From menarche to menopause: A population-based assessment of water, sanitation, and hygiene risk factors for reproductive tract infection symptoms over life stages in rural girls and women in India

Women's self-reported symptoms of reproductive tract infection, medical consultations, and factors influencing them in less developed regions: perimenopausal and older women in need of urgent attention

Background

Reproductive tract infections (RTIs) represent a critical public health concern impacting women's health, particularly pronounced in developing countries. We aim to investigates the prevalence of self-reported RTI symptoms in women aged 18 to 65 and the factors influencing gynecological examination behavior and associated risks are explored.

Methods

From May 6, 2022, to September 20, 2022, a comprehensive survey engaged 20,864 women aged 18 to 65 in 19 townships in Lueyang, Shaanxi. Each survey team, comprising a gynecologist, two female health center staff, and a master's student, conducted face-to-face questionnaire surveys in villages and households. The questionnaire featured three sections: prevalence of self-reported RTI symptoms, gynecological examination history, and factors influencing examination behavior.

Results

The high response rate of 98.69% yielded 20,590 valid questionnaires. Among surveyed women, 42.04% reported RTI symptoms, with a higher prevalence in those aged 30 and above, peaking at 44.88% in the 50-59 age group. Vulvar itching (24.73%), abnormal vaginal discharge (17.41%), and urinary tract irritation signs (11.73%) were most common. Older adult women (≥60) reported higher frequency and longer duration of symptoms. Only 9.88% of symptomatic women underwent gynecological examinations in 2022. Examination likelihood decreased with age, presenting a critical gap in healthcare utilization among older women. Reasons for checkups included routine checkups (47.02%), symptom concerns (41.29%), and the availability of free medical checkup programs (9.82%). Barriers included perceived lack of serious symptoms (23.7%), lack of necessity (4.41%) and lack of time (3.98%). Among those examined, 40.58% had a diagnosis of gynecological disorders, including pelvic inflammatory disease, human papilloma virus infection and cervical cancer.

Conclusion

Widespread RTI symptoms, particularly in perimenopausal and older women, underscore the need for enhanced healthcare. Barriers to gynecological examinations include awareness, education, and accessibility issues. Strategies must prioritize health education, routine examinations, and improved healthcare infrastructure in underdeveloped regions.

Water, sanitation and hygiene at sex work venues to support menstrual needs

Introduction

Adequate menstrual health and hygiene (MHH) is necessary for women's health and equity of all menstruators. Female sex workers (FSW) require good MHH to prevent discomfort and exposure to pathogens. No studies have evaluated water, sanitation, and hygiene (WASH) conditions of FSW. We report on a cross-sectional WASH assessment at FSW venues in Kisumu, western Kenya.

Methods

Stakeholders identified 77 FSW venues in Kisumu, of which 47 were randomly sampled and visited between April-May 2023. A standardized structured survey of WASH conditions was deployed by trained research staff using Android tablets after proprietor's consent. WASH scores ranging 0-3 were computed based on point each for direct observation of water available, soap available, and acceptable latrine. MHH scores ranging between 0-4 were computed (one point each) for direct observation of: currently available soap and water, locking door on a usable latrine, functional lighting, and a private area for changing clothes or menstrual materials, separate from the latrine(s). WASH and MHH scores were compared by venue type using non-parametric Kruskal-Wallis tests, and non-parametric Spearman rank tests.

Results

Full WASH criteria was met by 29.8% of venues; 34.0% had no adequate WASH facilities; 46.8% had no female latrine; and 25.5% provided soap and water in private spaces for women. While 76.6% had menstrual waste disposal only 14 (29.8%) had covered bins. One in 10 venues provided adequate MHM facilities. Poorest WASH facilities were in brothels and in bars, and three-quarters of bars with accommodation had no MHH facilities.

Discussion

WASH and MHH services were sub-optimal in the majority of FSW venues, preventing menstrual management safely, effectively, with dignity and privacy. This study highlights the unmet need for MHH support for this population. Poor MHH can deleteriously impact FSW health and wellbeing and compound the stigma and shame associated with their work and ability to stay clean. Acceptable and cost-effective solutions to sustainably improve WASH facilities for these populations are needed.

Trial registration

Clinicaltrial.gov NCT0566678.

Urinary and reproductive tract infection symptoms and menstrual hygiene practices in refugee camps in Jordan: A cross-sectional study

BACKGROUND

Urinary tract infections and reproductive tract infections pose significant health risks, particularly among women living in challenging conditions. Unhygienic menstrual practices can exacerbate these risks, impacting physical and psychological well-being.

OBJECTIVES

This study assessed the association between unhygienic menstrual care and self-reported urinary tract infection/reproductive tract infection symptoms among refugee women. In addition, it explored the association between these symptoms and mental health, specifically depressive symptoms.

DESIGN

This study adopted a cross-sectional observational design.

