SCHOOL OF NURSING AND MIDWIFERY COLLEGE OF HEALTH SCIENCE UNIVERSITY OF GHANA, LEGON RESEARCH THESIS DEPARTMENT OF MATERNAL AND CHILD HEALTH ADOLESCENT MALE AWARENESS AND SUPPORT ON MENSTRUAL HYGIENE MANAGEMENT IN THE SAGNARIGU MUNICIPALITY OF NORTHERN REGION BY ALIMATU ADAM (10239034) SUPERVISORS: PROF. FLORENCE NAAB DR. MARY ANI-AMPONSAH A THESIS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTER OF PHILOSOPHY DEGREE IN NURSING JUNE, 2022 University of Ghana http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh ABSTRACT In recent times, Menstrual Hygiene Management has become an issue of concern to both public health scholars and practitioners. However, managing menstruation hygienically has been a neglected issue which unfortunately has truncated the educational progress of several girls and women, particularly in developing countries. Scholarly debate on MHM is raging but focused on girls and women since MHM is seen as a ‘women issue’. Reckoning the importance of males in MHM, the scholarly and practice debates have been extended to embrace boys and men. This study contributed to the debate on MHM by focusing on adolescent male awareness and support on menstrual hygiene management in the Sagnarigu Municipality of the Northern Region of Ghana. An exploratory descriptive research design was adopted with a purposive sampling technique and a sample size of 15 adolescent males were recruited from Kalpohin Senior High School. Data was gathered using a semi-structured interview guide with an indepth face-to-face interview of each participant which lasted between 35 and 45 minutes. The interviews were audio-recorded and transcribed verbatim. Guided by the Theory of Planned Behaviour (TPB), the data was analysed thematically based on the five major theoretical themes of the constructs. Three emerged themes were identified from the data with twenty-three subthemes. Specifically, the findings revealed that adolescent males have some appreciable knowledge about menstruation and MHM as they contended their willingness to support female colleagues to manage menstruation hygienically. Recommendations from findings have been made to ministries of education and health. Key words: Menstrual Hygiene Management, Adolescent males, Theory of Planned Behaviour, Reproductive Tract Infections, Menstrual Health Hygiene. ii University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this work to my family especially my husband and four (4) children, more so my son, the youngest of the four siblings who has been my IT tutor. Their unflinching support, love and prayers during this study is what has brought me this far. iii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I am sincerely express gratitude to Allah for the successful completion of this academic study. I offer unceasing appreciation to my principal supervisor, Dr. Florence Naab and the co-supervisor, Dr. Mary Ani-Amponsah for the guidance and assistance granted me in the conduct of this study I cannot repay your efforts, all I can say is that the good Lord should richly bless you. To all the lecturers, I extend a big appreciation for the knowledge impacted me. Further up, a sincere gratefulness to my colleagues and friends for the camaraderie we shared during the programme. This study would not have come to fruition without the co-operation of the participants, from whom information and data were gleaned for the phenomenon of this study. In this regard, I say a big thank you for availing yourselves for the interactions. Finally, a note of appreciation goes to my family especially my husband and children, most especially, my son for his I.T skills that have impacted this work. I am appreciative of the support, love and prayer received throughout this study. iv University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENT DECLARATION ........................................................................................................................................... i ABSTRACT .................................................................................................................................................. ii DEDICATION ............................................................................................................................................. iii ACKNOWLEDGEMENT .......................................................................................................................... iv TABLE OF CONTENT ............................................................................................................................... v LIST OF ABBREVIATION ....................................................................................................................... xi CHAPTER ONE........................................................................................................................................... 1 INTRODUCTION ......................................................................................................... 1 1.1 Background to Study ................................................................................................................................ 1 1.2 Problem Statement.................................................................................................................................... 5 1.3 Purpose of the study ................................................................................................................................. 8 1.4 Specific objectives.................................................................................................................................... 9 1.5 Research Questions .................................................................................................................................. 9 1.6 Significance of the Study.......................................................................................................................... 9 1.7 Operational definitions of key terms .......................................................................................................10 1.8 Scope of the study ...................................................................................................................................11 1.9 Organisation of the Study........................................................................................................................11 CHAPTER TWO.........................................................................................................................................13 THEORETICAL FRAMEWORK AND LITERATURE REVIEW ......................................................13 2.1 Search for Theoretical Framework ..........................................................................................................13 2.2 Social Ecological Model..........................................................................................................................14 2.3. Theory of Reasoned Action....................................................................................................................15 2.4 Theory of Planned Behaviour (TPB) .......................................................................................................16 2.4.1 Attitude toward the behaviour ..............................................................................................................17 2.4.2 Subjective norms ..................................................................................................................................17 2.4.3. Perceived behavioural control .............................................................................................................17 2.4.4 Behavioural Intention ...........................................................................................................................18 2.4.4.1 Behavioural Intentions and Menstrual Hygiene Management...................................................18 2.4.5 Behaviour .............................................................................................................................................19 2.4.6 Application and justification of the Theory of Planned Behaviour ......................................................20 2.5 Literature Review .................................................................................................... 21 2.5.1 Attitude of male adolescent toward menstrual hygiene management...................................................22 2.5.2 Cultural beliefs, perceptions, and restrictions during menstruation (subjective and normative norms) .......................................................................................................................................................................25 2.5.3 The role of men and boys in menstrual hygiene management..............................................................26 v University of Ghana http://ugspace.ug.edu.gh 2.5.4 Perceived behavioural control and menstrual health management .......................................................28 2.5.5 Behavioural Intentions and menstrual hygiene management ...............................................................29 2.5.6 Behaviour towards menstruating girls and MHM activities .................................................................30 2.5.7 Global focus on menstrual hygiene management .........................................................................31 2.5.8 Menstrual hygiene management in developing countries.............................................................32 2.5.9 Menstrual hygiene management in Ghana....................................................................................33 2.6 Summary of literature reviewed ..............................................................................................................35 CHAPTER THREE.....................................................................................................................................38 METHODOLOGY......................................................................................................................................38 3.1 The Research Setting ...............................................................................................................................38 3.2 Research approach and design.................................................................................................................42 3.3 Research Design ......................................................................................................................................43 3.4 Population, Sampling technique and Sample size Procedures.................................................................45 3.4.1 Target Population .................................................................................................................................45 3.4.2 Inclusion Criteria ..................................................................................................................................45 3.4.3 Exclusion Criteria .................................................................................................................................45 3.4.4 Sampling technique and Sample size ...................................................................................................46 3.5 Data Collection Instrument......................................................................................................................47 3.5.1 Pretesting the interview guide ..............................................................................................................47 3.5.2 Data collection procedures ...................................................................................................................48 3.6 Data Management....................................................................................................................................49 