The pair are currently working on their final report. Please check back for details and follow them on Twitter using LJMUSociology , LJMUNepal and menstrualhealth. The release of the Bollywood film Pad Man has thrown the spotlight on periods — see Dr Kay Standing's response to this in The Independent newspaper.

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On average incidents of family violence are reported daily in Mexico, alleged victims of malicious injuries, 46 alleged victims of rape, and 10 murders femicides and homicides , with evidence of gender-based violence increasing during the pandemic Evidence suggests the need to focus efforts on very young adolescents ages , as earlier interventions may improve gender-based violence, adolescent pregnancy, early marriage and school dropout outcomes 23 , Instilling healthy behaviors and habits earlier in life could result in greater impacts for years to come 25 — UNESCO suggests initiating comprehensive sexuality education before puberty, within primary education Unfortunately, caretakers and teachers often feel ill equipped to deliver this information to children MHH literacy fits squarely within a comprehensive sexuality education CSE and puberty education, but is often poorly taught, not included in teacher training, and although these elements are typically part of the basic education curricula, they are not assessed 1 , In Mexico, the SEP offers a plethora of teacher continuing education courses focused on topics such as incorporating gender into the classroom, educating children on healthy lifestyles, and healthy development of students However, these potentially valuable offerings are not required, and depend on each teacher's ability and interest to partake in them.

Studies evaluating the impacts of MHH education on school attendance have yielded mixed results 33 — 38 , with different countries and programs demonstrating varying levels of absenteeism 39 — 41 and coping strategies among menstruating girls Alternatively, in qualitative studies, girls consistently elaborate on the struggles of managing their periods at school.

Girls' self-reports of reduced academic and school participation, fear and distraction 11 , 13 , self-isolation or social exclusion, missing class, and leaving school during the day 9 , 10 , 18 , 40 , 41 demonstrate the need to evaluate the impact of girls' menstruation experiences in school beyond absenteeism 43 , Consequently, studies are examining the linkages between menstrual health, menstrual health knowledge, sanitation, education, and psychosocial outcomes 30 , 42 , 45 — Psychosocial elements of menstrual health may be a more relevant indicator than attendance for the Mexican context.

Though enrollment rates remain high in early schooling, 5th grade is when the greatest dropouts occur in primary grades Education as a protective factor for other health outcomes is well known and relevant in Mexico.

Menstrual health is not well studied in Mexico, but what is taught through the education system may have important ramifications, as Mexico grapples with high rates of adolescent pregnancy, high prevalence of early sexual debut 52 and gender-based violence 22 , 53 — 55 , all of which are higher among girls who are out of school.

Intervening early to improve skills-based MHH literacy within a CSE framework, could be an important catalyst to increase girls' confidence in early adolescence and improve future health and education outcomes.

We See Equal WSE is a school-based intervention for very young adolescents VYA with the objective of increasing knowledge of physical, emotional and social changes associated with puberty, as well as increasing positive gender attitudes centered on themes of respect, equality and empathy WSE was designed in accordance with the Focusing Resources on Effective School Health FRESH Framework The Choices curriculum was included as the evidence-based education component Choices in Mexico was enhanced both in the structure and content, serving as a resource for teachers to use in the classroom and adapted to address the nuances of gender inequality for VYA in project locations.

Additionally, Choices in Mexico integrated three puberty and menstrual health lessons aligned with curricular requirements of the Secretariat of Public Education SEP in Mexico The final Choices curricula in Mexico consisted of eleven total lessons focusing on the following themes: Puberty Knowledge and Menstruation see Table 1 , Gender Equality, Respect, Empathy, and Empowerment By December , WSE had trained teachers women and 70 men and reached 10, children 5, girls and 5, boys in 47 public schools in Mérida, Mexico City, and Puebla, Mexico.

A team of eight school health promoters, one project lead and one part-time monitoring and evaluation staff implemented Choices in Mexico City, Puebla City and Mérida. Program inputs included an adapted Choices teacher manual 59 , staff training, teacher training, 11 teacher-led Choices lesson in 5th and 6th grade classrooms, extra-curricular student equality clubs and water, sanitation and hygiene WASH school improvement plans.

