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Experiences and perceptions of menstruation among women living in Central Uganda McCabe, Sarah 2018

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   EXPERIENCES AND PERCEPTIONS OF MENSTRUATION AMONG WOMEN LIVING IN CENTRAL UGANDA   by  SARAH McCABE  B.A., The University of Calgary, 2011         A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF ARTS   in   THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES  (Educational Studies)      THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)      December 2018   © Sarah McCabe, 2018    ii Committee Page The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, a thesis/dissertation entitled:  Experiences and Perceptions of Menstruation Among Women Living in Central Uganda  submitted by Sarah McCabe  in partial fulfillment of the requirements for the degree of Master of Arts in Educational Studies    Examining Committee: Dr. Shauna Butterwick Co-supervisor Dr. Jude Walker Co-supervisor  Dr. Maureen Kendrick Additional Examiner    iii Abstract This research amplifies the voices of ten Ugandan women as they speak to their experiences of menstruation and menstruation education. This study involved the use of a feminist standpoint lens and an asset-based approach to analyze interviews undertaken with ten Ugandan women. Data analysis revealed the strategies, complexities, and challenges the research participants have encountered in relation to their experiences of menstruation. This study revealed that the participants’ knowledge of menstruation when they were girls exists along a spectrum and that their knowledge and understanding about menstruation varied from person to person. Among these ten women, the study also found a spectrum of experiences in relation to their feeling prepared. Interestingly, some of the participants, while having some knowledge of menstruation still felt unprepared when the event occurred for the first time. Relationships between menstruation and its effects on everyday life were also explored. A key finding was the impact of menstruation on their daily lives, including being unprepared, dealing with pain, and teasing and bullying. However, menstruation was not a key factor that led to them missing school; this finding stands in contrast to other studies pointing to how many young women miss school because of menstruation. What were influential factors on school attainment, for the research participants, included pregnancy and insufficient funds to pay school fees. In relation to menstruation education, this study found that these young women learned from many sources, including family, friends, peers, and teachers. This information can inform future research and educational programs pertaining to menstrual health in Uganda that preserves the dignity and diversity of Ugandan women and girls. A key recommendation is to ensure menstruation education in schools and communities is timely and grounded in an approach that enables girls to learn about menstruation holistically.   iv Lay Summary In this qualitative research study, ten Ugandan women were interviewed about their experiences and knowledge of menstruation and menstruation education. Their knowledge of menstruation can be placed on a spectrum from having little knowledge to having more knowledge. While many participants reported that they knew about menstruation, some of them were shocked and unprepared when their first menstruation began. Menstruation education occurred within family, schools, and through their peers. Some studies state that young Ugandan women miss school because of their menstruation. This claim is not affirmed by this study, which found that a few respondents sometimes missed school. Specifically, those missing school did so in order to deal with menstrual pain. What did have a very significant impact on these women’s everyday lives was pregnancy. One recommendation of this study is to enable peers, parents, and teachers to better support young Ugandan girls’ knowledge and anticipation of menstruation.    v  Preface This thesis was written solely by the author and has not been published in part or whole in any other venues.  The University of British Columbia Vancouver Behavioural Research Ethics Board (BREB) granted ethical approval, certificate number H16-01850. Ethics approval was also granted by the Mildmay Uganda Research Ethics Committee (MUREC), certificate number 0617-2016 and the Ugandan National Council for Science and Technology (UNCST), certificate number SS4129.      vi Table of Contents  Abstract ......................................................................................................................................... iii Lay Summary ............................................................................................................................... iv Preface ............................................................................................................................................ v List of Tables ................................................................................................................................ ix List of Figures ................................................................................................................................ x List of Abbreviations ................................................................................................................... xi Glossary ....................................................................................................................................... xii Acknowledgements .................................................................................................................... xiii Dedication ................................................................................................................................... xiv Chapter 1: Introduction ............................................................................................................... 1 1.1 Context of the Study .......................................................................................................................... 2 1.2 Research Questions and Methodological Approach ...................................................................... 7 1.3 Researcher Positionality ................................................................................................................... 9 1.4 Significance and Dissemination of Research Study...................................................................... 14 1.5 Structure and Organization of Thesis ........................................................................................... 15 Chapter 2 – Literature Review .................................................................................................. 17 2.1 Uganda: A Brief Historical and Geo-Political Context ................................................................ 18 2.2 Sexual and Reproductive Health in Uganda ................................................................................. 20 2.3 Menstruation in Uganda ................................................................................................................. 24 2.4 Theoretical Framework .................................................................................................................. 28 2.5 Summary .......................................................................................................................................... 30  vii Chapter 3 – Methodology ........................................................................................................... 32 3.1 Research Design ............................................................................................................................... 32 3.1.1 Research Methods ...................................................................................................................... 32 3.1.2 Selection Criteria and Recruitment Process ............................................................................... 33 3.1.3 Interview Design ........................................................................................................................ 37 3.1.4 Ethical Considerations ............................................................................................................... 39 3.1.5 Informed Consent Process ......................................................................................................... 40 3.1.6 Data Collection Process ............................................................................................................. 42 3.1.7 Analysis of Data ......................................................................................................................... 44 3.2 Trustworthiness of This Study ....................................................................................................... 45 3.3 Summary .......................................................................................................................................... 46 Chapter 4 – Research Findings .................................................................................................. 47 4.1 Knowledge of Menstruation ........................................................................................................... 50 4.1.1 The Continuum of Knowledge and Embodied Knowing........................................................... 50 4.1.2 Keeping menstruation a secret ................................................................................................... 55 4.1.3 Men and Boys Knowing of Menstruation .................................................................................. 56 4.1.4 Care of One’s Health.................................................................................................................. 56 4.1.5 Menstrual Products .................................................................................................................... 57 4.1.6 Menstrual Health ........................................................................................................................ 58 4.2 Menstruation Education ................................................................................................................. 59 4.2.1 Menstruation as Normal ............................................................................................................. 61 4.2.2 Gender Segregation, and Boys and Men and Menstruation....................................................... 62 4.2.3 Importance of Age ..................................................................................................................... 63 4.3 Impact on Everyday Life ................................................................................................................ 63 4.3.1 Menstrual Pain ........................................................................................................................... 65  viii 4.3.2 Impact of Menstruation on Studies ............................................................................................ 67 4.3.3. Degrees of Impact of Menstruation on Everyday Life ............................................................. 68 4.4 Summary .......................................................................................................................................... 72 Chapter 5: Discussion and Conclusion ..................................................................................... 73 5.1 Goal of the Study and Research Questions ................................................................................... 73 5.2 Knowledge and Experience of Menstruation ................................................................................ 74 5.3 Keeping Menstruation a Secret ...................................................................................................... 77 5.4 Menstruation Education ................................................................................................................. 78 5.4.1 Teaching about menstruation ..................................................................................................... 79 5.4.2 Schools as sites of menstruation education ................................................................................ 84 5.4.3 The role of NGOs in menstrual health ....................................................................................... 85 5.5 Limitations of the Study.................................................................................................................. 86 5.6 Implications for Future Research, Policy, and Practice .............................................................. 89 5.7 Concluding Reflections ................................................................................................................... 92 References .................................................................................................................................... 94 Appendices ................................................................................................................................. 110 Appendix A: Verbal Recruitment Notice .......................................................................................... 110 Appendix B: Consent Forms .............................................................................................................. 111 English Consent Form ....................................................................................................................... 111 Luganda Consent Form ..................................................................................................................... 117 Appendix C: Interview Tool ............................................................................................................... 123   ix List of Tables Table 4.1  Basic demographic information on research participants ......................................... 49    x List of Figures Figure 1.1  Map of Africa highlighting Uganda .......................................................................... 2 Figure 1.2  Regional Map of Uganda highlighting Central Uganda ............................................ 3    xi List of Abbreviations AIDS  Acquired Immunodeficiency Syndrome BRAC  See section “Glossary” for explication FGM  Female Genital Mutilation HIV  Human Immunodeficiency Virus INGO  International Non-Government Organization MH  Menstrual Health MHM  Menstrual Hygiene Management NGO  Non-Government Organization SSA  Sub-Saharan Africa S&RH  Sexual and Reproductive Health UGX  Ugandan Shillings (currency abbreviation) UNESCO United Nations Educational, Scientific, and Cultural Organization UNFPA United Nations Population Fund (formerly United Nations Fund for Population Activities)  UNICEF United Nations Children’s Fund (formerly UN International Children’s Emergency Fund)    xii Glossary This study uses precise definitions of Uganda, Central Uganda, and mzungu, recognizing the historical, political, and socio-cultural and religious contexts in the country of Uganda; the broader context is briefly explained in Chapter 1.   BRAC1 Uganda An International NGO originating in Bangladesh, whose Uganda office is located in Nyanama, Kampala. BRAC is the organization I completed a research internship for, and who generated the dataset from which the interview participants were recruited.  Central Uganda A region of Uganda immediately surrounding and centering on the capital city of Kampala. For the purposes of this study, it includes Mukono and all of Kampala’s divisions, including Rubaga, Kawempe, Makindye, and Nakawa.  Baganda  A politically dominant ethnic group located in Central Uganda.  Luganda  Language of the Baganda people.  Muganda  A person who is Baganda.  Mzungu A word referring to a person of European descent. Common usage in Uganda meaning “foreigner” or “white person”. From the Swahili term “Mzungu” meaning “person who wanders aimlessly”. Alternate spelling: muzungu. It is not a neutral term. It is a many-layered word that carries different meanings. I do not fully understand the extent of the different meanings.   Uganda A country located in East Africa. A British colony/protectorate, Uganda’s borders encompass a number of different ethnic groups, religions, and languages.                                                    1 The letters BRAC originally stood for Bangladesh Rural Action Committee, but, given the growth of BRAC into an international organization, the acronym no longer fits and BRAC organizers are adjusting its meaning.  xiii Acknowledgements First and foremost acknowledgement goes to the tireless effort, support, and encouragement from my supervisor, Dr. Shauna Butterwick; this chick appreciates you, Mother Hen. Further, Dr. Jude Walker, co-supervisor, for her unique perspective and reassurance. Many thanks go to Dr. Maureen Kendrick for serving as external examiner. I must acknowledge the invaluable lessons I have learned both in and out of the classroom from my instructors and mentors at UBC: Dr. Sam Rocha, Dr. Ali Abdi, Dr. Jason Ellis, Dr. Deirdre Kelly, Dr. Claudia Ruitenberg, and Dr. Hongxia Shan in the Department of Educational Studies, Monika Naus in the School of Population and Public Health, and Saraswathi Vedam, Courtney Broten, and Jeanne Lyons of the Department of Midwifery.  I am so grateful for the love and support I have had the privilege to enjoy from my family and friends. Particular thanks go to Cameron McCabe for all his extra help. Also, I am indebted to Don and Sydney McCabe, who know how invaluable their contributions have been. To everyone who has helped me in their way: Dr. Carmen Thompson, Stephanie Pan, Corinna Peters, Catherine Macala, Stéphanie Black and Mike Hillman, Gabriella Maestrini, Liz Paynter and everyone in EnChor, Calgary’s Tuesdays writing Meetup, Kayla and Alex Koshynsky, Stephanie G., Lori C., Susan A/C., and Kathleen Jones. You are all so wonderful. Special thanks go to Denise Ferris, Laura Hytti, Mark Kadigo, Hadijah Asali Mall Nalukenge, and of course, the marvellous research participants.   xiv Dedication This work is dedicated to girls and women the world over. 1 Chapter 1: Introduction Menstruation is a significant event in a woman’s life and her menstruation experience has physical, emotional, and psychological impacts. The way girls and women perceive and experience their menstruation is part of women’s sexual and reproductive health rights and their universal rights. This study explored the experiences of menstrual health among a small group of young Ugandan women living in or near the capital city of Kampala. Their experiences and perceptions are important to consider because Ugandan women are subjects and recipients of (public) health research, interventions, and programs. It is therefore important to listen to how they perceive their own needs and wants when it comes to their health and wellbeing. As Kalipeni, Flynn, and Pope (2009) note, “women in Africa are not merely puppets of globalization, cultural norms, or biological imperatives, but rather agents of their own livelihoods” (p. 2). Documentation of women’s perceptions is needed in order to improve efficacy of programs and education with respect to the organization, structure, and outcomes of menstrual health, sexual and reproductive health (S&RH) practices, and education in Uganda and beyond.  This study has the potential to contribute to illuminating and reframing menstruation and menstrual health and education within academic and aid research and development circles by bringing Ugandan women’s voices to the fore. I spent a year in Uganda as a research intern at BRAC Uganda – a large international non-government organization (INGO) – and undertook my research study there. Later in this chapter, I provide more information about my social location as a researcher.    2  1.1 Context of the Study Uganda is a country in East Africa surrounded by the Democratic Republic of the Congo and Rwanda to the West/Southwest, South Sudan to the North, Kenya to the East, and Lake Victoria to the South. It is colloquially referred to as the Pearl of Africa.  Figure 1.1  Map of Africa highlighting Uganda This image shows the continent of Africa with the country of Uganda circled (Davykamanzi, 2018).     3  Figure 1.2  Regional Map of Uganda highlighting Central Uganda   This image shows the country of Uganda divided into its four general regions: Northern, Eastern, Western, and Central (United Nations, 2018). The region of Central Uganda is circled. The World Bank (2018) projects the population of Uganda to be approximately 42.86 million2, representing over 50 different ethnic groups and at least as many languages (Uganda Constitution, 1995). During the research process, Uganda was host of the world’s largest refugee camp, Bidi Bidi (Hattem in Impvepi, 2017). At the time of publication of this thesis, Bidi Bidi is considered to be the third largest refugee camp in the world. Between the refugee camp, the ongoing HIV\AIDS crisis, and ongoing civil conflict are major reasons for Uganda receiving foreign aid (Dow, 2018; Girod, 2015). Ugandans make a very strong distinction between city life and village life—a fact amplified by the women who participated in this study. It is important to note that while metropolitan areas in Uganda continue to grow and modernize—this is most                                                  2 While the Ugandan government conducted a population census in 2014, the most recent census population data available is from the World Bank; data collection was in 2016 and estimates a total population of 41.49 million people. This information was retrieved 4 November, 2018 from:  4 observable in the capital city of Kampala—the changes seen in rural areas are different, despite steady population growth.  The status of girls and women in Uganda has been the focus of many development organization interventions and research. Kyomuhendo Bantebya, Kyoheirwe Muhanguzi and Watson (2014) offer a description of the social climate that Ugandan women live in today:  Uganda has made significant progress in terms of overall poverty reduction, expansion of educational opportunities for young people and improving gender equality. Nevertheless, analysis of national and regional survey data reveals alarming proportions of adolescents still living in poverty, deprived of full educational attainment and – for girls – impelled into child marriage or early pregnancy, with sexual and reproductive health indicators revealing high levels of vulnerability. At national [sic] level, over a third of the girls who drop out of school do so because of marriage, and a quarter because of pregnancy. (viii)  In terms of the specific context of menstruation in Uganda, several published research studies have focused on Ugandan girls’ menarche. McMahon et al. (2011) argue that menarche “is a critical moment in a girl’s life that marks an opportunity to teach girls that they are the owners of their own bodies” (p. 10). Sommer, Hirsch, Nathanson, and Parker (2015) call upon NGOs, researchers, academics, and political leaders to “collectively raise awareness and instigate action” (p. 1309) to address barriers to menstrual health. Sommer is a public health scholar in the discussion about menstruation in sub-Saharan Africa, and she and her colleagues (2015) conclude: “of critical importance [is] the way that researchers and advocates leverage the multisectoral nature of the public health problem, both in the players documenting the evidence  5 and those advocating for the issue (e.g., WASH [Water, Sanitation and Hygiene], health, education)” (Sommer et al., 2015, p. 1311). In Uganda, rapid changes to family dynamics and communal structures have taken place, due in part to geopolitical conflict, and also due to the HIV epidemic (Sommer et al., 2015). The AIDS crisis has also contributed to the removal of “cultural responsibility from families for providing menstrual-related guidance” along with “the growing need for schools to take on the role of providing such guidance” (Sommer et al. 2015, p. 1305). While academic studies conducted in Uganda have mainly focused on how menstruation impacts school attendance and on menstrual hygiene management in refugee camps, most of them have not included the voices of these women. According to the United Nations Educational, Scientific, and Cultural Organization [UNESCO] (2014) booklet on Puberty Education and Menstrual Hygiene Management, “UNICEF estimates that 1 in 10 school-age African girls ‘do not attend school during menstruation’. World Bank statistics highlight absences of approximately 4 days every 4 weeks” (p. 15). This claim is peculiar because neither of the articles cited by this UNESCO report make any such claim. The World Bank (2005) toolkit actually only makes speculative claims that menstruation may impact girls’ attendance at school if certain criteria – access to clean water, private washroom facilities, and access to menstrual products – were to go unmet. The toolkit does say, “No systematic research has been conducted on the relationship between the lack of appropriate sanitary facilities and the drop-out rate of adolescent girls” (para. 4). School dropout rates in Uganda, particularly among females, are high. Data3 from the Uganda Education Management Information System (EMIS) and the Uganda Bureau of Statistics (UBOS) show that the dropout rates for girls and boys at the primary school level are                                                  3 Data from 2016 is provisional, according to EMIS.   6 approximately the same. While over 4.36 million girls in Uganda enrolled into Primary 1, only 70% of them go on to complete Primary 7 (the rate of dropout for boys is 70%). Only 691,871 girls were enrolled in Secondary school in 2016. Only 36% of girls who enrol in Senior (Secondary) 1 will complete Senior 4. The dropout rate for girls in secondary school is higher than the rate for boys. Studies like the ones described above from UNESCO, UNICEF, and World Bank exclude girls and women who are not in school. While important, the organizations that examine the challenges facing school-going females (UNESCO, 2014; World Bank, 2005) do not account for the experiences of non-enrolled females, who make up a large proportion of the female Ugandan population. These organizations also fail to acknowledge the advantages, opportunities, or strengths that women in Uganda possess—there is a deficit orientation to many of their reports and studies. This deficit-oriented approach is reflected, in some ways, in the development work of the numerous Non-Government Organizations (NGOs) across the country. Rose Bakenegura Narmara’s doctoral dissertation (2009) concludes that NGOs that participate in poverty reduction programs in Uganda have little to no actual effect on the poor or socially excluded. One of my research goals was to help fill the gap in the conversation about young women’s experiences of menstruation. I locate this study within a larger concern regarding the effects and efficacy of NGO and foreign aid contributions in the name of such things as poverty reduction, gender equity, or improving quality of life through health or education efforts. I hope this study contributes to improving menstrual health. Improved menstrual health would be measured, as outlined by Sommer et al. (2015), by girls and women experiencing safe and dignified menstruation without shame.  