A Time for Global Action: Addressing Girls' Menstrual Hygiene Management Needs in Schools

A systematic review of the menstrual experiences of university students and the impacts on their education: A global perspective

Background

Higher education attainment is linked to improved health and employment outcomes but the impact of university students’ experiences of menstruation on their education is less clear. The objective of this review was to synthesise qualitative and quantitative research on university students’ menstrual experiences and educational impacts.

Methods

Eligible studies were identified through systematic searching across eight peer-reviewed databases, websites for menstrual health organisations, grey literature databases, and reference lists of included studies. Eligible studies must have reported on at least one of the antecedents or components of menstrual experience outlined in the integrated model of menstrual experience in relation to university students or reported on the impact of their menstrual experiences on their education. Study characteristics and findings were extracted, analysed and presented as a narrative synthesis. The quality of evidence was assessed with the Mixed Methods Appraisal Tool. This study is registered on PROSPERO, number CRD42020178470.

Results

Eighty-three studies were eligible for inclusion. Most studies (n = 74; 89%) were quantitative and the highest proportion of studies were conducted in lower-middle-income countries (n = 31; 37%). Self-reported dysmenorrhea, other physical and emotional menstrual-related symptoms, and menstrual stigma contributed to negative menstrual experiences among female students. Very few studies considered the menstrual experiences of non-binary and transgender menstruating students, and culturally diverse students. Dysmenorrhea contributed to university absenteeism, impaired participation and concentration, and declining academic performance. Inadequate sanitation facilities for menstrual management and challenges containing menstruation also negatively impacted education.

Conclusions

Female university students’ experiences of menstruation can negatively impact their education, highlighting the need for program and policy responses at university to improve students’ wellbeing and educational engagement. Further research on the menstrual experiences of gender diverse, migrant and international students is needed as there is insufficient evidence to date.

The Stressor in Adolescence of Menstruation: Coping Strategies, Emotional Stress & Impacts on School Absences among Young Women in Nepal

Throughout the developing world, girls face hardships surrounding menstruation, often resulting in poor emotional wellbeing and missing school. Providing ways to keep girls in school will increase their educational and earning potentials, which will ultimately trickle down to improving the economic standing of nations in the next generation. Informed by the Transactional Model of Stress and Coping, this work evaluates the roles that cultural and school environments play in appraisals of menstruation as a major life stressor for adolescent females and the impacts of emotional stress on missing school. Using primary survey data from schools in Nepal, robust results are found to support the theoretical framework based on conditional mixed-process (CMP) estimation with fixed effects, utilizing multiple index building techniques. Strong cultural norms during menstruation appear to increase the probability of girls self-reporting emotional stress, while the presence of hygiene supporting infrastructure at schools reduces this outcome. Furthermore, there is strong support for the finding that the presence of emotional stress during menstruation increases the likelihood of not only missing school but also for an extended period of time. Our findings motivate increasing government policies to provide stronger hygiene infrastructure in schools to improve successful coping skills and attendance rates.

A qualitative study of adolescent girls' experiences of menarche and menstruation in rural Tamil Nadu, India

Background: In low- and middle-income countries, women and girls experience menstrual hygiene management-related health and social challenges such as urinary tract infections, social stigma, and school and workplace absenteeism.

Purpose: In this study, we sought to explore how adolescent girls in rural Thirumalaikodi, Tamil Nadu, India experience menarche and menstruation, how their experiences connect to the sociocultural context, and what strategies they use to manage menstruation. This study also informed the adaptation and development of a school-based water, sanitation, and hygiene intervention.

Methods: We conducted ten semi-structured qualitative interviews with adolescent girls in ninth standard from June-July 2018. Data were analysed using a thematic network approach.

Results: Findings revealed that menarche inaugurates biological transitions of puberty and cultural codes that shape gender norms. Gender norms in turn generate, maintain, and reproduce stigmatizing attitudes, beliefs, and practices that influenced the development of coping mechanisms at home and at school. Resulting adaptations to the intervention consisted of two activities (school lesson and an extracurricular activity) that address knowledge gaps and myths.

Conclusions: This study demonstrates the importance of qualitative research in unpacking adolescent girls’ experiences with menarche and menstruation. Study findings also show how formative research can contribute to the adaptation and development of a contextually and culturally-relevant water, sanitation, and hygiene intervention.

Menstrual hygiene practice among female adolescents and its association with knowledge in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Previous studies on menstrual hygiene practice were largely inconsistent and single national evidence is required. Thus, this study aimed to assess the pooled prevalence of menstrual hygiene and its association with knowledge about menstrual hygiene among female adolescents in Ethiopia.

METHODS

The study was designed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-2015 Guidelines). This systematic review included studies conducted on female adolescents in Ethiopia irrespective of their publication and study period until the end of July 1, 2020. The data extracted in the Microsoft Excel sheet format was exported into the STATA/SE14 version statistical software for further analysis. I2 test was used to test heterogeneity and publication bias was assessed by using Egger's weighted regression test.

RESULTS

Thirteen full-text articles including 6907 participants were included in this systematic review and meta-analysis. Using the random effect model, the pooled prevalence of poor menstrual hygiene practice was 48.98% [95% CI: (36.42, 61.53)]. Those female adolescents who had poor knowledge were 2.6 times more likely to have poor menstrual hygiene practice as compared to counterparts [AOR = 2.61, 95% CI: (1.45, 4.72)].

CONCLUSIONS

The prevalence of poor menstrual hygiene practice was high and knowledge regarding menstrual hygiene was significantly associated with poor menstrual hygiene practice. Information education communication and behavioral change communication at all levels of education should be the primary focus area of the government.

Prevalence and factors associated with menstruation-related school absenteeism among adolescent girls in rural northern Ghana

Background

Although menstruation is a normal physiological process that begins in girls during adolescence, it has the potential to negatively impact on the self-esteem and education of girls particularly those from low- and middle-income countries. We investigated the prevalence and factors associated with menstruation-related school absenteeism among adolescent girls in the Talensi district of rural northern Ghana.

Methods

We conducted a cross-sectional survey among 705 adolescent girls aged 12–19 years who had attained menarche. The sample size was estimated using Epi Info version 6 at 95% confidence interval and a 5% margin of error. A two-stage sampling technique was employed to recruit participants. We conducted univariate and multivariate logistic regression models to determine factors associated with menstruation-related school absenteeism which was defined as “being absent from school due to menstruation-related issues during the last menstruation.”

Results

The prevalence of menstruation-related school absenteeism was 27.5%. School absenteeism ranged from one to seven days during the menstrual period. Older adolescent girls, (aOR = 2.38, 95% CI 1.29–4.40), use of cloth as a sanitary material at the last menstruation, (aOR = 3.21, 95% CI 2.22–4.63), and cultural restriction, (aOR = 2.54, 95% CI 1.76–3.67) were associated with higher odds of menstruation-related school absenteeism. Meanwhile, girls from moderate income parent(s), [aOR = 0.57 95% CI 0.34–0.94] had lower odds of menstruation-related school absenteeism. Mother’s education and privacy in school were only significant at the univariate level.

Conclusions

The prevalence of menstruation-related school absenteeism highlights the need for interventions aimed at improving the availability of sanitary pads for girls, eliminating cultural restrictions associated with menstruation, and also improving parent(s) income level.

Are Nepal's water, sanitation and hygiene and menstrual hygiene policies and supporting documents inclusive of disability? A policy analysis

PURPOSE

This study assesses the inclusion of disability in Nepal's policy and guidance relevant to water, sanitation and hygiene (WASH), and menstrual hygiene management (MHM) in comparison to gender. We investigated both policy formulation and implementation, using the Kavrepalanchok district as a case study.

MATERIALS AND METHODS

We used the EquiFrame framework, adapted for disability and gender, and focusing on WASH and MHM. Ten Nepali policies and guidance documents were reviewed and scored for quality against the framework, which included 21 core concepts of human rights. We also interviewed key informants to consider the inclusion of disability in the implementation of MHM interventions. We applied stratified purpose sampling to 12 government officials and service providers working in Kathmandu and the Kavrepalanchock district; conducted in-depth interviews and analysed data thematically using Nvivo 11.

RESULTS

Disability was inadequately covered within the policy documents, and MHM policy commitments for disability were almost non-existent. Participation of people with disabilities in policy development was limited; within Kavrepalanchok, policy commitments were not implemented as intended and disability service providers were unable to allocate government resources. Inadequate data on disability and MHM resulted in limited professional understanding of the issues, as service providers had no training. A narrow WASH infrastructure approach to improving MHM for people with disabilities was prioritised. MHM interventions were delivered in schools; these failed to reach children with disabilities who are often out of school. Finally, there were indications that some caregivers seek sterilisation for people with disabilities who are unable to manage menstruation independently.