METHODS

This study was conducted between January and March 2023, involving 387 reproductive-age refugee women. Data collected included sociodemographic information and urinary tract infection/reproductive tract infection symptoms. In addition, we used the Menstrual Practice Needs Scale to evaluate menstrual hygiene practices and the Patient Health Questionnaire-9 for depressive symptoms. Statistical analysis was performed using Python version 3.9.12.

RESULTS

Of 387 refugee women, 92.25% reported having urinary or reproductive tract infection symptoms in the previous 3 months. Factors like older age (odds ratio = 1.764, 95% confidence interval = 1.083-2.873, p-value = 0.023), lower family income (odds ratio = 0.327, 95% confidence interval = 0.138-0.775, p-value = 0.011), lower educational level (odds ratio = 0.222, 95% confidence interval = 0.068-0.718, p-value = 0.012), and being married (odds ratio = 0.328, 95% confidence interval = 0.188-0.574, p-value < 0.001) were significantly associated with urinary or reproductive tract infection risk. Difficulties obtaining menstrual products and thus reusing them increased the odds of urinary or reproductive tract infection diagnosis (odds ratio = 2.452, 95% confidence interval = 1.497-4.015, p-value < 0.001). Women with urinary or reproductive tract infection symptoms exhibited higher Patient Health Questionnaire-9 scores than those without (12.14 ± 5.87 vs 9.99 ± 5.86, p-value < 0.001, respectively).

CONCLUSION

This study highlights a high prevalence of urinary or reproductive tract infection symptoms among refugee women residing in camps in Jordan, which was associated with poor menstrual hygiene practices and depressive symptoms. To reduce the urinary tract infection/reproductive tract infection burden in marginalized communities, public health initiatives should enhance healthcare accessibility, provide reproductive education, and promote holistic well-being practices for refugee women.

Assessing the link between hygienic material use during menstruation and self-reported reproductive tract infections among women in India: a propensity score matching approach

Background

Reproductive tract infections (RTIs) present a substantial health concern for women, especially in developing nations such as India, where inadequate access to proper sanitation and hygiene facilities frequently results in suboptimal menstrual health and hygiene (MHH), exacerbating the risk of RTIs. In this study, we analysed the self-reported prevalence of RTIs among young women in India and evaluated the impact of hygienic menstrual material usage on these RTIs.

Methods

The study used information on 27,983 women aged 15-24 years, from the National Family Health Survey (NFHS-5) (2019-21). The prevalence of RTIs was calculated for all the states and UTs of India, and propensity score matching (PSM) technique was used to evaluate the impact of hygienic material use on RTIs among women in India.

Results

Every four out of 100 women reported RTIs in India in 2019-21. Notably, RTI prevalence displayed substantial state-level disparities. West Bengal exhibited the highest RTI prevalence at 9.3%, followed by Meghalaya, Arunachal Pradesh, and Himachal Pradesh, all surpassing 6%. In contrast, the lowest RTI rates were recorded in Puducherry at 0.9%, succeeded by Andaman and Nicobar Islands, Odisha, and Jammu & Kashmir, all registering rates below 2%. The PSM analysis revealed that women who utilized hygienic materials during menstruation exhibited a reduced prevalence of RTIs (referred to as the "treated group" with an Average Treatment Effect on the Treated (ATT) of 0.0315) compared to those who did not utilize such materials (referred to as the "control group" with an ATT of 0.0416).

Conclusions

The study underscores the critical significance of using hygienic materials during menstruation as a preventive measure against RTIs among women in India. The findings suggest the need for targeted interventions focused at promoting hygienic menstrual materials to reduce the prevalence of RTIs among women in India.

Identity dimension of rural women and the sexual and reproductive health

OBJECTIVES

to analyze the social representations of rural women about being a woman in the rural context and its implications for sexual and reproductive health.

METHODS

this is a descriptive qualitative study with data triangulation, based on the Theory of Social Representations, developed with 31 women who live in the rural context of Minas Gerais (MG/BR). An in-depth interview with a semi-structured script was conducted. A lexical analysis was performed with the help of the ALCESTE 2012 software.

RESULTS

the family relationship, especially the couple's, demonstrated subjectivities and was permeated by violence and normalized sexual practice. The imagery dimension of the ideal family seems to be responsible for exerting domination over rural women.

FINAL CONSIDERATIONS

rural women are subject to the norms and prescriptions of a patriarchal society. It is urgent to increase attention to sexual and reproductive health in an egalitarian and liberating way in order to minimize the consequences of machismo and conservatism.