7 Nyamu-Musembi (2007) states that “much of the discussion of gender inequality in sub-Saharan Africa takes place through the medium of development” (p. 207) in the same way that discussion on women’s rights often takes place through the medium of economics. As such, Nyamu-Musembi argues that it becomes difficult to “explicitly define gender justice” (2007, p. 204). Furthermore, the factors affecting gender justice in East African countries are further complicated by the assumption that gender equality is only desirable because it is economically defensible, not intrinsically valuable. This study proceeds with the assumption that gender equality and gender justice are inherently valuable; the value of the stories the participants share is not mediated through their potential economic earnings or their capacity to drive development and modernization in Uganda. Furthermore, this thesis situates women’s perceptions of how menstruation impacts their everyday lives within the wider conversation about sexual and reproductive health, as well as how these topics are taught in Central Ugandan communities (including, but not limited to, schools). Sommer, Sutherland, and Chandra-Mouli (2015) argue that discussion about menstruation “could provide a natural entry point for beginning to educate a girl about her reproductive capacity and contraceptive choices” (p. 2). According to the authors, this discussion would ideally take place before a girl experiences her first menstrual period. The authors may be suggesting that girls generally are not currently being educated about menstruation, their reproductive capacity, or about contraceptive choice either at school or at home. 1.2 Research Questions and Methodological Approach The overall goal of this study was to identify and illuminate the ways in which the research participants perceived and experienced their menstruation. Secondary goals were to better understand how they interpreted the modes of education, as well as their  8 delivery, and how that may differ or bear similarities between individuals, particularly when considering the complex and numerous factors that contribute to the formation of a young woman’s experience. This study included ten Ugandan young women as participants, who shared their experiences of their first menstruation or menarche, and how their family and the wider community responded. The main research question was: How do women living in Central Uganda experience menstruation?  The secondary research questions were:  1. What are the perceptions young women living in Central Uganda have about menstruation?  2. How do they approach their personal menstrual hygiene management? 3. What have been their sources of information, including formal, non-formal, and informal education? In the semi-structured interviews, I explored both the opportunities and threats to menstrual health and menstruation education. The study participants ranged in age between 18 and 30 years old. They were all residents of Central Uganda at the time of the interviews, but some hailed from the farthest reaches of the country’s borders. The participants were recruited from an existing dataset at BRAC Uganda from a previous survey that had been conducted by their research unit.  This thesis uses a feminist standpoint theoretical perspective to offer a more holistic, in-depth, and alternative perspective on menstruation in Uganda than what is currently available in much of the research literature. This means, as previously stated, valuing the stories the participants shared as intrinsically worthwhile. This also means  9 respecting and preserving the stories of the participants as wholly as possible, avoiding processing their messages through some other medium, such as development, so-called “white” feminism, or economic potential. The use of a feminist standpoint theoretical perspective involves attending to women’s stories as told by them, and to the unique and complex experiences of the participants (Harding, 2004; hooks, 2015; Crenshaw, 1991).  For the purposes of this study, experience is defined (2010) as the practical contact with and observation of facts and events as reported by the research participants both as they reflect on the past and share about the present day. I define perception as the awareness, regard, or interpretation a participant may have about a particular concept, namely menstruation. 1.3 Researcher Positionality The intersection of health education and menstruation is an area of interest to me because of my dedication to women’s health and women’s health advocacy. These passions contributed to my decision to do an internship in the research unit of BRAC Uganda. BRAC Uganda is an international non-government organization (INGO) that has agricultural, microfinance, and research endeavours across the country, to name just a few of their larger initiatives. There, I was exposed to several research and evaluation projects that were ongoing in the Empowerment and Livelihoods of Adolescents (ELA) and MasterCard Scholars programs. I was given the opportunity to work on projects that were related to my areas of interest in women’s health, adolescent health, and girls’ empowerment. I arrived in Uganda in December 2015 and began a 3-month internship in BRAC’s research evaluation unit. I worked as a research assistant and facilitator on several projects, including a Photovoice pilot initiative, survey design and  10 implementation, and survey enumerator training facilitation. I returned to intern for 3 more months because I absolutely loved living and working in Uganda and I did not want to leave. I designed the original thesis research proposal so that I could collect the research data in Uganda. I remained there continuously until my return to Canada in December 2016.  I carried assumptions about Uganda and Ugandan women into this research study. Primarily, these assumptions were informed by the images created and developed by UNICEF and World Vision ads on television, Hollywood films like The Last King of Scotland, and by publications produced by the World Health Organization (WHO) or the various United Nations organizations, including UNICEF and UNFPA. While my intentions were to proceed in my research with awareness of these assumptions, they persisted and informed my reactions to the findings in the data.  As a relatively privileged, white woman living in Western Canada, I had not considered menstrual health as a key concern for women; I took my (menstrual) health for granted. It was not until I traveled to Uganda that I learned that this is not so for all women. The perspective of BRAC Uganda is that women across East Africa face numerous and endemic barriers to positive and healthy menstruation. Buehren, Burgess, et al. (2012) echo this observation, and suggest these barriers are due to a number of factors, including cultural beliefs, social stigma, lack of access to safe and sanitary menstrual hygiene management (MHM) products and facilities, and in rare, persisting cases, female genital mutilation (FGM) and labial pulling (Bell and Aggleton, 2013), particularly in rural areas and in diasporas (Gallo, Villa, and Pagani, 2006).   11 During the internship, I became keenly aware of the strain in some of the relationships between (white) researchers and NGO workers and Ugandans. As noted in the Glossary (p. xii), the term “mzungu” was one I encountered early and often. Whether it was being used by a stranger or by a colleague, or even by me to refer to myself or my fellow foreigners, its various connotations and meanings are still not entirely clear to me. Again, it is not a neutral term. I observed issues among these relationships that largely stem from (neo)colonialism, neoliberalism, patriarchy, and endemic racism. As English and Irving (2015) note, “neoliberal ideologies are persisting in gender and development approaches that fail to challenge the patriarchal ideologies that lay at the foundation of processes that perpetuate inequalities” (p. 111). For this research study, I approached the interviews and data analysis with awareness of the frames I brought to the study as a white Western researcher as much as possible. My approach was one of learning from the research participants and recognizing these young women’s capacity and agency not only focusing on their problems. A deficit orientation was an orientation I found very common in the world of the many NGOs and research publications in Uganda. It is difficult as a white, Western researcher to fully understand Ugandan culture and history because of my position as an outsider and as a newcomer to the country. Creese, Huang, Frisby, and Ngene Kambere (2011) articulate how problematic it can be to conduct research as white, middle-class, Canadian, English-speaking woman on or with people who belong to the dominant racial, linguistic, socio-economic, geographic, and cultural communities. Further, my outsider status impacted the already complex relationship I had with the research participants. As I detail in the Methdology chapter, I focused on interviewing participants with a conversational rather than interrogative approach. I fully acknowledge that my participants’ perception of me  12 had an impact on our interview conversations. Exactly what the impacts are and how they influence the data and my interpretation of our conversations is difficult to assess. In her book, “A Defense of Ignorance”, Cynthia Townley (2011) explains that  This issue of experts’ responsibility acknowledging their own social position is of critical concern to feminist theorists as, for example, they think about research practices involving members of less privileged groups, such as indigenous peoples and refugees, and approaches to understanding social oppression generally. (p. 82)  There may be philosophical differences, not just racial and socio-economic ones. It is therefore problematic to engage with white feminism as the framework for this study. As stated by Townley (2011), White… feminists have faced criticisms for taking their own middle-class position to represent all women, when as bell hooks, for example points out, a concern with the limitations of a life focused on domestic responsibilities is less important to many women than fair working conditions. (p. 82)  Ronald (2012) has problematized the notion of help using a feminist lens to support her argument. In her essay, Ronald echoes the words of Jane Addams, saying “Charity is interpretation, a complex relationship between giver and receiver” (p. 175), meaning white women want to help others that they perceive to be relatively without by contributing money to a “good cause”. Help can come in many different forms, and is especially meaningful and welcome when people help one another in a respectful, dignified, mutually-assuring way. However, the problematic divisions between have and  13 have-not can reinforce and perpetuate, rather than dismantle, hierarchies of power and wealth. Many philanthropic endeavours have abused and misused funds and initiative recipients in the past; a famous recent example is the Haiti Scandal4 (BBC, 2018). During the data collection phase of this thesis, a rash of stories were published about volunteer tourists and aid workers exploiting locals and misusing funds. One such story was of a 21-year-old American missionary who sexually assaulted children in a Kenya orphanage (Ferrigno, 2016-2017). In the effort to dismantle hierarchies, multiple feminist movements have arisen. In North America alone, there have been socio-political movements in the name of African American women, Black American women, and LGBTQIQ2APA5 persons, Indigenous peoples, and many more besides who are motivated toward justice (with)in and freedom from the legacy of oppression under patriarchal, male-dominated, white colonial empiricism around the globe. Abwunza (1997), an African feminist scholar, argues that it is  …curious—if not unethical—that the Western conception of overpopulation (i.e., that in some sense usually pertaining to world systems of economic theory, there are too many people) has been most frequently applied by outsiders to the situation in Africa. Western researchers, development workers, world financial organizations, foreign media, donor governments, and particularly these governments’ taxpayers describe African reproductive behaviour as “irrational” as if ignorance were a variable. (p. 131).                                                   4 The scandal arose when Oxfam workers in the wake of the Haiti earthquake, including the then-Director of Operations, were found to be exploiting survivors for sex.  5 LGBTIQIQ2APA stands for Lesbian, Gay, Bisexual, Transsexual, Queer, Intersex, Questioning, Two-Spirited, Asexual, Pansexual, and Allied. It is common in North America to use a shortened form of the acronym, “LGBTQ” or “LGBTI”.  14  She goes on to state that  …it is also curious and unethical that “causes” OF AND “solutions” to overpopulation are most often directed at women rather than both sexes, as if men do not procreate. One of the reasons postulated for the “failure” of family planning programs is the dependent status of women, who see a large family as an economic and social necessity. (original emphasis, p. 131)  Uganda has seen its own women’s movement ebb and flow, its initial wave rising up while still a British protectorate. According to Tripp (2000), women’s voluntary associations were formed and “the education of girls went hand in hand” (p. 34) with their growth. Looking to the modern Ugandan context, Tripp, Casimiro, Kwesiga, and Mungwa (2011) state, “[Ugandan] national women’s organization leaders point to the 1985 Decade of Women conference in Nairobi as a watershed moment for Ugandan women’s associations” (p. 351). The growth and spread of Ugandan women’s movements are evidenced every day when Ugandan girls and women enrol in school, own businesses, marry at a later age, and become mothers at a later age. 1.4 Significance and Dissemination of Research Study  Understanding how menstruation affects Ugandan girls and young women, not just when (or whether) they are in school, is key to identifying opportunities and barriers Ugandan women face while they negotiate pathways and obstacles to menstrual health in their daily lives. In giving voice to these women, my goal is that governments, NGOs, and community organizations will be encouraged to shift toward an inclusive, collective  15 approach, working with young girls and women on how they can improve their health, actualize empowerment, and achieve equity. I hope these explorations contribute to the discussions about Menstrual Hygiene Management (MHM), women’s health, and S&RH in Uganda. Upon completion of the thesis, I will be disseminating it to the Makerere University School of Public Health, as well as BRAC Uganda, and WoMena—two NGOs working in Uganda which, among other things, focus on gender equality and women’s health.  1.5 Structure and Organization of Thesis In this first chapter, I have introduced the purpose of my inquiry and some introductory background information about Uganda as an East African country with a unique and complex history. It outlined some of the current literature that has explored the status of menstrual health among girls and women in Uganda, particularly in schools and refugee camps across the country. I have noted the multiple actors, including the Ugandan government, foreign aid agencies, (I)NGOs, and researchers both foreign and local involved in research and interventions related to women’s menstrual health. I have briefly outlined the research design, limitations, and contributions of my study. In Chapter two, I expand on my review of the relevant research, literature, and current programs pertaining to: Uganda’s colonial history and current geo-political, socioeconomic, and cultural state of affairs; sexual and reproductive health in Uganda; and, finally, menstruation in Uganda. I conclude that chapter with the theoretical framework of the research study. Chapter three expands on the methodology of the research study including the research design, data collection process, and the steps taken during data analysis.   16 The research findings are presented in Chapter four. The fifth and final chapter in this thesis contains the discussion of the findings, conclusions, and recommendations for further research. The final chapter is followed by a series of appendices and a comprehensive reference list used to compose this thesis.    17 Chapter 2 – Literature Review The purpose of this chapter is to locate the study of young women’s experiences of menstruation and menstrual education in a wider context including the history and current context of Uganda, studies of women’s sexual and reproductive health, and a feminist theoretical framework. In the first section of this chapter, the historical and geo-political context of Uganda is expanded upon. In the second section, I discuss studies where the focus has been women’s sexual and reproductive health in Uganda. As noted in the previous chapter, this is a popular topic of research among researchers from Western countries, and is a particular focus of the Ugandan government, (I)NGOs in Uganda, and humanitarian aid efforts. When searching for information about menstruation in East Africa, researchers will encounter a large body of literature focusing on sexual and reproductive health and on WASH, of which menstruation is an integral yet small and underdeveloped subtopic. The second section includes literature that has explored menstruation education in Uganda; the use of the term ‘education’ in this section applies to the general concept of learning as it transpires in formal, informal, and non-formal ways. The final section explores the feminist framework I employed for the study. This literature search was conducted using Google Scholar, the UBC library digital catalogue, the University of Calgary library digital catalogue, and print resources from several public and academic libraries in Vancouver and Calgary, Canada. Support by professional colleagues in Canada and in Uganda also contributed to locating relevant works and ensuring that seminal, recent, and relevant research studies across disciplines were included. I sought resources from East African scholars and researchers by speaking with colleagues and contacting scholars at Makerere University in Kampala. Results from  18 these searches were limited due to lack of access to a Ugandan university library and limited response from Ugandan scholars; this was caused in large part by the major strike that took place at Makerere University in the year I lived in Uganda. The works used for this study were gathered between December 2016 and September 2018. Every effort was made to collect the most recent publications; however it is sometimes necessary to cite articles published earlier than 1995. 2.1 Uganda: A Brief Historical and Geo-Political Context Makembe K. Simamba premiered her outstanding theatrical solo work, “A Chitenge Story”6 in 2017. Simamba’s performance weaves her personal story with the intricacies of Zambian heritage and culture through the allegory of the chitenge fabric: a traditional, patterned cloth that has innumerable functional and symbolic uses. In Uganda, chitenge, most often spelled kitenge7, can be seen everywhere. Its patterned flashes of bright colour contrast starkly against lush, green farmlands and reddish-brown silt that characterize the landscapes in Central Uganda, the wild forests of southeastern Uganda, the sharp Rwenzori and Sipi mountain ranges, the ruddy brown and grey-blue shades of the Nile River and its source, Lake Victoria, and the yellowed edge of the Great Rift Valley. The borders that cluster these diverse regions together as one country were drawn by Britain in 1894 during the “scramble for Africa”—the ethnic groups, kingdoms, and nomadic groups were forced into closer proximity and were all impacted by British colonial rule (Chamberlain, 2010).                                                  6 For more information on the production, visit 7 The Swahili word for the fabric is kitenge, with the hard “k” pronunciation [kI-TENG-geI]. In Ugandan English, hard “k” sounds are pronounced as “ch” (as in choice) instead. Thus, “kitenge” is pronounced “chitenge” [chI-TENG-geI] in parts of Uganda.  19 Uganda gained independence in 1962. Years of political and economic chaos followed, including civil war and the genocidal dictatorships of Milton Obote and Idi Amin. Uganda’s current president, Yoweri Museveni, has held his position since 1986. Former US President Barack Obama famously criticized Museveni’s extended tenure during his remarks to the people of Africa at the African Union in Ethiopia in 2015. Obama did not name Museveni directly; however, the implication towards Museveni and any corrupt leader in Africa was clear. Obama said,  I have to also say that Africa’s democratic progress is also at risk when leaders refuse to step aside when their terms end (…). I love my work. But under our Constitution, I cannot run again. (…).  So there’s a lot that I'd like to do to keep America moving, but the law is the law. (Applause.) And no one person is above the law. Not even the President. (Applause.) (…). The point is, I don't understand why people want to stay so long. (Laughter.) Especially when they’ve got a lot of money. (Laughter and applause.) And sometimes you’ll hear leaders say, well, I'm the only person who can hold this nation together. (Laughter.) If that's true, then that leader has failed to truly build their nation. (Applause.) (para. 40-42)  These sentiments allude to the growing evidence of corruption in the Ugandan government. Murithi (2009) argues that government corruption and dysfunction have led Uganda to depend on “foreign official development assistance” (p. 4). The dependency between the Ugandan government and foreign aid (re)enforce the aid colonization process whereby Uganda becomes “addicted to aid” (p. 4), and there is  20 no economic incentive to strive for autonomy. One of the many consequences of heavy reliance on foreign aid is the donor’s or lender’s agenda. In her book chapter “Aid from a feminist perspective”, Awino Okech (2009) states, When international institutions, which have been important in terms of raising the profile of women’s concerns, take up gender agendas the counter effect has been the calibration of extremely complex issues and societies into vast statistics and slogans designed merely to respond to competing interests on a global stage. (p. 35) In Uganda, there are hundreds of aid institutions that target, in whole or in part of their overall agenda, girls’ and women’s issues. Recently, global attention on Africa has been informed by data prepared by organizations like the United Nations, the World Bank, Oxfam, and global news networks within the so-called post-colonial legacy of African nations. Aid institutions, researchers, policy makers, and development workers use these information sources to inform their practices and policies.  2.2 Sexual and Reproductive Health in Uganda The United Nations Population Fund (UNFPA, 2010) reported that, “for the first time in history, reproductive health has been recognized at the Security Council level” (p. iii); as a consequence, reproductive health became the subject of renewed and globalized focus among several developing nations. Governments, including Uganda, indicated public, legal resolution, and explicitly acknowledge “the need to ensure women and girls’ access to reproductive health services and reproductive rights to achieve better socioeconomic conditions in post-conflict situations” (p. iii). Studies about adolescent S&RH in low- and middle-income countries (LMICs) tend to focus on HIV and AIDS,  21 poverty reduction and livelihoods, family planning, domestic violence and conflict, and female genital mutilation (FGM) (UNFPA, 2010). Since the 2010 resolution passed in Uganda, S&RH is an established field of research and activism in Uganda. Scholars, NGOs, and government in and of Uganda agree that sexual and reproductive health are human rights, and that improved S&RH can impact other aspects of quality of life, such as education and livelihood (Hulton et al., 2000; Crofts and Fisher, 2012; UNFPA, 2010). Nyamu-Musembi (2007, citing Adjetey, 1995) offers confirmation of an observation I shared while I was living in Uganda, which is that women and girls have “little sexual and reproductive autonomy” (p. 192). This means that women sometimes have no power or control over when to have sex, when to get married, whether to use contraception, and, when pregnancy occurs, whether to raise a child alone. It is essential to note that while the Ugandan government resolves to improve reproductive health, it continues to operate abstinence-only sexual health education in public schools. Official documentation establishes that Ugandan schools feature abstinence-only sexual health education in order to prevent against HIV infection. The Ministry of Education and Sports (MES) states that the vision for its special HIV/AIDS Unit (MES, 2017) is to have no new HIV infections among people involved in the education and sports sectors. To this end, their goal is “to contribute to the reduction in the number of persons... engaged in high risk behaviours that facilitate ttransmission or acquisition of HIV infection” (para. 6). According to Cook (2010), the agenda of sexual health education in Uganda is “for HIV prevention” (p. 532). Abstinence-only education is proven, in other countries, to be ineffective against sexual activity and conception among teenagers (Collins, Alagiri, Summers, 2002; Stranger-Hall,  22 Hall, 2011; Santelli, Ott, Lyon et al., 2006). An assumption carried by some of the research participants in this study was that girls who become pregnant while they are still of school age are expelled and are not permitted to return to their studies after they become a mother. A comparison of the stories I heard from Ugandan friends and colleagues against any curricula or official statements from the government would have been ideal in order to corroborate this claim. I was unable to find scholarly or legislation information on school policies regarding student pregnancy. An article published by the Uganda daily newspaper New Vision (Natukunda, 2018) claims that “pregnant girls will take at least one year of maternity leave, under the Minstry of Education revised guidelines on school retention and re-entry” (para. 1), yet I have been unable to find any MES documents confirming such claims. Based on what the research participants have said, it seems as though schools are at liberty to disregard the government guideline recommending that girls be allowed to continue their studies while pregnant and after childbirth.  