3 .7 Data Processing and Analysis.................................................................................................................49 3.8 Methodological Rigour............................................................................................................................51 3.8.1 Credibility.............................................................................................................................................51 3.8.2 Transferability ......................................................................................................................................52 3.8.3 Dependability .......................................................................................................................................53 3.8.4 Confirmability ......................................................................................................................................53 3.9 Ethical Considerations.............................................................................................................................54 3.10 Chapter’s Summary...............................................................................................................................55 CHAPTER FOUR .......................................................................................................................................56 STUDY FINDINGS.....................................................................................................................................56 4.1 Characteristics of Participants .................................................................................................................56 4.2 Organisation of themes and subthemes ...................................................................................................56 4.3.1 Positive reaction of adolescent boys towards menstruating girls .........................................................59 4.3.2 Negative reaction of adolescent boys towards menstruating girls ........................................................60 4.3.3 Impression of adolescent boys towards menstruation and MHM.........................................................61 vi University of Ghana http://ugspace.ug.edu.gh 4.4 Beliefs and perception of adolescent boys about menstruating girls and motivation to comply (subjective norms) .........................................................................................................................................63 4.4.1 Personal beliefs about menstruation and MHM ...................................................................................63 4.4.2 Cultural beliefs {of adolescent boys on menstruation and MHM (normative norms)} ........................65 4.4.3 Factors influencing compliance of adolescent boys .............................................................................67 4.4.4 Advice and encouragement ..................................................................................................................68 4.5 Perceived behavioural control of adolescent boys towards menstruating girls .......................................69 4.5 1 Influence from Peers.............................................................................................................................71 4.5.2 Teachers influence................................................................................................................................73 4.5.3 Parental influence .................................................................................................................................73 4.5.4 Cultural/ religious impact .....................................................................................................................73 4.6 Behavioural intention of adolescent boys towards menstruating girls and MHM activities ...................74 4.6.1 Interest in helping menstruating girls ...................................................................................................75 4.6.2 Desire to assist in MHM activities........................................................................................................75 4.7 Adolescent boys’ behaviour towards MHM activities.............................................................................76 4.8 Conceptualisation of menstruation and MHM.........................................................................................78 4.8.1Knowledge of menstruation and MHM.................................................................................................78 4.8.2 Adolescent boys understanding of menstrual hygiene management ....................................................80 4.8.3 Sources of knowledge in menstrual hygiene management ...................................................................82 4.9 Adolescent male support to menstruating girls........................................................................................85 4.9.1 Willingness to support menstruating girls ............................................................................................85 4.9.2 Inspiring other boys to support menstruating girls and MHM activities ..............................................86 4.9.3 Provide financial support to menstruating girls ....................................................................................87 4.10 Barriers to menstrual hygiene management...........................................................................................87 4.10.1 Maltreatment from friends..................................................................................................................87 4.10.2 Cultural and religious perspective on menstruation............................................................................88 4.10.3 Unsupportive teachers ........................................................................................................................90 4.10.4 Teachers impact in MHM activities ...................................................................................................91 4.11 Summary of findings .............................................................................................................................91 CHAPTER FIVE.........................................................................................................................................92 DISCUSSIONS ............................................................................................................................................92 5.1 Demographic characteristics of participants............................................................................................92 5.2 Attitude (beliefs and evaluations) of adolescent boys towards menstruating girls ..................................93 5.3 Beliefs, perceptions and motivation to comply (subjective norms).........................................................96 5.4 Perceived behavioural control of adolescent boys towards menstruating girls .......................................98 5.5 Behavioural intentions of adolescent boys towards menstruating girls and MHM activities ..................99 5.6 Adolescent boys’ behaviour towards MHM Activities .........................................................................100 vii University of Ghana http://ugspace.ug.edu.gh 5.7 Conceptualisations of menstruation and MHM .....................................................................................100 5.8 Barriers to MHM ...................................................................................................................................103 5.9 Chapter’s Summary ...............................................................................................................................105 CHAPTER SIX..........................................................................................................................................106 SUMMARY, IMPLICATIONS, CONCLUSION, RECOMMENDATIONS AND LIMITATIONS .....................................................................................................................................................................106 6.1 Summary of the Study ...........................................................................................................................106 6.2 Implications of the Study.......................................................................................................................111 6.2.1 For Health/Nursing Education and Practice .......................................................................................111 6.2.2 For Nursing Research .........................................................................................................................111 6.2.3 For Public Education in Communities................................................................................................111 6.2.4 For policy formulation........................................................................................................................112 6.3 Conclusion.............................................................................................................................................112 6.4 Recommendations .................................................................................................................................113 6.5 Limitation of the Study..........................................................................................................................114 REFERENCES ..........................................................................................................................................116 APPENDICES ...........................................................................................................................................130 Appendix A: Introductory Letter – Pilot site ...............................................................................................130 Appendix B: Introductory Letter – Study site .............................................................................................131 Appendix C: Ghana Health Service Ethical Clearance................................................................................132 Appendix D: Consent Form.........................................................................................................................133 Appendix E: Interview Guide......................................................................................................................134 Appendix F: Profile of participants .............................................................................................................137 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: Organisation of themes and Subthemes.........................................................57 Table 2: Profile of participants……………………………………………………...138 ix University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Conceptual Framework of Theory of Planned Behaviour............................20 Figure 2: Map of Sagnarigu Municipality ...................................................................41 x University of Ghana http://ugspace.ug.edu.gh CAMFED IRB KASS LI MHM MOH NGO NOBISCO NMIMR RTI SEM SHS TPB TRA UNESCO UNICEF W/C W.H. O LIST OF ABBREVIATION Campaign for Female Education and Development Institutional Review Board Kalpohin Senior High School Legislative Instrument Menstrual Hygiene Management Ministry of Health Non-Governmental Organisation Northern School of Business Senior High School Noguchi Memorial Institute for Medical Research Reproductive Tract Infection Social Ecological Model Senior High School Theory of Planned Behaviour Theory of Reasoned Behaviour United Nations Educational Scientific and Cultural Organisation