Experience of girls on menstrual hygiene and health

This study explores and analyses the lived experiences and challenges faced by girl in menstrual hygiene and health during their menstruation in school. While exploring the experiences the study related to liberal feminism prospect as girls' personal experiences in menstrual hygiene and health followed the empowerment theory of three key dimensions i.e. agency, resources, and achievements, and applied phenomenological study designed. Information was collected and analyzed by transcribing the record in the native language, coding, creating themes, and interrelationships of themes. Interpretative Phenomenological Analysis (IPA). Results show that girls were able to empower, foster confidence, and change individuals and society through schools and retain them in the school education system. Better service and an enabling environment from colleagues, teachers, and family are important. This is drawn from the study that, peer education and boys’ involvement in menstrual hygiene and health issues in school education and service improvement as well as health promotion are recommended to be treated as a priority in the future.


Introduction
I have been working in my professional career in the Water Sanitation and Hygiene (WASH) sector for 6 years as a project implementer in the Sunsari districts of Nepal.I have met many adolescent girls in schools during the program implementation period.Observed many ongoing issues in schools WASH and Menstrual Hygiene and Health (MHH) which inspired me to explore and learn new knowledge about MHH in school experiences among girls as part of my study which is going to contribute to my professional career as well as with in the context of existing scholarship.I feel that still girls have knowledge gaps in Menstrual Hygiene and Health (MHH) at schools and they are still not coming to school regularly during the menstruation period.Especially in a school setting limited access to accurate information about the menstrual cycle and its management is creating challenges for girls and the existence of harmful social attitudes and taboos exist on menstruation.The study shows that 57.7% of the girls had an unsatisfactory level of understanding, 61.4% were absent from school and, 99.5% had experienced various forms of cultural constraints during the menstrual period (Khanal et al., 2022).In contrast with a study done (Khanal et al., 2022) another study shows that 89% of girls experienced certain types of constraints and marginalization in their lifetime mostly in western and mid-western regions of Nepal (Karki et al., 2017).This shows that, MHH practices of restrictions are increased which is 10% as compare to past five years.It is quite alarming and shows the further increased gaps is one of the reasons for further exploring of girls' experiences and support to generate new knowledge as a scope of this study.This means that girls really have multiple truths that they need to explore through their lived experiences and understand what those realities are and face challenges prevailing them for losing their confidence in school and facing challenges.It is important to understand why girls do not feel secure environment and confidence in front of teachers and boys' colleagues during their menstrual period.Menstrual Hygiene and Health (MHH) is a private issue in our society and family.Especially in the age of adolescence between the ages of 10-19 (Singh et al., 2019) is very crucial, and physical changes occur and need more facilitation and support.
To explore the experiences of school girls and understand their needs from the multiple reality prospect and share this research knowledge at different level i.e can be local government, school regularly with maintain menstrual hygiene and health with dignity and respect with high confidence.The school needs to create an environment for sustainable sanitation and hygiene behavior change in their educational setting to ensure girls are safe and confident and they receive dignified menstruation service in a school setting.It may help to improve their presence in school for regular study during mensuration.This research knowledge from the areas may be useful for me practically and I can contribute a chunk in making meaning through the lived experiences of girls in MHH in a school setting.
Menstrual Hygiene and Health (MHH) is extensively recognized as a public health, social, and educational issue (Sommer et al., 2016;Wilbur et al., 2021).Furthermore, The Geographical Journal of Nepal, Volume 17: 118-130, 2024 this must be realized to permit the realization of the human rights of women and girls.Hennegan et al., 2019 also highlighted that the realization of human rights is reserved by lack of provision for MHH, including the right to education.This challenging situation can arise due to insufficient infrastructure for water, sanitation, and hygiene (WASH) to facilitate menstruation both at home and in public places.
The majority of schools did not meet the national standard of student-to-toilet ratio, and hand washing ratio as well as 10 key school WASH indicators including MHH set by the Government of Nepal (WASH in School Procedural Guideline, 2019).There is different belief, in various religions, castes and ethnic groups of people in the country such as Brahmin have more restrictions as compared to another caste (Karki et al., 2017).Additionally, poor sanitation services and inaccessibility of water supply have aggravated poor menstrual hygiene among adolescent girls whereas only 28% of public schools in Nepal have sanitation i.e is separate toilet facilities for girls in school (Karki et al., 2017).With this data-based evidence, I am always curious to know the girls' lived experiences and learn more realities from the field context about MHH which is a gap in previous studies.
This study, explores the girls' experiences in schools during their menstruation period.Therefore, I analyses MHH-lived experiences among secondary school girls who are in adolescence age (10-19 yrs) to understand their personal experiences and challenges girls are facing during their menstruation period at schools and social setting.
It helps to dig out the personal experiences, self-confidence, and challenges they are experiencing.It allows us to address the research question of how secondary school girls experience on management of menstrual hygiene and health during their menstruation period.