Bell and Aggleton (2013) argue that there is plenty of evidence in the literature about context and influence of contributing factors, both proximal and distal, on young people’s sexual health. However, actively improving sexual health is an entirely other matter because it “requires actions to target a range of social, cultural and economic influences enabling and supporting health protective behaviour among young people and other community members” (p. 103). Chimphamba Gombachika, Fjeld, Chirwa, Sundby, Malata, and Maluwa (2012) reveal that challenges to accessing sexual and reproductive health services exist on the individual, interpersonal, communal, cultural, and societal levels. 3 According to Rijskijk et al. (2012), the ssenga’s role is in “educating  23 (‘instructing’) Ugandan girls about sex and marriage, including how to become a ‘good’ wife, that is, to be submissive to their husbands and his relatives, as well as ensuring all his needs are met, including sexual needs” (p. 411). Nobelius, Kalina, Pool, Whitworth, Chesters, and Power (2010) found the same, and that, to date, other sources include pornography8, family, in-school sexual health education, the latter of these sources are only available in English. However, Arube-Wani, Jitta, and Mpabulungi Ssengooba (2008) noted that while some of their adolescent research participants believe the ssenga is a central influence in matters of S&RH, many of their respondents felt that this practice is “dying out” and friends are increasingly replacing ssengas as sources of knowledge (p. 228). An outstanding quality of this study is that it indeed loudens the voices of its research participants. It is important to note that the ssenga teaching tradition arises in this study through the Baganda teachings I have been exposed to. Other ethnic groups or Mugandas who choose a religious tradition over their cultural one may or may not observe the tradition of the ssenga teaching. Knudsen (2006) points out, “even if a comprehensive sex education program were introduced into the school system, the challenge of reaching adolescents who are not in school would be great” (p. 42). Sex education programs brought to communities and villages in Uganda would face some challenges that include participant attrition, parental permission for children, public awareness and permission from elders where necessary, logistics and resource limitations, and development of curricula and plans of action that can account for diverse needs and demands of a given community, to name a few.                                                  8 Note that adolescent females enrolled in school created this list.  24  A final note on the context of Uganda: it is important to draw a distinction between the experiences and perceptions of women living in different parts of Uganda and women living in refugee camps. Refugee camps bear few similarities to the region that they occupy, and feature unique sets of resources and challenges. As just one example, sources of clean water and its degree of accessibility in Bidi Bidi may be different from what its occupants normally use. Routines surrounding the use of clean water, such as cooking, personal hygiene, and laundry, will be carried out in a way that is adapted to the resources available in the camp. There are many studies conducted in refugee camps in East Africa and elsewhere around the world. Uganda was, for a time, the location for the world’s largest refugee camp; Bidi Bidi, as it is called, surpassed the previous largest refugee camp, Dadaab, in Kenya. At its most populous, Bidi Bidi contained 800,000 people, mostly Sudanese refugees fleeing conflict. The current population of Bidi Bidi rests at around 274,000, according to the United Nations Human Rights Council (UNHCR, 2018) and Dadaab’s population rests at a size consistently larger than Bidi Bidi (UNHCR, 2018). As of the writing of this thesis, the world’s largest and fastest-growing refugee camp is Kutupalong, located in Bangladesh, hosting Rohingya Muslims fleeing Myanmar (UNHCR, 2018). 2.3 Menstruation in Uganda Menstruation is a categorical yet under-researched aspect of S&RH in Uganda. The literature features little information about specific barriers to women’s menstrual health in Uganda, but the body of literature is growing rapidly. Referred to as menstrual hygiene management (MHM), public health and development literature focuses on MHM among women living in refugee camps and girls enrolled in school.  25 This may be due in part to the relative ease of access to these populations as research objects/subjects, as well as the seemingly inextricable relationship between the Ugandan government and foreign aid. Sommer (2011) identifies menstruation as a key yet overlooked opportunity for public health intervention. There is literature and information from Kenya, Tanzania, Rwanda, The Democratic Republic of the Congo, and Nigeria that can be informative.  As previously stated, much of the literature that does exist on menstruation in Uganda focuses on in-school adolescent females and how their menstrual cycle affects school attendance. In relation to that literature, Parker, Smith, Verdemato, Cooke, Webster, and Richard (2014) verify that many initiatives across the continent have failed to draw firm conclusions9 around menstrual health and its impact on school absenteeism because of the wide variety of geographic location, socioeconomic status, and sociocultural positions. It is clear that different populations of adolescent girls face diverse challenges based on several complex and interconnected factors.  Crofts and Fisher (2012) identify several barriers to sanitary and dignified menstrual hygiene, including, but not limited to: lack of access to convenient, accepted, and affordable MHM products; lack of opportunity for safe MHM product use and disposal; social stigma and embarrassment surrounding menstruation, menstrual products, and general MHM; lack of awareness, information, and/or                                                  9 Parker, et al. (2014) are referring to the following citations to support their claim: Narayan et al., 2001; Bharadwaj and Patkar, 2004; WaterAid, 2005, 2009; Adhikan et al., 2007; Ten, 2007; Deo and Ghattargi, 2005; Kirk and Sommer, 2006; Dasgupta and Sarkar, 2008; Anibue et al., 2009; Dhingra et al., 2009; Erulkar et al., 2010; Sommer, 2010; McMahon et al., 2011; Thakre et al., 2011; Kamaljit et al., 2012; Shanbhag et al., 2012.   26 knowledge about puberty and MHM; inadequate water and sanitation facilities; and lack of financial means to purchase MHM products.  Information in the following section draws from personal observation and discussions while living in Kampala for one year (December 2015 to December 2016). No extensive survey of menstrual products available in Central Uganda has yet been published. If current availability of menstrual products in urban and rural shops is any indication, the only store-bought products on the shelves of shops and supermarkets are imported disposable pads. Menstruating girls and women who do not or cannot purchase disposable pads use cotton cloth (purchased as is, or otherwise improvised using available fabrics and rags), cotton wool, and sometimes even natural materials like banana leaves or cow dung. Tampons are available at pharmacies, but they are expensive and their uptake is under-researched. According to the several pharmacists and public health research colleagues in the I spoke to over the course of the year, tampons are seldom sold or purchased except by foreigners and occasionally Ugandans who are wealthy. There are alternative menstrual health products currently available commercially in Uganda: Ruby Cups menstrual cups and So Sure reusable pads were both newly available in 2016, but distribution of these products is extremely limited, so obtaining a reusable pad or menstrual cup is only possible if you know someone who distributes them. BRAC Uganda is one such distributor—in spring of 2016, BRAC had approximately 15 women selling SoSure pads and Ruby Cups in Central Uganda. The research participants in this study have had access to imported disposable pads and a couple of them have been exposed to SoSure reusable pads. While alternative products that are now available in Uganda, they are very new,  27 with restricted availability and limited product awareness. SoSure is a brand new product10 that is designed and manufactured in Uganda, and they are only commercially available in a few regions; Ruby Cups11, at 70,000 Ugandan shillings (about $27 Canadian Dollars) per item—is too expensive for most Ugandans. Traditional and historical practices surrounding menstruation vary greatly in sub-Saharan Africa. As a result, it is important to not assume the literature from studies conducted in other sub-Saharan countries applies to another country like Uganda. Neither is it appropriate to generalize about all women in Uganda given the diversity within the country’s borders. That being said, sometimes the only way outsiders can learn about an un(der)researched group of people is to read scholarly works produced from similar groups or nearby countries. The term “outsider” is borrowed from Botterill’s (2015) study, wherein she conducted research with Polish migrants as British woman. Outsider, in Botterill’s (2015) study, is defined as someone who does not match any or all descriptive qualities of another person or population. Literature often refers to Sub-Saharan Africa (SSA) or East Africa, which suggests, problematically, that this area is homogeneous. Many studies of Uganda also assume that the country is homogenous, ignoring the diversity that exists within its colonial borders. That said, research from Tanzania or Kenya, or even from Nigeria could be informative, especially as these countries all share some similarities. Among the investigations carried out specifically in Uganda, Larsen (2010) and Perez                                                  10 A subsidiary of AFRIPads, So Sure pads have only been commercially available since August 2014.  11 Sam Musoke is the distributor of Ruby Cups in Uganda, and was my next-door neighbour in Kampala. She has been growing her enterprise to make menstrual cups available in Uganda for years, and has been permitted to import cups as of mid-2014.  28 and Namulondo (2011) state that (in Bell and Aggleton, 2013), “girls approaching the onset of menstruation and puberty talked about ‘visiting the bush’ or ‘pulling’, referring to the practice of elongating the labia minora” (p. 107). These traditional, ceremonial practices are still evident in the rural and remote parts of Uganda.  2.4 Theoretical Framework I approached this research study with the supposition that there is more to the narrative about menstrual health among women in Uganda than is reflected in the current literature and the ongoing research projects and programs that focus on menstruation. In addition, I was troubled by the problem and deficit orientation of current studies. I also struggled with what I viewed as evidence of white saviour complex12. In my experience living in Uganda for a year, women of all ages demonstrated resilience, resourcefulness, and power that demanded respect and appreciation.  Given the above sensibilities and observations, I turned to feminist standpoint research as the guiding theoretical and methodological approach for this study. Feminist approaches engage with women as subjects, not objects; they are women-centered, equity-seeking, and critical. Feminist standpoint theory acknowledges women’s values, beliefs, and actions as part of their ontological reality (Hartsock, 1983; Hekman, 2007).  For Hekman (2007), a feminist standpoint methodological approach is based on the tenet that “the social position of
the knower determines the knowledge produced” (p. 8). This is similar to the perspective articulated by Nancy Hartsock (1983, 1998): a woman’s way of understanding the world is not the same as the way men understand it. In the revised version of                                                  12 White saviour complex is a term that describes the practice by a white person of perceiving and acting upon the assumption that non-white peoples need and want their help while also carrying out their own self-serving desires. For a satirical portrayal of the white saviour complex demonstrated in Uganda, visit the Instagram page for Barbie Saviour,  29 her book, Hartsock (1998) suggests that if men understand the world differently than women, then surely women understand the world differently from one another. This means that those of us trying to learn about and from women’s experiences must assume that their words reflect the truth of their experience of the world in which they exist. This contrasts with an orientation to truth as objective; that is, based on a judgment that claims to be uninfluenced by personal experience or opinion.  This also means that I must be aware of the limitations of feminist orientations built upon the lived experiences of White Western women and become familiar with African-based feminist engagement. For example, in SSA, movements of feminist thought and action took place toward the end of the 20th century. Oduol and Kabira (2002) write about the context of Kenya, stating that as women’s activism took on a “womanist”13 or “feminist” shape in the 1960s and 1970s, observers such as journalists began identifying it as a single movement. Indeed, in many Western countries, activists gave what they were doing the name “women’s movement”. The African case does not fit any singular definition, argue Oduol and Kabira (2002) in their chapter on the Kenya women’s movement. Activism was plural, multiple, and thus barely resembled a unified entity. Rwakabukoza’s (2018) podcast, Wulira! Uganda, has featured several episodes in recent years featuring discussions among Ugandan feminists and womanists and has been influential in this research study, as well.  There are many varieties of feminism and no single feminist ideology can capture the complexity and unique situation in Uganda. Feminisms born in the West are likely not sufficient to guide an investigation in East Africa. The problematic nature of the relationship between the                                                  13 The term “womanist” is used by women of colour, mainly in the United States of America; it is a term coined by Alice Walker to address the racism inherent in white feminism. See  30 Ugandan women as research participants and me as the researcher in this study made me question whether it was possible or right to carry out this work. Patti Lather (2006) argues that the dichotomous, supposedly incommensurable paradigms between academic practices must be reframed to “work within, against, and across traditions that are all positioned within a crisis of authority and legitimization as we search for practices that open to the irreducible heterogeneity of the other” (p. 52). This irreducibility of diversity among women is something I attempted to emphasize in my study. Undoubtedly, further studies that examine the relationships between women’s voices and subjectivities in relation to larger constructs are needed. It was not necessary to focus solely on our differences for this study, though. Shared experiences as women and similar perceptions about menstruation, sexual and reproductive health, and education were common grounds for understanding.  2.5 Summary The factors that play a role in the experiences and perceptions of menstruation among women living in Uganda are determined by Uganda’s specific context, S&RH in Uganda, and menstrual health and menstruation education in Uganda. Much of the literature about menstruation in Uganda (and East African countries) focuses on menstrual hygiene management by way of the public health and development disciplines. Additionally, there are contributions from such social sciences as anthropology and sociology. A large proportion of these publications are written by white European or North American researchers, but some of their studies and reports may include Ugandan researchers as third author or lesser. The literature reveals barriers to sexual health education, safe and dignified menstruation, and raises the concern that Ugandan girls are vulnerable to missing school because of their menstruation. There is more to the story  31 than can be fully explained by this body of literature, and a standpoint feminist approach informed by an African womanist perspective can be used to illuminate more.   32 Chapter 3 – Methodology In this chapter, I delineate the methodology and research methods drawn upon for this study. How the study was conducted is as important as what the study aims to reveal. As stated in the previous chapter, a feminist standpoint frames this study. The research design details the different processes and procedures that were followed in the conduct of this study, beginning with the formulation of the research methods and ending with a discussion of the trustworthiness of this research study. 3.1 Research Design In this section, I will detail the research methods, the selection criteria and recruitment process, interview design, ethical considerations, the informed consent process, and the data collection process. A description of the data analysis then follows. The purpose of going into such detail is twofold: first, to precisely illustrate how these processes worked to address the central research questions and methodology of the study, and; second, to explicate the processes to enable a clear understanding not only of what was done, but why it was done in that way.  3.1.1 Research Methods  The primary research question was: how do women living in Central Uganda experience menstruation? The secondary research questions were: what the perceptions young women living in Central Uganda have about menstruation? How do they approach their personal hygiene management? What have been their sources of information, including formal, non-formal, and information education? As indicated in the previous chapter, the vast majority of the research conducted in Uganda about menstruation, or S&RH more generally, are quantitative in method. I  33 approached the conversations I had with the young women informed by a feminist standpoint perspective, which seeks to listen to women’s everyday lived experience. The interview conversations with participants were similarly informed by an approach to qualitative interviewing used by Kvale and Brinkmann (2009), which “attempts to understand the world from the subject’ points of view, to unfold the meaning of their experiences, to uncover their lived world prior to scientific explanations” (p. 1). Cook’s (2010) study, which explored what women want from school sex education, influenced the research methods taken up in my research study. Qualitative explorations, Cook argues, “can provide a promising foundation for investigating how to make sex education programs relevant to young people’s wants and needs. Future research should take young women’s views into account to create better sex education programs" (p. 532). Lie (2008) writes that, among adolescents in Sub-Saharan Africa, “approaching issues of sexuality and reproductive health involves careful consideration of how to address people, for instance how to ensure that an individual’s integrity is protected, and how to show respect for existing societal values and sub-cultural values” (p. 78). Thus, the research questions are phrased with emphasis on how Ugandan women perceive their menstruation and menstruation education.  3.1.2 Selection Criteria and Recruitment Process I interviewed ten Ugandan women, ranging in age from 18 to 30. It took 11 weeks to conduct the ten interviews, starting November 3rd, 2016, the completion of which occurred within seven days of my departure from Uganda, November 28th, 2016. Participants in this study were those who are no longer in primary or secondary school. This decision was informed by the fact that the majority of studies conducted in Uganda  34 that focused on menstruation and MHM were conducted utilizing girls still enrolled in school. Because the majority of the females in Uganda are not enrolled in school and school dropout rates are high, this study can contribute to filling the gap in the research on women who are beyond secondary school achievement by inquiring about their experiences both in and beyond school. Additionally, placing the focus on girls and women who were finished school would reflect diverse perspectives, thereby contributing to a more holistic picture of the experiences of menstruation among women living in Central Uganda.  Participants who lived within Central Uganda were selected to participate for two reasons. Firstly, I lived in Kampala, so it was realistic and feasible for me to reach parts of the city and immediate suburban areas, but travelling further than that would be a greater challenge. Secondly, limits must be placed in terms of geography because where one lives in Uganda profoundly influences the culture, language, and experiences a person would experience on an everyday basis. As one illustration, Northern Uganda is very different from Central Uganda because of the presence of the Lord’s Resistance Army (LRA), the refugee camps (including Bidi Bidi, Larogo and Oryang camps), and the largest city, Gulu, being a very different city from Kampala in many respects (including, but not limited to, different dominant languages and ethnic groups). As another illustration, Eastern Uganda is characterized by the Sipi Mountain range and the Karamojong lands—again, very different cultural and ethic contexts than that of Central Uganda. It is important to note that not all participants were born or grew up in Central Uganda. For reasons of anonymity and protecting the privacy of the research participants, I will not identify the villages that the research participants have come from.   35 The age criteria for this study were women who are 18-30 years old. I bracketed the age criteria this way because 18 is the age of majority, and 30 is the rounded-up limit of the United Nations definition of youth. For reasons of ethical procedure and wishing this study to present as low-risk to participants, involving young women under the age of 18—thereby requiring the informed assent of their parent or guardian—was decided against. The number of interviews was limited to ten due to the restricted resources and time available for the data collection phase of the study.  Another key criterion for recruitment was that participants should have a comfortable grasp of the English language. There were many reasons for this requirement or perquisite. First and foremost, I am an English speaker; it would have been impossible to learn Luganda plus any number of other languages represented by research participants in the conduct of this study. Furthermore, including participants speaking different languages would result in significant challenges to translation, the paramount concern being the loss of understanding that occurs with translation. Many people living in Uganda speak English comfortably; other Ugandan researchers have found that conducting the interviews in English seemed to not be a significant barrier. Participants were informed that interviews would proceed in English and the final product – the research paper – would be written in English. Participants in this study were recruited through support and resources from BRAC Uganda’s Independent Evaluation and Research Cell (IERC). A research fellow and a research assistant within the department coordinated with me to generate a list of potential participants in this study based on participation in a survey previously conducted by the BRAC IERC. Because this previous survey pertained to health matters, and because  36 respondents indicated their ability to speak English by participating in the survey in English, the list of names generated from this survey was a convenient, accessible, and ethically approachable grouping. The BRAC research assistant performed the initial recruitment phase whereby he called prospective participants via a list generated from a list of previous survey respondents from a BRAC study conducted several months earlier. The original list of 65 eligible candidates was quickly narrowed, as most of them proved to be unreachable by the phone numbers they had provided in the survey. In Uganda, frequently changing one’s phone number or not having one at all for a period of time is not unusual. Then, the ones that the research assistant did manage to reach and to whom the “initial recruitment notice”14 speech was given to were not necessarily possible for me to reach. Of the 20+ women who consented past the assistant’s initial contact, I barely achieved 11 calls and conducted the ten interviews in time for my return to Canada. Another unforeseen communication challenge was that women who did not possess a phone of their own would provide a number for a friend or relative on the survey. There was no option to indicate whose number was being given, whether personal or familial; in one instance, 3 different eligible prospective participants were all only reachable through the same number of a mentor and leader in their community. Issues of confidentiality arose as a result. At one point, the owner of this phone number directly asked me if I had indeed interviewed her friend. I told her I could not tell her whether her friend interviewed with me or not as it was confidential. Ultimately, this participant told her friend that she had completed an interview with me and considered the matter a non-issue. However, if                                                  14 See Appendix 1: Verbal Recruitment Notice.  