United Nations Children’s Fund (formerly United Nations International Children’s Emergency Fund) Water Closet World Health Organisation xi University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background to Study In recent years’ menstrual hygiene management (MHM) has become an issue of grave concern in public health across the globe (Odey et al., 2021; Sommer et al., 2015). Defined as “women and adolescent girls using a clean menstrual management material to absorb and collect blood that can be changed in privacy as often as necessary for the duration of the menstrual period, using soap and water for washing the body as required, and having access to facilities to dispose of used menstrual management material” (Budhathoki et al., 2018). MHM has attracted immense interest in both practice and scholarly arenas (Budhathoki, Bhattachan & Sharma, 2018; Alam et al., 2017; Van Eijk et al., 2016; Sommer et al., 2016). This is in view of the realisation menstrual issues have impacted negatively on the progressive development of females particularly females from developing countries. For instance, menstrual problems have truncated the education of many young promising girls particularly in developing countries including Ghana (Mohammed, Larsen- Reindorf & Awal, 2020). This unpleasant trend feeds into the already gender inequality and gender roles persisting in societies. In fact, it is noted that reproductive and sexual health is usually influenced by gender roles as has been spelt out by the society. This split of gender roles by the society has impelled males to believe that reproductive and sexual health issues are women responsibilities. It has further shaped males’ attitudes in this regard. Knowledge on sexual and reproductive health for males is a requirement for a decent sexual health, which is fundamental in modelling males’ behaviour for future decision- making, attitudes change on reproductive health and perception about girls during menstrual period (Bergström, Ugarte, Guevara, & Eustachio Colombo, 2018). The lack of menstrual hygiene 1 University of Ghana http://ugspace.ug.edu.gh management among young girls aged 15–19 years is undoubtedly a scathing public health problem is predominantly in developing and under-developed countries (Sommer, Hirsch, Nathanson, & Parker, 2015). With over 0.6 billion adolescent girls (8% of the world’s population), the issue of menstrual hygiene by virtue of its magnitude is an issue of global concern. More than 80 percent of these adolescents reside in the Asian and African continents (Sommer et al., 2015; Sharma, Mehra, Brusselaers, & Mehra, 2020). During the period of adolescence, boys and girls go through different forms of transformations of which girls always have to deal with social, emotional and psychological problems associated with menstruation cycle (Mendle, Turkheimer, & Emery, 2007). Puberty in girls is noted to be associated with problems throughout adolescence, which includes depression, anxiety, and general emotional distress (Blumenthal, Dawson, & Hurskainen, 2011). Other studies on menstrual hygiene have indicated that about (65%) of adolescent girls have insufficient knowledge about puberty and sexuality (Darabi et al., 2018). This problem is further worsened by unavailability of water, washroom, sanitary pads coupled with lack of social support from their male counterparts (Bay, 2017; Winter, Dreibelbis, Dzombo, & Barchi, 2019). Davis et al. (2018) in research on menstrual hygiene management and absenteeism in schools postulated that of 1159 participants that participated in the study 11.1% had absented themselves one or more days from school due to menstruation. Further studies by Tegegne and Sisay (2014) also reported that 50% of girls absented themselves from school during the time they are having their menstruation period in Ethiopia. The study again reported that some of the girls (58%) indicated that their school performance declined as a result of menstruation and some girls’ dropout of school due to the stigma and humiliation that accompanies menstruation from their male peers (Tegegne & Sisay, 2014). An awareness, perceptions and practices studies conducted on menstruation and menstrual hygiene in 2 University of Ghana http://ugspace.ug.edu.gh Bengaluru, India, acknowledged the importance of the role of male in MHM. The study was quick also at admitting the lack of knowledge of men in the menstrual cycle and hygienic measure to take during menstruation. It was again noted that at policy levels men are often responsible for decisions on health and services that affect women. It was thus suggested that strategic inclusion of men and boys in different aspects in relation to menstruation beginning from the home, community, and workplace could significantly ensure changes in the attitudes and behaviour of men and boys towards menstruation (Srinivasan et al., 2019). In their findings, Srinivasan et al. (2019) indicated that young women had a better knowledge of menstruation than their counterpart young men. In the same study, participants’ attitudes were measured on restrictions of girls menstruating to entering house/temple, to eat with others/not allowed to eat certain foods items and whether they should not also attend functions and play sports. The results showed negative attitude among young men as high as 292 participants representing (78.55%), compared to 187 (48.4%), represented low negative among young women. In another study, female adolescents were seen to have little access to reliable information on reproductive health (Darabi et al., 2018). In addition, the study findings also mentioned among others inadequate communication among mothers and their daughters about menstruation, socio- cultural prohibitions, and taboo which brings about poor knowledge, attitudes and practices regarding menstrual health among teenaged girls. Many studies have laid so much emphasis on the girl-child on matters related to menstrual hygiene management (Winter, Dreibelbis, Dzombo, & Barchi, 2019; Darabi et al., 2018; Tegegne & Sisay, 2014). However, research conducted on ‘we do not know’, explored boys’ perception on menstruation in India (Mason et al., 2017). The study findings stated among others, that boys can be advocates moving forward the MHM agenda. It also mentioned the readiness of boys to acquire information about menstruation despite societal 3 University of Ghana http://ugspace.ug.edu.gh norms. Even though this finding is in a positive light, not much research has been done on male awareness, support and attitudes towards MHM. Whereas there is large body of literature on MHM, of which the concentration has been on adolescent girls and women, this one directional focus is still posing a challenge in many societies especially in male dominant cultures Ghana inclusive. When the roles of men and boys on MHM were examined, it was revealed that their roles are crucial and critical in the fight against negative tendencies associated with menstruation (Garg & Anand, 2015). It further noted that not only are the role of men and boys in supporting MHM was lacking, but also sensitisation programmes for men and boys. As part of challenges, cultural norms on menstruation were also identified as deeply rooted and therefore bring about gender inequality. This inequality subsequently affects women’s capacity and skills to manage their menstruation hygienically and healthily (Mahon, Tripathy & Singh, 2015). This therefore calls for a change to help enhance and improve menstrual hygiene management in significantly male dominated societies. Although males have been noted to play a significant role in family formation, as well as issues relating to domestic life globally (Meena, Verma, Kishore, & Ingle, 2015), males’ involvement in sexual and reproductive health has been seen to be little during their adults’ periods. This could be associated to low awareness level, sociocultural beliefs, and religion during their adolescent periods (Kyilleh, Tabong, & Konlaan, 2018). Indeed, even studies that have involved males in reproductive health matters, the focus has been largely on other reproductive areas such as pregnancy, labour, and puerperium and prominently on family planning and contraceptive related issues (Berhane, 1995). Whiles lack of education and societal gender role has been a contributing factor, lack of active involvement of boys during adolescent period has partly played in inadequate awareness of males with regard menstrual issues. 4 University of Ghana http://ugspace.ug.edu.gh Adolescence is a critical period in the life of both boys and girls, which cannot be ignored, especially the boys, in order to support menstrual girl ought to have in-depth knowledge on MHM so as to shape their attitudes towards girls during menstruation period (Meena et al., 2015). Although lack of sanitary facilities in most schools in developing countries and stigma associated with adolescent girls soiling themselves during menstruation have been identified as a major reason for isolation and school dropout by the girl child, lack of male adolescent support has also been regarded as one of the main reasons behind poor menstrual hygiene management among girls’ (Dutta, Badloe, Lee, & House, 2016). As noted earlier, in Ghana most schools lack sanitary facilities making it difficult for the adolescent girl menstruating to maintain hygiene during their menstrual period (Chinyama et al., 2019; Miiro et al., 2018). In addition to this, in Ghana, male adolescent socialisation on menstrual issues is a militating factor to males supporting their female counterparts during menstruation (Yagnik, 2015). In fact, although the literature on menstrual issues and MHM in Ghana is increasingly expanding (Sommer et al., 2015; Nanbigne, Alhassan, Kwansa, & Awedoba, 2016; Rheinlander et al., 2019; Baku et al., 2020; Mohammed, Larsen- Reindorf & Awal, 2020), studies focusing particularly on adolescent male awareness and support is conspicuously missing. Against this backdrop, this study explored the adolescent male attitude and support to menstrual hygiene management in the Sagnarigu Municipality of Ghana. 1.2 Problem Statement Menstruation and its management among pupils in under-developed and developing countries like Ghana has been observed to be problematic (Rheinlander et al., 2019; Sustainable Sanitation Alliance, 2017; UNICEF, 2014). Issues identified include inadequate knowledge about menstruation, menstrual hygiene management, and menstruation induced stigmatisation (Micheal et al., 2020; Hillard, 2014). Again, the availability of cheap absorbent materials; spaces to change 5 University of Ghana http://ugspace.ug.edu.gh privately; the availability of washing, cleaning and drying equipment; adequate disposal facilities are other relevant challenges reported (Bay, 2017; Sommer et al., 2016). The impact of menstruation has been reported to be one of the major reasons in school dropouts among adolescent girls (Miiro et al., 2018; Sivakami et al., 2019). Menstruation is still a neglected issue especially among school-age girls even though several international and regional conferences have been held across the globe to creat awareness and include menstrual hygiene schemes by nations in their reproductive and child interventions (Sustainable Sanitation Alliance, 2017; UNICEF, 2019). This policy still lacks educational support from stakeholders in health and education in some countries with regards to the implimentation through provision of financial and infrastructure support to schools for action. The programmes successful implementation is further threatened by anxiety, humiliation, societal taboos, and uninformed and uncooperative male teachers. Again, the absence of running water; washrooms for privacy, and disposal facilities, among others are the impinging environmental factors militating against the successful practicalisation within school premises (Sharma, Mehra, & Brusselaera, 2020). All the fore stated have been identified as problems that do not only adversely influence sexual and reproductive health but also affect the adolescent girls’ self-esteem and their capacity to make decisions and to act for themselves. This brings to bare the need to make MHM more comprehensive in schools so as to ensure friendly environments in the schools, to curtail school dropout and absenteeism rate of the adolescent girls (Sharma, Mehra, & Brusselaera, 2020). The consequence of dropout and absenteeism is, girls’ lag behind boys in the educational ladder and are prevented from attaining their potentials. This also has been identified as a public health problem. 