AFRIpads Underwear and UNHCR: Finding the Right Fit by afripads

A joint AFRIpads/ UNHCR Uganda Pilot, accessing the acceptability and effectiveness of AFRIpads Underwear and measurement tool in Bidibidi Settlement, Uganda

FINDING THE RIGHT FIT

Implemented by UNHCR — Arua Sub-Office, Field Units: Bidibidi/ Yumbe. With support of the Office of the Prime Minister (OPM), AFRIpads Ltd., and World Vision. Project timeframe: Sept–November 2020 Date of the report: 1 Dec 2020 Photos: AFRIpads Ltd. stock picture This report was written by Laura Hytti (consultant) for AFRIpads Ltd. The evaluation was funded by AFRIpads Ltd.

Contents ACRONYMS, 5 EXECUTIVE SUMMARY, 7 INTRODUCTION, 8 Menstrual Health and Hygiene in humanitarian contexts, 8 Menstrual Health and Hygiene in humanitarian contexts in Uganda, 10 AFRIpads Underwear and Underwear Sizing Tape, 11

METHODOLOGY AND INTERVENTION DESIGN, 12 Implementation and Evaluation, 12

Data Analysis, 13

FINDINGS, 14 Participant characteristics, 14 Menstrual practices and menstrual material donation preferences, 14 Unmet need for underwear, 15

Washing practices, 15

Satisfaction: Design, Fit and Durability, 16

Design, 16

Fit, 17

Durability, 18

SUMMARY OF FINDINGS AND CONCLUSION, 19 Limitations, 19 Conclusions, 19

Understanding underwear needs, 19

Defining Durability, 20

Feasibility of scaling up measurements, 20

REFERENCES, 21 ANNEX 1: UNDERWEAR DESIGN SPECIFICATION, 22 PARTNER INFORMATION, 23

Acronyms IP

R&D

Implementing Partner

Research and Design

MHH

UNFPA

Menstrual Health and Hygiene

Uniter Nations Population Fund

MHM

UNHCR

Menstrual Health Management

NFI

Non-food Item

NGO

United Nations High Commissioner for Refugees

UAM Unaccompanied Children

Non-Governmental Organisation

WASH

OPM

Water, Sanitation and Hygiene

Office of the Prime Minister

Executive Summary Restrictive social norms, a lack of access to menstrual materials and minimal menstrual education means that managing menstruation can be challenging for women and girls1. During emergencies and displacement, these challenges are further exasperated due to the loss of usual coping strategies and changes to physical and social environments (VanLeeuwen and Torondel, 2018). In refugee contexts, an overlooked obstacle to overcoming menstrual barriers is that women and girls often do not have sufficient underwear to manage their menstruation, and distributed underwear is often inadequate in number, poor quality and the wrong size or fit (Gade and Hytti, 2017; IFRC, 2015; Kuncio, 2018; Poulson, 2017).

Pilot Intervention In response to these needs, AFRIpads, a Ugandan social enterprise, manufacturing reusable pads, designed their own underwear to be worn in combination with AFRIpads Reusable Pads or as every-day underwear. They also developed a measuring tool (the Underwear Sizing Tape) to assist NGO field workers in selecting the right underwear size for recipients during distributions. In collaboration with UNHCR Uganda, AFRIpads facilitated a pilot intervention to test the acceptability of their new underwear and the effectiveness of the Underwear Sizing Tape. Two pairs of AFRIpads Underwear were distributed to 88 women and girls in Bidibidi Refugee Settlement in Northern Uganda, after they were measured using the Underwear Sizing Tape. Participants were followed up after 5 weeks of receiving their AFRIpads underwear.

Findings Baseline: Unmet underwear needs: 58% of respondents had received 1 to 3 pairs of underwear in the last 6 months, however only 4 respondents said that 2 to 4 pairs of underwear were sufficient for them to manage their menstruation comfortably. 56% were unsatisfied with the quality of the underwear received as donations and only 20% said they had received the right sized underwear in previous distributions.

Endline: Acceptability of underwear: 97% of respondents were either satisfied or very satisfied with the quality of the AFRIpads underwear. A majority (86%–97%) felt satisfied with the fit, side and back coverage, comfort, and drying time. Despite the high level of satisfaction, no respondents expected to be able to use their AFRIpads underwear for more than a year and 59% only expected to be able to wear the underwear for 1 to 3 months. The main reason for the low expectations in terms of durability, were related to the color of the underwear fading and turning brown due to frequent washing of the underwear, due to having only a few pairs. Acceptability and effectiveness of using the AFRIpads Underwear Sizing Tape to determine the right size of underwear for recipients: The measurements taken with the AFRIpads Underwear Sizing Tape proved accurate, with 98% of respondents, saying they had received the perfect fit and felt comfortable with the measurements being taken.

