Menstrual hygiene management amongst schoolgirls in the Rukungiri district of Uganda and the impact on their education: a cross-sectional study

Changes in the menstrual hygiene management facilities and usage among Bangladeshi school girls and its effect on school absenteeism from 2014 to 2018

BACKGROUND

The lack of menstrual hygiene management (MHM) information and facilities in schools is a major contributor to adolescent girls' school absenteeism in low- and middle-income countries like Bangladesh.

OBJECTIVES

This paper examines the changes over time in school MHM facilities, knowledge and perceptions among adolescent girls, in relation to school absenteeism between 2014 and 2018 in Bangladesh.

METHODS

We examined changes in MHM and school absenteeism among schoolgirls using nationally representative data from the Bangladesh National Hygiene Baseline Survey 2014 and National Hygiene Survey 2018. Given the repetitive nature of our data and its clustering within participants, our method included performing descriptive analysis, bivariate analysis, and multivariate Generalised Estimating Equation (GEE) modelling to analyse these changes.

RESULTS

Results showed that adolescent girls' menstruation-related absenteeism decreased between 2014 and 2018. Percentage of adolescents who missed school decreased from 25% to 14% (PD: -11; CI: -16 to -6.1), while the average number of missed days reduced from 2.8 to 2.5 (PD: -0.33; CI: -0.57 to -0.10). In the GEE model, we found that living in rural areas (coef: -5.6; CI: -10.06 to -1.14), parental restrictions on going outside (coef: 4.47; CI: 0.75 to 8.2), education levels of girls (coef: -9.48; CI: -14.17 to -4.79), girl's belief that menstruation affects school performance (coef: 23.32; CI: 19.71 to 26.93), and using old cloths (coef: -4.2; CI: -7.6 to -0.79) were significantly associated with higher absenteeism. However, participant's age, type of school, knowledge of menstruation before menarche, receiving information regarding MHM, separate place for changing absorbents, and separate latrine and urine facility were not significantly associated with the changes in absenteeism over time.

CONCLUSION

This paper emphasised the associations between changes in school absenteeism, parental restrictions on students, students' education levels, and menstruation-related misperceptions. Ongoing research, policy reviews, and targeted interventions to improve MHM perceptions among girls are required to provide long-term benefits for adolescent girls in Bangladesh.

Utilization of modern menstrual methods and related unmet needs among college going women in Coimbatore district: a descriptive cross-sectional study

OBJECTIVES

The primary objectives were to determine the proportion of modern menstrual method (MMM) users among college going women in Coimbatore district, Tamil Nadu; and to estimate the unmet needs associated with use of MMMs in comparison with other menstrual hygiene methods (MHMs). We also assessed the factors that determine MMM use among college going women.

METHODS

This was a descriptive cross-sectional study conducted among college going women in Coimbatore district, Tamil Nadu, India between October 2022 and January 2023 using a purpose predesigned, pretested, semi-structured proforma that included validated Menstrual Practice Needs Scale (MPNS-36).

RESULTS

Only 1.4% of the study participants used MMMs - menstrual cups (1.3%) and tampons (0.1%). Sanitary pads were the most common MHM of choice (96.3%); of which majority (98.6%) used disposable pads and more than half (50.4%) used non-biodegradable pads. Importantly, one in six (16.5%) were not aware of nature of sanitary pads (biodegradable or nonbiodegradable) used. The unmet needs associated with MMMs (menstrual cups and tampons) were significantly lower than that for other MHMs (including sanitary pads), in particular, the unmet material and home environment needs, unmet material reliability concerns, unmet reuse needs and unmet reuse insecurity. However, we found no significant difference between MMMs, sanitary pads and other MHMs in terms of unmet transport, college environment, change and disposal insecurity needs. The significant predictors of use of MMMs were age (more than 21 years of age), residence (urban), type of stay (off campus including home), socioeconomic status (upper), fathers' and mothers' education (high school and above), and presence of personal income. Discussions with friends (or peers) both before and after menarche regarding menstruation resulted in higher adoption of modern menstrual methods.

CONCLUSION

MMMs provided comparative advantage with lesser unmet needs for material reliability and reuse insecurity concerns, particularly in home environment. However, none of the MHMs fulfilled the user expectations for transport and disposal insecurity concerns, particularly outdoors.

Process evaluation of a parent-child communication intervention for adolescent sexual and reproductive health in Uganda

BACKGROUND

Previous initiatives concerning adolescent sexual and reproductive health (SRH) education in Low-or-Middle Income Countries (LMICs) have been limited by cultural norms and misinformation perpetuated within families. Responding to the paucity of research on the implementation of SRH interventions in LMICs and limited knowledge regarding their mechanisms, this study undertakes a process evaluation of a parent-focused intervention to promote parent-adolescent communication about SRH in Uganda.

METHODS

This paper explores the implementation, contextual factors and mechanisms of impact of the intervention, using the Medical Research Council (MRC) guidelines for process evaluations. Implementation was evaluated through indicators of dose, fidelity and adaptations, acceptability and feasibility. The contextual factors and mechanisms of impact were evaluated to refine the intervention's causal assumptions. Data was collected during April - October 2021 in South-Western Uganda using a mixed-methods approach, including document analysis, intervention observations, interviews, focus group discussions and most significant change stories.

RESULTS

The acceptability of the intervention was related to its community engagement, the strong rapport with delivery agents, and individual characteristics of participants. Five contextual factors influencing implementation were highlighted; (i) cultural norms, (ii) perceptions about youth SRH, (iii) poverty, (iv) Covid-19 pandemic, and (v) prior research projects in the community. When considering the intervention's mechanisms of impact, four causal pathways were identified; (i) Awareness of SRH needs helped parents overcome stigma, (ii) Parenting skills training improved SRH communication, (iii) Group learning stimulated shared parenting, and (iv) Group learning improved co-parenting.

CONCLUSION

The paper presented three key learnings and corresponding recommendations for future research. Firstly, implementation success was credited to meaningful community engagement which improved acceptability and uptake. Secondly, the complex influences of contextual factors highlighted the need for contextual analysis in research studies to inform intervention design. Finally, this evaluation recognised the interplay between mechanisms of impact and suggested further research consider such combined impacts when designing intervention content.

Perspectives on the side effects of hormonal contraceptives among women of reproductive age in Kitwe district of Zambia: a qualitative explorative study

BACKGROUND

Globally, hormonal contraceptives have proved to be effective in the prevention of unwanted pregnancies. However, despite evidence of the many benefits associated with the use of hormonal contraceptives, concerns related to their safety and side effects have been reported. We conducted a study to explore the perspectives on the side effects of hormonal contraceptives among women of reproductive age in Kitwe district of Zambia.

METHODS

An explorative qualitative study was done among 32 women of reproductive age (18-45 years). Participants were selected conveniently as they accessed family planning services at a designated reproductive, maternal, and child health facility. Data collection was done through in-depth interviews (IDIs). Recruitment of participants and data collection continued until the saturation point was reached. The interviews were recorded, translated, and transcribed verbatim. Data were imported into NVivo.x64 for coding and node generation after which categories and themes were developed manually.

RESULTS

Overall, participants demonstrated a considerable amount of knowledge of family planning, recounting the economic and health benefits as well as demerits of family planning use. The main reasons for discontinuing and switching hormonal contraceptive methods were the desire to get pregnant and the fear of unpleasant side effects, including excessive bleeding or prolonged menstruation, headache, dizziness, lower abdominal/back pain, and weight gain. Most importantly, participants cited concerns about the delay in the resumption of fertility after the termination of contraception and how the side effects disrupted their daily activities at home.

CONCLUSION

There is a need for family planning providers to offer family planning services that address the side effects of hormonal contraceptives during counselling and how women can manage them. Family planning services should adopt a patient-centred approach that takes into consideration the concerns regarding side effects and how this affects the quality of life among women. Also, there is a need to extend family planning services to include scheduled follow-ups and clinical management of contraceptive side effects among women.

Building menstrual health and hygiene-supportive environments: exploring teachers' experience in rural Western Kenya

Introduction

Existing school environments and staff play a critical role in Menstrual Health and Hygiene (MHH) for school aged girls in middle and low-income countries. This paper leverages teachers' perspectives on menstruation and the impact of the Menstrual Solutions (MS) study, an open cluster randomized controlled feasibility study to determine the impact of puberty education, nurses support, and menstrual product provision on girls' academic performance and emotional well-being.

Methods

Seventeen focus group discussions were conducted from October 2012 through November 2013 with teachers at six participating schools, held at three different time points during the study period.

Results

Key themes that emerged were emotions and blood, absenteeism, the role of teachers in MHH, and the impact of sensitization. Teachers noted that poor MHH had an impact on school attendance, transparency and openness with teachers, and student behavior in class. It was reported that adolescent girls would absent themselves for 3-5 days during their menstrual cycle depending on what materials they could use, and they would often shy away from teachers, when possible, only speaking to them about their menses if it was urgent or they needed to go home. Emotions such as fear and embarrassment were commonly associated with bleeding. At the midpoint and end of the study, teachers noted that the puberty education and menstrual product provision (where applicable) had a positive impact on girls' attendance, attention, and comfort in the classroom. Girls became more open with both male and female teachers about their menses, and more comfortable and confident in the classroom among all classmates.

