Sustainable Menstrual Health Teaching

Menstrual health (MH) is an often overlooked component of sexual and reproductive health (SRH), but cultivating supportive MH environments is essential to securing women's and girls’ sexual and reproductive health and rights. In particular, lack of accurate information about puberty and menstruation contributes to early marriage and pregnancy, perpetuation of social stigma, and increased risk of infection and disease. Today, approximately 500 million women and girls worldwide do not have what they need to manage their menstruation with health, choice and dignity. This significantly impacts their ability to participate fully in society, reach their goals and fulfill their potential. As a result, the World Health Organization recently called for MH to be recognized, framed and addressed as a health and human rights issue, not a hygiene issue (http://bit.ly/3X2Drvb). Also, while MH is not listed among the United Nations’ Sustainable Development Goals (SDGs), it is critically linked to seven of these 17 global goals (https://bit.ly/3Xa9Xf2).

When MH is not supported, women and girls face barriers in many other areas of life including:

-Good health, via urinary and genital infections

-Education, via absenteeism, difficulty focusing or performing as usual, and dropping out

-Workplace advancement via absenteeism, difficulty focusing or performing as usual, wage loss and supervisor disapproval

-Sexual and reproductive health and rights (SRHR), via early marriage and unplanned pregnancy

-Mental well-being, via stigmatization that contributes to anxiety and depression

Menstrual health is achieved when women and girls are able to decide if and how to participate in all spheres of life, free from menstrual-related barriers (Hennegan et al. 2021). The root causes of inadequate MH include a lack of reliable access to:

-Quality, safe and affordable menstrual products

-Accurate, age-appropriate and timely MH information for informed choices, reduced stigma and shame, and improved management of menstruation

-Sanitation infrastructure that is equipped with adequate water, soap and methods for waste disposal

-Positive social environments and gender-inclusive policies from local to national levels

In Cambodia specifically, teachers are a preferred source for Cambodian students who have questions about puberty and menstruation. However, teachers are often uncomfortable sharing the information or lack the correct MH details in the first place, both of which perpetuate stigma and misinformation. As such, many Cambodian girls lack access to MH products and information, negatively impacting their ability to participate in school and sports. A baseline Days for Girls study of 360 school-aged girls showed: that 298 girls had “poor MH knowledge” (scoring 49% or less on knowledge-based questions); 60 had “average MH knowledge” (between 50-79%); and two had “good MH knowledge” (80-100%). Without MH resources, girls rely on myth and resort to using materials such as leaves to manage periods.

Days for Girls International (DfG) is an award-winning NGO that works to shatter stigma and limitations associated with menstruation for improved sexual and reproductive (SRH) health, education and livelihood outcomes for girls, women and communities. We believe in a world where periods are never a problem. In our 15 years of operation, we have reached more than 3 million women and girls in 145 countries on six continents with quality, sustainable menstrual care solutions and health education.

DfG will transform the MH education landscape in Cambodia by equipping local teachers with the curriculum and tools they need to provide their students with timely, accurate, well-delivered, age-appropriate and culturally appropriate puberty and menstrual health education.

DfG efforts in Cambodia aim to put MH solutions in the hands of local schools. From 2019-2022, DfG successfully designed and implemented a pilot project including a training of teachers (ToT) program and Grade 5 Introduction to Puberty and MH lesson plans. After participating in DfG’s ToT, teachers were supported to deliver lessons to Grade 5 students. Monitoring, learning and evaluation (MLE) demonstrated the need for increased MH teacher training and education for students in Cambodia through both baseline findings and informal meetings with teachers, principals and community leaders, as well as the Ministry of Education, Youth and Sport (MoEYS). In these post-pilot-project meetings, the MoEYS, provincial governments, schools, principals, teachers and students requested an expansion of the project. All entities also requested the inclusion of washable MH products in the next phase.

Our multi-year project, occurring between 2023-25, will deliver DfG's MH Teacher Training (ToT) to 600 female and male public school teachers in Phnom Penh, Ratanakiri, Mondulkiri, Kratie and Kampong Som provinces to increase teachers’ confidence, knowledge and skills in teaching Grade 5 and Grade 8 puberty and MH lessons to students (potentially expanding lessons to additional grades in the future). Additionally, we will support teachers in delivering these lessons to 15,000 female and male Grade 5 and 8 students in these same provinces to increase students’ knowledge and confidence and shift their beliefs and attitudes about puberty and MH. We will also provide locally-made, washable menstrual pad DfG Kits to all female program participants. We also have a three-year memorandum of understanding (MOU) in place with the MoEYS, thereby ensuring the program’s long-term impact on individuals throughout the nation and the government’s exposure to positive MH and SRH paradigms.