37 the participant had wished for privacy, her friend learning about her participation could have been harmful. There was much conversation with other researchers at BRAC and at Mildmay Uganda, the ethics review board, over how and how much to fairly compensate research participants for their contribution. Ultimately, participants were compensated as follows: full reimbursement of all transportation costs, return trip to meet for the interview (no maximum); full reimbursement of all communication costs (text messages, messages using network data, and phone calls); and a 7,000 Ugandan Shilling (UGX) payment (approximately $2.25 Canadian Dollars at the time). This figure was decided on with the guidance of the researchers at Mildmay Uganda. 3.1.3 Interview Design The interview questions explored women’s sense of wellbeing, and were designed to inquire into their experiences as young women and about what they do and used to do to care for themselves. The framing of these questions reflects an asset-based approach. I did not want to ask questions from a problem-based perspective; rather, the interview questions were designed to give space for women to voice the advantages, strengths, and opportunities they faced. This approach to interview questions also allowed for the opportunity to capture the diversity of perspectives each woman would share. Given the wide age range of participants, I anticipated that an 18-year-old would have similarities and differences in experiences compared to a 30-year-old, and once data analysis was complete I realized that the inference was correct. The structure and question phraseology was inspired by the study conducted by Bartlett, Iwasaki, Gottlieb, Hall, and Mannell (2007) investigating Diabetes in among  38 Metis and First Nations peoples in central Canada. Bartlett et al. (2007) conducted an Aboriginal-guided approach that did not privilege Western ways of knowing or understanding one’s experience, and resisted “impos[ing] Western conceptions of matters of health and illness upon the research participants” (p. 2372). This study took inspiration from what Bartlett and colleagues called an Aboriginal-guided approach. The question, “tell me the story of your life growing up”, served three purposes: 1. To start out with a simple question that invites the telling of the story. And by simple, I do not necessarily mean that it is universally easy or comfortable to talk about one’s past, but simple being a question the respondent knows the answer to. 2. To gain an understanding of the participant’s family and home, and/or school life, and to use that information to contextualize their life experiences and perceptions. 3. To make our meeting less like an interview and more like a conversation where there is sharing and comfortable dialogue rather than the interrogative, back-and-forth, give-and-take format an interview might detrimentally assume. An unforeseen challenge with the interview tool was that many of the questions were unnecessarily long and had complicated phrasing. To facilitate both written and verbal comprehension, my participants would have benefitted from more simple and clearer questions. The interview tool used in this study, which can be found in Appendix C, provided equal parts structure and flexibility to the ten different interview conversations that took place.    39 3.1.4 Ethical Considerations It was important to the ethical considerations of the study and to the integrity of the research data that study participants enter into involvement in the study with full understanding of the aims of the work, the intentions of the researcher, and the benefits and risks associated with both. In an effort to protect the dignity and privacy of the research participants, I worked closely with the BRAC research assistant during the recruitment process to ensure participants had a full understanding that their participation was voluntary and would be compensated fairly. As noted above, the research assistant performed the initial recruitment phase, calling prospective participants from a list generated from a list of survey respondents from a previous BRAC study; he had not been involved in that study. This stage occurred so that any potential communication barrier could be eliminated by having the research assistant, who speaks fluent English and Luganda, communicate the recruitment notice effectively, answer any questions, and establish voluntary and informed participation eligibility clearly and fully. My status as a Canadian, female researcher was shared with the participants. There is great potential that this fact biased participants towards or indeed away from participating in the study. The biggest challenge to the ethics approval process was negotiating the requirements of three different ethical review bodies: the local, Internal Review Board (IRB), Mildmay Uganda, the federal review board, the Uganda National Council for Science and Technology (UNCST), and the University of British Columbia Behavioural Research Ethics Board (BREB). While I familiarized myself with the requirements of all three boards and developed my ethics application in consideration of the requirements set by all three, the two strongest issues were that the order of operations was unclear and that  40 the time and finances needed to achieve ethical approval were far greater than anticipated. Local ethical approval was achieved first, by submitting an ethics application to Mildmay Uganda: a hospital and research facility located west of Kampala. The review committee there requested revisions to further clarify the nature of qualitative research; once ethical approval was granted from that body, another application was prepared for UNCST. The ethical approval from UNCST was granted quickly with no revision, but the official letter that I was required to obtain before interviews could commence took over six weeks to arrive. This is due to the fact that every single research endeavour conducted in the country of Uganda must be registered and approved by the federal government. This is done so that the government is aware of these activities and can protect research participants from the harms and risks research studies may present. The ethics approval process, from research proposal completion to granted ethics certificate, took six months. To protect the identities of the research participants, each woman chose a pseudonym under which her story would be shared in this thesis. One participant did not want to use a pseudonym and would have been proud for her real name to be featured in this study; however, my ethics application did not have a provision for this preference, and after I discussed with this participant that her using her real name could compromise the anonymity of her fellow participants, she agreed to use a pseudonym. The pseudonyms for the 10 participants are: Emily (1E), Mary (2M), Sweet (3S), Robinah (4R), Fatu (5F), Harriet (6H), Olivia (O7), Amina (8A), Jane (9J), and Sharon (10S). 3.1.5 Informed Consent Process The informed consent process was given plenty of time before interviews began. It was very important to me to use the informed consent form review as an opportunity to  41 achieve two things: ensure that the person understood about the study and their rights thoroughly, and also as a chance to begin to build a rapport. One of the ways I did so was to come across as professional yet approachable by the way I dressed, to the way the consent forms were presented, to the way I spoke. Another way I tried to ensure a comfortable atmosphere was to select a convenient location that would be easy to find and would offer refreshments for sale, like a café or restaurant. I would purchase soda or tea and water for each of us to enjoy during an interview. I would also engage the person in small talk before bringing conversation around to the study. Several researchers in Uganda had told me that it is inadvisable to ask someone’s HIV status. I took this advice, and extended it to the degree where I never asked the research participants in this study about anything taboo or strongly personal unless they raised the subject spontaneously themselves.  All participants were given a copy of the informed consent form, and the entire form was reviewed and read together before signing and proceeding with the interview. The consent forms, both in English and Luganda, can be found in Appendix B. All participants were reminded repeatedly that they could choose to back out of the study at any time and that their interview could be deleted without any argument. This fact was re-iterated to all participants within 48 hours after the end of the interview, as well. While all interview participants were offered a copy of the informed consent form15 translated into Luganda, none of them needed the Luganda form in order to demonstrate they understood what the study was asking of them; only two of the ten participants asked for a copy of the Luganda version to retain as a reference. Both of these women were given English and                                                  15 See Appendix B: English and Luganda Consent Forms.  42 Luganda consent forms, and they both signed the signature page in English for use by the researcher. At least two participants did not speak any Luganda—I did not anticipate this because I had proceeded with the Luganda translation under the impression that the interview participants were likely to be Muganda given that they live in Central Uganda. After the start of the data collection process, I learned that many people living in Central Uganda migrate from all over the country, and that in fact some women living in Uganda lead transitory lives. My requirement that the participants speak comfortably in English helped to prevent any miscommunication or misunderstanding between myself and the participants who identified with other ethnic groups represented in Uganda. If non-Luganda-speaking participants had asked for a consent form in their language, I would have chosen to not include them in the study lest I risk involving an uninformed participant. All participants were given the opportunity to sit and read the Luganda consent form on their own time; however, none did so. In each instance, we read the informed consent forms together, with me reading it aloud and pausing frequently to ask if they had any questions and to ensure they understood what the form contained. I did this to ensure that the participants understood the study and its associated benefits and risks. 3.1.6 Data Collection Process In the first week of data collection, five interviews were conducted within seven days. The remaining five interviews would take three more weeks. The main cause for this was the time I took to focus on my continuing work with another research project in Uganda to do field visits. Communication challenges arose due to communication difficulties between the BRAC research assistant and me. Access to the participant list  43 was exclusive to him and therefore I had to wait for him to be available to compile a list of women I could call to schedule an interview.  For several participants, language and communication was a factor that required extra patience and humour to negotiate. Several participants benefitted from reading the interview tool along with me, both to follow our progress and also to enable better comprehension of the questions. Multiple copies of consent forms and the interview tool were always available to participants at the interviews. Participants were always invited to follow along with my interview prompts using the documents, and to retain their own copies afterwards. My (Canadian English) accent and my fast rate of speech was challenging for some participants, so I modified my pronunciation, rate of speech, and Ugandan English colloquialisms accordingly. The range of experience and comfort with the English language varied among participants. Interviews lasted anywhere between 20 minutes and one-and-a-half hours, not including time spent visiting before and after the actual interview, and not including time spent reviewing the consent forms.   An unforeseen benefit that occurred during the interviews was that three women expressed that they enjoyed our conversation and that they felt grateful for the opportunity to share their story. Our conversations were particularly comfortable and open. I attribute this to the rapport I built with each participant throughout our meeting. One of the ways I maintained an atmosphere of comfort was to not take notes during the interviews. It was very distracting to participants and made the meeting feel more like an interrogation than a conversation. Another way I encouraged the conversational tone to the interviews was to share my own stories and experiences in my life, especially if I shared something in common with a participants. As just one example, when Emily, Amina, then Sharon told  44 me they were 13 years old when their first menstruation began, I told them that I was also 13 when mine began. This became an opportunity to commiserate and bond together. 3.1.7 Analysis of Data Data analysis was informed by seminal qualitative research methods texts (Tesch, 2013; Kvale & Brinkmann, 2009; Bryman & Bell, 2016). Data analysis occurred over three phases. First, I transcribed the interviews with the assistance of a research transcription assistant. Once this was done, I listened to all of the recordings in order while also reading along with the transcripts. This first phase was rooted in an approach wherein the important ideas and stories arose from the data on their own, inductively. Special note was taken of repeated thoughts or ideas, of ideas or thoughts that were labeled or expressed as important by the interviewees, and of ideas and thoughts that I had while listening that were interesting, important, or relevant to me and my curiosities. The second phase entailed coding for themes that arose in the transcripts. No software was used for this process—all data analysis was done by hand solely on my own. Over 690 codes emerged across the ten transcripts, again with an inductive approach. The codes were identified based on three factors: it was important to the research participants, it was important or interesting to me, or it spoke to the research questions. In the third phase, the codes were organized and subcategorized into themes. This occurred by organizing the codes into five descriptive categories (five because that is the number of distinct coloured flagging stickers I bought): menstruation, menstruation education, abstract concepts (e.g., stress, taking it easy), concrete concepts (e.g., poverty, village life), emotions (e.g., fear, anger) and colonialism (i.e. mention of foreigners, British culture). This phase was challenging because while there were many important and interesting things shared in the  45 interviews, only themes that were connected to the research questions or that stood out as interesting were included; there are a lot of themes that arose that have not been included in this thesis. The themes included in this thesis, which are presented in Chapter 4, are organized into three over-arching topics capturing 12 themes (Kvale and Brinkmann, 2009; Bryman and Bell, 2016). Metaphorically speaking, every possible kitenge fabric seemed important to include in this thesis initially. However, for the purposes of this specific research endeavour, every possible pattern will not be individually described when the priority is to capture individual cloths from a handful of different vendors in a massive market. 3.2 Trustworthiness of This Study In this section, I will describe the ways this research is verifiably trustworthy. Tracy (2010) describes eight criteria for qualitative researchers to use as we design, implement, analyze, and write about their research. I have attempted to adhere particularly closely to the values defined in Tracy’s article of rich rigor, sincerity, worthy topic, and meaningful coherence. The pursuit of rich rigor meant using theoretical approaches, data, and contexts that were appropriate, complex, and sufficient to answer the research questions. Pursuing the research study with sincerity meant this study should be “characterized by self-reflexivity about subjective values, biases, and inclinations of the researcher [and] transparency about the methods and challenges” (p. 840). In addition to keeping a personal journal throughout my time in Uganda, I also kept journals of my first three months as an intern at BRAC Uganda for a practicum course at UBC in the Department of Educational Studies. The relevance, timeliness, significance, and appeal of the topic mark this research topic as a worthy one. Meaningful coherence, according to Tracy (2010), means the study “achieves what it purports to be about” (p. 840) and connects all dimensions,  46 including the literature, the research questions, findings, and discussions and interpretations of the findings in a meaningful, interconnected way. Through the principles described in her article, Tracy’s (2010) “big tent” conceptualization enables a balance between “structure for qualitative quality while still celebrating the complex differences amongst various paradigms” (p. 839). This research was conducted in pursuit of both structure and complexity, and may therefore be trusted as a piece of research conducted with adherence to clear standards.  3.3 Summary This chapter outlined the methodology for this study; one informed by an asset-based approach used from the design of the interview tool through to the data analysis, and a feminist standpoint approach. Also provided were the details of the recruitment phase, reimbursement of participants, ethics approval, obtaining informed consent, data collection, and analysis of the data. Details described for each of these processes reveals the rationale behind them. Lastly, the trustworthiness of this study and the criteria used to evaluate its quality were listed.   47 Chapter 4 – Research Findings This chapter contains the interpretive analysis of the interview data collected for this study. It is organized by three dominant topics that arose during data analysis: knowledge of menstruation as a continuum, the impact of menstruation on everyday life, and menstruation education. Within these three topics, 12 themes are elucidated. A note about participant quotes: when quoting a participant, their chosen pseudonym forms part of the code created to represent the data. The names of the participants (and their corresponding code) are: Emily (1E), Mary (2M), Sweet (3S), Robinah (4R), Fatu (5F), Harriet (6H), Olivia (7O), Amina (8A), Jane (9J), and Sharon (10S). The next numeral refers to the page number from the interview transcript, and the third set of numerals represent the line numbers. Here is a sample: (1E; 9; 20-21) means Emily’s interview, page 9, lines 20-21 of her interview transcript. All of these women were born and grew up in Uganda. They range in age from 19 to 30 years. All but two of them are mothers. Jane was pregnant with her first child at the time of our interview, and Emily and Sharon have not borne children. Emily spoke excitedly about menstruation but was private about personal details about her life. Mary was passionate about women’s health and had ambitions to be a public health researcher. Sweet, the eldest participant, has been a leader in her community and is extremely friendly. Robinah spoke out loud in Luganda to help her think, and she taught me a few terms in our brief time together. She moved home several times when she was growing up. Fatu was soft-spoken and works hard to support her family. Harriet raises her child with the help of her father, with whom she is very close. Olivia was the youngest participant and works hard in her role as a family caregiver. She and Fatu were the youngest—12 years old—when they first began menstruating. Amina was happy where she lived in her village and did not like Kampala when she first lived there, but she stayed  48 in the city because she felt she would get a better education that way. Jane was studying to become a nurse when we met, and she enjoyed her practicums. Sharon was preparing for final exams at her university when we met, and we rescheduled our meeting once so that she could study. The table that follows contains basic information on the research participants. I do not go into further detail about the locations of the participants, such as where they were born or where they have lived, in order to preserve their confidentiality. That said, all but one participant (Sharon) lived in what they called a village during the time when their first menstruation came. When I asked Sweet where she was living when her menarche began, she said, "I was [at home] in village” (3S; 12; 15).    49 Name Current Age Current Location Marital Status Education Completed Reason for Leaving School Age of Menarche Location of Menarche Told about menstruation before menarche? (Yes/No) Emily 22 Kyebando, Kampala Single Post-secondary Diploma Completed level desired 13 Home  Yes  Mary 22 Kisalosalo, Kampala Single Senior 4 Completed level desired 14 School Yes  Sweet 30 Kalerwe, Kampala Single Senior 4 No funds for fees 15 Home  No Robinah 26 Katoogo, Kampala Single Senior 5 Quit due to pregnancy 15 Home  Yes  Fatu 27 Ketifalawo, Kampala Married Senior 4 Quit due to pregnancy 12 School Yes and No Harriet 28 Kawempe, Kampala Single Post-secondary Diploma No funds for fees 14 Home Yes  Olivia 22 Mukono Single Senior 4 No funds for fees 12 School Yes  Amina 19 Kyebando, Kampala Single Senior 4 No funds for fees 13 Home Yes  Jane 24 Lukuli-Kasangati, Kampala Married Post-Secondary Diploma Completed level desired 15 School Yes  Sharon 22 Kalerwe, Kampala Single Senior 6 Other: currently in University 13 Home Yes   Table 4.1  Basic demographic information on research participants  The stories these women shared are presented in this chapter according to the key themes; however, doing so has led to a fragmentation of their words into small, separate pieces. The way these women spoke and the words they used have been preserved as closely as possible.  The first section of this chapter focuses on how the research participants have knowledge about menarche ranges across a spectrum of knowing. The second section, impact of  50 menstruation on everyday life, details the experiences and perceptions of menstruation in relation to their work, school, activities, and relationships. The key themes were: menstrual knowledge and experience, keeping menstruation a secret, and care of one’s health. The third and final section is on the topic of menstruation education; specifically, who teaches about menstruation and how it is taught. These themes enable me to discuss and share the results of the interviews with the research participants, but it should be noted that the boundaries between these areas are not rigid—that is, there is much overlap. 4.1 Knowledge of Menstruation  4.1.1 The Continuum of Knowledge and Embodied Knowing During the first level of data analysis, the degree or extent of knowledge about first menstruation was noted. At first, focus was placed on how much or how little a participant knew about menstruation around the time of her first menstrual period. However, these young women’s accounts required me to bring a more nuanced approach beyond placing women’s experiences as a dichotomy of knowing/not knowing. My study illustrated how the Ugandan women who participated in this study had diverse degrees of knowledge about menstruation. Ranking women on how much they know or do not know is too simplistic and misses some important dimensions of their experience, which, if better understood, could contribute to improved education and intervention. Through a deeper analysis, the data revealed that participants possessed knowledge about menarche that is best described as being on a continuum.  