CONCLUSION

Though the Constitution of Nepal enshrines gender equality and disability inclusion, there are consistent gaps in attention to disability and MHM in policies and practice. These omit and exclude people with disabilities from MHM interventions. Investment is required to generate evidence on the MHM barriers faced by people with disabilities, which would then be drawn on to develop training on these issues for professionals to improve understanding. Subsequently, policy makers could include more concepts of human rights against disability in relevant policies and service providers could implement policy commitments as intended.

'I do what a woman should do': a grounded theory study of women's menstrual experiences at work in Mukono District, Uganda

Menstrual health has received increasing recognition as an essential issue for public health and gender equality. A growing body of research has elucidated adolescent girls’ menstrual needs and informed policy and practice responses. However, the experiences of adult women have received little attention, particularly in the workplace where many spend a significant proportion of their lives. To address this gap, we took a grounded theory approach to generate a nuanced understanding of working women’s menstrual experiences, and the impact of menstruation on their work and health in Mukono District, Uganda. In-depth interviews were undertaken with 35 women aged 18–49. This included 21 women working in markets, 7 teachers and 7 healthcare facility workers. Frequent collaborative analysis sessions throughout data collection, coding of interview transcripts, and generation of participant, workplace, and category memos facilitated analysis. Our core category and underlying theory, ‘being a responsible woman’, underpinned women’s experiences. ‘Being responsible’ meant keeping menstruation secret, and the body clean, at all times. These gendered expectations meant that any difficulty managing menses represented a failure of womanhood, met with disgust and shame. Difficulties with menstrual pain and heavy bleeding were excepted from these expectations and perceived as requiring compassion. Commercial menstrual products were expensive for most women, and many expressed concerns about the quality of cheaper brands. Workplace infrastructure, particularly unreliable water supply and cleanliness, was problematic for many women who resorted to travelling home or to other facilities to meet their needs. Menstruation presented a burden at work, causing some women to miss work and income, and many others to endure pain, discomfort and anxiety throughout their day. Our findings can inform norm and resource-focused responses to improve experiences and should provoke critical reflection on the discourse used in menstrual health advocacy in Uganda.

Menstrual hygiene practices among high school girls in urban areas in Northeastern Ethiopia: A neglected issue in water, sanitation, and hygiene research

Background

Poor menstrual hygiene practices influence school girls’ dignity, well-being and health, school-absenteeism, academic performance, and school dropout in developing countries. Despite this, menstrual hygienic practices are not well understood and have not received proper attention by school WASH programs. Therefore, this study examined the extent of good menstrual hygiene practices and associated factors among high school girls in Dessie City, Amhara Region, northeastern Ethiopia.

Methods

A school-based cross-sectional study was employed to examine 546 randomly selected high school students in Dessie City, northeastern Ethiopia. Pretested interviewer-administered questionnaires and a school observational checklist were used for data collection. EpiData Version 4.6 and the Statistical Package for the Social Sciences Version 25.0 were used for data entry and analysis, respectively. Bivariate and multivariable logistics regression analyses were employed to identify factors associated with good menstrual hygiene practices. During bivariable analysis, variables with P-values less than 0.25 were retained for multivariable analysis. In the multivariable analysis, variables with a P-value less than 0.05 were declared to be significantly associated with good menstrual hygiene practices.

Results

Of the respondents, 53.9% (95% CI [49.6, 58.2]) reported good menstrual hygiene practices. The following factors were found to be significantly associated with good menstrual hygiene practices: age range 16–19 years (AOR = 1.93, 95% CI: [1.22–3.06]); school grade level 10 (AOR = 1.90, 95% CI: [1.18–3.07]); maternal education (primary) (AOR = 3.72, 95% CI: [1.81–7.63]), maternal education (secondary) (AOR = 8.54, 95% CI: [4.18–17.44]), maternal education (college) (AOR = 6.78, 95% CI: [3.28–14.02]) respectively]; having regular menses [AOR = 1.85, 95% CI: (1.03–3.32); good knowledge regarding menstruation (AOR = 2.02, 95% CI: [1.32–3.09]); discussing menstrual hygiene with friends (AOR = 1.79, 95% CI: [1.12–2.86]), and obtaining money for pads from the family (AOR = 2.08, 95% CI: [1.15–3.78]).

Conclusion

We found that more than half of high school girls had good menstrual hygiene practices. Factors significantly associated with good menstrual hygiene practices include high school girls age 16–18 years, girls grade level 10, maternal education being completed primary, secondary and college level, having regular menses, good knowledge regarding menstruation, discussing menstrual hygiene with friends and obtaining money for pads from the family. Therefore, educating of high school student mothers about MHP should be a priority intervention area to eliminate the problem of menstrual hygiene among daughters. Furthermore, in order to improve the MHP among high school girls, further attention is needed to improving knowledge regarding menstruation among high school girls, encouraging high school girls’ families to support their daughters by buying sanitary pads and promoting discussions among friends about menstrual hygiene. Schools need to focus on making the school environment conducive to managing menstrual hygiene by increasing awareness of safe MHP and providing adequate water/sanitation facilities.

Perceptions of Frontline Workers, Female Health Workers, and School Teachers in Menstrual Hygiene Promotion among Adolescent Girls of Delhi, India: A Qualitative Study

Background:

Government schemes for the promotion of Menstrual Hygiene Management (MHM) among adolescent girls in India are underpinned by crucial implementation efforts from the frontline health workers, community health workers, and school teachers.

Aim:

The aim of the study is to identify the perspectives on menstrual health and hygiene management with regard to government schemes for sanitary pad distribution to adolescent girls among the frontline workers and the government school teachers located in urban resettlement colonies in Delhi.

Methods:

In-depth interviews were conducted with 30 accredited social health activisits, 30 Anganwadi Workers (AWW), and 30 auxiliary nurse midwives (ANMs) and five focus group discussions among 28 government school teachers from the middle, high, and secondary standard.

Results:

Most participants recognized the phenomenon of menstruation-related problems in adolescent girls and were aware of some of the common sociocultural, religious, and hygiene-related menstrual restrictions prevalent in their communities. All the participants believed that the pad distribution scheme was highly beneficial. However, in spite of inclusion of menstrual health promotion in the school curriculum, teachers often lacked self-efficacy in discussing challenges and health concerns related to MHM with their students.

Conclusions:

Despite their potential as community resources for adolescent girls, FHWs, ANMs, and school teachers often fail to impart crucial menstrual hygiene information and skills-building needed toward achieving effective, safe, and optimal MHM.

Kenyan school book knowledge for water, sanitation, hygiene and health education interventions: Disconnect, integration or opportunities?

BACKGROUND

Schools, depending on their access to and quality of water, sanitation and hygiene (WASH) and the implementation of healthy behaviours, can be critical for the control and spread of many infectious diseases, including COVID-19. Schools provide opportunities for pupils to learn about the importance of hygiene and WASH-related practice, and build healthy habits and skills, with beneficial medium- and long-term consequences particularly in low- and middle-income countries: reducing pupils' absenteeism due to diseases, promoting physical, mental and social health, and improving learning outcomes. WASH services alone are often not sufficient and need to be combined with educational programmes. As pupils disseminate their acquired health-promoting knowledge to their (extended) families, improved WASH provisions and education in schools have beneficial effects also on the community. International organisations frequently roll out interventions in schools to improve WASH services and, in some cases, train pupils and teachers on safe WASH behaviours. How such interventions relate to local school education on WASH, health promotion and disease prevention knowledge, whether and how such knowledge and school books are integrated into WASH education interventions in schools, are knowledge gaps we fill.

METHODS

We analyzed how Kenyan primary school science text book content supports WASH and health education by a book review including books used from class 1 through class 8, covering the age range from 6 to 13 years. We then conducted a rapid literature review of combined WASH interventions that included a behaviour change or educational component, and a rapid review of international policy guidance documents to contextualise the results and understand the relevance of books and school education for WASH interventions implemented by international organisations. We conducted a content analysis based on five identified thematic categories, including drinking water, sanitation, hygiene, environmental hygiene & health promotion and disease risks, and mapped over time the knowledge about WASH and disease prevention.

RESULTS

The books comprehensively address drinking water issues, including sources, quality, treatment, safe storage and water conservation; risks and transmission pathways of various waterborne (Cholera, Typhoid fever), water-based (Bilharzia), vector-related (Malaria) and other communicable diseases (Tuberculosis); and the importance of environmental hygiene and health promotion. The content is broadly in line with internationally recommended WASH topics and learning objectives. Gaps remain on personal hygiene and handwashing, including menstrual hygiene, sanitation education, and related health risks and disease exposures. The depth of content varies greatly over time and across the different classes. Such locally available education materials already used in schools were considered by none of the WASH education interventions in the considered intervention studies.