Discussion

This research highlights the importance of building an MHH-supportive environment with multiple school personnel within schools to develop a gender-equitable environment for girls to learn confidently without undue interference. Teachers are key adults in adolescent girls' lives, having the potential to foster an environment that empowers girls with greater autonomy to manage their menses. This highlights a need to consider their perspectives in intervention development. Sensitization of teachers and puberty education across both genders are key components to developing the MHH-supportive environment in schools.

Exploratory systematic review and meta-analysis on period poverty

BACKGROUND

Period poverty is a global health and social issue that needs to be addressed. It has been reported that many females compromise their education, employment, and social commitments during their menstruation days due to a number of reasons, including lack of access to toilets or menstrual products.

AIM

To provide a comprehensive understanding on period poverty, including outcomes associated with menstruation.

METHODS

All observational and randomised clinical trials reporting menstruation challenges, menstrual poverty and menstrual products were included. Our search strategy included multiple electronic databases of PubMed, Web of Science, ScienceDirect, ProQuest and EMBASE. Studies published in a peer review journal in English between the 30^th of April 1980 and the 30^th of April 2022 were included. The Newcastle-Ottawa Scale was used to assess the risk of bias of the systematic included studies. Pooled odds ratios (ORs) together with 95% confidence intervals (CIs) are reported overall and for sub-groups.

RESULTS

A total of 80 studies were systematically selected, where 38 were included in the meta-analysis. Of the 38 studies, 28 focused on children and young girls (i.e., 10-24 years old) and 10 included participants with a wider age range of 15-49 years. The prevalence of using disposable sanitary pads was 45% (95%CI: 0.35-0.58). The prevalence of menstrual education pre-menarche was 68% (95%CI: 0.56-0.82). The prevalence of good menstrual hygiene management (MHM) was 39% (95%CI: 0.25-0.61). Women in rural areas (OR = 0.30, 95%CI: 0.13-0.69) were 0.70 times less likely to have good MHM practices than those living in urban areas.

CONCLUSION

There was a lack of evidence, especially from low- and middle- income countries. Further research to better understand the scope and prevalence of period poverty should be considered. This will enable the development of improved policies to increase access to menstrual products and medical support where necessary.

Assessment of menstrual hygiene management knowledge, practice, and associated factors among girls in Boset District, Ethiopia: a school-based cross-sectional study

BACKGROUND

Adolescent girls, particularly in lower socioeconomic settings, lack adequate knowledge of menstrual hygiene management and have subpar hygiene habits. Likewise, the factors related to it have not been well addressed, and schoolgirls are facing a range of challenges. To develop effective intervention approaches, a context-specific assessment of menstrual hygiene practices is useful. Thus, this study aimed to assess menstrual hygiene management knowledge, practice, and associated factors among girls in the Boset district, Ethiopia.

METHODS

A school-based cross-sectional study was conducted at Boset district secondary schools among 629 randomly selected girls using the multi-stage sampling technique. Data were collected using a self-administered, structured questionnaire. The collected data were entered into Epi-info version 7 and analyzed by Statistical Package for Social Science (SPSS) version 26. Binary logistic regression analysis was used to model the association between dependent and independent variables. An adjusted odds ratio and 95% confidence interval were used to measure the strength of the association, and a p-value < 0.05 was used to declare statistical significance.

RESULT

Of the total study participants, 51.2% (95% CI: 46.6-55.8%) had an appropriate practice of menstrual hygiene and 57.9% (95% CI: 53.3-62.5%) had good knowledge status on menstrual hygiene management. Being an urban resident (AOR = 1.84, 95% CI: 1.20-2.80), having a mother with a secondary and above educational level (AOR = 3.4, 95% CI: 2.07-5.57), earning regular pocket money (AOR = 2.19, 95% CI: 1.45-3.313), and discussing menstrual issues with parents and friends (AOR = 3.65, 95% CI: 2.327-5.727) were associated with good practice of menstrual hygiene.

CONCLUSION

In this study, nearly half of the school girls had good practice and knowledge of menstrual hygiene management. Educating mothers and promoting discussion about menstrual hygiene management issues, especially in rural areas, should be priority actions.

Menstrual Hygiene Problems and Challenges Faced by Adolescent Females in Rural Areas: A Narrative Review

Menstruation is a vital sign of reproductive health and development. Menstrual hygiene practices are consequently a significant public health issue. However, menstrual practices are still tainted by taboos and other sociocultural constraints, which adversely affect health since adolescent females in rural areas are unaware of the scientific facts regarding menstrual hygiene practices. The Indian government has recognized the significance of menstrual hygiene and developed and implemented several programs and schemes for menstrual hygiene management (MHM). But due to a lack of, little, or inaccurate knowledge and cultural practices and socio-economic status, adolescent females face many obstacles and suffer from health issues. A comprehensive literature and data search was done using key databases such as PubMed and Google Scholar and other sources such as the Ministry of Health and Family Welfare (MoHFW), the United Nations International Children's Emergency Fund (UNICEF), the World Health Organization (WHO), and Google to identify the relevant articles and reviewed publications using full-text search. A total of 40 articles out of 1,461 were selected for review after the screening and elimination of repeated articles. The objective of this literature review is to assess the awareness and knowledge of the importance of menstruation, the understanding of safe menstruation practices, the significance of properly disposing of menstrual products, and the knowledge of how to guard against reproductive system infection and its consequences and also to identify the problems and challenges faced by adolescent females during their menstrual hygiene practices or management. The core of many health issues is misinformation, myths, erroneous beliefs, lack of awareness, and incomplete or incorrect knowledge about menstruation. Therefore, it is essential to teach adolescent females about hygienic behavior and safe menstrual practices.

Menstrual hygiene practice and associated factors among adolescent girls in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Menstrual hygiene has not received adequate attention in Sub-Saharan Africa, and there is a lack of regional representative data. Therefore, this study aimed to estimate the pooled prevalence of good menstrual hygiene practices and associated factors among adolescent girls in sub-Saharan Africa.

METHODS

In this study, the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used to develop the review manuscript. Online electronic databases, such as PubMed/Medline, Google Scholar, and CINAHL, were searched to retrieve available studies. The database search was conducted from January 1 to May 17, 2022. The selection, quality assessment, and data extraction of the studies were performed. Quality assessment of the studies was performed using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. Subgroup analysis and meta-regression were performed based on country, study area, and sample size. Publication bias was examined by funnel plots and Egger's test. The statistical analysis was conducted using STATA version 14 software and RevMan software, and statistical significance was declared at a p value of less than 0.05.

PROTOCOL REGISTRATION NUMBER

CRD42020165628.

RESULTS

A total of 229 studies were retrieved, and 14 studies were included in the final meta-analysis. The pooled prevalence of good menstrual hygiene practices was 45% (95% CI, (37, 53). Adolescents from urban residences (OR = 3.03, 95% CI (2.3, 3.97)), able to afford menstrual sanitary products (OR = 2.17, 95% CI (1.42, 3.3)), and from educated mothers (OR = 2.33, 95% CI (1.32, 4.12)) were associated with increased odds of good menstrual hygiene practice.

CONCLUSION

The pooled prevalence of menstrual hygiene practices was low compared to the SDG 6.2 target by 2030. "Achieve access to adequate and equitable sanitation and hygiene for all, paying special attention to the needs of women and girls and those in vulnerable situations". Therefore, improving the accessibility of a safe water supply, hygiene, sanitation facilities and affordability of menstrual products and promoting maternal education are mandatory and should be part of government-level public health policy to prevent related health issues, loss of economic output and education opportunities.

Beyond access to adequate WASH facilities: Menstrual hygiene practices of high school adolescent girls

INTRODUCTION

Menstrual hygiene has been a major problem facing Adolescent Girls at all levels of education in developing countries. Yet, it has not received the needed attention.

METHODOLOGY

This study uses univariate analysis to investigate the menstrual hygiene practices of adolescent girls in Ghana, with the adoption of the Menstrual Practices Questionnaire (MPQ). A sample of 167 randomly selected adolescent girls (mean age of 14.5) from five high schools in Ghana were surveyed one time. The survey was administered in a community where access to adequate WASH facilities is sorely lacking.

RESULTS

Despite inadequate access to WASH facilities, majority of the girls' menstrual practices are hygienic. However, for a significant proportion of the girls, changing of menstrual materials (47.5%), washing of genitals (70.3%) and hands (70.9%), disposal of menstrual wastes (27.7%), sterilization of menstrual materials (31.4%), and management of cramps (64.5%) were found to be inadequate, poor, unhygienic, and unhealthy. Bridging this gap requires community-wide sensitization and adequate provision of WASH facilities.

