Firm-created content on YouTube for product promotion - A thematic analysis for menstrual cup

Mensuration cup is a mensural hygiene product about which people are less aware. Despite having many advantages there hasn't been much uptake. Research suggests that this is because of less accessible information. To overcome this, menstrual cup brands are creating several firm-created contents on YouTube. This study aimed at understanding and classifying the type of information available in 27 firm-created content about menstrual cup. The thematic analysis resulted in three themes Speaker & Language, Content presented, Type of information shared, contributing to the identification of promotional gaps, to be used by brands in building perspective towards menstrual cup.

Protocol for the Adolescent Menstrual Experiences and Health Cohort (AMEHC) Study in Khulna, Bangladesh: A Prospective cohort to quantify the influence of menstrual health on adolescent girls' health and education outcomes

BACKGROUND

Menstrual health is essential for gender equity and the well-being of women and girls. Qualitative research has described the burden of poor menstrual health on health and education; however, these impacts have not been quantified, curtailing investment. The Adolescent Menstrual Experiences and Health Cohort (AMEHC) Study aims to describe menstrual health and its trajectories across adolescence, and quantify the relationships between menstrual health and girls' health and education in Khulna, Bangladesh.

METHODS AND ANALYSIS

AMEHC is a prospective longitudinal cohort of 2016 adolescent girls recruited at the commencement of class 6 (secondary school, mean age=12) across 101 schools selected through a proportional random sampling approach. Each year, the cohort will be asked to complete a survey capturing (1) girls' menstrual health and experiences, (2) support for menstrual health, and (3) health and education outcomes. Survey questions were refined through qualitative research, cognitive interviews and pilot survey in the year preceding the cohort. Girls' guardians will be surveyed at baseline and wave 2 to capture their perspectives and household demographics. Annual assessments will capture schools' water, sanitation and hygiene, and support for menstruation and collect data on participants' education, including school attendance and performance (in maths, literacy). Cohort enrolment and baseline survey commenced in February 2023. Follow-up waves are scheduled for 2024, 2025 and 2026, with plans for extension. A nested subcohort will follow 406 post-menarche girls at 2-month intervals throughout 2023 (May, August, October) to describe changes across menstrual periods. This protocol outlines a priori hypotheses regarding the impacts of menstrual health to be tested through the cohort.

ETHICS AND DISSEMINATION

AMEHC has ethical approval from the Alfred Hospital Ethics Committee (369/22) and BRAC James P Grant School of Public Health Institutional Review Board (IRB-06 July 22-024). Study materials and outputs will be available open access through peer-reviewed publication and study web pages.

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.

Perception on Menstrual Cup Usage Among Teens and Reproductive Age Group Women: A Cross-Sectional Study

Introduction

One of the challenges to menstrual hygiene management in resource-limited settings is limited access to safe and affordable menstrual hygiene products. An alternative to the widely used sanitary pads is the menstrual cup, which has received less attention in low- and middle-income countries. This study was carried out to assess the perception on menstrual cup usage among teens and reproductive age group women assess attending a tertiary care institute in a rural setup in Andhra Pradesh.

Methodology

A prospective cross-sectional study was conducted among 164 teenage and reproductive age group women attending the Outpatient Department of Obstetrics and Gynecology with the help of a semi-structured, pretested and pre-piloted questionnaire to assess the perception of menstrual cup usage among the participants. Data were analyzed statistically using software, menstrual cup knowledge score was calculated based on data obtained from questionnaire.

Results

Most of the study participants (87.8%) were using sanitary pads during menstruation. Cloth was also used by some of the participants (11.59%). Only one participant (0.61%) was reported using menstrual cup. Majority of the participants [121 (73.7%)] reported that they had never heard of menstrual cup, whereas 43 [(26.3%)] study participants reported that they were aware of menstrual cup. Only 2(4.65%) out of 43 participants had a good knowledge on menstrual cup whose knowledge score was 12. Five (11.63%) out of 43 participants had got 0 score and remaining participants got the score between 0 and 12.

Conclusion

Most of the women were not aware of menstrual cup and even if they know about it, they do not have good knowledge about it. Awareness regarding menstrual cup should be promoted through media and awareness programs to reach everyone.

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.

