Together we are more: Evaluation of a menstrual hygiene management SBCC initiative for adolescent girls in India

Summary:

In India, adequate menstrual hygiene management (MHM) is impeded by diverse issues. GARIMA is a SBCC initiative from Uttar Pradesh, India that aimed to increase dialogue on menstruation, address related norms and restrictions, and foster an environment where girls can practice adequate MHM with dignity. Using a social ecological perspective, GARIMA included adolescent girls and their mothers as primary audiences and fathers, health workers, and teachers as secondary audiences. GARIMA was implemented in 1,975 villages reaching 64,000 girls. Mixed methods evaluation was based on OECD-DAC criteria. Quantitative structured interviews using an intervention-comparison design included programme beneficiaries (n = 2,289) and implementers (n = 315) matched with comparison group respondents (n = 2,370 and n = 212, respectively). GARIMA established relevance by complementing governmental infrastructural efforts. Effectiveness was established through significant direct and indirect positive effects and, while causal attribution is hard to determine, potential impact was seen through significantly higher adequate MHM behaviours among intervention respondents. Efficiency was assessed by evaluating the processes of local partners implementing activities using a standardized package of SBCC materials. Sustainability was evident from the integration of GARIMA within national and regional government initiatives. Dialogue remained concentrated at same-sex family and peer levels and reasons and expectancies for actions were not articulated, suggesting norm internalization. However, GARIMA empowered adolescents to voice actions around sexual harassment, child marriage, and education. Adolescent girls groups expanded social networks, increased social capital, and trained a cadre of peer educators and health workers as change agents.

Background/Objectives:

In India, adequate menstrual hygiene management (MHM) is impeded by a diverse set of issues, ranging from a lack of awareness and information on menstruation, a lack of access to menstrual absorbents and sanitation facilities, and a culture of silence around menstruation that make girls and women more vulnerable to disease, gender inequality, and social exclusion. GARIMA is a social and behaviour change communication (SBCC) initiative from Uttar Pradesh, India that aims to break the culture of silence by increasing dialogue on menstruation, address menstrual-related norms and restrictions, and foster an environment where girls can practice adequate MHM with dignity.

Description of Intervention and/or Methods/Design:

GARIMA was guided by the social ecological model, with adolescent girls and their mothers as primary audiences and fathers, health workers, and schoolteachers as secondary audiences. By integrating human rights, gender, and equity perspectives, GARIMA used: 1) capacity building; 2) community dialogue; and 3) interpersonal communication. GARIMA was implemented in 1,975 villages and reached over 64,000 girls. The project was evaluated based on the OECD-DAC criteria, assessing relevance, effectiveness, efficiency, impact, and sustainability. Secondary analysis included report reviews from the formative research, baseline and concurrent monitoring data, annual reports, and documented case studies. Primary data was collected through an intervention-comparison design using a mixed methods approach. Quantitative structured interviews conducted with programme beneficiaries (n = 2,289) and implementers (n = 315) matched with comparison respondents (n = 2,370 and n = 212, respectively). Qualitative data was collected through group and in-depth interviews including narrative, visual, and numeric participatory research techniques.

Results/Lessons Learned:

A majority of the existing government policies around MHM in India focus on infrastructure development. GARIMA established relevance by complementing these efforts through SBCC. Effectiveness was established by quantitative and qualitative data showing significantly higher levels of adequate MHM among intervention participants after controlling for background variables. Multivariate examination of exposure with SBC mediators and adequate MHM indicated significantly higher levels of knowledge, interpersonal communication and positive social norms among those practicing adequate MHM. Causal attribution is hard to determine, but potential impact was seen through significantly higher adequate MHM behaviours among intervention respondents. Efficiency was assessed by evaluating the processes of implementation. GARIMA was implemented by multiple local partner NGOs, however, the overall approach, activities, and communication materials were standardized to ensure quality delivery. Sustainability was evident from knowledge, interpersonal communication, and actual MHM practices being sustained one-year post-implementation and GARIMA being integrated within national and regional government initiatives.

Discussion/Implications for the Field:

Results lend validity to a social ecological approach to break the silence around menstruation. However, dialogue remained concentrated at same-sex family and peer levels. Intervention adolescents had significantly higher levels of approval and actual practice across all positive normative behaviours, however, most respondents were unable to clearly articulate reasons and expectancies for their actions suggesting norm internalization. GARIMA empowered adolescents by giving them confidence to voice actions around sexual harassment, child marriage and education. Adolescent girls groups expanded girls social networks and increased social capital and successfully trained a cadre of peer educators and frontline health workers as change agents.

Abstract submitted by:

Suruchi Sood - School of Public Health, Drexel University
Alka Malhotra - UNICEF
Shailesh Nagar - NR Management Consultants