Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694818878376.pdf (Australia)
Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Women and girls in Asia and the Pacific, like other parts of the world, experience challenges in managing menstruation effectively and hygienical- ly.
Menstruation, a natural bodily function experienced by most women and adolescent girls each month, is often surrounded by taboos and restrictive socio-cultural practices.

1 Food restrictions, segregation from the household, myths about bringing bad luck to men and other beliefs place restrictions on women’s and girls’ daily activities and involvement in religious and social activities.2 This social stigma is compounded by poor knowledge of menstruation due to a lack of information and education.
3 Beyond the social stigma, menstruation can be difficult to manage due to the high, unmet need for affordable sanitary pads, and adequate toilets or water supply to manage menstrual bleeding hygienically and privately.

4 These challenges contribute to barriers to participation in education, work and community life.

5 Sexual and reproductive health (SRH) is a similarly taboo topic in Asia and the Pacific.
Although access to information and services differs by socioeconomic status, geographical location and country, there is an overall lack of access to information about SRH and a high, unmet need for contraception.

6 Adolescent pregnancy is a particular concern, as it is the leading cause of death and disability for young girls aged 15 to 19 years.

Unplanned pregnancy also limits education and economic opportunities for women and girls, adversely affecting their livelihoods, health and wellbeing.
7 There are distinct overlaps in the challenges – and the impact of these challenges – women and girls experience in relation to menstrual health and SRH: • Both are highly taboo and stigmatised topics; • Menstruation and pregnancy affect women and girls, yet often women and girls are disempowered to make decisions about their bodies; • Women and girls often experience fear, embarrassment and secrecy due to a lack of quality education and information; and • Girl’s education, or women’s social and economic well-being may be adversely impacted where there is a lack of strategies or projects to address the challenges of both issues.
These commonalities create an opportunity for cross-sectoral and holistic solutions; solutions that require the expertise of a range of actors, in order to bring solutions to these issues together.
4 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Purpose of this paper This paper aims to provide health and WASH actors with an overview of gaps to identify opportunities for collaboration on the issue of menstrual health and SRH.

This paper argues that collaboration will improve the overall health, wellbeing and rights of women and girls.
WaterAid in collaboration with Marie Stopes International Australia have set out to explore the question: What are the opportunities and barriers for joint action to holistically address menstrual health in Asia and the Pacific region?

The objectives of this paper are to guide action and commitment to menstrual health by Australian and regional actors by framing: 1.

The intersection between WASH, SRH, and MH programming and policy; 2.
Current experience and thinking on WASH, SRH and MH through summarizing a desk-review and key informant interviews to identify gaps, intersections and opportunities; and 3.

Recommendations and opportunities for Australian and regional actors for joint action on menstrual health.

Methodology In exploring the key question, a broad desk-based review of peer-reviewed and grey literature on menstrual health, SRH and WASH was undertaken.
Nine key informant interviews with sector actors working in WASH or SRHR, who had some experience of menstrual hygiene management, were also analysed to identify key barriers and opportunities.

A total of 43 peer reviewed articles were analyzed to identify emerging themes.
5 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 literature resources were used to frame the An additional eight grey introduction of the paper, and analysed based on relevance to the emer- gent themes, made up of publications by a range of local and international non-government organisations (NGOs) and United Nations publications.
Annex 1 provides a list of the published articles and grey literature that was included in the desk review, under key themes.

Nine key informant interviews with sector actors working in WASH or SRHR who had some experience of menstrual health were analysed.
The interviews were conducted in 2016, consisting of: • Four WASH actors, made up of: one global researcher (UK, university), two technical specialists operating at the global level (UK Internation- al NGO; UK freelancer) and one field practitioner (Timor-Leste).
• Five SRHR actors were interviewed, made up of: two global adolescent health researchers (Australia, University and America, University), two adolescent health, SRHR and family planning practitioners (Australia, International NGO’s) and one SRH field practitioner (Timor-Leste).

Participants were interviewed via phone using a questionnaire to gather information about their knowledge of both sectors, intersection of approaches and opportunities for further collaboration.
Information from the desk review and key informant interviews was analysed and grouped by key themes.

Sub-category themes were then identified under each key theme.

This thematic refinement of the data enabled gaps and opportunities to emerge from the desk review, which discussion and recommendations.
informed the Limitations It is not the intent of this paper to present a complete literature review on the topic of menstrual health in Asia and the Pacific, nor does it claim to identify all the gaps and opportunities in the intersection between menstrual health and SRH.