Over the course of the project (2023-2025), we will reach 600 teachers and 15,000 students with vital menstrual health education. In 2023 alone, we are on track to reach 2,200 students - 1,000 of whom are female - with MH education and to have trained 270 teachers on how to confidently deliver accurate, timely, age-appropriate education to their students and supported them to do so. Additionally, this year, we are on track to reach 1,100 students and teachers with DfG Kits. Our efforts have profoundly affected the MoEYS, so much so that they have requested a three-year expansion of our project and have signed an MOU to ensure its continuation during that time. The structure and purpose of the project will remain constant throughout implementation while its scope will increase dramatically. For instance, in 2024, we will reach 6,000 students (3,000 girls, 3,000 boys) and 200 teachers; and in 2025, we will reach 7,000 students (3,500 girls, 3,500 boys) and 340 teachers.

Furthermore, we anticipate an increased cognizance of MH will trickle into corporate policies and national awareness as we advocate for MH in all our interactions. As those who participate in our MH education and programming share their MH knowledge with their families and communities, more positive MH environments may be created. For example, after participating in our MH lessons, one male Cambodian student said, “I will share to my family and my community. I will share to other men too as they will also have mother, sister and female relative. He will be able to share to other too.” This shows the interconnectedness of MH and how enhanced community knowledge of MH and SRH will continue to expand organically.

Engaging people in MH and SRH learning promotes well-being and uplifts communities. MH education, advocacy and products dismantle stigma and cultivate supportive environments for well-being among those who menstruate. Additionally, as students and teachers share their new MH and SRH knowledge with their families and communities, more positive MH and SRH environments may be created.

As a global organization based on a partnership model, we are keenly aware of the importance of life experience being the driving force of our work. Because MH is a nuanced, systemically integrated challenge related to SRH, DfG implements community-based strategies that respond to local needs and leverage local strengths. We cultivate lasting impact by engaging directly with local government and schools to equip women and girls with MH products and information they need now. Simultaneously, we advocate with key stakeholders to dismantle stigma, develop improved MH programs and policies and create supportive social environments for women and girls in the long term.

Centering local leaders is essential to our sustainable impact. DfG actively seeks out voices from the field and communities we serve. We respect, learn from and honor local wisdom. The current project began due to feedback from a Cambodian mother and daughter who run a local nonprofit. They reached out to DfG, identifying the need to train teachers to improve MH education in Cambodian schools. They requested to partner with DfG and presented the idea to the MoEYS who also recognized the need and signed an MOU with DfG. We then engaged with Cambodian schools and communities to tailor the MH curriculum to their education system and culture. DfG leaders in Cambodia understand the beliefs and nuances behind menstrual stigma, taboos and practices that may harm women and girls. They expertly tailor the delivery of DfG curriculum, facilitating discussions that respectfully challenge existing assumptions about menstruation, while offering new information for participants to consider.

Leyla Isin-Xiong, Chief Programs Officer at Days for Girls International, is the Team Lead for this program solution. Isin-Xiong oversees the implementation of the project and keeps DfG headquarters apprised of any and all developments. A resident of Laos, Leyla is based in Cambodia for the duration of the project. Isin-Xiong speaks English and basic Lao and is experienced in intercultural communication and project management and implementation, especially in Southeast Asia (Cambodia and Laos in particular). Isin-Xiong has been working in the menstrual health sector since 2016. Based in Luang Prabang, Laos, she spends 4-5 months of the year in Cambodia working on this project.

The demographics of our staff and board of directors reflect DfG’s target demographic. The vast majority of our staff, volunteers and board members are women, who naturally have first-hand knowledge of menstruation and SRH. We also employ several men at Days for Girls, which is appropriately representative of our MH education outreach to men and boys.

In 2023, we aim to educate 2,200 students, including 1,000 females, and to train 270 teachers to provide accurate and timely MH and SRH education to Grade 5 and 8 students. We also plan to distribute DfG Kits to 1,100 students and teachers. Looking forward, in 2024, our goal is to reach 6,000 students (3,000 girls, 3,000 boys) and 200 teachers, and in 2025, we aim to reach 7,000 students (3,500 girls, 3,500 boys) and 340 teachers.

However, the broader impact of our project is impossible to calculate as each participant shares what they learn with their families and friends. Entire communities are affected as girls and women have access to accurate MH and SRH information - this creates more supportive social environments and can have lasting generational change. Additionally, our work with the MoEYS is profoundly affecting the MH views of those in government, as they observe the impact of MH and SRH education on the youth populations.

