An Early Window of Opportunity for Promoting Girls' Health: Policy Implications of the Girl's Puberty Book Project in Tanzania

"Given the numerous health-related risks faced by adolescent girls and women in low-income countries, such as infection with HIV/AIDS, unsafe abortions, and gender-based violence, attention to policy and programming that aim to ensure that girls transition through puberty with a healthy body and a sense of empowerment over that body is an important component of ensuring improved population health."

Noting that the onset of puberty and, specifically, menstruation, is an opportune moment for reaching girls as they transition into adolescence and young womanhood, this document describes the Girls' Puberty Book Project. Developed through participatory research conducted with Tanzanian girls in 2006-2007, this pilot project aimed to publish, evaluate, and distribute 16,000 copies of a girls' puberty book designed for 10-14 year olds in Tanzania. The book provides basic guidance to girls on menstruation and body change. Participatory activities associated with the book that are carried out as part of the project include menstrual stories, anonymous puberty questions, design of a puberty curriculum, and drawing of a "Perfect Girl's Toilet". The project was funded by the Nike Foundation, with subsequent support from the United Nations Population Fund (UNFPA) and the United Nations Children's Fund (UNICEF) to print 124,000 additional copies. Sustained efforts with local stakeholders led to the book being integrated into government-level policy in education and water, sanitation, and hygiene (WASH) in schools: The book was adopted by the Tanzania Ministry of Education for the primary school curriculum.

The entire process and outcome of developing the project is described in this report. In short, the central purpose is to improve girls' comfort levels around managing pubertal body changes in frequently girl-unfriendly school environments - e.g., a predominance of male teachers and administration and "severely lacking" water and sanitation facilities in schools - facilities that are essential for girls' menstrual hygiene management. As was demonstrated in Tanzania, the girl's puberty book also provides an entry point for parental- and teacher-led discussions with young girls about reproduction and body change, reaching "an important window in young people's lives before the onset of sexual activity." The project was developed through a 3-phase process: In Phase I, an in-depth comparative case study was conducted on girls' experiences of menstruation and schooling, which utilised participatory activities with girls and collected information critical for the content of the book. In Phase II, the author focused on continued stakeholder building and the book's development. Phase III included dissemination and evaluation of the book, as well as advocacy for local policy change and sustainable financing in Tanzania.

An outcome evaluation was conducted in August 2009 which included a pre-post test survey with girls in Standards 5, 6 and 7 at 2 primary schools (peri-urban and rural) and girls in Form 1 at 1 secondary school. One girl said: "[The book] helps a student to educate her fellow students about carrying a kanga [cloth wrap], and a pad, so as to help herself and others." It is noted here that, although the survey sample was small, "the findings pointed to an increased level of knowledge and a shift in girls' attitudes towards puberty and menstruation."

Key findings from the process and outcome evaluation include:

1. "[G]irls' strong enthusiasm for teaching other girls (such as younger girls, fellow students, and girls out of school) about the changes of puberty so they will not be afraid upon finding blood the first time, and will feel empowered through knowing how to manage their menstrual flow suggests the great potential for building or strengthening social networks between girls."
2. "[G]irls' strong recommendation that the girl's book be shared with mothers, aunties, sisters, grandmothers, and teachers so they will be better informed to teach girls about the changes in their bodies and menstrual management further supports the findings from the original research that many girls are receiving inadequate information/guidance from elder girls and women."
3. "[G]irls' interest in additional books being developed that help them to address and manage sexual pressures and other challenges of later adolescence reinforces the findings from the original research that girls are receiving insufficient guidance on how to navigate sexual pressures of adolescence and also supports the model of a book with actual girls' stories as a potential new successful mechanism for empowering girls."
4. "[T]he strong support received from the Ministry of Education points to a critical gap in pubertal guidance that the book is filling, and to its success in capturing the local cultural and social context through its presentation and contents."
5. "[S]trong interest from parents and teachers for the development of a similar book for boys, which would both teach boys about the changes of puberty and promote among boys the need for better treatment (and respect) of girls and women, underscores the importance of enhancing projects aimed at empowering girls to include boys, recognizing the gender dynamic within countries, and acknowledging the impossibility of truly improving girls' lives without also engaging with the social norms being conveyed to boys..."

The report concludes that the book project has "tapped into an unmet need (guiding girls through the onset of puberty) in Tanzania - a gap that appears to exist in countries across sub-Saharan Africa, South Asia, and other low- income regions of the world. The importance of filling this significant gap in the current policy and programming on reproductive health and HIV cannot be emphasized enough. The implications for pubescent girls are critically important given the significant changes in expectations around their behaviors and futures that frequently emerge after the arrival of puberty. It is essential that girls are empowered to take care of their changing bodies...The most important message to be conveyed to policymakers working in the arena of girls' health, girls' education and women's health from the example of the Tanzania girl's puberty book project is how the process of the book's development and dissemination, one that incorporated the channeling of girls' own stories and questions into a book capturing their voices, led to both its subsequent uptake among girls, parents and teachers across the country and recognition of its contextual relevance and topical importance by the government of Tanzania through its integration of the girl's book into educational curriculum and policy."

March 2013 update: Organisers have now finished the girl's puberty books in Ghana, Cambodia, and Ethiopia; they can all be found on the Grow and Know website. To date, the Ghana and Cambodia books have been approved for use in the primary and lower secondary schools by the Ministry of Education in each of those countries. Organisers are distributing 15,000 copies in each new country. The Ethiopia book was completed in March 2013. In addition, 320,000 copies total have been distributed in Tanzania with support from the UN and other organisations.