Choices teacher training and classroom implementation were implemented over one school semester. Each Choices lesson lasted approximately 1 hour and was structured to include a review of key messages from the previous lesson, a central lesson, and space for reflection.

Energizers and relaxation exercises were incorporated throughout lessons. Teachers were encouraged to create ground rules during the first session that would foster trust and respect among students, and to display their ground rules before every Choices session. A question box was set up in each classroom so that students could ask questions anonymously after each session.

Teacher training and Choices session were organized in three blocks so that teachers were trained on sessions at a time and then implemented those sessions in the classroom prior to the next training.

This allowed program staff to collect feedback from teachers on the success of implementation. Promoters delivered three 4-h teacher trainings with teachers per session.

Trainings included practical application of Choices, as well as the theoretical underpinnings of the curricula related to child rights, adolescent sexual reproductive health and gender. Promoters observed at least one in-class lesson per trained teacher to monitor fidelity of instruction.

This paper will explore program monitoring data collected at program baseline and endline across three cohorts to identify trends that suggest providing menstrual health and puberty education in schools can improve girls' experiences managing their periods at school, reducing stress and increasing feelings of self-efficacy.

This analysis aimed to answer the following research questions: 1 To what extent does menstrual health and hygiene MHH interventions contribute to increased menstruation-related engagement and self-efficacy and reduced menstruation-related stress MENSES?

Does WSE narrow those gaps? This study used a cross-sectional quantitative cohort approach to document changes in girls' experiences and perceptions around managing menstruation in schools.

A random sample of girls and boys was derived from all 5th and 6th grade rosters of participating schools in Mexico City, Puebla and Mérida. Digital surveys were read aloud by trained enumerators and collected via tablets using KoBo Toolbox.

Each child assessed was assigned a numeric code to de-identify participants from personal data and to link baseline and endline results for analysis. This study focuses on female students at baseline and at endline from all 47 schools across three semester cohorts between September and December The analysis examines a subset of menstruation and puberty-specific questions among girls who self-reported to have reached menarche and had managed their periods while in school.

A pre-and post-test approach with no comparison group tracked trends in girls' menstruation-related school engagement, stress, and self-efficacy MENSES. The analysis combined three cohorts to increase statistical power and to disaggregate data by socioeconomic status SES and knowledge levels.

MENSES item responses measured frequency almost always, sometimes, and never , strength a lot, a little, and never , and agreement strongly agree, agree, disagree, and strongly disagree with girls' school engagement, feelings and beliefs, respectively. Scales were converted from ordinal scales to percentage scales to simplify interpretation over time and across subgroups.

For this analysis, responses were coded on a scale of for the participation and stress domain, and the self-efficacy was coded on a scale of For the knowledge questions, girls responded whether they have learned about puberty and menstruation at school yes, a little, and no.

This was the only SES-related question included in the WSE KAP survey. Data analysis was conducted using statistical software Stata Summary statistics from the analysis are presented to display girls' knowledge and MENSES outcomes.

Multivariate regression models were used to explore relationships between MENSES outcomes and girl's knowledge and other sociodemographic characteristics.

We fit three Ordinary Least Squares regression models, adjusting the standard errors for clustering girls at the school level. The error term ϵ ij consists of unobserved girl characteristics.

Note that, except where explicitly noted, statistical significance does not indicate a causal link between two variables; it means only that there is an observed relationship.

Additionally, some of the results are disaggregated by socioeconomic status and knowledge levels. The Menstruation-related Engagement, Self-Efficacy and Stress MENSES assessment aims to measure girls' experiences managing their menses at school 60 , 61 using 45 questions across three domains, or outcomes: school engagement, stress, and self-efficacy.

The tool was adapted to the Mexico context and translated sensitively to ensure that the meaning of the questions remained the same as in previous pilots in differing country contexts.

