Systematic review of educational interventions to improve the menstrual health of young adolescent girls

Unmet menstrual needs and psychosocial well-being among schoolgirls in Northern Tanzania: baseline results from the PASS MHW study

INTRODUCTION

Improving menstrual health among schoolgirls is essential to meeting the Sustainable Development Goals (SDGs) of good health and wellbeing (SDG 03), quality education (SDG 04), and gender equality (SDG 05). School participation and wellbeing among girls in low and middle-income countries are impacted by inadequate access to quality menstrual materials and WASH facilities, taboos around menstruation, and poor knowledge. Comprehensive evidence is needed to address these challenges and guide policy and practice.

METHODS

An assisted self-completed questionnaire was used to collect socio-demographic information, menstrual-related data, and school climate data from 486 girls in four mixed-gender government secondary schools in Mwanza, Tanzania. The mean (SD) of three Menstrual Practices and Needs Scale (MPNS-36) sub-scores were calculated. Specifically, the extent to which girls perceived needs for carrying and changing menstrual material in school (transport and school environment); washing and drying menstrual material (reuse needs); and privacy and drying menstrual material in school (reuse insecurity) were met. An ANOVA test compared MPNS scores for groups, and logistic regression examined the association between menstrual health and wellbeing outcomes (self-efficacy, menstrual anxiety, school attendance, and participation) and MPNS subscale scores.

RESULTS

The mean age of the 486 participants was 15.6 years (SD 1.3); 87% had started menstruating; the mean age at menarche was 14.2 years (SD 1.15). The majority (75%) of girls experienced pain during the last menstrual period, 39% had menstrual-related anxiety, and 16% missed at least one day of school due to menstruation. The mean MPNS subscale score (out of 3) for the reuse needs ranged from 1.0 to 2.1 across schools; 1.6 to 2.1 for reuse insecurity; and 0.9 to 1.8 for transport and school environment needs. The MPNS subscales had sufficient reliability (Cronbach alpha = 0.74 to 0.9). The subscales also had good construct validity with menstrual-related self-efficacy: higher scores for transport and school environment were associated with confidence to seek menstrual support, participate in class, and predict when periods were about to start.

CONCLUSIONS

Schoolgirls have unmet needs related to transporting and using menstrual material in school, and these needs differed across schools in northern Tanzania. Menstrual-related pain remains a major reason for poor school attendance and participation. Interventions to address menstrual practice needs in schools are required and should include a strong pain management component.

Social Determinants of Health and Dysmenorrhea: A Systematic Review

Social determinants of health play a key role in health disparities. Dysmenorrhea is a highly prevalent and impactful public health problem affecting reproductive-age females. Systematically examining social determinants of health (SDoH) in dysmenorrhea is important for identifying gaps in the literature and informing research, policy, and clinical practice to reduce the public health burden associated with dysmenorrhea. The purpose of this systematic review was to synthesize the literature on SDoH and dysmenorrhea. The review protocol was prospectively registered. We searched Medline, EMBASE, CINAHL, PsycINFO, Scopus, and Google Scholar through February 2024 using search strategies informed by the literature. Screening of the articles, data extraction, and risk-of-bias (RoB) assessment were conducted independently by at least 2 reviewers on the Covidence platform. Among 2,594 unique records screened, 166 met eligibility criteria and were included for data extraction and RoB assessment. Evidence suggests traumatic experiences, toxic environmental exposures, female genital mutilation, job-related stress, lack of menstrual education, and low social support were associated with worse dysmenorrhea outcomes. However, evidence was equivocal regarding the relationships between dysmenorrhea outcomes and SDoH factors, including socioeconomic status, geographical location, race/ethnicity, employment, and religion. Nearly all articles (99.4%) had a high or very high overall RoB. The relationships between SDoH and dysmenorrhea outcomes were often inconsistent and complicated by heterogeneous study populations and methodologies. More rigorous research examining SDoH in dysmenorrhea is needed to inform policy and clinical practice. PERSPECTIVE: This systematic review synthesizes evidence linking SDoH and dysmenorrhea. The relationships between SDoH and dysmenorrhea were often equivocal and complicated by heterogeneous study populations and methodologies. We identify directions for future research and SDoH factors that could be addressed clinically (eg, trauma, menstrual education, and occupational stress).