Rather, this paper intends to facilitate a discussion between actors in the region on opportunities to address MH and SRH cross-sectional issues.
6 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Framing of menstrual health in SRHR and WASH WASH publications largely framed menstrual health as a hygiene issue within a broader sanitation mission, such as designing girl-friendly toilets in schools.
‘Menstrual hygiene management’ (MHM) is defined as: Women and adolescent girls are using a clean menstrual management material to absorb or collect menstrual blood, that can be changed in privacy as often as necessary for the duration of a menstrual period, using soap and water for washing the body as required, and having access to facilities to dispose of used menstrual management materials.
They understand the basic facts linked to the menstrual cycle and how to manage it with dignity and without discomfort or fear.

8 By contrast the term ‘menstrual health’ encompasses menstrual hygiene management “as well as the broader systemic factors that link menstru- ation with health, well-being, gender, education, equity, empowerment, and rights”.

9 For the purposes of this paper, the term menstrual hygiene management is used to present findings.
However an outcome of this review is the recommendation for ‘menstrual health’ to be the preferred framing, as a starting point for actors to drive holistic solutions.

While most publications covering MHM did not reference SRH education or services, two critical papers highlighted the linkages between menstrual health and SRH.
A 2016 report commissioned by the Gates Foundation provides an overview of the current menstrual health global landscape, calling for menstruation to be seen as an entry point to “address sexual reproductive health, empowerment, and other critical life outcomes”.
10 A UNICEF 2016 regional synthesis report across 17 countries of MHM in schools found that “some examples exist of linkages between the education, WASH, adolescence and SRH sectors; but multiple untapped opportunities exist from improved coordination and communication across sectors, for increasing the quality and breadth of impacts”.

11 In the interviews, one field SRHR actor saw menstruation as a factor leading to unintended pregnancies, relevant to the provision of family planning services.
“… the calls we get about menstru- ation, the confusion we get from clients about menstruation and fertility … in every appointment we have with a female client we have to ask about last menstrual period and we have to provide family planning counselling that includes informa- tion about impacts and benefits of different family planning methods on the menstruation cycle, so you know it pops up in our work all the time.” “The dream would be to incorporate SRHR into puberty and menstruation discussions, but in reality we are facing so many challenges for this to happen.” 8 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Similarly, a global WASH practitioner recognized that SRH was important in their MHM work, but felt it was “challenging” because WASH teams are not equipped with resources and training to educate young people.
“The dream would be to incorporate SRHR into puberty and menstruation discussions, but in reality we are facing so many challenges for this to happen.” The desk review and is framed differently, depending on the sector.

WASH focuses on its hygienic management, while SRHR focus on issue.

Neither sector is framing it holistically.


interviews show that menstruation it as a puberty education Addressing social norms and taboos The desk review framed menstruation as an issue surrounded by social norms and taboos, such as being viewed as an illness and women and girls being ‘dirty’ or ‘unclean’.

In some contexts, social norms meant that women and girls were restricted from bathing, handling food, swimming and attending church.
Reach- ing menarche was viewed by some adolescents as something to fear and a source of shame.

Often menstruation was only discussed after the event, which led to girls feeling fear or embarrassment.

There was discussion of the importance of addressing psychosocial aspects of menstruation in order to improve the health and wellbeing of women and girls.

The literature highlighted that levels of acceptance of talking aboutSRH and menstruation varies greatly depending on the context.
However, addressing these social norms and taboos can be difficult, due to the variety of factors that influence the acceptance of gender and social norms.

For example, interviewee responses ranged from not viewing social taboos and stigma of menstruation as challenge, to viewing other SRH issues as more urgent to deal with.

This acceptance of social norms and taboo around MHM demonstrates a minimization of the negative impacts on women and girls.
“Women have and continue to deal with menstruation, so why is this a problem now?

Why do we need to address it?

There are no real harms, women can cope with this.” “The tricky thing is getting condom demonstration, sexual activity, more of the pointy end around consent and violence, that’s the stuff that’s challenging now, not so much about menstruation or puberty.” Other SRH actors felt that healthcare workers might find it difficult to address the underlying norms and stigma of menstruation.
“A lot of health workers will be comfortable … talking about puberty, but in a very biological sense; ‘what is menstruation?’ and ‘this will happen’.

What’s missing is what it means in terms of identity, what it means in terms of the changes and if this is causing stress.

Or what it means in terms of a community, what it means in terms of how you would seek advice or help.
That’s often missing.” 9 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 These perspectives demonstrate that in some contexts, menstruation is likely to remain a highly taboo topic, similar to sex.

