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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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Ghandour R, Hammoudeh W, Stigum H, Giacaman R, Fjeld H, Holmboe-Ottesen G. The hidden burden of dysmenorrhea among adolescent girls in Palestine refugee camps: a focus on well-being and academic performance. BMC Public Health 2024; 24:726. [PMID: 38448826 PMCID: PMC10918951 DOI: 10.1186/s12889-024-18219-0] [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: 08/22/2023] [Accepted: 02/26/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Dysmenorrhea (painful menstruation) is a condition that may have a profound effect on adolescent girls' health status and well-being. It can impede their engagement in daily activities and hamper their regular school attendance. This study aims to explore the relationship between dysmenorrhea, well-being, and academic performance among adolescent girls living in Palestine refugee camps in the West Bank and Jordan. METHODS We conducted a household survey between June and September 2019, with a total sample of 2737 adolescent girls 15 to 18 years old. Dysmenorrhea severity was assessed using the Working Ability, Location, Intensity, Duration of pain Dysmenorrhea scale (WaLIDD). The WHO-5 scale was used to evaluate the girls' overall well-being. Menstrual academic disruption (MAD) was measured using a self-reported scale. Multiple linear regression models were employed to evaluate the association between dysmenorrhea, well-being, and academic performance. Directed Acyclic Graphs (DAGs) were employed to identify variables for control in regression models. RESULTS The mean dysmenorrhea score was 6.6 ± 2.6, with 37.9% and 41.2% expressing moderate and severe symptoms, respectively. The mean WHO-5 score was 58.7 ± 25.1, and 34.9% reported a low well-being status. The mean MAD score was 3.1 ± 3.3. 26% reported missing school due to dysmenorrhea, 36% said dysmenorrhea impacted their ability to concentrate, and 39% were unable to study for tests, and complete homework. The first regression analysis showed a reduction of 1.45 units in WHO-5 score for each unit increase in dysmenorrhea. The second regression analysis showed a non-linear increase in MAD score for increasing dysmenorrhea. For each dysmenorrhea score less than 4 (mild) there was a modest increase in MAD scores (coefficient 0.08, p-value = 0.006), and for each dysmenorrhea score above 4 there was a stronger increase in MAD scores (coefficient 0.95, p < 0.001). CONCLUSION Dysmenorrhea poses significant challenges to the well-being and academic performance of adolescent girls living in Palestine refugee camps. Collaborative efforts and multifaceted approaches are crucial to address dysmenorrhea effectively. This involves research, targeted interventions, culturally sensitive strategies, and fostering a supportive environment that empowers girls to thrive academically and beyond.
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Affiliation(s)
- Rula Ghandour
- Institute of Community and Public Health, Birzeit University, Occupied Palestinian territory (oPt) Said Khoury Building for Development Studies, Birzeit, P.O. Box 14, Palestine.
- Department of Community Medicine and Global Health, University of Oslo, Postboks 1130 Blindern, 0318, Oslo, Norway.
| | - Weeam Hammoudeh
- Institute of Community and Public Health, Birzeit University, Occupied Palestinian territory (oPt) Said Khoury Building for Development Studies, Birzeit, P.O. Box 14, Palestine
| | - Hein Stigum
- Department of Community Medicine and Global Health, University of Oslo, Postboks 1130 Blindern, 0318, Oslo, Norway
| | - Rita Giacaman
- Institute of Community and Public Health, Birzeit University, Occupied Palestinian territory (oPt) Said Khoury Building for Development Studies, Birzeit, P.O. Box 14, Palestine
| | - Heidi Fjeld
- Department of Community Medicine and Global Health, University of Oslo, Postboks 1130 Blindern, 0318, Oslo, Norway
| | - Gerd Holmboe-Ottesen
- Department of Community Medicine and Global Health, University of Oslo, Postboks 1130 Blindern, 0318, Oslo, Norway
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Rodríguez-Camacho MF, Sanchís-Ramón MJ, Ortiz-Barreda G, La Parra-Casado D, Gil-González D. Menarche and reproductive health in Spanish Roma women from a reproductive justice perspective: a qualitative study. Reprod Health 2024; 21:17. [PMID: 38308316 PMCID: PMC10837920 DOI: 10.1186/s12978-023-01726-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 12/13/2023] [Indexed: 02/04/2024] Open
Abstract
OBJECTIVES This study aimed to explore the perceptions of Roma women about their experience of menarche and reproductive health considering the principles of reproductive justice. DESIGN Qualitative study based on semi-structured interviews with Roma women ages 18 through 67 in different neighborhoods in the southeast of Spain. Using a thematic analysis, we analyzed experiences related to menarche and menstruation and their significance for reproductive health, the preparation for the phase of menarche and intergenerational support. RESULTS The Roma women interviewed shared their approach to the experiences of menarche and menstruation as children in their family environments with a focus on access to information provided by other women in the family and community for reproductive health management. In their discourses we observed that the onset of menstruation supposes a rupture in the public and private spaces of girls and women. CONCLUSIONS The results of this study suggest that women and girls do not gain access to information that contributes to their reproductive wellbeing through their experience of menarche. Access to resources and skills to manage biological changes in adolescents could contribute to reducing the impact of cultural myths, false ideas and taboos that prevent advocacy and empowerment on issues of reproductive justice.