'Everyone needs to be educated': pupils' voices on menstrual education

BACKGROUND

Physical, affective and behavioural symptoms associated with the menstrual cycle are commonplace. Adolescents with problematic symptoms have reported a negative impact on school attendance, behaviour and participation in physical activity. In the United Kingdom, evidence suggests that menstrual health education delivered by teachers focusses on menstrual cycle biology as opposed to management of menstruation and menstrual cycle related symptoms. Through obtaining the pupil voice, this study aimed to understand young people's perceptions and experiences of menstrual education in schools and their experiences of menstruating whilst at school, including within Physical Education.

METHODS

To address the aims, a qualitative descriptive study was conducted. Nine focus groups with female pupils (n = 48; ages 10-15 years) were completed across six school locations in England and Wales, including primary and secondary schools. A range of elements relating to the menstrual cycle, education at school and PE were discussed by pupils.

RESULTS

Four main themes were developed (a) Education preferences, (b) Period positive environments, (c) Personal experiences and (d) Impact on school. Similarities were reflected across focus groups in terms of current (lacking) education, lesson style and preferences, comfort of conversations, lack of school support and impact on school and PE.

CONCLUSION

The findings highlight the lack of menstrual education received and subsequent impact of menstruation and menstrual-related symptoms in school and PE. The abundance of information requested by pupils highlights the deficit in understanding about how to manage periods in school and remain engaged in physical activity. Schools can utilise information from the current study to; create period positive environments; consider lesson content and format; and explore how to support girls to stay physically active in PE.

Effect of Video Modeling With Simulation on Improving Menstrual Hygiene Skills for Adolescents With Autism Spectrum Disorder

Background Menstruation is a biological process experienced by women every month. This project intends to improve menstrual hygiene skills using video modeling with simulation. Educating adolescent girls with autism spectrum disorder to engage in personal care during their menstrual cycle, particularly sanitation and hygiene, is essential. It is important to develop the knowledge and skills necessary for effective self-care during menstruation to prevent sexual health problems. Additionally, the project aims to provide a safe environment for adolescents to practice their menstrual hygiene routines and relieve the stress from their caregivers. Aim and objective The study aims to evaluate the effect of video modeling with simulation to improve menstrual hygiene skills in adolescents with autism. The ultimate objective of the study is to determine whether video modeling with simulation in the experimental group enhances the practice of menstrual hygiene among adolescent girls with autism, as well as the impact of traditional occupational therapy intervention on improving menstrual hygiene in this population. Methodology This is a quasi-experimental design with convenience sampling and selected samples (n=50), who were then split into two groups: an experimental group (n=25) and a control group (n=25) based on the inclusion and exclusion criteria. The experimental group received video modeling and simulation, while the control group did not receive any specific intervention except parent education and pictorial representations. Pre- and post-tests were conducted to measure the changes. Indian Scale for Assessment of Autism was the screening tool used and the Menstrual Practice Needs Scale (MNPS) was administered. The duration of the study was six months, three sessions per week, lasting 45 minutes to an hour each. The statistical analysis was done with significance at a 1% alpha level using IBM SPSS Statistics for Windows, Version 26 (Released 2019; IBM Corp., Armonk, NY, USA). Results The pre-test and post-test data were analyzed using the Wilcoxon signed-rank test and the Mann-Whitney test. The results demonstrated the comparison of the pre-test and post-test mean scores of the MNPS scores were highly statistically significant (p-value of 0.000) when compared to the control group. Following the implementation of video modeling with simulation, the experimental group's post-test scores were significantly higher than the control group's (p-value of 0.000). Thus, the study showed that video modeling with simulation improved menstrual hygiene in adolescents with autism spectrum disorder. Conclusion The clinical significance of this study was that the adolescents were excited to watch the videos and perform the activities; furthermore, after video modeling with simulation was implemented, there was a significant improvement in the experimental group when compared to the control group. This enhances the practice of the menstrual hygiene skills independently by the adolescents. Video modeling with simulation has paved the way for improving menstrual hygiene in adolescents with autism. Although the findings from the study are positive, more clinical trials are needed to prove that video modeling with simulation can be used as a therapeutic modality.

