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Betsu BD, Medhanyie AA, Gebrehiwet TG, Wall LL. Menstrual hygiene management interventions and their effects on schoolgirls' menstrual hygiene experiences in low and middle countries: A systematic review. PLoS One 2024; 19:e0302523. [PMID: 39172930 PMCID: PMC11340951 DOI: 10.1371/journal.pone.0302523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 04/07/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND Inadequate menstrual hygiene management can result in physical, social, psychological, and educational challenges for schoolgirls. To address these issues, researchers have conducted intervention studies, but the impact on school attendance has varied. This review has systematically collected and evaluated evidence about the effects of menstrual hygiene interventions on schoolgirls. METHOD A systematic search of the literature was done and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA statement). Both peer-reviewed journals and gray literature were searched using PubMed and Google Scholar. The search included individual, or cluster randomized controlled trials, and quasi-experimental studies, and covered the period from the date of indexing until January 3, 2023. RESULT A review of sixteen trial studies showed that menstrual hygiene interventions have a positive effect on schoolgirls' school attendance, performance, and dropout rates, as well as on their menstrual knowledge, attitudes, practices, and emotional well-being. There was a low to medium risk of bias in most of the studies. Additionally, the literature overlooked the impact of interventions that involve parental and male engagement, interventions correcting community misperceptions about menstruation, and the impact of infrastructure improvements on water, sanitation, and hygiene. CONCLUSION Interventions aimed at improving menstrual hygiene management can enhance schoolgirls' educational outcomes, and can improve their menstrual knowledge, attitudes, and practices by helping them manage their periods more effectively. Most interventions have focused on the provision of menstrual products and menstrual education but have neglected improvements in the physical environment at home and school and the social norms surrounding menstruation. Trial studies should take a holistic approach that considers the total socio-cultural environment in which menstrual hygiene management takes place, thus enabling stakeholders and policymakers to develop sustainable, long-term solutions to these problems.
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Affiliation(s)
- Balem Demtsu Betsu
- Department of Midwifery, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Araya Abrha Medhanyie
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | | | - L. Lewis Wall
- Department of Anthropology, College of Arts and Sciences, Washington University in St. Louis, St. Louis, MO, United States of America
- Department of Obstetrics & Gynecology, Washington University in St. Louis, St. Louis, MO, United States of America
- Department of Obstetrics & Gynecology, Ayder Comprehensive Specialized Hospital, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
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García-Egea A, López-Jiménez T, Jacques-Aviñó C, Morero Beltrán AM, Pi Sánchez A, Martínez-Bueno C, Carrilero-Carrió N, Berenguera A, Medina-Perucha L. [Menstrual experiences and acceptability of a menstrual equity intervention among adolescents in Catalonia (Spain)]. GACETA SANITARIA 2024; 38:102415. [PMID: 39047371 DOI: 10.1016/j.gaceta.2024.102415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 06/12/2024] [Accepted: 06/13/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE To explore menstrual knowledge, menstrual management, the use of menstrual products, the prevalence of menstrual poverty and to assess the acceptability of a menstrual equity intervention among students in the fourth grade of compulsory secondary education in Catalonia (Spain). METHOD Post-intervention mixed-methods study (cross-sectional study and qualitative study with focus groups) with a critical and gender perspective. It was conducted between July 2022 and March 2023. Descriptive and bivariate statistical analyses stratified by gender were carried out. Qualitative data were analysed using thematic analysis. RESULTS Women and people who menstruate rated the intervention favourably, while some men were reluctant. The intervention promoted the use of some reusable menstrual products, although some barriers to use menstrual cups were identified. Participants reported institutional barriers to menstrual management in the school setting and 19.4% stopped attending school during menstruation in the 6 months prior to the study. Between 10.9-16.4% reported menstrual poverty in the 6 months prior to the study, and 29,0% took actions to reduce the environmental impact of menstrual products. CONCLUSIONS This study highlights the need for co-designing menstrual interventions that consider gender dynamics and sexist attitudes with students, as well as targeting it to teachers. The provision of reusable menstrual products can be helpful in promoting their use, although accompaniment should be provided. In parallel, it is crucial to strengthen menstrual education, as well as to reduce menstrual poverty and school absenteeism during menstruation.
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Affiliation(s)
- Andrea García-Egea
- Fundació Institut Universitari per a la Recerca a l'Atenció Primária de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, España; Universitat Autónoma de Barcelona, Bellaterra (Cerdanyola del Vallès, Barcelona), España
| | - Tomàs López-Jiménez
- Fundació Institut Universitari per a la Recerca a l'Atenció Primária de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, España; Universitat Autónoma de Barcelona, Bellaterra (Cerdanyola del Vallès, Barcelona), España
| | - Constanza Jacques-Aviñó
- Fundació Institut Universitari per a la Recerca a l'Atenció Primária de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, España; Universitat Autónoma de Barcelona, Bellaterra (Cerdanyola del Vallès, Barcelona), España; Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), España
| | - Anna María Morero Beltrán
- Departament d'Igualtat i Feminismes, Generalitat de Catalunya, Barcelona, España; Departament de Sociologia, Universitat de Barcelona, Barcelona, España
| | - Aina Pi Sánchez
- Servei d'Atenció a la Salut Sexual i Reproductiva (ASSIR), Direcció Assistencial d'Atenció Primària, Institut Català de la Salut, Barcelona, España
| | - Cristina Martínez-Bueno
- Grup de Recerca de l'Atenció a la Salut Sexual i Reproductiva (GRASSIR), Barcelona, España; Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Barcelona, España; Grup de Recerca en Atenció Primària i Comunitària en Barcelona (APICBA), Hospital del Mar Research Institute, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España
| | - Neus Carrilero-Carrió
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), España; Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Barcelona, España; Grup de Recerca en Atenció Primària i Comunitària en Barcelona (APICBA), Hospital del Mar Research Institute, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España
| | - Anna Berenguera
- Fundació Institut Universitari per a la Recerca a l'Atenció Primária de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, España; Universitat Autónoma de Barcelona, Bellaterra (Cerdanyola del Vallès, Barcelona), España; Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), España; Departament d'Infermeria, Universitat de Girona, Girona, España
| | - Laura Medina-Perucha
- Fundació Institut Universitari per a la Recerca a l'Atenció Primária de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, España; Universitat Autónoma de Barcelona, Bellaterra (Cerdanyola del Vallès, Barcelona), España; Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), España.
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Tembo M, Simms V, Weiss HA, Bandason T, Redzo N, Larsson L, Dauya E, Nzanza T, Ishumael P, Gweshe N, Nyamwanza R, Ndlovu P, Bernays S, Chikwari CD, Mavodza CV, Renju J, Francis SC, Ferrand RA, Mackworth-Young C. High uptake of menstrual health information, products and analgesics within an integrated sexual reproductive health service for young people in Zimbabwe. Reprod Health 2024; 21:56. [PMID: 38649934 PMCID: PMC11036648 DOI: 10.1186/s12978-024-01789-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 04/09/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Despite being integral to women's well-being, achieving good menstrual health (MH) remains a challenge. This study examined MH services uptake (including information, analgesics, and a choice of MH products - the menstrual cup and reusable pads) and sustained use of MH products within an integrated sexual and reproductive health intervention for young people in Zimbabwe. METHODS This mixed-methods study was nested within a cluster randomised trial of integrated sexual and reproductive health services (CHIEDZA) for youth in three provinces (Harare, Mashonaland East, and Bulawayo). The study collected qualitative and quantitative data from 27,725 female clients aged 16-24 years, who accessed CHIEDZA from April 2019 - March 2022. Using a biometric (fingerprint recognition) identification system, known as SIMPRINTS, uptake of MH information, products, and analgesics and other services was tracked for each client. Descriptive statistics and logistic regression were used to investigate MH service uptake and product choice and use over time, and the factors associated with these outcomes. Thematic analysis of focus group discussions and interviews were used to further explore providers' and participants' experiences of the MH service and CHIEDZA intervention. RESULTS Overall, 36,991 clients accessed CHIEDZA of whom 27,725 (75%) were female. Almost all (n = 26,448; 95.4%) took up the MH service at least once: 25433 took up an MH product with the majority (23,346; 92.8%) choosing reusable pads. The uptake of cups varied across province with Bulawayo province having the highest uptake (13.4%). Clients aged 20-24 years old were more likely to choose cups than reusable pads compared with those aged 16-19 years (9.4% vs 6.0%; p < 0.001). Over the implementation period, 300/1819 (16.5%) of clients swapped from the menstrual cup to reusable pads and 83/23346 (0.4%) swapped from reusable pads to the menstrual cup. Provision of the MH service encouraged uptake of other important SRH services. Qualitative findings highlighted the provision of free integrated SRH and MH services that included a choice of MH products and analgesics in a youth-friendly environment were key to high uptake and overall female engagement with SRH services. CONCLUSIONS High uptake demonstrates how the MH service provided much needed access to MH products and information. Integration of MH within an SRH intervention proved central to young women accessing other SRH services.
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Affiliation(s)
- Mandikudza Tembo
- MRC International Statistics & Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK.
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe.
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - Victoria Simms
- MRC International Statistics & Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen A Weiss
- MRC International Statistics & Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Tsitsi Bandason
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Nicol Redzo
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Leyla Larsson
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
- Division of Infectious Diseases and Tropical Medicine, Ludwig Maximilian University Hospital, Munich, Germany
| | - Ethel Dauya
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Tafadzwa Nzanza
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Pauline Ishumael
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Nancy Gweshe
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Rangarirai Nyamwanza
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Precious Ndlovu
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Sarah Bernays
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
- School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Chido Dziva Chikwari
- MRC International Statistics & Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Constancia Vimbayi Mavodza
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenny Renju
- MRC International Statistics & Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Suzanna C Francis
- MRC International Statistics & Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Rashida A Ferrand
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Constance Mackworth-Young
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Poague KIHM, Blanford JI, Martínez JA, Anthonj C. Preparing schools for future pandemics: Insights on water, sanitation and hygiene solutions from the Brazilian school reopening policies. Int J Hyg Environ Health 2024; 257:114325. [PMID: 38330729 DOI: 10.1016/j.ijheh.2024.114325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/04/2024] [Accepted: 01/25/2024] [Indexed: 02/10/2024]
Abstract
Post-COVID-19, schools urgently need to enhance infection control and prevention (IPC) measures, including water, sanitation, and hygiene (WASH), to prepare for future outbreaks and pandemics. Particularly in Brazil, that is of particular concern, as students are still recovering from the 20th longest school closure in the world. Hence, the current study had two goals: (i) to describe WASH solutions outlined in policies released at the federal, state, and capital city levels in Brazil during the COVID-19 pandemic for the safe reopening of schools and (ii) to discuss their potential to enhance school's capacity to remain operational during a new pandemic or outbreak. With a qualitative exploratory approach, we performed content analysis to discuss the direction (what, where, how and for whom?) of 66 public policies by integrating four frameworks. Solutions were discussed in the light of the principles of human rights and the human rights to water and sanitation, international guidelines for WASH and IPC in schools and the Sphere minimum standards for humanitarian aid. One hundred and fifty-nine solutions, spanning five thematic areas and five population groups, including software and hardware interventions, were compiled for potential use in Brazil and beyond. While suggested solutions have the potential to provide a cleaner and safer learning environment, it is essential to exercise caution when implementing these measures and adapt them to the specific circumstances of each school.
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Affiliation(s)
- Kasandra I H M Poague
- Faculty of Geo-Information Science and Earth Observation-ITC, University of Twente, Enschede, the Netherlands.
| | - Justine I Blanford
- Faculty of Geo-Information Science and Earth Observation-ITC, University of Twente, Enschede, the Netherlands
| | - Javier A Martínez
- Faculty of Geo-Information Science and Earth Observation-ITC, University of Twente, Enschede, the Netherlands
| | - Carmen Anthonj
- Faculty of Geo-Information Science and Earth Observation-ITC, University of Twente, Enschede, the Netherlands
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Head A, Huggett C, Chea P, Yamakoshi B, Suttor H, Hennegan J. Systematic review of the effectiveness of menstrual health interventions in low- and middle-income countries in the East Asia and Pacific region. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 20:100295. [PMID: 38234706 PMCID: PMC10794107 DOI: 10.1016/j.lansea.2023.100295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/07/2023] [Accepted: 09/26/2023] [Indexed: 01/19/2024]
Abstract
Background In the context of rapidly expanding policy and practice, this systematic review collates and appraises evidence for the effectiveness of menstrual health interventions in the East Asia and Pacific region. Methods Structured searches were undertaken in 7 databases and Google Scholar. Grey literature was identified through searching and survey of stakeholders. Quantitative evaluations were eligible. We audited the interventions and outcomes assessed in current evidence, undertook risk of bias assessment, and narrative synthesis of findings. The review protocol was registered prior to searching (PROSPERO: 343613). Findings Eighteen studies were eligible; categorised according to the requirements for menstrual health they addressed. Information and education intervention studies (n = 11) found school-based programs improved menstrual knowledge test scores but did not evaluate impacts on broader outcomes. Evaluations of interventions providing materials, facilities, and services for menstruation (n = 4) focused on product acceptability. Studies exhibited a serious risk of bias without adequate controls, limitations in intervention allocation, adherence, and participant retention. Six studies of interventions to improve care for menstrual discomforts found decreased self-reported pain but had serious bias without placebo controls. Two interventions targeted the supportive social environment for menstruation. Interpretation There is insufficient evidence for the effectiveness of menstrual health interventions in the East Asia and Pacific region. Future research must improve reporting, provide clear intervention theory of change, and improve measurement of core concepts. Evaluations of interventions that align with policy and practice are needed, facilitated by partnerships between researchers, government, and practitioners. Funding UNICEF. Reckitt Global Hygiene Institute. NHMRC.