CONCLUSIONS

The thematic gaps/under-representations in books that we identified, namely sanitation, hygiene and menstrual hygiene education, are all high on the international WASH agenda, and need to be filled especially now, in the context of the current COVID-19 pandemic. Disconnects exist between school book knowledge and WASH education interventions, between policy and implementation, and between theory and practice, revealing missed opportunities for effective and sustainable behaviour change, and underlining the need for better integration. Considering existing local educational materials and knowledge may facilitate the buy-in and involvement of teachers and school managers in strengthening education and implementing improvements. We suggest opportunities for future research, behaviour change interventions and decision-making to improve WASH in schools.

Seeking menstrual products: a qualitative exploration of the unmet menstrual needs of individuals experiencing homelessness in New York City

Background

There has been increasing recognition that certain vulnerable populations in the United States of America struggle to meet their menstruation-related needs, including people experiencing homelessness. Media and policy attention on this subject has focused on the provision of free menstrual products to vulnerable populations, including a New York City legislative bill, which guarantees access to menstrual products for Department of Homeless Services shelter residents (Intros 1123-A).

Methods

This qualitative study explored the challenges people experiencing homelessness in New York City face in accessing menstrual products. Data collection was conducted from June to August 2019 and included: Semi-structured key informant interviews with staff from relevant government agencies and homeless service providers (n = 15), and semi-structured in-depth interviews with individuals with experience living on the street and in shelters (n = 22). Data were analysed using thematic analysis.

Results

Key themes that emerged included: (1) insufficient and inconsistent access to menstrual products; (2) systemic challenges to providing menstrual products; and (3) creative solutions to promote access to menstrual products. Both shelter- and street-living individuals reported significant barriers to accessing menstrual products. While both populations struggle, those in shelters were more likely to be able to purchase menstrual products or access free products at their shelter, while those living on the streets were more likely to have to resort to panhandling, theft, or using makeshift materials in place of menstrual products. Across both populations, individuals described barriers to accessing free products at shelters and service providers, primarily due to distribution systems that rely on gatekeepers to provide a few pads or tampons at a time, sometimes of inadequate quality and only upon request. Shelters and service providers also described challenges providing these products, including inconsistent supply.

Conclusion

These findings highlight the critical importance of expanding and improving initiatives seeking to provide access to menstrual products for vulnerable populations. Despite policy level efforts to support menstrual product access, individuals experiencing homelessness in New York City, whether living in shelters or on the street, are often not able to access the menstrual products that they need to manage their monthly menstrual flow.

'Making of a Strong Woman': a constructivist grounded theory of the experiences of young women around menarche in Papua New Guinea

Background

Menarche, the first menstruation, is a significant developmental milestone for females. In Papua New Guinea (PNG), menarche is an important socio-cultural event marking transition from girlhood to womanhood. PNG is a culturally and linguistically diverse nation, with wide-ranging socio-cultural beliefs and practices around menarche. This study explored post-menarcheal women’s understanding about body changes and menarche, preparation for menarche, and related cultural beliefs and practices at menarche.

Methods

A constructivist grounded theory study was conducted with 98 female participants who originated from four PNG provinces: Eastern Highlands Province; East Sepik Province; Milne Bay Province; and National Capital District. The participants were purposively and theoretically sampled, with 10 focus group discussions and six individual interviews conducted using a semi-structured interview guide for data collection. Focus group discussions and interviews were voice recorded and transcribed. Data were inductively analyzed using initial, intermediate and advanced coding, memos and constant comparative methods to develop a theoretical model that explains women’s experiences at menarche. Interview participants also identified actions required to improve future experiences of girls at menarche in PNG.

Results

A grounded theory comprising the core category of ‘Making of a Strong Woman’ and four interconnecting categories (‘Having Baby Sense’; ‘Beginning of Learning’; ‘Intensifying Learning’; and ‘Achieving Womanhood’) was constructed. ‘Urban’ and ‘Rural’ represented both geographical and socio-cultural intervening conditions that influence the experiences of girls at menarche. Experiences of young women at menarche were rooted in socio-cultural beliefs and practices. Women reported being physically and emotionally distressed and unprepared at onset of menarche. Mothers were considered important support, however, their ability to adequately prepare their daughters is limited by shame and secrecy. Despite these limitations, cultural practices at menarche provided an opportunity for intensive preparation of girls for womanhood.

Conclusion

Limited pre-menarcheal awareness of the meaning of body changes and menarche of girls was linked to culture of shame and secrecy about open discussion on sexuality. However, traditional cultural practices provide an opportunity for collective support and focused learning for girls. Findings from this study have implications for broader sexual and reproductive health education programs in addressing menstrual health and hygiene in PNG, and the Pacific.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01229-0.

Exploring young women's menstruation-related challenges in Uttar Pradesh, India, using the socio-ecological framework

Menstruation frequently poses psychological, social, and health challenges for young women living in low- and middle-income countries. In countries such as India, where menstruation is stigmatised, it can be particularly difficult. This paper examines challenges related to menstruation for young women living in slums in Lucknow, Uttar Pradesh, India. The research was informed by the socio-ecological model. Life course interviews were conducted with 70 young women ages 15–24 living in the slums of Lucknow. Thematic analysis was used to identify salient themes regarding individual, social, and systemic challenges related to menstruation. On the individual level, young women lack knowledge about menstruation. In the social sphere, young women experience stigma around menstruation, lack opportunities to discuss menstruation, and experience limitations around mobility and other activities during menstruation. At the institutional level, for example in school, there are few resources to support menstruating young women as toilets are dirty and doors are broken. Therefore, menstruating adolescents and young women in Lucknow, Uttar Pradesh, India, face an array of challenges at multiple levels. These findings suggest that multi-level interventions are warranted to create a supportive context for menstruation.

Qualitative study exploring the barriers to menstrual hygiene management faced by adolescents and young people with a disability, and their carers in the Kavrepalanchok district, Nepal

Background

Menstrual hygiene management (MHM) is a recognised public health, social and educational issue, which must be achieved to allow the realisation of human rights. People with disabilities are likely to experience layers of discrimination when they are menstruating, but little evidence exists.

Methods

The study aims to investigate barriers to MHM that people with disabilities and their carers face in the Kavrepalanchok, Nepal, using qualitative methods. Twenty people with disabilities, aged 15–24, who menstruate and experience ‘a lot of difficulty’ or more across one or more of the Washington Group functional domains were included, as well as 13 carers who provide menstrual support to these individuals. Purposeful sampling was applied to select participants. Different approaches were used to investigating barriers to MHM and triangulate data: in-depth interviews, observation, PhotoVoice and ranking. We analysed data thematically, using Nvivo 11.

Results

Barriers to MHM experienced by people with disabilities differ according to the impairment. Inaccessible WASH facilities were a major challenge for people with mobility, self-care and visual impairments. People with intellectual impairments had difficulty accessing MHM information and their carers despaired when they showed their menstrual blood to others, which could result in abuse. No support mechanisms existed for carers for MHM, and they felt overwhelmed and isolated. Menstrual discomfort was a major challenge; these were managed with home remedies, or not at all. Most participants followed menstrual restrictions, which were widespread and expected; many feared they would be cursed if they did not. As disability is often viewed as a curse, this demonstrates the layers of discrimination faced.

Conclusion

Issues related to MHM for people with disabilities is more complex than for others in the population due to the additional disability discrimination and impairment experienced. Research exploring these issues must be conducted in different settings, and MHM interventions, tailored for impairment type and carers requirements,should be developed. Attention to, and resourcing for disability inclusive MHM must be prioritised to ensure ‘no one is left behind’.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10439-y.

Menstrual hygiene management practices and associated health outcomes among school-going adolescents in rural Gambia

Inadequate menstrual hygiene management (MHM) practices have been associated with adverse health outcomes. This study aimed to describe MHM practices among schoolgirls from rural Gambia and assess risk factors associated with urogenital infections and depressive symptoms. A cross-sectional study was conducted among adolescent schoolgirls in thirteen schools in rural Gambia. A questionnaire was used to collect information on socio-demographics, MHM practices and clinical symptoms of reproductive and urinary tract infections (UTIs). A modified Beck Depression Inventory-II was used to screen for depressive symptoms. Mid-stream urine samples were collected to assess for UTIs. Modified Poisson regression analysis was used to determine risk factors for symptoms of urogenital infections and depression among adolescent girls. Three hundred and fifty-eight girls were recruited. Although, 63% of the girls attended schools providing free disposable pads, reusable cloths/towels were the commonest absorbent materials used. Heavy menstrual bleeding was associated with depressive symptoms (adjusted prevalence ratio, aPR 1.4 [95% CI 1.0, 1.9]), while extreme menstrual pain (aPR 1.3 [95% CI 1.2, 1,4]), accessing sanitary pads in school (aPR 1.4 [95% CI 1.2, 1.5]) and less access to functional water source at school (aPR 1.4 [95% CI 1.3, 1.6]) were associated with UTI symptoms. Conversely, privacy in school toilets (aPR 0.6 [95% CI 0.5, 0.7]) was protective for UTI symptoms. Heavy menstrual bleeding (aPR 1.4 [95% CI 1.1, 2.0]) and taking <30 minutes to collect water at home were associated with RTI symptoms (aPR 1.2 [95% CI 1.0, 1.5]) while availability of soap in school toilets (aPR 0.6 [95% CI 0.5, 0.8] was protective for RTI symptoms. Interventions to ensure that schoolgirls have access to private sanitation facilities with water and soap both at school and at home could reduce UTI and RTI symptoms. More attention is also needed to support girls with heavy menstrual bleeding and pain symptoms.