CONCLUSION

Inadequate access to WASH facilities may not be as huge a hindrance to observing good menstrual hygiene among adolescent girls as reported in conventional literature. Sociocultural factors such as religion and culture might explain this phenomenon. The study therefore recommends further studies to explore factors influencing this phenomenon which would hopefully provide an idiosyncratic genesis that might go a long way in shaping the otherwise "biased" perspectives with which religion and culture are viewed in the menstrual hygiene discourse.

Menstrual health and period poverty in Lebanon during economic crisis: A qualitative analysis of the challenges and recommendations

Objective

Recently, severe period poverty has had a dramatic spread throughout Lebanon as a result of several crises: the COVID-19 pandemic, the Beirut explosion, and the economic collapse. Period poverty is the lack of access to menstrual hygiene materials, comfortable environments, and adequate education about menstrual health. Due to the great implications of period poverty on Lebanese women's health, our study aims to explore stakeholder's perspective on the Lebanese public health policy regarding menstrual health, the evolving challenges it faces in the context of the current economic collapse, and to suggest recommendations for solutions.

Methods

Our study is qualitative in nature, where data collection was done via online semi-structured interviews with stakeholders from the public and private sectors of the Lebanese healthcare system in addition to non-governmental organizations (NGOs) and physicians. Data were then analyzed based on themes and subthemes that emerged from the interviews.

Results

Nine stakeholders were interviewed: five from NGOs, two obstetrics and gynecology physicians, and two public sector representatives. The challenges to menstrual health were subcategorized into previously existing and new ones. The consequences of poor menstrual health were tackled on the mental, physical, and social levels. Stakeholders suggested both short-term and long-term recommendations. Short-term recommendations included decreasing the monetary burden by subsidizing menstrual products or via a coupon system. Long-term recommendations included proper education on multiple levels, cooperation between key players in the private and public sectors, and encouragement of local production to ensure future sustainability.

Conclusion

Menstrual health is a neglected public health issue in Lebanon, causing detrimental effects on girls and women residing in the country. Proper planning and collaboration between the private and public sectors are required to address this human rights issue.

Schools preparedness for menstrual hygiene management: a descriptive cross-sectional study in the West Gonja Municipality, Savannah Region of Ghana

OBJECTIVE

This study aimed to investigate schools' preparedness for menstrual hygiene management in the West Gonja Municipality of Ghana.

DESIGN

This was a cross-sectional study with a mixed-methods approach.

SETTING

Junior high schools in the West Gonja Municipality.

PARTICIPANTS

Twenty-six schools were randomly selected, and 13 schoolgirls were purposively chosen for qualitative interviews.

ANALYSIS OF DATA

The quantitative and qualitative data were analysed using Microsoft Excel and thematic content analysis, respectively. The transcriptions were printed out and read repeatedly to identify similar wordings, phrases, concept and meanings.

OUTCOMES

Presence of menstrual hygiene facilities in basic schools.

RESULTS

Majority (69.2%) of the schools were poorly prepared towards menstrual hygiene management. Only 38.5% schools had water, most schools (61.5%) did not have waste bins, 30.8% of the schools had designated places for changing of menstrual materials. No school had menstrual hygiene materials available for emergency use. All participants acknowledged inadequate hygiene facilities in their schools. During menses, adolescent girls often absent themselves from school. Girls tend to be very inactive during their menstrual period for fear of embracement from their male counterparts. The following themes were obtained 'unavailability of hygiene material', 'involvement in class during menses' and 'absence from school'.

CONCLUSION

Schools in West Gonja Municipality have inadequate menstrual hygiene management facilities that could be a major setback to the health and educational attainment of young girls. The Ministry of Sanitation and Water Resources should expand menstrual hygiene and its management to reach the West Gonja Municipality as part of the National Sanitation and Hygiene Strategy.

Water, Sanitation and Hygiene in Schools in Low- and Middle-Income Countries: A Systematic Review and Implications for the COVID-19 Pandemic

The global COVID-19 pandemic has revealed the extent to which schools are struggling with the provision of safe drinking water, sanitation and hygiene (WASH). To describe the WASH conditions in schools and discuss the implications for the safe reopening of schools during the ongoing COVID-19 pandemic, a systematic review of peer-reviewed literature on WASH in schools in low- and middle-income countries was performed. In April 2021, five databases, including MEDLINE (via PubMed), Web of Science, Scopus, AJOL, and LILACS, were used to identify studies. Sixty-five papers met the inclusion criteria. We extracted and analyzed data considering the Joint Monitoring Programme (JMP) definitions and the normative contents of Human Rights to safe drinking water and sanitation. Publications included in this systematic review considered 18,465 schools, across 30 different countries. Results indicate a lack of adequate WASH conditions and menstrual hygiene management requirements in all countries. The largely insufficient and inadequate school infrastructure hampers students to practice healthy hygiene habits and handwashing in particular. In the context of the COVID-19 pandemic, being hindered to implement such a key strategy to contain the spread of SARS-CoV-2 in the school environment is of major concern.

Menstrual hygiene practice among adolescent girls in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Adolescent girls face several challenges relating to menstruation and its proper management. Lack of adequate sanitary products, inadequate water supply, and privacy for changing sanitary pads continue to leave adolescent girls with limited options for safe and proper menstrual hygiene in many low-income settings, including Ethiopia. These situations are also compounded by societal myths, stigmas surrounding menstruation, and discriminatory social norms. This systematic review and meta-analysis aimed to estimate the pooled proportion of safe menstrual hygiene management among adolescent girls in Ethiopia using the available studies.

METHODS

We searched PubMed, Google Scholar, African Journal Online (AJOL), Hinari, Science Direct, ProQuest, Direct of Open Access Journals, POPLINE, and Cochrane Library database inception to May 31, 2021. Studies reporting the proportion of menstrual hygiene management among adolescent girls in Ethiopia were considered. The Cochrane Q test statistics and I2 tests were used to assess the heterogeneity of the included studies. Since the included studies revealed considerable heterogeneity, a random effect meta-analysis model was used to estimate the pooled proportion of menstrual hygiene management (MHM).

RESULTS

Of 1,045 identified articles, 22 studies were eligible for analysis (n = 12,330 participants). The pooled proportion (PP) of safe MHM in Ethiopia was 52.69% (95%CI: 44.16, 61.22). The use of commercial menstrual absorbents was common 64.63% (95%CI: 55.32, 73.93, I2 99.2%) followed by homemade cloth 53.03% (95%CI: 22.29, 83.77, I2 99.2%). Disposal of absorbent material into the latrine was the most common practice in Ethiopia 62.18% (95%CI: 52.87, 71.49, I2 98.7%). One in four girls reported missing one or more school days during menstruation (PP: 32.03%, 95%CI: 22.65%, 41.40%, I2 98.2%).

CONCLUSION

This study revealed that only half of the adolescent girls in Ethiopia had safe MHM practices. To ensure that girls in Ethiopia can manage menstruation hygienically and with dignity, strong gender-specific water, sanitation, and hygiene (WASH) facilities along with strong awareness creation activities at every level are needed.

"The weather is not good": exploring the menstrual health experiences of menstruators with and without disabilities in Vanuatu

Background

Menstrual health is essential for gender equality and achieving the sustainable development goals. Though currently lacking, understanding and addressing menstrual health and social related inequalities requires comparison of experiences between menstruators with and without disabilities.

Methods

We completed a mixed-methods population-based study of water, sanitation and hygiene, disability and menstrual health in TORBA and SANMA Provinces, Vanuatu. Methods included a census, nested case-control study, in-depth interviews (IDIs), focus group discussions (FGDs), PhotoVoice and structured observations. We undertook a population census of 11,000+ households and recruited 164 menstruators with and 169 without disabilities (aged 10-45) into a nested case-control study. 20 menstruators across both groups were selected for the qualitative component.

Findings

Menstruators with disabilities were five times (adjusted Odds Ratio [aOR] 5.5, 95% Confidence Interval 1.8 - 16.5) more likely to use different bathing facilities to others in the household, nearly twice as likely (1.8, 1.1 - 3.1) to miss social activities, and three times (3.0, 1.6 - 5.7) more likely to eat alone during menstruation. Menstrual restrictions were widespread for all, but collecting water and managing menstrual materials was harder for menstruators with disabilities, particularly those requiring caregivers' support. These factors negatively impacted menstruators with disabilities' comfort, safety and hygiene, yet they reported less interference of menstruation on participation.

Interpretation

Negative factors affecting all menstruators disproportionately impact those with disabilities, compounding existing inequalities. Menstruators with disabilities may have reported less interference because they are accustomed to greater participation restrictions than others.

Funding

Australian Government's Water for Women fund and public donations.

Confidence to manage menstruation among university students in Australia: Evidence from a cross-sectional survey

Objectives:

There has been increased attention to university students’ experiences of menstrual disorders, and access to menstrual products, in high-income countries. Less attention has been directed to other aspects of their menstrual experience, including confidence for menstrual management. This study aimed to understand the factors affecting university students’ confidence to manage menstruation at university.