Theoretical integration
Empowerment theory from the dimensions of resources, agency, and achievements linked with MHH experiences of school girls from the educational and philosophical aspects theorizing with this study is important as a researcher.
Here, I am trying to link this study results with multiple truths of the girls and their experience during mensuration and managing their hygiene and health.Although girls are deprived and facing many restrictions and challenges in that situation, they become self-empowered with the support of boys' colleagues, school teachers, family, and hygiene promotion activities and getting better MHH service in schools.Empowerment theory has described by many scholars of education but here I have considered Cornelia Durga Uprety: Experience of girls on menstrual hygiene and health Flora as main theorist followed her as per her theory through highlights the role of resources and community assets in empowering individuals and communities to improve their wellbeing (Aigner et al., 2001).
In this study, I wanted to describe empowerment as the development of individuals through which individuals improve their capacity to make better knowledge in their life to make better decisions with the aim of achieving preferred results in the coming days comparing the past and looking forward better though they have faced restrictions and challenges (Kabeer, 1999).Here, Kabeer has focused on three dimensions that are resources, agency, and achievements which also follow Flora's principles.Reviewing the result of this phenomenological study of school girls' experiences, I have adopted these three dimensions.These are important factors to align with as the results shown below in enhancements of girl's education through MHH service and facilities in schools as well as girls developed their confidence as empowered through child club and boys' colleague ateacher's support are key measurable and visible outcomes in this study.This theory is aligned with Indian Feminism theory and practice which is also aligned with social-liberal feminism theory (Banu, 2020).The socio-cultural contexts of Nepal and India are similar and predetermines factors are similar.

Methodology
In this study, I have applied the qualitative research method called phenomenological study to explore and understand the multiple realities of personal lived experiences of school girls on MHH.The central question of the study is, how do secondary school girls experience on management of menstrual hygiene and health (MHH) during their menstruation period?My ontology of this study is to explore multiple realities based on individual perceptions of individual lived experiences who have lived experiences on the reality of going through regular menstruation who are student from secondary school.Further, the study interpreted the experiences of respondents in order to understand the spirit of phenomena and its context.The epistemology is a multiple way of knowing on empowerment and making meaning from experiences.I developed the open-ended probing guiding research checklist based on the central research question and objective of the study.I have collected data from in-depth interviews with two girls and one theoretical sample was adopted.The interviewees were from secondary level aged between 10-19 years.They fall under the adolescence group and have personal experiences on menstrual hygiene and health.This was purposive sampling from the school.Before, selecting the research respondents, I contacted to school head teacher and MHH focal teacher and explained the purpose of the study, with their verbal consent and information, I managed to select students from class 9 and 10.During the process of the interview, established trustworthy interpersonal The Geographical Journal of Nepal, Volume 17: 118-130, 2024 relationships between students and me as I am a development worker and working in the same geographic location.
I assured both respondents, by committing I will not misuse their information and data as per the data privacy policy and relationship and provided information.Written consent was taken with individual respondents before the in-depth interview and recording of it.I was more mindful of what is the influence of my own (past and present experiences) values and beliefs in interpreting the thoughts and feelings of students (Taylor & Medina, 2013).An in-depth interview was taken in a school setting and was recorded on mobile recording system and transcribed using a manual process and computerized it in the native language.I have applied the Interpretative Phenomenological Analysis (IPA) process in my data analysis process.Once I read and analyzed the data, many subthemes were generated through the coding process and again it became the main theme and compiled the coding in subtheme and global theme.Finally, I started to write the result by making an anonymous identity as given the respondents A, and B in the text.
Theoretical sampling was adopted during this research process as school was closed for the summer vacation.Most of the students were already on leave.I have opportunity to have short verbal discussion with other girls in short time period about MHH personal experiences.That experiences also reflected as theoretical sample of this study as defined name as respondent C. Her MHH experiences are also helpful for the information saturation process of this study and reflected in the result and findings.