'You don't have to sleep with a man to get how to survive': Girl's perceptions of an intervention study aimed at improving sexual and reproductive health and schooling outcomes

In sub-Saharan Africa, girls suffer from high rates of morbidity and mortality, enduring high exposure to sexual and reproductive health harms. Staying in school helps protect girls from such harms. Focus group discussions were conducted in a rural, impoverished area of Kenya with adolescent girls participating in a 4-arm cluster randomised controlled trial, evaluating menstrual cups, cash transfer, or combined cups plus cash transfer against controls. To explore girls' perceptions of how trial interventions affected their SRH risks and schooling, semi-structured discussions were held at baseline, midline, and study end. Data was explored using thematic analysis. At baseline there were no discernible differences between the 4 intervention groups regarding their perceptions of relationships with boys/men, and difficulties attending or remaining in school. Midline and endline discussions found that narratives from those receiving cash transfer only, or alongside a cup were similar; girls noted fewer pregnancies and less school dropout, attributed to the cash transfer reducing the need for transactional sex. Lower absenteeism was reported by the cup only group, with perceived minimal effect on pregnancy and dropout. Girls in control and cup only groups described feeling valued through inclusion, benefitting from puberty and hygiene education. Although seemingly having little effect on reducing pregnancy or dropout, these inputs reportedly empowered girls, whilst cash transfer girls were emboldened to refuse male sexual advances. Girls noticed benefits from trial interventions, with a reduction in transactional sex and resulting pregnancy impacting on school dropout, or reduced menstrual related absenteeism. Education and study inclusion were perceived as important. Future programmes should consider alleviating material deprivation which prevents girls from attending or performing at school through schemes such as cash transfer, alongside hygiene and education packages. This will empower girls to refuse unwanted sex and understand risks, in addition to motivating academic achievement and school completion. Trial registration: ClinicalTrials.gov NCT03051789.

Study of Adaptability and Efficacy of Menstrual Cups in Managing Menstrual Health and Hygiene: A Descriptive Longitudinal Study

Introduction

Menstrual cup is a device made up of silicon for menstrual hygiene. Despite its being safe, eco-friendly, cheap, and durable its non-acceptability may be due to higher adoption barriers. We conducted this study to assess the adaptability and efficacy of menstrual cups.

Methods

It was a descriptive longitudinal study, conducted in a tertiary care institute in eastern India. Women of 18-50 years of age, educated till secondary level were included in the study, to be conducted over three months. The quantitative response for the satisfaction with the menstrual cup was measured on a five-point Likert scale after each menstrual cycle. Side effects, the quantity of blood flow and frequency of cleaning the menstrual cup, and how many participants will continue to use it were also asked.

Results

After the third menstrual cycle, 68.9% of participants stated that they would continue the menstrual cup usage. The mean total satisfaction score improved from 5.4 (first cycle) to 12.6 (third cycle) (p<0.001). The majority (67%) had no side effects, 10% had irritation and leakage, and 13% had an unpleasant odor.

Conclusions

The study shows that menstrual cups are a better alternative. Adaptability increases gradually through proper counseling, peer support, and practice.

Cost-Effectiveness and Cost-Benefit Analyses of Providing Menstrual Cups and Sanitary Pads to Schoolgirls in Rural Kenya

Objective

To analyze the relative value of providing menstrual cups and sanitary pads to primary schoolgirls.

Design

Cost-effectiveness and cost-benefit analyses of three-arm single-site open cluster randomized controlled pilot study providing menstrual cups or sanitary pads for 1 year.

Participants

Girls 14-16 years of age enrolled across 30 primary schools in rural western Kenya.

Methods

Cost-effectiveness analysis was conducted based on the health effects (reductions in disability-adjusted life years [DALYs]) and education effects (reductions in school absenteeism) of both interventions. The health and education benefits were separately valued and compared with relative program costs.

Results

Compared with the control group, the cost of menstrual cups was estimated at $3,270 per year for 1000 girls, compared with $24,000 for sanitary pads. The benefit of the menstrual cup program (1.4 DALYs averted, 95% confidence interval [CI]: -4.3 to 3.1) was higher compared with a sanitary pad program (0.48 DALYs averted, 95% CI: -4.2 to 2.3), but the health effects of both interventions were not statistically significant likely due to the limited statistical power. Using point estimates, the menstrual cup intervention was cost-effective in improving health outcomes ($2,300/DALY averted). The sanitary pad intervention had a cost-effectiveness of $300/student-school year in reducing school absenteeism. When considering improvements in future earnings from reduced absenteeism, the sanitary pad program had a net benefit of +$68,000 (95% CI: -$32,000 to +$169,000).

Conclusions

The menstrual cup may provide a cost-effective solution for menstrual hygiene management in low-income settings. This study outlines a methodology for future analyses of menstrual hygiene interventions and highlights several knowledge gaps that need to be addressed. Trial registration: ISRCTN17486946.