Methods:

An online survey was completed by 410 participants (age range: 16–46 years, mean = 20.1 years) who menstruate and study at an Australian university. Participants reported demographic characteristics, confidence to manage menstruation at university, and personal, physical and environmental factors. A Mann–Whitney U-test analysed differences in confidence between groups of students. Pearson’s correlation coefficient and bivariate linear regressions determined associations between factors and confidence. Statistically significant associations were inputted into a multiple linear regression model. P-values less than 0.05 were considered significant.

Results:

A minority of students (16.2%) felt completely confident to manage their menstruation at university. Menstrual knowledge, positive perceptions of menstruation and comfort to discuss menstruation with others positively predicted confidence. Physical menstrual symptoms, negative perceptions of menstruation, perceived stigma and using a menstrual cup or period underwear predicted lower confidence. In multiple regression, private and clean and sanitary university bathroom facilities, changing menstrual products at university, perceived stigma and negative perceptions of menstruation remained significant predictors.

Conclusion:

Most students did not have complete confidence to manage their menstruation at university. Several personal, physical and environmental factors were related to students’ confidence to manage menstruation. Assessment of these factors in future research with university students is recommended to enable a comprehensive understanding of their menstrual needs, and inform interventions aimed at improving their menstrual management confidence at university.

Menstrual characteristics, menstrual anxiety and school attendance among adolescents in Uganda: a longitudinal study

BACKGROUND

Qualitative data show negative impacts of menstruation on health and education in many settings, but there are few longitudinal quantitative studies of the impact of menstruation. We analyse associations with menstrual anxiety and school attendance in a study of Ugandan secondary school students.

METHODS

Data were from a longitudinal pilot study of a menstrual health intervention (MENISCUS), conducted in two secondary schools in Entebbe sub-district, Uganda. Self-completed menstrual-related data, including menstrual anxiety, were collected from 232 participants pre- and post-intervention. A sub-cohort of 100 randomly-selected post-menarcheal girls were asked to self-complete daily diaries during 10 months of follow-up, with data on menstrual flow, pain, and school attendance. We used multivariable logistic regression to estimate associations with menstrual anxiety among all girls at baseline, and random-effects logistic regression to estimate associations of menstrual characteristics with school non-attendance for 3 months pre-intervention in the sub-cohort, adjusting for within-girl clustering.

RESULTS

Overall, 130/222 (58.6%) of menstruating girls reported being anxious about their next period. Menstrual anxiety was higher in those not living with their mother (adjusted odds ratio (OR) = 1.91; 95% confidence interval (CI) 1.01-3.60), believing menstrual myths (aOR = 1.83; 0.95-3.50 for not agreeing that it is healthy for a girl to run, dance or cycle during her period; aOR = 1.97; 1.04-3.73 for agreeing that when a girl has her period she is unclean), lower menstrual confidence (aOR = 2.49; 1.33-4.65 for avoiding physical activity during her period; aOR = 1.68; 0.89-3.17 for not feeling comfortable to talk to other girls about her period; aOR = 2.89; 1.28-6.54 for agreeing that boys/girls tease them about their periods; and aOR = 2.27; 1.21-4.27 for worrying about being teased during her period). Those with lower knowledge about menstruation were less likely to report anxiety (aOR = 0.44; 0.23-0.84). During the pre-intervention period of the sub-cohort, school non-attendance was associated with menstrual pain, with 21.7% of girls missing school on days when they reported pain vs. 8.3% on days when no pain was reported (aOR = 3.82; 1.66-8.77).

CONCLUSIONS

Menstruation causes substantial anxiety in Ugandan schoolgirls, and menstrual pain is associated with missing school on period-days. Menstrual health interventions should address socio-cultural aspects of menstruation to reduce anxiety, and provide education on pain management strategies to support school attendance.

Association between experience of specific side-effects and contraceptive switching and discontinuation in Uganda: results from a longitudinal study

Background

There is substantial evidence that contraceptive side-effects are a major deterrent to consistent use of contraception but few studies in low- or middle-income countries explore the role of specific side-effects on contraceptive use dynamics. This study used population-based, longitudinal data to explore the effect of specific side-effects on contraceptive continuation, discontinuation, and switching in Uganda.

Methods

Data for this study come from two rounds of survey data collection in Uganda: PMA2020’s sixth cross-sectional survey and a follow-up survey conducted 1 year later. The main outcomes of interest were discontinuation and switching among users of hormonal contraceptive methods (implants, injectables and oral pill) and the IUD at baseline (n = 560). Multivariable logistic regressions assessed the association of experiencing specific side-effects (more bleeding, less bleeding, irregular bleeding, increased dryness/reduced libido, and physical discomfort) with discontinuation and switching 1 year later, adjusting for socio-demographic characteristics, type of method, and length of use. We also examined the differential effects of side-effects between discontinuation and switching risks.

Results

About 23% of hormonal and IUD contraceptive users reported experiencing side-effects at baseline survey. Overall, discontinuation and switching were higher among injectables and pill users, compared to IUD and implants users. Reporting more bleeding or less bleeding increased the odds of discontinuation and switching by 2.74 (95% CI 1.00–7.51) and 1.86 (1.04–3.34), respectively. There was no significant difference in discontinuation and switching by side-effects.

Conclusions

Greater attention should be paid to understanding the unique contributions of side-effects to contraceptive behavior using population-based data. While about a quarter of women reported experiencing side effects, those who experienced bleeding specific side effects were at higher risk of contraceptive discontinuation and switching. Providing greater individualized care that includes information and counseling about common side-effects, how they may impact daily life, and how tolerable these effects may be is necessary.

Research has shown that experiencing side-effects is related to stopping use of contraception, even when women wish to avoid pregnancy. Most research, however, does not differentiate between distinct side-effects, such as increased bleeding or changes to sexual experience, and instead combined all into “side-effects or health concerns”. We used data from 560 women in Uganda, who were interviewed twice, 1 year apart, to see if women who reported different side-effects at the first interview were more likely to stop using contraception or switch to a different contraceptive method than women who did not report experiencing side-effects. We found that increased or decreased menstrual bleeding was associated with a higher odds of contraceptive discontinuation and switching, Contraceptive discontinuation or switching was not different by women’s reporting of vaginal dryness/reduced libido or physical discomfort, such as cramping. It is important to understand what side-effects are likely to motivate stopping or switching contraception so that education and counseling can inform women of side-effects they may experience, help them choose the best method based on what side-effects they deem important, and if necessary, aid in switching contraceptive methods.

Disparities in menstrual hygiene management between urban and rural schoolgirls in Northeast, Ethiopia

INTRODUCTION

Even though menstruation is a normal biological process, adolescents are facing managing their menstruation when they are at school. It causes girls to miss their class on average three days every month. Studies in some countries showed that the magnitude of menstrual hygiene management problems is higher in rural adolescent girls, but little is known in the Ethiopia context. The objective of this study was to assess and compare menstrual hygiene management practices among rural and urban schoolgirls, Northeast, Ethiopia.

METHODS

An institution-based comparative cross-sectional study was employed among 1078 schoolgirls (539 urban and 539 rural) from February to March 2020. The participants were selected using a multi-stage sampling technique. A structured self-administrative questionnaire and observational checklist were used for data collection. Bivariate and multivariable logistic regression analysis with a 95% confidence interval was employed. A P- value less than 0.05 was used to declare statistical significance.

RESULTS

Overall, the magnitude of good menstrual hygiene practice was 52.9% (95%CI: 50.3%-56.5%), which was 65.9% (95% CI: 62.8%-70.7%) among urban and 39.9% (95% CI: 36.2%-44.6%) among rural schoolgirls. Among urban schoolgirls, the odds of good menstrual hygiene management practice was higher for girls aged below 18 years (AOR = 1.58, 95%CI: 1.05-2.39), learned about menstrual hygiene at school (AOR = 1.89, 95%CI: 1.21-2.97), heard about menstrual hygiene before menarche (AOR = 4.98, 95%CI: 2.71-9.13), and discussed menstrual hygiene with parents (AOR = 2.56, 95%CI: 1.25-5.27). Whereas, the odds of good menstrual hygiene management practice was higher among those who were knowledgeable on menstrual hygiene (AOR = 5.47, 95%CI: 3.68-8.12), those who learned about menstrual hygiene at school (AOR = 1.75, 95%CI: 1.13-2.70), and girls who heard about menstrual hygiene before menarche (AOR = 3.34, 95%CI: 1.44-7.76) in rural schoolgirls.

CONCLUSIONS

Though the overall menstrual hygiene practice was low, it was relatively better among urban schoolgirls. This calls for more effort to solve these problems and achieve sustainable development goals. Therefore, education and awareness creation on menstrual hygiene for schoolgirls, even before menarche at both settings should be strengthened. Encouraging parent-adolescent discussion on menstrual hygiene would have paramount importance, particularly to urban schoolgirls.

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.

Awareness on menstrual hygiene management in Bangladesh and the possibilities of media interventions: using a nationwide cross-sectional survey

OBJECTIVES

Menstrual hygiene management (MHM) has become a growing public health concern in many low-income and middle-income nations for its association with several health risks. This study observed types of menstrual absorbents used among women in Bangladesh and analysed the associated sociodemographic factors with the hypothesis that mass media can increase awareness regarding MHM. The study includes recommendations for possible intervention strategies designed to address this lack of awareness.

