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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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          Most cited references 55

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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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            'The girl with her period is the one to hang her head' Reflections on menstrual management among schoolgirls in rural Kenya

            Background The onset of menstruation is a landmark event in the life of a young woman. Yet the complications and challenges that can accompany such an event have been understudied, specifically in resource-poor settings. As interventions aim to improve female attendance in schools, it is important to explore how menstruation is perceived and navigated by girls in the school setting. This research conveys rural Kenyan schoolgirls' perceptions and practices related to menstruation Methods Data were collected at six rural schools in the Nyanza Province of Western Kenya. Using focus group discussions, in-depth interviews, and field notes from observations, researchers collected information from 48 primary schoolgirls and nine teachers. Systematic analysis began with a reading of transcripts and debriefing notes, followed by manual coding of the narratives. Results Focus group discussions became opportunities for girls to share thoughts on menstruation, instruct one another on management practices and advise one another on coping mechanisms. Girls expressed fear, shame, distraction and confusion as feelings associated with menstruation. These feelings are largely linked to a sense of embarrassment, concerns about being stigmatized by fellow students and, as teachers explained, a perception that the onset of menstruation signals the advent of a girl's sexual status. Among the many methods for managing their periods, girls most frequently said they folded, bunched up or sewed cloth, including cloth from shirts or dresses, scraps of old cloth, or strips of an old blanket. Cloth was reported to frequently leak and cause chafing, which made school attendance difficult particularly as the day progressed. Attitudes and practices of girls toward menstruation have been arranged into personal, environmental and behavioural factors. Conclusion Further research on menstrual management options that are practical, sustainable and culturally acceptable must be conducted to inform future programs and policies that aim to empower young girls as they transition into womanhood. Stakeholders working within this and similar contexts must consider systematic mechanisms to explain to young girls what menstruation is and how to manage it. Providing sanitary supplies or guiding girls on how to create supplies serve as critical components for future interventions.
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              Overcoming the taboo: advancing the global agenda for menstrual hygiene management for schoolgirls.

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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
                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.

                Article
                PONE-D-18-34874
                10.1371/journal.pone.0220114
                6675075
                31369595
                © 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.

                Page count
                Figures: 1, Tables: 2, Pages: 23
                Product
                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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