Earning pocket money and girls' menstrual hygiene management in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Many adolescent girls in Ethiopia and elsewhere missed school during their monthly cycles due to a lack of affordable menstrual absorbent materials or money to buy sanitary pads. So far, few studies have looked into the relationship between earning pocket money and maintaining good menstrual hygiene. Hence, this systematic review and meta-analysis aimed to synthesize the best available evidence regarding the association between earning pocket money and menstrual hygiene management among adolescents in Ethiopia.

METHODS

We systematically searched PubMed, Hinari, Science Direct, Cochrane Library, ProQuest, POPLINE, African Journal Online, Direct of Open Access Journals, and Google Scholar for studies examining the association between earning pocket money and menstrual hygiene management among adolescent girls in Ethiopia, without restriction in a publication year. The Joanna Briggs Institute quality assessment tool for the cross-sectional studies was used to assess the quality of included studies. A prefabricated checklist, including variables: first author, publication year, sample size, type of questionnaire, and the region was used to extract data from the selected articles. A random-effect meta-analysis model was used to estimate the pooled odds ratio (OR) of the association between earning pocket money and menstrual hygiene management. The heterogeneity and publication bias was assessed by using I² test statistics and Egger's test, respectively.

RESULTS

Data from nine studies involving 4783 adolescent girls were extracted. The meta-analysis revealed that adolescent girls who earned pocket money from their parents or relative had 1.64 times higher odds of having good menstrual hygiene management than their counterparts [pooled OR = 1.64, 95% CI: 1.16-2.34, I²:66.7%, n = 7 (number of studies)]. Similarly, the likelihood of having good menstrual hygiene management was lower by 49% among adolescent girls who did not receive any pocket money from their parents compared to their counterparts (pooled OR = 0.51, 95% CI: 0.35-0.74, I²:48.4%, n = 2).

CONCLUSIONS

The findings revealed that adolescent girls who earned pocket money were more likely to practice good menstrual hygiene management. Progress toward better menstrual hygiene will necessitate consideration of this factor.

Effects of Menstrual Health and Hygiene on School Absenteeism and Drop-Out among Adolescent Girls in Rural Gambia

Poor knowledge and management of menstruation impacts girls' school attendance and academic performance. This paper aims to explore how menstrual hygiene management practices and related factors influence school absenteeism and drop-out among primary and secondary school girls in rural Gambia. Mixed-method studies were conducted among students and key informants from 19 schools from July 2015-December 2017. Focus group discussions, in-depth interviews, cross-sectional surveys, menstrual diaries, and school water, sanitation and hygiene (WASH) facility observations were used. Key findings from the interviews were that menstrual pain, cultural beliefs, fear of peers knowing menstrual status, and poor school WASH facilities led to school absenteeism, however, they had no impact on school drop-out. Of the 561 girls surveyed, 27% reported missing at least one school day per month due to menses. Missing school during the most recent menstrual period was strongly associated with menstrual pain (extreme pain adjusted odds ratio (AOR) = 16.8 (95% CI: 7.29-38.74)), as was having at least one symptom suggestive of urinary tract infection (AOR = 1.71 (95% CI: 1.16-2.52)) or reproductive tract infection (AOR = 1.99 (95% CI: 1.34-2.94)). Clean toilets (AOR = 0.44 (95% CI: 0.26-75)), being happy using school latrines while menstruating (AOR = 0.59 (95% CI: 0.37-0.93)), and soap availability (AOR = 0.46 (95% CI: 0.3-0.73)) were associated with reduced odds of school absenteeism. This study suggests menstrual pain, school WASH facilities, urogenital infections, and cultural beliefs affected school attendance among menstruating girls in rural Gambia.

In Vitro Study to Assess Effective Cleaning Techniques for Removing Staphylococcus aureus from Menstrual Cups

Background: We sought to determine the effectiveness of common cleaning procedures in eliminating S. aureus from silicone menstrual cups. Methods: In this in vitro study, we tested four cleaning techniques: (1) cold water; (2) cold water and liquid soap; (3) cold water followed by steeping the cup in boiled water for 5 min in a ceramic mug covered with a small plate; and (4) cold water and soap followed by steeping the cup in boiled water as in (3). Human blood was coated to the inner and outer surface of each cup, dried, and incubated with 10⁶S. aureus colony-forming units (CFU/mL). All tests were performed in triplicate. Viable bacterial abundance was measured with decadic dilution and drop plate or surface plating. Results: Bacteria were most effectively eliminated by cleaning cups with soap and water and then steeping in boiled water (0 CFU/cup vs. 2.075 × 10⁸/cup no cleaning, p = 0.005). This was not statistically significantly different from washing cups with water only and steeping 5 min in boiled water (14 CFU/cup). Raised lettering on the outer surface of the menstrual cups resulted in more bacterial recovery from pieces with lettering than without lettering. Conclusions: These results advance knowledge of between-period menstrual cup cleaning recommendations, suggesting that the logistical challenges of continuous boiling may be eliminated with steeping at least 5 min.