Conclusions The findings of this evaluation point towards an unmet need for underwear among refugee women and girls and suggests that there is a need to better understand user practices, perceptions of durability and preferences to ensure women and girls have sufficient, comfortable underwear to manage their menstruation. The AFRIpads underwear were acceptable to the women and girls in this pilot and the use of the AFRIpads Sizing Tape was effective in determining the right size for recipients. The issue of the underwear fading should be addressed by further considerations to design, but more importantly, by ensuring women and girls have sufficient pairs of underwear. Measurements using the Underwear Sizing Tape should be further tested to ensure recipient privacy and comfort can be maintained in larger distributions.

1 This report refers to women’s and girls’ experiences of menstruation throughout, but AFRIpads recognizes that not all people who menstruate are women and girls, and not all women and girls menstruate.

Introduction Restrictive social norms, a lack of access to menstrual materials and minimal menstrual education means that managing menstruation can be challenging for women and girls1. Particularly in low-resource settings, access to basic services such as clean water, private spaces for changing and safe disposal facilities are limited. During emergencies and displacement, these challenges are further exasperated due to the loss of usual coping strategies and changes to physical and social environments (VanLeeuwen and Torondel, 2018). During displacement, people are often forced to leave behind their belongings and clothes and may not be able to afford to purchase menstrual materials (UNICEF, 2019), including underwear. In refugee contexts, women and girls often report the lack of sufficient underwear as a challenge to managing their menstruation, (Kuncio, 2018; Parker et al., 2014; Pujol-Mazzini, 2017), whether as their primary method of menstrual management, or to hold in place menstrual materials (such as cloth, pads and in some cases, natural materials like leaves or banana fibers). When consulted, women and girls in humanitarian contexts often rank underwear among the most important items they would like to receive (Abbott et al., 2011; Kuncio, 2018). Although underwear is supplied alongside menstrual materials, the distributed underwear may fail to meet their menstrual needs. Underwear is often inadequate in number (Gade and Hytti, 2017; Kuncio, 2018; Poulson, 2017), of poor quality and the wrong size or fit (IFRC, 2015; Kuncio, 2018) and at times, culturally inappropriate (Rohwerder, 2014). Lack of access to sufficient, comfortable, quality underwear is an overlooked obstacle to overcoming menstrual barriers in humanitarian settings. AFRIpads, a Ugandan social enterprise, manufacturing reusable pads, has worked with both humanitarian and development partners to distribute AFRIpads Menstrual Kits in over 30 countries. First-hand feedback from the field, partner survey results and anecdotal evidence from collaboration with partners, clearly suggests that the women and girls they work with, lack access to good quality, comfortable underwear that fits their bodies. In response, AFRIpads designed their own underwear to be worn in combination with AFRIpads Reusable Pads or as every-day underwear. They also developed a measuring tool (the underwear sizing tape) to assist NGO field workers in selecting the right underwear size for recipients during distributions. In collabo-

GOAL Test the acceptability of AFRIpads underwear & Assess the effectiveness of the underwear sizing tape

ration with UNHCR Uganda, AFRIpads facilitated a pilot intervention in Bidibidi Refugee Settlement in Northern Uganda, to test the acceptability of their new underwear and the effectiveness of the underwear sizing tape.

Menstrual Health and Hygiene in humanitarian contexts Menstrual challenges and responses to them, differ depending on the nature of the humanitarian emergency, its length and location (Nelis, 2018). Although menstrual hygiene management (MHM) has often been considered a Water Sanitation and Hygiene (WASH) issue, inadequate or poor menstrual health and hygiene (MHH) can adversely impact health and well-being, dignity and safety, gender equality and the right to employment and education (Nelis, 2018). It is increasingly acknowledged that responding to MHH needs requires an intersectional approach and collaboration across different sectors (WASH, Protection, Health, Education, Non Food Items (NFIs) and Shelter) (Sommer et al., 2017). Emergency contexts are characterized by many different actors (national authorities, UN agencies and international NGOs) working jointly to address the needs of vulnerable and displaced populations, which can further complicate responding to MHH, due to its multisectoral nature (VanLeeuwen and Torondel, 2018).

The MHM in Emergencies Toolkit (Sommer et al., 2017) defines a holistic humanitarian response to addressing unmet MHH needs, as including: 1. Access to menstrual materials and supplies: appropriate menstrual materials and supportive materials for storage, washing and drying and demonstration on using the materials. 2. Supportive MHM facilities: safe and private toilet and bathing facilities for changing, washing, and drying materials, disposal options. 3. Menstrual information: MHH promotion and education, addressing harmful cultural or social norms related to menstruation.