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Affiliation(s)
- Alexandra Head
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | | | - Pisey Chea
- WaterAid Australia, Melbourne, VIC, Australia
| | | | - Heather Suttor
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Julie Hennegan
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
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Plesons M, Torondel B, Caruso BA, Hennegan J, Sommer M, Haver J, Keiser D, van Eijk AM, Zulaika G, Mason L, Phillips-Howard PA. Research priorities for improving menstrual health across the life-course in low- and middle-income countries. Glob Health Action 2023; 16:2279396. [PMID: 38010372 PMCID: PMC10795652 DOI: 10.1080/16549716.2023.2279396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/31/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Research on menstrual health is required to understand menstrual needs and generate solutions to improve health, wellbeing, and productivity. The identification of research priorities will help inform where to invest efforts and resources. OBJECTIVES To identify research priorities for menstrual health across the life-course, in consultation with a range of stakeholder groups from a variety of geographic regions, and to identify if menstrual health research priorities varied by expertise. METHODS A modified version of the Child Health and Nutrition Research Initiative approach was utilized to reach consensus on a set of research priorities. Multisector stakeholders with menstrual health expertise, identified through networks and the literature, were invited to submit research questions through an online survey. Responses were consolidated, and individuals were invited to rank these questions based on novelty, potential for intervention, and importance/impact. Research priority scores were calculated and evaluated by participants' characteristics. RESULTS Eighty-two participants proposed 1135 research questions, which were consolidated into 94 unique research questions. The mean number of questions did not differ between low- and middle-income country (LMIC) and high-income country (HIC) participants, but significantly more questions were raised by participants with expertise in mental health and WASH. Sixty-six participants then ranked these questions. The top ten-ranked research questions included four on 'understanding the problem', four on 'designing and implementing interventions', one on 'integrating and scaling up', and one on 'measurement'. Indicators for the measurement of adequate menstrual health over time was ranked the highest priority by all stakeholders. Top ten-ranked research questions differed between academics and non-academics, and between participants from HICs and LMICs, reflecting differences in needs and knowledge gaps. CONCLUSIONS A list of ranked research priorities was generated through a consultative process with stakeholders across LMICs and HICs which can inform where to invest efforts and resources.
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Affiliation(s)
- Marina Plesons
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Belen Torondel
- Department of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Bethany A. Caruso
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Julie Hennegan
- Maternal, Child, and Adolescent Health Program, Burnet Institute, Melbourne, Australia
| | - Marni Sommer
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Jacquelyn Haver
- School Health and Nutrition, Department of Education and Children Protection, Save the Children US, Washington, DC, USA
| | | | - Anna M. van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Garazi Zulaika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Linda Mason
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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Cherenack EM, Rubli J, Melara A, Ezaldein N, King A, Alcaide ML, Raccamarich P, Fein LA, Sikkema KJ. Adolescent girls' descriptions of dysmenorrhea and barriers to dysmenorrhea management in Moshi, Tanzania: A qualitative study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001544. [PMID: 37410763 DOI: 10.1371/journal.pgph.0001544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 05/22/2023] [Indexed: 07/08/2023]
Abstract
Dysmenorrhea (menstrual pain) is common among adolescent girls globally, but many girls in Sub-Saharan Africa do not receive effective treatment. Qualitative interviews were used to describe adolescent girls' experiences of dysmenorrhea and identify sociocultural barriers to dysmenorrhea management in Moshi, Tanzania. From August to November 2018, in-depth interviews were conducted with 10 adolescent girls and 10 adult experts (e.g., teachers, medical providers) who have experience working with girls in Tanzania. Thematic content analysis identified themes related to dysmenorrhea, including descriptions of dysmenorrhea and the impact of dysmenorrhea on well-being, as well as factors influencing the use of pharmacological and behavioral pain management strategies. Potential barriers to dysmenorrhea management were identified. Dysmenorrhea negatively impacted the physical and psychological well-being of girls and hindered girls' ability to participate in school, work, and social events. The most common pain management strategies were resting, drinking hot water, engaging in physical activity, and taking paracetamol. Barriers to dysmenorrhea management included beliefs that medications are harmful to the body or can hinder fertility, limited knowledge about the benefits of hormonal contraceptives to manage menstruation, little continuing education for healthcare providers, and a lack of consistent access to effective medications, medical care, or other supplies necessary for pain management. Medication hesitancy and inconsistent access to effective medication and other menstrual supplies must be addressed to improve girls' ability to manage dysmenorrhea in Tanzania.
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Affiliation(s)
- Emily M Cherenack
- Department of Public Health Sciences, University of Miami, Miami, Florida, United States of America
- Department of Psychology and Neuroscience, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | | | - Abraham Melara
- Division of Infectious Diseases, Department of Medicine, University of Miami, Miami, Florida, United States of America
| | - Nada Ezaldein
- Division of Infectious Diseases, Department of Medicine, University of Miami, Miami, Florida, United States of America
| | - Aisha King
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
| | - Maria L Alcaide
- Department of Public Health Sciences, University of Miami, Miami, Florida, United States of America
- Division of Infectious Diseases, Department of Medicine, University of Miami, Miami, Florida, United States of America
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Miami, Miami, Florida, United States of America
| | - Patricia Raccamarich
- Division of Infectious Diseases, Department of Medicine, University of Miami, Miami, Florida, United States of America
| | - Lydia A Fein
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Miami, Miami, Florida, United States of America
| | - Kathleen J Sikkema
- Department of Psychology and Neuroscience, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Sociomedical Sciences, Columbia University, New York, New York, United States of America
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Sebert Kuhlmann A, Palovick KA, Teni MT, Hunter E. Period Product Resources and Needs in Schools: A Statewide Survey of Missouri's School Nurses. THE JOURNAL OF SCHOOL HEALTH 2023; 93:557-564. [PMID: 36893763 DOI: 10.1111/josh.13326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 02/13/2023] [Accepted: 02/26/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND School nurses play a vital role in ensuring the health and well-being of their students, but little is known about menstrual products and resources available in schools. This study assessed period product resources and needs in Missouri schools from the perspective of school nurses and analyzed differences by district enrollment characteristics. METHODS An electronic survey was emailed to public, charter, private, and parochial school nurses in Missouri who served fourth grade or older. From January through March 2022, 976 self-administered surveys were completed (40% response rate). Logistic regressions examined the associations between student needs and district characteristics. RESULTS Among the sample, 70.7% knew students who could not afford period products, and 68.0% knew students who had missed school because of their period. When controlling for district size, race/ethnicity, and urban/rural classification, as the percentage free- or reduced-lunch (FRL) eligibility increases in a school, awareness of students struggling to afford products increases (AOR = 1.008, 95% confidence interval 1.000, 1.015). IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY School nurses need the resources and educational materials to support students to help reduce menstruation-related absences. CONCLUSIONS Issues of period poverty cut across districts of differing enrollment characteristics, yet FRL percentage is an important predictor.
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Affiliation(s)
- Anne Sebert Kuhlmann
- College for Public Health and Social Justice, Saint Louis University, St. Louis, MO
| | - Kirstin A Palovick
- College for Public Health and Social Justice, Saint Louis University, St. Louis, MO
| | - Mintesnot T Teni
- College for Public Health and Social Justice, Saint Louis University, St. Louis, MO
| | - Emily Hunter
- College for Public Health and Social Justice, Saint Louis University, St. Louis, MO
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Tembo M, Simms V, Weiss HA, Bandason T, Redzo N, Larsson L, Dauya E, Nzanza T, Ishumael P, Gweshe N, Nyamwanza R, Ndlovu P, Bernays S, Chikwari CD, Mavodza CV, Renju J, Francis SC, Ferrand RA, Mackworth-Young C. High uptake of menstrual health information, products and analgesics within an integrated sexual reproductive health service for young people in Zimbabwe. RESEARCH SQUARE 2023:rs.3.rs-3058045. [PMID: 37461550 PMCID: PMC10350165 DOI: 10.21203/rs.3.rs-3058045/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
Background Achieving good menstrual health (MH), integral to women's well-being, remains a challenge. This study examined MH services uptake (including information, analgesics, and a choice of MH products - the menstrual cup and reusable pads) and sustained use of MH products within an integrated sexual and reproductive health intervention for young people in Zimbabwe. Methods This study was embedded within a cluster randomised trial of integrated sexual and reproductive health services (CHIEDZA) in three provinces (Harare, Mashonaland East, and Bulawayo). The study collected qualitative and quantitative data from female clients aged 16-24 years, who accessed CHIEDZA from April 2019 - March 2022. Uptake of MH information, products, and analgesics and other services was tracked for each client. Descriptive statistics and logistic regression were used to investigate MH service uptake and product choice and use over time, and the factors associated with these outcomes. Thematic analysis of focus group discussions and interviews were used to further explore providers' and participants' experiences of the MH service and CHIEDZA intervention. Results Overall, 36991 clients accessed CHIEDZA of whom 27725 (75%) were female. Almost all (n = 26448; 95.4%) took up the MH service at least once: 25433 took up an MH product with the majority (23346; 92.8%) choosing reusable pads. The uptake of cups varied across province with Bulawayo province having the highest uptake (13.4%). Clients aged 20-24 years old were more likely to choose cups than reusable pads compared with those aged 16-19 years (9.4% vs 6.0%; p < 0.001). Over the implementation period, 300/1819 (16.5%) of clients swapped from the menstrual cup to reusable pads and 83/23346 (0.4%) swapped from reusable pads to the menstrual cup. Provision of the MH service encouraged uptake of other important SRH services. Qualitative findings highlighted the provision of free integrated SRH and MH services that included a choice of MH products and analgesics in a youth-friendly environment were key to high uptake and overall female engagement with SRH services. Conclusions High uptake demonstrates how the MH service provided much needed access to MH products and information. Integration of MH within an SRH intervention proved central to young women accessing other SRH services.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jenny Renju
- London School of Hygiene & Tropical Medicine
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10
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Delanerolle G, Yang XJ, Cavalini H, Kurmi OP, Røstvik CM, Shetty A, Saraswat L, Taylor J, Sajid S, Rathod S, Shi JQ, Phiri P. Exploratory systematic review and meta-analysis on period poverty. World J Meta-Anal 2023; 11:196-217. [DOI: 10.13105/wjma.v11.i5.196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/18/2023] [Accepted: 05/06/2023] [Indexed: 06/16/2023] Open
Abstract
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 30th of April 1980 and the 30th 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.
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Affiliation(s)
- Gayathri Delanerolle
- Department of Research & Innovation, Southern Health NHS Foundation Trust, Southampton SO30 3JB, United Kingdom
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 7JX, United Kingdom
| | - Xiao-Jie Yang
- School of Statistics and Mathematics, Yunnan University of Finance and Economics, Kunming 650221, Yunnan Province, China
- University College London, London WC1E 6BT, United Kingdom
| | - Heitor Cavalini
- Department of Research & Innovation, Southern Health NHS Foundation Trust, Southampton SO30 3JB, United Kingdom
| | - Om P Kurmi
- Centre for Intelligent Healthcare, Institute of Health and Wellbeing, Coventry University, Coventry CV1 5LB, United Kingdom
| | - Camilla Mørk Røstvik
- Centre for Contemporary Art, University of St Andrews, Scotland KY16 9AJ, United Kingdom
| | - Ashish Shetty
- University College London, London WC1E 6BT, United Kingdom
- Pain Management Centre, University College London Hospitals NHS Foundation Trust, London W1T 4AJ, United Kingdom
| | - Lucky Saraswat
- Aberdeen Centre for Women’s Health, University of Aberdeen, Aberdeen AB24 3FX, United Kingdom
| | - Julie Taylor
- School of Nursing, University of Birmingham, Birmingham B152TT, United Kingdom
| | - Sana Sajid
- Department of Research & Innovation, Southern Health NHS Foundation Trust, Southampton SO30 3JB, United Kingdom
| | - Shanaya Rathod
- Department of Research & Innovation, Southern Health NHS Foundation Trust, Southampton SO30 3JB, United Kingdom
| | - Jian-Qing Shi
- Department of Research & Innovation, Southern Health NHS Foundation Trust, Southampton SO30 3JB, United Kingdom
- Statistics and Data Science, Southern University of Science and Technology, Shenzhen 518055, Guangdong Province, China
| | - Peter Phiri
- Department of Research & Innovation, Southern Health NHS Foundation Trust, Southampton SO30 3JB, United Kingdom
- School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton SO17 1BJ, United Kingdom
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11
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Yang YT, Chen DR. Effectiveness of a menstrual health education program on psychological well-being and behavioral change among adolescent girls in rural Uganda. J Public Health Afr 2023; 14:1971. [PMID: 37197264 PMCID: PMC10184177 DOI: 10.4081/jphia.2023.1971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 07/04/2022] [Indexed: 05/19/2023] Open
Abstract
Objectives. Menstrual hygiene management is one of the main barriers to girls' education attainment in low-and middle-income countries. Poor access to sanitary products and lack of menstrual knowledge affect students' performance at school compared to the opposite sex. Limited evidence is available to provide solutions for schoolgirls. This study examines the effectiveness of menstrual health education programs on well-being and behavioral change among adolescent girls in rural Uganda. Methods. A cluster randomized controlled trial was conducted across 3 schools, including 66 girls aged 13-17 years, in a rural village in Mukono District, Uganda. Schools were randomly allocated to 2 groups: i) health education program intervention and ii) control group (no intervention). Results. After 5 weeks of the Health Education Program, the schoolgirls in experiment groups showed significantly less fear of sharing the menstruation-related concern with parents and pupils [Mean Difference (MD)=0.87, P=0.029) (MD=2.02, P=0.000), and the sense of shameful feelings during menstruation (MD=1.65, P= 0.004); conversely, the fear to go to school during menstruation did not differ between experiment and control groups (MD=-0.04, P=0.94). However, the changes in feeling comfortable having a period at school were significantly different between the experiment and control groups (P=0.001). Conclusions. The study demonstrated promising results of a low-cost intervention for enhancing girls' menstrual health education in a low-income context. Puberty education and reusable pad sewing provision were strongly associated with improving schoolgirls' psychosocial wellbeing related to menstrual management.