What socio-demographic factors support disposable vs. sustainable menstrual choices? Evidence from India's National Family Health Survey-5

For over a decade, improving menstrual hygiene among poor girls and women in low-and-middle-income-countries has been a prominent global goal. Towards this, governments in the Global South have worked to promote the uptake of disposable sanitary pads. Despite this, we continue to see a high prevalence of period poverty mainly because disposable pads require monthly purchasing that may be burdensome for many women. Not only are pads financially unsustainable but also represent a heavy environmental burden which has kindled an interest in re-usable innovations like menstrual cups that present a sustainable solution. However, there is little understanding of factors that promote the take-up of disposable vs. sustainable products at population levels. In this paper, we draw on India's National Family Health Survey-5 to understand the socio-demographic determinants of period product usage among girls and women, differentiated by their sustainability quotient. Our findings suggest that awareness of sustainable products and cultural factors are the key driver to promote their use. Women with exposure to menstrual cups either via education or mass media were more likely to use them. Belonging to urban areas and to disadvantaged social categories are other driving factors, at least partly because taboos of vaginal insertion are less of a concern among these groups. These findings suggest that improving the uptake of menstrual cups requires a paradigm shift in menstrual health policies from the promotion of disposable pads alone to spreading awareness of sustainable period choices among women via innovative use of mass media and community networks. Some micro-level evidence of change supports our conclusions.

Associations Between Unmet Social Needs and Overactive Bladder

PURPOSE

There is growing interest in how social determinants of health may explain relationships between social conditions and health. Overactive bladder is common in the United States, posing a significant public health burden. It was the goal of the present study to assess whether overactive bladder was associated with unmet social needs in a large, cross-sectional sample of patients.

MATERIALS AND METHODS

A community-based sample of adults was recruited electronically to complete questionnaires on clinical and demographic information, urinary symptoms and unmet social needs. Multivariable logistic regression was used to assess for association between overactive bladder and multiple unmet social needs.

RESULTS

The sample of 3,617 participants had a mean±SD age of 47.9±17.3 years. The majority of participants identified as White, non-Hispanic (83.5%), and female (77.6%). A total of 1,391 patients (38.5%) were found to have overactive bladder. The presence of overactive bladder was associated with numerous unmet social needs, including housing instability, food insecurity, worry about utilities, lack of transportation, skipping medical appointments, needing legal help, stress in personal relationships, worry about toilet access and plumbing at home, and lack of social supports. On multivariable analysis adjusting for multiple covariates, all associations between overactive bladder and social needs remained significant.

CONCLUSIONS

Multiple unmet social needs were associated with overactive bladder, which may have implications for the overall management of overactive bladder patients. It is important for providers to consider these unmet social needs of patients, as highlighting and addressing these factors hopefully can help improve care of individuals with overactive bladder.

Revalidation and adaptation of the Menstrual Practice Needs Scale (MPNS) in a cross-sectional survey to measure the menstrual experiences of adult women working in Mukono District, Uganda

OBJECTIVES

The Menstrual Practice Needs Scale (MPNS) is a comprehensive measure of menstrual self-care experience including access to sufficient, comfortable materials to catch or absorb bleeding, supportive spaces for managing menstruation and for disposal and laundering of used materials. It addresses a critical measurement gap to improve quantitative menstrual health research and programme evaluation. The scale was validated in a population of adolescent schoolgirls. This study appraises its performance among adult women.

DESIGN

Cross-sectional survey.

SETTING AND PARTICIPANTS

Seven cognitive interviews provided insights into the interpretability of scale items. A survey of 525 working women who had menstruated in the past 6 months (435 working in markets, 45 in schools and 45 working in healthcare facilities) in Mukono District, Uganda was used to test the dimensionality, reliability and validity of the measure.

RESULTS

The 36 scale items were well understood by the study population. Dimensionality was tested for the 28 items relevant to women disposing of menstrual materials and 32 items relevant to those washing and reusing materials. The original subscale structure fit with the data, however, fell short of recommended thresholds for those disposing of materials (root mean squared error of approximation, RMSEA=0.069; Comparative Fit Index, CFI=0.840; Trucker-Lewis Index, TLI=0.824). An alternative subscale structure was an acceptable fit for those disposing (RMSEA=0.051; CFI=0.911; TLI=0.897) and reusing materials (RMSEA=0.053; CFI=0.915; TLI=0.904). MPNS total and subscale scores demonstrated acceptable internal consistency. Higher scores reflected more positive menstrual experiences and were associated with well-being (total score r=0.24, p<0.001), not missing work due to the last menstrual period (total score OR=2.47 95% CI 1.42 to 4.30) and confidence to manage menstruation.

CONCLUSIONS

The MPNS offers a valid and reliable way to assess menstrual health needs. The revised factor structure can be used for samples of adult workers. Findings also highlight challenges in assessing the variety of experiences relevant to managing menstrual bleeding.

Associations between water, sanitation, and depression among older people in Ghana: empirical evidence from WHO-SAGE Wave 2 survey

BACKGROUND

While depression is the most frequent psychiatric disorder among the older adults, the use of water and sanitation has been associated with both physical and psychological adverse outcomes. We investigated the associations of water and sanitation with depressive symptoms among older adults in Ghana.

METHODS

The study used data from 4,735 participants in the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 2 of adults aged ≥50 years. Major depressive episode (MDE) was assessed using the World Mental Health Survey version of the Composite International Diagnostic Interview and we classified water and sanitation sources based on the Joint Monitoring Program. Multivariate logistic regressions evaluated the associations.