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Affiliation(s)
- María Félix Rodríguez-Camacho
- Autonomous Federation of Roma Associations of Alicante, FAGA, Alicante, Spain.
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science, University of Alicante, Alicante, Spain.
| | | | - Gaby Ortiz-Barreda
- Department of Health Promotion and Development, University of Bergen, Bergen, Norway
| | | | - Diana Gil-González
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science, University of Alicante, Alicante, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Barcelona, Spain
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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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Shah SF, Punjani NS, Rizvi SN, Sheikh SS, Jan R. Knowledge, Attitudes, and Practices Regarding Menstrual Hygiene among Girls in Ghizer, Gilgit, Pakistan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6424. [PMID: 37510656 PMCID: PMC10378792 DOI: 10.3390/ijerph20146424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/29/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION Menstrual hygiene is a critical issue encountered by women and girls of reproductive age that negatively affects their health and empowerment. It is still deemed a taboo subject in several parts of the world, and girls hesitate to discuss menstruation with their family members, friends, or schoolteachers, which creates hurdles when they experience their menarche. Girls residing in rural areas encounter more problems, since they lack proper resources and knowledge to manage their menstruation in school as well as at home. The purpose of this study was to evaluate the knowledge, attitudes, and practices regarding the menstrual hygiene of girls residing in rural areas of Gilgit, Pakistan. METHODS A descriptive cross-sectional design was used to assess the study questions. The consecutive sampling technique was applied to recruit 300 female participants from remote areas of Gilgit, Pakistan, who were 13 to 22 years old. A pre-tested questionnaire was utilized to collect the data, and SPSS version 21.0 was used to analyze them. RESULTS The study found that more than half of the participants had a poor level of knowledge and practices and negative attitudes towards menstrual hygiene. This could be due to many cultural and social factors associated with menstrual hygiene. CONCLUSIONS The study concluded that the study participants were not knowledgeable about menstrual hygiene. They had poor practices and attitudes regarding menstrual hygiene. Hence, it is recommended that frequent sessions should be conducted by healthcare workers to enhance the knowledge of parents, teachers, and young girls, to increase their positive attitudes and practices regarding menstrual hygiene.