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Affiliation(s)
- Yi-Ting Yang
- Master of Public Health, College of Public Health, National Taiwan University, Taipei
| | - Duan-Rung Chen
- Institute of Health Behaviors and Community Sciences, College of Public Health, National Taiwan University, Taipei, Taiwan
- Institute of Health Behaviors and Community Sciences, College of Public Health, National Taiwan University, Taipei, Taiwan, No. 17, Xu-Zhou Road, Taipei, Taiwan. +886-2-3366-8066.
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12
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Poague KIHM, Blanford JI, Martínez JA, Anthonj C. Water, sanitation and hygiene (WASH) in schools in Brazil pre-and peri-COVID-19 pandemic: Are schools making any progress? Int J Hyg Environ Health 2023; 247:114069. [PMID: 36423433 PMCID: PMC9637527 DOI: 10.1016/j.ijheh.2022.114069] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 10/23/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022]
Abstract
The previous paucity of data and research on water, sanitation and hygiene (WASH) in schools in Brazil have been preventing an assessment of how safe and healthy schools are to reopen during the COVID-19 pandemic. This study aimed first to assess the current situation of WASH in schools in Brazil and, second, to evaluate to what extent Brazilian schools have been making any progress in providing WASH since the beginning of the COVID-19 pandemic. Data on WASH conditions in schools in Brazil was retrieved from the 2020 and 2021 Brazilian National School Census (BNSC). For the first objective, frequencies of 31 variables were calculated for the whole country and regions, considering all 173,700 schools from BNSC of 2021. Five main variables were considered as indicators of adequate WASH infrastructure in schools. T-test and ANOVA were used to assess differences in these five variables according to the locality, management model and regions. For the second objective only schools presented in both datasets (n = 170,422) were considered to compare WASH in schools pre- and peri-COVID-19 pandemic. Frequencies of 31 variables were calculated for the whole country and regions before and during the pandemic. Paired t-tests were conducted when differences in variables across the years were observed. At the present moment, the majority of schools in Brazil have bathrooms (97%), drinking water with quality suitable for human consumption (95%), improved sanitation facilities (78%) and solid waste collection (70%). Between 2020 and 2021, there was a mix of improvements and deterioration in the school's WASH infrastructure in all regions of the country. Overall, solely considering the WASH infrastructure, schools in the South and Southeast regions of the country are better prepared for the safe reopening. Nevertheless, public schools, schools located in rural areas and the North and Northeast regions of the country, are more in need of WASH interventions. Results indicate that little progress was achieved, and schools in Brazil are still in need of improvements.
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Affiliation(s)
- Kasandra I H M Poague
- Faculty of Geo-Information Science and Earth Observation-ITC, University of Twente, Enschede, the Netherlands.
| | - Justine I Blanford
- Faculty of Geo-Information Science and Earth Observation-ITC, University of Twente, Enschede, the Netherlands
| | - Javier A Martínez
- Faculty of Geo-Information Science and Earth Observation-ITC, University of Twente, Enschede, the Netherlands
| | - Carmen Anthonj
- Faculty of Geo-Information Science and Earth Observation-ITC, University of Twente, Enschede, the Netherlands
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13
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Babagoli MA, Benshaul-Tolonen A, Zulaika G, Nyothach E, Oduor C, Obor D, Mason L, Kerubo E, Ngere I, Laserson KF, Tudor Edwards R, Phillips-Howard PA. Cost-Effectiveness and Cost-Benefit Analyses of Providing Menstrual Cups and Sanitary Pads to Schoolgirls in Rural Kenya. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2022; 3:773-784. [PMID: 36185073 PMCID: PMC9518800 DOI: 10.1089/whr.2021.0131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Masih A. Babagoli
- Department of Economics, Barnard College, Columbia University, New York, USA
| | | | - Garazi Zulaika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Elizabeth Nyothach
- Centre for Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Clifford Oduor
- Centre for Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - David Obor
- Centre for Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Linda Mason
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Emily Kerubo
- Centre for Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Isaac Ngere
- County Health Headquarters, Ministry of Health, Siaya County, Kenya
| | - Kayla F. Laserson
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Rhiannon Tudor Edwards
- Centre for Health Economics and Medicines Evaluations, Bangor University, Bangor, United Kingdom
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Shah V, Phillips-Howard P, Hennegan J, Cavill S, Sonko B, Sinjanka E, Camara Trawally N, Kanteh A, Mendy F, Bah AB, Saar M, Ross I, Schmidt W, Torondel B. Puberty health intervention to improve menstrual health and school attendance among adolescent girls in The Gambia: study methodology of a cluster-randomised controlled trial in rural Gambia (MEGAMBO TRIAL). Emerg Themes Epidemiol 2022; 19:6. [PMID: 35842700 PMCID: PMC9287699 DOI: 10.1186/s12982-022-00114-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 06/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Menstrual health (MH) is a recognised global public health challenge. Poor MH may lead to absence from school and work, and adverse health outcomes. However, reviews suggest a lack of rigorous evidence for the effectiveness of MH interventions on health and education outcomes. The objective of this paper is to describe the methods used in a cluster-randomised controlled trial to estimate the effect of a multi-component intervention to improve MH and school attendance in The Gambia. METHODS The design ensured half the schools (25) were randomised to receive the intervention which comprised of the following components: (i) Peer education camps and menstrual hygiene laboratories in schools, (ii) Mother's outreach sessions, (iii) Community meetings, and (iv) minor improvements of school Water Sanitation and Hygiene (WASH) facilities and maintenance. The intervention was run over a three-month period, and the evaluation was conducted at least three months after the last intervention activity was completed in the school or community. The other 25 schools acted as controls. Of these 25 control schools one Arabic school dropped out due to COVID-19. The primary outcome was the prevalence of girls missing at least one day of school during their last period. Secondary outcomes included: Urinary Tract Infection (UTI) symptoms, biochemical markers of UTI in urine, Reproductive Tract Infection symptoms, self-reported menstruation related wellbeing, social support and knowledge, perceptions and practices towards menstruation and MH in target school girls. In addition, a process evaluation using observations, routine monitoring data, survey data and interviews was undertaken to assess dose and reach (quantitative data) and assess acceptability, fidelity, context and possible mechanisms of impact (qualitative data). Cost and cost-effectiveness of the intervention package will also be assessed. CONCLUSION Results will add to scarce resources available on effectiveness of MH interventions on school attendance. A positive result may encourage policy makers to increase their commitment to improve operation and maintenance of school WASH facilities and include more information on menstruation into the curriculum and help in the reporting and management of infections related to adolescent menstruation. Trial Registration PACTR, PACTR201809769868245, Registered 14th August 2018, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=3539.
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Affiliation(s)
- Vishna Shah
- Environmental Health Group, Department of Infectious Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Penelope Phillips-Howard
- grid.48004.380000 0004 1936 9764Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - Julie Hennegan
- grid.1056.20000 0001 2224 8486Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia
| | | | - Bakary Sonko
- grid.415063.50000 0004 0606 294XNutrition Theme, MRCG Keneba, Medical Research Council Unit, Banjul, The Gambia
| | - Edrisa Sinjanka
- grid.415063.50000 0004 0606 294XNutrition Theme, MRCG Keneba, Medical Research Council Unit, Banjul, The Gambia
| | - Nyima Camara Trawally
- grid.415063.50000 0004 0606 294XNutrition Theme, MRCG Keneba, Medical Research Council Unit, Banjul, The Gambia
| | - Abdou Kanteh
- Nova Scotia Gambia Association (NSGA), Banjul, The Gambia
| | - Francois Mendy
- Nova Scotia Gambia Association (NSGA), Banjul, The Gambia
| | - Amadou B. Bah
- Nova Scotia Gambia Association (NSGA), Banjul, The Gambia
| | - Momodou Saar
- Nova Scotia Gambia Association (NSGA), Banjul, The Gambia
| | - Ian Ross
- grid.8991.90000 0004 0425 469XEnvironmental Health Group, Department of Infectious Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Wolf Schmidt
- grid.8991.90000 0004 0425 469XEnvironmental Health Group, Department of Infectious Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Belen Torondel
- grid.8991.90000 0004 0425 469XEnvironmental Health Group, Department of Infectious Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
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Baird S, Hamory J, Gezahegne K, Pincock K, Woldehanna T, Yadete W, Jones N. Improving Menstrual Health Literacy Through Life-Skills Programming in Rural Ethiopia. Front Glob Womens Health 2022; 3:838961. [PMID: 35873135 PMCID: PMC9304804 DOI: 10.3389/fgwh.2022.838961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 06/09/2022] [Indexed: 11/14/2022] Open
Abstract
Despite its cultural and biological importance, limited knowledge about menstruation and cultural taboos in many contexts mean that menarche often brings fear and stigma. In Ethiopia, the context of this paper, lack of knowledge and the stigma around menstruation create challenges for adolescent girls related to menstrual hygiene management and their reproductive health more broadly. This paper uses a cluster-randomized controlled trial (cRCT), with 97 communities (kebeles) randomly assigned to treatment or control, to assess the impact of a gender-transformative life-skills intervention [Act With Her-Ethiopia (AWH-E)] on the menstrual health literacy of very young adolescent girls and boys (10–14) in two diverse regions of Ethiopia (South Gondar, Amhara and East Hararghe, Oromia). The evaluation employs a longitudinal mixed-methods design, with baseline data collected in late 2017/early 2018 and follow-up data collected in late 2019/early 2020. Quantitative surveys were undertaken with 2,492 very young adolescents and their primary caregivers, and complemented by qualitative interviews with 291 adolescents and their caregivers, as well as 96 key informants at community and district levels. Our quantitative findings highlight large and statistically significant improvements on norms around menstruation, knowledge about menstruation and biological function, and knowledge and behavior related to menstrual hygiene management, but with important differences by location and gender. Qualitative findings further unpack these gender and regional differences, highlighting the importance of adapting programming to the local context and, where possible, connecting to other health and gender initiatives. This analysis helps fill the evidence gap on “what works” to improve menstrual health literacy in rural low- and middle-income contexts.
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Affiliation(s)
- Sarah Baird
- Department of Global Health, George Washington University, Washington, DC, United States
- *Correspondence: Sarah Baird
| | - Joan Hamory
- Department of Economics, University of Oklahoma, Norman, OK, United States
| | - Kiya Gezahegne
- Department of Social Anthropology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Kate Pincock
- Gender and Adolescence: Global Evidence (GAGE), ODI, London, United Kingdom
| | - Tassew Woldehanna
- Department of Economics, Addis Ababa University, Addis Ababa, Ethiopia
| | - Workneh Yadete
- Gender and Adolescence: Global Evidence (GAGE), Quest Consulting, Addis Ababa, Ethiopia
| | - Nicola Jones
- Gender and Adolescence: Global Evidence (GAGE), ODI, London, United Kingdom
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Evans RL, Harris B, Onuegbu C, Griffiths F. Systematic review of educational interventions to improve the menstrual health of young adolescent girls. BMJ Open 2022; 12:e057204. [PMID: 35676001 PMCID: PMC9185475 DOI: 10.1136/bmjopen-2021-057204] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To systematically review interventions that include an element of menstrual education delivered to young adolescent girls. DESIGN This was a systematic review and meta-analysis. Selected articles were quality assessed using the Mixed Methods Appraisal Tool quality appraisal checklist. A meta-analysis was conducted on a subset of articles, and the effect size of the intervention was calculated using Cohen's d. A logic model was constructed to frame the effect of menstrual education interventions on menstrual health. SETTING Papers reporting on interventions in high-income and low-income and middle-income countries were sought. INFORMATION SOURCES Seven electronic databases were searched for English-language entries that were published between January 2014 and May 2020. PARTICIPANTS The interventions were aimed at younger adolescent girls aged 10-14 years old. INTERVENTIONS The interventions were designed to improve the menstrual health of the recipients, by addressing one or more elements of menstrual knowledge, attitude or practices (KAP). ELIGIBILITY CRITERIA Interventions that had not been evaluated were excluded. PRIMARY AND SECONDARY OUTCOMES The most common type of output was a difference in knowledge or skill score ascertained from a pre and post test. Some studies measured additional outcomes, such as attitude or confidence. RESULTS Twenty-four eligible studies were identified. The number of participants varied from 1 to 2564. All studies reported improvements in menstrual KAP. The meta-analysis indicates that larger effect sizes were attained by those that encouraged discussion than those that distributed pamphlets. CONCLUSIONS Education interventions are effective in increasing the menstrual knowledge of young adolescent girls and skills training improves competency to manage menstruation more hygienically and comfortably. Interactive interventions are more motivating than didactic or written. Sharing concerns gives girls confidence and helps them to gain agency on the path to menstrual health. TRIAL REGISTRATION NUMBER For this review, a protocol was not prepared or registered.
