that in 90% of cases the sources of access to sanitary products came from mothers; we can easily understand that the majority of girls used cotton which was an appropriate material for menstrual hygiene. On the other hand, it was also noted in our study that 4% of the girls still used pieces of cloth for the practice of the management of their menses, because a bad management of the menstrual hygiene can be cause of the infections and have a negative impact on reproductive health [8].

The Impact of Menstruation on School Attendance
Menstruation is a period of permanent disruption and anxiety for the girl due to shame, stress, pain and the lack of appropriate environmental amenities. This situation created many challenges which the girl had to face with. These challenges result in reduced class participation in sporting activities, delays and absences in class. In our study during menstruation, one in ten girls or 10% preferred to stay at home rather than go to school. This figure was close to that given by UNESCO cited by Red Pride [3] [9] which estimated that one in ten adolescent girls in Africa missed school during menstruation and ended up dropping out of school. When asked about the reasons for absenteeism from school, 50% of the girls mentioned dysmenorrhea, 20% the shame or fear of having a blood leak on their clothes and for 30% the sanitary infrastructures were inadequate for practicing menstrual hygiene see Table 6. In reality, absenteeism due to menstruation is linked to a combination of several factors. According to Croft, absenteeism from school is linked to the lack of appropriate hygienic protection and dysmenorrhea which cause schoolgirls to feel unwell, if moreover, the school had no place to rest or if pain relievers are not immediately available [10]. The implications of the menstruation on girls were found in the study carried out in Burkina Faso where they used pieces of loincloth, hygienic cotton and sometimes handmade towels to manage their periods. Regardless of the type of protection used for the management of menses, some girls washed their menstrual blood in preference at home because the latrines at school were not suitable to their needs. Because of the ignorance and consequently of the control of their menstrual cycle, the girls made an overload of the underwear and clothes to avoid getting dirty at school. This method of managing menstruation had consequences on the participation of girls in school activities ranging from truancy to abandonment due to dysmenorrhea unlike boys who do not have these constraints [3]. If, however, the menstruation surprised them at school, they developed strategies to help each other by exchanging the loincloths or scarves that permit them to hide their bloodstained clothes and be able to return home discreetly. The onset of menstruation was a sensitive and difficult period for young girls. The difficulties faced by girls during this period in school are individual, societal and environmental.

Social, Cultural, Environmental and Financial Obstacles
Environmentally, WASH infrastructure for (water, latrines and handwashes) is often missing in schools in low-income countries or when present does not provide for girls an ideal service for hygienic menstruation management. The current WHO recommendation was one toilet for 25 girls and one for female staff; and a toilet plus a urinal for 50 boys, and one for male staff. In addition, WHO emphasizes in its WASH guidelines for schools that men's and women's toilets should be completely separated to ensure privacy and security [11]. In sub-Saharan Africa, few schools comply with these recommendations, observations made in the two study schools clearly show that the sanitary facilities do not integrate the specific needs of women during menstruation. Indeed, during the discussions with the girls of the schools, it emerged that; -96% of girls find the toilets inadequate.
-100% of the girls stated that the lack of toilet paper soap and container permitting to use water for the toilet constitute a real handicap. -83% of girls mention the lack of privacy. -Finally, other reasons have been raised, such as frequent water cuts or even the toilet position. On the socio-cultural level, menstruation which is an integral part of the female identity is however interpreted differently according to countries, communities, ethnic groups, religions, customs and traditions. Indeed, in many African communities, women and girls during menstruation are still often considered "dirty" or "unclean". The taboo and the silence surrounding menstruation made them an invisible problem, particularly in developing countries leading to situations of isolation and stigmatization. Either way, this taboo leads to stigma and discrimination against women in their communities. Half of the girls in this study had no information about menstruation before their menarche. For these girls the question remained taboo. Similar studies in India found that more than half of the girls had no information about menstruation before menarche Open Journal of Obstetrics and Gynecology [7].
As a result, in this state of total ignorance, the girls have the feeling of shame, fear and anxiety about the menarche rather than apprehending it as a natural process. Yet, it was an obstacle that we have to overcome. Current efforts were aimed at turning that shame or fear, or anxiety into pride, the pride of being a woman. However, knowing the menstrual cycle here refers to knowing what the menstrual cycle is and one's own menstrual cycle. In the overall sample of the study carried out in Niger by Mimche H. et al., almost half of the respondents say they know what the menstrual cycle is, however there are some variations depending on the regions of the country [12]. Today, the question seems so important to governmental and non-governmental organizations that, during an event organized by the concertation council for water supply and sanitation on the occasion of the International Day of Woman in March 2013 in Geneva, Dr Jyoti Sanghera, head of the office of economic, social and cultural rights at the Office of the United Nations High Commissioner for Human Rights, recalled that the stigma of menstruation and menstrual hygiene constituted a violation of several fundamental rights, in particular the right to human dignity, but also the right to non-discrimination, equality, physical integrity, health, privacy, as well as the right not to be subjected to inhuman or degrading treatment, to violence or to ill-treatment [9] [12] [13].

Conclusions
It is obvious that the management of menstrual hygiene in schools faces many difficulties, reflecting major obstacles to the advancement of women in Africa. These obstacles constitute major challenges to be met in order to achieve the objectives of sustainable development by the year 2030. Neglected for a long time, today the management of menstrual hygiene has become a current issue in low-income countries involving, governments, institutions, NGOs and those most affected, women. Indeed, only a synergy of actions will permit at least three Sustainable Development Goals, namely gender equality, quality education for young girls and access to water and sanitation. However, the application of the following recommendations allowed good management of menstrual hygiene: -Remove the taboo on menstruation by encouraging schoolgirls to speak out and discuss it; -Integrate the study of the menstrual cycle and menstrual hygiene in school training programs; -Create health infrastructure in schools for proper management of menstruation hygiene; -Involve the community, politicians and non-governmental organizations in actions such as the fight against taboos, the acquisition of infrastructure and hygiene products, training etc.

Conflicts of Interest
I, Dr. FANE Seydou, declares that I have no direct or indirect financial or