6 University of Ghana http://ugspace.ug.edu.gh In Ghana, 95% of girls occasionally absent themselves from school during their menstruation periods; a situation which is more pronounced in Northern Ghana where poverty levels are relatively high (House, Mahon, & Cavill, 2013; Supply, Programme, & Organisation, 2015). In Tamale, the lack of facilities to support menstrual health and practices in school, the pain and discomfort girls may experience during their menstruation and the prevalence of cultural taboos such as the belief that women are unclean during their menstruation is a hinderance to their attendance at school during such times. Girls often preferred to absent themselves from school than to ask for the assistance of their male teachers or headmasters. There are times where these adolescent girls are asked to go home owing to lack of proper facilities or the inability to access sanitary pads or cloths at school (Nanbigne, Alhassan, Kwansa, & Awedoba, 2016). In a related study conducted in Tamale, it was evident that most of the places of convenience available were dirty and not properly kept. Again, these places were used by the entire community and had a high demand with little room for privacy and cleanliness. Items such as toilet rolls, running water, soap, dustbins were seen sparingly (Rhinlander et al., 2019). The belief that girls were unclean and should be separated, quiet, and inactive during these times also meant that they would not be allowed to participate in the school’s activities and so preferred to stay out of school. The fear of having their clothes stained with blood which could bring embarrassment and stigmatisation also kept them away from school (Nanbigne et al., 2016). Access to disposable sanitary pads for the effective and efficient management of their menstruation is not affordable and accessible to these girls whose families cannot afford them on a monthly basis. Many to resort to reusable cloths or rags resulting in increasing risk to reproductive tract related infections. 7 University of Ghana http://ugspace.ug.edu.gh To effectively handle and mitigate these challenging issues faced by adolescent girls in a patriarchal society like Tamale, men need to be knowledgeable in the practices of menstrual hygiene management for women, which over the years has been neglected. In Tamale, men have more authority in the decision-making process due to the practice a patriarchy. Also, since most women do not share information about their menstruation with men and boys, they have little knowledge about the normal physiology of menstruation and the menstrual cycle. Inspite of the fact that, men make most of the decisions regarding facilities such as the availability of toilets and places of convenience, availability of sanitary towels, and services needed by women and girls, for their menstrual hygiene, as well as women and girls’ participation in awareness creation sessions and town meetings, little is known about their awareness and support towards menstrual hygiene management. It is therefore worthy that researchers should drift towards studies involving males on MHM. This has motivated the need for a study on this perspective. This study therefore explored the adolescent male’s awareness in menstrual hygiene management among senior high school (SHS) students, in order to assess their capacity to assist their ‘sisters’. The study targeted at SHS male students because; this stage is a milestone in the life of adolescents. As both males and females are at critical periods in their level of the educational carrier. The Theory of Planned Behaviour was adopted to explore adolescent male attitude and support in menstrual hygiene management in the Sagnarigu municipality of the Northern Region. 1.3 Purpose of the study The purpose of this study was to explore the awareness and support of adolescent males on menstrual hygiene management in the Sagnarigu municipality of the northern region of Ghana. 8 University of Ghana http://ugspace.ug.edu.gh 1.4 Specific objectives The specific objectives were derived from the constructs of the Theory of Planned Behaviour. These specific objectives; 1. Assessed the attitude (behavioural beliefs and outcome evaluations) of adolescent males’ towards menstruating females. 2. Explored the subjective norm (normative beliefs, and motivation to comply) of adolescent males about menstruating girls. 3. Identified the perceived behavioural control (control beliefs and influence of control beliefs) of adolescent males towards menstruating girls and MHM. 4. Described the behavioural intention of the adolescent male towards menstruating girls and support MHM activities. 5. Described the behaviour of adolescent boys towards menstruating girls and MHM. 1.5 Research Questions 1. What was the attitude of adolescent males towards menstruating females in the Sagnarigu municipality? 2. What was an adolescent male subjective norm toward menstruating girls in the Sagnarigu municipality? 3. What were the perceived behavioural control factors of adolescent males towards girls and MHM in the Sagnarigu municipality? 4. What was the behavioural intention of the adolescent male towards menstruating girls and support of MHM activities? 5. What was the behaviour of adolescent boys towards menstruating girls and MHM? 1.6 Significance of the Study The findings of this study will be useful to different stakeholders such as Government Agencies, NGO’s and academic institutions. This research for the government can give decision makers a platform to design policies and programmes to increase the awareness and support of male 9 University of Ghana http://ugspace.ug.edu.gh adolescent to menstruating female. The study will also determine current levels of male adolescent support in menstrual hygiene management (MHM) in the Sagnarigu municipality. Academically, the study contributes to the literature by proffering insights and data on awareness, support and factors that determine the motivation of male students to support their female colleagues on menstrual hygiene management in the Sagnarigu municipality. 1.7 Operational definitions of key terms Menstrual hygiene management: relates to having access to items to absorb or collect menstrual blood, to change the products in private, to facilities to dispose spent menstruation management materials, and to portable water to wash or clean oneself, including hand hygiene. Menstruation: it is a process in which a woman, with the exception of during pregnancy, releases blood through the vagina and other substances from the uterine lining at intervals of roughly one month from puberty until menopause. Male adolescent: it is a stage of growth and development that occurs between childhood and the ages of 10 and 19 and marks the transition from childhood to adulthood. Menstrual Awareness: the level of consciousness or quality of being aware of menstrual hygiene products to absorb or collect menstrual blood, privacy to change the materials, and access to facilities to dispose of used menstrual management materials and clean oneself. Menstrual Support: to give or assist in giving menstrual hygiene products to absorb or collect menstrual blood, privacy to change the materials, access to facilities to dispose of used menstrual management materials, being able provide water and soap and to encourage girls who stain their dresses. 10 University of Ghana http://ugspace.ug.edu.gh Menstruator: is the female who menstruates and therefore has menstrual health and hygiene needs. Menstrual hygiene materials: refers to the products/materials used to catch menstrual flow such as pads, cloths, tampons or cups. Menstrual facilities: can be defined as those facilities mostly associated with a safe and dignified menstruation such as toilets, water infrastructure and pits/containers. Menstruation supplies: are any supportive items needed for menstruation health and hygiene which include; body and laundry soap, underwear and pain relief items. 1.8 Scope of the study The study’s scope, in terms of respondents embodied adolescent male students in second cycle institutions. Geographically, the study domain was also in the Sagnarigu Municipality of the Northern Region of Ghana. 1.9 Organisation of the Study The study composed of six chapters. Chapter one which introduces the study specifically focused on the background to the study. It also embodied the problem of the study, purpose of the study, the research specific objectives and questions, operational definitions of terms used, the significance of the study, scope and limitations of the study. Chapter two looked at the concepts, theories and the reviews of relevant literature of the study. This also focused on selection of a theoretical framework, the theory of planned behaviour, the application of the theory to the study 11 University of Ghana http://ugspace.ug.edu.gh and justification for choice of TPB and also review of related empirical studies. Whereas chapter three presented the methodology employed to carry out the study which entailed; introduction, research design and settings, target population, sampling techniques and sampling size; inclusion and exclusion criterion, data collection, piloting tool for data collection and data collection procedure, data management, data analysis and methodological rigour. Chapter four presented the data collected from the field and the research findings, introduction, socio demography and characteristics of participants, as well as organisation of themes and application of the constructs. Chapter five was concerned with discussions of the study while chapter six looked at summary, implications, conclusion, recommendations and limitations of the study. 12 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO THEORETICAL FRAMEWORK AND LITERATURE REVIEW This section looks at the theoretical foundations mooring this study. Essentially, the literature points out that there are several theories usually employed to study behaviour in health studies. The theoretical and empirical literatures presented in this chapter highlighted three models namely: Social Ecological Model, Theory of Reasoned Behaviour model and Theory of Planned Behaviour Model. 2.1 Search for Theoretical Framework There were three different theoretical frameworks considered for this study. They are; Social Ecological Model, Theory of Reasoned Behaviour model and Theory of Planned Behaviour Model. The social ecological model was not relevant to the study because the model emphasises multifaceted level of influences that does not fit into the phenomenon of study. Also, Theory of Reasoned Behaviour model by Fishbein & Ajzen (1980) highlights only two constructs namely; attitude and subjective norm. It fails to cater for another key determinant that influences behaviour. This determinant is referred to as perceived behavioural control. However, another model, the theory of planned behaviour model by Ajzen (1985) has been adopted to understand and predict behaviours as the highlights of the constructs include, attitudes toward the behaviour, subjective norms, and perceived behavioural control, intention and then behaviour. This model relates well with the phenomenon of study, and as such, the reason for selecting the constructs of theory of planned behaviour model to guide this study. 