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Affiliation(s)
- Rebecca Lane Evans
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Bronwyn Harris
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Chinwe Onuegbu
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Frances Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Long JL, Haver J, Mendoza P, Vargas Kotasek SM. The More You Know, the Less You Stress: Menstrual Health Literacy in Schools Reduces Menstruation-Related Stress and Increases Self-Efficacy for Very Young Adolescent Girls in Mexico. Front Glob Womens Health 2022; 3:859797. [PMID: 35496727 PMCID: PMC9047952 DOI: 10.3389/fgwh.2022.859797] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/17/2022] [Indexed: 11/13/2022] Open
Abstract
Improving the menstrual health literacy of girls and boys is a key strategy within a holistic framework of Save the Children's school health and comprehensive sexuality education programming. As menstrual health is an emerging area of study and programming, Save the Children continues to learn and adjust its interventions using program evaluations and rigorous monitoring. This paper will examine program-monitoring data from three cohorts, representing 47 public schools in Mexico City, Puebla, and Mérida, Mexico. The study focuses on female students in 5th and 6th grade who participated in We See Equal, a school-based program centered on gender equality and puberty education, between September 2018 and December 2019. This study used a cross-sectional quantitative cohort approach to document changes in girls' experiences and perceptions around managing menstruation in school. The analysis compares girls' knowledge and experiences before and after participation in We See Equal to understand how knowledge changes over the program and how those changes may contribute to menstruation-related school engagement, stress, and self-efficacy (MENSES) outcomes. Multivariate regression models explored relationships between MENSES outcomes, knowledge and socioeconomic status (SES). Overall, results show that the more knowledge girls acquired, the higher their self-efficacy score and the lower their stress score, however, certain MHH knowledge was more predictive of MENSES outcomes and varied by SES. Among girls from lower SES, we observed significant relationships between knowing what their period was prior to menarche and the three MENSES outcomes. Decreases in menstruation-related stress were driven by items related to the practical knowledge of how to dispose of sanitary pads and reduced feelings of nervousness on days they had their period at school. Increases in self-efficacy were primarily driven by girls' confidence in their ability to track their period from month to month, feelings that they could still do well on an exam if they had their period at school, and security that they could ask a friend to lend them a pad if they needed one. Implications for future menstrual health literacy programming and targeting populations for menstrual health education, as well as priorities for future research will be discussed.
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Affiliation(s)
- Jeanne L. Long
- Department of Education and Child Protection, Save the Children, Washington, DC, United States
| | - Jacquelyn Haver
- Department of Education and Child Protection, Save the Children, Washington, DC, United States
| | - Pamela Mendoza
- Department of Education and Child Protection, Save the Children, Washington, DC, United States
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B H, M G, M P, A S, M S, S F, L M, L S, K S, M S, S F, R H, H A. Access to menstrual hygiene products through incentivised, community-based, peer-led sexual and reproductive health services before and during the COVID-19 pandemic: findings from the Yathu Yathu trial. BMC Public Health 2022; 22:554. [PMID: 35313860 PMCID: PMC8935110 DOI: 10.1186/s12889-022-12915-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 03/02/2022] [Indexed: 11/25/2022] Open
Abstract
Background Access to affordable and effective menstrual hygiene products (MHP) is critical to the menstrual health of adolescent girls and young women (AGYW). In this mixed-methods analysis, we use data from a programme delivering comprehensive sexual and reproductive health (SRH) services to describe access to MHP and how COVID-19-related closures affected access to MHP; we use qualitative data to understand AGYW’s experience accessing products during the study. Methods Between September 2019-January 2021, we used data routinely collected from ten Yathu Yathu hubs offering community-based, peer-led SRH services to adolescents and young people aged 15–24. Hubs offered free MHP (primarily disposable pads) as a service. To incentivise service access, a “loyalty” card system was embedded within Yathu Yathu, allowing individuals to gain points for services accessed and redeem rewards using these points. Branded pads, tampons and reusable pads were among available rewards. We describe access to service pads and to reward MHP, and use logistic regression to investigate factors associated with accessing pads and reward products before (Sept 2019-March 2020) and after (July 2020-Jan 2021) COVID-19-related closures. Focus group discussions explored accessibility of offering MHP through hubs. Results Between September 2019-January 2021, 6374 AGYW made 34,116 hub visits to access an SRH service and/or redeem a reward. At 30% of these visits, AGYW accessed any MHP. Before COVID19-closures, an average of 17% of monthly visits were for freely-available disposable pads compared to 34% after hubs reopened (p < 0.001). Results were similar for reward visits. Overall, 63% of 6374 AGYW collected pads as a service at least once. Prior to COVID19-closures, AGYW aged 18–24 were more likely to access service pads than adolescents (15–17-years). After reopening, access was lower among older AGYW. Prior to hub closures, uptake of reward MHP was higher among AGYW with some secondary education but not after reopening. Discussions revealed that, for adolescents aged 15–19, COVID-19-related hub closures required reverting to using ineffective materials to manage menstruation. Conclusion Availability of MHP through Yathu Yathu provided a large number of AGYW with access to these products. Hubs seemed particularly important for adolescent girls. Community-based, peer-led hubs should be considered as spaces to provide AGYW access to affordable and effective MHP.
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Affiliation(s)
- Hensen B
- Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | | | | | - Schaap A
- Zambart, Lusaka, Zambia.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Floyd S
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | - Fidler S
- Imperial College and Imperial College NIHR BRC, London, UK
| | - Hayes R
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Ayles H
- Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.,Zambart, Lusaka, Zambia
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19
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Shah V, Nabwera H, Sonko B, Bajo F, Faal F, Saidykhan M, Jallow Y, Keita O, Schmidt WP, Torondel B. Effects of Menstrual Health and Hygiene on School Absenteeism and Drop-Out among Adolescent Girls in Rural Gambia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:3337. [PMID: 35329020 PMCID: PMC8954348 DOI: 10.3390/ijerph19063337] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 12/04/2022]
Abstract
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.
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Affiliation(s)
- Vishna Shah
- Environmental Health Group, Department of Infectious Diseases, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (W.-P.S.); (B.T.)
| | - Helen Nabwera
- Department of Education and Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK;
| | - Bakary Sonko
- The Medical Research Council Unit the Gambia, London School of Hygiene & Tropical Medicine, Banjul P.O. Box 273, The Gambia; (B.S.); (F.B.); (F.F.); (M.S.); (Y.J.)
| | - Fatou Bajo
- The Medical Research Council Unit the Gambia, London School of Hygiene & Tropical Medicine, Banjul P.O. Box 273, The Gambia; (B.S.); (F.B.); (F.F.); (M.S.); (Y.J.)
| | - Fatou Faal
- The Medical Research Council Unit the Gambia, London School of Hygiene & Tropical Medicine, Banjul P.O. Box 273, The Gambia; (B.S.); (F.B.); (F.F.); (M.S.); (Y.J.)
| | - Mariama Saidykhan
- The Medical Research Council Unit the Gambia, London School of Hygiene & Tropical Medicine, Banjul P.O. Box 273, The Gambia; (B.S.); (F.B.); (F.F.); (M.S.); (Y.J.)
| | - Yamoundaw Jallow
- The Medical Research Council Unit the Gambia, London School of Hygiene & Tropical Medicine, Banjul P.O. Box 273, The Gambia; (B.S.); (F.B.); (F.F.); (M.S.); (Y.J.)
| | - Omar Keita
- Regional Education Directorate Four, Ministry of Basic and Secondary Education, Mansakonko Lower River Region, Banjul P.O. Box 989, The Gambia;
| | - Wolf-Peter Schmidt
- Environmental Health Group, Department of Infectious Diseases, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (W.-P.S.); (B.T.)
| | - Belen Torondel
- Environmental Health Group, Department of Infectious Diseases, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (W.-P.S.); (B.T.)
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20
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Poague KIHM, Blanford JI, Anthonj C. Water, Sanitation and Hygiene in Schools in Low- and Middle-Income Countries: A Systematic Review and Implications for the COVID-19 Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:3124. [PMID: 35270814 PMCID: PMC8910349 DOI: 10.3390/ijerph19053124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/21/2022] [Accepted: 03/03/2022] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Kasandra I. H. M. Poague
- Faculty of Geo-Information Science and Earth Observation–ITC, University of Twente, Hengelosestraat 99, P.O. Box 217, 7500 AE Enschede, The Netherlands; (J.I.B.); (C.A.)
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21
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A Structured Review of Emotional Barriers to WASH Provision for Schoolgirls Post-Disaster. SUSTAINABILITY 2022. [DOI: 10.3390/su14042471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pubescent girls face unique emotional barriers to returning to school after a disaster concerning water, sanitation and hygiene (WASH). This paper explores themes of WASH, gender violence, the lack of dignity and sense of shame arising from inadequate WASH facilities for girls in disaster settings. We conducted a structured literature review of 126 sources to investigate the emotional constraints facing pubescent girls concerning WASH in schools in Indonesia, a region prone to frequent disasters. Findings are synthesised into four major themes: psychological experiences of WASH, challenges faced by girls in schools, barriers to inclusive WASH provision and how to create a holistic approach to WASH. Key conclusions include the need for interdisciplinary research, cross sectoral collaboration, more evidence and research in Indonesia, especially regarding menstrual hygiene management, improved toilet design to reduce the physical barriers linked to emotional barriers and inclusive design for those with disabilities.
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22
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Holst AS, Jacques-Aviñó C, Berenguera A, Pinzón-Sanabria D, Valls-Llobet C, Munrós-Feliu J, Martínez-Bueno C, López-Jiménez T, Vicente-Hernández MM, Medina-Perucha L. Experiences of menstrual inequity and menstrual health among women and people who menstruate in the Barcelona area (Spain): a qualitative study. Reprod Health 2022; 19:45. [PMID: 35183195 PMCID: PMC8857732 DOI: 10.1186/s12978-022-01354-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/29/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Menstrual health and menstrual inequity have been neglected in social, economic, healthcare and political spheres. Although available evidence is scarce, it already suggests a link between experiencing menstrual inequity (which refers to the systematic disparities in accessing menstrual health and education, menstrual products and spaces for menstrual management, among other aspects) and menstrual health outcomes. The aim of this study was to explore experiences of menstrual health and menstrual inequity among women and people who menstruate aged 18-55 in Barcelona and surrounding areas (Spain). METHODS A qualitative study, using a critical feminist perspective, was conducted. Sampling was purposeful and selective. Recruitment was through sexual and reproductive health centres, social media and snowball sampling techniques. Thirty-four semi-structured photo-elicitation interviews were conducted between December 2020 and February 2021. Interviews took place in sexual and reproductive health centres, public spaces, and by telephone. Data were analysed using Reflexive Thematic Analysis. RESULTS Three themes were identified: "Systemic neglect of menstruation and the menstrual cycle", "When "the private" becomes public: menstrual management" and "Navigating menstrual health: between medicalization and agency". Experiences of menstrual inequity appeared to be widespread among participants. They referred to the impact of having to conceal menstruation and the barriers to managing menstruation in public spaces. Choosing menstrual products was often influenced by price and availability; several participants reported menstrual poverty. A general lack of menstrual education was described. Menstrual education was usually gained through personal experience and self-learnings, or through families and friends. Menstruation and the menstrual cycle had a significant impact on participants' day-to-day. Accessing and navigating the healthcare system was challenging, as participants mostly reported feeling dismissed and almost exclusively offered hormonal contraception as a panacea to address menstrual health. CONCLUSIONS The impact of menstrual inequity appears to be far-reaching. Multidimensional structural policies should promote agency in individuals and communities to enable opportunities for menstrual education, access to menstrual products, healthcare services and adequate menstrual-management facilities. Health professionals' training is also necessary to improve access to and quality of menstrual healthcare. Policies need to be inclusive of non-binary and trans people, and vulnerable populations.