RESULTS

Approximately 7.3% of respondents reported a MDE, 90% and 78% used improved water sources and sanitation facilities respectively, and 77% shared sanitation facilities. Individuals who used unimproved water sources and unimproved sanitation were 1.6 and 1.3 times more likely to report MDE respectively. Also, sex-based analysis showed that the effect of the use of unimproved water and sanitation on depression was much appreciable and more substantial among women compared to men.

CONCLUSIONS

The findings suggest the importance of water and sanitation to the well-being of older people, particularly among women. Policies targeted at improving the mental health in old age should include water and sanitation.

Reusable sanitary napkins in rural India: a remote quality improvement project for adolescent girls promoting menstrual hygiene health during the COVID-19 pandemic

Medical and public health research supports an ongoing need for health promotion in meeting menstrual hygiene needs, including menstrual hygiene management (MHM) education and the adoption of reusable sanitary napkins. This quality improvement project focuses on menstruation education for adolescent girls in rural Tamil Nadu, India and the promotion of reusable sanitary napkins. Results indicate a significant improvement in MHM knowledge, confidence in managing menstruation, adoption of reusable sanitary napkins, and a decrease in missed school days. These findings support global recommendations for health promotion in India.

Effect of a combined household-level piped water and sanitation intervention on reported menstrual hygiene practices and symptoms of urogenital infections in rural Odisha, India

Adequate menstrual hygiene management (MHM) requires access to water and sanitation and can be challenging for many women and girls living in resource-poor settings. Inadequate MHM has been associated with urogenital infections. The aim of this study is to assess the impact of a combined household-level piped water and sanitation intervention on MHM practices and urogenital infection symptoms (UGS) among women living in rural communities of Odisha (India). This study was nested within a pair-matched cohort study designed to assess impact of the Gram Vikas MANTRA program, which provided household-level piped water, bathing areas and latrine to all households in intervention villages, on diarrheal disease (primary outcome). The program did not specifically promote menstrual hygiene practices. Forty-five intervention villages were randomly selected from a list of those where implementation was previously completed at least five years before and matched to 45 control villages. Data for the main study was collected in four rounds from June 2015 to October 2016. For the MHM sub study, household surveys were administered in round four to randomly selected women aged 18 or older among study households from the 90 villages, to assess self-reported MHM practicesand urogenital infections symptoms. MHM practices were deemed adequate if they met some of the criteria developed on the basis of international monitoring that the GV program could modify (adequate frequency of absorbent change, washing the body with soap and privacy for managing menstruation). Multilevel mixed-effects logistic regression with a random effect distribution at the level of the pair and village was used to estimate the effect of the intervention on adequate MHM practices (primary outcome) and reported UGS (secondary outcome). A total of 1045 women (517 from intervention and 528 from control) were included in the study. Women who lived in the villages receiving the intervention, were more likely to report adequate MHM practices than those in control villages (Adjusted OR (AOR) 3.54, 95% Confidence Interval (CI): 1.86-6.78). 14.51% and 15.53% of women living in the control and intervention villages reported having at least one UGS. There was no evidence of an intervention effect on reported UGS (AOR = 0.97, 95%CI: 0.64-1.46). While household latrines or bathing areas with access to piped water improve the environment that enable MHM practices related to privacy, the provision of such facilities alone had only a moderate impact in adequate MHM and did not have an effect on self-reported UGS. More targeted inventions that include behavior change strategies and that address other barriers may be necessary to improve MHM practices.

The practice of menstrual hygiene management and associated factors among secondary school girls in eastern Ethiopia: The need for water, sanitation, and hygiene support

BACKGROUND

During menstruation, school girls face obstacles connected to menstrual hygiene management in schools. Due to their monthly period, up to 20% of girls miss school globally, and one in ten will drop out entirely. Three hundred thirty-five million girls attended school without access to running water or soap. In Ethiopia, 67% of girls have no access to education on puberty and menstrual health; menstrual hygiene management continues to be one of the major problems among school girls. Thus, context-specific assessment of the practice may be useful in developing customized intervention approaches. Thus, the objective of the study was to assess practices of menstrual hygiene management and associated determinants among secondary school girls in East Hararghe, Ethiopia from 1 to 30 December 2020.

METHODS

A school-based cross-sectional survey was undertaken with 486 randomly selected female students. Data were collected by pretested self-administered questionnaire. Descriptive statistical tests and multivariate logistic regression were used to describe the study variables and to examine the association. Statistical package for social science version 23 was used for data analysis, and a p-value of 0.05 was considered as a cut-off point for statistical significance.

RESULTS

Of the total, 328 (68%) of the study participants practiced appropriate menstrual hygiene. Besides, 350 (72.6%) had a good level of understanding about menstrual hygiene. A higher level of knowledge (adjusted odds ratio = 2.12, 95% confidence interval = 1.28, 3.53), a greater wealth indexed family (adjusted odds ratio = 7.14, 95% confidence interval = 3.98, 12.88), earning permanent pocket money (adjusted odds ratio = 0.495, 95% confidence interval = 0.299, 0.821), and being in grade level (11-12) (adjusted odds ratio = 3.45, 95% confidence interval = 1.75, 4.501) were significant predictors of the good menstrual hygiene practice.