Menstrual distress in females of reproductive age: a literature review

Menstrual-related issues have significant public-health ramifications. Women who are having menstruation troubles should get their mental health checked by healthcare specialists. In young women, a menstrual-related condition has serious health implications. Young females who have menstrual issues miss job and school, and their behavioural and mental development suffers as a result. Depression and anxiety have an impact on women's menstrual periods in adults. Symptoms like as cramps, tiredness, backache, swelling abdomen, and painful breasts have also been described in women with menstrual misery. Menstrual distress has been shown to impair women's daily activities, as well as their reproductive and psychological health, according to research. Menstrual periods are frequently accompanied by a variety of unpleasant symptoms, such as premenstrual syndrome, which includes symptoms such as mild cramping and exhaustion. The severity of these symptoms, on the other hand, differs from woman to woman, depending on their health, food, way of life, and other factors. Women with menstrual-related issues have also reported smoking, alcohol intake, and an increase in hunger. Furthermore, young women experience emotional disturbances such as melancholy, restlessness, and despair. It is a sign of an atypical menstrual cycle if there is no cycle or if the bleeding is atypical or light. As a result, it is critical to maintain contact with a gynaecologist in order to detect any significant changes in a regular menstrual cycle.

How do women and girls experience menstrual health interventions in low- and middle-income countries? Insights from a systematic review and qualitative metasynthesis

Increasing recognition of the difficulties women and adolescent girls face during menstruation has the prompted rapid implementation of menstrual health programmes and policies. Yet, there remains limited understanding of the influence of these interventions on individuals' menstrual experiences. We systematically reviewed and synthesised qualitative studies of participant experiences of menstrual health interventions. Included studies were undertaken in 6 countries (India, Uganda, Kenya, Ethiopia, Zimbabwe, South Africa) and involved over 900 participants. Interventions focused on menstrual product or education provision. Only 6 of the 12 included studies were rated as high or medium trustworthiness. Exposure to new menstrual products led to changes in women's and girls' expectations of what a menstrual material should offer, with recipients highly valuing reduced fears of leakage and improved freedom of movement. After learning how to use new products or receiving educational materials, women and girls reported feeling more empowered and aware of the physiological process of menstruation, and in some cases wanted to share this knowledge with others in their communities. For each intervention, the process of introduction, trial and error, and acceptance of the new technologies or information was influenced by the sociocultural environment including parents, peers and teachers.

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.

Comparison between menstrual cups: first step to categorization and improved safety

OBJECTIVES

Menstrual cups come in a range of shapes, sizes, and firmnesses, but unlike tampons are not categorized in any way. With these factors having an impact on product leaks and comfort, as well as being linked to illness and injury, women need the same level of transparency when purchasing a menstrual cup. The comparison of physical and mechanical properties of menstrual cups will be the first step to achieve this.

METHODS

In October 2020, 14 popular and highly rated menstrual cups underwent quantitative comparison in laboratory settings (the United Kingdom), and they were compared in terms of their dimensions, volume, and compressive strength (firmness) using the Instron Universal Testing System. The overall designs were compared including shape, material, and features.

RESULTS

Although all the products in this comparison were marketed to women below 30 years of age having never given birth, total volume varied from 18.88 mL to 38.14 mL, and compressive load to compress the menstrual cup 50% (±0.5%) maximum diameter varied from 3.39 N to 13.92 N.

CONCLUSIONS

Women are not sufficiently informed when choosing a menstrual cup. With no correlation between menstrual cup size, shape, and its volume, or material, shape, and its firmness, consumers cannot estimate which menstrual cup might be most suitable, and incorrect choice could cause injury. Transparency is needed across menstrual cup brands. With this and further regulation, women will make an informed decision to choose the correct menstrual cup and minimize injury. This work recommends firmness categories, ranging from 'very soft' to 'very firm' as a first step.