Menstrual Hygiene Practices of Adolescent Girls in Rural Maharashtra

Menstrual practices of adolescent girls in rural parts of India are greatly influenced by taboos and socio-cultural beliefs. In this study, the menstrual hygiene practices and beliefs of 122 adolescent girls between the ages of 13 and 19 years from rural Maharashtra were evaluated by personal interview and questionnaires. None of the girls had the right scientific knowledge about menstruation and were isolated during menstruation. They used cloth or home-made sanitary pads and were at risk of infections. There is a dire need for knowledge dissemination among school children and their families, increased awareness of menstrual hygiene and access to the requisite sanitary products in rural areas.

Seeking synergies: understanding the evidence that links menstrual health and sexual and reproductive health and rights

Global efforts to improve menstrual health and sexual and reproductive health and rights (SRHR) are fundamentally intertwined and share similar goals for improving health and well-being and increasing gender equality. Historically, however, the two fields have operated independently and missed opportunities to build upon their biological and sociocultural linkages. Biological touchpoints connecting the two fields include genital tract infections, menstrual disorders, contraception, and menopause. From a sociocultural perspective, intersections occur in relation to the experience of puberty and menarche, gender norms and equity, education, gender-based violence, and transactional sex. We describe evidence linking menstrual health and SRHR and offer recommendations for integration that could strengthen the impact of both fields.

Hearing the unheard voice-puberty experiences of young Pakistani men: A qualitative study

INTRODUCTION

Puberty experiences of male adolescents can have significant impacts on physical and psychological health outcomes. This qualitative study explored the puberty experiences of young males in Pakistan, as there are limited accounts of what shapes these puberty experiences, especially for adolescent males living in a restrictive culture.

METHODS

Twenty-two young Pakistani men (aged 18-21 years) from two urban sites in Karachi participated in individual face-to-face (n=19) and Skype (n=3) interviews. Qualitative thematic analysis was conducted using an inductive approach to identity and examine the patterns emerging from the data.

RESULTS

Participants described puberty as a challenging phase for which they were unprepared with a combination of various socio-cultural factors exposing them to negative impacts. As a result, young men expressed feelings of anxiety, embarrassment and isolation. Societal and gender norms around masculinity, sexuality and the roles and responsibilities of young men had a significant impact on how participants experienced puberty. While negative reactions towards puberty were dominant, participants described adopting coping strategies (e.g. social support) to help them deal with negative experiences.

CONCLUSIONS

Findings highlight the significance of culturally appropriate puberty education and various facilitating factors that may improve the puberty experiences for future young men. While extending current literature, this study also identifies key factors that could inform the development of health promotion programmes, which may aid adolescent males' puberty transition and positively influence their long-term health, well-being and identity.

The state of adolescent menstrual health in low- and middle-income countries and suggestions for future action and research

In recognition of the opportunity created by the increasing attention to menstrual health at global, regional, and national levels, the World Health Organization’s Department of Sexual and Reproductive Health and Research and the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction convened a global research collaborative meeting on menstrual health in adolescents in August 2018. Experts considered nine domains of menstrual health (awareness and understanding; stigma, norms, and socio-cultural practices; menstrual products; water and sanitation; disposal; empathy and support; clinical care; integration with other programmes; and financing) and answered the following five questions: (1) What is the current situation? (2) What are the factors contributing to this situation? (3) What should the status of this domain of adolescent menstrual health be in 10 years? (4) What actions are needed to achieve these goals? (5) What research is needed to achieve these goals? This commentary summarizes the consensus reached in relation to these questions during the expert consultation. In doing so, it describes the state of adolescent menstrual health in low- and middle-income countries and sets out suggestions for action and research that could contribute to meeting the holistic menstrual health needs of adolescent girls and others who menstruate worldwide.

Menstrual hygiene management in schools: midway progress update on the "MHM in Ten" 2014-2024 global agenda

Progress has been made in recent years to bring attention to the challenges faced by school-aged girls around managing menstruation in educational settings that lack adequate physical environments and social support in low- and middle-income countries. To enable more synergistic and sustained progress on addressing menstruation-related needs while in school, an effort was undertaken in 2014 to map out a vision, priorities, and a ten-year agenda for transforming girls' experiences, referred to as Menstrual Hygiene Management in Ten (MHM in Ten). The overarching vision is that girls have the information, support, and enabling school environment for managing menstruation with dignity, safety and comfort by 2024. This requires improved research evidence and translation for impactful national level policies. As 2019 marked the midway point, we assessed progress made on the five key priorities, and remaining work to be done, through global outreach to the growing network of academics, non-governmental organizations, advocates, social entrepreneurs, United Nations agencies, donors, and national governments. This paper delineates the key insights to inform and support the growing MHM commitment globally to maximize progress to reach our vision by 2024. Corresponding to the five priorities, we found that (priority 1) the evidence base for MHM in schools has strengthened considerably, (priority 2) global guidelines for MHM in schools have yet to be created, and (priority 3) numerous evidence-based advocacy platforms have emerged to support MHM efforts. We also identified (priority 4) a growing engagement, responsibility, and ownership of MHM in schools among governments globally, and that although MHM is beginning to be integrated into country-level education systems (priority 5), resources are lacking. Overall, progress is being made against identified priorities. We provide recommendations for advancing the MHM in Ten agenda. This includes continued building of the evidence, and expanding the number of countries with national level policies and the requisite funding and capacity to truly transform schools for all students and teachers who menstruate.

How addressing menstrual health and hygiene may enable progress across the Sustainable Development Goals

There is increasing global attention to the importance of menstrual health and hygiene (MHH) for the lives of those who menstruate and gender equality. Yet, the global development community, which focuses on issues ranging from gender to climate change to health, is overdue to draw attention to how addressing MHH may enable progress in attaining the Sustainable Development Goals (SDGs). To address this gap, we undertook a collective exercise to hypothesize the linkages between MHH and the 17 SDGs, and to identify how MHH contributes to priority outcome measures within key sectoral areas of relevance to menstruating girls in low- and middle-income countries. These areas included Education, Gender, Health (Sexual and Reproductive Health; Psychosocial Wellbeing), and Water, Sanitation and Hygiene (WASH). These efforts were undertaken from February - March 2019 by global monitoring experts, together with select representatives from research institutions, non-governmental organizations, and governments (n = 26 measures task force members). Through this paper we highlight the findings of our activities. First, we outline the existing or potential linkages between MHH and all of the SDGs. Second, we report the identified priority outcomes related to MHH for key sectors to monitor. By identifying the potential contribution of MHH towards achieving the SDGs and highlighting the ways in which MHH can be monitored within these goals, we aim to advance recognition of the fundamental role of MHH in the development efforts of countries around the world.

Acceptability of menstrual products interventions for menstrual hygiene management among women and girls in Malawi

Background

A key challenge for menstruating girls and women in low-resource countries is the inadequate and unreliable supply of menstrual products. Although development partners are implementing menstrual product interventions to address this challenge in Malawi, there is a paucity of information on the distribution of menstrual products and the acceptability of these interventions among users.

Methods

We conducted in-depth interviews with girls (n = 20) and women (n = 26) and 4 focus group discussions (FGDs) with women (n = 35) and 7 FGDs with girls (n = 60) to explore the acceptability of menstrual products interventions in 8 districts. Teachers (n = 12), community leaders (n = 6), community health workers (n = 8) and service providers (n = 9) were also interviewed to explore implementation issues and their views regarding the effect of menstrual products interventions on girls and women. Data were analyzed using content analysis.

Results

Common menstrual products being promoted include locally made reusable pads, commercially made disposable pads and menstrual cups. Overall, adult women preferred reusable pads and young girls preferred disposable pads. Reported benefits of using any type of material distributed included enhanced cleanliness and reduced school absenteeism for girls. While community leaders and teachers applauded the use of disposable menstrual products they expressed concern that they are not affordable for an average Malawian and bemoaned the indiscriminate disposal of used disposable pads. Women and girls highlighted their lack of facilities to effectively wash and dry reusable pads. Service providers bemoaned poor coordination and the lack of national standards to regulate the quality of menstrual products distributed at national level. Improved inclusion of males and health workers could enhance the sustainability of programmes.