The engagement domain covers school participation experiences during menstruation. Girls are asked to think about behaviors they may or may not have done the last time they had their period at school, such as raising a hand or volunteering to answer a question if the answer is known, engaging in school-based social activities, classroom concentration, and missing class time for menstrual management.

The stress domain probes on menstrual related fears or worries a girl may have experienced the last time she managed her menstruation while at school.

The questions ask about nervousness and worries related to experiencing a stain, teasing from classmates, menstrual pain, using the bathroom, having access to water, and ability to dispose of used menstrual materials.

The section also inquires about feelings of loneliness during menstruation. The self-efficacy domain measures girls' beliefs in their own ability to do a menstrual-related task or school activity when menstruating at school. The questions include ability to request support from teachers or peers, gaining access to the school bathrooms, disposing of a sanitary material, accessing menstrual materials if needed, or standing up for herself or a friend if being teased about menstruation.

The questions also cover confidence to perform well academically during menses. Puberty and menstruation questions in the digital KAP survey were primarily used for monitoring i. and as filters for MENSES questions. Boys and girls who had not begun their menses were asked other menstruation knowledge questions not captured in this analysis.

Schools were purposely selected in Puebla, Mérida, and Mexico City, in coordination with local education officials. A total of girls were surveyed at baseline from 47 schools across three semester cohorts between September and December At endline, data was collected from as many original participants as could be found in the selected schools.

This sample is a random representative sample of girls from these 47 schools. Out of total girls, girls at baseline and girls at endline reported having their period at school. In Table 2 , we present the study sample characteristics for the girls who had their period at school at the interview.

At endline, more girls were surveyed, as more girls reached menarche over the course of the school semester.

The study was submitted to the Save the Children US Ethics Review Committee, the assigned reviewer granted final approval in June 21, , FWA Caregiver signed consent and verbal assent was obtained by children prior to starting the survey questionnaire. General knowledge regarding puberty and menstruation in this population was high at baseline.

Table 5 shows the change in MHH and puberty knowledge among menstruating girls and the entire female WSE sample. Table 6. Girls from high and low socioeconomic groups demonstrated statistically significant improvements in stress and self-efficacy Table 7 , and MHH knowledge Table 8 after WSE.

At baseline, low SES girls reported significantly higher levels of menstruation-related stress than high SES girls 5pp.

After WSE, low SES girls still had higher stress levels, but the difference was no longer statistically significant and they experienced a 1pp higher improvement in stress levels compared to their high SES peers.

Conversely, differences between self-efficacy among the two SES groups were not statistically significant and we observed statistically significant improvements over time among high and low SES girls, 6 and 5pp, respectively.

Table 8. Change in MHH knowledge by socioeconomic status among all female WSE survey respondents. Trends in MHH knowledge differed across SES groups. Results for all girls surveyed highlight that while high SES girls had greater awareness of these topics at baseline and endline, the knowledge gaps for low SES girls reduced in all knowledge questions, except having a trusted adult they could talk to about puberty.

In particular, Table 8 shows that compared to high SES girls, low SES girls demonstrated the largest increases in knowing about puberty 18 vs. MENSES outcomes were examined by level of MHH knowledge at baseline and endline Table 9. Prior to the WSE program, girls with lower MHH knowledge demonstrated statistically significant lower MENSES outcomes compared to their peers with more MHH knowledge.

At endline, the gaps narrowed for engagement and stress, though differences between girls with high and low knowledge were no longer statistically different.

However, for menstruation-related self-efficacy the gap widened between low and high knowledge girls at endline, increasing from 3 to 7 pp, suggesting that girls that had already obtained puberty and MHH information boosted their confidence on managing menstruation at schoolm.

These relationships were further examined among only low SES girls Table 10 and similar trends emerged, except that at baseline the engagement and stress gaps were slightly wider between those with higher and lower knowledge 8 pp and differences in self-efficacy were non-significant.

Similar to the aggregate group, at endline, girls with higher knowledge had significantly higher self-efficacy and the differences in other MENSES outcomes were not significant.