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

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

Acceptability of the menstrual cup among students in further education institutions in KwaZulu-Natal, South Africa

OBJECTIVE

The primary objective of this research was to evaluate long-term user acceptability of menstrual cups in a student population in South Africa.

METHODS

A cohort of female students aged 18-24 years attending 10 further education institutions including 22 campus sites in KwaZulu-Natal, South Africa, were offered menstrual cups after receiving education and training in their use. The students were followed for up to 12 months to assess menstrual cup acceptability, user experiences and continuation.

RESULTS

A total of 509 students were enrolled. Disposable pads were the primary menstrual hygiene product used in the 3 months prior to the baseline interview (95.5%, n = 486), and 8.1% (n = 41) of students reported that they had used toilet paper or newspapers. Of the 463 (91%) students interviewed at 1 month follow-up, 86% reported that they had tried to use the menstrual cup. There was mixed reporting on ease of insertion and removal on first use. Of those who attempted use, half (49.5%, n = 197) reported that inserting the menstrual cup on first use was very easy or quite easy. Of those who did not find it easy, 80% reported that two to three insertions were required to achieve comfort. A maximum of five insertions was mentioned to achieve comfort. The majority who had used the cup (>90%) reported they would continue to use it at each follow-up visit.

CONCLUSION

The menstrual cup was well accepted among this student population and should be considered as a cost-effective and environmentally sustainable option in menstrual health management initiatives in South Africa.

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

Objectives

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

Materials and methods

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

Results

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

Conclusion

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

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

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

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

Background

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

Methods

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

Discussion

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

Trial registration

ClinicalTrials.gov NCT03051789, 15th February 2017.

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

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

Menstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysis

BACKGROUND

Girls and women need effective, safe, and affordable menstrual products. Single-use products are regularly selected by agencies for resource-poor settings; the menstrual cup is a less known alternative. We reviewed international studies on menstrual cup leakage, acceptability, and safety and explored menstrual cup availability to inform programmes.

METHODS

In this systematic review and meta-analysis, we searched PubMed, Cochrane Library, Web of Science, Popline, Cinahl, Global Health database, Emerald, Google Scholar, Science.gov, and WorldWideScience from database inception to May 14, 2019, for quantitative or qualitative studies published in English on experiences and leakage associated with menstrual cups, and adverse event reports. We also screened the Manufacturer and User Facility Device Experience database from the US Food and Drug Administration for events related to menstrual cups. To be eligible for inclusion, the material needed to have information on leakage, acceptability, or safety of menstrual cups. The main outcome of interest was menstrual blood leakage when using a menstrual cup. Safety outcomes of interest included serious adverse events; vaginal abrasions and effects on vaginal microflora; effects on the reproductive, digestive, or urinary tract; and safety in poor sanitary conditions. Findings were tabulated or combined by use of forest plots (random-effects meta-analysis). We also did preliminary estimates on costs and environmental savings potentially associated with cups. This systematic review is registered on PROSPERO, number CRD42016047845.

FINDINGS

Of 436 records identified, 43 studies were eligible for analysis (3319 participants). Most studies reported on vaginal cups (27 [63%] vaginal cups, five [12%] cervical cups, and 11 [25%] mixed types of cups or unknown) and 15 were from low-income and middle-income countries. 22 studies were included in qualitative or quantitative syntheses, of which only three were of moderate-to-high quality. Four studies made a direct comparison between menstrual cups and usual products for the main outcome of leakage and reported leakage was similar or lower for menstrual cups than for disposable pads or tampons (n=293). In all qualitative studies, the adoption of the menstrual cup required a familiarisation phase over several menstrual cycles and peer support improved uptake (two studies in developing countries). In 13 studies, 73% (pooled estimate: n=1144; 95% CI 59-84, I2=96%) of participants wished to continue use of the menstrual cup at study completion. Use of the menstrual cup showed no adverse effects on the vaginal flora (four studies, 507 women). We identified five women who reported severe pain or vaginal wounds, six reports of allergies or rashes, nine of urinary tract complaints (three with hydronephrosis), and five of toxic shock syndrome after use of the menstrual cup. Dislodgement of an intrauterine device was reported in 13 women who used the menstrual cup (eight in case reports, and five in one study) between 1 week and 13 months of insertion of the intrauterine device. Professional assistance to aid removal of menstrual cup was reported among 47 cervical cup users and two vaginal cup users. We identified 199 brands of menstrual cup, and availability in 99 countries with prices ranging US$0·72-46·72 (median $23·3, 145 brands).