13 University of Ghana http://ugspace.ug.edu.gh 2.2 Social Ecological Model The Social Ecological Model (SEM) emerged in the early 1970s as a model introduced to comprehend human development (Bronfenbrenner, 1977). With this beginning it has been adopted in other fields of studies including health. Basically, the theory postulates that there exist dynamic and complex relationships among individuals, groups and their environment. The SEM was influenced by a systems orientation of human development in which individuals are noted to influence and be influenced by people and institutions with which they interact. Not only these, but also the societal norms and rules (Bronfenbrenner, 1992; Golden et al. 2015). In health studies it has become a prominent theoretical framework employed to comprehend health issues and interventions (Lieberman et al., 2015, Sallies, Owen & Fisher, 2008; Golden & Earp, 2012; Blas & Kurup, 2010). The model presumes that human behaviour and attitude in relation to an issue are influenced not only by multiple levels influence but also that these levels are perpetually interactive and reinforcing (Golden & Earp, 2012). Also, SEM presents that the social, physical, and cultural aspects of an environment have a significant effect on health issues. According to Stokol (1996) the environment in which individuals find themselves is multi-layered with institutions and organisations embedded in the larger society and that the environmental context could influence the behaviour of individuals based on their peculiar beliefs and practices. In this light, this theory is relevant to this study because males-adolescents are embedded in societies which greatly influence the behaviour and attitude towards menstrual issues. Thus, in a study to understand adolescents’ (males) behaviour and perceptions about MHM it is indispensable to take cognisance of the adolescent and their environments as the environment shapes and forms them as they mature into adulthood. The SEM identifies the following layers (individual microsystem, mesosystem, exosystem, macrosystem) in relation to a child’s development. 14 University of Ghana http://ugspace.ug.edu.gh However, these layers are similarly strong influencers in adolescent lives with regard to their worldviews about menstrual issues and MHM. These layers are explicated below. The individual age and sex health and physical appearance inform and shape the perception, behaviour and attitude about life including menstrual issues. For instance, the manner in which adolescent (males) would view and perceive menstrual issues is not the same as it would be viewed about their female counterparts. The micro-level is the arena closest to the adolescent. This level includes the relationships and interactions adolescents have with their immediate surroundings such as families, schools, peers, religious institutions and neighborhoods These institutions without doubt have significant impacts on the perceptions and behaviours of adolescents. The mesosystem is much wider realm that connects several institutions that impacts significantly on the life of adolescents. It links and proffers a connection between the structures of adolescents’ micro-environment. The macrosystem is bigger cultural context which embodies attitudes and social conditions within the cultures in which adolescents reside. This system describes the cultural or social context of varied social groups including social classes, ethnic groups or religious grouping. This stage is the outmost layers which is much influential in the adolescents’ lives. The ecological model was not adopted in this study because, the researcher noticed the inadequacy of the model in relation to the subject under consideration. 2.3. Theory of Reasoned Action Like the SEM, the TRA is widely applied in public health works to study the behaviour and actions of individuals (Hankins, M., French, D. & Horne, R. 2000; Cooke & French, 2008). The Theory was coined in 1975 by Fishbein and Azjen. Basically, it postulates the development of a system of observation of two categories of variables. These are: 15 University of Ghana http://ugspace.ug.edu.gh a. Attitudes referred to as a positive or negative feeling in relation to the achievement of an objective and b. Subjective norms, which are the very representations of the individuals’ perception in relation to the ability of reaching those goals. The proposers of the theory reiterated the importance of intention more than the reality of usage. The main thrust of the TRA is that people behaviours are determined by their intentions to perform the behaviour, and that this intention is, in turn a function of their attitude towards the behaviour and subjective norms (Fishbein & Ajzen, 1975). In other words, TRA is employed to predict how individuals will behave based on their preexisting attitudes and behavioural intentions. In fact, TRA also tries to understand people’s voluntary action by examining the underlying basic motivation to perform the action. Again, the theory further posits that social norms surrounding an act also contribute to whether or not the person will actually perform a behaviour. Theory of reasoned behaviour like the Social Ecological model is adequate relative to the topic being explored. 2.4 Theory of Planned Behaviour (TPB) The Theory of planned behaviour is an extension of the TRA (Ajzen & Fishbein 1980; Cooke & French, 2008), which this study relied on to serve as the theoretical framework for the phenomenon reviewed. The theory of planned behaviour is a theory mostly used to understand and predict behaviours; the theory posits that behaviours are directly influenced by behavioural goals and, in some situations, of three constructs as attitudes towards the behaviour, subjective norms, and perceived behavioural control which determines behavioural intents (Ajzen, 1985, 1991; Ajzen & Madden, 1986). Icek Ajzen created the theory of planned behaviour (TPB) as a broad model to 16 University of Ghana http://ugspace.ug.edu.gh predict and explain behaviour over a wide spectrum of various sorts of behaviours. One of the main ideas to develop the evidence-based interventions was TPB. According to TPB, behaviour is immediately preceded by intention since attitudes, subjective norms, and perceived behavioural control all contribute to the development of behaviour (Ajzen, 1985). 2.4.1 Attitude toward the behaviour The first factor is attitude toward the behaviour, which is an individual’s estimation (i.e., favourability or unfavourability) of executing a particular behaviour (Ajzen, 1985). This study assessed male adolescent awareness towards menstrual hygiene management and its relationship with providing support to menstruating girls. 2.4.2 Subjective norms The second factor of behavioural intention is subjective norms. This is an individual’s perception that most people who are important to him (or her) think he (or she) should or should not execute a particular behaviour. This perception, however, may or may not reflect what those important others actually think (Ajzen, 1985). This determinant allowed the study to assess the subjective norms and the behavioural intention to support menstrual hygiene management. Normative norms on the other hand, are standard rules and regulations that are binding on a group of individuals but are dependent on the type of motivation as these can predict behaviour (Glanz, Rimer, & Viswanath, 2008). Hence, an adolescent male’s cultural, religious and family beliefs and values on MHM and the impact of this on his support on MHM was also measured. 2.4.3. Perceived behavioural control The execution of a particular behaviour is dependent at an extent on one’s actual behavioural control (i.e., the ability to perform a behaviour). When an opportunity arises and the resources 17 University of Ghana http://ugspace.ug.edu.gh required to perform that behaviour (e.g., time, money, skills, cooperation of others, etc.) increase for an individual, the chances that the individual will perform that behaviour also increases. Perceived behavioural control refers to an individual’s assessment of the ease or difficulty of performing a particular behaviour of interest (Ajzen, 1985). This helped the researcher to assess the relationship between male adolescents perceived behavioural control in providing support and awareness creation on menstrual hygiene management. 2.4.4 Behavioural Intention In the model of TPB, behavioural intentions are the embodiment of the three components of TPB (Ajzen, 1985). In other words, it is based on attitudes to behaviour, subjective norms and perceived behavioural control. It is about people preparedness to undertake a given behaviour. It is presumed to be an immediate antecedent of behaviour. The three components predict intentions, which in turn predicts behaviour of an individual. The intention is a good predictor of behaviour. 2.4.4.1 Behavioural Intentions and Menstrual Hygiene Management For several decades and even hitherto menstruation and its associated issues including MHM has been masked in mystery and tabooed in many parts of the world (Mahon, 2015; Mason et al., 2017; Mohammed & Larsen-Reindorf, 2020; UNICEF, 2019). Undoubtedly, this outlook has informed and shaped societies particularly men and males view about menstrual issues (Mason et al., 2017; Erchull, 2020). Behavioural intentions of men and males are generally negative or indifferent (Chang et al., 2012). Mahon et al. (2015) contended that males’ intentions about menstrual issues were the reflection of the societal view of the phenomenon that have been propagated for generations. The result of this was that men and boys’ role in the support of menstrual management was lacking. The study that when men and boys were recruited and sensitised about MHM, 18 University of Ghana http://ugspace.ug.edu.gh and it lead to change in intentions and behaviours of those who received the sensitisation and empowerment, and that male students and their family members can play a role and become advocates for MHM as the study argued. “As a result of the initiative [sensitisation programme], men and boys begun to talk about menstruation more freely and are better able to support the MHM needs of women and girls with the households, community and schools” (Mahon et al., 2015:7). In Taiwan, it was noted that boys shied away from discussing menstrual issues because of punishment that were meted out to them when caught talking about menstrual issues. This made them to develop an indifferent behaviour or unfavourable intention about menstruation (Chang et al., 2012). Many other studies have also reported the negative behaviours of boys or men in general to menstrual issues and MHM (Mohamed & Larsen-Reindorf, 2020; Erchull, 2020). In particularly, in the school environment adolescent boys often mock menstruators when they are experiencing symptoms of menstruations (Mohammed & Larsen Reindorf, 2020). In the work environment, adult men, who it is assumed would know better are caught in the web of jesting about menstruation when they noticed a female colleague is experiencing her menses and at work (Erchull, 2020). 2.4.5 Behaviour Behaviour, in the everyday parlance, is the way in which people act or conduct themselves towards others or things. The concept of behaviour has been deployed in disciplines including health studies. Also, behaviour has been analysed by many analysts. In this light, Ajzen (1980) and Ajzen and Fishbein (1980) have offered a framework in the Theory of Planned Behaviour to elucidate behaviour. The model suggests intentions drive behaviour and intentions are actual the results of attitudes, subjective norms and perceived behavioural control. Besides, the model also contends perceived behavioural control can pointedly espouse behaviour. Figure 1 represents the conceptual framework adopted for the study. 