Table MENSES domains for girls with low SES by level of knowledge over time. Multivariate regression models controlling for region and cohort explored relationships between MENSES outcomes, MHH knowledge and SES.

Regression analyses shows that aggregated knowledge including all five questions is significantly negatively associated with stress and positively associated with self-efficacy at baseline and endline.

SES was significantly positively associated with self-efficacy. In sum, the more knowledge girls acquired, the higher their self-efficacy score and lower their stress score Figure 1.

Figure 1. Association between menstrual health and puberty knowledge and MENSES outcomes. Among girls from low SES households, there were additional unique relationships identified. Low SES girls who reported knowing what their period was when they had it for the first time, showed significantly stronger engagement and self-efficacy, and lower stress compared to girls that did not Table These relationships were not observed among girls from the high SES group see Table 2 in Appendix 2 in Supplementary Materials.

All girls who responded they trusted an adult to ask about puberty showed significantly lower stress compared to girls who did not have this adult in their life Figure 2.

When stratified by SES status, having a trusted adult they could talk to about puberty remained associated with lower stress and was statistically significant among low SES girls see Table 3 in Appendix 2 in Supplementary Materials. Other factors, such as cohort and region, were not significant predictors for MENSES outcomes.

Predicted MENSES scores by SES and knowledge level about what their period was when they had it for the first time. Figure 2. Relationship between MENSES outcomes and trusting an adult to ask about puberty.

We See Equal was a small school-based gender equality program in 47 public schools across three urban centers in Mexico City, Puebla and Mérida, Mexico.

This study utilizes program monitoring data to explore relationships between MHH and puberty knowledge and menstruation-related school engagement, stress and self-efficacy MENSES outcomes among menstruating girls in 5th and 6th grade before and after program implementation.

This study contributes to understanding how early school-based MHH literacy interventions can improve girls' educational experiences by increasing school participation, reducing stress and improving self-efficacy among VYA girls who are managing their periods at school.

There are limitations to the interpretation of the data. Results are descriptive; it is not possible to draw any causal inferences about the impact of the program on MENSES outcomes.

The sample is a random sample of 5th and 6th grade girls from the 47 WSE schools, not a representative sample of girls from Puebla, Mexico City, and Mérida. Additionally, the average age of menarche in Mexico is unknown. Girls may have felt uncomfortable talking about their period during surveys and chosen not to report their menstrual status.

Results should be interpreted with caution, as the study is underpowered to detect changes in MENSES outcomes across and between multiple subgroups.

Finally, in-depth menstruation and puberty knowledge taught in classrooms through WSE, such as tracking the menstrual cycle, understanding menstruation and fertility, and discussion of normal physical discomforts, may have more effect on MENSES outcomes, but were not captured in the KAP results or analyzed in this study.

Previous studies have examined psychosocial outcomes and MHH as a way to measure effectiveness of MHH programming 62 , 63 , in particular measuring self-efficacy using existing self-efficacy scales 33 , 47 , Results from our study support the hypothesis that increasing MHH literacy significantly improves girls' menstruation-related stress and self-efficacy, though not school engagement Figure 1.

The lack of invariance of the engagement domain requires exploring further relationships, a recent psychometric study identifies the MENSES constructs and the items that are most strongly correlated The engagement and stress domains measure girls' experiences at school in such a unique way that further research is needed to determine whether both domains might collectively measure one construct related to well-being and social support.

Future studies should incorporate causal research in order to better understand the impact of different combinations of MHH strategies on MENSES outcomes in Mexico, particularly in terms of dosage and cost-effectiveness. We examine the existence of MENSES gaps by level of MHH knowledge at baseline and the extent to which gaps reduce by endline.

Results suggest that increased MHH knowledge through WSE programming has contributed to closing engagement and stress gaps, especially for girls from low SES, consistent with other studies 19 , 65 , 66 Tables 9 , Despite these improvements, work is needed to improve self-efficacy for girls with low MHH knowledge, especially girls from low SES households.

Our results suggest that practitioners must continue to assess the design and delivery of their MHH programs to improve desired MHH outcomes for all girls.