CONCLUSION

One-third of the school girls had poor menstrual hygiene practices which may affect their school performance and the reproductive health. Hence, tailored menstrual hygiene information should be given to school girls and parents. Besides, efforts ought to be made for the provision of affordable sanitary materials in schools.

Water, Sanitation, and Hygiene (WaSH) practices and morbidity status in a rural community: findings from a cross-sectional study in Odisha, India

INTRODUCTION

Global evidence indicates an association between poor WaSH practice and inferior health outcomes. In rural areas, this practice is predominantly compromised with limited access to safe drinking water, knowledge gaps, and unhealthy socio-behavioural practices. Suboptimal WaSH practice leads to increased vulnerability of various infections, thereby posing a challenge to the primary health care system.

METHODS

A community based cross-sectional study was conducted among 879 participants of two villages in Tigiria block, Cuttack district, Odisha, India. Information pertaining to socio-demography, WaSH practices and self-reported morbidities were captured and analysed. Bi-variate analysis was done to assess the association between WaSH practices and any acute illnesses. Differences were considered statistically significant if p-value was less than 0.05.

RESULTS

Tube well was the main source of drinking water (49.3%) followed by dug well (46.6%). Only 7.1% of participants reported to purify drinking water and around 40% were still practicing open defecation. The prevalence of acute and chronic illnesses was 9.2% and 19.1% respectively. Major acute illnesses were respiratory diseases, diarrhoeal disorders, and musculoskeletal problems, while major chronic illnesses were gastrointestinal problems, musculoskeletal problems, and hypertension. After adjusting for age, gender, and education, a significant odds ratio of 3.79 [CI = (1.23-11.70)] was observed between drinking water source (surface water Vs tube well water) for acute illnesses.

CONCLUSIONS

Poor WaSH practices among rural people make them vulnerable to acute and chronic morbidities. Health awareness and socio behavioural changes pertaining to WaSH practices need utmost priority to ensure better health for rural people of Odisha.

Gender inequities in treatment-seeking for sexual and reproductive health amongst adolescents: Findings from a cross-sectional survey in India

CONTEXT

India's adolescent health policy aims to improve sexual and reproductive health, especially amongst the most vulnerable. There is limited evidence on how gender influences treatment-seeking patterns amongst unmarried adolescents.

METHODS

We analyzed data from 11,651 unmarried adolescent boys and girls aged 15-19 from a cross-sectional survey conducted in two large states of India. We conducted sex-disaggregated analyses to estimate the prevalence of symptoms of genital infections and compare treatment-seeking patterns. We identified correlates through multivariable regression and used a conceptual framework to explore structural, household, social and individual factors that influence gender inequities in adolescent sexual and reproductive health.

RESULTS

One in five unmarried adolescents reported symptoms of genital infections, such as burning or discharge, in the past three months. Factors associated with reporting symptoms varied between boys and girls, except for a common correlation with symptoms of depression. At least two-thirds of boys sought treatment, compared to approximately one in four girls (rural: 66.2% boys, 23.1% girls; urban: 69.4% boys, 30.7% girls). Boys primarily sought care from medical shops or private facilities, while girls used both private and government services. Amongst boys, having friends and being in school was associated with seeking treatment (aOR: 11.47; 95% CI: 2.75, 47.87; aOR: 1.95; 95% CI: 1.24, 3.07, respectively). Odds of seeking treatment were higher amongst girls with exposure to any mass media (aOR: 1.93; 95% CI: 1.25, 2.99) and who had discussed puberty with a parent (aOR: 1.98; 95% CI: 1.32, 2.98).

CONCLUSION

Stark sex differentials in factors associated with symptoms and in treatment-seeking illustrate how structural gender inequities, such as access to economic resources and education, influence sexual and reproductive health amongst adolescents. Along with health system interventions, addressing gender inequities calls for strategies to strengthen parental engagement, social support and girls' access to resources.

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

OBJECTIVES

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

DESIGN AND PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

Understanding Period Poverty: Socio-Economic Inequalities in Menstrual Hygiene Management in Eight Low- and Middle-Income Countries

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.