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Affiliation(s)
- Anna Sofie Holst
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Gran Via de les Corts Catalanes, 587 attic, 08007, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
| | - Constanza Jacques-Aviñó
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Gran Via de les Corts Catalanes, 587 attic, 08007, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Anna Berenguera
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Gran Via de les Corts Catalanes, 587 attic, 08007, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
- Departament d'Infermeria, Universitat de Girona, Girona, Spain
| | - Diana Pinzón-Sanabria
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
- SomiArte Taller, Barcelona, Spain
| | | | - Jordina Munrós-Feliu
- Atenció a la Salut Sexual i Reproductiva (ASSIR) Muntanya/La Mina, Institut Català de la Salut, Barcelona, Spain
| | - Cristina Martínez-Bueno
- Servei d'Atenció a la Salut Sexual i Reproductiva (ASSIR). Direcció Assistencial d'Atenció Primària, Institut Català de La Salut, Barcelona, Spain
- Sexual and Reproductive Health Care Research Group (GRASSIR), Barcelona, Spain
| | - Tomàs López-Jiménez
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Gran Via de les Corts Catalanes, 587 attic, 08007, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | | | - Laura Medina-Perucha
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Gran Via de les Corts Catalanes, 587 attic, 08007, Barcelona, Spain.
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain.
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23
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Stoilova D, Cai R, Aguilar-Gomez S, Batzer NH, Nyanza EC, Benshaul-Tolonen A. Biological, material and socio-cultural constraints to effective menstrual hygiene management among secondary school students in Tanzania. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000110. [PMID: 36962274 PMCID: PMC10021794 DOI: 10.1371/journal.pgph.0000110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 11/18/2021] [Indexed: 11/18/2022]
Abstract
Menstrual hygiene management is an important determinant for girls' educational outcomes. We develop a method of cross-sectional analysis that quantifies the relative importance of four distinct mechanisms: material, biological, social and informational constraints and consider four main schooling outcomes: absenteeism, early departure, concentration and participation. We use survey data from 524 female students enrolled in four co-educational secondary schools in Northern Tanzania. Average age at first period is 14.2 years (standard deviation = 1.1, range 9-19). Information is the least binding constraint: 90-95% of girls report they received information about menstruation and how to manage it. In contrast, biological constraints are hindering: (i) the distribution of menstrual cramps and pain is bifurcated: most girls report very light or very strong pain (rather than moderate) with considerable educational impacts for girls in the latter group, (ii) irregular cycles (62%) and difficulty predicting the cycle (60%) lead to stress and uncertainty. Socio-cultural constraints are binding as 84% would feel shame if male peers knew their menstrual status, and 58% fear being teased over periods. Material constraints include prohibitive costs: girls spending between 12-70% of the daily national poverty line (6,247 TSH per day) on pads during their period. However, we discern no statistically significant relationship between access to pads and absenteeism. In contrast, biological and socio-cultural constraints as well as lack of sanitary infrastructure have significant effects on absenteeism. The results have several implications. First, sanitary pad interventions should consider participation and concentration as main outcomes, in addition to absenteeism. Second, biological (menstrual cramps and pain) and socio-cultural (fear, stigma) constraints are drivers of menstruation-related absenteeism and participation in the classroom and need to be evaluated in trials. We suggest exploring analgesic use, alternative pain-management techniques, menstrual cycle tracking technologies, and social programming in future trials.
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Affiliation(s)
- Dani Stoilova
- Department of Economics, Barnard College, Columbia University, New York City, NY, United States of America
| | - Rebecca Cai
- Columbia University, New York City, NY, United States of America
| | | | | | - Elias Charles Nyanza
- Department of Environmental and Occupational Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Anja Benshaul-Tolonen
- Department of Economics, Barnard College, Columbia University, New York City, NY, United States of America
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Chirgwin H, Cairncross S, Zehra D, Sharma Waddington H. Interventions promoting uptake of water, sanitation and hygiene (WASH) technologies in low- and middle-income countries: An evidence and gap map of effectiveness studies. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1194. [PMID: 36951806 PMCID: PMC8988822 DOI: 10.1002/cl2.1194] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Background Lack of access to and use of water, sanitation and hygiene (WASH) cause 1.6 million deaths every year, of which 1.2 million are due to gastrointestinal illnesses like diarrhoea and acute respiratory infections like pneumonia. Poor WASH access and use also diminish nutrition and educational attainment, and cause danger and stress for vulnerable populations, especially for women and girls. The hardest hit regions are sub-Saharan Africa and South Asia. Sustainable Development Goal (SDG) 6 calls for the end of open defecation, and universal access to safely managed water and sanitation facilities, and basic hand hygiene, by 2030. WASH access and use also underpin progress in other areas such as SDG1 poverty targets, SDG3 health and SDG4 education targets. Meeting the SDG equity agenda to "leave none behind" will require WASH providers prioritise the hardest to reach including those living remotely and people who are disadvantaged. Objectives Decision makers need access to high-quality evidence on what works in WASH promotion in different contexts, and for different groups of people, to reach the most disadvantaged populations and thereby achieve universal targets. The WASH evidence map is envisioned as a tool for commissioners and researchers to identify existing studies to fill synthesis gaps, as well as helping to prioritise new studies where there are gaps in knowledge. It also supports policymakers and practitioners to navigate the evidence base, including presenting critically appraised findings from existing systematic reviews. Methods This evidence map presents impact evaluations and systematic reviews from the WASH sector, organised according to the types of intervention mechanisms, WASH technologies promoted, and outcomes measured. It is based on a framework of intervention mechanisms (e.g., behaviour change triggering or microloans) and outcomes along the causal pathway, specifically behavioural outcomes (e.g., handwashing and food hygiene practices), ill-health outcomes (e.g., diarrhoeal morbidity and mortality), nutrition and socioeconomic outcomes (e.g., school absenteeism and household income). The map also provides filters to examine the evidence for a particular WASH technology (e.g., latrines), place of use (e.g., home, school or health facility), location (e.g., global region, country, rural and urban) and group (e.g., people living with disability). Systematic searches for published and unpublished literature and trial registries were conducted of studies in low- and middle-income countries (LMICs). Searches were conducted in March 2018, and searches for completed trials were done in May 2020. Coding of information for the map was done by two authors working independently. Impact evaluations were critically appraised according to methods of conduct and reporting. Systematic reviews were critically appraised using a new approach to assess theory-based, mixed-methods evidence synthesis. Results There has been an enormous growth in impact evaluations and systematic reviews of WASH interventions since the International Year of Sanitation, 2008. There are now at least 367 completed or ongoing rigorous impact evaluations in LMICs, nearly three-quarters of which have been conducted since 2008, plus 43 systematic reviews. Studies have been done in 83 LMICs, with a high concentration in Bangladesh, India, and Kenya. WASH sector programming has increasingly shifted in focus from what technology to supply (e.g., a handwashing station or child's potty), to the best way in which to do so to promote demand. Research also covers a broader set of intervention mechanisms. For example, there has been increased interest in behaviour change communication using psychosocial "triggering", such as social marketing and community-led total sanitation. These studies report primarily on behavioural outcomes. With the advent of large-scale funding, in particular by the Bill & Melinda Gates Foundation, there has been a substantial increase in the number of studies on sanitation technologies, particularly latrines. Sustaining behaviour is fundamental for sustaining health and other quality of life improvements. However, few studies have been done of intervention mechanisms for, or measuring outcomes on sustained adoption of latrines to stop open defaecation. There has also been some increase in the number of studies looking at outcomes and interventions that disproportionately affect women and girls, who quite literally carry most of the burden of poor water and sanitation access. However, most studies do not report sex disaggregated outcomes, let alone integrate gender analysis into their framework. Other vulnerable populations are even less addressed; no studies eligible for inclusion in the map were done of interventions targeting, or reporting on outcomes for, people living with disabilities. We were only able to find a single controlled evaluation of WASH interventions in a health care facility, in spite of the importance of WASH in health facilities in global policy debates. The quality of impact evaluations has improved, such as the use of controlled designs as standard, attention to addressing reporting biases, and adequate cluster sample size. However, there remain important concerns about quality of reporting. The quality and usefulness of systematic reviews for policy is also improving, which draw clearer distinctions between intervention mechanisms and synthesise the evidence on outcomes along the causal pathway. Adopting mixed-methods approaches also provides information for programmes on barriers and enablers affecting implementation. Conclusion Ensuring everyone has access to appropriate water, sanitation, and hygiene facilities is one of the most fundamental of challenges for poverty elimination. Researchers and funders need to consider carefully where there is the need for new primary evidence, and new syntheses of that evidence. This study suggests the following priority areas:Impact evaluations incorporating understudied outcomes, such as sustainability and slippage, of WASH provision in understudied places of use, such as health care facilities, and of interventions targeting, or presenting disaggregated data for, vulnerable populations, particularly over the life-course and for people living with a disability;Improved reporting in impact evaluations, including presentation of participant flow diagrams; andSynthesis studies and updates in areas with sufficient existing and planned impact evaluations, such as for diarrhoea mortality, ARIs, WASH in schools and decentralisation. These studies will preferably be conducted as mixed-methods systematic reviews that are able to answer questions about programme targeting, implementation, effectiveness and cost-effectiveness, and compare alternative intervention mechanisms to achieve and sustain outcomes in particular contexts, preferably using network meta-analysis.
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Affiliation(s)
- Hannah Chirgwin
- International Initiative for Impact Evaluation (3ie)London International Development CentreLondonUK
| | | | | | - Hugh Sharma Waddington
- London School of Hygiene and Tropical Medicine and International Initiative for Impact Evaluation (3ie)London International Development CentreLondonUK
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Krenz A, Strulik H. The impact of menstruation hygiene management on work absenteeism of women in Burkina Faso. ECONOMICS AND HUMAN BIOLOGY 2021; 43:101067. [PMID: 34655853 DOI: 10.1016/j.ehb.2021.101067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 09/08/2021] [Accepted: 10/02/2021] [Indexed: 06/13/2023]
Abstract
Women in developing countries face challenges in terms of managing their menstrual hygiene. They often do not possess the appropriate means, materials, or have access to suitable facilities. Using a newly released dataset for Burkina Faso and propensity score matching, we provide for the first time evidence of the impact of advanced menstrual hygiene management on work attendance. We show that the use of disposable sanitary pads rather than old cloth reduces work absenteeism of women by approximately 24% points. We report the robustness of the results with respect to alternative specifications of the propensity score model and investigate the results for samples stratified by education, wealth, marital status, and religion.
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Affiliation(s)
- Astrid Krenz
- University of Sussex, Digit Research Centre, Jubilee Building, Falmer, Brighton BN1 9SL, UK.
| | - Holger Strulik
- University of Göttingen, Department of Economics, Platz der Göttinger Sieben 3, 37073 Göttingen, Germany.
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26
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van Eijk AM, Jayasinghe N, Zulaika G, Mason L, Sivakami M, Unger HW, Phillips-Howard PA. Exploring menstrual products: A systematic review and meta-analysis of reusable menstrual pads for public health internationally. PLoS One 2021; 16:e0257610. [PMID: 34559839 PMCID: PMC8462722 DOI: 10.1371/journal.pone.0257610] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 09/06/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Girls and women need effective, safe, and affordable menstrual products. Single-use menstrual pads and tampons are regularly provided by agencies among resource-poor populations. Reusable menstrual pads (RMPs: fabric layers sewn together by an enterprise for manufacture of menstrual products) may be an effective alternative. METHODS For this review (PROSPERO CRD42020179545) we searched databases (inception to November 1, 2020) for quantitative and qualitative studies that reported on leakage, acceptability, or safety of RMPs. Findings were summarised or combined using forest plots (random-effects meta-analysis). Potential costs and environmental savings associated with RMPs were estimated. RESULTS A total of 44 studies were eligible (~14,800 participants). Most were conducted in low- and middle-income countries (LMIC, 78%), and 20% in refugee settings. The overall quality of studies was low. RMP uptake in cohort studies ranged from 22-100% (12 studies). One Ugandan trial among schoolgirls found leakage with RMPs was lower (44.4%, n = 72) compared to cloths (78%, n = 111, p<0.001). Self-reported skin-irritation was 23.8% after 3 months among RMP-users in a Ugandan cohort in a refugee setting (n = 267), compared to 72.8% at baseline with disposable pad use. There were no objective reports on infection. Challenges with washing and changing RMP were reported in LMIC studies, due to lack of water, privacy, soap, buckets, and sanitation/drying facilities. Among 69 brands, the average price for an RMP was $8.95 (standard deviation [sd] $5.08; LMIC $2.06, n = 10, high-income countries [HIC] $10.11), with a mean estimated lifetime of 4.3 years (sd 2.3; LMIC 2.9, n = 11; HIC 4.9 years, n = 23). In 5-year cost-estimates, in LMICs, 4-25 RMPs per period would be cheaper (170-417 US$) than 9-25 single-use pads, with waste-savings of ~600-1600 single-use pads. In HICs, 4-25 RMPs would be cheaper (33-245 US$) compared to 20 single-use tampons per period, with waste-savings of ~1300 tampons. CONCLUSION RMPs are used internationally and are an effective, safe, cheaper, and environmentally friendly option for menstrual product provision by programmes. Good quality studies in this field are needed.
