The onset of puberty is a critical moment for reaching girls with health messages and information, and the stakes are particularly high in countries where the HIV/AIDS epidemic rages and where threats to female reproductive health abound. Yet to date, the healthcare community in low-resource countries has tended to neglect this opportunity and instead concentrate efforts on young women who are older and of reproductive age.
In Tanzania, a multi-year project to address this gap has been led by Marni Sommer, DrPH, MSN, RN, at Columbia University's Mailman School of Public Health. Since 2006, Dr. Sommer has worked with Tanzanian girls and health authorities to develop a culturally sensitive programin the form of a bookthat delivers critical information about puberty and health, answering questions that the girls, themselves raise. Research on this project, known as the Girl's Puberty Book Project appears in the current issue of the International Electronic Journal of Health Education.
"The Girl's Puberty Book provides a critical interim step towards improving girls' comfort levels during puberty and offers an opportunity for teacher and parent discussions with young girls on reproduction, menstrual onset and management, and body change, reaching an important window before the onset of sexual activity," said Dr. Sommer. "Given the numerous health-related risks faced by adolescent girls and women in low-income countries, such as infection with HIV, unsafe abortions, and gender-based violence, policy and programs that aim to ensure that girls transition through puberty with a healthy body and a sense of empowerment are an important component of improving population health."
The first phase of the Girl's Book Project occurred in 2006 - 2007 when Dr. Sommer explored girls' experiences of puberty and menstruation using in-depth interviews and participatory activities to capture the voices of Tanzanian girls and information from the adults in their lives, including teachers, parents, and health workers.
The study revealed a significant gap in girls' knowledge about menstruation and body change during puberty. Many girls described feelings of shame and mentioned "reacting with panic at the sight of their first bleeding, thinking they had a terrible disease, or that they had behaved badly in some way." Although some girls sought out guidance, many girls were "fearful of telling anyone."
"The goal was to learn from girls what puberty-related guidance they felt was needed and then pass on their recommendations to policy makers. A particularly positive aspect of the book project expressed by the girls was the fact that they could learn about puberty on their own without needing to depend on teachers for information, many of whom are male in Tanzania."
Dr. Sommer next focused on developing the book with a seed grant from the Nike Foundation. Dr. Sommer felt strongly about field testing the content with the girls prior to finalizing the publication. "It was essential for the book to be well-grounded in the local context, with illustrations and content that would be satisfactory to parents and teachers, and most importantly, appealing to the appropriate reading level for the target age range of girls (10-14 years old)."
The next steps in the project included dissemination, evaluation, and advocacy for policy change. Many girls reported that the book "gave me the courage of how to talk about this with parents and guardians" and recommended the book to "all girls, especially those who have not reached puberty. The Girl's Book has now been integrated into government level policy in education, water and sanitation, and over 140,000 copies have been distributed. In addition, UNICEF is aiming to raise sufficient funds so that all 1.5 3 million girls within the target age range of 10-14 years across Tanzania have their own copies.
Dr. Sommer notes that the government of Tanzania has made a strong commitment narrowing the gender gap in education, as well as addressing the priority health challenges facing girls. However, this is the first project that focuses broad attention and resources on female puberty, menstrual onset and management in sub-Saharan Africa.
As a result of the positive response, Dr. Sommer is adapting the girl's book to Ghana, with plans for developing an Ethiopia book in 2012. There also is strong interest from Tanzanian parents and teachers for the development of a similar book for boys. "A Puberty Book for Boys would send a powerful message and not only teach boys about the changes of puberty but promote among boys the need for better treatment and respect of girls and women," observed Dr. Sommer.
Other girls' book projects underway as a result of the Tanzania book include adaptations by experts in Zimbabwe, Nepal, and South Africa.