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Affiliation(s)
- Sanober Fazal Shah
- School of Nursing and Midwifery, Aga Khan University, Karachi 75950, Pakistan
| | | | - Syeda Naghma Rizvi
- School of Nursing and Midwifery, Aga Khan University, Karachi 75950, Pakistan
| | | | - Rafat Jan
- School of Nursing and Midwifery, Aga Khan University, Karachi 75950, Pakistan
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Ubochi NE, Chinweuba UA, Iheanacho NP, Osuchukwu EC, Nwodo CO, Nnamani AJ, Ogbonnaya NP, Ubochi VN. Menstruation behaviour influencer model: a grounded theory of menstrual experiences of shame, embarrassment, stigma and absenteeism among pubescent girls in semi-urban and rural secondary schools in Enugu State, Nigeria. Pan Afr Med J 2023; 45:47. [PMID: 37575520 PMCID: PMC10422039 DOI: 10.11604/pamj.2023.45.47.39675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/08/2023] [Indexed: 08/15/2023] Open
Abstract
Introduction severally, studies had identified menstrual-associated shame, embarrassment, stigma, and absenteeism among pubescents in school with resultant challenges on their bio psycho-social functioning. However, what is not clear is the contribution of the home and school to the experiences. The objectives of the study were to explore the experiences with menstruation and menstrual hygiene management; explore the experiences with menstrual-associated shame, embarrassment, stigma, and absenteeism among participants; explore the bio-psycho-social issues associated with the experiences; understand the meaning of the experiences and propose a mid-range theory that explains the influences on pubescents´ menstrual behaviours. Methods constructivist grounded theory design was used to explore the experiences of 20 purposively recruited pubescents from rural and semi-urban secondary schools. In-depth Interviews, focused group discussions, key informant interviews, and observations were employed to collect data until data saturation. Open and focused coding was conducted to identify emerging themes and sub-themes. These themes were returned to participants and literature for verification. Results four (4) categories and eleven (11) sub-categories emerged from the data and formed four (4) themes that influence pubescents´ menstrual behaviour. They include: 1) individuals´ bio-physiological status, knowledge of menstrual health and menstrual characteristics; 2) regimenting school through strict rule enforcement, punishment/motivation, forced participation, and compliance; 3) scheduling academic activities/examination, sporting and other extra curricula activities; and 4) providing menstrual support by individual and institutional efforts to pubescents. Based on the relationship with other themes, the menstrual behaviour influencer model was proposed. Conclusion menstrual influencers require the interaction between menstrual support and menstrual enablers by institutions for positive menstrual behavior. Failure to achieve this balance will lead to menstrual-associated shame, embarrassment, stigma, absenteeism, and school drop-out.
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Affiliation(s)
- Nneka Edith Ubochi
- Department of Nursing, Faculty of Health Sciences and Technology, College of Medicine, University of Nigeria Enugu Campus, Enugu State, Nigeria
| | - Ukamaka Anthonia Chinweuba
- Department of Nursing, Faculty of Health Sciences and Technology, College of Medicine, University of Nigeria Enugu Campus, Enugu State, Nigeria
| | - Njideka Peace Iheanacho
- Department of Nursing, Faculty of Health Sciences and Technology, College of Medicine, University of Nigeria Enugu Campus, Enugu State, Nigeria
| | | | - Chijioke Oliver Nwodo
- Department of Nursing, Faculty of Health Sciences and Technology, College of Medicine, University of Nigeria Enugu Campus, Enugu State, Nigeria
| | - Anulika Jennifer Nnamani
- Department of Nursing, Faculty of Health Sciences and Technology, College of Medicine, University of Nigeria Enugu Campus, Enugu State, Nigeria
| | - Ngozi Phoeba Ogbonnaya
- Department of Nursing, Faculty of Health Sciences and Technology, College of Medicine, University of Nigeria Enugu Campus, Enugu State, Nigeria
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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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Secor-Turner M, Huseth-Zosel A, Ostlund R. Menstruation Experiences of Middle and High School Students in the Midwest: A Pilot Study. J Sch Nurs 2020; 38:504-510. [PMID: 33207994 DOI: 10.1177/1059840520974234] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The purpose of this pilot study was to expand understanding of the experience of menstruation for girls in the United States and its impact in the school setting. A qualitative approach was used to gather data from focus group interviews. Descriptive content analysis was used to categorize the range and types of menstruation experiences described by 12 participants aged 12-16 years. Findings revealed four main themes: (1) learning about menstruation, (2) experiencing menstruation, (3) managing menstruation, and (4) social norms and meaning of menstruation. Participants described multiple challenges faced learning about and experiencing menstruation, especially in the school setting. Participants described the limited understanding of menstruation experiences and confusion about the use of menstrual hygiene products. Challenges experienced at school included not having adequate access to menstrual hygiene products, limited time for changing products, fear of leaking menstrual blood, and impacts on school attendance. School nurses are well-positioned to contribute to creating school environments that are supportive of menstruation.
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Affiliation(s)
| | | | - Rachel Ostlund
- School of Nursing, North Dakota State University, Fargo, ND, USA
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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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