INTERPRETATION

Our review indicates that menstrual cups are a safe option for menstruation management and are being used internationally. Good quality studies in this field are needed. Further studies are needed on cost-effectiveness and environmental effect comparing different menstrual products.

FUNDING

UK Medical Research Council, Department for International Development, and Wellcome Trust.

Use of menstrual cups among school girls: longitudinal observations nested in a randomised controlled feasibility study in rural western Kenya

BACKGROUND

A menstrual cup can be a good solution for menstrual hygiene management in economically challenged settings. As part of a pilot study we assessed uptake and maintenance of cup use among young school girls in Kenya.

METHODS

A total of 192 girls between 14 to 16 years were enrolled in 10 schools in Nyanza Province, Western Kenya; these schools were assigned menstrual cups as part of the cluster-randomized pilot study. Girls were provided with menstrual cups in addition to training and guidance on use, puberty education, and instructions for menstrual hygiene. During repeated individual visits with nurses, girls reported use of the menstrual cup and nurses recorded colour change of the cup.

RESULTS

Girls were able to keep their cups in good condition, with only 12 cups (6.3%) lost (dropped in toilet, lost or destroyed). Verbally reported cup use increased from 84% in the first 3 months (n = 143) to 96% after 9 months (n = 74). Colour change of the cup, as 'uptake' indicator of use, was detected in 70.8% of 192 participants, with a median time of 5 months (range 1-14 months). Uptake differed by school and was significantly higher among girls who experienced menarche within the past year (adjusted risk ratio 1.29, 95% CI 1.04-1.60), and was faster among girls enrolled in the second study year (hazard ratio 3.93, 95% CI 2.09-7.38). The kappa score comparing self-report and cup colour observation was 0.044 (p = 0.028), indicating that agreement was only slightly higher than by random chance.

CONCLUSIONS

Objective evidence through cup colour change suggests school girls in rural Africa can use menstrual cups, with uptake improving with peer group education and over time.

TRIAL REGISTRATION

ISRCTN17486946 . Retrospectively registered 09 December 2014.

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.

Physical, Social, and Political Inequities Constraining Girls' Menstrual Management at Schools in Informal Settlements of Nairobi, Kenya

Access to adequate water and sanitation is limited in informal settlements, contributing to girls' challenges managing menstruation at school, especially when they cannot access materials to absorb menstrual blood and appropriate facilities for hygiene. This study documents differences between girls' experience of menstruation at public schools (where the Kenyan government provides menstrual pads) and private schools (where pads are not provided) in two informal settlements of Nairobi, Kenya. Results showed that supply chains to public schools were not reliable, and equitable pad provision was not assured. Girls in private schools struggled to access pads because they were not provided. Sanitation facilities were physically available, but Muslim girls were unable to practice ablution due to the design of toilets in our study schools. Girls experienced fear and anxiety due to harassment from male peers and had incomplete information about menstruation from teachers. Findings suggest that practitioners and policy-makers should acknowledge the diversity of school populations and monitor programs to ensure efforts do not contribute to inequity.

Menstrual hygiene management among Bangladeshi adolescent schoolgirls and risk factors affecting school absence: results from a cross-sectional survey

BACKGROUND

Many adolescent girls in low-income and middle-income countries lack appropriate facilities and support in school to manage menstruation. Little research has been conducted on how menstruation affects school absence. This study examines the association of menstrual hygiene management knowledge, facilities and practice with absence from school during menstruation among Bangladeshi schoolgirls.

METHODS

We conducted a nationally representative, cross-sectional study in Bangladeshi schools from March to June 2013 among girls 11 to 17 years old who reached menarche. We sampled 700 schools from 50 urban and 50 rural clusters using a probability proportional to size technique. We interviewed 2332 schoolgirls and conducted spot checks in each school for menstrual hygiene facilities. To assess factors associated with reported school absence, we estimated adjusted prevalence difference (APD) for controlling confounders' effect using generalised estimating equations to account for school-level clustering.

RESULTS

Among schoolgirls who reached menarche, 41% (931) reported missing school, an average of 2.8 missed days per menstrual cycle. Students who felt uncomfortable at school during menstruation (99% vs 32%; APD=58%; CI 54 to 63) and who believed menstrual problems interfere with school performance (64% vs 30%; APD=27; CI 20 to 33) were more likely to miss school during menstruation than those who did not. School absence during menstruation was less common among girls attending schools with unlocked toilet for girls (35% vs 43%; APD=-5.4; CI -10 to -1.6). School absence was more common among girls who were forbidden from any activities during menstruation (41% vs 33%; APD=9.1; CI 3.3 to 14).

