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Stress, Menstruation and School Attendance: Effects of Water Security on Adolescent Girls in South Gondar, Ethiopia

Fehr, Alexandra Elizabeth Thomp (2011)
Master's Thesis (84 pages)
Committee Chair / Thesis Adviser: Brown, Peter J
Committee Members:
Research Fields: Education, Social Sciences; Health Sciences, Public Health
Partnering Agencies: International Non-governmental organization (e.g., CARE, Inc.)
Keywords: Stress; Menstrual Management; School Attendance; Gender; Adolescents ; Ethiopia
Program: Rollins School of Public Health, Hubert Department of Global Health
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Stress, Menstruation and School Attendance: Effects of Water Security on Adolescent
Girls in South Gondar, Ethiopia
By Alexandra Fehr
Background: Water, sanitation and hygiene (WASH) issues are a growing concern
globally and disproportionately affect women and girls in low-resource settings. Many of
the physical health outcomes of poor WASH have been studied, but little attention has
been garnered to mental health. This is especially true among adolescents, an oft-
neglected group in public health research. Initial research on the topic has shown that
water insecurity, much like food insecurity, is significantly associated with poor mental
health among women.
Objective: The objective of this study is to determine to what extent water insecurity,
particularly water collection, menstrual management and school hygiene, affect stress and
school attendance among adolescent girls, aged 13-18. This study took place in South
Gondar, Ethiopia during the summer of 2010.
Methods: This study was conducted using a survey, free-listing and ranking activities, in
addition to focus group discussions. A variety of qualitative and quantitative analysis
methods, including consensus analysis, were used.
Results: 38% and 43% of participants had missed school due to water collection and
menstruation, respectively. School hygiene was found to be in a poor state, with 90% of
post-menarcheal girls stating their school did not have a place to maintain hygiene while
menstruating. Consensus analysis, however, showed that among the items causing stress
and school absence, menstruation was ranked eighth for stress and ninth for school
Discussion: This study has several implications. First, it further demonstrates the need
for WASH interventions and studies to include mental health outcomes in addition to
physical ones. Second, it sheds light on the complications of adolescent life, especially in
regard to barriers to health, well-being and school attendance. Thirdly, by analyzing this
study's results and the already established associations between different components of
WASH and health, this study proposes a theoretical model for which water insecurity
leads to gender disparities in health.

Table of Contents

Table of Contents

Chapter 1: Introduction - 1
Chapter 2: Literature Review - 4
2.1: Contextual Level - 7
2.1.a: Drought - 7
2.1.b: Poverty - 8
2.1.c: Poor WASH Infrastructure - 9
2.1.d: Institutionalized Gender Inequality - 12

2.2: Individual Behavioral Level - 14
2.2.a: Universal Individual Behavioral Factors - 14
2.2.b: Female-Specific Individual Behavioral Factors - 14
2.2.b.i: Water Collection - 15
2.2.b.ii: Menstruation and Menstrual Management - 16
2.2.b.iii: Decreased Educational Opportunities - 19
2.2.b.iv: Early Marriage and Early Pregnancy - 22
2.3: Population Level - 24
2.4: Cultural Consensus - 28
Chapter 3: Manuscript - 30
3.1: Introduction - 30
3.2: Methods - 33
3.3: Results - 36
3.4: Discussion - 43
3.5: Conclusion - 47
Chapter 4: Discussion - 48
References - 57
Appendix - 57


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