MENSTRUAL CHALLENGES IN HUMANITARIAN CONTEXTS: • Cultural taboos and restrictions related to MHM • Lack of sanitary materials, including underwear • Lack of private female friendly toilets and bathing spaces • Lack of knowledge on menstruation • Anxiety and embarrassment around leakage and discomfort • Overcrowding and severely diminished privacy

ACCESS TO MENSTRUAL MATERIALS AND UNDERWEAR Menstrual materials (disposable pads and cloth) and underwear have been included as standard items in hygiene kits distributed to households during emergencies. However, in response to the increasing awareness of women’s and girls’ unmet MHH needs, various organizations have started distributing MH Kits, which are often also women and girl’s main access point to underwear. UNHCR was one of the first actors to address MHM by supplying refugee women and girls with disposable pads or cloth, underwear and soap. They have also piloted the provision of reusable pads (Kuncio, 2018). UNFPA has distributed context-specific, locally procured, dignity kits since 2001 as one-off distributions. The kits are aimed at promoting dignity, mobility and safety and in addition to menstrual materials and underwear include items like headscarves, whistles and torches (Abbott et al., 2011). Many other NGOs now distribute personal hygiene or MH kits that consist of a selection of soap, water containers, disposable or reusable menstrual pads, underwear, cloth and other items (IFRC, 2018; Plan International, 2019; Tellier and Hyttel, 2017). The IFRC conducted a study in Madagascar, Somalia and Uganda, looking at 3 menstrual kits (disposable pads, reusable pads (AFRIpads) or both) based on which MHM relief items are now a part of their Emergency Items Catalogue, including disposable and reusable menstrual pads, underwear, laundry soap, buckets and other items (Robinson and Obrecht, 2016). Increasingly, organisations are also introducing Cash and Voucher Assistance or mobile money for MH Kit distribution (Plan International, 2019).

Source: Sommer et al., 2017

KEY TERMS Menstrual Hygiene Management (MHM) refers to the management of hygiene associated with the menstrual process, including clean menstrual materials, that can be changed in privacy as often as necessary, using soap and water for washing the body as required, and access to safe, convenient facilities to dispose of used materials. Menstrual Health and Hygiene (MHH) includes both MHM and the broader systematic factors that link menstruation with health, well-being, gender equality, education, equity, empowerment, and rights. Menstrual (Hygiene) Materials are the products used to catch menstrual flow, such as disposable or reusable pads, cloths, tampons or menstrual cups. Menstrual Supplies are other supportive items needed for MHH, such as body and laundry soap, underwear, and pain relief items. Source: UNICEF, 2019

THE TROUBLE WITH UNDERWEAR IN UGANDAN REFUGEE CONTEXTS A pilot intervention in three Southwestern Ugandan refugee settlements to test the appropriateness of reusable menstrual pads (AFRIpads) found that 71% of respondents reported not having enough menstrual products and 59% not having enough underwear to manage their menstruation. After the intervention, access to menstrual products was no longer reported as a top challenge, but despite all girls receiving 3 pairs of underwear, 60% reported not having enough, both before and after the intervention (Kuncio, 2018). Anecdotal evidence suggests that it is common for distributed underwear to be the wrong size, poor quality, inappropriate or uncomfortable and insufficient in quantity. If recipients do not have underwear that fits them properly, in sufficient quantities, it may also affect the functionality of their menstrual materials and their feelings of comfort and dignity during their period (Gade and Hytti, 2017).

Menstrual Health and Hygiene in humanitarian contexts in Uganda Uganda is one of the largest refugee-hosting countries in Africa, hosting over 1.4 million refugees and asylum seekers, a majority of whom are from South Sudan (65.4.%), the Democratic Republic of Congo (30.9%) and Burundi (3.6%). Approximately, 30% of refugees in Uganda are girls and women aged 12 to 59 (UNHCR, 2020). A majority of refugees live in settlements alongside local communities and Uganda’s progressive refugee policy allows refugees freedom of movement, the right to work and establish businesses and access to health care and education (UNHCR, 2019). Globally, the UNHCR WASH cluster is the technical lead for MHH, however it is often the Protection team that takes a lead on the ground (Kuncio, 2018), working across clusters and in partnership with various implementing partners (IPs) to distribute menstrual materials to women and girls. In Uganda, the UNHCR is nationally mandated to provide all refugee women and girls of reproductive age with 6 bars of soap, 6 packets of disposable sanitary pads and 3 pairs for underwear, bi-annually (Kuncio 2018). The frequency of distribution may differ between settlements. In Bidibidi Refugee Settlement, where the pilot was conducted, the UNHCR, aims to distribute MHM kits quarterly as general distributions supported by World Vision. The kits consist of 3 packets of disposable menstrual pads (10–12 pieces per packet), 2 pieces of underwear and 3 pieces of laundry soap (250 grams). During general distributions, women and girls have the option to choose from S, M, L and XL-sized underwear. Samples are displayed to guide choice (Omara, 2020). In addition to the inclusion of MHM Kits in general distributions, the UNHCR provides an emergency stock of underwear, menstrual pads and laundry soap to schools every term and to protection houses, women’s centers and detention facilities on a needs basis (Omara, 2020). There are also several INGOs working within the settlement that include MHH in their programming. Where UNHCRs MHM Kit or underwear distributions are affected by procurement or pipeline delays, they work with partners across sectors to limit delays in distributions.