Conclusion

While the available menstrual products interventions are acceptable among participants, we note several challenges including affordability, poor disposal methods, lack of attention on sanitation facilities and the lack of standard protocols to regulate the quality of menstrual products. Recommendations to address these issues are reported.

Menstrual product choice and uptake among young women in Zimbabwe: a pilot study

Background

Menstrual health and hygiene (MHH) is a human rights issue; yet, it remains a challenge for many, especially in low- and middle-income countries (LMICs). MHH includes the socio-political, psychosocial, and environmental factors that impact women’s menstrual experiences. High proportions of girls and women in LMICs have inadequate MHH due to limited access to menstrual knowledge, products, and stigma reinforcing harmful myths and taboos. The aim of this pilot was to inform the design of an MHH sub-study and the implementation and scale-up of an MHH intervention incorporated into a community-based cluster-randomized trial of integrated sexual and reproductive health (SRH) services for youth in Zimbabwe. The objectives were to investigate (1) uptake of a novel MHH intervention, (2) menstrual product preference, and (3) the factors that informed uptake and product choice among young women.

Methods

Female participants aged 16–24 years old attending the community-based SRH services between April and July 2019 were offered the MHH intervention, which included either a menstrual cup or reusable pads, analgesia, and MHH education. Descriptive statistics were used to quantitatively assess uptake and product choice. Focus group discussions and in-depth interviews with participants and the intervention team were used to investigate the factors that influenced uptake and product choice.

Results

Of the 1732 eligible participants, 1414 (81.6%) took up the MHH intervention at first visit. Uptake differed by age group with 84.6% of younger women (16–19 years old) compared to 79.0% of older women (20–24 years old) taking up the intervention. There was higher uptake of reusable pads (88.0%) than menstrual cups (12.0%). Qualitative data highlighted that internal factors, such as intervention delivery, influenced uptake. Participants noted the importance of access to free menstrual products, analgesics, and MHH education in a youth-friendly environment. External factors such as sociocultural factors informed product choice. Barriers to cup uptake included fears that the cup would compromise young women’s virginity.

Conclusions

Pilot findings were used to improve the MHH intervention design and implementation as follows: (1) cup ambassadors to improve cup promotion, sensitization, and uptake; (2) use of smaller softer cups; and (3) education for community members including caregivers and partners.

Trial registration

Registry: Clinicaltrials.gov

Registration Number: NCT03719521

Registration Date: 25 October 2018

Menstruation Experiences of Middle and High School Students in the Midwest: A Pilot Study

The purpose of this pilot study was to expand understanding of the experience of menstruation for girls in the United States and its impact in the school setting. A qualitative approach was used to gather data from focus group interviews. Descriptive content analysis was used to categorize the range and types of menstruation experiences described by 12 participants aged 12-16 years. Findings revealed four main themes: (1) learning about menstruation, (2) experiencing menstruation, (3) managing menstruation, and (4) social norms and meaning of menstruation. Participants described multiple challenges faced learning about and experiencing menstruation, especially in the school setting. Participants described the limited understanding of menstruation experiences and confusion about the use of menstrual hygiene products. Challenges experienced at school included not having adequate access to menstrual hygiene products, limited time for changing products, fear of leaking menstrual blood, and impacts on school attendance. School nurses are well-positioned to contribute to creating school environments that are supportive of menstruation.

The Menstrual Practices Questionnaire (MPQ): development, elaboration, and implications for future research

High-quality evidence is needed to inform policies and programmes aiming to improve menstrual health. Quantitative studies must address the many evidence gaps in this field, and practitioners have increased monitoring and evaluation efforts to track their progress. A significant barrier to improving the rigor of this work is the lack of comprehensive and comparable measures to capture core concepts. The Menstrual Practices Questionnaire (MPQ) is a new tool to support comprehensive and standardised assessment of the activities undertaken in order to collect, contain, and remove menstrual blood from the body in self-report surveys. The questionnaire is freely available online for download and can be adapted for use across contexts and age groups. In this article, we describe the purpose of the MPQ as a best-practice tool to align the description of menstrual practices and provide a foundation for further question refinement. We outline the development of the tool using systematic review of qualitative studies of menstrual experiences, audit of measures used in the study of menstrual health and hygiene, survey of experts, insights from past research, and examples from piloted questions in a survey of adolescent girls in Soroti, Uganda. We describe the identification of menstrual practices as a priority for measurement, coverage of practices included in the MPQ, and justify the inclusion of location-specific questions. For each section of the questionnaire, we outline key reasons for the inclusion of practice items alongside elaboration for users to help inform item selection. Finally, we outline priorities for future research to refine the assessment and reporting of menstrual practices, including the identification of minimum reporting requirements for population characteristics to facilitate comparison across studies, testing the extent to which experiences during the most recent menstrual period reflect those over longer time periods, and further exploration of biases in self-report.

The Prevalence and Educational Impact of Pelvic and Menstrual Pain in Australia: A National Online Survey of 4202 Young Women Aged 13-25 Years

STUDY OBJECTIVE

To explore the prevalence and impact of dysmenorrhea, pelvic pain and menstrual symptoms on young women at school or in tertiary education.

DESIGN AND SETTING

Cross-sectional online survey in Australia.

PARTICIPANTS

A total of 4202 adolescent and young women (13-25 years of age; median age 17 years), having reached menarche, living in Australia and currently attending school (n = 2421) or tertiary education (n = 1781).

INTERVENTIONS

Online survey hosted by Qualtrics between November 2017 to January 2018. Data were collected on sociodemographic data, menstrual cycle characteristics, dysmenorrhea, pelvic pain, and educational and social impact.

MAIN OUTCOME MEASURES

Information on menstrual and pelvic pain impact, academic absenteeism and presenteeism, impact on non-academic activities and interactions with teaching staff.

RESULTS AND CONCLUSIONS

Dysmenorrhea was reported by 92% of respondents. Dysmenorrhea was moderate (median 6.0 on a 0-10 numeric rating scale) and pain severity stayed relatively constant with age [r_s(3804) = 0.012, P = .477]. Noncyclical pelvic pain at least once a month was reported by 55%. Both absenteeism and presenteeism related to menstruation were common. Just under half of women reported missing at least one class/lecture in the previous three menstrual cycles. The majority of young women at school (77%) and in tertiary education (70%) reported problems with classroom concentration during menstruation. Higher menstrual pain scores were strongly correlated with increased absenteeism and reduced classroom performance at both school and in tertiary education. Despite the negative impact on academic performance the majority of young women at school (60%) or tertiary education (83%) would not speak to teaching staff about menstruation.

A Qualitative Study Exploring Menstruation Experiences and Practices among Adolescent Girls Living in the Nakivale Refugee Settlement, Uganda

(1) Background: Girls in low- and lower-middle income countries face challenges in menstrual health management (MHM), which impact their health and schooling. This might be exacerbated by refugee conditions. This study aimed at describing menstruation practices and experiences of adolescent girls in Nakivale refugee settlement in Southwestern Uganda. (2) Methods: We conducted a qualitative study from March to May 2018 and we intentionally selected participants to broadly represent different age groups and countries of origin. We conducted 28 semistructured interviews and two focus group discussions. Data were transcribed and translated into English. Analysis included data familiarization, manual coding, generation and refining of themes. (3) Results: Main findings included: (a) challenging social context with negative experiences during migration, family separation and scarcity of resources for livelihood within the settlement; (b) unfavorable menstruation experiences, including unpreparedness for menarche and lack of knowledge, limitations in activity and leisure, pain, school absenteeism and psychosocial effects; (c) menstrual practices, including use of unsuitable alternatives for MHM and poor health-seeking behavior. (4) Conclusions: A multipronged approach to MHM management is crucial, including comprehensive sexual education, enhancement of parent–adolescent communication, health sector partnership and support from NGOs to meet the tailored needs of adolescent girls.

Students' Menstrual Hygiene Needs and School Attendance in an Urban St. Louis, Missouri, District

PURPOSE

To assess the menstrual hygiene needs and related school absences among female students in an urban St. Louis, MO district.

METHODS

Students (n = 58) completed a self-administered survey during registration and orientation before the 2019-2020 school year.

RESULTS

Nearly half (48.3%) needed period products at least once last school year but did not have money to buy them. The majority (62.1%) accessed period products at school last year. Seventeen percent missed at least one day at school because of an inadequate supply of period products, including significantly more ninth graders than 10th-12th graders (33.3% vs. 6.1%, respectively, p < .01).

CONCLUSIONS

Students reported a substantial need for menstrual hygiene products but also frequent utilization of school resources to access products. Given that incoming ninth graders reported more absences related to an inadequate supply of products, the district may need to focus more attention on this issue in the junior high school and younger grades.