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Affiliation(s)
- Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Naduni Jayasinghe
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Garazi Zulaika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Linda Mason
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Holger W. Unger
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Department of Obstetrics and Gynaecology, Royal Darwin Hospital, Darwin, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
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Austrian K, Kangwana B, Muthengi E, Soler-Hampejsek E. Effects of sanitary pad distribution and reproductive health education on upper primary school attendance and reproductive health knowledge and attitudes in Kenya: a cluster randomized controlled trial. Reprod Health 2021; 18:179. [PMID: 34465344 PMCID: PMC8406733 DOI: 10.1186/s12978-021-01223-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adolescent girls' risk of school dropout and reproductive health (RH) challenges may be exacerbated by girls' attitudes toward their bodies and inability to manage their menstruation. We assessed effects of sanitary pad distribution and RH education on girls in primary grade 7 in Kilifi, Kenya. METHODS A cluster randomized controlled trial design was used. Eligible clusters were all non-boarding schools in three sub-counties in Kilifi County that had a minimum of 25 girls enrolled in primary grade 7. 140 primary schools, 35 per arm, were randomly assigned to one of four study arms: (1) control; (2) sanitary pad distribution; (3) RH education; or (4) both sanitary pad distribution and RH education. Outcomes were school attendance, school engagement, RH knowledge and attitudes, gender norms, and self-efficacy. For outcomes measured both at baseline and endline, difference-in-differences (DID) models were estimated and for outcomes without baseline data available, analysis of covariance models were used. RESULTS The study enrolled 3489 randomly selected girls in primary grade 7, with a mean age of 14.4 (SD 1.5). Girls in arms 2 and 4 received on average 17.6 out of 20 packets of sanitary pads and girls in arms 3 and 4 participated on average in 21 out of 25 RH sessions. Ninety-four percent of the baseline sample was interviewed at the end of the intervention with no differential attrition by arm. There was no evidence of an effect on primary school attendance on arm 2 (coefficient [coef] 0.37, 95% CI - 0.73, 1.46), arm 3 (coef 0.14, 95% CI - 0.99, 1.26) or arm 4 (coef 0.58, 95% CI - .37, 1.52). There was increased positive RH attitudes for girls in arm 3 (DID coef. 0.63, 95% CI 0.40-0.86) and arm 4 (DID coef. 0.85, 95% CI 0.64, - 1.07). There was also an increase in RH knowledge, gender norms and self-efficacy in arms 3 and 4. CONCLUSIONS The findings suggest that neither sanitary pad distribution nor RH education, on their own or together, were sufficient to improve primary school attendance. However, as the RH education intervention improved RH outcomes, the evidence suggests that sanitary pad distribution and RH education can be positioned in broader RH programming for girls. TRIAL REGISTRATION ISRCTN, ISRCTN10894523. Registered 22 August 2017-Retrospectively registered, http://www.isrctn.com/ISRCTN10894523.
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Affiliation(s)
- Karen Austrian
- Poverty, Gender and Youth Program, Population Council-Kenya, PO Box 17643-00500, Nairobi, Kenya.
| | - Beth Kangwana
- Poverty, Gender and Youth Program, Population Council-Kenya, PO Box 17643-00500, Nairobi, Kenya
| | - Eunice Muthengi
- Poverty, Gender and Youth Program, Population Council-Kenya, PO Box 17643-00500, Nairobi, Kenya
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The Stressor in Adolescence of Menstruation: Coping Strategies, Emotional Stress & Impacts on School Absences among Young Women in Nepal. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18178894. [PMID: 34501484 PMCID: PMC8431475 DOI: 10.3390/ijerph18178894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/12/2021] [Accepted: 08/13/2021] [Indexed: 11/25/2022]
Abstract
Throughout the developing world, girls face hardships surrounding menstruation, often resulting in poor emotional wellbeing and missing school. Providing ways to keep girls in school will increase their educational and earning potentials, which will ultimately trickle down to improving the economic standing of nations in the next generation. Informed by the Transactional Model of Stress and Coping, this work evaluates the roles that cultural and school environments play in appraisals of menstruation as a major life stressor for adolescent females and the impacts of emotional stress on missing school. Using primary survey data from schools in Nepal, robust results are found to support the theoretical framework based on conditional mixed-process (CMP) estimation with fixed effects, utilizing multiple index building techniques. Strong cultural norms during menstruation appear to increase the probability of girls self-reporting emotional stress, while the presence of hygiene supporting infrastructure at schools reduces this outcome. Furthermore, there is strong support for the finding that the presence of emotional stress during menstruation increases the likelihood of not only missing school but also for an extended period of time. Our findings motivate increasing government policies to provide stronger hygiene infrastructure in schools to improve successful coping skills and attendance rates.
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Mahfuz MT, Sultana F, Hunter EC, Jahan F, Akand F, Khan S, Mobashhara M, Rahman M, Alam MU, Unicomb L, Luby SP, Winch PJ. Teachers' perspective on implementation of menstrual hygiene management and puberty education in a pilot study in Bangladeshi schools. Glob Health Action 2021; 14:1955492. [PMID: 34338160 PMCID: PMC8330768 DOI: 10.1080/16549716.2021.1955492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To assess the perspectives of Bangladeshi teachers on the feasibility of delivery and potential for long-term sustainability of puberty and menstruation education in urban and rural schools. METHOD We developed a multi-module puberty and menstrual hygiene management education curriculum that teachers piloted for six months in four urban and rural government and private schools in Bangladesh. We conducted monthly assessments during piloting, discussion for manual revision and four group discussions with 20 participating teachers to understand perceived benefits, barriers, and sustainability of puberty and menstruation education among school children. RESULTS Teachers acknowledged the importance of school-based puberty and menstruation education to improve students' perception and preparedness. They found that the training and instructors' manual they received were useful tools for effectively communicating with students. Teachers noted school and community pressure to de-emphasize educational content not included on nationally standardized examinations, and insufficient time and pre-service training for teaching sensitive topics served as barriers to implementing the pilot curriculum. CONCLUSION Pressure from school authorities and community may hinder the successful long-term delivery of school-based puberty and menstruation education programs that are external to the national curriculum. Our findings indicate that feasibly and sustainably improving education on these topics in Bangladeshi classrooms should be achieved through 1) revision of the current national curriculum to incorporate more comprehensive puberty and menstruation information including its physiology, management, and social context, 2) adequate training and support for teachers to deliver the content, and 3) incorporation of puberty and menstruation content into students' national examinations which may better ensure teachers are given the tools and opportunity to prioritize teaching this content.
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Affiliation(s)
- Mehjabin Tishan Mahfuz
- Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Bangladesh
| | - Farhana Sultana
- Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Bangladesh
| | - Erin C Hunter
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Farjana Jahan
- Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Bangladesh
| | - Farhana Akand
- Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Bangladesh
| | - Shifat Khan
- Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Bangladesh
| | - Mosammat Mobashhara
- Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Bangladesh
| | - Mahbubur Rahman
- Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Bangladesh
| | - Mahbub-Ul Alam
- Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Bangladesh
| | - Leanne Unicomb
- Environmental Interventions Unit, Infectious Disease Division, International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Bangladesh
| | | | - Peter J Winch
- John Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Kumbeni MT, Ziba FA, Apenkwa J, Otupiri E. Prevalence and factors associated with menstruation-related school absenteeism among adolescent girls in rural northern Ghana. BMC WOMENS HEALTH 2021; 21:279. [PMID: 34340667 PMCID: PMC8327434 DOI: 10.1186/s12905-021-01418-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/28/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
| | | | - Joana Apenkwa
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Easmon Otupiri
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Hennegan J, OlaOlorun FM, Oumarou S, Alzouma S, Guiella G, Omoluabi E, Schwab KJ. School and work absenteeism due to menstruation in three West African countries: findings from PMA2020 surveys. Sex Reprod Health Matters 2021; 29:1915940. [PMID: 33969811 PMCID: PMC8118433 DOI: 10.1080/26410397.2021.1915940] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Reports of school and work absences due to unmet menstrual needs have prompted increased attention to menstruation in policy and practice. However, there appear to be few quantitative studies reported in published literature capturing the prevalence of this hypothesised absenteeism. This study undertook secondary analysis of nationally representative Performance Monitoring and Accountability 2020 (PMA2020) data from Burkina Faso and Nigeria, and city-representative data from Niamey, Niger to determine the extent of women’s and girls’ self-reported absence from school and work due to menstruation. Among women and adolescent girls aged 15–49 years who had worked outside the household in the past month in Burkina Faso (n = 998), Niger (n = 212) and Nigeria (n = 3638), 19%, 11% and 17%, respectively, reported missing work due to menstruation. Among those aged 15–24 years who attended school in the past year in Burkina Faso (n = 461), Niger (n = 213) and Nigeria (n = 1574), 17%, 15% and 23% reported missing school in the past year due to menstruation. Findings support the assertion that menstruation is a source of absenteeism in West Africa and indicate that greater attention from research, practice, and policy is needed. In presenting this data we also reflect critically on the performance of questions regarding menstrual-related absenteeism in national monitoring surveys. Future monitoring efforts should consider the interpretability of similar survey data when many respondents did not attend any school or work and were ineligible to answer questions regarding absenteeism. Further, without additional research identifying the reasons for absenteeism, findings from similar survey questions may be difficult to interpret with relevance for policy decision making.
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Affiliation(s)
- Julie Hennegan
- Research Associate, The Water Institute, Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. Correspondence:
| | - Funmilola M OlaOlorun
- Senior Lecturer, Department of Community Medicine, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
| | - Sani Oumarou
- Statisticien Démographe, Conseiller du Directeur Général, l'Institut National de la Statistique du Niger, Niamey, Niger
| | - Souleymane Alzouma
- Ingénieur Statisticien Economiste, Directeur des Enquêtes et des Recensements, l'Institut National de la Statistique du Niger, Niamey, Niger
| | - Georges Guiella
- Lecturer, Institut Supérieur des Sciences de la Population, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Elizabeth Omoluabi
- Senior Lecturer, Department of Statistics, University of the Western Cape, Cape Town, South Africa
| | - Kellogg J Schwab
- Professor, The Water Institute, Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Understanding Period Poverty: Socio-Economic Inequalities in Menstrual Hygiene Management in Eight Low- and Middle-Income Countries. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18052571. [PMID: 33806590 PMCID: PMC7967348 DOI: 10.3390/ijerph18052571] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 02/05/2023]
Abstract
Menstrual hygiene management and health is increasingly gaining policy importance in a bid to promote dignity, gender equality and reproductive health. Effective and adequate menstrual hygiene management requires women and girls to have access to their menstrual health materials and products of choice, but also extends into having private, clean and safe spaces for using these materials. The paper provides empirical evidence of the inequality in menstrual hygiene management in Kinshasa (DRC), Ethiopia, Ghana, Kenya, Rajasthan (India), Indonesia, Nigeria and Uganda using concentration indices and decomposition methods. There is consistent evidence of wealth-related inequality in the conditions of menstrual hygiene management spaces as well as access to sanitary pads across all countries. Wealth, education, the rural-urban divide and infrastructural limitations of the household are major contributors to these inequalities. While wealth is identified as one of the key drivers of unequal access to menstrual hygiene management, other socio-economic, environmental and household factors require urgent policy attention. This specifically includes the lack of safe MHM spaces which threaten the health and dignity of women and girls.
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Adolescent Menstrual Health Literacy in Low, Middle and High-Income Countries: A Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18052260. [PMID: 33668788 PMCID: PMC7956698 DOI: 10.3390/ijerph18052260] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/14/2021] [Accepted: 02/20/2021] [Indexed: 11/27/2022]
Abstract
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.
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Gundi M, Subramanyam MA. Curious eyes and awkward smiles: Menstruation and adolescent boys in India. J Adolesc 2020; 85:80-95. [PMID: 33122150 DOI: 10.1016/j.adolescence.2020.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/31/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Most Indian studies on menstruation include only girls/women as participants, making it a 'women's' topic. This exclusion of adolescent boys fails to understand menstruation as a social epidemiological entity with existing gender inequalities. For engaging boys to play a meaningful role in improving women's health, studying their knowledge, beliefs regarding topics such as menstruation and socioeconomic characteristics influencing their menstruation-related experiences need attention. Addressing this is an essential step for reducing gender disparities in adolescent health. Thus, we explore boys' knowledge, beliefs and attitudes regarding menstruation and the impact of social determinants on their menstruation-related experiences. METHODS A sequential mixed-methods study comprising 21 semi-structured interviews, 5 Focus Group Discussions and 12 key respondent interviews; followed by a cross-sectional survey of 744 boys from Nashik district, India was conducted. We employed thematic analysis for qualitative data and multivariable regression to model risk ratios for outcomes. RESULTS An amalgam of curiosity and awkwardness regarding menstruation was observed. Many lacked accurate knowledge and possessed misinformation. Social and individual-level determinants influenced boys' menstruation related experiences. Fully adjusted models revealed that being admitted in private unaided schools; having mothers with at least a college education; and comfort with teacher positively influenced boys'knowledge, attitudes and beliefs (incidence rate ratios at 95% CI: 2.67 [1.02, 6.95], p < 0 0.05; 3.16 [1.35, 7.38], p < .05 and 1.92 [1.24, 2.99],p < .01, respectively). CONCLUSION Our study highlights the need of improving Indian boys' understanding and beliefs about menstruation by addressing the social determinants that influence their menstruation-related experiences.
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Affiliation(s)
- Mukta Gundi
- Social Epidemiology, Indian Institute of Technology Gandhinagar, India.