Photo 1: Bidibidi Refugee Settlement

AFRIpads in a leading manufacturer of reusable menstrual pads and has worked in Uganda since 2010. AFRIpads Reusable Menstrual Kits have been included in projects supporting MHH by over 100 partner organizations. In most instances, AFRIpads are distributed with one or several pairs of underwear, in accordance with the partner organizations procurement and distribution policies. Evaluations of the acceptability of AFRIpads in humanitarian contexts, have found that reusable pads may be preferred as a donation item, compared to disposable pads, due to lasting longer and relieving recipients of their dependence on, sometimes delayed, distributions (Gade and Hytti, 2017; Kuncio, 2018; Poulson, 2017).

AFRIpads Underwear and Underwear Sizing Tape AFRIpads Underwear were launched in 2020 in response to the first-hand accounts and evidence AFRIpads had gathered on the quality of underwear available to the women and girls using their products. The AFRIpads Research and Design (R&D) team worked closely with women and girls to integrate a human centered design approach, ensuring the underwear was comfortable, well-fitting, and durable. The underwear is made from high quality, cotton-spandex. They come in fives sizes, from XS to XL and are stretchy to accommodate a range of body sizes. They are designed to be worn in combination with AFRIpads Reusable Pads or as every-day underwear.

Material

Design

Durability

Extra stretchy material for a guaranteer fit. 95% cotton + 5% spandex. Cotton is breathable and spandex allows for super-stretch. Fade-resistant, discrete black color.

Figure 1: AFRIpads Underwear design features

To accompany a size ratio breakdown table, to help partners procure the right ratio of underwear sizes for distributions (see Annex 1), AFRIpads developed an Underwear Sizing Tape to solve the common distribution challenge of incorrect sizing. To use the measuring tape, the staff member taking the measurement wraps the tape measure around the hips of the recipient and reads the size. Where a measurement is on the boarder of two sizes, the recipient can choose which size they would prefer. Photo 2: Being measured for the right fit

Figure 2: AFRIpads Underwear Sizing Tape

Methodology and Intervention Design This pilot aimed to test the acceptability, in terms of the comfort, fit and durability, of AFRIpads underwear for day-to-day use and use during menstruation, and to assess the acceptability and effectiveness of using the AFRIpads Underwear Sizing Tape to determine the right size of underwear for recipients. The results of this pilot will inform the AFRIpads R&D team’s design decisions for further product development and will assist the UNHCR in its aim to ensure that all products selected for distribution by the UNHCR and its partners, are adapted to the needs and wishes of the communities they serve. The pilot was carried out in Bidibidi Refugee Settlement, in Yumbe district, Northern Uganda, between September and November 2020, in collaboration between AFRIpads, UNHCR Uganda and World Vision, the implementing partner responsible of NFI distributions.

Participants were randomly selected by UNHCR, with support from World Vison, from the child protection beneficiary list of 10 villages in Zone 4 of the settlement. Selected participants included caregivers, child protection committee members, unaccompanied children (UAM) and children at risk. In total 88 participants were recruited. Figure 3: Map of Bidibidi Refugee Settlement Source: FACILITIES MAP — Bidibidi Settlement — Zone 4 (South) — Yumbe — Uganda, UNHCR, 2018. Available at: https://reliefweb.int/sites/reliefweb.int/files/resources/reach_ uga_map_bidibidi_zone4_south_facilities_24oct2018_a3_0.pdf

Implementation and Evaluation The pilot was carried out over a period of 5 weeks. The enumerators were trained by AFRIpads in conducting the surveys, using KoboCollect and on the use of the Underwear Sizing Tape. Participants were recruited and consented verbally (parental or caregiver consent was sought for participants under the age of 18 and assent obtained from the participant) by World Vision staff.

Underwear Distribution and Use

Baseline survey • 22–23 September 2020 • 88 participants

Survey Topics • Demographics details • Water/soap availability & washing practicies • Menstrual materials donation experiences and preferences • Underwear donation experiences and preferences • Underwear purchases

• Measurements taken by enumerators and WV staff with Underwear size tape • 2 pairs of AFRIpads underwear given according to measurements to 88 participants • 3 weeks of product use

Endline survey • 3–5 Nov 2020 • 86 participants

Survey Topics • Fit of underwear and comfort with measurement • Underwear satisfaction • Perceptions of fit, comfort and durability • Washing practices

Figure 4: Pilot intervention overview

A baseline survey was conducted at the start of September 2020, each survey taking approximately 10 minutes. The distribution of underwear was carried out after the baseline survey by four enumerators and two World Vision case workers, under the supervision of AFRIpads staff. Each selected participant received two pairs of AFRIpads underwear. The distributions were carried out in private rooms in three conveniently located Child Friendly Spaces in three different villages in Zone 4. All participants were measured with an AFRIpads Underwear Sizing Tape before receiving their underwear. All measurements where done by female staff and validated by AFRIpads staff. If the measurement was on the margins of two sizes, respondents were asked which size they would prefer. All respondents received two of the same sized underwear.

Survey interviews were conducted face-to-face using KoboCollect1 on Android devices. The endline survey was carried out by the same team in early November 2020. Baseline and endline surveys were conducted in English, Arabic, Lugbara, Aringa and Kakwa.

DATA ANALYSIS Responses were stored securely and downloaded into an anonymized excel spreadsheet. Descriptive analysis was done using a spreadsheet application.

