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

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          Abstract

          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.

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          A Systematic Review of the Health and Social Effects of Menstrual Hygiene Management

          Background Differing approaches to menstrual hygiene management (MHM) have been associated with a wide range of health and psycho-social outcomes in lower income settings. This paper systematically collates, summarizes and critically appraises the available evidence. Methods Following the PRISMA guidelines a structured search strategy was used to identify articles investigating the effects of MHM on health and psycho-social outcomes. The search was conducted in May 2012 and had no date limit. Data was extracted and quality of methodology was independently assessed by two researchers. Where no measure of effect was provided, but sufficient data were available to calculate one, this was undertaken. Meta-analysis was conducted where sufficient data were available. Results 14 articles were identified which looked at health outcomes, primarily reproductive tract infections (RTI). 11 articles were identified investigating associations between MHM, social restrictions and school attendance. MHM was found to be associated with RTI in 7 papers. Methodologies however varied greatly and overall quality was low. Meta-analysis of a subset of studies found no association between confirmed bacterial vaginosis and MHM (OR: 1.07, 95% CI: 0.52–2.24). No other substantial associations with health outcomes were found. Although there was good evidence that educational interventions can improve MHM practices and reduce social restrictions there was no quantitative evidence that improvements in management methods reduce school absenteeism. Conclusion The management of menstruation presents significant challenges for women in lower income settings; the effect of poor MHM however remains unclear. It is plausible that MHM can affect the reproductive tract but the specific infections, the strength of effect, and the route of transmission, remain unclear. There is a gap in the evidence for high quality randomised intervention studies which combine hardware and software interventions, in particular for better understanding the nuanced effect improving MHM may have on girls’ attendance at school.
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            Women’s and girls’ experiences of menstruation in low- and middle-income countries: A systematic review and qualitative metasynthesis

            Background Attention to women’s and girls’ menstrual needs is critical for global health and gender equality. The importance of this neglected experience has been elucidated by a growing body of qualitative research, which we systematically reviewed and synthesised. Methods and findings We undertook systematic searching to identify qualitative studies of women’s and girls’ experiences of menstruation in low- and middle-income countries (LMICs). Of 6,892 citations screened, 76 studies reported in 87 citations were included. Studies captured the experiences of over 6,000 participants from 35 countries. This included 45 studies from sub-Saharan Africa (with the greatest number of studies from Kenya [n = 7], Uganda [n = 6], and Ethiopia [n = 5]), 21 from South Asia (including India [n = 12] and Nepal [n = 5]), 8 from East Asia and the Pacific, 5 from Latin America and the Caribbean, 5 from the Middle East and North Africa, and 1 study from Europe and Central Asia. Through synthesis, we identified overarching themes and their relationships to develop a directional model of menstrual experience. This model maps distal and proximal antecedents of menstrual experience through to the impacts of this experience on health and well-being. The sociocultural context, including menstrual stigma and gender norms, influenced experiences by limiting knowledge about menstruation, limiting social support, and shaping internalised and externally enforced behavioural expectations. Resource limitations underlay inadequate physical infrastructure to support menstruation, as well as an economic environment restricting access to affordable menstrual materials. Menstrual experience included multiple themes: menstrual practices, perceptions of practices and environments, confidence, shame and distress, and containment of bleeding and odour. These components of experience were interlinked and contributed to negative impacts on women’s and girls’ lives. Impacts included harms to physical and psychological health as well as education and social engagement. Our review is limited by the available studies. Study quality was varied, with 18 studies rated as high, 35 medium, and 23 low trustworthiness. Sampling and analysis tended to be untrustworthy in lower-quality studies. Studies focused on the experiences of adolescent girls were most strongly represented, and we achieved early saturation for this group. Reflecting the focus of menstrual health research globally, there was an absence of studies focused on adult women and those from certain geographical areas. Conclusions Through synthesis of extant qualitative studies of menstrual experience, we highlight consistent challenges and developed an integrated model of menstrual experience. This model hypothesises directional pathways that could be tested by future studies and may serve as a framework for program and policy development by highlighting critical antecedents and pathways through which interventions could improve women’s and girls’ health and well-being. Review protocol registration The review protocol registration is PROSPERO: CRD42018089581.
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              A Time for Global Action: Addressing Girls’ Menstrual Hygiene Management Needs in Schools

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

                Contributors
                Role: Formal analysisRole: VisualizationRole: Writing – original draft
                Role: Funding acquisitionRole: MethodologyRole: Writing – review & editing
                Role: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: MethodologyRole: SupervisionRole: VisualizationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                1 August 2019
                2019
                : 14
                : 8
                : e0220114
                Affiliations
                [1 ] Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
                [2 ] Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
                [3 ] London School of Hygiene and Tropical Medicine, London, United Kingdom
                Università degli Studi di Perugia, ITALY
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0001-5201-4760
                http://orcid.org/0000-0001-9738-9857
                Article
                PONE-D-18-34874
                10.1371/journal.pone.0220114
                6675075
                31369595
                b763e89d-c030-436a-bdbc-4c92bd401d49
                © 2019 MacRae et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 5 December 2018
                : 21 June 2019
                Page count
                Figures: 1, Tables: 2, Pages: 23
                Funding
                This research was made possible with funding from the Bill & Melinda Gates Foundation (BMGF). The BMGF had no role in research design, data collection, analysis, interpretation of findings or the decision to submit this article. BAC was funded in part by the NIH/NIGMS Institutional Research and Academic Career Development Award (IRACDA), 5K12-GM000680-18. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Health Care
                Environmental Health
                Sanitation
                Medicine and Health Sciences
                Public and Occupational Health
                Environmental Health
                Sanitation
                Biology and Life Sciences
                Physiology
                Physiological Processes
                Urination
                Medicine and Health Sciences
                Physiology
                Physiological Processes
                Urination
                Earth Sciences
                Marine and Aquatic Sciences
                Bodies of Water
                Ponds
                Ecology and Environmental Sciences
                Pollution
                Water Pollution
                Biology and Life Sciences
                Anatomy
                Body Fluids
                Blood
                Medicine and Health Sciences
                Anatomy
                Body Fluids
                Blood
                Biology and Life Sciences
                Physiology
                Body Fluids
                Blood
                Medicine and Health Sciences
                Physiology
                Body Fluids
                Blood
                Medicine and Health Sciences
                Public and Occupational Health
                Hygiene
                People and Places
                Geographical Locations
                Asia
                India
                Social Sciences
                Sociology
                Education
                Schools
                Custom metadata
                There are ethical restrictions to sharing our data publicly. Specifically, participants in this study did not give consent for their data to be released to anyone other than the research team. Further, the overall qualitative data set from which the specific data for this study is drawn, contains not only information on menstruation and menstruation behaviors, but also urination and defecation behaviors, discussions about safety and violence, and concerns about shame and how the practices described may hurt women’s and their family’s reputation. In order to collect meaningful data, assurances regarding participant privacy were critical. Participants were informed that the information they shared would not directly benefit them, but that the collective information shared would be used to inform research and programs on women’s health needs. Any inquiries regarding or requests for the qualitative data can be directed to Matthew Freeman, matthew.freeman@ 123456emory.edu .

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