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Period teasing, stigma and knowledge: A survey of adolescent boys and girls in Northern Tanzania. PLoS One 2020; 15:e0239914. [PMID: 33112868 PMCID: PMC7592731 DOI: 10.1371/journal.pone.0239914] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 09/16/2020] [Indexed: 11/19/2022] Open
Abstract
Emerging evidence suggests that menstruation-related teasing is a common experience among adolescent girls with ramifications on their school participation, yet empirical evidence on the prevalence and determinants of period teasing in schools remain scarce. Menstrual hygiene research and policies almost exclusively focus on girls and women, leading to a dearth of knowledge of male attitudes. We conducted the first quantitative survey of period teasing in schools in sub-Saharan Africa, focusing on 432 male and 524 female students in four co-educational secondary schools in northern Tanzania. Period teasing is prevalent; 13% of girls have experienced period teasing, and more than 80% fear being teased, especially by male classmates. Girls’ fears are associated with insufficient menstrual hygiene management resources and practices. Girls cope by reducing school attendance, participation, and concentration in the classroom during periods. Boys engage in period teasing because they perceive periods as embarrassing, especially visible markers of periods (odor or stains). Social norms, such as peer behavior and home restrictions on menstruating women, are associated with more teasing. Boys believe it is strongly inappropriate for girls to reveal period status or to discuss periods with males, including male teachers. In contrast, boys are well informed about basic biological facts of menstruation (scoring 60% on a knowledge quiz, not statistically different from the girls) and have received information from school curricula and health workers. Lack of suitable menstrual hygiene practices and restrictive social norms is correlated with period teasing, which hinders gender equality in educational opportunities. Providing narrowly bio-medical focused education about menstruation may not be enough to reduce period teasing in contexts with period stigma.
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Hennegan J, Nansubuga A, Akullo A, Smith C, Schwab KJ. The Menstrual Practices Questionnaire (MPQ): development, elaboration, and implications for future research. Glob Health Action 2020; 13:1829402. [PMID: 33052077 PMCID: PMC7594862 DOI: 10.1080/16549716.2020.1829402] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Julie Hennegan
- The Water Institute, Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health , Baltimore, MD, USA
| | | | | | | | - Kellogg J Schwab
- The Water Institute, Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health , Baltimore, MD, USA
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Medina-Perucha L, Jacques-Aviñó C, Valls-Llobet C, Turbau-Valls R, Pinzón D, Hernández L, Briales Canseco P, López-Jiménez T, Solana Lizarza E, Munrós Feliu J, Berenguera A. Menstrual health and period poverty among young people who menstruate in the Barcelona metropolitan area (Spain): protocol of a mixed-methods study. BMJ Open 2020; 10:e035914. [PMID: 32727738 PMCID: PMC7394147 DOI: 10.1136/bmjopen-2019-035914] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The importance of menstrual health has been historically neglected, mostly due to taboos and misconceptions around menstruation and androcentrism within health knowledge and health systems around the world. There has also been a lack of attention on 'period poverty', which refers to the financial, social, cultural and political barriers to access menstrual products and education. The main aim of this research is to explore menstrual health and experiences of period poverty among young people who menstruate (YPM). METHODS AND ANALYSIS This is a convergent mixed-methods study, which will combine a quantitative transversal study to identify the prevalence of period poverty among YPM (11-16 years old), and a qualitative study that will focus on exploring menstruation-related experiences of YPM and other groups (young people who do not menstruate (YNM); primary healthcare professionals; educators and policy-makers). The study will be conducted in the Barcelona metropolitan area between 2020 and 2021. Eighteen schools and 871 YPM will be recruited for the quantitative study. Sixty-five YPM will participate in the qualitative study. Forty-five YNM and 12 professionals will also be recruited to take part in the qualitative study. Socioeconomic and cultural diversity will be main vectors for recruitment, to ensure the findings are representative to the social and cultural context. Descriptive statistics will be performed for each variable to identify asymmetric distributions and differences among groups will be evaluated. Thematic analysis will be used for qualitative data analyses ETHICS AND DISSEMINATION: Several ethical issues have been considered, especially as this study includes the participation of underage participants. The study has received ethical approval by the IDIAPJGol Research Ethics Committee (19/178 P). Research findings will be disseminated to key audiences, such as YPM, YNM, parents/legal tutors, health professionals, educators, youth (and other relevant) organisations, general community members, stakeholders and policy-makers, and academia.
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Affiliation(s)
- Laura Medina-Perucha
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Catalunya, Spain
| | - Constanza Jacques-Aviñó
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Catalunya, Spain
- Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Catalunya, Spain
| | | | | | - Diana Pinzón
- SomiArte Taller, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Catalunya, Spain
| | | | | | - Tomàs López-Jiménez
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Catalunya, Spain
- Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Catalunya, Spain
| | - Enara Solana Lizarza
- Department of Education, Universidad Internacional de la Rioja - Campus de Logrono, Logrono, La Rioja, Spain
| | - Jordina Munrós Feliu
- Atenció a la Salut Sexual i Reproductiva (ASSIR) Muntanya/La Mina, Institut Català de la Salut, Barcelona, Catalunya, Spain
| | - Anna Berenguera
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Catalunya, Spain
- Universitat Autònoma de Barcelona, Barcelona, Catalunya, Spain
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Hennegan J, Brooks DJ, Schwab KJ, Melendez-Torres GJ. Measurement in the study of menstrual health and hygiene: A systematic review and audit. PLoS One 2020; 15:e0232935. [PMID: 32497117 PMCID: PMC7272008 DOI: 10.1371/journal.pone.0232935] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 04/09/2020] [Indexed: 11/18/2022] Open
Abstract
Background The lack of established measurement tools in the study of menstrual health and hygiene has been a significant limitation of quantitative studies to date. However, there has been limited exploration of existing measurement to identify avenues for improvement. Methods We undertook two linked systematic reviews of (1) trials of menstrual health interventions and their nested studies in low- and middle-income countries, (2) studies developing or validating measures of menstrual experiences from any location. Systematic searching was undertaken in 12 databases, together with handsearching. We iteratively grouped and audited concepts measured across included studies and extracted and compared measures of each concept. Results A total of 23 trials, 9 nested studies and 22 measure development studies were included. Trials measured a range of outcomes including menstrual knowledge, attitudes, and practices, school absenteeism, and health. Most measure validation studies focused on assessing attitudes towards menstruation, while a group of five studies assessed the accuracy of women’s recall of their menstrual characteristics such as timing and cycle length. Measures of menstrual knowledge, attitudes, beliefs and restrictions were inconsistent and frequently overlapped. No two studies measured the same menstrual or hygiene practices, with 44 different practices assessed. This audit provides a summary of current measures and extant efforts to pilot or test their performance. Conclusions Inconsistencies in both the definition and operationalisation of concepts measured in menstrual health and hygiene research should be addressed. To improve measurement, authors should clearly define the constructs they aim to measure and outline how these were operationalised for measurement. Results of this audit indicate the need for the development and validation of new measures, and the evaluation of the performance of existing measures across contexts. In particular, the definition and measurement of menstrual practices, knowledge, attitudes, norms and restrictions should be addressed. Review protocol registration CRD42018089884.
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Affiliation(s)
- Julie Hennegan
- The Water Institute, Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Deborah Jordan Brooks
- The John Sloan Dickey Center for International Understanding and Department of Government, Dartmouth College, Hanover, New Hampshire, United States of America
| | - Kellogg J. Schwab
- The Water Institute, Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - G. J. Melendez-Torres
- Peninsula Technology Assessment Group, College of Medicine and Health, University of Exeter, Exeter, United Kingdom
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Crankshaw TL, Strauss M, Gumede B. Menstrual health management and schooling experience amongst female learners in Gauteng, South Africa: a mixed method study. Reprod Health 2020; 17:48. [PMID: 32293481 PMCID: PMC7158143 DOI: 10.1186/s12978-020-0896-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 03/09/2020] [Indexed: 02/05/2023] Open
Abstract
Background There has been increased attention to the menstrual health management (MHM) needs of girls and young women in Eastern and Southern Africa, relating to dignity, and to the potential link between the lack of access to sanitary products and school absenteeism. In the South Africa, there is inadequate evidence to guide appropriate national responses. This study explored the extent of access to modern sanitary products amongst female high school learners and the range of needs and challenges that they face in managing their menses in school settings in Gauteng, South Africa. Methods We collected mixed method data from 10 schools in Sedibeng district between June and August 2018. The qualitative component consisted of in-depth interviews with female learners (n = 30), educators (n = 8) and mothers of female learners (n = 9) and focus group discussions (FGDs) with male learners (n = 7) and female learners (n = 10). Five hundred and five female learners were recruited into the quantitative component consisting of a self-administered survey focussing on factors associated with access to sanitary products. Results The median age of survey participants was 17 years (interquartile range 16–18 years) and average age at menarche was 13.36 years. One in seven female learners reported not having enough sanitary products for every period in the last 3 months and this was reflected across the school quintiles. There was a complex interaction between menstrual-related challenges (physical discomfort, teasing, and feeling distracted in class) experienced by female learners, often amplified or compounded by factors in the school environment (unhygienic sanitation facilities and inadequate rest areas), and schooling participation and attendance. Girls who did not have enough products for every period in the last 3 months more likely reported missing school than those who reported sufficient products (46.27% vs 22.49% respectively, p < 0.001). However, there was no statistically significant difference between the groups in number of days missed. Conclusions Provision of sanitary products is important but only one component of a comprehensive MHM response. Ongoing attention over the link between product access and absenteeism risks overlooking complex systemic and structural factors which can negatively impact the sexual and reproductive health of learners in the school context, and more broadly.
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Affiliation(s)
- Tamaryn L Crankshaw
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Westville Campus, Private Bag X54001, Durban, 4000, South Africa.
| | - Michael Strauss
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Westville Campus, Private Bag X54001, Durban, 4000, South Africa
| | - Bongiwe Gumede
- Legal Resources Centre, P.O. Box 9495, Johannesburg, 2000, South Africa
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40
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Belay S, Kuhlmann AKS, Wall LL. Girls' attendance at school after a menstrual hygiene intervention in northern Ethiopia. Int J Gynaecol Obstet 2020; 149:287-291. [PMID: 32083719 DOI: 10.1002/ijgo.13127] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/12/2019] [Accepted: 02/19/2020] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Shewaye Belay
- Department of Microbiology and Parasitology, Institute of Biomedical Sciences, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Anne K Sebert Kuhlmann
- College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, USA
| | - L Lewis Wall
- Department of Anthropology, College of Arts and Sciences, Washington University in St. Louis, St. Louis, MO, USA.,Department of Obstetrics & Gynecology, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
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Hennegan J, Sol L. Confidence to manage menstruation at home and at school: findings from a cross-sectional survey of schoolgirls in rural Bangladesh. CULTURE, HEALTH & SEXUALITY 2020; 22:146-165. [PMID: 30931818 DOI: 10.1080/13691058.2019.1580768] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 02/05/2019] [Indexed: 06/09/2023]
Abstract
This study investigated girls' confidence to undertake menstrual management tasks at home and in school environments using cross-sectional data from a survey of 1,359 schoolgirls in Bangladesh. At home, 57% of girls reported they were 'very confident' undertaking tasks to manage their menstrual bleeding, while this figure was only 7% at school. We assessed personal, interpersonal and environmental contributors for each context. The use of sanitary pads was positively associated with confidence to manage menstruation at home, while other menstrual hygiene practices were unrelated. In multivariable models, features of sanitation facilities such as cleanliness and the presence of a bin were associated with increased confidence at home. At school, supportive policies, such providing permission to use the toilet when needed, were associated with greater confidence. Talking to a friend about menstruation was positively associated with confidence at school, while at home having discussed menstruation with parents predicted lower confidence. Findings provide quantitative support for the role of multiple independent predictors in girls' confidence to manage menstruation highlighted by qualitative studies. There is unlikely to be a single 'silver bullet' to improving menstrual experience.
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Affiliation(s)
- Julie Hennegan
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lidwien Sol
- School of Business and Economics, Maastricht University, Maastricht, The Netherlands
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42
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van Eijk AM, Zulaika G, Lenchner M, Mason L, Sivakami M, Nyothach E, Unger H, Laserson K, Phillips-Howard PA. Menstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysis. Lancet Public Health 2019; 4:e376-e393. [PMID: 31324419 PMCID: PMC6669309 DOI: 10.1016/s2468-2667(19)30111-2] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 06/15/2019] [Accepted: 06/17/2019] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Garazi Zulaika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Madeline Lenchner
- Population Health Sciences, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Linda Mason
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Muthusamy Sivakami
- Centre for Health and Social Sciences, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, Maharashtra, India
| | - Elizabeth Nyothach
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Holger Unger
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK; Department of Obstetrics and Gynaecology, Edinburgh Royal Infirmary, Edinburgh, UK
| | - Kayla Laserson
- Bill & Melinda Gates Foundation, India Country Office, New Delhi, India
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Dolan C, Gordon C, Steinfield L, Hennegan J. Logics of affordability and worth: Gendered consumption in rural Uganda. ECONOMIC ANTHROPOLOGY 2019. [DOI: 10.1002/sea2.12157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Catherine Dolan
- Department of Anthropology, School of Oriental and African StudiesUniversity of London London WC1H 0XG UK
| | | | | | - Julie Hennegan
- Johns Hopkins Bloomberg School of Public HealthJohns Hopkins University Baltimore MD 21205 USA
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Crockett LJ, Deardorff J, Johnson M, Irwin C, Petersen AC. Puberty Education in a Global Context: Knowledge Gaps, Opportunities, and Implications for Policy. JOURNAL OF RESEARCH ON ADOLESCENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR RESEARCH ON ADOLESCENCE 2019; 29:177-195. [PMID: 30869838 DOI: 10.1111/jora.12452] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Youth programs and policies provide opportunities for institutions and societies to support healthy adolescent development. Puberty education programs are universally important, as they provide crucial knowledge and skills to help youth and their caregivers navigate the physical, emotional, and interpersonal changes of puberty with positive outcomes. However, few puberty programs have been rigorously evaluated, resulting in a lack of evidence-based knowledge and practice in this area. This review examines the status of research on puberty education and related programs and draws on the broader intervention literature and recent research findings on adolescence to identify program features that might improve program effectiveness. Implications for policy are also discussed. The need for rigorous program evaluation is emphasized throughout.