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

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Reproductive Tract Infection Among Women Suffering From Rheumatoid Arthritis in India: A Clinical-Based, Cross-Sectional Study

Background: Much research has been done on reproductive tract infections (RTIs), but no study exists about RTIs among rheumatoid arthritis women. Objectives: This study investigated the prevalence and risk factors of RTIs among reproductive-aged women with rheumatoid arthritis in Pune, India. Methods: This clinical-based, cross-sectional study enrolled a sample of 400 consenting Indian women aged 15 -49 years with a history of at least three months’ rheumatoid arthritis referring to a popular community center. Patients were interviewed comprehensively using previously validated relevant questionnaires. Women underwent gynecological examinations and vaginal smears (wet mount) by a microbiologist to diagnose candidiasis, bacterial vaginosis, and trichomoniasis. Syphilis serological testing was performed for the study population. Results: The prevalence obtained was 39.3%. Infection with bacterial vaginosis was 32.0%, Candidiasis 6.5%, and trichomoniasis 0.8%. Syphilis seroconversion was not observed. Adjusting for confounding factors in logistic regression showed that four factors remained significant, including age under 30 years [AOR: 2.4, 95% CI: 1.2 - 4.9], living in a crowded and small one-room house [AOR: 2.5, 95% CI: 1.2 - 5.1] , improper linen for menstruation bleeding [AOR: 1.9, 95% CI: 1.1 - 3.3], and oral disease-modifying anti-rheumatic drugs [AOR: 3.96, 95% CI: 1.9 - 7.9]. Conclusions: This study demonstrated a large burden of RTIs in women suffering from rheumatoid arthritis. Regular screening algorithms for RTIs are urgently required to prevent neglect and improve overall standard care in rheumatology practice. The presence of an oral disease-modifying anti-rheumatic drug as a risk factor shows that more investigation is necessary in this case.

Does menstrual hygiene management and water, sanitation, and hygiene predict reproductive tract infections among reproductive women in urban areas in Ethiopia?

Reproductive tract infections (RTIs) are a public health concern in Ethiopia. However, the relationship between menstrual hygiene management (MHM) and water, sanitation, and hygiene (WASH) factors to RTIs have not been well addressed. A community-based cross-sectional study was conducted from January to March 2019 among 602 systematically selected reproductive-age women aged 15-49 years in Dessie City. Data were collected using a questionnaire and a direct observation checklist. RTIs were identified by the presence during one year before data collection of one or more signs of vaginal discharge, itching/irritation or ulcers/lesions around the vulva, pain during urination and sexual intercourse, and lower abdominal pain and lower back pain. Data were analyzed using multivariable logistic regression analysis with 95%CI (confidence interval). The self-reported prevalence of RTIs was 11.0%(95%CI:8.5-13.7%) during one year prior to the survey. The most commonly reported symptoms of RTI were burning micturition (9.1%) and vaginal discharge (6.1%). Three-fourths 443(75.0%) of households used traditional pit latrines and the majority of the study participants 527(89.2%) did not meet the basic access requirement of 20 liters of water per capita per day. The majority 562(95.1%) of the study participants did not have multiple sexual partners during the last year and 97.8% did not practiced sexual intercourse during menstruation. The most common type of blood-absorbent material used was a sanitary pad 497(84.8%) followed by cloth 89(15.2%). Factors significantly associated with RTIs were using unclean latrines (AOR: 4.20; 95%CI:2.00-8.80), not washing hands with soap before touching the genital area (AOR: 3.94; 95%CI:1.49-10.45), history of symptoms of RTIs in the past year (AOR: 5.88; 95%CI:2.30-14.98), having multiple sexual partners in the past year (AOR: 4.46; 95%CI:1.59-12.53), changing absorbent material only once per day (AOR: 8.99; 95%CI:4.51-17.92), and washing the genital area only once per day during menstruation (AOR: 5.76; 95%CI:2.07-16.05). The self-reported prevalence of RTI showed that one women experienced RTI among ten reproductive-age women. Designing a women's health policy that focuses on ensuring availability of WASH facilities and improving MHM at the community level is key for sustainably preventing RTIs.

Hand cleaning with ash for reducing the spread of viral and bacterial infections: a rapid review

BACKGROUND

Handwashing is important to reduce the spread and transmission of infectious disease. Ash, the residue from stoves and fires, is a material used for cleaning hands in settings where soap is not widely available.

OBJECTIVES

To assess the benefits and harms of hand cleaning with ash compared with hand cleaning using soap or other materials for reducing the spread of viral and bacterial infections.

SEARCH METHODS

On 26 March 2020 we searched CENTRAL, MEDLINE, Embase, WHO Global Index Medicus, and the WHO International Clinical Trials Registry Platform.

SELECTION CRITERIA

We included all types of studies, in any population, that examined hand cleaning with ash compared to hand cleaning with any other material.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and full texts, and one review author extracted outcome data and assessed risk of bias, which another review author double-checked. We used the ROBINS-I tool for observational studies, we used RoB 2.0 for three interventional studies, and we used GRADE to assess the certainty of the evidence. We planned to synthesise data with random-effects meta-analyses. Our prespecified outcome measures were overall mortality, number of cases of infections (as defined in the individual studies), severity of infectious disease, harms (as reported in the individual studies), and adherence.