The Extent to Which Menstruation-Related Issues Are Included in Graduate-Level Public Health Curricula

Objectives: Menstruation is increasingly recognized as an issue in domestic and global public health. Public health graduates of U.S. schools of public health must have adequate competencies to address menstruation and its implications for health and well-being in their future endeavors in research, practice and policy. This study sought to understand the extent to which U.S. schools currently integrate menstruation-related content (menstrual health, menstrual hygiene, etc.) and related competencies into their curricula.

Methods: We reviewed the course directories of the top 20 US schools of public health as ranked in 2018. Courses were selected based on inclusion of menstruation and adolescent health-related search terms. Syllabi were subsequently obtained and analyzed for inclusion of specific menstruation-related terms. Syllabi including these terms were further analyzed to determine the level of inclusion of menstruation-related topics in relation to public health competencies, and the area of specialization.

Results: Of an estimated 5,000 courses assessed, 28 included menstruation-related topics. Most frequently, this inclusion was minimal (e.g., a single reading or assignment), and was limited in scope. Content was typically found within global health, environmental health, and maternal and child health.

Conclusions: Given growing attention to menstruation domestically and globally, and the limited current inclusion of this issue in US schools of public health curricula, graduates may not be receiving adequate training on a critically important topic of relevance within population health. Schools should consider reviewing their curricula to assess whether there are opportunities to integrate menstruation-related content in relation to the relevant public health competencies.

The Sustainability and Scalability of Private Sector Sanitation Delivery in Urban Informal Settlement Schools: A Mixed Methods Follow Up of a Randomized Trial in Nairobi, Kenya

There are considerable challenges to achieving the Sustainable Development Goals’ target of universal access to basic sanitation in schools. Schools require safe, clean, and sex-segregated facilities for a large number of students. Robust and affordable solutions are needed to address the economic, spatial, social, institutional, and political factors which contribute to poor sanitary conditions in informal settlements. In 2015, we undertook a randomized controlled trial to assess the feasibility of private sector sanitation delivery (PSSD) in 20 primary schools, in informal settlements of Nairobi, Kenya. Our preliminary evaluation after one year of service delivery suggested that PSSD of urine-diverting dry latrines with routine waste collection and maintenance provided a feasible, lower-cost alternative to the government standard delivery (GSD) of cistern-flush toilets or ventilated improved pit latrines. We conducted a mixed-methods follow-up study to assess sanitation delivery over 3–4 years and investigate prevailing drivers and barriers that may influence the scalability of PSSD. The conditions of newly constructed and rehabilitated GSD facilities diminished quickly, reverting to the conditions of existing facilities, indicating lower sustainability compared to sanitation delivered from the private sector. Barriers in financial aspects related to the ongoing implementation of PSSD emerged, particularly among public schools, and few were able to pay for continued service. Our study demonstrates that the engagement of the private sector may lead to improvements in affordable, safely managed sanitation for schools and their students. Yet, to reach a sustained scale, additional guidance is needed on how to develop these partnerships, streamline procurement and contracting processes, and incorporate appropriate financing mechanisms.

Touch for Health: Use of Pavlovian Processes with Physical Touch as a Means to Improve Menstrual Hygiene Management Initiatives, Measured by Willingness to Pay

BACKGROUND

To combat the lack of proper facilities and menstrual health knowledge in developing countries, many WASH (Water, Hygiene, and Sanitation) initiatives are including menstrual hygiene management (MHM) components. However, evidence shows that prior efforts have not been ultimately successful in inducing relevant behavior changes, due in part to cultural constraints and unidimensional interventions. As such, MHM research may need to include consideration of new theories/approaches. Evidence is growing of the role that physical presence/proximity and ability to touch objects has on incentives for consumers to purchase goods, captured through willingness to pay (WTP) figures. Such findings can be partially explained by Pavlovian processes.

OBJECTIVE

This study sought to provide field-work validation of such findings of the role of Pavlovian processes and endowment effect on WTP figures for a female hygiene kit, reflecting motivation to adopt better hygiene behaviors.

METHODS

This study used primary survey data collected from females in two upper-level schools in southwestern Nepal (n = 169). When presented in conjunction with a hygiene education session, one group of females was allowed physical interaction with a female hygiene kit, while another was not, before being surveyed on their WTP for the kit. Both non-parametric and parametric statistical analyses were performed to assess the impact of this ability to touch the kits on WTP figures.

RESULTS

Results show a statistically significant difference between the WTP figures of those females allowed interaction with the kits prior to being surveyed and those who did not. This confirms the positive impact of physical presence/touch on motivations to use/acquire hygiene-related tools.

CONCLUSIONS

Such findings reveal how, through application of the theory of Pavlovian processes, future (menstrual) health education efforts could harness the human instinct to consume, remember, and use those objects presented in physical form, and include personal contact and demonstrations of better health practices in future MHM and WASH education initiatives. Such an approach may allow protocols and interventions to have more success, and dissemination of healthier behaviors and knowledge to be more prominent.

Acceptability and safety of the menstrual cup: A systematic review of the literature

Objectives

To conduct a systematic review of the literature and assess the acceptability and safety of the menstrual cup as a feminine hygiene product.

Materials and methods

A search was conducted in the PubMed, Cochrane Library, Scopus, PopLine and Google Scholar databases for publications be- tween 1966 and July 2019. The terms ("Menstrual" AND "Cup") OR ("Copa" AND "Menstrual") were used. Quantitative, qualitative and mixed studies were included, as well as case series and case reports published in English and Spanish assessing the menstrual cup in women in childbearing age. The studies were selected and the data extracted by two reviewers working independently. Acceptability and safety were assessed as the primary result. The summary of the information is presented in narrative form.

Results

Overall, 737 titles were found for initial review and, in the end, 38 studies were included in this work. The acceptability of the menstrual cup ranges between 35 % and 90 %. Between 10 to 45 % of women found it difficult to use. It was described as more comfortable when compared to tampons and pads. Continued use of the cup ranges between 48 and 94 %. In terms of safety, there was one case of toxic shock syndrome, one case of mechanical entrapment, and another case of allergy; and a higher risk of expulsion was found among intrauterine device users.

Conclusion

The menstrual cup appears to be a comfortable, safe and efficient option for menstrual hygiene. Further randomized controlled studies and long-term prospective cohort studies are needed in order to determine the risk of complications due to excess bacterial colonization or retrograde menstruation.

Unmet Needs and Experiences of Adolescent Girls with Heavy Menstrual Bleeding and Dysmenorrhea: A Qualitative Study

STUDY OBJECTIVE

To identify and examine the key areas of need and explore the experiences of adolescent girls with heavy menstrual bleeding and/or dysmenorrhea.

DESIGN AND SETTING

Qualitative interview study using semi-structured interviews. Gynaecology outpatient clinic at The Royal Children's Hospital, Melbourne, Australia.

PARTICIPANTS

Adolescent girls (12-18 years; mean age, 14.8 ± 1.5 years) presenting with heavy menstrual bleeding and/or dysmenorrhea at the clinic (N = 30).

INTERVENTIONS AND MAIN OUTCOME MEASURES

In-depth semi-structured interviews were conducted between May and August 2018. Interview data were thematically analyzed using a grounded theory approach. Themes covered experiences and unmet needs of adolescent girls with heavy menstrual bleeding and/or dysmenorrhea.

RESULTS

A total of 12 themes were identified, and covered the impact of symptoms, experiences, and/or unmet needs of these adolescents. Key themes highlighting experiences and unmet needs related to (1) coordination of healthcare, (2) day-to-day coping, (3) school, and (4) information surrounding menstrual issues. From these themes, 7 unmet needs emerged and were organized under 3 key areas of need: (1) treatment, management, and care, (2) improvements in the school environment, and (3) menstrual health as a gendered issue.

CONCLUSION

Menstrual concerns can have a profound physical and psychosocial impact on adolescents. Effective school-based menstrual education programs may be key in reducing stigma, fear, and shame surrounding menstruation, in teaching positive management strategies and in encouraging adolescents to seek help for their menstrual concerns.

Assessing Women's Menstruation Concerns and Experiences in Rural India: Development and Validation of a Menstrual Insecurity Measure

Qualitative research has documented menstruator's challenges, particularly in water and sanitation poor environments, but quantitative assessment is limited. We created and validated a culturally-grounded measure of Menstrual Insecurity to assess women's menstruation-related concerns and negative experiences. With cross-sectional data from 878 menstruating women in rural Odisha, India, we carried out Exploratory (EFA) and Confirmatory (CFA) Factor Analyses to reduce a 40-item pool and identify and confirm the scale factor structure. A 19-item, five factor model best fit the data (EFA: root mean square error of approximation (RMSEA) = 0.027; comparative fit index (CFI) = 0.994; Tucker-Lewis index (TLI) = 0.989; CFA: RMSEA = 0.058; CFI = 0.937; TLI = 0.925). Sub-scales included: Management, Menstrual Cycle Concerns, Symptoms, Restrictions, and Menstruation-Related Bodily Concerns. Those without access to a functional latrine, enclosed bathing space, water source within their compound, or who used reusable cloth had significantly higher overall Menstrual Insecurity scores (greater insecurity) than those with these facilities or using disposable pads. Post-hoc exploratory analysis found that women reporting experiencing tension at menstrual onset or difficulty doing work had significantly higher Menstrual Insecurity scores. This validated tool is useful for measuring Menstrual Insecurity, assessing health inequities and correlates of Menstrual Insecurity, and informing program design.