19 University of Ghana http://ugspace.ug.edu.gh Figure 1: The Conceptual Framework of Theory of Planned Behaviour 2.4.6 Application and justification of the Theory of Planned Behaviour The theory of planned behaviour is influenced directly by an intention. However, for an intention to manifest a behaviour, there are some drives to an intention. These include attitudes, subjective norms, normative norms and perceived behavioural control. Preliminary in the theory as enumerated are constructs forming the basis for an intention, which then become an intermediary and this in turn influence a behaviour. This theory was deemed appropriate as a conceptual framework for the phenomenon under study. Merited in this framework is the impact of plan on any action to be engaged. An adolescent male mind set with regards to this perspective can therefore be described as planned. And as such a planned behaviour is enshrouded in it constructs in the framework. So therefore, an adolescent male awareness of the phenomenon studied is entrenched in his perceptions, feelings, beliefs, thinking as they underpin understanding and this may lead to knowledge and eventually awareness. Gaining insight of any phenomenon determines the intention and subsequently a behaviour which becomes the outcome (as to whether an adolescent male may support a female counterpart or otherwise). This was dependent on whether the adolescent male conforms to societal standards as to want to belong and not to be seen as an outcast. The influential others of the adolescent male such as parents, religious leaders, teachers 20 University of Ghana http://ugspace.ug.edu.gh and friends also shape the behaviour in this regard. The outcome of the adolescent male behaviour was impacted based on whether the significant others’ reactions are acceptable or rejected. The social ecological model was not relevant to the study because the model emphasised multifaceted level of influences that does not fit into the phenomenon of study. Also, Theory of Reasoned Behaviour model by Fishbein & Ajzen (1980) highlights only two constructs namely; attitude and subjective norm. It fails to cater for another key determinant that influences behaviour. This determinant is referred to as perceived behavioural control. However, another model, the theory of planned behaviour model by Ajzen (1985) has been adopted to understand and predict behaviours as the highlights of the constructs include, attitudes toward the behaviour, subjective norms, and perceived behavioural control. The model relates well with the phenomenon of study, and as such, the reason for selecting the constructs of theory of planned behaviour model to guide this study. 2.5 Literature Review This chapter presented a review of relevant literature regarding research of male involvement on menstrual health hygiene. The literature review section of this study was based on the objectives of the study and the constructs in the model. Data bases used for the search were Cochrane, Medline, CINAHL, Science Direct, Google, Google Scholar, and PubMed. To get relevant articles for this research topic, the Boolean technique was employed by a combination of words such as; male adolescent menstrual health management, cultural beliefs and menstrual hygiene management, restriction and menstruation, male support and menstrual hygiene. Adding to this, the use of “AND”, “OR” were used to enhance the search. The review considered recent articles published from 2014 upwards and selected from the suitable ones. However, in areas with limited 21 University of Ghana http://ugspace.ug.edu.gh literature, some articles published in 2005 and above but related and relevant to the phenomenon of the study were also reviewed. The review of literature was organised under the following: attitude of male adolescent on menstrual hygiene management, subjective norms of adolescent male on menstrual hygiene management, cultural beliefs and restrictions during menstruation (normative norms), the role of men and boys in menstrual hygiene, perceived behavioural control and menstrual health management, behavioural intentions and menstrual health management and the behaviour. The section also reviewed the extant literature across the globe on menstruation hygiene management and issues related and relevant to MHM and a summary of the review of the literature. 2.5.1 Attitude of male adolescent toward menstrual hygiene management The first construct of the theoretical model of TPB is attitude toward the behaviour, which is an individual’s evaluation (i.e., the favourability and unfavourability) of performing the behaviour in question (Ajzen, 1985). In this study, attitude of adolescent males’, which is their behavioural beliefs and outcome evaluations (positive, negative and general impression) of the phenomenon studied was assessed. Some literature regarding adolescents and menstruation, attitude of males towards menstruation and menstrual health management related issues has been reviewed. According to the World Health Organisation, an adolescent refers to a person aged 10-19 years (Sommer, Hirsch, Nathanson, & Parker, 2015). This period is considered a special period in both girls’ and boys’ life comprising significant physical, psychological, and biological development (Sharma, Mehra, Brusselaers, & Mehra, 2020). It is the stage a woman experiences menarche which marks an important biological milestone in the life of a woman and marks the beginning of the reproductive phase of her life (Chandra-Mouli et al., 2019). 22 University of Ghana http://ugspace.ug.edu.gh Women across the globe have developed different tactics to manage this period of time in their lives. These tactics and strategies vary widely due to individual preferences, accessibility resources, financial and family status, cultural, and traditional beliefs, educational status and knowledge about menstruation (Sharma et al., 2020). The health implications such as toxic shock syndrome, reproductive tract infections (RTI), and other vaginal diseases that can occur when menstrual hygiene is neglected makes it a major concern (Chandra-Mouli et al., 2019). The estimated population of girls aged between 15 and 19 years is over 0.6 billion which represents 8% of the world’s population with more that 805 of them living in Asia and Africa. The population of these girls makes it almost impossible to turn a blind eye to inadequate menstrual hygiene management (MHM). Inadequate menstrual hygiene is of global concern due to its implications if left unattended (Sharma et al., 2020). It is evident that inadequate amenities and sanitation facilities makes it difficult for girls to practice hygienic menstruations (Panakalapati, 2013). A technical report by UNESCO in 2014 observed that male teachers might be less sensitive to the needs of girls experiencing their menstruation, and so refused them permissions to use the washroom during their lecture times as such male rather thought that those girls were not interested in the lesson (Mahon, Tripathy, & Singh, 2015). Other studies revealed that male teachers were found teasing such girls. This insensitive behaviour might be engineered by ignorance, entrenched local myths, and cultural taboos related to menstrual blood among men (Kirk, 2005; Mahon et al., 2015; Panakalapati, 2013). This behaviour was not only limited to teachers but students inclusive. Topics related to menstruation was often neglected or not taught well. Studies attributed the higher predominance and cultural related taboos to this behaviour (Rastogi, Khanna, & Mathur, 2019). It was further observed that girls were often ridiculed and embarrassed by boys and male teachers in schools when they stained their clothes 23 University of Ghana http://ugspace.ug.edu.gh during their periods (Mahon et al., 2015). Boys and men generally have a negative attitude towards menstruation due to their inadequate knowledge of menstruation (Mason et al., 2017; Sharma et al., 2020). According to another study, most men were ill-informed about menstruation and the physiological changes women undergo when they have their periods which makes it difficult for them to change their perceptions and ideologies about women and girls during such times (Mason et al., 2017). This behaviour is attributed to their unwillingness to change their mindset, myths, prejudices, and misconceptions, associated with menstruation hence making it difficult to have an open discussion on menstruation with men and boys. However, through continual engagement, these perceptions could be changed to inform them of their responsibilities for managing menstrual hygiene. This assertion is supported by another study which revealed the unwillingness of male and female educators to address menstruation and care of menstrual hygiene with their students. There is also the situation where female teachers were not available in many schools. It was again reported that male teachers felt shy and uncomfortable discussing topics related to menstruation during their lessons (Gupta & Sinha, 2006; Sommer, Kjellén, & Pensulo, 2013). This unsupportive attitude of male teachers and students resulted in some female students being hesitant to stand to answer questions in the fear that they might have soiled their clothes and may be seen by their colleagues. In other cases, parents did not allow their girls to attend school once they reach puberty in the fear that they may be harassed by their male colleagues and even male teachers. (Kaur, Kaur, & Kaur, 2018; Rheinländer, Gyapong, Akpakli, & Konradsen, 2019). To surmount these issues, male teachers and students should be well informed and educated to be confident about menstruation and menstrual hygiene management to enable them support girls/women by providing a safe environment and their privacy. 24 University of Ghana http://ugspace.ug.edu.gh 2.5.2 Cultural beliefs, perceptions, and restrictions during menstruation (subjective and normative norms) Studies have shown that cultural norms have an impact on menstrual hygiene practices. A few of these standards operate as obstacles to maintaining good menstrual health. Many women encounter limitations when it comes to cooking, working having sex, bathing, worship, and eating particular foods (Kumar, Datta, & Bandyopadhyay, 2015; Rastogi et al., 2019). The existence of these restrictions is the result of the people perceiving menstruation as dirty and polluting over the years (Solanki & Yadav, 2019). Women and girls are mandated to wash themselves and their clothes in secrecy and at night when all others are asleep and away from others since menstrual secretions are said to have the potential to be employed in black magic (Sommer, Chandraratna, Cavill, Mahon, & Phillips-Howard, 2016). Women hid their menstrual pads out of concern for being cursed and also for the fact that such clothes were seen as dirty and polluted by the society. Some studies also revealed that menstrual waste was thought to be associated with witchcraft and danger, hence such residue was buried and hidden from witches so that they cannot locate the owners to destroy them by causing them to be infertile women (Boakye-Yiadom et al., 2018; Umeora & Egwuatu, 2008). Touching a woman who was having her menstruation was even seen as toxic. These norms make girls feel subnormal, diseased, or traumatised (Deo & Ghattargi, 2005). Additionally, menstruation is considered a curse, disease or sin by adolescent girls in Uganda (Boosey, Prestwich, & Deave, 2014). Unprepared girls experienced menarche with fear, confusion, and feelings of embarrassment and are more likely to have negative attitudes towards menstruation (Rastogi et al., 2019). This was further supported by a study conducted in Northern Ghana, where the poor attitude towards menstrual hygiene management was partly attributed to the negative socio-cultural norms 25 University of Ghana http://ugspace.ug.edu.gh and practices that stigmatise menstruation, hence, inadequate support from community leaders who are predominantly of male gender (Boakye-Yiadom et al., 2018). These beliefs and perceptions highlight the need for education for both men and women regarding menstruation. Though, these prohibitions are more in the rural areas than in the urban areas, girls in the urban areas are not completely immune to its effects. The study therefore assessed these prohibitions and their relationship with menstrual hygiene management in the urban centers. 