Through deeper analysis of their accounts, three kinds of experiences emerged. First, some women reported they had knowledge about menstruation before their first menstruation and understood what was happening to them when their menarche began. Second, others indicated that while they knew about menstruation before menarche, they described not knowing  51 what was happening to them when menarche began. And third, there were some who reported having no knowledge about menstruation before menarche and did not know what was happening to them when it began. Eight out of the ten research participants indicated that they had been taught some information about menstruation before their own menarche began: Emily, Mary, Robinah, Harriet, Olivia, Jane, and Sharon (1E, 2M, 4R, 6H, 7O, 8A, 9J, 10S), and they were all taught as girls. They were taught by a teacher, a family member, or a neighbour or friend. More information about menstruation education is detailed in the last section of this chapter. While having some knowledge before the event, almost all eight reported feelings of fear and shock when their first period came. Emily said, “I didn’t know what it was or what was happening to me” (1E; 9; 20-21) even though she reported having been taught about menstruation. Other women, who reported thinking in this way, echoed Emily’s words. Fatu, as you can see from the Table 4.1, had heard about menstruation but was never directly taught about it. When her first menstrual period occurred, she said she cried and felt ashamed (5F; 3; 29-3), explaining that, “because I’ve never - I’ve never feeling that thing. I was just hearing from friends and seeing from aunts, putting on pad. What’s that? I don’t know.” (5F; 4; 19-21). Amina explained that even though she had exposure to menstruation through friends and education from school teachers, her first menstrual period still caught her by surprise because she thought it would happen to her when she was 11 or 12, then when it did not come at that age, she thought it would never happen to her. At 13 years old, she said, “when mine started, I didn’t expect that” (8A; 6; 24). During the unexpected appearance of her first menstrual period, Amina got help from a neighbour as her mother was out of the village at that time. Olivia said, (7O; 5; 25,27-28:  52 “[Olivia exhales deeply.] “I was in Primary 7…. I was at school…Short call,16 then the children started laughing at me.” Olivia reported that she had indeed been taught about menstruation before hers came to her. However, when her first period came, she said, I didn’t know what was happening, so when my teacher told me, she called me and she told me what I was supposed to do, then I told her, me I didn’t know, this is my first time. So she helped me out. (7O; 5; 30-2) Olivia knew about menstruation but did not know what was happening to her when her first period came. She said her mother had taught her by way of her older sisters. But, she said, “I didn’t know it would happen at this age, or at that time or day. But I knew about it” (7O; 7; 4,6-7). Mary explained that while she had been taught about menstruation alongside her female classmates at Primary school, the actual event was still a surprise. “A friend of mine saw me. I couldn’t realize what was going on. And she knew about it and she just took somewhere and we-she took me in the bathroom. She called our senior teacher” (2M; 3; 23-24, 26-27). Mary’s friend and senior teacher helped her in the moment of her first menstruation, but only after her friend had seen the stains on Mary’s uniform. Mary expressed feeling embarrassed and ashamed. After receiving help from her friend and her senior teacher, though, Mary was able to resume her day comfortably, though she would withstand a lot of teasing and bullying from (mostly male) classmates about her menstrual period from then on. Olivia had the similar experience of staining her clothes and finding out she was menstruating in the same moment as the rest of her classmates. After her teacher helped her and gave her a pad to wear, Olivia told her teacher, “I’m not going back to that class” (7O; 7; 16-17). She opted to go home for two days, but when she came back to school she still felt embarrassed and her classmates laughed at her.                                                   16 ‘Short call’ is what is said in English in Uganda to say, “going to the bathroom.”  53 Just as we can try to understand about what childbirth or orgasm is like, all of the descriptors in the world do not adequately bestow someone with that level of embodied understanding—these are lessons that only experience can complete. Many participants articulate the challenge that, regardless of one’s knowledge about menstruation, we cannot know the month or the year, let alone the day or the hour, the menstrual period will begin. Because of this unpredictability, all girls are in for some degree of surprise and, indeed, of shock. This is the case regardless of race, socio-economic background, geopolitical location, or age. A key motivation for this study was to build on studies of Ugandan women’s menstruation, studies which emphasized how it interrupts girls schooling. Digging a bit deeper, I came to a more complex understanding of women’s knowledge of menstruation. Their accounts reveal a significant difference between knowing about menstruation—as an idea or concept—and living it. Emily puts it eloquently when she says, “I thought what it was, but not what it is.” (1E; 3; 29-30). Here, Emily is saying that she thought that this might be menstruation because of what she had been taught, but she could not know for sure because of her lack of experience. For many of the participants, having some awareness of or information about menstruation did not help them anticipate the event nor ease the distress when it happened. This led me to consider the importance of embodied knowledge, a kind of knowing that is different from what might be categorized as cognitive knowing. In their work on embodied knowing, Butterwick and Selman (2012) describe a moment of learning wherein “it’s felt in the body, often before intellectual interpretation” (p. 66). A girl experiencing her first menstruation might eventually recall that she had been taught something about it. Her initial reaction, though, can often be one of fear and shock. To a certain extent, no amount of teaching can fully prepare girls for the moment they discover they are menstruating, but we can definitely do a better job of educating and preparing  54 girls for the shock and empowering them with a stronger feeling of preparedness. Perhaps this involves moving away from the didactic format, towards a more arts-based and embodied educational approach, like theatre. Harriet reported that she felt no fear or embarrassment when she began her first menstruation, which occurred at school, because she had been taught. She said she got a “small shock” (6H; 6; 8,10) but that she did not feel bad overall about her first menstrual period. Robinah, when asked whether she had experienced any fear when she got her period for the first time, said, “no, because I seed [saw] my sister” (4R; 10; 4-5). For the two participants who reported not knowing about menstruation before it started, Sweet and Fatu, they indicated that their first menstrual period was scary, stressful, and they did not know who to tell. Not knowing about menstruation before it started lead them to experience high levels of fear; they described crying, shutting themselves away in the bathroom, and feeling ashamed to tell even their mother or grandmother. Sweet shared the story of finding she had started her menstruation, saying, “What am I going to do? I’ve got a disease? I started crying in the house. She [grandmother] asked me, ‘Why are you crying?’ I refused to tell her” (3S; 11; 11-15). While Sweet was eventually taught about menstruation by her grandmother and learned that it was a normal process, she recalled this experience with great detail and fervour. Fatu explained that she was at home when her first menstruation began, and her grandmother had to come into the bathroom before Fatu would admit what was happening. She reported feeling ashamed (5F; 3; 30). Fatu said, “I was just hearing from friends and seeing from aunts, putting on pad. What’s that? I don’t know” (5F; 4; 19-21). Indeed, all of the participants, when telling the story of their first menstrual period, were expressive and meticulous in their recollection suggesting that first  55 menarche was a profound experience, details of which have remained in their memory years afterward. 4.1.2 Keeping menstruation a secret Part of the larger theme of participants’ knowledge about menstruation was the matter of knowing about menstruation and their efforts to keep menstruation a secret. Keeping it a secret, participants told me, helped them avoid shaming, bullying, and accusations of sexual misconduct. Keeping it a secret was also important as menstruation was considered a private matter. While some participants were fearful of blood stains showing through their clothing, which would cause embarrassment and shame and possible bullying, they also feared other consequences. Being accused of sexual misconduct was an outcome participants feared if they discussed the matter with a family member or teacher. Sweet reported that she was afraid to tell her grandmother about her first menstrual period because she feared being accused of having had sexual intercourse.  To avoid being shamed and bullied, particularly by their male peers, in public—including at school, secrecy was an important tool. When asked why she kept her menstruation a secret, Robinah reported: Robinah: When you talk, ah, it’s not going to be good. Sarah: Why is it bad to talk to others?  Robinah: Because the others, they have wide mouths, eh? They can talk to boys and they started laughing for you, yeah. (4R; 20; 17-21)  Robinah went on to say that it is especially bad for young boys to know about menstruation. She said this is because they tease, they start fights, and they bully. She then qualified her response  56 by describing how it is different for older men—a husband—to know: “old boys, they can know” (4R; 20; 22-28).  4.1.3 Men and Boys Knowing of Menstruation Indeed, other participants also reported having a male family member know about menstruation proved to be advantageous and pleasant. Amina lived with her older brother in Kampala, so when she was menstruating and ill from the cramps, her brother would buy her pads and painkillers (8A; 4; 12). When Amina was living with her brother in Kampala, she told the story of how her brother found out about her menstrual period: When I was sleeping, I was in pain when he called me to do something, that’s when I told him, ‘I’m not fine.’ … That’s, ‘are you having malaria?’ I said no. Um, okay I told him just I’m in my period… (8A; 7; 11-18)  There are many instances in my conversations with participants where the role of men and boys arises in relation to menstruation. Harriet’s father knew about her menstruation and was supportive; he taught her about menstruation (6H; 5; 9) because Harriet shared a closer bond with him than with her mother. She explained, My dad was my best friend, better than even the mother. So when my father is at home I could say that, ‘please dad I want to take this one’ he could give me. But my mom was somehow rude, so I could fear her. (6H; 17; 9-14) 4.1.4 Care of One’s Health Within the conversation about menstruation, participants expressed concerns about sexual and reproductive health matters like pregnancy, cervical cancer, and family planning. It is important to remember that events like menstruation take place in the wider context of  57 participants’ lives, which prompted me to ask them what their life was like growing up, including experiences of poverty, childhood, and of rural and urban life. Six participants expressed their belief that first menstruation is a time of fertility and maturation. All participants reported that menstruation is a time to keep clean by washing oneself and wearing clean clothes.  4.1.5 Menstrual Products All except two participants, Emily and Jane, reported challenges related to obtaining store-bought menstrual products. Sharon said that because her parents were relatively wealthy, she never went without something she needed, but even her mother could not always afford menstrual products, nor could she always get money to buy them for her daughter when they were apart, and so Sharon’s mother taught her how to make a cloth pad (10S; 10-11; 26, 1-5). Emily said she never failed to get menstrual products because they are available and inexpensive (1E; 14; 6,8,10), and Jane echoed these reasons. The remaining eight participants reported that, at some point in their life since menarche, finding and/or purchasing menstrual products in time for their next period was sometimes difficult. At times like these, the women would use other ways to catch the menstrual blood: they would make a pad using cloth (cut from clothes) or cotton wool. This resourcefulness is related to barriers established by poverty; despite the challenges these women have been faced with over the years, they find ways to persevere. This leads to an understanding of these women as resilient, resourceful, and strong. The most popular menstrual product among the research participants was the disposable pad, usually of the Always brand. Participants described Always pads as comfortable and almost always adequate to capture the amount of blood flow. Sweet reported using SoSure reusable pads. She explained that owning reusable pads meant that there would never be a question as to whether she had the products she needs for her next menstrual period. She said,   58 I choose [reusable pads] because the disposable pad, you can get menstruation, eh, when you don’t have money. And you cannot even afford to buy by that time. But this one, I move in my bag... The blood, it cannot wait for you to get money. (3S; 23; 5-10).  All but one participant, Jane, reported using homemade cloth, cotton wool, or wads of toilet paper at some point in their lives. Often times, participants reported using such products when they or their parents could not afford to purchase disposable pads. Sometimes it happened that menstruation began in a time or place (e.g., in a taxi or matatu) when the participant did not have any disposable pads with her. All participants were taught to wash, dry, and iron homemade cloth pads. Emily said she was taught how to maintain cloth pads at school by her teacher, explaining, “they used to tell us, “If you get a cloth, you wash it cleanly, you, you, you hang it to dry it, and iron it”” (1E; 5; 26-27).  4.1.6 Menstrual Health Participants think of menstruation not just in terms of hygiene and hygiene management but in terms of menstrual health on the whole; and, also, of menstrual health as part of the larger concept of sexual and reproductive health. This impression is generated by the fact that the research participants speak about personal hygiene, fertility, and sex as much as menstruation itself. Mary said, “Menstruation is that time when a girl – your body changes and you have to decide – because that time you are mature” (2M; 6; 1-3). Harriet said she was taught that menstruation “mean[t] that if you go make any slight mistake you are going to get a child” (6H; 7; 4-5). She said that when she and her classmates were being taught about menstruation, they were also taught about sexual intercourse and pregnancy. Harriet clarified that boys and girls are  59 both taught about the reproductive system, and that they were separated when it came time to teach the girls specifically about menstruation (6H; 7; 13-19).  Robinah spoke of the practice of labial pulling17. She shared this information in the context of two different places. She explained that she had been taught about labial pulling by teachers at school, saying, “They told us, have you visit [the bush]? They told you, the word you call pulling? When you are in menstruation you must pull. Pull, pull, pull” (4R; 13; 24-31). She also explained that care workers working in clinics or hospitals will tell women preparing to give birth to practice labial pulling and stretching before birth. Robinah was taught, by her physician, that if she did not do this during her pregnancy, then he would not serve as her doctor. She says that he said, “I’m not going to treat you... Shame upon you. Ah-ah, you go” (4R; 13; 24-31). Robinah taught me that this is part of the Baganda culture and the impression she gave was that this practice was of cultural importance to some Baganda people. I chose not to ask further about the details about labial pulling because it is beyond the scope of this thesis, and is also beyond my ability as an outsider to understand well. Other research has explored at length matters of female circumcision, and has also revealed that labial pulling is practiced for purposes of easing discomfort during menstruation and/or childbirth and enhances sexual pleasure (Bell & Aggleton, 2013; Gallo, Villa, and Pagani, 2006).  4.2 Menstruation Education The previous section explored what the research participants reported about their experiences and perceptions of menarche. This section explores the sources of information the participants had access to. While women in Uganda may, if they are enrolled in school, be                                                  17 Labial pulling begins at menstruation and is continued regularly throughout a young woman’s life; she will pull her inner labia outwards, stretching them away from her body, to elongate them.  60 exposed to information about menstruation through teachers, there are other sources of information beyond formal education, including: mother, father, grandmother, ssenga (Paternal Aunt), friend(s) at school, friend(s) not at school, visiting educators at school (Ugandan or foreign), and neighbour. Family configurations of each of the research participants impacted how she, as a young girl, learned about menstruation. For example, Fatu was raised by her grandmother because her mother left when she was a baby. As a result, Fatu’s grandmother taught her about menstruation. Sweet was also living with her grandmother growing up because her mother fled from her torturous father. She explained, “Because my father would torture her a lot… so [she] decided to run away from home” (3S; 3; 26,28). While all of the participants reported being taught about menstruation at some point in school, there was great variation on when it was taught—as in, how old they were and what level (Primary 4 or 5, or Senior 1) at school—what was taught, and whether it was considered appropriate from the perspective of the research participant. Emily reported that her school did the menstruation lessons after her menstrual period had already begun. A key observation I made when hearing what the participants say was that information about menstruation is often verbal and through word of mouth. The participants did not report having access to or did not use written, digital, or online information about menstruation; this was not something I explored with them. Participants did not mention whether their teachers used educational videos, handouts, or any other form of written, digital, or online information. Jane described how her teacher opened a pad in front of the girls as part of her teaching about menstruation, saying, “I don’t know how to use these, uh, pads... I just ask how they use [pads], so they had to teach us how we use it” (9J; 7; 7-10).   61 When asked if there was something teachers could do to improve how they teach about menstruation, Harriet said, “some teachers, they just teach us some small notes about it. They may tell you in theory but they don’t tell you in practically. ...They should use both: practical and theory” (6H; 11; 17-20). An analysis of Ugandan curriculum on menstruation or menstrual health is beyond the scope of this study. While none of the participants had experienced being taught by foreigners, Mary shared this story: A friend of mine goes to a school. And she was in secondary. And those whites came at school and was like: “uh, you girls of this school, we are to help you because your teachers told us some can’t afford to buy pads and you know, that way some were embarrassed. (2M; 16; 8-12,14)  4.2.1 Menstruation as Normal All of the participants in the study reported that they were taught that menstruation is normal. This belief contrasts with information I came across during my BRAC internship that suggested that some women might believe menstruation to be a form of illness, disease, or a curse or spell. These assumptions were present in two different studies I was involved in at BRAC, both of which pertained to themes of sexual and reproductive health. I saw one survey that had been designed based on the view that some Ugandans are taught that menstruation is the result of a witch’s spell. No results of this study have yet been published. Emily said that her teacher told her that menstruation is normal and “don’t be so much worried” (1E; 5; 8-10).    62 4.2.2 Gender Segregation, and Boys and Men and Menstruation As the research participants discussed how menstruation is taught at school, all talked about gender segregation, describing how the boys were separated from the girls when it came time to teach about female anatomy, menstruation, and menstrual health. When I asked Robinah for clarification on whether it was bad for boys to know about menstruation, we had this conversation: Sarah18: is it bad for boys to know about menstruation?  Robinah: Kale [okay], now, old boys. They can know. Eh. With his wife. Young ones…  Sarah: Because young boys, they are teasing, they are fighting, they are bullying, right?  Robinah: Yeah. (4R; 20; 22-28) Harriet received a lot of help, support, and education from her father, who used to be a teacher, and with whom she shares a close relationship. "I learnt it in P419. And when I was at home my father could use me to teach [his other students]” (6H; 5-6; 33-1). Jane said that in her Senior-level boarding school, there were informal weekly meetings where young women would meet and talk about menstruation. She said, “we used to give so many ideas, and we have to teach even these younger, these Senior One kids, eh? About it. So I gave some other people about it” (9J; 10; 20-22). Amina said she also gave advice to “the young one who have just started” (8A; 8; 11-12).                                                   18 Here, I am asking leading questions. This was because I wanted confirmation of the emerging theme that boys tease and bully girls; here, I had begun to draw from what others had been saying in the interviews.  19 P4 is Primary 4. Harriet would have been 10 to 11 years old, assuming there were no interruptions in her school attendance.  63 4.2.3 Importance of Age Two research participants, Robinah and Jane, emphasized the importance of a person’s age when talking and educating about menstruation. Robinah especially stressed that anyone teaching girls about menstruation should be older than the girls being taught. She said, “older than me can help me, me I can help younger one than me” (4R; 37; 16-17). When I asked her whom would she prefer to see teaching about menstruation ideally, she responded, “I would like my auntie…because is the elder of me” (4R; 18; 19-2).  All of the participants remarked that girls in Uganda should be taught about menstruation before their first menstrual period comes. Participants who identified themselves as having strong Baganda values, wherein it is important for the ssenga to assume the responsibility of teaching about menstruation and related topics, also agreed that menstruation should be taught before the first menstrual period comes. That said, many of the participants agreed that knowing exactly when to initiate teaching would be a challenge. Mary expressed concern about what stage a girl should be taught, saying, “It’s not good, like, a child of nine, 10 years” (2M; 12; 15-17). For women like Emily, the menstruation education at school came before her menstrual period had already begun. However, such is not always the case. There can be great variation between age in school and level achieved. This is because not all girls and young women attend continuously from P1 through to the end. Many girls and young women will experience breaks and gaps, caused by things like lack of funds to pay school fees, pregnancy, and staying home to take care of a sick family member.  4.3 Impact on Everyday Life  Research participants had both similar as well as different perceptions about menstruation. All but three of the participants described difficulty when they experienced their first menstrual  64 cycle, but at the time of the interviews, nine of them described their menstruation as manageable, normal, and relatively easy. The exceptional participant, Sweet, stated that she was experiencing an irregular cycle caused by her birth control. Two participants, Sweet and Fatu, also now experience severe menstrual cramp pain compared to when they were younger, but they both say this is not too difficult to cope with. All participants described the various ways menstruation impacted their lives, particularly when it came to reproduction. For example, while Emily perceived that overall, menstruation “wasn’t easy” (1E; 3; 31) when she was younger, she noted that it does not have any effect on her activities as an adult.  The participants described various effects on their activities when menstruating. No one participant said that menstruation unequivocally had no effect or major effect; each participant described various degrees of effect through stories of their experiences and also through exchange of mutual experience and understanding between themselves and me as the interviewer. The degrees of effect vary based on what the activity was, and what the activity required of that individual. When asked if she modified her activities during menstruation, Harriet said no, adding, “Me, I do, even netball. If I find it, I can do” (6H; 17; 1,5,21). When asked the same question, Sweet said, “I can’t, I cannot stop [my activities]. Because exercise, it can even help you eh?” (3S; 25; 26). Here, Sweet is speaking to the fact that exercise can help some women cope with menstrual cramp pain and other menstruation symptoms. Amina said that during her menstrual period she would avoid performing the following activities: “Like, jumping. Playing. Running. Or like, carrying water in jerry cans” (8A; 14-15; 31,4). Robinah and Harriet also spoke about avoiding carrying jerry cans or carrying smaller ones during their menstrual period.     65 4.3.1 Menstrual Pain The most common effect among the participants was also the most impactful, that is, menstrual pain. Every participant complained about the severity of the pain and the extent to which it affected their everyday life. Every participant reported experiencing menstrual cramps, and all of them placed particular emphasis on how painful they were. Some participants did not experience painful menstrual cramps until later in life, while most report that menstrual cramps have always been painful. Two of the participants, Sweet and Amina, indicated that menstrual pain became more uncomfortable after they had borne children. Mary reported that as a young woman, she felt so poorly because of her menstrual period that she was admitted to a hospital at least twice (2M; 5; 1-2). Robinah reported pain so severe it made her vomit (4R; 32; 6). Participants shared the ways their menstrual pain would be so bad as to prevent them from working, going to school, or engaging in regular, daily activities, such as fetching water or spending time with friends. Robinah shared this story, If you want to stand eh, you can’t. You just this [mimes hesitation to move or stand and grabs her stomach in mock pain] just say that, ‘let me still sleep, I’m feeling bad, come, you can call someone, or maybe you can help for me to buy me medicine. My aunt will pay. Later.’ (4R; 23; 6-10) For both Sweet and Robinah, menstruation impacted their everyday life because their pain reached unmanageable levels. When asked how often this occurs, Sweet said, “Sometimes it is unmanageable. It goes far. And I decided even to sleep” (3S; 22; 3.8-9). Robinah told me that on the first day of her menstrual cramps she has tremendous pain, and that it continues to affect her life “because that day I can’t work - I can’t go to work. Yeah. I stay at home, that day, next, next but once I take 4 days at home.” She clarified the only aspect of her menstruation that has  66 such a large impact is the menstrual cramps, explaining, “Yeah. It’s because of the pain. You can’t work if you have pain” (4R; 32; 6). Throughout discussion and continued contemplation, Harriet came to realize that menstrual pain did have some effect in her life. She said, “It [doesn’t] affect me except of the back pain... Because this one, I guess, if I’m in my menstruation, when you can [carry], like, jerry can of water, [I] feel much pain. That’s the only thing, but the rest remain the same” (6H; 18; 1,4-7). She said this only after thinking specifically about the question of whether her menstruation had any effect on her activities this is precisely how the interview question was posed to her.  In addition to discussing the difficult aspects of menstruation, the participants all explained the various things they do to cope. Sweet reported taking painkillers (3S; 22; 3.8-9), paracetamol20 being a highly common over-the-counter pill at any pharmacy. Robinah said she preferred to use traditional medicine that she can bring along with her for when it is needed because, especially when she was young, painkillers were not as affordable as her traditional medicines (4R; 17; 2-5). Traditional medicine included tea from herbs and painkillers made from ingredients easily found or purchased. For some, cramps are a welcome indication that the menstrual period is restarting—a sign that a woman is not pregnant. Fatu said, “I feel good because if you don’t menstruate, if you miss it you might think, eh…. But if I menstruate I feel happy” (5F; 7; 23-24,26).  Menstrual pain, accompanied with simultaneous monthly changes within a woman’s body, as the participants noted, was part of a larger narrative about their adolescence and young womanhood.                                                   20 Pracetamol is the British term for acetaminophen. A common brand name for paracetamol in Uganda is Panadol. A common brand name for acetaminophen in Canada is Tylenol.  67 4.3.2 Impact of Menstruation on Studies A key theme in existing research is the effect menstruation has on the girls’ studies. As noted in the literature review, organizations like the World Bank and UNESCO estimate that menstruation has a huge impact on education attainment. This study is not large enough to conclusively support or refute this claim. But, in one of the questions in the interview, I directly explored the impact menstruation had on the participants’ school attendance. The participants shared experiences of when their menstruation did or did not impact their studies. Emily said that it was not menstruation itself, but the painful cramps that come with it that may force some girls to miss school, stating, “there was so uncomfortable, very painful… If she’s going to take four days, meaning that week she’s not going to school… Cause it was so paining every day, she could not stand, she could not sit…” (1E; 10; 22-28). Emily explained that she did not have the same experience as her friends, particularly because she had more pain than they did when it came to menstruation, but she still emphasized that being able to talk openly about menstruation is valuable and important (1E; 11; 7-9). When asked if she had ever missed work or school because of menstruation, both Sweet and Robinah said yes. Robinah remembered, “Yeah, one day, it was a test paper. Chemistry paper” (4R; 23; 4). She was then asked if she missed school many times or a few times; she said a few times. According to the stories shared by the participants in this study, teen pregnancy has had more of an effect on their studies than menstruation ever could. Sweet said that she discovered she was pregnant while she was sitting her O Level exams in Senior 4 (3S; 8; 1-6). Robinah explained that she became pregnant before she could begin Senior 6.  68 After she had her girl, she said, “I told them I want to go back to school. They just say, ‘Ah ah [no], no, it’s over.’ ” (4R; 3; 18-19). Fatu said that she became pregnant during her final exams of Senior 4, at which time, she said, “My uncle cut off paying my fees up to Senior 4” (5F; 2; 10). Olivia did not stop going to school because of her pregnancy; she explained she stopped after Senior 4 because “by that time my mother was sick. She was suffering from heart. So [I] had to sit down” (7O; 2; 25-26) and stay home to take care of her. She explained that it was during this two-year period that she conceived her child. She returned to school to complete Senior 5 but could not finish Senior 6 because “there was now little money” (7O; 3; 4).  4.3.3. Degrees of Impact of Menstruation on Everyday Life Robinah reported that she had to modify or change her activities due to menstrual pain: I have big jerry cans, eh? I get my jerry cans and I got to tap to get water. By that time, I can’t - I take a small jerry can, eh? … If I do this [mimes squatting down to do laundry], eh, I can’t. I change so many things. Robinah chooses not to fetch large jerry cans of water when menstruating. When menstruating, she carries small Jerry cans. A lot of other small changes happen during menstruation, such as doing the washing. She explained, though, that she simply catches up on the washing when she is feeling up to it again. Fatu, when explaining about her missing Friday mosque when she is in her menstrual period, spoke in a manner that suggests she is not overly disturbed or upset by this religious/cultural practice, saying, "I miss church because we Muslim women if you are in menstruation, you cannot enter the mosque” (5F; 14; 13). She went on to teach me that, "even cooking food, they say when you are in menstruation you must not cook food. It means that food is dirty” (5F; 20-22). She explained that while she chooses to skip mosque, she does not abstain  69 from cooking food during her menstrual period. She said that not many Muslim women she knows follow this practice “because these days women are not following the rules” (5F; 14; 14).  When asked if she changes activity when menstruating, Harriet said, “No…. Me, I do, even netball. If I find it, I can do” (6H; 17; 1, 5, 21). Emily echoed this sentiment. Fatu expressed a positive effect when asked how her menstruation impacts her life overall. She said, "I feel normal. And I feel good because if you don’t menstruate, if you miss it you might think, eh [gestures with her hands, wondering, ‘maybe I am pregnant’]…. But if I menstruate I feel happy” (5F; 7; 23-24,26). She also said, “When I feel shy, bored, I don’t feel normal. I feel uncomfortable. Sometimes you get annoyed because people are calling you. You get annoyed” (5F; 16; 26-28). These realizations are coming to light through conversation with me, in which participants had the space and time to think, dialogue, wonder, ask questions, take breaks, and discuss. Fatu here is showing the complexity of the experience of menstruation, and there is obviously impact while also acknowledging that menstruation has little or no impact. Harriet does the same thing when she says,  It affects me except of the back pain, but the rest remains no. Because this one, I guess, if I’m in my menstruation, when you can, like, jerry can of water, feel much pain. That’s the only thing, but the rest remain the same. (6H; 18; 1,4-7) Other participants described ways in which menstruation has or has had a large or profound effect on overall everyday life. Sweet, when asked if menstruation has a big impact on her everyday life, said,  “When you have nothing21, it [menstruation] can affect you” (3S; 25; 20). In answer to the same question, Fatu said the largest impact on her everyday life is a good one. She explained her life does impact her everyday life, but, “In a good way” (5F; 16; 21).                                                  21 Sweet has experienced significant poverty, and when she says ‘have nothing’ she is referring to not having basic needs met, such as shelter or food or menstrual products.   70 Menstruation affects her life “in a good way” because it lets her know her own health. Fatu also said,  It can affect your life and don’t take care of yourself. You don’t seek advice before. It can affect your life. You might get syphilis. … And after there you get pregnant. If you don’t get advice before. If you get advice before you might take care of yourself. (5F; 16; 14-18) Participants shared wonderfully detailed stories exposing their varied experiences with menstruation. These stories really ground their experiences in a way that enable outsiders to see the participants as people with complex lives and with important information to share. Sweet describes the typical experience of starting your menstrual period and getting caught unawares:  First of all, when you are at work, and the blood started coming out; you have to work, you can’t leave, you have no money to buy Always [pads]. Now we started moving up and down, you ask friend, ‘do you have?’…Bathroom and get the tissues and you put that inside to protect then blood and you - have to change every 10 minutes... It can come when you in a taxi. You can’t move! Haha, and you leave the place which the taxi - they have to drop you there. (3S; 24-25; 29-31, 6-7, 11, 13-14) Sweet said that missing work is not an option. She shared her story in a jocular way. Sweet revealed that no one person is always fine or always struggling when it comes to menstruation itself. Everyone struggles, and everyone carries on. During the telling of this story, Sweet and I both were laughing at the hilarity of the situations she describes, and also at how funny it is that we have both experienced such circumstances as menstruating women. Similarly, Fatu and I shared a laugh when talking about laughing during menstruation. She said,  "If you laugh, you  71 see blood coming. Even if you sneeze – even if you are running. You feel like your head is aching. You feel out of the place” (5F; 7; 6, 8-9). Fatu explained that the gushes of blood and headache that many women feel every menstrual period are inescapably demanding of our consciousness as women.  Each individual participant spoke of the ways they had adjusted to and created ways of navigating menstruation. Emily said that she does not feel different when she is menstruating because “it’s part of you, part of your usual life” (1E; 14; 21-22). Sweet says that even when menstruation occurs, activities like exercise, work, or school cannot stop; “I can’t, I cannot stop. Because exercise, it can even help you eh?” (3S; 25; 26)  Mary, sharing about how she feels differently when menstruating, said, “I don’t think about it. I just wear well and I got for my training. So it doesn’t affect my work” (2M; 10; 10-11). Mary has come to learn that cramps precede her menstrual period, so when they come, she said, “then I get prepared… change if I am going to wear a light clothes I get something which is black and something which is, you know?” (2M; 9; 23,25-27). When she said, “which is, you know?” she gestured to me in a way that suggests that wearing dark clothing is common sense, and is a common practice among all women. In the same challenge of preventing against visible leaks, Sweet said, “There is a difference because when you’re in menstruation you can, eh, every time you can look about yourself, eh? Haha, yes!” (3S; 22; 21; 23-24). It is because of this constant practice of “looking about yourself” that Sweet reported she feels different during menstruation. All participants explained that while it took time (sometimes as much as a year) to adjust to menstruating, it is now easy to live with and there is no major effect on their everyday lives overall. That is to say, the participants have normalized the challenges of menstruation as adults,  72 such as painful cramps, bearing children, or modifying what they wear or missing mosque for that period of time. To this end, the participants do not feel that menstruation itself majorly impacts their everyday life. That said, it is clear that the major impacts in their lives are more closely related to challenges with poverty and pregnancy.  4.4 Summary The key findings presented in this chapter were as follows: that knowledge about menstruation among the participants ranged along a spectrum between knowing nothing to knowing plenty before their first menstrual period began; that menstruation education occurred in formal, informal, and non-formal ways among the participants; and that the impact of menstruation on everyday life is complex and varied individual to individual. The implications of these findings are discussed in the next chapter.   73 Chapter 5: Discussion and Conclusion This final chapter concludes the thesis. It begins with a discussion of the previous chapter findings. The research goals and questions are reviewed, and summaries of the findings are made, with links to relevant literature and implications for policy and practice. A discussion then follows, exploring the study’s limitations and implications for future research. The chapter concludes with some personal reflections on this research journey.  5.1 Goal of the Study and Research Questions The overall goal of this study was to share stories from and amplify the voices of a select group of young Ugandan women about their experiences of menstruation, including how and where they acquired knowledge of menstruation. The perspective that there are different standpoints about menstruation informed this study. As a researcher, I sought to listen carefully and to centre the views of young Ugandan women. The main research question was: how do women living in Central Uganda experience menstruation? In the first section of this chapter I discussed the three key findings: the menstrual knowledge continuum, menstruation education, and the impact of menstruation on everyday life. The findings pointed to the different ways in which the participants perceived their menstruation experiences and how they interpreted the modes of education, illustrating a range of experiences. In the next section, I explore the three secondary research questions: What are the perceptions young women living in Central Uganda have about menstruation? How do the participants approach their personal menstrual hygiene management? What have been their sources of information, including formal, non-formal, and informal education? In the final section of the summary and discussion, further details on some of the key findings of this study are explored.   74 5.2 Knowledge and Experience of Menstruation All of the participants were able to recall their early experiences of their menstruation with great clarity and detail. I was somewhat surprised to learn that the research participants reported many of the same experiences I myself have had. And, the things the participants have done to negotiate the effects that menstruation brings into their lives are not all that different from what I would do or have done in the past, including modifying activities, skipping school or work, taking painkillers or applying heat to ease menstrual cramp pain, and feeling grateful that I was receiving confirmation that I was not pregnant. The preconceived notions I held about Uganda, or Africa more generally was that it was not as developed or modern as it turned out to be once I had lived there for a time and gotten to know people living there. The research participants did not experience menstruation as something that significantly interrupted their everyday life. What was significant and what did change their everyday lives, however, were pregnancy and motherhood. That said, this study also revealed that there were ways in which menstruation did have an impact but not a significant one overall. The extent of that impact depended on the complex relationships between poverty, education, resources, empowerment, and confidence. Here, we begin to see that the experience of menstruation itself must be considered within the wider context of the lives of young women. Menstruation becomes an issue when the cramp pain is too unbearable to go to school, or when bleeding (or fear thereof) forces someone to escape to a private place, or when their peers—particularly boys at school—tease and bully them.  The participants’ stories served to illustrate the deep complexity of menstruation as a recurring event in their lives. Participants experiencing their first menstruation, while either at school or at home, reported physical sensations and emotions that were both unique to them and,  75 to a certain extent, shared by others. Emily, Mary, Sweet, Robinah, Harriet, Olivia, Amina, Jane, and Sharon all shared their accounts with laughter and sadness, and did so in a way that made me, as the interviewer and researcher, recall my own experiences with menstruation.  A commonality among the participants was that menstruation is manageable. In relation to missing school, the four participants who reported missing school because of their menstruation were Sweet, Robinah, Harriet, and Sharon. These women told that when they missed school, it was specifically because of menstrual pain. Olivia told the story of her experience missing a couple days of school when her first menstruation occurred, not because of pain, but because she had been humiliated by her classmates and was permitted to go home. She said, “"I feel bad because, I told my teacher I’m not going back to that class” (7O; 7; 16-17) In the literature exploring the impact of menstruation on young Ugandan women, there is a tendency to see a causal link between menstruation and reasons for girls missing school. In the World Bank Blog post by Lusk-Stover, Rop, Tinsley, and Rabie (2005), they cite the previously discussed UNESCO (2014) report, claiming,  … One in ten girls in Sub-Saharan Africa misses school during their menstrual cycle. By some estimates, this equals as much as twenty percent of a given school year. Many girls drop out of school altogether once they begin menstruating. Should young women miss twenty percent of school days in a given year due to a lack of facilities or a lack of information or a lack of sanitary products? (para. 1)  What the young women in my study told me was that while there was stigma and teasing, particularly from young boys, which made their school experience difficult, this did not necessarily keep them from attending school. Rather, what kept them at home was their physical discomfort. In relation to the larger context in which these young women live, their level of access to clean running water and to menstrual products and pain medication had an impact. While most communities in the Global North have the amenities of in-home running water, this  76 is not always the case for those living in the Global South. Atekyereza (2001) also claims, “poor latrines have, for example, been identified as a cause of girls dropping out of school especially for those who are starting menstruation and want privacy” (p. 133). The women I spoke to in this study told stories that suggested to me that they would do anything in their power to go to and stay in school and it seems that poor latrines would not be the cause of them dropping out of school altogether. We need to understand the complexity of factors that come together to better understand why girls leave school, and include in those studies whether teasing, bullying, or humiliation from other students and teachers has an impact on enrolment. This study points to the importance of listening carefully to young Ugandan women and approaching their experiences holistically. It speaks to how schools and communities need to not only provide desirable, affordable menstrual products, they also need to support young women with pain management tools (such as traditional medicine and painkillers) and accommodate the need to go home to recover. Most importantly, steps need to be taken with regards to unplanned pregnancy. Given that this is a profoundly impactful event in the lives of the research participants it deserves attention. The current government position is abstinence-only education, U.S. studies such as Kohler, Manhart, and Lafferty (2008) indicate that abstinence-only education does not reduce adolescent pregnancy. Studies on the impact of sexual health education in African countries show similar findings (e.g., Hindin & Fatusi, 2009).  In the consent process of the interviews, I spoke with each participant about the resources that were available to them in their area for more support or services with S&RH. The resources listed in the consent form were: Marie Stopes Uganda and Ask Without Shame. All of the participants recognized at least one of the S&RH services listed in the consent form22.                                                  22 See the full English consent form in Appendix B.  77 Additionally, discussion with each research participant revealed that some of them were also aware of Reproductive Health Uganda (RHU) as an available, accessible service in Central Uganda. I did not list RHU on the consent form because I could not, at the time, establish whether their services were free or confidential.  According to this study’s participants, the biggest challenges and interruptions to everyday life had little or nothing to do with menstruation. Things that were issues included affording school fees, finding work, and meeting their basic needs and those of their children. These issues were paramount in their minds as they shared their stories and educated me about their lives. A third commonality among the participants is that they were all taught that menstruation is normal. As a result, participants were not made to feel dirty, abnormal, diseased, or misaligned with religious or cultural values (i.e., sinful). Teaching that menstruation is normal goes a long way to reducing stigma and shame about menstruation that might be felt by girls when their first few menstrual cycles occur.  5.3 Keeping Menstruation a Secret All participants reported that, while they may have discretely told a trusted family member, friend, or teacher in a time of need, for the most part, they kept their menstruation a secret in order to protect themselves against harassment and stigma. Given that family members and peers were an important source of information about menstruation, paradoxically, keeping it a secret also meant that other young women did not learn in this way and could thus be vulnerable. Three participants, Robinah, Harriet, and Sharon, felt that their menstruation came as little or no surprise when their menarche began. Robinah said this was because she had seen her sister go through the experience and understood that she would experience the same thing  78 eventually. Harriet explained that her close relationship with her father enabled her to have a good understanding about menstruation, and after a “small shock” (6H; 6; 8,10) felt well supported in her menarche experience. Sharon reported that she felt strange but still normal (10S; 8; 24), and she attributes this to the fact that her mother’s and her teacher’s support “was enough” for her (10S; 9; 1-5). The remaining participants were less informed and might have felt more prepared if there was less secrecy.  This study did not seek to assess exactly what or how much the participants knew about the physiology of menstruation, nor of female reproductive anatomy. Understanding about the physiology of menstruation may or may not improve Ugandan girls’ experience of menstruation in and of itself. 5.4 Menstruation Education Research participants wished others to know that they believe menstruation education to be very important, and that all girls should be taught about menstruation before their first menstrual period occurs. They described the many different ways they were exposed to menstruation and menstruation education: seeing a sister go through the experience of menstruation; being taught about menstruation at school and/or at home; discussing about menstruation among friends; and sharing their advice with others or helping others in need of support in their own menstruation. There were diverse ways the research participants were being educated about menstruation; influencing factors included school location and level, religious and cultural practices, age, family structure, and whether home was in the village or in the city. My preconceived notions led me to expect that a larger proportion of the research participants would know little or nothing about menstruation at the time of their menarche. Reviewing the relevant literature, which often describes young Ugandan peoples as fragmented,  79 and terrorized by conflict and the HIV/AIDS epidemic, formed this impression. This assumption also led me to interpret a key finding in the data a certain way: the participants who reported feeling shocked or afraid during their first menstrual period even though they had been taught about menstruation beforehand. I initially assumed this to mean that their education had not made sense to them or it was taught in a way that they did not understand. I have since come to see that the participants were explaining that even though they had been educated about menstruation, they still experienced some shock because they could not know the day or the hour their period would start—they were, in some cases, simply expressing the shock of being caught unawares.  