DESIGN AND PARTICIPANTS

The analysis used the data from the nationally representative Bangladesh Multiple Indicator Cluster Survey 2019 that employed a two-stage, stratified cluster sampling approach, with a study sample of 54 242 women aged between 15 and 49 years. A generalised linear model was fitted to the data adjusting for survey weights and cluster/strata variations along with bivariate analyses and spatial mapping.

RESULTS

Only a quarter of women (24.3%) used modern absorbents for MHM with most resorting to unhygienic traditional practices. Spatial distribution showed that the use of modern absorbent of MHM was limited to the major cities. The women who had mobile phones and regular access to the media were nearly 43% (adjusted OR (AOR) 1.43 with 95% CI 1.33 to 1.54) and 47% (AOR 1.47 with 95% CI 1.35 to 1.60) more likely to use the modern absorbents of MHM, respectively. Furthermore, educated women living in urban solvent households with educated house heads were also found to use modern absorbents of MHM.

CONCLUSIONS

There appeared to be scope for interventions through a combined national effort to raise awareness using multifaceted media channels regarding MHM among women in order to meet the Sustainable Development Goals 3.7 and 6.2 of addressing women's healthcare and hygiene needs.

The effect of education based on PEN-3 cultural model on students' menstrual health behaviors: a mixed method study

Menstruation is a natural process in girls, but sometimes it is accompanied by beliefs and behaviors with cultural roots that result in poor health consequences; this study aimed to consider perceptions of individual, families and community to current cultural beliefs, and to determine the effect of education based on the PEN-3 cultural model on students' menstrual health behaviors in Iran. Study had a mixed method design. In the qualitative phase, data were collected from students, their mothers and teachers through focused group discussion and in-depth interviews. In the quantitative phase, training was done in four 2-h sessions for intervention group. The data were collected immediately and 2 months after the training by a questionnaire and they were analyzed by Friedman and Wilcoxon non-parametric tests. Training was effective on all of the model structures and significantly increased mean score of the health behavior after training and 2 months later by 8.74 and 13.86, respectively, in intervention group (P<0.05). The perception and behavior of the others and access to sanitary services and products, especially cultural factors affect girls'' menstrual health behaviors, therefore, it is necessary to design the health plans regarding each of these factors, and the cultural context of each community.

Adolescent Menstrual Health Literacy in Low, Middle and High-Income Countries: A Narrative Review

Background: Poor menstrual health literacy impacts adolescents’ quality of life and health outcomes across the world. The aim of this systematic review was to identify concerns about menstrual health literacy in low/middle-income countries (LMICs) and high-income countries (HICs). Methods: Relevant social science and medical databases were searched for peer-reviewed papers published from January 2008 to January 2020, leading to the identification of 61 relevant studies. Results: A thematic analysis of the data revealed that LMICs report detrimental impacts on adolescents in relation to menstrual hygiene and cultural issues, while in HICs, issues related to pain management and long-term health outcomes were reported more frequently. Conclusions: In order to improve overall menstrual health literacy in LMICs and HICs, appropriate policies need to be developed, drawing on input from multiple stakeholders to ensure evidence-based and cost-effective practical interventions.

Acceptability and feasibility of using vaginal menstrual cups among schoolgirls in rural Nepal: a qualitative pilot study

INTRODUCTION

Menstrual hygiene management can be challenging in low-income settings and among school-aged girls due to traditional beliefs, lack of knowledge and information on best hygienic practices, and limited access to appropriate and affordable menstrual hygiene products. An alternative method for menstrual hygiene management, instead of sanitary pads or tampons, is the vaginal menstrual cup. As evidence on the use of menstrual cups is relatively limited, this study aimed to explore the acceptability and feasibility of using vaginal menstrual cups among school-aged girls in Thokarpa, Sindupalchowk, Nepal.

METHODS

This is an exploratory study based on four focus group discussions with a purposive sample of 28 schoolgirls between 13 and 19 years of age who were provided with vaginal menstrual cups in Thokarpa, Sindupalchowk, Nepal. The data were collected between February and March 2019, i.e. approximately three months after the distribution of the menstrual cup. Participants were included in the study if they had started their menstruation and never given birth. Conventional content analysis was applied.

RESULTS

Most participants perceived the menstrual cup positively. Not missing a single class in school due to problems related to menstrual hygiene management was described as a major benefit. The participants found using the menstrual cup easy and convenient, and described economic and environmental advantages of using it. Cleaning the menstrual cup did not cause any problems, according to the participants. Discomforts mentioned by the participants were: pain when inserting the menstrual cup, feeling the menstrual cup sticking out of the vagina, feeling a constant urge to urinate and leakage. Concerns were related to the size, shape and texture of the menstrual cup, and that it may "get stuck" in the vagina, while relatives were said to be concerned about the use of the menstrual cup leading to reduced fertility or losing virginity.

CONCLUSION

The use of vaginal menstrual cups for menstrual hygiene management among schoolgirls in Thokarpa, Sindupalchowk, Nepal, appears feasible and acceptable, as it involves practical, economic and environmental advantages. However, the scale-up of menstrual cups will require resolving described concerns and discomforts and fostering peer and family support.

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 Hygiene Management Practices and Associated Factors among Secondary School Girls in East Hararghe Zone, Eastern Ethiopia

Background. Many adolescent girls in developing countries lack appropriate information, means or materials, and access to the right sanitary facilities to manage menstruation. Hence, they adopted unsafe hygienic practices during menstruation that in turn has a negative impact on their dignity, health, and education. Thus, this study aimed to assess the practices of menstrual hygiene management and associated factors among secondary school girls in East Hararghe Zone. Methods. A school-based cross-sectional study was conducted from April to May 2017 among secondary school girls in East Hararghe Zone, Eastern Ethiopia. A total of 672 girls were selected randomly and interviewed using a structured interviewer-administered questionnaire. Logistic regression analysis was employed to identify predictors of good menstrual hygiene management practices. Result. Overall, 58.3% of the girls had good menstrual hygiene management practices. Around two-thirds (66.1%) of them used commercial sanitary pads as absorbents, 56.4% changed sanitary materials more than three times a day, and 68.3% cleaned their external genitalia daily during their menstruation. During multivariate analysis, living in urban areas (AOR = 2.59, 95% CI: 1.77, 3.80), having moderate (AOR = 2.78, 95% CI: 1.64, 5.28) and good knowledge about menstruation (AOR = 3.87, 95% CI: 2.21, 6.77), and mothers’ secondary and above education (AOR = 1.83, 95% CI: 1.01, 3.30) showed a positively significant association with good menstrual hygiene management practices. Conclusion. In this study, the practice of good menstrual hygiene management of secondary schoolgirls was low. Factors independently influencing menstrual hygiene management practices were girls’ place of residence, knowledge status of menstruation and its hygiene management, and mothers’ educational status. This highlights a need for targeted interventions to raise awareness of school girls especially for rural residents and the public in general to improve the knowledge and practices of menstrual hygiene management.

Menstrual hygiene among adolescent girls in junior high schools in rural northern Ghana

Introduction

the issue of menstrual hygiene is inadequately acknowledged and efforts to address the gaps has been unsatisfactory. Hygienic menstrual practice such as the use of sanitary pads is crucial during menstruation. Lack of sanitation facilities, especially for school girls, makes them vulnerable to emotional and physical challenges during their menstrual days. This study sought to investigate menstrual hygiene management among adolescent girls in junior high schools in rural northern Ghana.

Methods: a school-based cross-sectional study design was used. Multistage sampling technique was employed to select 730 school girls who had attained their menarche. Menstrual hygiene management was rated using the Selvi and Ramachandran scale. Bivariate analysis was conducted to compare good and poor menstrual hygiene management. The data were analyzed using STATA version 13.1.

Results

the prevalence of good menstrual hygiene was 61.4%. Mothers' education and parents' socio-economic status were significantly associated with menstrual hygiene management. Inadequate sanitation facilities was a major challenge to menstrual hygiene management at schools. The use of sanitary pads was significantly associated with school attendance (p-value < 0.0001).

Conclusion

the level of menstrual hygiene among in-school adolescent girls in northern Ghana is described as average. Although most of the schools had toilet facilities, they lacked clean water, soap, privacy and dustbins which are necessary for menstrual hygiene management. Interventions should target improving water, sanitation and hygiene facilities in schools as well as supply of pads to girls in rural school.