Results
Experiences of Adolescent Girls Regarding Menstrual Health and Hygiene Based on the collected data and its analysis has been made by following themes:

Understanding and experience of menstrual hygiene and health
Everyone has distinctive experiences in menstrual hygiene and health in relation to personal context and socio-cultural practice.As per the lived experience of girls faced many difficulties due to physical symptoms such as abdomen pain and not having pad in the school setting.Respondent A said, "In the past, if menstruation happened in schools I was shy to tell my teachers and finally spoke with Female School Teacher (FST) about the need to go home as having pain.I had to take 4 days of automatic leave and lost my class in the past but now there is an MHH service and pad available in school.I do not have to go home but can-do pad changes and dispose of and use the toilet in a school setting.Which is a good experience as compared to 4 years before?"Currently, girls are confident in managing menstrual hygiene and health in school during menstruation.

Durga Uprety: Experience of girls on menstrual hygiene and health
As compared to the past, current trends are improved.Girls are taking pad and spellout without hesitation and do not leave school during the menstruation period.Girls are unknown about first menstruation and its management.Many girls and women get scared when they have first menstruation and they were unknown about how to maintain hygiene and health care during this period.Respondent B said, "When I had first menstruation I was already 13 years old, I did not understand what menstruation was, I was having bleeding when I was in the toilet, then I became scared to tell my mother.Then I shared it with my friend.My friend suggested me to go and shared with your mother then get the pad.I was from poor family so my mother could not afford to buy pad for me.Then I used cotton cloths as a pad.I become used to wear cotton cloths and come school."Availability and accessibility of menstrual hygiene and health management materials at school support and promote girl's retention in school.

Enhancement of girl's education through MHH service and facilities
The physical facility of WASH and MHH and health care counseling support enhance regularity of girls at school.The common experiences of girls reflect that adequate water supply, separate toilets, and hand washing facility as well as regular pad supply in schools with the proper disposable system, having rest room facility and health care support with counseling from school nurse is making more better environment and it is supporting to retaining of girls in schools as they used to lose 4 days class before during menstruation.Respondent A said, "When we had menstruation in school we have a pad available, if we have pain in the abdomen nurse gives the medication and explains and we have a rest room, separate toilet pad changing, and disposable facility.If I need to take rest.I always take 10-15 min rest in the room and then attend class regularly."Similarly, respondent B also "re-emphasized the support of the MHH facilities like having pad in school with rest room, changing and disposable facility and water and clean and separate toile is providing helps girls to stay in school."Health counseling from the school health nurse and availability and functionality of WASH and MHH services in school promote to girls in attend school regularly.Similarly, respondent C also expressed that, "the current school support service of sanitary pad is very helpful for girls when they have menstruation at school.Therefore, we feel that, menstruation is not very big issue for us."These all facilities with pad changing and separate toilet allow girls to stay in school and attain regular class.MHH service in schools with school nurse have very big role in girl's education support.