5.4.1 Teaching about menstruation All participants agreed that girls should be taught about menstruation before menarche. Several participants, however, felt that timing of the teaching was key; it was important to avoid teaching girls who were too young. With the question, “how young is too young?” some participants were concerned that a nine- to ten-year-old or younger girl should not be taught about menstruation. Robinah especially stressed that anyone teaching girls about menstruation should be older than the girls being taught. This seems to suggest that peer teaching, at least teaching by others a little older, would be useful. Peer education could be quite powerful with the necessary supports in place. Amina spoke about getting help and then helping others. She said, “there are things that you want to learn from others and there are things that you want to know from others in order to help others” (8A; 16; 20-21). She said this when I asked her why she felt comfortable talking with me about menstruation. Emily suggested that if there were to be some sort of girl’s club, either in a school or in a community, “that talks about it, I think it would help” (1E; 11; 6-7) some girls and young women learn about menstruation from other women in the  80 community. Another recommendation arising from this study is to enable and empower mothers, ssengas, grandmothers, and any others who anticipate fulfilling the role as teacher and/or supporter to a pre-menstrual girl. Sweet shared with me that she had attempted to teach about menstruation to girls in her community in Kalerwe. She said, “We try it. We teach them. But [some of] their parents, they didn’t allow them” (3S; 30; 23-24). Sweet did not know why some parents would not allow their daughters to participate in education about menstruation in the community, but she identified that a possible barrier to community education was that perhaps parents need details in order to be informed about the education being offered. Atekyereza (2001) correctly predicted that the Ugandan National Strategic Plan for Girls’ Education in 2000 would fall short of its targets, arguing that “unless first things are handled first with the meaningful involvement of parents, little can be achieved by the targeted year of 2003” (p. 142). The World Health Organization (WHO, 2004) sponsored an investigation into adolescent health development wherein the authors identified the need for nurses and midwives to “understand adolescent health and development within the context of families, communities and health care systems” (p. 4). I argue that all public health practitioners and scholars who are exploring topics in health and education in East Africa should also heed this entreaty. I agree with the United Nations Population Fund [UNFPA] (2010) when they say “we have a collective responsibility to uphold and realize the right to reproductive health for all women, men and adolescents” (p. iv). Timeliness is also a factor due to the problematic gap between studies that research menstruating girls in school and large proportion of the female population that range greatly in levels of schooling attained. Embracing this complexity is precisely what African feminisms call for. In the podcast, “Wulira!” (Rwakabukoza, 2018) African feminist scholar Jessica Horn calls for Africans, and for  81 all of us, to embrace complexity and honour the various feminisms that exist. Horn teaches us that feminism, in the context of Uganda, was developed by key individuals. The producer and hosts at Wulira! cite the profound influence of Sugra Visram (1923-2012) on Ugandan feminism, who founded the Family Planning Association of Uganda in 1957 (now called Reproductive Health Uganda) with the vision that women should have the same opportunities in life that men have, and that family planning is a key that can unlock opportunities. Visram is quoted in the podcast as saying, “my initial goal was to help Ugandan mothers and children of Uganda to get a good education, obtain better living conditions, and have the economic ability to provide…” (07:05 to 07:23). The relationship between menstruation and overall health and wellbeing are closely tied, or even inseparable, in Uganda. This is different from the medically dominated Western, atomistic approaches in which different systems are considered and treated separately. Another key finding is that formal, non-formal, and informal education are all important in relation to teaching girls about menstruation. All of the participants were taught, whether by a teacher, a parent, or a grandparent, about menstruation at school and at home. Significant learning and education, as demonstrated in this study, occur in informal places through informal processes. Informal learning took place among the research participants; recall when Robinah spoke about learning about menstruation by having seen her sister experience it, and when Jane spoke about meeting with younger women in her Senior boarding school to share about menstruation and related topics. It is important, going forward, that researchers, policy makers, and program designers expand their assumption that learning only takes place in formal settings, like a formal classroom, and that learning about menstruation is multi-sectoral. Further investigation and making use of the opportunity to encourage non-formal and informal learning is an excellent yet vastly under-researched opportunity.   82 Cattell (1998) writes about age hierarchies, and although she does not speak directly about Uganda (she writes about an ethnic group in Kenya), she emphasizes the importance of senior teachers, elder family members, and older female siblings teaching younger girls. When the participants were asked whose responsibility it was to teach girls about menstruation, nearly all agreed that education from both teachers at school as well as female caregivers (e.g. mother, grandmother) is ideal. Harriet said, “When you teach me about [menstruation], I will be comfort in my heart” (6H; 10; 1). She explained that because she was taught about menstruation, she did not feel bad, she felt comfortable, she knew what to do, and she was able to get the products she needed. For participants who identify with strong Baganda values, they believe that education should come from schoolteachers and also from the Ssenga. One of the great challenges to answering the call the women in this study made for more support and education from teachers is that many teachers in Uganda are untrained, under-qualified, and lacking resources they need to teach. Atekeyereza (2001) describes in detail many of the shortcomings of Uganda’s schools in rural areas, including the limitations of teachers; “other policies that would be effective in the education of girls are rendered ineffective by the barriers described above” (p. 136). Therefore, even with such initiatives as individual NGOs visiting schools to give girls free menstrual products, they cannot hope to make long-term, meaningful, widely-felt impact on their own. Participants spoke of being the ones who will be ensuring timely and adequate teaching when her daughters or nieces are of age; they felt that they would be preparing, protecting, and empowering the young women in their lives by being actively involved in their menstruation education and experience. Participants in this study also expressed that they valued talking to other girls and women about menstruation. None of the participants explicitly expressed an opinion about the girls-only  83 menstruation education they had all received in schools. However, this may have as much, if not more, to do with tradition and cultural values than individual preference alone. In Cook’s (2010) study comparing Ugandan and Scottish schoolgirls’ preferences talking about sex and sexual health in school, she found that “female teachers and single-sex classes were considered very important by both groups as this makes them feel “more comfortable” and less embarrassed” (p. 530).  It is not the place here to enter into a debate about whether the current practice of gender segregation in menstruation education in Ugandan schools should be maintained. More research into the impact of menstruation education in schools in general is needed. However, the findings in my study, as well as Cook’s (2010), are both based on listening to participants and understanding their experiences. Cook highlighted the voices of the teachers and students in Uganda and in Scotland. Going forward, policy makers, program designers, and future researchers must bring the voices of the participants and the recipients of various interventions to the forefront of their planning.  The participants talked about the extent to which boys and men play a role in menstruation experiences and menstruation education. WoMena, a Kampala-based non-government organization, features male educators on its team. Co-founded by Marianne Tellier and Maria Hyttel, both Danish researchers, WoMena is a community-led team of educators that operates a number of research and policy initiatives in Ugandan communities. One of their many initiatives is to train young women enrolled in BRAC Uganda’s Empowerment and Livelihoods of Adolescents (ELA) program, which was custom-built to educate the ELA women on menstrual hygiene management and the use of menstrual cups and reusable pads.    84 5.4.2 Schools as sites of menstruation education Atekyereza (2001) writes in detail about the challenges girls and women face as they attend school. Sweet reported that her school was closed due to lack of financial support and resources and she was forced to study elsewhere at great interruption to her studies, and she lost the fees already paid by her benefactor in the process (3S; 5; 22-23). The closing of schools was also Atekyereza’s (2001) concern. He found that, especially in rural areas,  “…these institutions have a poor physical and material infrastructure. Some education institutions were started with political and religious backing that could not be sustained later. A number of schools have no permanent structures or inadequate ones” (p. 133). He further delineates the complex relationships between social, cultural, economic, and political forces that effect and are affected by education and school attendance, arguing that these complexities must be better understood before they can be mitigated. In basic terms, he says, “The standards of education of girls cannot improve when the general standards are worsening” (p. 143). Given the data on dropout rates in Uganda and given the stories shared by the research participants, improving education for girls means improving education for all. Eliminating, or at least significantly decreasing, school fees would go a long way to ensure all girls and boys are able to stay enrolled in school.  Sometimes, science impacts our understanding of health and reduces our complex bodies to the simplicity and predictability of a machine; this atomistic viewpoint is one that has been thoroughly problematized across several disciplines (Conrad, 2007). The potential exists that the atomistic, scientized view of women’s bodies will be the basis for menstruation education in Uganda; a purely physiological approach to menstruation education could mean girls are taught about ovaries and uterine linings, but does this form of education enable girls and young women to make that connection to their own bodies? A creative storytelling, arts-based, or theatrical  85 approach that includes physiological information as well as personal anecdotes would reach students better than physiological teaching alone. 5.4.3 The role of NGOs in menstrual health WoMena has a program that teaches men and boys about menstrual health. They say the program was initiated through listening to what Ugandan women, girls, and even men and boys wanted to see from WoMena. One could argue that this is a Westernizing or (neo)colonizing approach. Shamirah, one of the WoMena volunteers and program designers, argues that this is not a Westernization, but a modernization, of S&RH in Uganda. It appears that this education program and others with WoMena could be considered an Indigenizing approach; working within the colonial structure while also trying to transform it. Many efforts to achieve modernization within Ugandan communities actually fail in their goals. This occurs because the underlying (neo)colonial dynamics of power have not been taken into consideration. Furthermore, Wong, Zimmerman, and Parker (2010) suggest, “a helping relationship is inherently one of power over. A power over dynamic can potentially undermine any initial well-meaning intentions” (p. 107, original emphasis). This is an extreme perspective, but is one that challenges us to ask whether any helping relationship has power dynamics that need to be identified and addressed. The experiences of intended recipients of S&RH improvement efforts must be considered in determining whether a program or research endeavour succeeded in transforming the power dynamic for the better. In her interview, Mary said, “Yes, those people - like, they take us for granted. I don’t know why. Mostly those whites, they take us - these Black people, they take them for granted” (2M; 15; 6-8). She went on to say, “we should like help but how are you helping us? Not like taking us for granted” (2M; 15; 23-24). Kenyan scholar Rose Waruhiu (1995) agrees with the statement made by the participant about  86 being taken for granted, saying, “they should be consulted, not told” (p. 137). Mary gave an example of how she would like to be consulted, saying, I think it’s if you come and ask me, like, you have come [Mary gestures to me] and ask me that’s how do you feel? What brand would you like to use? And you give me that brand what I have told you. That to think for me that this will work for the other girls – yeah. (2M; 16; 17-21) Mary is speaking about the climate of help some Ugandans are experiencing, informed by a sense that “beggars can’t be choosers”—a deeply problematic view that should never be employed when it comes to research and program development in Uganda in the field of S&RH. Safe, dignified S&RH without shame must be based on the voices of Ugandan women and girls. 5.5 Limitations of the Study First and foremost, it is important to note that all claims made in this study are applicable only to the research participants and their direct circumstances – no claims can be made to other Ugandan individuals or communities, nor should any attempt by others to use these claims as such.  An important limitation of this study is its small sample size. The data cannot be generalized to any Ugandan sub-population; generalizability is not the goal of this study. Another significant limitation is that my own cultural background and outsider position limit the information that participants are willing to share, and limit my ability to interpret and disseminate the data perfectly.  I acknowledged during the design phase of this study that there would be different cultural, logistical, and language challenges during the participant recruitment and interview phases, but the interviews were to be conducted by myself in English nonetheless. As a result,  87 there is potential for misunderstanding and misinterpretation between researcher and participant. Furthermore, these limitations may have forced participants to modify their answers in a way that would not be necessary if they had the freedom to speak their preferred language (be it their first language or one they are most fluent in) to a researcher who was also fluent.  The strategy I employed to mitigate the limitations within my control was to be honest and vulnerable. Transparency with regards to the difficulties faced while conducting this study has been shared in an attempt at honesty and vulnerability. As Page (2017) argues,  A vulnerable method does not attempt to resolve discomfort immediately through problem solving, or by forms of sense- making that utilise particular relational elements of cause and effect. Instead, what is at the heart of vulnerable methods and vulnerable writing is ongoing questions about what unsettles, about relations to the unfamiliar and strange, and about the erasure of the complexities of subjectivity when individuals and bodies and their actions do not fit or adhere to coherent themes of knowledge. This unsettled uncertainty of the research process, rather than foreclosing on further understandings, provides space for new forms of unknowing and continued attempts at understanding the stories of others (p. 28). The data analysis and writing processes were conducted with a strong sense of unsettled uncertainty with the goal of representing the stories of the research participants accurately and respectfully. As such, the findings are presented in a way that preserves the stories as intact as possible. However, it is not possible to include every single word—words that are gifts—in this  88 thesis; some stories were not relevant to the research questions or did not fit thematically with the key findings that arise. The small number of participants means that the realities we, as readers of these stories, are only seeing a glimpse of what Ugandan girls and women have experienced. While all but one participant were born and raised in rural or remote villages, they were interviewed at a time when they were living in urban or peri-urban areas. This means that their stories may not capture the experiences of girls and women who have spent their entire lives living in rural and remote parts of the country. That said, it is important not to assume differences among Ugandans based on where they grew up or where they currently live; this could serve to artificially organize people into categories that lead to inappropriate generalizations in the future. For example, categorizing the participants in this study as peri-urban or urban residents does not capture their experiences living in villages nor their experiences moving back and forth, sometimes repeatedly, between rural, peri-urban, and urban living throughout their lifetimes. I must also acknowledge the biases I bring to this research that may impact findings, results, and conclusions. For example, as a result of the surprise from unexpected discussion points that arose during interviews, I may have missed opportunities to ask different kinds of questions that could have taken us deeper into what the participants knew and how they knew. I am an outsider to this country and culture and as an outsider I maybe have missed the meaning behind some of what these young women told me. Specifically, I am a foreigner, so participants may have felt pressure to participate in or consent to the study due to the presence of many other foreigners in the country. The offer of compensation for travel and payment for their time may mean that the ten women participated in order to earn the money more so than their passion or interest in the topic. A Ugandan research assistant at BRAC Uganda, who fully disclosed I was a  89 female Canadian researcher, recruited the participants and this may have influenced those contacted away from or toward participating in this study. I assumed participants might have certain feelings about talking to me as a foreigner. Several participants said they felt comfortable talking to me despite my foreigner state because I was a woman.  While I think this study did no harm to these young women and was, through our focused conversations beneficial, I am not in a position to fully appreciate how this study was helpful or harmful, beneficial or exploitative. Outsider researchers must seek the guidance and the blessing—not just ethical approval—from Ugandan peoples. Another limitation is the tremendous logistical difficulty in sharing the final results of this study with the research participants. After the interviews with research participants were completed, I was able to stay in touch with some of them via WhatsApp. Over time, contact with all of the participants dissipated. When I returned to Canada, an unforeseen communication barrier arose: I was forced to change my WhatsApp number when I got a new phone and new phone number, as my old number was no longer available. When this change was made, the participants had no way to reach me, except by email (or by contacting the local supervisor, or my supervisor in Canada). None of the research participants had email when I met them except one person. As of the writing of this thesis, Sharon is the only participant whom I can confirm will be receiving a digital copy of the completed study.  5.6 Implications for Future Research, Policy, and Practice I have already outlined some of the implications in the discussion of the findings. Here is a reminder of those points already made: • The most significant impact on the everyday lives of the research participants regarding menstruation and S&RH is pregnancy and motherhood.  90 • Women need access to clean water, menstrual products, and pain relief; providing for these needs must include to communities and schools, not just on individuals. • Issues of affording school fees, finding work, and meeting their basic needs and those of their children are paramount in the minds of the research participants. • Continuing to teach that menstruation is normal contributes to reducing stigma and shame about menstruation. • Anyone teaching girls about menstruation should be older than the girls being taught, but peer educators who are slightly older may be excellent candidates for educating girls and women if necessary supports are in place. • Empower mothers, ssengas, grandmothers, and any others who anticipate fulfilling the role as teacher and/or supporter to a pre-menstrual girl in their life. This can be done in communities, schools, or individually. • Recognition of the significant learning and education that occurs in informal places through informal processes. • Creative storytelling, theatre, physiological information, and personal anecdotes would reach students learning about menstruation better than teaching about physiology alone. • Improving education for girls means improving education for all Ugandans, as the challenges to school attainment affect boys and girls nearly equally. Eliminating, or at least significantly decreasing school fees would go a long way to ensure all girls and boys are able to stay enrolled in school. Policies and practices (including school curricula, community programs, and NGO programming) should be designed and implemented with these points in central focus.   91  In terms of implications for future research, the following points were made: • Further investigation of and making use of the opportunity to encourage non-formal and informal learning holds a lot of promise, yet is vastly under-researched.  • More research into the impact of menstruation education in schools is needed. These are all areas of opportunity for further research. Studies with large numbers of participants that include qualitative and quantitative data but that still preserve the different contexts of the diverse regions and cultures represented in Uganda are needed to explicate the relationship between S&RH and school attainment. There is not enough information to conclude whether menstruation causes girls in Uganda to miss school, and conclusive research in this matter would enable researchers, policy makers, and program designers to focus their efforts where it is truly needed. Researchers, policy makers, and program designers—including teachers and school administrators—can learn a lot from the research participants in this study. First and foremost among them is this: more attention must be paid to the voices of the girls and women that research and programs intend to help. This should occur before, throughout, and after a program or research study is undertaken. To echo Mary, “we should like help but how are you helping us?” (2M; 15; 23). Any undertaking that does not explore women’s experiences and include their voices risks objectifying young girls and women and not seeing them as subjects of their own lives. Furthermore, ignoring their voices risks taking focus away from the needs and desires of Ugandan women and placing that focus elsewhere. Future research and education should not (re)colonize, harm, or oppress Ugandan women and girls through ignorance, homogenization, and power hierarchies masking intentions to help.    92 5.7 Concluding Reflections Over the course of the study, a lot of obstacles and achievements arose, both anticipated and unforeseen. Overall, this study has been a journey through understanding just how deep the complexities of the lives of women in Uganda extend. I conclude that the depth of experiences and perceptions about menstruation among women living in Central Uganda cannot be fully explored by an outsider researcher. When I asked participants why they felt comfortable talking to me about their stories, they said it was because I was a woman—someone with shared experiences and thereby respect for their stories and the personal information they were sharing with me. They each expressed to me that they felt they could talk with me about menstruation because I could understand despite being an outsider. I was initially surprised that Ugandan women had so many similar experiences to me and women I know. I made this assumption through reviewing the literature on menstruation and S&RH in Uganda, which paints the image that Ugandan women are underprepared to handle the challenges associated with menstruation. As a white, privileged, Western researcher, I was influenced by colonial views of Africa, even despite my best intentions to avoid it. Some of the research participants were eager to give an interview in order to help me finish my Master’s degree. Amina said, “I know it will also achieve your goals” (8A; 17; 27-28, 30).  