2.5.3 The role of men and boys in menstrual hygiene management According to Mahon et al., (2015), men and boys can support women and girls to manage menstruation effectively across different social domains including households, communities, schools, and work. The influence of men and boys on menstrual hygiene management permeates through many roles, including as husbands, fathers, brothers, students, peers, teachers, community leaders, entrepreneurs, employers, development and humanitarian practitioners, and policymakers (Mahon et al., 2015). Further studies attribute the neglect of menstrual hygiene management to gender inequality. Unequal power relations between men and women result in women and girls’ voices not being heard in decision making within households, communities, and development programmes (House et al., 2012). These have also led to cultural taboos, stigma, and shame around menstruation (House et al., 2012). In a related study, it was found that males who are household heads do not encourage women to practice good menstrual hygiene, and they never bring up the subject with their wives or daughters. According to the research, males who make decisions at the household level frequently refuse to spend money on menstruation goods such as disposable sanitary pads, tampons, and menstrual 26 University of Ghana http://ugspace.ug.edu.gh cups because they view doing so as money wasted (Alexander et al., 2014; Kaur et al., 2018; O’Reilly & Louis, 2014). Women are forced to utilize inexpensive reusable cotton pads that require washing, drying, and repeated usage as a result of this. In other instances, males are hesitant part up cash to purchase menstrual hygiene products because of their limited income family income. According to O’ Reilly and Louis (2014). Another study’s conclusion was that males may support women and girls by building latrines, incinerators, and toilets with chutes in their homes, schools, and communities. At the household level, they assist by providing menstruation products, money, and toilet facilities with privacy, water, and soap (Alexander et al., 2014). Making household budgeting for sanitary products supports and empowers women by letting them to move freely with a decreased risk of stains because decision making authority is in the hands of males. Men in politics should assist menstrual hygiene management by enacting laws that are kinder to girls and women, giving sanitary products at a discount or for free, installing portable toilets and other forms of sanitation in their communities, and holding training and seminars. A study conducted in a Peri-Urban Community in Ghana revealed that teachers of which male constitutes the majority can significantly influence the conversations and to increase the active engagement of girls themselves in menstrual health management (Rheinländer et al., 2019). Though, the role of men in ensuring menstrual hygiene management cannot be over emphasized, there is not enough empirical evidence in explaining the relationship between their role and menstrual hygiene management. 27 University of Ghana http://ugspace.ug.edu.gh 2.5.4 Perceived behavioural control and menstrual health management A study conducted in India to determine the social and behavioural change interventions effect on knowledge, attitudes and restrictions with menstrual health hygiene showed that parents, peers and the community exerts a considerable influence on adolescents’ attitude towards menstrual health hygiene. This could either facilitate or inhibit male adolescents support for menstrual hygiene management (Ramaiya et al., 2019). Another study conducted in Dares Salaam city to assess acceptability of parents/guardians of adolescents towards reproductive health education found that parents play a critical role in sexual and reproductive health behaviours. Parents usually influence their children’s reproductive health behaviour through care and control (Mbonile & Kayombo, 2008) Again, findings from Taghdis, Babazadeh, Moradi, & Shariat (2016) suggest that a positive family environment influences adolescents’ attitude towards reproductive health behaviours. Consistent with these results is the findings by Bilal, Spigt, Dinant, and Blanco (2015) that, parents can facilitate adolescent attitude towards reproductive related behaviours. Moreover, a related study conducted in low- and middle-income countries reports that mothers were mentioned as a main source of information on MHM in some areas, while in other areas mothers were avoided. In the areas where mothers are avoided, grandmothers or peers are usually preferred (Chandra-Mouli & Patel, 2017) Again, Chandra-Mouli and Patel (2017) argued that family support and community support in the form of access to products and sanitary infrastructure greatly influences the perception of adolescent towards menstrual hygiene management. They further added the role of health workers and leaders in creating a positive perception towards menstrual hygiene among adolescent males. 28 University of Ghana http://ugspace.ug.edu.gh 2.5.5 Behavioural Intentions and menstrual hygiene management For several decade and even hitherto menstruation and its associated issues including MHM has been shrouded in secrecy and tabooed in many parts of the world (Mahon, 2015; Mason et al., 2017; Mohammed & Larsen-Reindorf, 2020; UNICEF, 2019). Undoubtedly, this outlook has informed and shaped societies particularly men and males view about menstrual issues (Mason et al., 2017; Erchull, 2020). Behavioural intentions of men and males are generally negative or indifferent (Chang et al., 2012). Mahon et al. (2015) contended that males’ intentions about menstrual issues were the reflection of the societal view of the phenomenon that have been propagated for generations. The result of this is that men and boys’ role in the support of menstrual management is lacking. The study also mentioned that when men and boys were recruited and sensitised in the school setting about MHM, it lead to change in intentions and behaviours of those who received the sensitisation and empowerment, and that male students and their family members can play a role and become advocates for MHM. As the study argued “As a result of the initiative, men and boys have begun to talk about menstruation more freely and are better able to support the MHM needs of women and girls with the households, community and schools” (Mahon et al., 2015:7). In Taiwan, it was noted that boys shied away from discussing menstrual issues because of punishment that were meted out to them when caught talking about menstrual issues. This made them to develop an indifferent behaviour or unfavourable intention about menstruation (Chang et al., 2012). Many other studies have also reported the negative behaviours of boys or men in general to menstrual issues and MHM (Mohamed & Larsen-Reindorf, 2020; Erchull, 2020). In particularly, in the school environment adolescent boys often mock menstruators when they are experiencing symptoms of menstruations (Mohammed & Larsen Reindorf, 2020). In the work environment, adult men, who it is assumed would know better are caught in the web of jesting about menstruation when they noticed a female colleague is experiencing her menses and at work (Erchull, 2020). 29 University of Ghana http://ugspace.ug.edu.gh 2.5.6 Behaviour towards menstruating girls and MHM activities Behaviour, in the everyday parlance, is the way in which people acts or conducts themselves towards others or things. The concept of behaviour has been deployed in disciplines including health studies. Also, behaviour has been analysed by many analysts. In this light, Ajzen (1980) and Ajzen and Fishbein (1980) have offered a framework in the Theory of Planned Behaviour to elucidate behaviour. The model suggests intentions drive behaviour and intentions are actual the results of attitudes, subjective norms and perceived behavioural control. Besides, the model also contends perceived behavioural control can pointedly espouse behaviour. Like many aspects ‘women issues’, male adolescents’ behaviour towards menstruation and MHM activities has attracted attention (Erchull, 2020; Wong et al., 2013; Allen et al., 2011; Benshaul- Tolonen et al., 2020). It is well documented that males or adolescent boys’ behaviour toward menstrual issues has been generally skewed towards negative behaviour (UNICEF, 2017; Wong et al., 2013). In a recent study Benshaul-Tolonen et al., (2020) observed that adolescent males engaged in mocking and teasing menstruating girls. The adolescent boys perceive the flow of blood associated with menstruation to be embarrassing. (Benshaul-Tolonen et al., 2020). This implies boys would tease or mock females when they see signs and or symptoms of menstruation. Yet, stains of blood on the attire of female could be the lack of suitable menstrual hygiene practices. Earlier studies particularly Singh, Bloom and Tsui (1998) had reported males showing positive behaviour towards menstruation and MHM activities. With a study setting in India, Singh et al. (1998) sought not only to measure the knowledge of husbands on menstrual health issues, but also captured the behaviour they put up in relation to their wives as far as MHM is concerns. The study indicated that some men comprehend the feeling of women during menstruation, and therefore were supportive and sympathetic to them. Again, Erchull (2020) in a study showed that boys exhibit positive behaviour towards females when they properly understand the ramifications of 30 University of Ghana http://ugspace.ug.edu.gh menstruation and its management. Similarly, males expressing positive behaviour has been reported by Mohammed and Larsen-Reindorf (2020). Although social norms and barriers influence boys’ unimpressive behaviour towards menstruating girls, boys on their own, stated they feel the plight of menstruator and thus must be good to them. 2.5.7 Global focus on menstrual hygiene management Following the realisation that MHM can remedy the pernicious and anti-development impacts associated with menstruation, it has become an international issue highly supported by several international organisations. For instance, the UNICEF (2019) have contributed immensely to ensure MHM is popularised and adopted in developing countries. Through their effort, they developed a guide to menstrual hygiene management materials. The guide is intended to provide guidance for staff from UNICEF on the selection and procurement of appropriate materials and supplies for MHM, particularly during humanitarian response. Although developed for the consumption of UNICEF staff, the guide is indispensable to all persons engaged in humanitarian response. It underscores key characteristics and requirements for the most common menstrual hygiene material and to dispose or recycle these materials. World Vision International, an international NGO has focused on menstrual issues for women and especially for girls in schools. In a study titled menstrual hygiene management in schools, the World Vision International (2016) catalogued barriers to MHM in schools. Some of these barriers mentioned are the lack of access to sanitation products and facilities, lack of social support, schools’ lack of access to consistent supplies of necessaries material to management menstruation and stigmatisation of menstruation. Also, the study pointed out systemic factors that impede the quality of MHM. These factors include: informed professionals, social norms, policies and health services (World Vision, 2016). 