Understanding associations between the COVID-19 pandemic and menstrual hygiene management among adolescent girls in Ethiopia: findings from a mixed-methods longitudinal study.

OBJECTIVE: To understand the relationship between the COVID-19 pandemic and menstrual hygiene management (MHM) among adolescent girls in Ethiopia and to explore which girls were most affected by pandemic disruptions. DESIGN: Two rounds of data from surveys and interviews were collected with adolescent girls immediately prior to and during the COVID-19 pandemic. The primary analysis is cross-sectional, controlling for pre-COVID-19 covariates. SETTING: The setting was three zones in two regions of Ethiopia: East Hararghe and East Shewa Zones in Oromia and South Gondar Zone in Amhara. Data were collected in December 2019-March 2020 and September 2020-February 2021. PARTICIPANTS: 742 adolescent girls, ages 11-25 years. OUTCOME MEASURES: Four primary outcomes were explored (1) the number of challenges girls experienced; (2) adolescent-identified challenges managing menstrual hygiene; (3) adolescent-identified difficulties accessing MHM products and (4) adolescent-identified difficulties accessing soap or water. RESULTS: Girls who were more vulnerable to COVID-19 were more likely to have worse MHM outcomes. An SD increase in household vulnerability to COVID-19 was associated with an 8.7 percentage point increase in the likelihood that the respondent had difficulty getting MHM products (p<0.001), a 6 percentage point increase in the likelihood that she reported facing a challenge managing her menstruation (p=0.003) and a 5.2 percentage point increase in the likelihood she lacked soap or water (p=0.001). Qualitative themes, used to triangulate the quantitative findings, suggest that mobility restrictions, shutdowns of the local market, disruptions in supply chains, poverty, stigma and fear about contracting COVID-19 affected girls' access to MHM supplies. CONCLUSIONS: The results of this study suggest that MHM was left behind in the COVID-19 response. New programming and policy interventions need to address financial hardship and disruptions to supplies to manage menstruation as well as tackle the inequitable gender norms that stigmatise menstruation during emergencies.

Improving Menstrual Health Literacy Through Life-Skills Programming in Rural Ethiopia.

Despite its cultural and biological importance, limited knowledge about menstruation and cultural taboos in many contexts mean that menarche often brings fear and stigma. In Ethiopia, the context of this paper, lack of knowledge and the stigma around menstruation create challenges for adolescent girls related to menstrual hygiene management and their reproductive health more broadly. This paper uses a cluster-randomized controlled trial (cRCT), with 97 communities (kebeles) randomly assigned to treatment or control, to assess the impact of a gender-transformative life-skills intervention [Act With Her-Ethiopia (AWH-E)] on the menstrual health literacy of very young adolescent girls and boys (10-14) in two diverse regions of Ethiopia (South Gondar, Amhara and East Hararghe, Oromia). The evaluation employs a longitudinal mixed-methods design, with baseline data collected in late 2017/early 2018 and follow-up data collected in late 2019/early 2020. Quantitative surveys were undertaken with 2,492 very young adolescents and their primary caregivers, and complemented by qualitative interviews with 291 adolescents and their caregivers, as well as 96 key informants at community and district levels. Our quantitative findings highlight large and statistically significant improvements on norms around menstruation, knowledge about menstruation and biological function, and knowledge and behavior related to menstrual hygiene management, but with important differences by location and gender. Qualitative findings further unpack these gender and regional differences, highlighting the importance of adapting programming to the local context and, where possible, connecting to other health and gender initiatives. This analysis helps fill the evidence gap on "what works" to improve menstrual health literacy in rural low- and middle-income contexts.

Disrupted education trajectories: Exploring the effects of Covid-19 on adolescent learning and priorities for "building back better" education systems in Ethiopia.

MOTIVATION: The Covid-19 pandemic delivered an unprecedented shock to education systems globally, with school closures affecting 1.6 billion children. Education systems in LMICs are facing significant budget cuts further constraining capacities to adapt to Covid-19 impacts. The need for evidence to inform policy dialogues about how best to mitigate impacts and support education systems to "build back better" is pressing. PURPOSE: In Ethiopia, schools reopened in October 2020 after a 7-month pandemic-related closure. Employing an adapted resilience systems analysis framework, this article focuses on the extent to which Ethiopia's education system-which has in recent decades seen rapid progress in enrolment rates-has adapted to the impacts of the pandemic on adolescents' education and learning, and has achieved this equitably. METHODS AND APPROACH: The article draws on mixed-methods data from Ethiopia collected virtually with a pre-existing cohort of 3,066 adolescents (1,683 girls & 1,383 boys) during the immediate onset of the pandemic (April-June 2020) and following the reopening of schools (November 2020-February 2021). Adolescent perspectives are complemented by 27 key informant interviews at community and district levels. FINDINGS: Findings highlight that rural adolescents, girls and adolescents with disabilities were less likely to access distance education during school closures due to connectivity challenges and discriminatory norms, and to subsequently re-enrol. Implementation of adaptive measures, including hygiene guidance, smaller class sizes and catch-up classes, has been highly uneven, and outreach to support re-enrolment of socially marginalized adolescents very limited. POLICY IMPLICATIONS: For LMICs like Ethiopia to build back better post-pandemic and stay on track to achieve Sustainable Development Goal 4's commitment to inclusive and equitable quality education for all, scaled-up investments in blended learning approaches, addressing the digital divide, and ensuring targeted outreach and social protection to support re-enrolment of socially marginalized adolescents is critical.