Menstrual knowledge, sociocultural restrictions, and barriers to menstrual hygiene management in Ghana: Evidence from a multi-method survey among adolescent schoolgirls and schoolboys

On a daily basis, schoolgirls in low and middle-income countries discover blood on their clothing for the first time in school environments without toilets, water, or a supportive teacher, mentor, or role model to help them understand the changes happening in their bodies. This study aimed to examine the menstrual knowledge, sociocultural restrictions, and barriers to menstrual hygiene management in school environment among adolescent schoolgirls in a rural community. We collected quantitative data from 250 adolescent schoolgirls and qualitative data from thirty schoolboys and five schoolteachers in five Junior High Schools in the Kumbungu district of northern Ghana. Binary logistic regression models were fitted to determine the predictors of poor menstrual knowledge. Qualitative data were transcribed verbatim, coded, and organized into themes. Overall, 53.6% of the girls had poor knowledge about menstruation. Most of the boys had heard about menstruation and had an idea about what menstruation is with most of them describing it as "the flow of blood through the vagina of a female." The boys revealed that terms such as "Vodafone," "Red card," and "Palm oil" are used to describe menstruation in the schools and within the community. After adjusting for the effect of other sociodemographic factors, we found evidence that girls in their late adolescents were less likely to have poor menstrual knowledge compared to those aged 10-14 years (aOR 0.20, 95%CI 0.08-0.48). Maternal education was protective against poor menstrual knowledge. When compared to adolescents whose mothers were illiterates, those whose mothers had basic education (aOR 0.62, 95%CI 0.28-1.40) and those whose mothers had secondary or higher education (AOR 0.22, 95%CI 0.06-0.76) were less likely to have poor knowledge about menstruation. Adolescents from homes with no television and radio sets were more likely to have poor menstrual knowledge compared to those from homes with television and radio sets (aOR 2.42, 95%CI 1.41-4.15). Comfort, safety, and cost were the major factors that influenced their choice of sanitary products. Most of the teachers said the schools do not provide students with sanitary products, even in emergencies. We found that girls were not to prepare some local dishes (e.g. Wasawasa) during their periods and are forbidden from participating in religious activities (i.e. read the Holy Quran or pray in the mosque) during the period of menstruation. Open discussions about menstruation and its management are not encouraged and girls are considered unclean and impure during the period of menstruation. None of the schools had a regular supply of water in WASH facilities, a mirror for girls to check their uniforms for bloodstains or soap in the toilet facilities for handwashing. Menstrual education through the standard school curriculum, starting from primary school, could prepare girls for menarche, improve their knowledge on menstruation, and teach boys how to support girls and women during the period of menstruation. This could also eliminate the sociocultural misconceptions surrounding 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.

Perceptions, Practices, and Challenges Regarding Menstrual Hygiene Among Women in Karachi, Pakistan: A Comparison Between General Population and Healthcare Workers

Background

Menstruation is a natural physiological phenomenon, yet considered a stigmatized subject, particularly in low- and middle-income countries like Pakistan. It is seldom discussed openly, leading to flow of incorrect and incomplete knowledge. The resultant unhealthy practices not only affect the health of the menstruator but can also contribute to considerable psychosocial stress. Menstrual hygiene management (MHM) is an important facet, which is associated with a variety of practices and beliefs in different parts of the world, some of which may not be correct. Identifying these poor methods is necessary in order to rectify them. Hence, our study aimed at determining the level of knowledge, beliefs, and practices pertaining to menstruation in the general female populace of Karachi. Healthcare workers have a potential role in the dissemination of authentic knowledge and practices. Therefore, we assessed and compared the accuracy and reliability of the aforementioned parameters in them and the need for an educational intervention.

Methods

A descriptive, cross-sectional study was conducted on females visiting the Gynecologic and Obstetrics Outpatient Department (OPD), and healthcare workers employed at Dr. Ruth K. M. Pfau Civil Hospital Karachi and Dow University Hospital Ojha. Using non-probability convenience sampling, a self-structured questionnaire was used to collect data from 353 respondents over a duration of three months from October 2019 to January 2020. Data was tabulated in Statistical Package for the Social Sciences (SPSS) version 24.0 (IBM Corp., Armonk, NY, US). In accordance with the objectives of the study, descriptive analysis was performed, and data was presented in the form of frequencies and percentages. 

Results

Of the 353 participants, 176 were from the general population and 177 were healthcare workers. At menarche, only 28.4% of the general population and 29.4% of healthcare workers had an idea of menses and proper placement of absorbent. Significantly lower number of females from the general population were found to be aware of tampons and menstrual cups (15.9% and 11.4% respectively) as compared to healthcare workers. For both groups, the source of knowledge was mostly their mother. The study showed that 77.8% of the general population and 66.1% of healthcare workers avoided bathing on certain days during menses, with the most common reason being that "it causes irregular flow". As compared to healthcare workers, a significantly higher number of women from the general population had restrictions of activity (53.4%) and avoided washing of groin area during menstruation (31.2%). Majority of women from the general population mentioned that they were scared when they menstruated for the first time. The most common absorbent used by respondents was pads, followed by cloth. The data showed 64.2% of females from the general population and 28.8% of healthcare workers abstained from eating certain foods. Seeking treatment for gynecological issues was not widespread among respondents.

Conclusion

Our study demonstrated insufficient menstrual knowledge, and consequent incorrect practices in the female population of Karachi. Destigmatizing menstruation and educating women and young girls is indispensable to overcoming this gap. At the same time, reinforcing the availability of MHM products is long overdue and is a crucial milestone towards facilitation of MHM for the women of Pakistan.

Menstrual Hygiene Management and School Absenteeism among Adolescents in Ghana: Results from a School-Based Cross-Sectional Study in a Rural Community

The study aimed to deepen our understanding of the menstrual hygiene management (MHM) of adolescents and the influence of menstruation on school absenteeism. We employed a school-based cross-sectional design in five Junior High Schools combining both quantitative and qualitative data collection methods. A questionnaire was used to collect quantitative data from 250 schoolgirls, and key informant interviews were conducted with a teacher in each of the five schools. We performed logistic regression analysis to provide crude and adjusted effect estimates and 95% confidence intervals. About fifty percent of the girls were engaged in good MHM, and approximately forty percent of them reported menstrual-related school absenteeism. We did not find evidence (p = 0.858) of association between MHM and menstrual-related school absenteeism. However, after controlling for the effect of other factors, we found evidence that the age of the schoolgirls, their father's occupation, and the receipt of allowance for menstrual care products were associated with MHM. When compared to those aged 17 to 19, those aged 10 to 13 years had 0.72 (95% CI 0.21, 2.44) decreased odds of poor MHM while those aged 14 to 16 had almost 3-fold increased odds (95% CI 1.49, 4.55) of poor MHM. The adolescents whose fathers were farmers had 0.42 (95% CI 0.21, 0.82) decreased odds of poor MHM while those whose fathers were unemployed had 0.24 (95% CI 0.10, 0.61) decreased odds of poor MHM. We found that girls who did not receive regular allowance for menstrual care products had nearly 2-fold increased odds (95% CI 1.06, 3.09) of poor MHM compared to those who received allowance for menstrual care products. Menstrual pain (82.2%), fear of staining clothing (70.3%), fear of being teased (70.3%), nonavailability of sanitary pad (63.4%), and lack of private place to manage period at school (60.4%) were the common reasons cited for menstrual-related school absenteeism.

Multidimensional Benefits of Improved Sanitation: Evaluating 'PEE POWER®' in Kisoro, Uganda

With 2.3 billion people around the world lacking adequate sanitation services, attention has turned to alternative service provision models. This study suggests an approach for meeting the sanitation challenge, especially as expressed in Sustainable Development Goal 6.2, using a toilet technology system, such as Pee Power® that generates electricity using diverted urine as a fuel. A field trial was carried out in a girls' school in Kisoro, Uganda, where the generated electricity was used to light the existing toilet block. The trial was evaluated in terms of social acceptability and user experience using a multidimensional assessment protocol. The results of our assessment show that users felt safer when visiting the toilets at night. Lights provided from the technology also helped with the perceived cleanliness of the toilets. The technology was well accepted, with 97% of the respondents saying that they liked the idea of the Pee Power® technology and 94% preferring it over other facilities on site. This shows how the technology helps meet SDG target 6.2, with its particular focus on vulnerable populations.

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.

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.

The impact of menstrual hygiene management on adolescent health: The effect of Go! pads on rate of urinary tract infection in adolescent females in Kibogora, Rwanda

OBJECTIVE

To determine the rates of urinary tract infection (UTI) in adolescent users of menstrual pads versus non-users in a rural area of Rwanda.

METHODS

An interventional prospective cohort study was conducted at four secondary schools in the Western Province of Rwanda from May 12, 2017 to October 20, 2017. Inclusion criteria were female students aged 18-24 who were menstruating and volunteered to participate in the study. In total, 240 adolescent participants were assigned to two cohorts; 120 received menstrual pads for 6 months and the other 120 did not use pads. Baseline symptoms and urine cultures were obtained. Symptoms and methods of menstrual hygiene management were assessed and urine cultures were obtained every 2 months. The primary outcome was the presence of UTI diagnosed by positive urine culture. Secondary outcomes were symptoms of UTI, vulvovaginal symptoms, sexual activity, dyspareunia, and self-reported sexually transmitted infection. Generalized estimating equations with nesting were used to assess associations of pad use with study outcomes.

RESULTS

A total of 209 participants completed the study. There was no difference in rates of positive urine culture. A decreased odds of vulvovaginal symptoms was found in self-reported "always" versus "never" pad users (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.43-0.96; P=0.031).