Integrating WASH-related MHM efforts with SRH services, will create grounds for education efforts across all actors on the importance of MHM.
Through an integrated approach, both MHM and SRH will be seen as equally important issues to improving outcomes for women and girls.

Access to age-appropriate education and information Education was a strong theme in both the MHM and SRHR literature.

Some articles discussed parent-child communication, while most MHM articles mentioned teacher-student communication and peer education as key strategies to address gaps in knowledge.
Overall a key message in the literature was that sources of information – predominantly older women, parents and teachers – need to be supported to be able to have informed discussions with adolescent girls, who information and confidence to discuss issues.

lack accurate Similar to the desk-review findings, SRH practitioners understood mothers, and older female family members such as sisters and aunts to be key sources of information on both SRH and MHM.
They expressed similar concerns to those expressed in the literature; that is that mothers as the main source of knowledge for girls on SRH and MHM posed the real risk of providing misinformation due to their own gaps in knowledge.

“…and then the question relating to ‘where would you want to get that information from?’ was from their mother.
But when you look at the data around do mothers have the knowledge and do they feel comfortable to talk to their daughters about growing up, [and] what to expect – they [the mothers] wanted to but they didn’t have the knowledge or the confidence.” it is critical for education programs to address This highlights that intergenerational gaps in knowledge and information.
Recognition that the two sectors – MHM and SRH – are working on similar challenges, and are in fact aiming for similar outcomes, creates an opportunity for integrated programming.
10 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 This presents the opportunity for WASH and SRHR actors to leverage one another’s efforts and have a greater impact.
By normalizing discussions among women, men and young people on reproduction, menstruation and SRH, both sectors can contribute to raising the profile of menstrual health as an important issue for women and girls, and contribute to shifting cultural norms, gender attitudes and addressing taboos.

Education emerged as a key theme across most of the findings.
Educating actors, women, men, girls and boys in menstrual health and SRH is argua- bly therefore critical in overcoming social barriers, addressing intergenera- tional gaps in knowledge, and engaging men and boys positively to support for women and girls.

improved health and psychosocial outcomes intergenerational, Identifying cross-sectional opportunities gender transformative MHM and SRH education should therefore be a key strategy in future efforts to improve menstrual health.
to provide Reaching vulnerable groups was highlighted as an unmet need in MHM, specifically women and girls with a disability.

Vulnerable groups were doubly stigmatized, by being largely overlooked in needing SRH services as well.

Taking MHM and SRH services beyond education settings is critical to reaching these most vulnerable people in the community.
Photo credit: WaterAid/Jerry Galea 15 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 1.
WASH and SRH actors to leverage one another’s efforts for a greater impact on improving menstrual health • Develop shared terminology on ‘menstrual health’, which encompasses the hygienic aspects of menstruation as well as the broader systemic factors such as education and rights.

This can bring greater clarity to a joint development agenda by WASH, SRHR, and other actors.
• Identify shared goals across sectors and develop cross-sectoral platforms, plans and financial structures to jointly address menstrual health.

• Establish shared indicators and targets for activities.

• Strengthen cross-sectoral learning and documentation between WASH and SRH actors, to bolster effective menstrual health programming approaches.

• Conduct joint operational research to guide collaborative WASH and SRHR approaches to addressing menstrual health.
• Design and deliver joint, rights-based menstrual health programming solutions.

2.

Strengthen education and community awareness of menstrual health • Strengthen age-appropriate puberty education canvassing both menstrual health and hygiene and SRH.

• Develop and deliver education on menstrual health to those identified as sources of information by adolescent girls (such as mothers, older sisters, aunts).
• Accessible and inclusive integrated menstrual health solutions and SRHR education that go beyond school settings to reach women and girls with disabilities and other marginalized groups.

• Engage men and boys, using gender transformative approaches to menstrual health to address underlying issues of gender and power and uphold ‘do no harm’ principles.

• Utilize existing SRHR platforms and services to broaden menstrual health knowledge and services.

3.
3.

Extend the reach of integrated menstrual health solutions and SRH services • Accessible and inclusive integrated menstrual health, WASH and SRH services that go beyond school settings to reach women and girls with disabilities and other marginalized groups.

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23 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Disclaimer This publication has been funded by the Australian Government through the Department of Foreign Affairs and Trade.

The views expressed in this publication are the author’s alone and are not necessarily the views of the Australian Government.
Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 22 - Attachment 1