31 University of Ghana http://ugspace.ug.edu.gh The World Bank is another development agency that has conducted and extended knowledge on MHM. In a featured study the Bank indicated how MHM could enable women and girls to reach their full potential (World Bank, 2018). With recent evidence, the study sheds light on MHM issues in several countries and their impact on human development outcomes. They concluded by recommending how issues of MHM be incorporated into the global campaigns on water and sanitation. 2.5.8 Menstrual hygiene management in developing countries Undoubtedly, the literature focusing on menstruation and MHM in the global south is extensive (Mohammed & Larsen-Reindorf, 2020; Bobel, 2019; Chinyama et al., 2019; World Bank, 2018; Kuhlmann, Henry & Wall, 2017; Sommer, 2013). Bobel in her book ‘the managed body: developing girls and menstrual health in the global south’ critiqued the complicated discourses of MHM including its conceptual and practical linkage with water, sanitation and hygiene development sector. Using in-depth interviews, participant observations and digital materials of NGOs, the book indicates how MHM frames problems and solutions to seek attention and obtain resources to this highly tabooed issue. The book argues that organisations promoting MHM of inadvertently rely upon frail evidence to adduce claims of hygienic crisis that needs urgent solutions (Bobel, 2019). Further Bobel asserted that proffered solutions are mostly material, that fail to challenge social constructions of the menstrual body as dirty and in need of concealment. Indeed, demand on the menstruator to disassociate and isolate from the society is highly prevalent in many jurisdictions. In these places the open discussions of menstrual issues are frown upon. Issues of menstruation and its management are surrounded by secrecy and myths. For instance, most part of India hitherto the mere mention of menstruation has been a taboo (Garg & Anand, 2015; Patil et al., 2011). “Culturally in many parts of India, menstruation is still considered to be 32 University of Ghana http://ugspace.ug.edu.gh dirty and impure” Garg & Anand, (2015:184) stated. Although the impurity is mostly spiritual or religious, it sometimes extends to the physical where menstruators are considered unhygienic and unclean, and hence food they prepare, or handle are regarded contaminated (ibid). The negative stereotypes are being propped and driven by culture and religious beliefs that interpret menstruation to have spiritual connotations. For instance, in Surinam menstrual blood is deemed to be dangerous which aid in the potency of black magic. In certain cultures, too, clothes worn by women during menstruation are buried in order to prevent evil spirits from using it. Unfortunately, some of these practices are still being enforced (Garg & Anand, 2015). Nonetheless, these spiritual positions about menstruation are untenable in the face of the well proved scientific evidence about the cause of menstrual cycle. 2.5.9 Menstrual hygiene management in Ghana In Ghana the literature on issues about menstruation and MHM is rapidly burgeoning (Mohammed & Larsen-Reindorf, 2020; Baku, Adrakpanya, Konlan & Adatara, 2020; Boakye-Yiadom et al., 2018; Mohammed, Larsen-Reindorf, & Awal, 2020). UNICEF (2016) in a research brief on a study named ‘menstrual hygiene: challenges, taboos and impact on girls’ education in Ghana. The study included 12 senior high schools in northern part of Ghana. Using an interview technique to gather data, it found that 95% of girls sometimes absented from school due to menstruation. Taboos and stigma surrounding menstruation is prevalent in many of the communities on which the study focused. In schools, male colleagues often teased their female counterparts when there are stained, and this heaps unbearable shame on the girl in question. Like other places, homes where traditional religion is practiced, girls cannot prepare food during their menses. For instance, women abandoned their homes for the period of their menses to stay in a relative’s house (UNICEF, 2016:1). In schools the study noted that girls and other female teachers served as support network 33 University of Ghana http://ugspace.ug.edu.gh to menstruators. Male teachers tend to gloss over menstruation during lessons and boys teased girls when menstrual issues are being discussed. The negative impact of in the form of school absenteeism is well document in a study by Mohammed et al. (2020). With a sample size of 250 students, employing a combination of quantitative and qualitative techniques (Surveys and key informant interviews), they observed that girls episodically miss school in other to manage their menstrual symptoms. Even those who come to school often seek permission to return home. The reasons for occasional school absenteeism obtained included menstrual pain, fear of staining clothing, and shame of being mocked by male colleagues (Mohammed et al., 2020). Although stereotyping was prevalent, knowledge of menstrual hygiene was high. Over 60% reported using sanitary pads. This finding is corroborated by Kumbeni, Otupiri and Ziba (2020). Although their study targeted junior high school students, the findings stated that 61.4 percent of students who participated in the study practiced good menstrual hygiene. However, in terms of facilities within school premises to support menstruators were unavailable. Most of the schools even though had toilet facilities, they lacked clean water, soap, privacy and dustbins indispensable for menstrual hygiene management. In a related study in Legon, Accra, Blessing (2016) conducted research for her academic thesis on the management of menstrual hygiene among students. The outcome showed that MHM was being supported at home and at school. In this regard, about 50% of the respondents reported changing their sanitary items three times each day when they were menstruating. More than 60% take two daily baths. Teenage girls had a high level of MHM knowledge as well. In that area, which is an elite community, girls in elementary schools maintained good menstrual hygiene, with socioeconomic considerations helping them to properly dispose of their menstrual products. Baku et al. (2020) also investigated MHM, but they turned their attention to a peri-urban senior high 34 University of Ghana http://ugspace.ug.edu.gh school in Ghana’s Volta Region. Through a cross-sectional descriptive design, the study assessed menstrual hygiene management with 250 students. Findings showed that 52.8 percent had accurate knowledge on menstruation and its management. However, the study reported the challenges including unavailability of water and materials necessary for good MHM in schools. Menstrual hygiene management is gaining currency in Ghana. Through the efforts of international and local agencies such as UNICEF, World Vision, USAID and Global Communities knowledge on menstruation and its management as well as the necessary resource needed to promote MHM is being garnered. For instance, Global Communities through its efforts have extended funding to several senior high schools to acquire infrastructure and materials necessary for good menstrual hygiene management. In a study titled holistic menstrual management in Ghana, Global Communities (2021) outlined projects and advocacy campaigns undertaken in Ghana. Without doubt, these campaigns yielded fruits as government of Ghana succumbed to the demands to provide sanitary pads to elementary school students free of charge. Government of Ghana through budgetary allocations imported and distributed sanitary pads in 2016. 2.6 Summary of literature reviewed The first determinant of attitude toward menstrual hygiene management looked at an individual’s favourable or unfavorable evaluation of performing a behaviour while the second determinant, subjective norms, looked at a person’s beliefs and perception about how people who are important to him (or her) think he (or she) should perform a particular behaviour and vice versa. Cultural norms and its impact were also measured as these are the normative norms and can influence greatly the behaviour of individuals as they live and practice the societal rules and are regulated by them for sanity. The last determinant perceived behavioural control refers to people perception of the ease or difficulty of performing the behaviour of interest. The theory of planned 35 University of Ghana http://ugspace.ug.edu.gh behaviour is influenced directly by intention which in turn is influenced by key drivers like attitudes, subjective norms, normative norms and perceived behavioural control. From the review, studies conducted in Ghana and outside the country recognised difficulties with menstruation management for girls in school. Despite the fact that the majority of the research to date has emphasised the need for better school water and sanitation facilities, and also provision of culturally appropriate measures has been discussed. Other studies have also highlighted the importance of male involvement and support to ensuring adequate menstrual hygiene management. However, there seems to be limited evidence on the awareness and support of male adolescents in ensuring adequate menstrual hygiene management are effectively implimented. The review of literature revealed that the knowledge of male adolescents on menstrual hygiene management is woefully lacking with several of them being insensitive to the needs of menstruating girls. Further review revealed that men and boys do not play much of a role in menstrual hygiene. They do not offer much support with regards to menstrual hygiene and shy away from discussing such issues with their wives and daughters. From a cultural stance, there are several cultural norms which inhibit the practice of good menstrual hygiene. These norms which are mostly prevalent in rural areas make it uncomfortable for women and girls during the menarche. Parents, peers and the community exert a considerable influence on adolescents’ attitudes towards menstrual health hygiene. It is therefore necessary to provide the relevant support in creating a positive perception towards menstrual hygiene among adolescent males. This in the long run would be of great benefit to the young women and girls in our societies. The chapter again reviewed literature on different levels, the global level, from the perspective of developed and 36 University of Ghana http://ugspace.ug.edu.gh developing countries. Lastly literature on MHM related to Ghana was reviewed. The succeeding chapter focused on the methodology of this study. 37 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY This chapter focuses on the methods and processes used to carry out this study. Appropriate methods, techniques and approaches for the study were employed. It also presented the rationale for the chosen methods and techniques. Further, the chapter specifically described the research design, targeted population, sampling and sampling procedures and instruments employed for data collection. Lastly the data collection procedures and analysis were presented. 3.1 The Research Setting The research setting is the Sagnarigu municipality. It was established in 2012 with legislative instrument (LI) 2066. The assembly forms part of the 28 assemblies in the Northern Region of Ghana. It was carve