CONCLUSIONS

Despite not finding any difference in rates of UTI, the present study showed a decreased rate of vulvovaginal symptoms in users of menstrual pads. Further research investigating rates of genital infections in this population is thus necessary.

Improving Female Adolescents' Knowledge, Emotional Response, and Attitude toward Menarche following Implementation of Menarcheal Preparation Reproductive Health Education

Menarche and menstruation are considered taboos and disconcerting by communities, including female adolescents. The Menarcheal Preparation Reproductive Health Education program was designed to prepare female adolescents for menarche. The aim of this study was to identify the influence of reproductive health education on female adolescents’ preparation, knowledge, emotional response, and attitude toward menarche. The research design was a quasi-experimental, pre–post test with control group design. We selected 174 female adolescents by a stratified random sampling technique. The respondents were divided into two groups: control and intervention. The intervention group was provided Menarcheal Preparations Reproductive Health Education program in the form of a booklet, whereas the control group experienced no intervention. Data analyses involved the use of a chi-square test, McNemar test, and logistic regression. The results showed that there were significant differences in terms of knowledge (p = .001), emotional responses (p = .001), and attitude (p = .001) between the groups, as well as before and after intervention in the intervention group. Logistic regression revealed that reproductive education was the most influencing factor among female adolescents’ knowledge (OR = 45.1; 95% CI: 13.8–148.1), emotional responses (OR = 12.7; 95% CI: 5.6–28.5), and attitude (OR = 12.4; 95% CI: 5.8–26.6) toward menarche. Therefore, this study supports a recommendation of using Reproductive Health Education Related to Menarcheal Preparation in schools and community settings to prepare female adolescents for menarche.

Women's and girls' experiences of menstruation in low- and middle-income countries: A systematic review and qualitative metasynthesis

BACKGROUND

Attention to women's and girls' menstrual needs is critical for global health and gender equality. The importance of this neglected experience has been elucidated by a growing body of qualitative research, which we systematically reviewed and synthesised.

METHODS AND FINDINGS

We undertook systematic searching to identify qualitative studies of women's and girls' experiences of menstruation in low- and middle-income countries (LMICs). Of 6,892 citations screened, 76 studies reported in 87 citations were included. Studies captured the experiences of over 6,000 participants from 35 countries. This included 45 studies from sub-Saharan Africa (with the greatest number of studies from Kenya [n = 7], Uganda [n = 6], and Ethiopia [n = 5]), 21 from South Asia (including India [n = 12] and Nepal [n = 5]), 8 from East Asia and the Pacific, 5 from Latin America and the Caribbean, 5 from the Middle East and North Africa, and 1 study from Europe and Central Asia. Through synthesis, we identified overarching themes and their relationships to develop a directional model of menstrual experience. This model maps distal and proximal antecedents of menstrual experience through to the impacts of this experience on health and well-being. The sociocultural context, including menstrual stigma and gender norms, influenced experiences by limiting knowledge about menstruation, limiting social support, and shaping internalised and externally enforced behavioural expectations. Resource limitations underlay inadequate physical infrastructure to support menstruation, as well as an economic environment restricting access to affordable menstrual materials. Menstrual experience included multiple themes: menstrual practices, perceptions of practices and environments, confidence, shame and distress, and containment of bleeding and odour. These components of experience were interlinked and contributed to negative impacts on women's and girls' lives. Impacts included harms to physical and psychological health as well as education and social engagement. Our review is limited by the available studies. Study quality was varied, with 18 studies rated as high, 35 medium, and 23 low trustworthiness. Sampling and analysis tended to be untrustworthy in lower-quality studies. Studies focused on the experiences of adolescent girls were most strongly represented, and we achieved early saturation for this group. Reflecting the focus of menstrual health research globally, there was an absence of studies focused on adult women and those from certain geographical areas.

CONCLUSIONS

Through synthesis of extant qualitative studies of menstrual experience, we highlight consistent challenges and developed an integrated model of menstrual experience. This model hypothesises directional pathways that could be tested by future studies and may serve as a framework for program and policy development by highlighting critical antecedents and pathways through which interventions could improve women's and girls' health and well-being.

REVIEW PROTOCOL REGISTRATION

The review protocol registration is PROSPERO: CRD42018089581.

A rite of passage: a mixed methodology study about knowledge, perceptions and practices of menstrual hygiene management in rural Gambia

BACKGROUND

Appropriate menstrual hygiene management (MHM) is impeded by taboos and secrecy surrounding menstruation. Unhygienic menstrual practices and unpreparedness for managing menstruation has been associated with adverse health and social outcomes among adolescent girls. In The Gambia, there is limited data on menstrual practices among girls and women in rural communities and the sources of information about menstruation for the adolescents. This study aimed to explore knowledge, preparedness and practices of menstruation and its management among adolescents, mothers and teachers in rural Gambia.

METHODS

A mixed methods study was conducted in the rural Kiang West district of The Gambia. Twenty focus group discussions and thirteen in-depth interviews were conducted among mothers, adolescents and teachers to explore their views on menstruation, cultural beliefs, sources and level of knowledge on menstruation and MHM practices. In addition, a survey was done among 331 school girls to assess their knowledge, practices and attitudes of menstruation and its management. Inductive content analysis was used to analyse the qualitative data, and descriptive analysis and chi-squared tests were used to analyse quantitative data.

RESULTS

All participants had different levels of knowledge about menstruation. Knowledge score was higher among post-menarche girls compare with pre-menarche girls (p = 0.0001). All groups expressed difficulties, embarrassment and shame in relation to discussing menstruation. Two thirds of the surveyed girls reported having learnt about menstruation before menarche, however at menarche most felt unprepared. Teachers were the main source of information, but when asking for advice most girls preferred to ask their mothers. Mothers reported facing difficulties in discussing menstruation with their children and felt that boys did not need to be taught about it, however boys were very curious to know about. Most girls used reusable cloth unless they are given free pads from school.

CONCLUSION

Taboos, secrecy and embarrassment associated with discussing menstruation hinder adolescents from seeking advice from parents and teachers on appropriate MHM practices. Strategies to encourage positive social norms towards menstruation would help to promote more open discussions about it at the family, community and national level, which will support improvements in MHM in this and similar communities in low and middle income settings.

Menstrual hygiene management in rural schools of Zambia: a descriptive study of knowledge, experiences and challenges faced by schoolgirls

Introduction

While in school, girls require an environment that is supportive of menstrual hygiene management (MHM) in order to ensure regular school attendance and participation. Little is known about schoolgirls access to and practice of MHM in rural Zambia. This study explores girls’ experiences of MHM in rural schools of Zambia from the perspectives of schoolgirls, schoolboys and community and school-based adults key to MHM for schoolgirls.

Methods

In July and August 2015, we conducted this qualitative exploratory study in six rural schools of Mumbwa and Rufunsa districts of Zambia. Twelve in-depth interviews (IDIs) and six focus group discussions (FGDs) were conducted among girls ages 14–18 who had begun menstruating. Two FGDs with boys ages 14–18 and 25 key informant interviews were also conducted with teachers, female guardians and traditional leaders to provide the context within which schoolgirls practice MHM.

Results

Most girls reported learning about menstruation only at menarche and did not know the physiological basis of menstruation. They reported MHM-related challenges, including: use of non-absorbent and uncomfortable menstrual cloth and inadequate provision of sanitary materials, water, hygiene and sanitation facilities (WASH) in schools. In particular, toilets did not have soap and water or doors and locks for privacy and had a bad odor. Girls’ school attendance and participation in physical activities was compromised when menstruating due to fear of teasing (especially by boys) and embarrassment from menstrual leakage. Boys said they could tell when girls were menstruating by the smell and their behaviour, for instance, moving less and isolating themselves from their peers. Girls complained of friction burns on their inner thighs during their long journey to school due to chaffing of wet non-absorbent material used to make menstrual cloth. Girls preferred to dispose used menstrual materials in pit latrines and not waste bins for fear that they could be retrieved for witchcraft against them. Though traditional leaders and female guardians played a pivotal role in teaching girls MHM, they have not resolved challenges to MHM among schoolgirls.

Conclusion

When menstruating, schoolgirls in rural Zambia would rather stay home than be uncomfortable, inactive and embarrassed due to inadequate MHM facilities at school. A friendly and supportive MHM environment that provides education, absorbent sanitary materials and adequate WASH facilities is essential to providing equal opportunity for all girls.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6360-2) contains supplementary material, which is available to authorized users.

Sexual health of very young adolescents in South Western Uganda: a cross-sectional assessment of sexual knowledge and behavior

BACKGROUND

In most Sub-Saharan African countries, little is known about young adolescents' sexual and reproductive health (SRH). Though some efforts have been made to understand and improve SRH of older adolescents, very young adolescents (VYAs) are often overlooked, and little is known about their sexual knowledge and behaviors. The goal of this study was to describe SRH knowledge, information-seeking, and sexual behavior of VYAs in Uganda.