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45
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Coast E, Lattof SR, Strong J. Puberty and menstruation knowledge among young adolescents in low- and middle-income countries: a scoping review. Int J Public Health 2019; 64:293-304. [PMID: 30740629 PMCID: PMC6439145 DOI: 10.1007/s00038-019-01209-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 01/12/2019] [Accepted: 01/18/2019] [Indexed: 11/30/2022] Open
Abstract
Objectives This study presents a scoping review of evidence relating to knowledge and experiences of puberty and menstruation among females aged 10–14 years in low- and middle-income countries. Methods Forty-four items from 12 countries were identified from a systematic scoping review and screening of 8083 items. Included studies were quality assessed. Results A majority (40/44) of studies used school-based samples, and fifteen studies reported on interventions. Girls had inadequate knowledge about menstruation; menarche as a trigger for girls learning about menstruation was common. Adolescents struggled with menstrual hygiene. Negative emotions were associated with menarche and menstrual management. A minority of studies dealt explicitly with puberty. Most girls obtained information about menstruation and/or puberty from their mothers, although mothers were not necessarily girls’ preferred source for learning about these topics. Conclusions Young adolescent girls are under-prepared for puberty and menstruation. Predominantly school-based studies mean we know little about young out-of-school adolescents. The evidence base lags behind the rise in interest from practitioners as well as the development (and evaluation) of puberty and/or menstruation interventions. Electronic supplementary material The online version of this article (10.1007/s00038-019-01209-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ernestina Coast
- Department of International Development, London School of Economics and Political Science, London, UK.
| | - Samantha R Lattof
- Department of Social Policy, London School of Economics and Political Science, London, UK
| | - Joe Strong
- Department of Social Policy, London School of Economics and Political Science, London, UK
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46
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Wall LL, Teklay K, Desta A, Belay S. Tending the 'monthly flower:' a qualitative study of menstrual beliefs in Tigray, Ethiopia. BMC WOMENS HEALTH 2018; 18:183. [PMID: 30424763 PMCID: PMC6234636 DOI: 10.1186/s12905-018-0676-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 10/28/2018] [Indexed: 11/23/2022]
Abstract
Background Menstruation is a universal aspect of human female reproductive life. Management of menstrual flow presents hygiene challenges to girls and women in low-income countries, especially when they first start their periods. As part of a project to improve menstrual hygiene management in the Tigray Region of Ethiopia, we explored the local understanding of menstruation through focus-group discussions and individual interviews. Methods A detailed ethnographic survey of menstrual beliefs was carried out through 40 focus group discussions, 64 in-depth key informant interviews, and 16 individual case histories in the Tigray Region of northern Ethiopia. A total of 240 individuals participated in six types of focus groups (pre-menarchal girls, menstruating adolescents, married women of reproductive age, post-menopausal women, adolescent males, and married men). In-depth interviews were also carried out with 80 individuals, including Orthodox Christian priests, imams from the Muslim community, principals of primary and secondary schools, teachers and nurses, as well as menstruating schoolgirls and women. Audio data were transcribed and translated, then broken down into discrete codes using Atlas Ti software (version 7.5.4, Atlas.ti Scientific Software Development Mnbh, Berlin) and further grouped into related families and sub-families based on their content. The results were then synthesized to produce a cohesive narrative concerning menstruation in Tigray. Results Recurrent themes identified by participants included descriptions of the biology of menstruation (which were sometimes fanciful); the general unpreparedness of girls for menarche; cultural restrictions imposed by menstruation on females (particularly the stigma of ritual uncleanliness in both Christian and Muslim religious traditions); the prevalence and challenges of unmet menstrual hygiene needs at schools (including lack of access to sanitary pads and the absence of acceptable toilet/washing facilities); and the stigma and shame associated with menstrual hygiene accidents in public. Conclusions Changes in the educational system in northern Ethiopia are required to improve student understanding of the biology of menstruation, to foster gender equity, to overcome the barriers to school attendance presented by poor menstrual hygiene management, and to create a society that is more understanding and more accepting of menstruation.
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Affiliation(s)
- L Lewis Wall
- Department of Anthropology, College of Arts and Sciences, Washington University in St. Louis, Campus Box 1114, One Brookings Drive, St. Louis, MO, 63130, USA. .,Department of Obstetrics & Gynecology, Ayder Comprehensive Specialist Hospital, College of Health Sciences, Mekelle University, Mekelle, Ethiopia. .,Department of Obstetrics & Gynecology, Washington University in St. Louis, St. Louis, MO, USA.
| | | | - Alem Desta
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Shewaye Belay
- Department of Microbiology and Parasitology, Institute of Biomedical Sciences, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
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Davis J, Macintyre A, Odagiri M, Suriastini W, Cordova A, Huggett C, Agius PA, Faiqoh, Budiyani AE, Quillet C, Cronin AA, Diah NM, Triwahyunto A, Luchters S, Kennedy E. Menstrual hygiene management and school absenteeism among adolescent students in Indonesia: evidence from a cross-sectional school-based survey. Trop Med Int Health 2018; 23:1350-1363. [PMID: 30286270 DOI: 10.1111/tmi.13159] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the prevalence of menstrual hygiene management (MHM) knowledge and practices among adolescent schoolgirls in Indonesia, and assess factors associated with poor MHM and school absenteeism due to menstruation. METHODS A cross-sectional survey enrolled a representative sample of urban and rural school-going girls aged 12-19 years in four provinces of Indonesia. A semi-structured, self-administered questionnaire obtained socio-demographic characteristics, knowledge, practices and attitudes related to menstruation, MHM and school absenteeism. School water, sanitation and hygiene (WASH) facilities were also assessed. Univariate weighted population prevalence was estimated and multivariable logit regression analyses applied to explore associations. RESULTS A total of 1159 adolescent girls with a mean age of 15 years (SD = 1.8) participated. Most girls (90.8%, 95% confidence interval (95% CI) = 79.7-96.1) had reached menarche. Over half (64.1%, 95% CI = 49.9-76.2) reported poor MHM practices, and 11.1% (95% CI = 8.1-15.2) had missed one or more days of school during their most recent menstrual period. Poor MHM practices were associated with rural residence (Adjusted odds ratio (AOR) = 1.73, 95% CI = 1.13-2.64), province (various AOR), lower school grade (AOR = 1.69, 95% CI = 1.05-2.74) and low knowledge of menstruation (AOR = 3.49, 95% CI = 1.61-7.58). Absenteeism was associated with living in rural areas (AOR = 3.96, 95% CI = 3.02-5.18), province (various AOR), higher school grade (AOR = 3.02, 95% CI = 2.08-4.38), believing menstruation should be kept secret (AOR = 1.47, 95% CI = 1.03-2.11), experiencing serious menstrual pain (AOR = 1.68, 95% CI = 1.06-2.68) and showed mixed associations with school WASH facilities. CONCLUSIONS High prevalence of poor MHM and considerable school absenteeism due to menstruation among Indonesian girls highlight the need for improved interventions that reach girls at a young age and address knowledge, shame and secrecy, acceptability of WASH infrastructure and menstrual pain management.
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Affiliation(s)
- Jessica Davis
- Maternal and Child Health Program, Burnet Institute, Melbourne, Vic, Australia
| | | | | | | | | | | | - Paul A Agius
- Maternal and Child Health Program, Burnet Institute, Melbourne, Vic, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia.,Judith Lumley Centre, La Trobe University, Melbourne, Vic, Australia
| | - Faiqoh
- Aliansi Remaja Independen, Jakarta, Indonesia
| | | | - Claire Quillet
- UNICEF, Jakarta, Indonesia.,P.T Towards Sustainable Businesses, Jakarta, Indonesia
| | | | - Ni Made Diah
- Ministry of Health, Government of Indonesia, Jakarta, Indonesia
| | - Agung Triwahyunto
- Ministry of Education and Culture, Government of Indonesia, Jakarta, Indonesia
| | - Stanley Luchters
- Maternal and Child Health Program, Burnet Institute, Melbourne, Vic, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia.,International Centre for Reproductive Health, Department of Obstetrics and Gynaecology, Ghent University, Ghent, Belgium
| | - Elissa Kennedy
- Maternal and Child Health Program, Burnet Institute, Melbourne, Vic, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia
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48
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Alexander KT, Zulaika G, Nyothach E, Oduor C, Mason L, Obor D, Eleveld A, Laserson KF, Phillips-Howard PA. Do Water, Sanitation and Hygiene Conditions in Primary Schools Consistently Support Schoolgirls' Menstrual Needs? A Longitudinal Study in Rural Western Kenya. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15081682. [PMID: 30087298 PMCID: PMC6121484 DOI: 10.3390/ijerph15081682] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/01/2018] [Accepted: 08/04/2018] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Kelly T Alexander
- Liverpool School of Tropical Medicine, Liverpool L35QA, UK.
- Cooperative for Assistance and Relief Everywhere (CARE), 151 Ellis St NE, Atlanta, GA 30303, USA.
| | - Garazi Zulaika
- Liverpool School of Tropical Medicine, Liverpool L35QA, UK.
| | | | - Clifford Oduor
- Kenya Medical Research Institute, Kisumu 1578-40100, Kenya.
| | - Linda Mason
- Liverpool School of Tropical Medicine, Liverpool L35QA, UK.
| | - David Obor
- Kenya Medical Research Institute, Kisumu 1578-40100, Kenya.
| | - Alie Eleveld
- Safe Water and AIDS Programme, Kisumu 3323-40100, Kenya.
| | - Kayla F Laserson
- Kenya Medical Research Institute, Kisumu 1578-40100, Kenya.
- Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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49
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Hennegan J, Torondel B, Phillips-Howard PA, Sommer M, Montgomery P. Time to talk about menstruation: a response. Lancet 2017; 390:845-846. [PMID: 28850036 DOI: 10.1016/s0140-6736(17)31950-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 07/04/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Julie Hennegan
- Centre for Evidence Based Intervention, University of Oxford, Oxford OX1 2ER, UK.
| | - Belen Torondel
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Marni Sommer
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Paul Montgomery
- Department of Social Policy and Social Work, University of Birmingham, Birmingham, UK
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50
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A qualitative understanding of the effects of reusable sanitary pads and puberty education: implications for future research and practice. Reprod Health 2017; 14:78. [PMID: 28655302 PMCID: PMC5488479 DOI: 10.1186/s12978-017-0339-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 06/11/2017] [Indexed: 11/10/2022] Open
Abstract
Background The management of menstruation has come to the fore as a barrier to girls’ education attainment in low income contexts. Interventions have been proposed and piloted, but the emerging nature of the field means limited evidence is available to understand their pathways of effect. Methods This study describes and compares schoolgirls’ experiences of menstruation in rural Uganda at the conclusion of a controlled trial of puberty education and sanitary pad provision to elucidate pathways of effect in the interventions. Semi-structured interviews were undertaken with schoolgirls who participated in the Menstruation and the Cycle of Poverty trial concurrent with the final set of quantitative surveys. A framework approach and cross-case analysis were employed to describe and compare the experiences of 27 menstruating girls across the four intervention conditions; education (n = 8), reusable sanitary pads (n = 8), education with reusable sanitary pads (n = 6), and control (n = 5). Results Themes included: menstrual hygiene, soiling, irritation and infection, physical experience, knowledge of menstruation, psychological, social and cultural factors, and support from others. Those receiving reusable pads experienced improvements in comfort and reliability. This translated into reduced fears around garment soiling and related school absenteeism. Other menstrual hygiene challenges of washing, drying and privacy remained prominent. Puberty education improved girls’ confidence to discuss menstruation and prompted additional support from teachers and peers. Conclusions Findings have important implications for the development and evaluation of future interventions. Results suggest the provision of menstrual absorbents addresses one core barrier to menstrual health, but that interventions addressing broader needs such as privacy may improve effectiveness. Puberty education sessions should increase attention to body awareness and include strategies to address a wider range of practical menstrual challenges, including pain management. Interviews revealed possibilities for improving quantitative surveys in future research. Trial registration Pan-African Clinical Trials Registry PACTR201503001044408
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