Given the current topics covered by research publications out of Uganda in recent years, I was surprised that research participants did not raise such matters as HIV/AIDS, Female Genital Mutilation (FGM), conflict, and more experiences with extreme poverty. This is not to say that participants had no experiences with any of these matters—the opposite could be true. It was not within the scope of this study to explore these topics, nor did I ask the participants to do so. I explicitly stated that uncomfortable, personal, or confidential facts need not be discussed during  93 the informed consent process. I also learned in my BRAC internship that it is considered extremely rude and taboo to directly ask someone’s HIV status. Perhaps the absence of these matters from the data in this study may suggest that they are not relevant to the research participants. It may also mean that the research participants have indeed been impacted by such things but chose not to share it with me. I am not arguing that things like HIV/AIDS or FGM and S&RH are not unrelated; I chose to not delve into these matters in order to not distract me from exploring the participants’ experiences and perceptions of menstruation. These participants wanted to talk about what was important to them, and they have demonstrated how much they valued the opportunity to talk about their lives and about menstruation.  The participants in this study begin to paint a picture that reveals a more complex image than can be found in other studies. There is far more to each participant’s story than has been shared here. Weaving a story that is more holistic going forward enables us as outsiders to stand with, not above, participants.   94 References Abwunza, Judith M. (1997). “SHE EATS FOR NOTHING!” In J.M. Abwunza, (Ed.). 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She is asking for participants who are over 18 but are younger than 30 to participate. She would like to meet you at a place of your choice to do an interview. It will take 1-1.5 hours of your time.  The purpose of her study is to collect stories from Ugandan women and share their experiences about their lives and their menstruation within Ugandan and Canadian communities. She is interviewing 10 women in Kampala and nearby area to share their stories about growing up and about menstruation to learn about their experiences and perceptions.  Your participation will be anonymous and confidential, meaning that you will not be identified in the research in any way. Sarah will ensure that all of the information you share with her will be protected. She and her supervisor at UBC will be the only one to hear your story and access the interviews. She will record your interview on a secure smartphone and she will not share it with anyone. Your participation is voluntary. That means that you can choose if you want to participate or not. You are welcome to say no at any time, even when the interview is finished.  When the interviews are finished, Sarah will write about them and will share them with you, and with people in Uganda and in Canada. She hopes to spread knowledge about Ugandan women, especially about their successes and challenges.  Do you consent to have Sarah contact you to arrange a meeting for an interview?    YES    NO   Name:  Contact:      111 Appendix B: Consent Forms English Consent Form  “Perceptions and Experiences of Menstruation among Women in Central Uganda” Consent Form  Please read this consent agreement carefully before you decide to participate in the study.  Purpose: The purpose of this study is to learn from Ugandan women living in the Central Uganda area through their stories and experiences. Women face many challenges, and one of the experiences almost every woman has is menstruation. While menstruation experiences are different for everyone, Sarah McCabe, a graduate student at the University of British Columbia, is the main researcher (her UBC supervisor Dr. Shauna Butterwick, is consider the Principal Investigator), wishes to hear women’s stories and experiences to learn about how women rise to the challenges they face. These stories will form the basis of her MA thesis. What will happen in the study: 10 individual women will be recruited to participate in an interview. The interviews will all ask the same questions, about growing up, experiencing menstruation, and how women go about their everyday life. When the interviews are completed, Sarah will type them up and analyze the stories to look for themes that emerge. She will write an academic thesis paper about the interviews to share what she learned with other academics in Canada and in Uganda. She will also share her paper with you, the participant.  Time required:  Your first meeting with Sarah will take about 10 minutes during which time she will review the study and consent form and answer any questions. She will collect some basic background  112 information and then arrange for a time and date for the second, longer interview which will take 1 to 1 ½ hours. Once your interview is finished, Sarah will return to Canada with all of the stories so that she can write about them. She will share her results with you by email in November and December, 2016.  Risks:  There are no risks to you for participating in this study. While the focus of this study is on your stories and on menstruation, you are not required to share any information that you feel is personal or sensitive. The interview will be done in a place that is convenient to you in order to avoid any stress. Benefits:  The immediate benefit of your work with Sarah is that you will share your story with someone who is interested to hear what you have to say and who wants to learn from it. In the future, through her MA thesis, others will also learn about participants’ stories. Your interview will contribute to the understanding of women’s health in Uganda. This means that people who work with women’s health, including researchers, NGOs, and health professionals, could read Sarah’s research paper and learn from it. Confidentiality Measures to Protect your Privacy: Sarah will record your interview on her personal smartphone, which is passcode protected. She will not share these recordings with anyone. The recordings will always be kept safe and private. Sarah will take notes during your interview, and those will be kept secure and private, too.  When all the interviews are recorded, Sarah will save them on a passcode-protected personal computer, and the original recordings will be stored on an encrypted storage drive so that no one else can ever access them.  113 Sarah will be the only one to write about your interview, so she will be the only one who knows that you spoke with her. She will not record your name or contact information in the same place as she records the interviews. This means that your interview is anonymous and confidential, so you do not have to worry that anyone you know will be able to identify you from your interview. If you would like to listen to your recorded interview, Sarah will work with you to make that happen. If you would like to have any part of the interview deleted, or if you would like to delete the whole recording entirely, Sarah will respect your decision.  Names of all participants will only be recorded in consent forms. Names will NOT be used in Sarah’s research paper. Instead, you can choose a fictitious name for Sarah to write in the paper, or Sarah can suggest one for you. Voluntary participation:  Your participation in the study is entirely voluntary. This means that you should not feel pressured in any way to participate in the interview. As soon as you decide that you are willing to participate, you can contact Sarah to arrange the interview. If you change your mind, you can choose to stop your participation at any time. Sarah respects your time and your privacy, so you can stop participating before, during, or after your interview.  Please, do not agree to participate in this study unless you understand the study, you trust Sarah to keep your information confidential, and you feel you can benefit from participating. Thesis dissemination: After Sarah’s graduate thesis is written, she can send you a copy. The results of this study will be presented in a graduate thesis. The findings may also be presented as papers at conferences and may also be submitted as articles to be published in journals.   114 Right to withdraw from the study:  You have the right to withdraw from the study at any time. There are no negative consequences for doing so. If you decide to withdraw, your interview will immediately be destroyed.  Payment: Interview participants will receive 7,000 Ugandan Shillings (UGX) to compensate them for their time and their contribution. In addition, participants needing extra support for transportation and airtime will be accommodated on an individual basis.  UBC Graduate Contact for information on the study:   If you have questions about the study, contact:  Primary Researcher: Sarah McCabe Graduate Student, Department of Educational Studies  Tel: [redacted] WhatsApp: [redacted] Email: [redacted]  University of British Columbia 6445 University Boulevard Vancouver BC, V6T 1Z2  Local Supervisor:  Mark Kadigo, Research Assistant IERC – BRAC Uganda  Plot 90, Busingiri Zone Off Entebbe Rd, Nyanama Email: [redacted] Tel: [redacted]  Principal Investor (UBC Supervisor): Dr. Shauna Butterwick Graduate Student, Department of Educational Studies  University of British Columbia  115 6445 University Boulevard  Vancouver BC, V6T 1Z2 Tel: [redacted] Email: [redacted]  If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, please contact:  Dr. Christine Nabiryo, Chairperson Mildmay Uganda Research Ethics Committee (MUREC) Plot 27, Lweza Tel: [redacted] Email: [redacted]  Research Participant Complaint Line in the UBC Office of Research Ethics [redacted]or if long distance,  e-mail [redacted] or call toll [redacted] through WhatsApp.  Psychological and Informational Support:  If you feel you would like further information or support about your experiences in your life, Sarah would like to encourage you to seek it out. Here are two organizations that you can contact that give free, anonymous services and support to women in Uganda.  Marie Stopes Uganda (+256) 414 347 129 ~ Ask Without Shame 070 6666 001 Call, SMS, WhatsApp, or download “Ask Without Shame” App for smartphone  Agreement:  By signing this form, you indicate that you voluntarily give your informed consent to participate in an interview. You have the right to refuse or withdraw your contribution at any time without question or penalty up until October 1, 2016.   Your signature indicates that you consent to participate in this study.   Consent:   I would like my personal data (name) to be kept confidential: Yes___    No___  I have chosen a fictitious name that I would like to be used:       116  I agree to participate in the research study described above – please sign below.   Name:          Signature:           Date:           Contact person name:       Contact person phone:       Email address:            Mailing Address:                          Contact phone:         WhatsApp:              117 Luganda Consent Form “ Entegeera no’bumanyirivu kunsoonga zo’kubeera mumweezi wakati wabakyaala abomumasekatti ga Uganda” Ekiwandiiko Ekisaba Olukusa lwo okwetaba mukunonyeleza kuno  Tukusaba osome bulungi ekiwandiiko kino nga tonaba kwetaba mukunonyereza kuno   Omugaso gwo’kunonyerezakuno:   Omugaso gwo’kunonyereza kuno kwe kuyigira ku bakyala bamasekkati ga uganda ku bumanyirivu bwabwe. Abakyala basanga obuzibu bungi mubulamu bwabwe naye okusinga,  buli mukyala alina obumanyirivu obukwatagana kunsonga za bakyala yade ngo’bumanyilivu buno bwaawukana okuva kumukyala omu okudda kumulala, Sarah McCabe akulira okunoonyereza kuno yandyagadde okuwulila  kumbozzi no’bumanyirivu bwabakyaala asobole okuyiga engeri abakyala jjebakwaasaganyaamu okukaluubirizibwa kwebasaanga. Mu mboozi zinno mwanaasiinzira okufulummya ekyiwaandiiko. Ekyinaatuukawo mukunoonyereza kuno:  Abakyala 10 bajja kulondebwa okwetaba mukunonyereza kuno. bagenda kubuzibwa ebibuuzo byebimu ebikwatagana ku ngeri gyebakulamu, ensoonga zokubeera mumweezi, nengeri gye batambuzamu obulamubwaabwe obwabulijjo.  Okubuuzibwa bwekunaaba kuwedde, Sarah agenda kungaanya ebinaaba biddiddwaamu alyooke afune omulamwa ogwawamu, bwamala agenda kuwandiika alipoota evudde mukunonyereza   alyooke abigabaneko namatendekero amalala ekanada ne mu Uganda naawe eyyetabye mukunonyereza kuno. Kyinno ajja kukyikolla nga akuweerezza imeyillo kumukuttu gwa yintanneeti oba ajjakuyitta kussimu. Laba nti owaandiise ebyo byona ebikwatakko mungeri jayiinza okukufunamu okukudizza obubaka.   118 Obudde Obwetaagisa:  Mugya kumala akadde ka saawa emu oba emukyitundu ngamwogerezeganya , bwanaamalla okubuuza bona abetabye mukunonyereza, agya kudda mu kanada olwo alyoke awandiike alipoota  gyaagenda okugabana naawe kubyanaaba agye mukunonyereza nga akozesa omukutu gwa yintanenti ogwa imeyiro oba mu posta.  Obutyaabaga:  Tewali katyaabaga kona kayinza kutuukako olwokwetaba mukunoonyereza kuno, newankubadde ngokunonyeleza kukwaata ku mboozi zamwe  ne nsonga ezokubeera mu mweezi, tewetagisa kwatula ebyo byo wulila nti byakyaama gyoli. Okubuzibwa ebibuuzo kugya kuba mukifo ekitakuleetere kwelalikirilla oba okukaluubirizibwa. Okuganyulwa:  Nga ogabanye embozziyyo ne Sarah, ojjakuganyulwaamu nti embooziyyo ojjiigabana nomuntu ayagala okugiwulira ate ayagala oku gifunnamu ekyokuyiga. Mubiseera ebyomumaaso, Sarah agya kugabana emboozi zamwe abetabye mukunoonyereza nabo basobolle okuzifunamu ekyokuyiga. Byemunaaba muzeemu bigya kuyaamba okuleetawo enongoseleza kubikwata ku byobulamu bwabakyala, kino kitegeza nti buli muntu akola kubikwatagana kubyobulamu byabakyala omwo mwemuli nabanonyeleza gatako nebitongole ebitali bya gavumenti basobola okusoma ku alipota ya Sarah nabo basobole okugyamu ekyokuyiga.  Engeri gyetugeenda okukuumamu ebyaamabyo Sarah agya kulikodinga embozzi yo naye ku simu ye ayomungallo erimu paasiwaadi. Emboozi yyo tejja kugabanyizibwa na  muntu yena. Byanaba alikodinze agya kubikuuma nga byakyaama. Sarah era agya kuba abako byawandiika mukatabo ke ngamuli mukunyumyamu naye, ebyobyona byanaaba awandiise bigya kukuumibwa nga byakyaama, obubaka bwona  119 bwanalikodiinga agya kubukuumira ku kompyuuta yye era nga nayo erimu pasiwaadi nga yeka yagimanyi era tewali muntu yenna agyakuba na busobozi buwuliriza oba obusoma mboozi yo ne Sarah gyemunaaba munyumizza okujjakko Sarah n’omukullu akulira ebyokunoonyerezza.                                                                                                       Sarah yemuntu yeka agyokuba nga awandiika ku mbozi yyo era yekka yagy’okumanya ntiwayogerako naye. Erinnyalyo terijja kuwandiikibwa oba kilikondiingibwa, kyino kyitegeeza nti emboozi yo nayye egyakuba yakyaama era teli agyakutegeera nti weetaba mumboozi yonna nayye. Tewali noomu ajja kkutegeera mu alipoota enaaseembayyo. Bwonaba oyagala okuwuliriza kubyonaaba oyogedde mu mbozzi yo nga Sarah abirikodiinze, agya kolagana naawe asobole okutuukiriza kino. Okutundu konna mumbooziyyo konaaba oyagalla kajjibweemu kabe nga kajjibwaamu, oba ngo’yagalla embozzi yo naye ebe ngejjibwa kukataambi nakyo agya kukikolla.  Ammanya gaabo bonna abanaaba beetabye mukunoonyereza kuno aganaaba gawandikiddwa tegajja kukozesebwa  wantu wona, naye osobolla okulonda ekinnyannya kyona kyoyiinza okwaagala Sarah akozese nga awandiika alipota ye, oba Sarah ayinza okuyambako okukyiroonda.  Okwetaba mumbozzi eno kwa kyeyagalire:  Okwetaba mukunonyereza kunno sikwabuwazze, kinno kitegeeza nti Sarah tayagalla offune kwelaliikirila kwona. Amangu ddala bwoba osazeewo okwetaba mukunonyereza kuno, osobola oku kwatagana ne Sarah nategeka okukusisiinkana. Embozzi yo ne Sarah bwenaba emazze okulikondingibwa ogyakuba olina pakka omweezi ogwo mweenda nga lumu okusallawo obuteetaba mu kunoonyereza  kuno.  120 Osabibwa okwetaba mukunonyereza kuno ngo’tegedde okunonyereza kyekukwaatako, era nga wessizze Sarah okukuuma obubaka bwonaaba omuwadde nga bwekusifu ela ngowulila oganyulwa mukunoonyereza kunno. Okugabana ebivudde mukunonyeleza:   Sarah bwanaaba amaze okuwandiika alipoota ye, asobolla okusindikira ku alipoota eno nga akozesa omukutu gwa yintaneeti ogwa imeyiro oba okukubira essimu. Alipoota eno ekwaata kubivudde mukunoonyereza kuno egya kuba ngeteekebwa mu bitabo ebimu nokugabana ko nabantu mu nkungaana ezimu.  Obuyiinza okuva mu kunoonyereza kuno.  Olina olukusa okuva mukunoonyereza kunno obudde bwona, era emboozi yo eja kusazibwaamu mangu ddala.  Okusasulibwa  Abaneetaba mukunoonyereza kuno bagya kusasulibwa nussu kasaanvu (7000) eza Uganda okusassulira obudde bwebanaaba bamazze, naabo abaneetaaga obuyaambi mubyentambulla nebyokusulla bajjakuyaambibwa kyinoomu.  Bwoba olina ekibuzzo kyona ekikwatagana ku kunoonyereza kuno, osobola okwebuuza kubantu bano wamaanga:  Anoonyereza:  Sarah McCabe  University of British Columbia  6445 University Boulevard   Vancouver BC, V6T 1Z2  Tel: [redacted]  What’s App: [redacted]  Email: [redacted]  Local Supervisor:   Mark Kadigo, Research Assistant IERC – BRAC Uganda   121 Plot 90, Busingiri Zone  Off Entebbe Rd, Nyanama  Email: [redacted] Tel: [redacted]   UBC Supervisor: Shauna Butterwick,  University of British Columbia 6445 University Boulevard Vancouver, BC  V6T 1Z2 E: [redacted]  Bwoba olina Okwemulugunya kwona   Bwoba olina Okwemulugunya kwona, nekikwatagana ku kukunoonyereza kuno oba byoyiseemu  mukunoonyereza kunno Kwatagana ne banno wamaanga   Dr. Christine Nabiryo, akulila  Mildmay Uganda Research Ethics Committee (MUREC) Plot 27, Lweza  [redacted] email: [redacted]   Offiisi ekulira okwemulugunya ku yunivaasite ya British Columbia  [redacted] or if long distance,   e-mail [redacted]    or call toll free [redacted] through WhatsApp   Bwooba weetaaga obuyambi obwengeli yona:   Bwooba weetaaga obuyaambi bwonna obukwatagana kubulamu bwo, Sarah akukubiriza okusaba obuyaambi  okuva mubitongole bino wamaanga, era bijja kuwwa obuyaambi kubweerere.   Marie Stopes Uganda (+256) 414 347 129  Ask Without Shame 070 6666 001 Osobola okuba, oba okuweereza obubaka, oba ku WhatsApp, “Ask Without Shame”  Enzikiliziganya:   122 Okuteeka omukono kukyiwandiiko kyino kyiraga nti okirizza okwetaba mukunoonyereza kunno, olina olukusa okuva mukunoonyerezza kunno obudde bwonna awatali kubuuzibwa oba okubonerezebwa mungeli yonna paka nga lumu ogwoomweenda, 2016  Okuteeka omukono kundagaano eno kitegeeza nti okirizza okweetaba mukunoonyereza kuno.  Okukiriza:   Njagalla ebinkwaatakko (erinya lyange) bikuumibwe nga byakyaama:  Iyye________ Nedda__________   Nonze ekinnyannya kyenandyaagadde okukozesa_________________________________   Nzikirizza okwetaba mukunoonyerezza kunno, teeka omukono wamaanga   Ammanya gwo__________________________________   Omukono gwo         Enakuzoomweezi___________________________________ Omuntuwo  gwetusobolla okutuukirira                       Amanya ge          Enaba ye eyessimu_______________________________________  Emeyiro yye____________________________      Akasanduke ka posta okumuwelezaako ebbaluwa         Enambaye eya Watisapu____________________          123 Appendix C: Interview Tool  “Ugandan Women’s Perceptions and Experiences of Menstruation” Shauna Butterwick, Principal Investigator Sarah McCabe, Primary Researcher Semi-Structured Interviews Introduction to Respondent to be Interviewed  INTERVIEWER SHALL COLLECT THE SIGNED INFORMED CONSENT FORM BEFORE PROCEEDING. Do you have any questions?  Do you agree to participate in this interview?  Yes  No Section A. Identification of Respondent A1 Surname of Respondent               A2 Other Name of Respondent               A7 Urban/peri-urban/rural/remote [select one] 1= URBAN 2= PERI-URBAN 3= RURAL 4= REMOTE A9 Mobile Numbers 0 7         0 7          A10 Respondent’s age  [RECORD IN COMPLETE YEARS]    A12 Birth Year      A13 Are you currently attending school? 1=Yes → A15 0=No  A14 Why is it that you are not currently attending school? SELECT ALL THAT APPLY 0=Never went to school 1=HAD TO DROP OUT OF SCHOOL [SPECIFY REASONS] 2=Already completed level of studies desired 3=Got married 4=Quit due to pregnancy 5=Family responsibilities 6=regularly attending became too much of a challenge [specify reasons] 88=Other [specify]   A15 What is your highest level of education completed?       A16 What is your current marital status? 1=MARRIED/LIVING TOGETHER 2=DIVORCED/SEPARATED 3=WIDOWED 4=SINGLE   124 Section B: First Menstruation This section focuses on women’s recollections of their first menstruation.  Part B.1 Story of growing up and first menstruation Topic Focus Core questions INTERVIEWER TO READ ALL Additional questions or prompts Early Adolescence and  First Menstruation   1. What was your life like when you were a young teenager?  2. Tell me the story about when you had your first menstrual period.   3. What did you know about menstruation before you started menstruating? Who/what told you?   1. Where were you? How old were you? Where were you living? How did you feel? What did you do?  2. Where were you? How old were you? Where were you living? How did you feel? What did you do?  3. Who, if anyone, told you about menstruation before your first period came?  Did you know what menstruation was before your first menstruation?   Part B.2 Thoughts and feelings about first menstruation Topic Focus Core questions INTERVIEWER TO READ ALL Additional questions or prompts Reflections on first menstruation – emotional and physical 4. How did you feel when you menstruated for the first time?  Probe: emotionally, physically, mentally? 5. How is the way you feel about your menstruation today different from when you had your first menstrual period? 4. How did you feel about your first menstruation after it was over?  Did anyone you didn't want to know find out? How did they react? Did you fear others finding out? Who?   5.  How did you feel / what did you think about menstruation in general after your first experience? Overall, was it a happy and good time? Or was it annoying, scary, or did it make you unhappy?     125 Section C: Talking about Menstruation with parents, family members, and others (elders, friends, teachers, etc.)  Section C.1 Experiences of menstruation within family, friend, and community dynamics  Topic Focus Core questions  INTERVIEWER TO READ ALL Additional questions or prompts Parents and family    -    Friends and community members  5. Did your parents (aunt/elders/other adults) ever tell you about menstruation or discussed any matters related to menstruation with you? What about other members of your family or community? Brothers/sisters, grandparents, aunts and uncles, or teachers, church members, friends, etc.? 6. [IF Answer to 5 is “no”] Why do you think your parents (aunt/elders) have never spoken to you? 7. Would you have liked your parents (aunt) /other family and community members to be more open? About what issues? In what ways? 8. How important are parents (aunt)/ other members of your family/ community as sources of information?  Who would you most prefer to talk to about issues like menstruation            7. Who initiated the discussion? How was it approached? What did you discuss? Topics / ages? Can you remember much about what was said? Did you already know about it? How did you feel at the time? How did you react? How did they feel? How did they react? 8. How does your experience compare with your friends?     126 Section D: Menstrual Experience(s) Since Menarche This section focuses on capturing women’s menstrual history and experiences since their first menstruation, particularly as perceptions and experiences change over time.  Part D.1: Experiences of menstruation since first menstruation (menarche)  Topic Focus Core questions INTERVIEWER TO READ ALL Additional questions or prompts Activities through the years to the current time (menstrual history) [READ PREAMBLE] Thinking now about the time since your first menstruation…  6. How long have you been menstruating?  7. How would you describe your periods now? Do they tend to be manageable? Unmanageable?  8.  Would you say you feel different when you are menstruating? How?  9. Would you say you are treated differently when you are menstruating compared to when you are not menstruating? How or by whom?  10. Tell me how menstruation affects your everyday life overall. 6. Are there any patterns or phases with your menstrual cycle?  7. Have there been times since your first menstruation that it affected your activities earning income or going to school?  What influences your menstrual product choice/selection? Are you fearful of others finding out when you are menstruating? Who? Why?  What activities have you / do you normally engage in that you avoid or change when you are menstruating? Some examples [PROBE, DO NOT LEAD PARTICIPANT]: a. school or church attendance? b. income-generating activity? c. childcare? d. sports, events, others? Do these activities mean different things to you when you menstruate? How do you feel about them?  9. How does menstruation have an effect in your day? What are some things that happen differently because of your period?    127 Section E: Talking about Menstruation This section focuses on identifying and describing women’s sources of information when it comes to learning about menstruation and menstrual hygiene management (MHM).  Part E.1 Menstruation and the Research Study, including perceptions of the Researcher  Topic Focus Core questions INTERVIEWER TO READ ALL Additional questions or prompts Impressions of talking about and thinking about menstruation 11. How do you feel about talking to me about menstruation today?  12. I am passionate about women’s health and about giving women’s voices a space to be heard. Why do you think I want to talk to you about menstruation?  11 I feel very comfortable talking about menstruation. Why do you think that is? Why do you think you fell  [REPEAT RESPONDENT’S WORDS USED TO DESCRIBE HER FEELINGS]?     12 What do you think I can learn from talking to you? How can you benefit from our conversation?   Part E.2  Topic Focus Core questions INTERVIEWER TO READ ALL Additional questions, prompts, or probes Main sources of information  Most frequently used and most important sources  13 Who do you talk to about menstruation? Tell me about your relationships with this (these) person (people). How important to you is (are) s/he (they)?  14 How did you first learn about menstruation?  15 How do you know when you are about to get your period? 13. Can you tell me a specific example/piece if information that [SOURCE] gave you? What did you think about it? Bodily changes, menstruation or “period”, puberty, cramps? 14. Can you remember what you were told/what you found out? How old were you? How did you feel / act? 15. Bodily changes, cramps, bloating? How does your body feel when you are menstruating?   


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