1 Survey tools are available on request.

Photo 3: Data collection activities

Findings PARTICIPANT CHARACTERISTICS

Age range Median range Table 1: Underwear sizes distributed % (n= 88)

88 participants took part in the baseline survey and product distribution. Two participants were lost to follow-up and 86 participants took part in the endline survey. Participants were all female, between the ages of 12 and 59, with an average age of 28. A majority (77.3%) of respondents received medium sized underwear, and 12.5% received small underwear. All sizes were distributed to both adult women and girls, however the larger the underwear size, the higher the median age of the respondents was. 66 (75%) were menstruating at the time of the distribution. At end line 56 (65%) respondents had menstruated since receiving the underwear.

Menstrual practices and menstrual material donation preferences FIGURE 5: (Baseline) Were the donated pads enough to manage your menstrual flow? (%) (n=59) 100% 80%

33%

53%

60% 40%

66%

47%

20% 0% Disposable Pads

Yes

Reusable Pads

59 (67%) respondents had received either reusable (17) or disposable pads (42) in the last 12 months. • Reusable pad recipients were more satisfied with the received materials (82% either satisfied of very satisfied) compared with 59% of disposable pad recipients. • 53% of reusable pad recipients felt the pads received were enough to manage their menstruation compared to 33% of disposable pad recipients. • 63% of respondents who had menstruated since receiving their AFRIpads underwear, used disposables only, 23% used reusable materials (AFRIpads, other factory-made pads, self-made pads, and cloth), 13% used a combination of materials. Only one respondent used underwear only (only measured at endline).

At baseline, respondents had an equal preference for receiving either reusable pads (47%) or disposable pads (42%) and 10% preferred to receive a combination for the two as a donation. At endline more respondents would have preferred to receive a combination of disposables and reusables (24%) and there was a slight decrease in respondents wanting only disposables (34%) or only reusables (40%). 14

Unmet need for underwear

FIGURE 6: (Baseline) How many pieces of underwear do you wear in a day during your period/ when not on your period? (%) (n=75)

76 (86%) respondents reported using at least two pairs of underwear a day (at least one pair during the day and another at night), regardless of whether they were menstruating or not. 83% of menstruating respondents said they used 3 or more pairs of underwear a day during menstruation. The most frequently stated reason for wearing more than one pair a day was feeling cleaner, (79%, n=59) and the second most frequent response was changing underwear due to leakages (45%, n=34).

0.9

83%

0.8 0.7

65%

0.6 0.5

53% of respondents had received between 1 and 3 pairs of underwear by donation in the last 6 months. 83% said that they also purchased underwear, paying an average of 1880 Ugandan Shillings (approx. 0.50 USD) per underwear purchase.

0.4 0.3 0.2

Most respondents (61% baseline, 64% endline) said they never had enough underwear to manage their menstruation and when asked at baseline what three items they would most prefer to receive as donations in addition to menstrual materials, 84% selected underwear as one of the options, superseded only by soap (selected by 91% of respondents). When asked at endline if they had any other comments, 14 (16%) respondents commented that the underwear should be distributed with soap and a bucket or basin.

22% 15%

14%

0.1

0 Not menstruating

1 pair of underwear

Menstruating

2 pairs of underwear

3 or more pairs of underwear

At baseline, when asked how many pairs of underwear they would need to manage their menstruation comfortably, responses ranged from 2 to 30 pairs. 24% stated they need six pairs of underwear to manage their menstruation comfortably and only four respondents stated that 2 to 3 pairs were enough to manage their menstruation.

FIGURE 7: (Baseline) Number of underwear received as donation vs number of underwear needed (n=88) 30 25

23 23

10 5

17 7

0 1 pair

2 pairs

3 pairs

13 4 4 pairs

5 pairs

6 pairs

7 pairs

8 pairs

9 pairs

Reveiced in last 6 months

13 10 pairs

11 12 pairs

15 pairs

20 pairs

30 pairs

Needed

Washing practices • At baseline 75% of respondents always or often had access to water for washing clothes, however 73% only sometimes, had soap to wash clothes. • 75% washed their underwear with a combination of water and soap. • 24% used either ash, Jik or Dettol, one respondent used peroxide and one respondent water only. • 69% reported sometimes, often, or always wearing their underwear without washing it with soap. • At endline, 98% of respondents said they washed their underwear with soap and water and the percentage of respondents wearing underwear without washing it reduced to 26%.

Satisfaction: Design, Fit and Durability

All respondents said they would recommend AFRIpads underwear to a friend and that they would like to receive more as a donation. 97% of respondents said wearing the underwear made them feel more confident.

Respondents were more satisfied with the quality of AFRIpads underwear and underwear they had purchased themselves, than other donated underwear. At baseline, 90% of respondents who had purchased underwear (n=73) were satisfied or very satisfied with the quality of the underwear, compared to only 42% of respondents who received donated underwear (n=47) being either satisfied or very satisfied with the donated underwear. At endline, 93% of respondents stated they were either satisfied or very satisfied with the quality of the AFRIpads underwear. 73% said they would prefer to receive underwear through donations, rather than purchasing them themselves.