Menstrual Cup Use Intention and the Moderating Effects of Sexual Orientation and Gender Characteristic Among Female University Students in Taiwan: A Theory-Driven Exploration

Menstruation plays an important role in women's lives as it accompanies about half of their living years. However, little is known about women's intention to use menstrual cups, a relatively new menstrual product in Taiwan. Therefore, this study aimed to systematically explore the factors associated with menstrual cup use (MCU) intention among female university students in Taiwan, using the Theory of Planned Behavior (TPB). Data from 1245 female university students in Taiwan were collected using an anonymous online survey based on the TPB from December 2016 through January 2017. Multivariate logistic regression found the following TPB factors associated with high MCU intention: positive attitudes about positive (adjusted odds ratio [AOR] = 4.35, 95% confidence interval [CI] 2.87-6.60) and negative (AOR = 2.32, 95% CI 1.54-3.49) outcomes of MCU, supportive subjective norms (AOR = 1.88, 95% CI 1.33-2.65), and high perceived control over MCU under constraining conditions (AOR = 3.40, 95% CI 2.24-5.16). Sexual orientation and gender characteristic were also found to have moderating effects. For example, bisexual college girls with masculine characteristic who perceived high control over MCU under constraining conditions had elevated MCU intention (AOR = 2.45, 95% CI 1.04-5.76). Therefore, to improve women's menstrual health, future health education could focus more on introducing the different features of various menstrual products, including menstrual cups, and help users make informed decisions about which menstrual products could best suit their needs.

Connecting Female Genital Schistosomiasis and Menstrual Hygiene Initiatives

Effective future control of female genital schistosomiasis (FGS) requires an integrated and multisectoral approach, bringing together HIV, sexual and reproductive health, and reproductive rights sectors. In this article, an underappreciated but important connection between FGS and menstrual hygiene initiatives in Africa is highlighted.

Menstrual health management and schooling experience amongst female learners in Gauteng, South Africa: a mixed method study

Background

There has been increased attention to the menstrual health management (MHM) needs of girls and young women in Eastern and Southern Africa, relating to dignity, and to the potential link between the lack of access to sanitary products and school absenteeism. In the South Africa, there is inadequate evidence to guide appropriate national responses. This study explored the extent of access to modern sanitary products amongst female high school learners and the range of needs and challenges that they face in managing their menses in school settings in Gauteng, South Africa.

Methods

We collected mixed method data from 10 schools in Sedibeng district between June and August 2018. The qualitative component consisted of in-depth interviews with female learners (n = 30), educators (n = 8) and mothers of female learners (n = 9) and focus group discussions (FGDs) with male learners (n = 7) and female learners (n = 10). Five hundred and five female learners were recruited into the quantitative component consisting of a self-administered survey focussing on factors associated with access to sanitary products.

Results

The median age of survey participants was 17 years (interquartile range 16–18 years) and average age at menarche was 13.36 years. One in seven female learners reported not having enough sanitary products for every period in the last 3 months and this was reflected across the school quintiles. There was a complex interaction between menstrual-related challenges (physical discomfort, teasing, and feeling distracted in class) experienced by female learners, often amplified or compounded by factors in the school environment (unhygienic sanitation facilities and inadequate rest areas), and schooling participation and attendance. Girls who did not have enough products for every period in the last 3 months more likely reported missing school than those who reported sufficient products (46.27% vs 22.49% respectively, p < 0.001). However, there was no statistically significant difference between the groups in number of days missed.

Conclusions

Provision of sanitary products is important but only one component of a comprehensive MHM response. Ongoing attention over the link between product access and absenteeism risks overlooking complex systemic and structural factors which can negatively impact the sexual and reproductive health of learners in the school context, and more broadly.

National Monitoring for Menstrual Health and Hygiene: Is the Type of Menstrual Material Used Indicative of Needs Across 10 Countries?

Surveys monitoring population health and sanitation are increasingly seeking to monitor menstrual health. In the absence of established indicators, these surveys have most often collected data on the type of menstrual material used. This study investigated whether such data provides a useful indication of women's menstrual material needs being met. Using data from 12 national or state representative surveys from the Performance Monitoring and Accountability 2020 program, we compared self-reported menstrual material use against respondents' reported menstrual material needs (including needing clean materials, money, or access to a vendor). The use of menstrual pads did not indicate that menstrual material needs were met for many respondents. Of those exclusively using pads, a pooled 26.4% (95% Confidence Interval 17.1-38.5) of respondents reported that they had unmet material needs. More disadvantaged groups were particularly misrepresented; of rural women exclusively using pads, a pooled 38.5% (95%CI 27.3-51.1) reported unmet material needs, compared to 17.1% (95%CI 12.4-23.0) of urban women. Similar disparities were observed for levels of education and wealth, with a pooled 45.9% (95%CI 29.2-63.6) of women in the lowest wealth quintile reporting unmet material needs. Findings suggest that caution is needed when using menstrual material use as an indicator for menstrual health.

Girls' attendance at school after a menstrual hygiene intervention in northern Ethiopia

OBJECTIVE

To evaluate the effect on school attendance of a menstrual hygiene intervention that distributes educational booklets to school children and menstrual hygiene kits to schoolgirls in northern Ethiopia.

METHODS

Attendance was tracked for 8839 students in grades 7-12 during the 2015-2016 academic year when the intervention was implemented. Negative binomial regression was used to test whether student sex predicted post-intervention school absences when controlling for grade-level and pre-intervention absences. Similar attendance data were analyzed for 3569 students in grades 7, 9, and 11 for the 2014-2015 academic year as a historical comparison.

RESULTS

Over 12 211 educational booklets were distributed to students and 5991 menstrual hygiene kits were distributed to schoolgirls. After the intervention, girls had 24% fewer school absences than boys. Sex was not a predictor of absences during a similar time-period in the prior school year.

CONCLUSION

This is one of the first large studies to show a positive relationship between a menstrual hygiene intervention and girls' school attendance. These positive results suggest such interventions should be expanded to other schools in northern Ethiopia. Future research should explore whether similar interventions can also decrease the rate at which girls drop out of school around menarche.

Measuring menstrual hygiene experience: development and validation of the Menstrual Practice Needs Scale (MPNS-36) in Soroti, Uganda

OBJECTIVE

This study describes the development and validation of the Menstrual Practice Needs Scale (MPNS-36), which measures the extent to which respondents' menstrual practices and environments meet their needs.

METHODS

A 54-item pool was developed following systematic review of qualitative and quantitative studies and expert feedback. Item reduction and scale validation were undertaken using a cross-sectional survey of 538 menstruating schoolgirls in Soroti, Uganda. Test-retest reliability was assessed in a subsample of 52 girls 2 weeks after the first administration. Construct validity was tested through relationships with hypothesised correlates: confidence to manage menses, self-reported school absenteeism and mental health symptoms.

RESULTS

The MPNS-36 comprises 28 items applicable to all respondents and 8 items capturing washing and drying experiences for those reusing menstrual materials. A four-factor solution for the core 28 items was the best fit for the data (root mean square error of approximation (RMSEA)=0.028-0.029; comparative fit index (CFI)=0.961-0.964; Tucker-Lewis index (TLI)=0.953-0.955), supplemented by two factors for reuse (RMSEA=0.021-0.030; CFI=0.987-0.994; TLI=0.981-0.991). Subscale and total scores were calculated as mean scores to support accessibility for practitioners. The subscales were 'material and home environment needs' (11 items, αordinal=0.84), 'transport and school environment needs' (5 items, αordinal=0.73), 'material reliability concerns' (3 items, αordinal=0.55), 'change and disposal insecurity' (9 items, αordinal=0.80), 'reuse needs' (5 items, αordinal=0.76) and 'reuse insecurity' (3 items, αordinal=0.56). Relationships between subscales and hypothesised correlates supported validity. Home-based and school-based items were more strongly associated with confidence to manage menstruation at home and school, respectively. Higher total scores indicated more positive experiences and were associated with greater odds of not missing school during the last menstrual period (OR=2.62, 95% CI 1.52 to 4.50). Test-retest reliability was moderate (total score: intraclass correlation coefficient, ICC(2,1)=0.69).