Efficacy of the Flo App in Improving Health Literacy, Menstrual and General Health, and Well-Being in Women: Pilot Randomized Controlled Trial

BACKGROUND

Reproductive health literacy and menstrual health awareness play a crucial role in ensuring the health and well-being of women and people who menstruate. Further, awareness of one's own menstrual cycle patterns and associated symptoms can help individuals identify and manage conditions of the menstrual cycle such as premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). Digital health products, and specifically menstrual health apps, have the potential to effect positive change due to their scalability and ease of access.

OBJECTIVE

The primary aim of this study was to measure the efficacy of a menstrual and reproductive health app, Flo, in improving health literacy and health and well-being outcomes in menstruating individuals with and without PMS and PMDD. Further, we explored the possibility that the use of the Flo app could positively influence feelings around reproductive health management and communication about health, menstrual cycle stigma, unplanned pregnancies, quality of life, work productivity, absenteeism, and body image.

METHODS

We conducted 2 pilot, 3-month, unblinded, 2-armed, remote randomized controlled trials on the effects of using the Flo app in a sample of US-based (1) individuals who track their cycles (n=321) or (2) individuals who track their cycles and are affected by PMS or PMDD (n=117).

RESULTS

The findings revealed significant improvements at the end of the study period compared to baseline for our primary outcomes of health literacy (cycle tracking: D̄=1.11; t311=5.73, P<.001; PMS or PMDD: D̄=1.20; t115=3.76, P<.001) and menstrual health awareness (D̄=3.97; t311=7.71, P<.001), health and well-being (D̄=3.44; t311=5.94, P<.001), and PMS or PMDD symptoms burden (D̄=-7.08; t115=-5.44, P<.001). Improvements were also observed for our secondary outcomes of feelings of control and management over health (D̄=1.01; t311=5.08, P<.001), communication about health (D̄=0.93; t311=2.41, P=.002), menstrual cycle stigma (D̄=-0.61; t311=-2.73, P=.007), and fear of unplanned pregnancies (D̄=-0.22; t311=-2.11, P=.04) for those who track their cycles, as well as absenteeism from work and education due to PMS or PMDD (D̄=-1.67; t144=-2.49, P=.01).

CONCLUSIONS

These pilot randomized controlled trials demonstrate that the use of the Flo app improves menstrual health literacy and awareness, general health and well-being, and PMS or PMDD symptom burden. Considering the widespread use and affordability of the Flo app, these findings show promise for filling important gaps in current health care provisioning such as improving menstrual knowledge and health.

TRIAL REGISTRATION

OSF Registries osf.io/pcgw7; https://osf.io/pcgw7 ; OSF Registries osf.io/ry8vq; https://osf.io/ry8vq.

Perceptions, Beliefs, and Experiences about the Menstrual Cycle and Menstruation among Young Women: A Qualitative Approach

The experience of menstruation is often associated with negative connotations and gender stereotypes, which results in making it invisible. This research aimed to explore the perceptions, beliefs, and knowledge of young Spanish women regarding the menstrual cycle and menstruation and their impact on their lives. The study delves into their understanding, menstrual management practices, the types of menstrual products employed, and their experiences related to menstrual health. Qualitative methodology was used with discussion groups as a data collection technique. The participants comprised 45 young Spanish women, aged between 18 and 23, hailing from both rural and urban areas. The majority were university students, with some engaged in part-time work, and one participant working full-time. While many experienced menstrual pain ranging from mild to debilitating, a normalization of this pain often led them to forego seeking specialist assistance. Disposable menstrual products (DMPs) are the most used by participants, despite limited awareness of their absorption capacity. Regarding reusable menstrual products (RMPs), menstrual cup users emphasized comfort but expressed a need for proper training. Negative menstruation experiences could evoke fear and difficulties, underscoring the importance of providing comprehensive menstrual health education encompassing both theoretical and practical components.

Perspectives on menstrual policymaking and community-based actions in Catalonia (Spain): a qualitative study

BACKGROUND

Menstrual research and policymaking have become imperative worldwide. It is necessary that these are informed by women and people who menstruate (PWM) alongside expert professionals and activists.