FIGURE 8: (Baseline, Endline) Level of satisfaction with other donated underwear, purchased underwear and AFRIpads Underwear (%) 0.9

77%

0.8 0.7

64%

0.6

51%

0.5

40%

0.4 0.3

26%

0.2

16%

0.1

Very unsatisfied

Unsatisfied

Other donated underwear (n=47)

Neutral Purchased underwear (n=73)

2% Satisfied

Very satisfied

AFRIpads Underwear (n=86)

DESIGN Respondents expressed high levels of satisfaction with the fit, comfort, and drying time of AFRIpads underwear at endline.

97%

91%

86%

98%

of respondents found the underwear to be very comfortable or comfortable. The three respondents who found the underwear uncomfortable, said it was too large.

of respondents were very satisfied or satisfied with the back coverage of the underwear, with 63% stating that this was because it covered the whole buttocks.

of respondents were either very satisfied or satisfied with the side coverage of the underwear

of respondents were either very satisfied or satisfied with the time it took for the underwear to dry.

of the respondents who used the AFRIpads underwear during their LMP with a pad (disposable of reusable) or cloth (n=53), felt the underwear held the menstrual material in place.

When asked if they had any additional comments at the end of the survey, 22 (26%) respondents said that the color of the underwear should be changed or that different colors should be available. Three comments suggested that the crotch area of the underwear should be softer. Other respondents said they liked the material of the underwear. Respondents were also asked how the underwear was different from previously received underwear. Respondents felt the fabric was heavier and stronger than other underwear and the fit was better because of the measurements. Some respondents said the AFRIpads underwear did not fade in comparison to other underwear. In terms of the color, it was not clear whether the black color was perceived positively or negatively.

FIGURE 9: (Endline) What did you most like about the AFRIpads underwear? (n=86) Don’t know

Quality (doesn’t rip or tear)

39 68

Comfort Size (fit)

79 31

Style Color

13 0

100

Table 2: How do you think this underwear is different from other underwear you have received as a donation before? Example responses

MATERIAL/ FABRIC

PERFECT SIZE

THE COLOR

DOES NOT FADE

OTHER

“It is heavier than those distributed by others.”

“The size is perfect because it’s measured”

“It is good but very black”

“It doesn’t fade everywhere but only where the private part is put”

“When you wash this knicker remains soft compared to previous ones”

“Has no color”

“Fabric is stronger”

“The pant is ok and it doesn’t fade”

“Waistline is good and strong”

FIT At baseline, only 20% of respondents who had received donated underwear, felt they had received correctly fitting underwear. 40% considered the underwear received to be so ill-fitting, it was unwearable. In line with this, when asked what the most important thing about donated underwear was to respondents, 58% said getting the right size was the most important, followed by color, durability, that soap is given with the underwear and that enough pieces of underwear are given. 20% of respondents also felt drying time was important. At endline, 98% of respondents described the fit of the AFRIpads underwear received as perfect and felt they received the right size. Two respondents said that the underwear was too big but could still be worn and would have preferred smaller underwear. Only one respondent stated that they felt uncomfortable when being measured for the underwear. Correspondence for the UNHCR team in Yumbe also suggests that taking the measurements did not significantly increase the time taken to complete the distribution.

“THE SIZE IS PERFECT BECAUSE IT’S MEASURED”

DURABILITY 80% of respondents at endline stated that the AFRIpads underwear did not become damaged or broken in anyway during the 5 weeks of use. Those who stated that the underwear did become damaged, said the elastic became loose, the color faded, the fabric tore, or the waist ripped. 33 (38%) respondents said the color of the underwear faded and turned brown, all over or in the crotch area, due to regular washing.

wear away when it started to look old, because the elastic stopped working, because the underwear broke or got dirty or because they had been told to throw their underwear away after a certain time. At endline respondents were asked for how long they expected to be able to use the AFRIpads underwear before it became worn out. No respondents expected to be able to use their AFRIpads underwear for more than a year and 59% only expected to be able to wear the underwear for 1 to 3 months before it becomes worn out. 63.4% of respondents stated that wearing and washing the underwear frequently, because of having only a few pairs of underwear, was the reason for their estimation of durability.

At baseline, respondents were asked how long they usually use their underwear for and why they threw it away. Respondents reported using their underwear from 1 month to 2 years. At baseline 25% of respondents said they used their underwear for over 6 months. They decided to throw the under-

FIGURE 10: (Baseline, Endline) How long can the underwear be worn before it gets worn out? (%) 70%

59%

60% 50% 40%

32%

30%

23%

20%

33% 14%

10%

0% 1% > 1 month

0% 1–3 months

3–6 months

6–12 months

Baseline (n=88)

12–18 months

0% 18–24 months

2% 0% >2 years

Endline (n=86)

Most respondents (70%) linked the estimated durability of the underwear to frequent washing, because of having only a few pairs or to the material becoming faded, torn, or broken. However, 27% linked their estimation of durability to the material being good, long-lasting, or strong.