CONCLUSIONS

The MPNS-36 demonstrated acceptable reliability and validity. It is the first measure to capture perceived menstrual hygiene and may be useful across a range of study designs. Future research should explore the validity and suitability of the measure across contexts and populations.

Menstrual health intervention and school attendance in Uganda (MENISCUS-2): a pilot intervention study

OBJECTIVES

Achieving good menstrual health and hygiene (MHH) is a public health challenge and there is little evidence to inform interventions. The aim of this study was to pilot test an intervention to improve MHH and school attendance in Uganda, in preparation for a future cluster-randomised trial.

DESIGN

Longitudinal study with pre-post evaluation of a pilot intervention.

SETTING

Two secondary schools in Entebbe, Uganda.

PARTICIPANTS

Of the 473 eligible students in secondary 2 (S2) at baseline, 450 (95.1%; 232 girls and 218 boys) consented/assented. 369 students (188 girls; 81.0%; and 181 boys; 83.0%) participated in the endline survey.

INTERVENTION

The intervention comprised training teachers to improve delivery of government guidelines for puberty education, training in use of a menstrual kit and pain management, a drama skit, provision of analgesics and improvements to school water and sanitation hygiene facilities.

PRIMARY AND SECONDARY OUTCOME MEASURES

Feasibility and acceptability of delivering the intervention. Baseline and endline quantitative surveys were conducted, with qualitative interviews conducted at endline. School attendance was assessed using self-completed daily diaries among a nested cohort of 100 female students.

RESULTS

There were high levels of uptake of the individual and behavioural intervention components (puberty education, drama skit, menstrual hygiene management (MHM) kit and pain management). The proportion of girls reporting anxiety about next period decreased from 58.6% to 34.4%, and reported use of effective pain management increased from 76.4% to 91.4%. Most girls (81.4%) reported improved school toilet facilities, which improved their comfort managing menstruation. The diary data and qualitative data indicated a potential intervention impact on improving menstrual-related school absenteeism.

CONCLUSIONS

The pilot study showed that the multicomponent MHM intervention was acceptable and feasible to deliver, and potentially effective in improving menstruation knowledge and management. A cluster-randomised trial is needed to evaluate rigorously the intervention effects on MHM and school attendance.

TRIAL REGISTRATION NUMBER

NCT04064736; Pre-results.

Menstrual cups and cash transfer to reduce sexual and reproductive harm and school dropout in adolescent schoolgirls: study protocol of a cluster-randomised controlled trial in western Kenya

Background

Adolescent girls in sub-Saharan Africa are disproportionally vulnerable to sexual and reproductive health (SRH) harms. In western Kenya, where unprotected transactional sex is common, young females face higher rates of school dropout, often due to pregnancy, and sexually transmitted infections (STIs), including HIV. Staying in school has shown to protect girls against early marriage, teen pregnancy, and HIV infection. This study evaluates the impact of menstrual cups and cash transfer interventions on a composite of deleterious outcomes (HIV, HSV-2, and school dropout) when given to secondary schoolgirls in western Kenya, with the aim to inform evidence-based policy to improve girls’ health, school equity, and life-chances.

Methods

Single site, 4-arm, cluster randomised controlled superiority trial. Secondary schools are the unit of randomisation, with schoolgirls as the unit of measurement. Schools will be randomised into one of four intervention arms using a 1:1:1:1 ratio and block randomisation: (1) menstrual cup arm; (2) cash transfer arm, (3) cups and cash combined intervention arm, or (4) control arm. National and county agreement, and school level consent will be obtained prior to recruitment of schools, with parent consent and girls’ assent obtained for participant enrolment. Participants will be trained on safe use of interventions, with all arms receiving puberty and hygiene education. Annually, the state of latrines, water availability, water treatment, handwashing units and soap in schools will be measured. The primary endpoint is a composite of incident HIV, HSV-2, and all-cause school dropout, after 3 years follow-up. School dropout will be monitored each term via school registers and confirmed through home visits. HIV and HSV-2 incident infections and risk factors will be measured at baseline, mid-line and end-line. Intention to treat analysis will be conducted among all enrolled participants. Focus group discussions will provide contextual information on uptake of interventions. Monitoring for safety will occur throughout.

Discussion

If proved safe and effective, the interventions offer a potential contribution toward girls’ schooling, health, and equity in low- and middle-income countries.

Trial registration

ClinicalTrials.gov NCT03051789, 15th February 2017.

"How can we leave the traditions of our Baab Daada" socio-cultural structures and values driving menstrual hygiene management challenges in schools in Pakistan

INTRODUCTION

Despite the growing attention to the relationship between menstruation and girls schooling, there remain many challenges to addressing the issue. Current interventions, which mostly focus on developing WASH infrastructure and sanitary hygiene management products, while necessary, may not be sufficient. This paper aimed to identify the root causes of poorly maintained WASH infrastructure, and understand the deeply embedded socio-cultural values around menstrual hygiene management that need to be addressed in order to provide truly supportive school environments for menstruating girls.

METHODS

Qualitative data were collected in rural and urban sites in three provinces in Pakistan using participatory activities with 312 girls aged 16-19 years, observations of 7 School WASH facilities, 42 key informant interviews and a document review.

RESULTS

Three key themes emerged from our data: (1) a poorly maintained, girls-unfriendly School WASH infrastructure was a result of gender-insensitive design, a cultural devaluation of toilet cleaners and inadequate governing practices; (2) the design of WASH facilities did not align with traditionally-determined modes of disposal of rag-pads, the most common used absorbents; (3) traditional menstrual management practices situate girls in an 'alternate space' characterised by withdrawal from many daily routines. These three socio-culturally determined practices interacted in a complex manner, often leading to interrupted class engagement and attendance.

CONCLUSIONS

To be truly effective, current menstrual hygiene management strategies need to address the root causes of poor WASH infrastructure and ensure facility design is sensitive to the gendered and deeply embedded local socio-cultural values and beliefs around menstrual hygiene management.

How does a Social and Behavioral Change Communication Intervention Predict Menstrual Health and Hygiene Management: A Cross-Sectional Study

Background

Interventions in India to improve menstrual health and hygiene management (MHHM) have been implemented at the national, state, district and school level. However, evaluations of these interventions have been scarce. The objective of the study was to determine if a social and behavioral change communication (SBCC) intervention (GARIMA) had a relationship with knowledge, attitudes, interpersonal communication, restrictions and MHHM using a comparison group post-test only design among 2206 adolescent girls.

Methods

Intervention villages and adolescent girls were selected through stratified random sampling based on where GARIMA was implemented. Villages and adolescent girls in comparison villages were matched socio-demographically to intervention villages and adolescent girls. Multi-level logistic regressions assessed the relationship between the encoded exposure, mediators and MHHM.

Results

The results showed that the encoded exposure predicted all behaviors corresponding to MHHM. Additionally, adolescent girls in the high encoded exposure group had significantly higher knowledge about puberty and reproductive parts (AOR: 2.03 (95% CI: 1.31 – 3.15)), positive attitudes towards gender (AOR: 1.48 (95% CI: 1.02 – 2.16)) and higher levels of some discussion and dialogue (AOR: 1.41 (95% CI: 1.04 – 1.92)).

Conclusions

Future programs should use SBCC to improve MHHM behavior but involve families, peers and community members to a greater extent in order to improve attitudes towards menstruation, attitudes towards restrictions, attitudes towards absorbent use and reduce restrictions within the community.

'It's like a burden on the head': Redefining adequate menstrual hygiene management throughout women's varied life stages in Odisha, India

There has been growing recognition of menstrual hygiene management (MHM) as a significant public health issue. However, research has predominately focused on the experiences of adolescent girls in school settings. The purpose of this research is to examine detailed accounts of menstruation for women in rural Odisha, India at various life stages with a view toward improving international monitoring of MHM. Focus group discussions and in-depth interviews were conducted to understand women’s experiences of menstruation across four life stages (unmarried women, recently married women, married women, and older women). Thematic analysis was used to identify menstruation-related challenges and needs. We found women voiced needs that aligned with those captured by the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) definition for MHM: access to clean materials, privacy for changing materials, soap and water for bathing, and disposal facilities for materials. However, we also found women require materials that are not only clean but comfortable and reliable; soap and water for more than bathing; privacy for the full spectrum of menstruation-related practices, not just when changing; and disposal facilities that are private and safe, not just accessible. Additionally, we identified needs that extend beyond the existing definition: pain management, social support, and an enabling sociocultural environment. Overall, women representing all life stages discussed menstruation challenges, including bathing, pain, and washing, drying, and storing cloth materials. Cloth management challenges were most acute for unmarried and recently married women, who were concerned that practices could reveal their menstrual status and harm their reputations, thus informing their preference for disposable materials, if attainable. We propose a revised definition of adequate MHM for this population that more comprehensively captures their needs. This definition may also prove useful for other populations, future research, creating measures of assessment, and guiding interventions and program priorities.