METHODS

A cross-sectional survey was administered in 33 primary schools in June and July of 2016. Trained interviewers administered surveys to adolescents ages 10-14 regarding SRH knowledge, information-seeking, sexual behavior, and relevant covariates. Continuous variables were summarized as means (SD) or medians (IQR) whereas categorical variables were summarized as proportions (percentages).

RESULTS

A total of 1096 adolescents were included in this analysis, 81.8% of which were from rural areas, with a median age of 12. Regarding sexually transmitted infections (STIs) knowledge; 95% knew HIV while 37% knew other STIs apart from HIV. Although 47% knew at least one way in which HIV is acquired only 8% knew at least four ways. Regarding contraceptive knowledge, 56% mentioned at least one modern method of preventing pregnancy (condoms, pills, intrauterine devices, implants, or injections). The majority (85%) of VYAs reported accessing SRH information in the media with 35% reporting accessing media with sexual content while 10% vs 22% consulted their father or mother respectively and 31% a school source. At least 7.6% of VYAs had ever had sexual intercourse, 90% of which were not using any protection.

CONCLUSION

Comprehensive SRH knowledge was low among VYAs in this study. Media remains an important source of information for SRH for this age group though it may be misused as some adolescents reported accessing sexual content that may be inappropriate. A large proportion of sexually active VYAs reported sexual risky behaviors. This study highlights the need for an accurate and more comprehensive SRH education approach for VYAs in Uganda at an opportune age before the majority engage in sexual behavior.

Do Water, Sanitation and Hygiene Conditions in Primary Schools Consistently Support Schoolgirls' Menstrual Needs? A Longitudinal Study in Rural Western Kenya

Many females lack access to water, privacy and basic sanitation—felt acutely when menstruating. Water, sanitation and hygiene (WASH) conditions in schools, such as access to latrines, water, and soap, are essential for the comfort, equity, and dignity of menstruating girls. Our study was nested within a cluster randomized controlled pilot feasibility study where nurses provided menstrual items to schoolgirls. We observed the WASH conditions of 30 schools from June 2012–October 2013 to see if there were any changes in conditions, to compare differences between study arms and to examine agreement between observed and teacher-reported conditions. Data came from study staff observed, and school teacher reported, WASH conditions. We developed scores for the condition of school facilities to report any changes in conditions and compare outcomes across study arms. Results demonstrated that soap availability for students increased significantly between baseline and follow-up while there was a significant decrease in the number of “acceptable” latrines. During the study follow-up period, individual WASH indicators supporting menstruating girls, such as locks on latrine doors or water availability in latrines did not significantly improve. Advances in WASH conditions for all students, and menstrual hygiene facilities for schoolgirls, needs further support, a defined budget, and regular monitoring of WASH facilities to maintain standards.

Menstrual Hygiene Management in Resource-Poor Countries

Importance

Adequate management of menstrual hygiene is taken for granted in affluent countries; however, inadequate menstrual hygiene is a major problem for girls and women in resource-poor countries, which adversely affects the health and development of adolescent girls.

Objective

The aim of this article is to review the current evidence concerning menstrual hygiene management in these settings.

Evidence Acquisition

A PubMed search using MeSH terms was conducted in English, supplemented by hand searching for additional references. Retrieved articles were reviewed, synthesized, and summarized.

Results

Most research to date has described menstrual hygiene knowledge, attitudes, and practices, mainly in sub-Saharan Africa and South Asia. Many school-based studies indicate poorer menstrual hygiene among girls in rural areas and those attending public schools. The few studies that have tried to improve or change menstrual hygiene practices provide moderate to strong evidence that targeted interventions do improve menstrual hygiene knowledge and awareness.

Conclusion and Relevance

Challenges to improving menstrual hygiene management include lack of support from teachers (who are frequently male); teasing by peers when accidental menstrual soiling of clothes occurs; poor familial support; lack of cultural acceptance of alternative menstrual products; limited economic resources to purchase supplies; inadequate water and sanitation facilities at school; menstrual cramps, pain, and discomfort; and lengthy travel to and from school, which increases the likelihood of leaks/stains. Areas for future research include the relationship between menarche and school dropout, the relationship between menstrual hygiene management and other health outcomes, and how to increase awareness of menstrual hygiene management among household decision makers including husbands/fathers and in-laws.

Target Audience

Obstetricians and gynecologists, family physicians.

Learning Objectives

After completion of this educational activity, the obstetrician/gynecologist should be able to define what is meant by “adequate menstrual hygiene management,” identify the challenges to adequate menstrual hygiene management that exist in resource-poor countries, and describe some of the intervention strategies that have been proposed to improve menstrual hygiene management for girls and women in those countries.

Menstrual hygiene management among adolescent girls in sub-Saharan Africa

Menstruation is a delicate physiological process through which a shedding of uterine lining occurs each month in females of reproductive age. Often considered a taboo subject, menstruation is seldom openly discussed in developing parts of the world. This article explores menstrual hygiene management (MHM) in sub-Saharan Africa and emphasizes the urgent and neglected need for feasible solutions, especially among adolescent girls. Optimizing menstrual hygiene interventions will require an integration of both knowledge and skill training gained through education on MHM alongside an improvement of access to girl-friendly water, sanitation and hygiene facilities in addition to access to low-cost hygienic sanitary products. To facilitate the identification and implementation of feasible and cultural relevant programs we recommend the utilization of public health intervention research.

Mapping the knowledge and understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low- and middle-income countries

Background

Menstruation is a natural physiological process that requires proper management. Unlike other normal bodily processes, menstruation is linked with religious and cultural meanings that can affect the perceptions of young girls as well as the ways in which the adults in the communities around them respond to their needs.

Objectives

This review aims to answer the following questions: (1) how knowledgeable are adolescent girls in low- and middle-income countries about menstruation and how prepared are they for reaching menarche, (2) who are their sources of information regarding menstruation, (3) how well do the adults around them respond to their information needs, (4) what negative health and social effects do adolescents experience as a result of menstruation, and (5) how do adolescents respond when they experience these negative effects and what practices do they develop as a result?

Methods

Using a structured search strategy, articles that investigate young girls’ preparedness for menarche, knowledge of menstruation and practices surrounding menstrual hygiene in LMIC were identified. A total of 81 studies published in peer-reviewed journals between the years 2000 and 2015 that describe the experiences of adolescent girls from 25 different countries were included.

Results

Adolescent girls in LMIC are often uninformed and unprepared for menarche. Information is primarily obtained from mothers and other female family members who are not necessarily well equipped to fill gaps in girls’ knowledge. Exclusion and shame lead to misconceptions and unhygienic practices during menstruation. Rather than seek medical consultation, girls tend to miss school, self-medicate and refrain from social interaction. Also problematic is that relatives and teachers are often not prepared to respond to the needs of girls.

Conclusion

LMIC must recognize that lack of preparation, knowledge and poor practices surrounding menstruation are key impediments not only to girls’ education, but also to self-confidence and personal development. In addition to investment in private latrines with clean water for girls in both schools and communities, countries must consider how to improve the provision of knowledge and understanding and how to better respond to the needs of adolescent girls.

Measuring the prevalence and impact of poor menstrual hygiene management: a quantitative survey of schoolgirls in rural Uganda

OBJECTIVES

The primary objective was to describe Ugandan schoolgirls' menstrual hygiene management (MHM) practices and estimate the prevalence of inadequate MHM. Second, to assess the relative contribution of aspects of MHM to health, education and psychosocial outcomes.

DESIGN

Secondary analysis of survey data collected as part of the final follow-up from a controlled trial of reusable sanitary pad and puberty education provision was used to provide a cross-sectional description of girls' MHM practices and assess relationships with outcomes.

SETTING

Rural primary schools in the Kamuli district, Uganda.

PARTICIPANTS

Participants were 205 menstruating schoolgirls (10-19 years) from the eight study sites.

PRIMARY AND SECONDARY OUTCOME MEASURES

The prevalence of adequate MHM, consistent with the concept definition, was estimated using dimensions of absorbent used, frequency of absorbent change, washing and drying procedures and privacy. Self-reported health, education (school attendance and engagement) and psychosocial (shame, insecurity, embarrassment) outcomes hypothesised to result from poor MHM were assessed as primary outcomes. Outcomes were measured through English surveys loaded on iPads and administered verbally in the local language.

RESULTS

90.5% (95% CI 85.6% to 93.9%) of girls failed to meet available criteria for adequate MHM, with no significant difference between those using reusable sanitary pads (88.9%, 95% CI 79.0% to 94.4%) and those using existing methods, predominantly cloth (91.5%, 95% CI 85.1% to 95.3%; χ² (1)=0.12, p=0.729). Aspects of MHM predicted some consequences including shame, not standing in class to answer questions and concerns about odour.

CONCLUSIONS

This study was the first to assess the prevalence of MHM consistent with the concept definition. Results suggest that when all aspects of menstrual hygiene are considered together, the prevalence is much higher than has previously been reported based on absorbents alone. The work demonstrates an urgent need for improved assessment and reporting of MHM, and for primary research testing the links between menstrual management and health, education and psychosocial consequences.