Fostering self-confidence in girls
Based on the collected data and its analysis following themes were generated: The Geographical Journal of Nepal, Volume 17: 118-130, 2024

Empowerment and confidence
Health and hygiene promotion and mobilization of child and MHH club boost empowerment and confidence of girls on MHH.Teaching on MHH, having hygiene promotion sessions in schools, empowerment through child clubs and MHH clubs with speech competition program activity by external facilitation and support making girls to develop confidence while they speak about MHH and other issues.Respondent A reflected that "we openly talk with boys, and teachers about menstruation and asked pad without hesitation even with the male teacher if our FST and school nurse absent in school."Furthermore, respondent B said, "I am very confident to ask pad even with male teachers but some girls are not so I always speak up for them on behalf".She reinforced that "still not all girls are confident enough to talk about MHH they feel shy.So, boys tease and bully them but not me."Therespondent C seems very much open and confidence to expressed that, "we are confident to talk with teacher and male colleagues about menstruation and seeking pad during menstruation at school."Some girls are developing confidence and talk openly about MHH in schools with boys, male teachers, and external visitors, though not all girls.Therefore, sharing confident girls' experiences with other girls' is important, and making an enabling environment for them is equally important for all girls.

Support and enabling environment at school and family
Positive institutional environment and family support create enabling environment for girl's education through MHH of school.Family, teachers, boy colleagues and school WASH facilities, child clubs involvement, including MHH facility along with school nurse program and social and religious restriction are important for girls to get supportive and enabling environment in their school education as well as get better understanding and MHH service for having confidence among girls.In relation with boys in supporting school context respondent A said, aes] 6fx? g nhfpF 5g\ g lh:sfpF 5g\ olt;Dd eG5g\ ls h] k| jnd 5 xfdLnfO{ eg, xfdL ;Ne u5f} { , k} ;f 5} g eg] ltldx?nfO{Kof8 lsg] / NofOlbG5f} F AE .
Boy's colleagues support, teacher counseling, and family freedom are important for girls to reduce fear and develop high confidence.There is an important role in creating an enabling environment in institutional and social settings that can support girls to develop their confidence, empowerment, and better education.

Social and behavior change through family and school education
Information and knowledge sharing from the mother, having health and hygiene promotion sessions in school by the school nurse as well as external support helps to change the MHH-related behavior of girls and boys in school.Individual sharing in peer Durga Uprety: Experience of girls on menstrual hygiene and health and from senior to junior also makes some difference in making the adoption of new behavior.Respondent A said, "the boys students who attended the speech competition on MHH in school changed their behavior and they are always supportive towards female friends and don't bully anyone in schools and outside school"."She emphasizes that, again we need to organized the MHH related speech competition in school and engaged boys on it which is important to transform them.Boys who will involve in MHH program they will be supportive to reduce the challenges occur in school such as bully and teasing to girls by boys during menstruation." Continuous health promotion sessions in school and engaging boys in the MHH session and speech competition are important to make them ambassadors of MHH for change to reduce different types of challenges in school.

Challenges experienced by adolescent girls
Girls are fearful, shy, embarrassed, hesitate, and have physical and mental problems due to bully and an unfavorable school environment.Lack of understanding of mensuration as well a poor sanitation, inadequate water supply, lack of separate girls' toilets, and lack of MHH facilities in school are other challenges for girls to stay in schools during menstruation which impacts the girls' education and their agency.Respondent A reflected that "she felt fear during her first menstruation as did not have any understanding of menstruation and its management."Whereas Respondent B said about Physical problem, "I have had pain abdomen during menstruation and was scared to come school with my physical condition before."Similar with respondent A, respondent C also fear experiences at first menstruation.
Many girls don't do any mental and physical preparation during the first menstruation so they get scared, have mental stress, and absent from school, and are bullied by colleagues