DfG’s solution is innovative for the following reasons:

1. Iterative contextuality - Although many organizations have some form of MH education, DfG has a curriculum that is tailored specifically to those regions in which we work. Our curriculum is translated into Khmer, and our trainers apply and adapt it to the local context by weaving in personal stories and directly addressing country and community-specific taboos and practices. This allows us to meet people where they are and teach them in a way that is tailored to and builds off of their local culture and context.

2. Quality - Local Enterprises and volunteers make our washable, sustainable menstrual pads with natural, holistically sourced materials. Using our patented design and adhering to our global standard of excellence, our washable pads are designed to be dignified, high-quality, appealing, comfortable and long-lasting. Each female participant in our MH education program receives a DfG washable pad Kit.

3. Inclusivity - While others in the MH field focus exclusively on girls, DfG brings tailored, culturally specific education to women, boys and men too. By taking a community approach, we establish allies and environments of MH support.

4. Student-centered learning: The MH education is participatory and interactive. Teachers are trained not only in content but on techniques for teaching MH effectively.

5. A policy approach: By partnering with governments, the project contributes to the development and implementation of MH policy, allowing the program to reach more people and proving its innovative approach to scaling up. The goal is to equip teachers in all public schools across Cambodia to deliver MH education to grade five and eight students and extend its reach to grades 6-12.

The main objective of this project is to increase access to accurate and timely MH and SRH education among students across Cambodia, building on the incredible success of our project. For the whole project, between 2023-2025, we aim to reach 15,000 students (7,500 girls, 7,500 boys) and 600 teachers. The following beneficiary milestones demonstrate the advancement of the project over the years:

• 2023:

  • 2,200 students (including 1,000 girls)

  • 270 teachers

• 2024:

  • 6,000 students (3,000 girls, 3,000 boys)

  • 200 teachers

• 2025:

  • 7,000 students (3,500 girls, 3,500 boys)

  • 340 teachers

Additionally, all female participants will receive DfG Kits. The milestones we seek to achieve throughout the project are:

1. Renewed local buy-in at the district level throughout the first year of the project.

   1. Based on MLE from the pilot project, we expect to receive positive feedback from principals and teachers regarding whether the training, education and products are improving teacher and student MH experiences. 

2. Among teachers, increased confidence, broader MH knowledge and mastery of MH curriculum methodology and teaching techniques.

   1. A positive shift in attitudes about menstruation from those teachers who participate in the program. Teacher training pre- and post-tests will indicate whether these outcomes are being achieved by September 2023. The same timeline will apply in 2024 and 2025.

3. Positive changes in students’ knowledge, confidence, attitudes and beliefs surrounding puberty and menstruation.

   1. In our pilot project, we saw that student knowledge was significantly impacted by MH education. Prior to the lessons, only 56% of surveyed students believed that menstruation is a natural sign of being a healthy woman, compared with 94% after. Student lesson pre- and post-tests and focus group discussions will indicate whether these outcomes are being achieved by the end of 2023. The same timeline will apply in 2024 and 2025.

4. Knowledge retention and improved menstrual experience with DfG Kits for students. 

   1. Student four-month follow-up surveys will provide data regarding this outcome, as they will have had time to try using the Kits to manage their menstruation. 

5. Positive impacts on families and communities.

   1. Using in-depth interviews and focus group discussions, we will gather data for future learnings and to see the impact of the project on families and communities through qualitative data. If this milestone is achieved in 2023, we will be able to predict similar outcomes for communities in 2024 and 2025. 

When people have access to accurate MH and SRH education, they are equipped to make informed choices about their bodies. Women and girls in particular gain skills to manage menstrual symptoms and seek help from healthcare professionals when needed. As the project continues to expand in year two (2024) and year three (2025), we hope to apply learnings from MLE and continue to see positive impacts on students, teachers and communities.

We expect our MH and SRH education solution approach to have a positive impact on MH and SRH attitudes moving forward because we have already witnessed positive change through our pilot project. By engaging with a third-party MLE company to ensure validity, DfG employed a mixed-methods study to measure outcomes and evaluate effectiveness. This included conducting quantitative written pre/post/3-4 month follow-up surveys, qualitative focus group discussions and in-depth interviews to measure the program’s impact on teachers and students:

• Prior to the ToT, 0% of teachers could correctly name the number of phases of the menstrual cycle, compared to 100% after.

• Prior to the ToT, 0% of teachers knew how long sperm can live in the fallopian tubes/uterus. Following the ToT, 100% knew the correct answer.