CONCLUSION

Risk factors for school absence included girl's attitude, misconceptions about menstruation, insufficient and inadequate facilities at school, and family restriction. Enabling girls to manage menstruation at school by providing knowledge and management methods prior to menarche, privacy and a positive social environment around menstrual issues has the potential to benefit students by reducing school absence.

Examining the safety of menstrual cups among rural primary school girls in western Kenya: observational studies nested in a randomised controlled feasibility study

OBJECTIVE

Examine the safety of menstrual cups against sanitary pads and usual practice in Kenyan schoolgirls.

DESIGN

Observational studies nested in a cluster randomised controlled feasibility study.

SETTING

30 primary schools in a health and demographic surveillance system in rural western Kenya.

PARTICIPANTS

Menstruating primary schoolgirls aged 14-16 years participating in a menstrual feasibility study.

INTERVENTIONS

Insertable menstrual cup, monthly sanitary pads or 'usual practice' (controls).

OUTCOME MEASURES

Staphylococcus aureus vaginal colonization, Escherichia coli growth on sampled used cups, toxic shock syndrome or other adverse health outcomes.

RESULTS

Among 604 eligible girls tested, no adverse event or TSS was detected over a median 10.9 months follow-up. S. aureusprevalence was 10.8%, with no significant difference over intervention time or between groups. Of 65 S.aureus positives at first test, 49 girls were retested and 10 (20.4%) remained positive. Of these, two (20%) sample isolates tested positive for toxic shock syndrome toxin-1; both girls were provided pads and were clinically healthy. Seven per cent of cups required replacements for loss, damage, dropping in a latrine or a poor fit. Of 30 used cups processed for E. coli growth, 13 (37.1%, 95% CI 21.1% to 53.1%) had growth. E. coli growth was greatest in newer compared with established users (53%vs22.2%, p=0.12).

CONCLUSIONS

Among this feasibility sample, no evidence emerged to indicate menstrual cups are hazardous or cause health harms among rural Kenyan schoolgirls, but large-scale trials and post-marketing surveillance should continue to evaluate cup safety.

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.

Menstrual hygiene management among adolescent schoolgirls in low- and middle-income countries: research priorities

BACKGROUND

A lack of adequate guidance on menstrual management; water, disposal, and private changing facilities; and sanitary hygiene materials in low- and middle-income countries leaves schoolgirls with limited options for healthy personal hygiene during monthly menses. While a plethora of observational studies have described how menstrual hygiene management (MHM) barriers in school impact girls' dignity, well-being, and engagement in school activities, studies have yet to confirm if inadequate information and facilities for MHM significantly affects quantifiable school and health outcomes influencing girls' life chances. Evidence on these hard outcomes will take time to accrue; however, a current lack of standardized methods, tools, and research funding is hampering progress and must be addressed.

OBJECTIVES

Compile research priorities for MHM and types of research methods that can be used.

RESULTS

In this article, we highlight the current knowledge gaps in school-aged girls' MHM research, and identify opportunities for addressing the dearth of hard evidence limiting the ability of governments, donors, and other agencies to appropriately target resources. We outline a series of research priorities and methodologies that were drawn from an expert panel to address global priorities for MHM in schools for the next 10 years.

CONCLUSIONS

A strong evidence base for different settings, standardized definitions regarding MHM outcomes, improved study designs and methodologies, and the creation of an MHM research consortia to focus attention on this neglected global issue.

Schoolgirls' experience and appraisal of menstrual absorbents in rural Uganda: a cross-sectional evaluation of reusable sanitary pads

Background

Governments, multinational organisations, and charities have commenced the distribution of sanitary products to address current deficits in girls’ menstrual management. The few effectiveness studies conducted have focused on health and education outcomes but have failed to provide quantitative assessment of girls’ preferences, experiences of absorbents, and comfort. Objectives of the study were, first, to quantitatively describe girls’ experiences with, and ratings of reliability and acceptability of different menstrual absorbents. Second, to compare ratings of freely-provided reusable pads (AFRIpads) to other existing methods of menstrual management. Finally, to assess differences in self-reported freedom of activity during menses according to menstrual absorbent.

Methods

Cross-sectional, secondary analysis of data from the final survey of a controlled trial of reusable sanitary padand puberty education provision was undertaken. Participants were 205 menstruating schoolgirls from eight schools in rural Uganda. 72 girls who reported using the intervention-provided reusable pads were compared to those using existing improvised methods (predominately new or old cloth).