Discussion
Availability and accessibility of MHH management and materials play fundamental role in supporting and promoting girl's retention in school.I have observed that, the school I visited have managed the MHH room, sanitary pad as well availability of water and separate toilet are opportunity to make better understanding on MHH among students and teachers.This always supports to develope girl's agency as linking with dimension of empowerment theory mentioned in theoretical integration.In contrast with it positive outcomes of the MHH facilities, if there is poor sanitation services and inaccessibility The Geographical Journal of Nepal, Volume 17: 118-130, 2024 of water supply that worsely effect in menstrual hygiene and health among adolescent girls (Karki et al., 2017).
Provision of MHH service in school, particularly with school nurse plays a vital role in supporting girl's education.Having the school nurse program initiatives plays an important role in schools as the students benefit from the nurse to get a better understanding of MHH and health and hygiene promotion education.Collaboration with school nurses and proper mobilization of technical resources in school settings help to benefit the girls and other children in school.This shows the integration of resources dimension for getting girls a better life, retaining education, and developing their agency.
Girls are able to speak confidently about MHH even in front of boys, teachers, and family, not all girls.Retention of girls' confidence is quite important as the agency needs to retain and sustain continuously which helps to develop full potentiality in girls in the future and is linked with the empowerment theory dimension.Cultural restrictions are big barriers that deprive the full potential of girls in the context of Nepal (Mukherjee et al., 2020).
Creating an enabling environment within both institutional and social, family settings plays an essential role in empowering girls, boosting their confidence, and ultimately enhancing their educational opportunities.I fully do agree with these findings as I have seen this practically in many contexts and environments.Similarly, the writer (Maton, 2008) also agreed with this idea by mentioning empowering individuals in the community from the social setting work for social change as key knowledge in his paper.
Boys' engagement in MHH is helping to transform the socio-cultural change as a change agent and sustainable change in society.I agreed with it, boys and men engagement make more difference in making many decisions as well as cultural and social change process.Similarly, the symposium paper on MHH highlighted the importance of involving boys and men in MHH-related activities was widely emphasized (UNFPA et al., 2020).Men can make a difference in socio-cultural issues and support on decisionmaking to women if they are mobilized as champions or ambassadors.
Pre-menarche preparation is missing in Nepali society;therefore, girls have many mental, physical, social, and institutional challenges in the early stage of menstruation with poor hygiene management.This is quite important to understand and promote in Nepali culture and society.In my opinion, peer education of girls and boys in MHH in secondary school education is important which helps to develop the confidence and Durga Uprety: Experience of girls on menstrual hygiene and health agency of girls.Similarly, a quantitative study done by (Bari et al., 2023) shows that there is a positive impact of peer group education to reduce premenstrual anxiety at the high school level

Strengths and limitations of the study
As I am female and know on the WASH and health sectors with familiar face, girls allowed me to take information collection easily and smoothly and girls were very happy to share their experiences with me is my one of the strengths I felt this during the information collection process.However, to explore the girls lived experiences may made stronger evidence by having some additional information collection with school MHH focal teachers, nurse and local government education focal person.It may have added more strength in this study outcomes and able to explore additional prospective of the MHH knowledge and experiences.Learning from this small-scale study, I will keep those reflection in mind for my future scope of study.

Conclusion and recommendation
Menstrual Hygiene and Health are important socio-cultural, human rights and dignityrelated issue for adolescence age school girls.Exploring the girl's experiences underpin with empowerment theory.The analysis of school girls lived experiences and challenges they are facing is main aim of this study.In line with the research question and aim of the study, results are highlighted on understanding and experience of menstrual hygiene and health, enhancement of girls' education through MHH service and facilities, fostering girl's confidence through empowerment and confidence, support and enabling environment at school and family, social and behavior change through family and school education and challenges experienced by adolescent girls are key result reflected from the live experiences.
The overall result and discussions linked with empowerment theory shows that empowerment key dimensions of agency, resources, and achievements are equally important in girls' life to empower, confidence, and change society through schools and retain them in the school education system with the support of colleagues, teachers, and family.This is clearly drawn from the study along with the importance of peer education and boys' involvement in the MHH issues in school education are recommended to treat likewise.

Authors self-reflections
As a beginner of qualitative researcher, I felt that I was able to learn about the methodology of phenomenological study and some techniques and ideas of taking interviews as well as information on analysis process.At the beginning of my work I was so worried and overwhelm about theorization and linked of it with results of the study.However, I try to The Geographical Journal of Nepal, Volume 17: 118-130, 2024 make myself very simple way by using the observed reality related theory in my study.With this simplicity and simplification process, I found and learn small initiation can make big contribution in learning with high morale and commitment.