Examination of the individual items within each MENSES domain lend itself to consider practical school MHH interventions. Between two-thirds to three-quarters of menstruating girls consistently reported worrying about pain, getting their period unexpectedly, bloodstains, and using the school toilets Appendix 1 in Supplementary Materials.

Further exploration is required to understand what the WASH concerns may be in each context and added investments that are required, but low cost simple fixes such as locks and hooks on the doors, covered trashcans in stalls, mirrors and adequate light can alleviate some of the added burdens that girls experience using bathrooms during their menstrual period 6 , 8 , The large proportion of girls experiencing anxiety on a monthly basis suggests that beyond education, a combination of basic MHH interventions could vastly improve girl's wellbeing 11 , In addition to addressing WASH concerns, ensuring schools have a supply of pads, extra school uniforms, pain relief methods, as well as an easy and discrete mechanism for girls to access these services 7 , 9 , 10 , 36 , 42 , 47 , 64 , 68 could provide peace of mind and tangible support during this new life stage.

Creating comprehensive MHH programs should include strategies that further enable behavior change and reinforce MHH information, such diversifying forms of support 69 , ensuring safe and functional infrastructure 8 , 19 , and creating linkages to youth-friendly health services 70 — Girls' socioeconomic status was an important factor for MHH literacy and MENSES outcomes, as well as the associations between them.

A study reviewing data across eight LMIC's found that lower income households were less likely to have access to safe spaces that lock where women could manage their periods, increasing lower SES women's risk of experiencing GBV While our analysis did not focus on MHM spaces, or WASH in schools, teaching girls the practicalities of menstrual hygiene without providing safe, clean and adequate infrastructure may negate or minimize any improvements in stress or self-efficacy achieved through information alone.

Girls with less economic resources may still experience increased stress attempting to practice a behavior without the proper enabling environment. In our study, girls from the low SES group demonstrated higher menstruation-related stress and less menstruation-related self-efficacy before and after the program, though there was a slight improvement in stress at endline.

Further, high SES girls consistently had higher levels of MHH knowledge compared to their low SES peers, though low SES girls experienced larger gains at endline Table 8 , most notably knowing what puberty was 24 vs. These findings suggests that girls from lower income households may rely more on schools for critical and timely MHH and puberty education, while those from higher SES families have access to the information from other sources.

Beyond the provision of accurate and practical MHH information, having a trustworthy adult that girls can turn to arose as a key factor for MENSES outcomes. While the WSE program did not increase the proportion of girls who reported having a trusted adult they could talk to about puberty, among girls in the low SES group, having said adult was significantly associated with lowered menstruation-related stress compared to girls who did not.

Though adolescence is a time that children seek more acceptance from peers 73 , 74 , this finding aligns with previous studies highlighting the desire of adolescents to communicate with their parents or caretakers about these topics Additionally, it highlights the importance of in-service teacher training to ensure that they can sensitively provide information to their students who cannot have those critical conversations at home 3 , The need to provide such social-emotional support alongside puberty information may be even more acute among girls living in more impoverished families.

As SES was crudely measured using the proxy of computer ownership, it likely oversimplifies the relationship between household resources, MHH knowledge, and MENSES outcomes.

Overall, the associations between having a trusted adult and reduced stress, as well as the individual items responsible for decreases in stress and increases in self-efficacy Table 4 ; Figure 2 , suggest that the WSE program not only improved MENSES outcomes through increasing information, but importantly it improved social support among these students.

Openly discussing menstruation with peers may increase feelings of support among girls simply by reducing the stigma of menstruation 67 , while practical information, such as how to dispose of menstrual pads and how to track their period, led girls to feel empowered in their own abilities.

Results from this study support existing recommendations to initiate CSE and puberty education before girls reach menarche Simply knowing what menstruation was before experiencing menarche was associated with lower levels of stress and higher self-efficacy and engagement among girls in WSE Table Though puberty and menstruation knowledge among this population of VYA girls was high at baseline, global research has documented that many girls learn about their period and puberty after they experience menarche We observed differences between reported MHH and puberty knowledge between the sub-population of girls who had their first period and the aggregate group.