Results

Schoolgirls using reusable pads provided significantly higher ratings of perceived absorbent reliability across activities, less difficulties changing absorbents, and less disgust with cleaning absorbents. There were no significant differences in reports of outside garment soiling (OR 1.00 95%CI 0.51–1.99), or odour (0.84 95%CI 0.40–1.74) during the last menstrual period. When girls were asked if menstruation caused them to miss daily activities there were no differences between those using reusable pads and those using other existing methods. However, when asked about activities avoided during menstruation, those using reusable pads participated less in physical sports, working in the field, fetching water, and cooking.

Conclusions

Reusable pads were rated favourably. This translated into some benefits for self-reported involvement in daily activities, although reports of actual soiling and missing activities due to menstruation did not differ. More research is needed comparing the impact of menstrual absorbents on girls’ daily activities, and validating outcome measures for menstrual management research.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-016-0260-7) contains supplementary material, which is available to authorized users.

Menstrual hygiene management among adolescent girls in India: a systematic review and meta-analysis

OBJECTIVES

To assess the status of menstrual hygiene management (MHM) among adolescent girls in India to determine unmet needs.

DESIGN

Systematic review and meta-analysis. We searched PubMed, The Global Health Database, Google Scholar and references for studies published from 2000 to September 2015 on girls' MHM.

SETTING

India.

PARTICIPANTS

Adolescent girls.

OUTCOME MEASURES

Information on menarche awareness, type of absorbent used, disposal, hygiene, restrictions and school absenteeism was extracted from eligible materials; a quality score was applied. Meta-analysis was used to estimate pooled prevalence (PP), and meta-regression to examine the effect of setting, region and time.

RESULTS

Data from 138 studies involving 193 subpopulations and 97,070 girls were extracted. In 88 studies, half of the girls reported being informed prior to menarche (PP 48%, 95% CI 43% to 53%, I(2) 98.6%). Commercial pad use was more common among urban (PP 67%, 57% to 76%, I(2) 99.3%, n=38) than rural girls (PP 32%, 25% to 38%, I(2) 98.6%, n=56, p<0.0001), with use increasing over time (p<0.0001). Inappropriate disposal was common (PP 23%, 16% to 31%, I(2) 99.0%, n=34). Menstruating girls experienced many restrictions, especially for religious activities (PP 0.77, 0.71 to 0.83, I(2) 99.1%, n=67). A quarter (PP 24%, 19% to 30%, I(2) 98.5%, n=64) reported missing school during periods. A lower prevalence of absenteeism was associated with higher commercial pad use in univariate (p=0.023) but not in multivariate analysis when adjusted for region (p=0.232, n=53). Approximately a third of girls changed their absorbents in school facilities (PP 37%, 29% to 46%, I(2) 97.8%, n=17). Half of the girls' homes had a toilet (PP 51%, 36% to 67%, I(2) 99.4%, n=21). The quality of studies imposed limitations on analyses and the interpretation of results (mean score 3 on a scale of 0-7).

CONCLUSIONS

Strengthening of MHM programmes in India is needed. Education on awareness, access to hygienic absorbents and disposal of MHM items need to be addressed.

TRIAL REGISTRATION NUMBER

CRD42015019197.

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

Marni Sommer and colleagues reflect on priorities needed to guide global, national, and local action to address girls' menstrual hygiene management needs in schools.

'He is the one who is providing you with everything so whatever he says is what you do': A Qualitative Study on Factors Affecting Secondary Schoolgirls' Dropout in Rural Western Kenya

Education is an effective way to improve girls’ self-worth, health, and productivity; however there remains a gender gap between girls’ and boys’ completion of school. The literature around factors influencing girls’ decision to stay in school is limited. Seven focus group discussions took place among 79 girls in forms 2 to 4 at secondary schools in rural western Kenya, to examine their views on why girls absent themselves or dropout from school. Data were analysed thematically. Lack of resources, sexual relationships with boyfriends, and menstrual care problems were reported to lead directly to dropout or school absence. These were tied to girls increased vulnerability to pregnancy, poor performance in school, and punishments, which further increase school absence and risk of dropout. Poverty, unmet essential needs, coercive sexual relationships, and an inequitable school environment collude to counter girls’ resolve to complete their schooling. Lack of resources drive girls to have sex with boyfriends or men who provide them with essentials their family cannot afford, such as sanitary pads and transport to school. While these improve quality of their school life, this dynamic increases their exposure to sexual risk, pregnancy, punishment, and dropout. Evaluation of interventions to ameliorate these challenges is warranted, including provision of pocket money to address their needs.