METHODS

The main aim of this study was to identify and propose policies and community-based actions to address menstrual inequity and promote menstrual health in Catalonia (Spain). This study consisted of two qualitative studies: (a) 34 individual photoelicitation interviews with women and PWM, (b) a World Café study with 22 professionals and activists. Sampling for both studies was purposive and selective. Recruitment was conducted through healthcare centres, social media, key contacts, and snowball sampling techniques. Data were collected in December 2020-September 2022, and analysed using Framework Analysis.

RESULTS

Participants considered the implementation of menstrual policies that address the taboo and stigma of menstruation to be crucial. They stressed the need for menstrual education, which should be integrated into formal education curricula. Participants, and especially women and PWM, highlighted the need to improve the access and quality of healthcare services, so that the menstrual cycle and menstruation are seen as health indicators. Health professionals should encourage agentic informed decisions, hence why both participant groups considered menstrual health education amongst health professionals to be pivotal. Taking action to improve the access and affordability of menstrual products was also imperative for participants, especially for socioeconomically vulnerable populations. Participants agreed on guaranteeing fully equipped menstrual management facilities, and and professionals discussed gender-neutral and sex-segregated bathrooms. Workplace menstrual policies to accommodate and ensure menstrual self-care were also suggested.

CONCLUSIONS

Our study highlights the need for multi-dimensional menstrual policies. These should include actions to address menstrual taboo and stigma, to promote menstrual education that goes beyond the hegemonic biomedical prism, to improve the access and quality of menstrual health services, along with policies ensuring adequate menstrual management facilities in public spaces and the access to menstrual products. Policymaking should also focus on how to ensure menstrual management and care in workplaces. Menstrual policies and community-based actions should be framed within intersectionality, to consider how societal structures of power and oppression influence menstrual experiences.

A mixed-methods study measuring the effectiveness of a menstrual health intervention on menstrual health knowledge, perceptions and practices among young women in Zimbabwe

OBJECTIVES

While integral to women's physical and mental well-being, achieving good menstrual health (MH) remains a challenge for many women. This study investigated the effectiveness of a comprehensive MH intervention on menstrual knowledge, perceptions and practices among women aged 16-24 years in Harare, Zimbabwe.

DESIGN

A mixed-methods prospective cohort study with pre-post evaluation of an MH intervention.

SETTING

Two intervention clusters in Harare, Zimbabwe.

PARTICIPANTS

Overall, 303 female participants were recruited, of whom 189 (62.4%) were seen at midline (median follow-up 7.0; IQR 5.8-7.7 months) and 184 (60.7%) were seen at endline (median follow-up 12.4; IQR 11.9-13.8 months). Cohort follow-up was greatly affected by COVID-19 pandemic and associated restrictions.

INTERVENTION

The MH intervention provided MH education and support, analgesics, and a choice of menstrual products in a community-based setting to improve MH outcomes among young women in Zimbabwe.

PRIMARY AND SECONDARY OUTCOMES

Effectiveness of a comprehensive MH intervention on improving MH knowledge, perceptions, and practices among young women over time. Quantitative questionnaire data were collected at baseline, midline, and endline. At endline, thematic analysis of four focus group discussions was used to further explore participants' menstrual product use and experiences of the intervention.

RESULTS

At midline, more participants had correct/positive responses for MH knowledge (adjusted OR (aOR)=12.14; 95% CI: 6.8 to 21.8), perceptions (aOR=2.85; 95% CI: 1.6 to 5.1) and practices for reusable pads (aOR=4.68; 95% CI: 2.3 to 9.6) than at baseline. Results were similar comparing endline with baseline for all MH outcomes. Qualitative findings showed that sociocultural norms, stigma and taboos around menstruation, and environmental factors such as limited access to water, sanitation and hygiene facilities affected the effect of the intervention on MH outcomes.

CONCLUSIONS

The intervention improved MH knowledge, perceptions and practices among young women in Zimbabwe, and the comprehensive nature of the intervention was key to this. MH interventions should address interpersonal, environmental and societal factors.

TRIAL REGISTRATION NUMBER

NCT03719521.