MAIN RESULTS

We included 14 studies described in 19 records using eight different study designs, but only one randomised trial. The studies were primarily conducted in rural settings in low- and lower-middle-income countries. Six studies reported outcome data relevant to our review. A retrospective case-control study and a cohort study assessed diarrhoea in children under the age of five years and self-reported reproductive tract symptoms in women, respectively. It was very uncertain whether the rate of hospital contacts for moderate-to-severe diarrhoea in children differed between households that cleaned hands using ash compared with households cleaning hands using soap (RR 0.97, 95% CI 0.84 to 1.11; very low-certainty evidence). Similarly, it was very uncertain whether the rate of women experiencing symptoms of reproductive tract infection differed between women cleaning hands with ash compared with cleaning hands using soap (RR 0.48, 95% CI 0.12 to 1.86; very low-certainty evidence) or when compared with handwashing with water only or not washing hands (RR 0.50, 95% CI 0.13 to 1.96; very low-certainty evidence). Four studies reported on bacteriological counts after hand wash. We rated all four studies at high risk of bias, and we did not synthesise data due to methodological heterogeneity and unclear outcome reporting.

AUTHORS' CONCLUSIONS

Based on the available evidence, the benefits and harms of hand cleaning with ash compared with soap or other materials for reducing the spread of viral or bacterial infections are uncertain.

Frequency and determinants of health care utilization for symptomatic reproductive tract infections in rural Indian women: A cross-sectional study

Introduction

The public health burden of reproductive tract infections (RTIs) among women in rural areas of low-income countries is poorly addressed because health care seeking for treatment of RTIs is inadequate. There are gaps in knowledge about whether low care seeking behavior stems from challenges in accessing health care versus women's recognition of and response to RTI-specific disease symptoms. We aim to identify determinants of care seeking behavior and analyze the difference in utilization of health care resources in response to symptoms of an RTI versus non-RTI disease symptoms in rural India. This will aid in the design of interventions that promote RTI care seeking behavior.

Methods

Our analysis uses data from a cross-sectional, population-based surveillance survey among rural, non-pregnant women in Odisha, India, from 2013–2014 (n = 3,600). We utilized bivariate logistic regression to determine the degree that certain determinants are associated with a woman’s likelihood to seek RTI treatment, and chi-Squared tests to assess for differences in health care resources used for non-RTI versus RTI symptoms.

Results

Married women were significantly more likely to seek health care for RTI symptoms (Odds Ratio (OR) = 1.9, 95% Confidence Interval (CI): 1.2–3.0) while unmarried adolescents were less likely to seek treatment (OR = 0.4, CI: 0.2–0.6). There was no association between RTI health care seeking with education level, belief about whether symptoms can be treated, or poverty. The majority (73.8%) of women who did not seek treatment for RTI symptoms reported not seeking treatment because they did not know treatment was needed. Women utilized formal health care providers at a higher rate in response to RTI symptoms than in response to their most recent symptoms of any kind (p = 0.003).

Conclusions

Community-based reproductive health education interventions are needed to increase health care seeking behavior for RTIs in rural Indian women. Interventions should target unmarried women and focus on both sexual health education and access to care.

Sanitation for Low-Income Regions: A Cross-Disciplinary Review

Sanitation research focuses primarily on containing human waste and preventing disease; thus, it has traditionally been dominated by the fields of environmental engineering and public health. Over the past 20 years, however, the field has grown broader in scope and deeper in complexity, spanning diverse disciplinary perspectives. In this article, we review the current literature in the range of disciplines engaged with sanitation research in low- and middle-income countries (LMICs). We find that perspectives on what sanitation is, and what sanitation policy should prioritize, vary widely. We show how these diverse perspectives augment the conventional sanitation service chain, a framework describing the flow of waste from capture to disposal. We review how these perspectives can inform progress toward equitable sanitation for all [i.e., Sustainable Development Goal (SDG) 6]. Our key message is that both material and nonmaterial flows-and both technological and social functions-make up a sanitation "system." The components of the sanitation service chain are embedded within the flows of finance, decision making, and labor that make material flows of waste possible. The functions of capture, storage, transport, treatment, reuse, and disposal are interlinked with those of ensuring equity and affordability. We find that a multilayered understanding of sanitation, with contributions from multiple disciplines, is necessary to facilitate inclusive and robust research toward the goal of sanitation for all.

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

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

Imperfect Information in Menstrual Health and the Role of Informed Choice

This article explores how imperfect information and the culture of silence around menstruation have shaped the menstrual hygiene product market. It is generally considered that the use of sanitary napkins is equivalent to hygiene. This view is critically evaluated in light of evidence. In a highly competitive market, materials used in sanitary napkin products have evolved significantly. Policymakers and regulators need to be informed about the nature of products entering the Indian market and their implications on women’s health and cost to the environment. The menstrual hygiene market now offers some less-known innovations such as menstrual cups, reusable cloth pads and compostable sanitary napkins that could offer a more sustainable direction to the industry. However, they also have their own barriers to access and use. Given the increasing choice available in the market and potential for accessing information, it has become pertinent that relevant stakeholders—such as women, government officials and the media—are made aware of the basket of options for menstrual hygiene management. Field experiments done to this end indicate that informed choice will automatically ensure that cost to women’s health and the environment is minimised.