• Prior to the ToT, 47% of teachers knew the average age of menarche for girls, compared to 94% after.

• Only 56% of surveyed students believed that menstruation is a natural sign of being a healthy woman prior to the lessons, compared with 94% after.

• The pre-education survey found only 25% of students knew the menstrual cycle duration, compared to 88% afterward.

• Only 19% of surveyed students knew the correct average age of menarche prior to the training, compared with 81% after.

• Prior to our lessons, only 54% of students felt confident talking about menstruation, compared to 85% after.

• We learned from qualitative evaluation efforts that teachers experienced increased confidence discussing menstruation – one male teacher from Ratanakiri province shared, “When I was a student, I had much shyness, but now that I am a teacher and a leader, I have to let go of my shyness, make sure students get this knowledge.”

The project is also inspiring local change makers who are stepping up to be MH advocates and leaders. For example:

• Under Secretary of State, Her Excellency Khun Rachana, requested that the teacher training in Kampong Som Province be aligned with International Women’s Day. She traveled several hours to hold a closing ceremony, where she told an audience of around 100 people about the importance of MH.

• One male teacher sent to the 2022 training by his principal was unaware of the topic when he arrived. He completed the training and afterward said, "I wanted to run away when you told us what this training was. But I'm so so glad that I stayed. I have learned so much new and important information. Now I can teach all my students, both male and female about this, I can teach my daughter and not be shy. I'm so glad I stayed."

• MoEYS has included MH in its strategy and signed a three-year MOU with DfG for the expansion of the project.

• Isin-Xiong was invited to attend the MoEYS 2023 National Education Congress where Phnom Penh Teacher Education College director, H.E. Set Seng, included the MH teacher training program in his discussion to demonstrate how important MH education is to the wider education sector.

Following Days for Girls International’s mission, and while keeping the DfG team apprised of developments, Leyla Isin-Xiong works with various government officials at the MoEYS and engages with staff and master teachers at the Phnom Penh Teacher Education College, where the ToT phase of the project takes place. Isin-Xiong also works with local leaders to ensure a sustainable approach to MH education. Meanwhile, the DfG washable menstrual pad Kits are produced by staff at the local, DfG affiliated Enterprise, Project G.

The pilot project for this program began in 2019, but ideation and strategy began in 2018.

At DfG, our organization is committed to prioritizing female involvement. We also recognize that men are essential in any effort to affect sustainable, global menstrual health (MH) changes. As such, while the vast majority of our staff are women, we do employ several men in our International and country offices. Additionally, we understand that menstruating individuals encompass myriad genders, and, in LGBTQIA+-friendly countries, we strive to provide for the needs of all those who menstruate. We believe that everyone should have the right to menstruate with dignity, regardless of gender.

DfG is an equal opportunity employer that values diversity, equity and inclusion. We do not discriminate on the basis of race, ethnicity, religion, national origin, sexual orientation, gender identity, age, marital status, veteran status, or disability status. All are welcome in our organization.

We believe in hearing every voice. In the MH sphere, we prioritize the voices of girls, women and others who menstruate as they have the lived experience that often goes untold. We also are sure to incorporate men and boys in our programming, as we cannot affect lasting systemic MH change unless we garner support from male allies.

Days for Girls’ scalable solutions approach to menstrual health and SRH engages individuals, families and communities and hinges on a holistic trifecta of programming that addresses menstrual-related barriers through: 

• Production and distribution of high quality, cost-effective and environmentally sustainable, washable menstrual pad Kits (DfG Kits);

• Advocacy to local and national leaders to improve MH policies and programs;

• Delivery of comprehensive, timely and age-appropriate MH education;

  • Our curriculum is translated into local languages, and our trainers apply and adapt it to the local context by weaving in personal stories and directly addressing country and community-specific taboos and practices.

  • While others in the MH field focus exclusively on girls, DfG brings tailored, culturally specific education to women, boys and men too. By taking a community approach, we establish allies and sustainable environments of MH support.

DfG believes strongly in the power of collaboration and has partnerships at the international, national, and community levels. We engage individual donors, promote seasonal fundraising campaigns and apply for grants on an ongoing basis. We also work with impact partners - corporate partners that support our mission. Several of DfG’s impact partners include:

• The Starbucks Foundation

• doTERRA Healing Hands Foundation

• This is L (Procter & Gamble)

• Popsocket

• Revlon

• Goldman Sachs

With these and other impact partners as well as our diversified revenue streams, DfG can maintain financial sustainability and confidently cover our expected expenses, allowing us to focus on our mission of providing menstrual health education and resources to create supportive MH and SRH environments for women and girls throughout Cambodia.