FIGURE 11: (Endline) Reasons for durability expectations (n=86) 60%

50%

40%

Wearing and washing frequently because of limited number of underwear

30%

The material is good, longlasting, strong 20%

10%

1 > 1 month

Because it is already faded, torn or broken

6 1–3 months

1 8 3–6 months

5 6–12 months

Because doesn’t wear pants for long

Summary of findings and conclusion • The pilot had a short follow up period. Only 56% of respondents had their period during intervention and 44% of respondents were not able to try their underwear during their menstruation. This may have led to an inaccurate estimation of acceptability of underwear during menstruation. • Considering the findings related to underwear fading in color and issues relating to the perceived durability of the underwear, the short follow up period may have resulted in a higher level of acceptance then if the follow up period was longer. There may also have been a comprehension issue in relation to the question on perceived durability of AFRIpads Underwear (C3. Based on the quality of this underwear, how long do you think you will be able to wear the underwear before it gets worn out?).

Conclusions UNDERSTANDING UNDERWEAR NEEDS The findings in the evaluation indicate that women’s and girl’s needs in relations to underwear, particularly for menstrual management, are currently not being met. For someone who changes their underwear three times a day, or more, during menstruation (87% of respondents in this evaluation), three pairs of underwear are only sufficient of one day of menstruation and can lead frequent washing. In this evaluation, 96% of respondent said they needed more than 4 pairs of underwear to manage their menstruation comfortably, but the responses ranged from 2 to 30 pairs. It is not clear, what the unmet need is or what affects the number of underwear needed. The number of underwear needed or wanted also varies between evaluations (IFRC, 2016; Kuncio, 2018; Rohwerder, 2014) carried out in different contexts, asking the questions in different ways.

Limitations Unmet underwear needs 58% of respondents had received 1 to 3 pairs of underwear in the last 6 months, however only 4 respondents said that 2 to 4 pairs of underwear were sufficient for them to manage their menstruation comfortably. 56% were also unsatisfied with the quality of the underwear received as donations and only 20% said they had received the right sized underwear in previous distributions.

Acceptability — comfort, fit and durability of AFRIpads underwear for day-to day use and during menstruation 97% of respondents stated they were either satisfied or very satisfied with the quality of the AFRIpads underwear. A majority (86% to 97%) felt satisfied with the fit, side and back coverage, comfort, and drying time of AFRIpads underwear. All respondents said they would recommend AFRIpads underwear to a friend and wanted to receive more as donations. Although the level of satisfaction was high, this was not reflected in respondents’ expectation for the durability of the underwear. No respondents expected to be able to use their AFRIpads underwear for more than a year and 59% only expected to be able to wear the underwear for 1 to 3 months before it becomes worn out. Respondents reported some issues in relation to the underwear tearing or becoming loose, however the main reason for the respondents low expectations in terms of durability were related to the color fading and the underwear turning brown due to frequent, often daily, washing of the underwear, due to having only a few pairs.

Acceptability and effectiveness of using the AFRIpads Underwear Sizing Tape to determine the right size of underwear for recipients The measurements taken with the AFRIpads Underwear Sizing Tape proved accurate as all, but one respondent, said they had received the perfect fit and felt comfortable with the measurements being taken. 19

To ensure women and girls receive enough underwear to manage their menstruation comfortably and to use menstrual materials effectively, their need for underwear should always be evaluated before distribution. How the provision of durable underwear, effective menstrual materials, and menstrual heath information, might impact the perceived or actual need to change and wash underwear frequently and thus the number of underwear needed, should be investigated. Further consideration should also be given to the cost and dignity implications of providing too few or low-quality underwear to support menstruation.

DEFINING DURABILITY Respondents in the evaluation, estimated the durability of underwear to be low in general and 59% of respondents said they expected the AFRIpads underwear to wear out within 1 to 3 months. This however did not lower respondents’ level of satisfaction with the underwear. Respondents said that one of the reasons they decide to throw away underwear is when it starts to look old. AFRIpads underwear was reported to fade due to frequent washing. There were no reports of underwear being washed with detergents that might enhance fading, such as peroxide. Although black or opaque colors are often deemed more suitable for menstruation as stains are not as visible, some respondents did request for a wider variety of colors to choose from. The issue of the underwear fading should be addressed by further considerations to design, but more importantly, by ensuring women and girls have sufficient pairs of underwear.

FEASIBILITY OF SCALING UP MEASUREMENTS The measurement process using the Underwear Sizing Tape was perceived positively by participants and was effective in determining the right sized underwear for recipients. Although the measurements were not reported to significantly slow down the distribution, conducting the measurements during larger distributions would likely need additional workforce and time. The measurement process was highly acceptable to participants; however, it may be difficult to conduct the measurements in a private location or ensure measurements are taken by female staff during larger distributions, which could impact recipients’ level of comfort and willingness to be measured. The current COVID-19 situation may also require adaptative measures to ensure minimal risks to persons involved in the process(Omara, 2020). Although not a subject on investigation in this evaluation, the sizing ratios recommended by AFRIpads for procurement of underwear (See Annex 1), do not match sizes distributed, after measurement, in this evaluation. In larger distributions, there is a risk that the procured underwear will not match the requirements based on measurements. Further information should be collected across AFRIpads distributions to test the validity of the sizing table or to inform procurement recommendations.