Impact of social capital, harassment of women and girls, and water and sanitation access on premature birth and low infant birth weight in India

BACKGROUND

Globally, preterm birth (PTB) and low infant birth weight (LBW) are leading causes of maternal and child morbidity and mortality. Inadequate water and sanitation access (WASH) are risk factors for PTB and LBW in low-income countries. Physical stress from carrying water and psychosocial stress from addressing sanitation needs in the open may be mechanisms underlying these associations. If so, then living in a community with strong social capital should be able to buffer the adverse effects of WASH on birth outcomes. The objective of this study is to assess the relationships between WASH access and social conditions (including harassment and social capital) on PTB and LBW outcomes among Indian women, and to test whether social conditions modified the association between WASH and birth outcomes.

METHODS AND FINDINGS

This cohort study examined the effect of pre-birth WASH and social conditions on self-reported PTB status and LBW status for 7,926 women who gave birth between 2004/2005 and 2011/2012 Waves of the India Human Development Survey. PTB and LBW occurred in 14.9% and 15.5% of women, respectively. After adjusting for maternal biological and socioeconomic conditions, PTB was associated with sharing a building/compound latrine (Odds Ratio (OR) = 1.55; 95% Confidence Interval (CI) = 1.01, 2.38) versus private latrine access, but suggested an effect in the opposite direction for sharing a community/public latrine (OR = 0.67; CI = 0.45, 1.01). Open defecation, type of drinking water source, minutes per day spent fetching water, and one-way time to a drinking water source were not associated with PTB. LBW was associated with spending more than two hours per day fetching water compared to less than two hours (OR = 1.33; CI = 1.05, 1.70) and suggested an association with open defecation (OR = 1.22; CI = 1.00, 1.48), but was not associated with other types of sanitation, type of drinking water source, or time to a drinking water source. Harassment of women and girls in the community was associated with both PTB (OR = 1.33; CI = 1.09, 1.62) and LBW (OR = 1.26; CI = 1.03, 1.54). The data also showed a possible association of local crime with LBW (OR = 1.30; CI = 1.00, 1.68). Statistically significant (p<0.05) evidence of effect modification was only found for collective efficacy on the association between type of sanitation access and PTB. In addition, stratified analyses identified differences in effect size for walking time to the primary drinking water source and PTB by crime, sanitation access and PTB by harassment, and total hours per day fetching water and LBW by collective efficacy. Limitations of this observational study include risk of bias, inability to confirm causality, reliance on self-reported outcomes, and limited sub-group sample sizes for testing effect modification.

CONCLUSIONS

The relationship between adverse birth outcomes and sanitation access, domestic water fetching, crime, and gender-based harassment suggests physical and psychosocial stress are possible mechanisms by which WASH access affects PTB and LBW among Indian women. Interventions that reduce domestic responsibilities related to water and sanitation and change social norms related to gender-based harassment may reduce rates of PTB and LBW in India.

Association between unhygienic menstrual management practices and prevalence of lower reproductive tract infections: a hospital-based cross-sectional study in Odisha, India

Background

The extent to which reproductive tract infections (RTIs) are associated with poor menstrual hygiene management (MHM) practices has not been extensively studied. We aimed to determine whether poor menstrual hygiene practices were associated with three common infections of the lower reproductive tract; Bacterial vaginosis (BV), Candida, and Trichomonas vaginalis (TV).

Methods

Non-pregnant women of reproductive age (18–45 years) and attending one of two hospitals in Odisha, India, between April 2015 and February 2016 were recruited for the study. A standardized questionnaire was used to collect information on: MHM practices, clinical symptoms for the three infections, and socio-economic and demographic information. Specimens from posterior vaginal fornix were collected using swabs for diagnosis of BV, Candida and TV infection.

Results

A total of 558 women were recruited for the study of whom 62.4% were diagnosed with at least one of the three tested infections and 52% presented with one or more RTI symptoms. BV was the most prevalent infection (41%), followed by Candida infection (34%) and TV infection (5.6%). After adjustment for potentially confounding factors, women diagnosed with Candida infection were more likely to use reusable absorbent material (aPRR = 1.54, 95%CI 1.2–2.0) and practice lower frequency of personal washing (aPRR = 1.34, 95%CI 1.07–1.7). Women with BV were more likely to practice personal washing less frequently (aPRR = 1.25, 95%CI 1.0–1.5), change absorbent material outside a toilet facility (aPRR = 1.21, 95%CI 1.0–1.48) whilst a higher frequency of absorbent material changing was protective (aPRR = 0.56, 95%CI 0.4–0.75). No studied factors were found to be associated with TV infection. In addition, among women reusing absorbent material, Candida but not BV or TV - infection was more frequent who dried their pads inside their houses and who stored the cloth hidden in the toilet compartment.

Conclusion

The results of our study add to growing number of studies which demonstrate a strong and consistent association between poor menstrual hygiene practices and higher prevalence of lower RTIs.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3384-2) contains supplementary material, which is available to authorized users.