References Abbott, L., Bailey, B., Karasawa, Y., Loius, D., McNab, S., Patel, D., Lopez, C., Rani, R., Saba, C., Vaval, L., 2011. Evaluation of UNFPA’s Provision of Dignity Kits in Humanitarian and Post Crisis Settings. School of International and Public Affairs, Columbia University. Gade, A., Hytti, L., 2017. Menstrual Health in Rhino Refugee Settlement, West Nile, Uganda. Pilot Intervention Report. WoMena. IFRC, 2018. Addressing menstrual hygiene management (MHM) needs - Guide and Tools for Red Cross and Red Crescent Societies. International Federation of Red Cross and Red Crescent Societies, Geneva, Switzerland. IFRC, 2016. Menstrual Hygiene Management (MHM) in Emergencies: Consolidated Report. IFRC, 2015. Final report: Operational Research on Menstrual Hygiene Management (MHM) Kit for Emergencies - Somalia (Dilla & Alleybadey). IFRC. Kuncio, T., 2018. Pilot Study Findings on the provision of hygiene kits with reusable sanitary pads - Testing the appropriateness and acceptability of AFRIpads reusable sanitary pads in southwestern (Ugandan) refugee context among schoolgirls. Nelis, T., 2018. Operational Practice Paper: Menstrual Hygiene Management in Humanitarian Emergencies. Institute of Development Studies. Omara, 2020. Personal communication with UNHCR representation, Yumbe. Parker, A., Smith, J., Verdemato, T., Cooke, J., Webster, J., Carter, R., 2014. Menstrual management: a neglected aspect of hygiene interventions. Disaster Prev. Manag. 23, 437–454. Plan International, 2019. CVA and MHM Kit Guidance Note. Poulson, C., 2017. HIF Evaluation Case Study: IFRC Menstrual Hygiene Management in Emergencies. Ehrla. Pujol-Mazzini, A., 2017. For refugee women, periods a dangerous, shameful time [WWW Document]. news.trust.org. URL https://news.trust.org/item/20170308150652-db2y1/ (accessed 11.27.20). REACH. (2018). FACILITIES MAP - Bidibidi Settlement - Zone 4 (South) - Yumbe - Uganda. Available at: https://reliefweb.int/sites/reliefweb.int/files/resources/reach_uga_map_ bidibidi_zone4_south_facilities_24oct2018_a3_0.pdf (Accessed: 24 November 2020). Robinson, A., Obrecht, A., 2016. Improving menstrual hygiene management in emergencies: IFRC’s MHM kit’ HIF/ALNAP Case Study. ODI/ANLAP, London. Rohwerder, B., 2014. Non-food items (NFIs) and the needs of women and girls in emergencies (GSDRC Helpdesk Research Report 1107), Helpdesk Research Report. GSDRC, University of Birmingham., Birmingham, UK. Sommer, M., Schmitt, M., Clatworthy, D., 2017. A Toolkit for Integrating Menstrual Hygiene Management (MHM) into Humanitarian Response. Tellier, S., Hyttel, M., 2017. Menstrual Health Management in East and Southern Africa:a Review Paper. UNFPA. UNHCR, 2020. Operational Update Uganda: 1 – 31 July 2020. UNHCR. UNHCR, 2019. Uganda 2019 Operational Context [WWW Document]. Uganda Glob. Focus. URL https://reporting.unhcr.org/uganda (accessed 11.27.20). UNICEF, 2019. Guidance on Menstrual Health and Hygiene. VanLeeuwen, C., Torondel, B., 2018. Improving menstrual hygiene management in emergency contexts: literature review of current perspectives [WWW Document]. Int. J. Womens Health. https://doi.org/10.2147/IJWH.S135587

Annex 1: Underwear Design Specification

Partner information The United Nations High Commissioner for Refugees (UNHCR) is the global organization dedicated to protecting the rights of refugees, displaced communities Congo (DRC) and Burundi. AFRIpads was established in Sub Saharan Africa in 2010. For 10 years, the focus at AFRIpads has been to overcome menstrual barriers for women and girls through product innovation, education and evidence. AFRIpads has worked with over 200 humanitarian and development organisations in over 30 countries. Together with their partners, they have reached over 3.5 million women and girls with AFRIpads Menstrual Kits. AFRIpads collective impact has proven that high-quality reusable sanitary pads can have a transformative impact on the lives of women and girls around the world. AFRIpads manufacturing operations are based in rural Uganda, employing 150 employees. AFRIpads offers a holistic Menstrual Health and Hygiene (MHH) solution. Alongside Reusable Menstrual Kits, they provide partners with a range of resources including a MHH Education Toolkit and a Monitoring and Evaluation framework.