Additionally, there were larger increases at endline among menstruating girls who reported learning about menstruation at school compared to the entire female sample 10 vs. The comparison of these data points suggests a disconnect between menstruation and puberty education among girls in WSE schools, with the potential that some teachers are omitting MHH information during puberty lessons or only sharing details with the girls they believe require it.

This points to a need to expand MHH teacher training and monitoring to ensure teachers have the information, skills and confidence to elaborate on the topic for all students in the classroom We See Equal is a puberty education program with strong linkages to gender equality and empowerment.

WSE aimed to not only increase MHH literacy and puberty knowledge, but also to create empathy between girls and boys by demonstrating both their shared and unique social and emotional transitions during puberty. Future research should examine the benefit of gender-equality focused education on girls' school experiences, particularly menstruation-related self-efficacy and school engagement, which may be more influenced by class lessons that leverage gender equality to empower girls Similarly, this study did not examine the relationship between MENSES outcomes and male student knowledge, gender attitudes, or empathy for girls who are experiencing this change.

Understanding how MHH literacy among boys influences girls' MENSES outcomes, especially items related to social support, would further bolster the need to involve boys and men 79 to create truly gender transformative programs that advance gender equality.

Current SEP curricula focuses on biology and human reproduction, which while important, may not improve the greater wellbeing of girls and boys as they pass through this life stage. Improving the study designs of future programs would allow practitioners to make robust statements about how these programs change child-level outcomes and may have more gravitas when advocating to education authorities for improved curricula in schools and teacher training.

The analysis of We See Equal monitoring data lend themselves to concrete suggestions for future strategies to improve the overall quality of MHH programs. The finding that, girls with a trusted adult they can ask about puberty also have lower menstruation-related stress, indicates a necessity for greater parent and caretaker involvement in these programs.

Parents and caretakers need MHH and puberty education themselves 80 , as well as the soft skills to have these conversations with their children. Teachers may attempt to fill this gap, especially for boys and girls from lower SES groups, but teachers require additional training to address the social-emotional elements of the topic Leaving out parents and caretakers in these programs contributes to the cycle of worse health and education outcomes for poorer families and children.

Future programs that aim to improve MHH literacy, MENSES outcomes and puberty education should focus on locations with lower-income populations, intervening before puberty onset, and piloting new pedagogy practices to increase social support and meet girls' needs.

WSE took place in urban centers in Mexico with the majority of girls having high levels of MHH knowledge at baseline.

However, girls from higher SES had more knowledge before and after the program, suggesting that these girls already had access to the information outside of schools. WSE programming may have more impact among populations with less economic resources that rely more on schools and teachers for puberty education.

This finding implies that schools are already late in providing this information to students and should consider initiating age-appropriate CSE in the 4th grade. Finally, several observations from the analysis suggest that one of the benefits of WSE was that puberty and menstruation education reduced stress and increased self-efficacy by improving girls' social support.

WSE was designed to not only provide accurate and timely information to VYAs, but also provide teachers the skills and resources to conduct dynamic sessions that facilitated discussion and interaction among classmates. Future programs should explore ways to expand on this strength, potentially piloting alternative modalities that allow girls and boys to explore these topics in-depth among same-sex peers before engaging with mixed sex classrooms, building a sense of safety and confidence prior to delving into shared adolescent experiences and issues UNESCO reported that in many learners lost access to CSE and girls across the globe are less likely than boys to have the resources to participate in virtual learning, more likely to become responsible for household tasks, and experience higher feelings of stress and anxiety resulting from the pandemic Trends already hint at the realization of our worst fears for girls, as the impacts of the global pandemic are showing increases in assault, domestic, and sexual violence in Mexico The education and health sector, including governments and civil society, will need to adapt menstrual health and puberty education with low-tech or no-tech methods in order to reach families with this critical information If Mexico wants to achieve its goal to reduce adolescent pregnancy among year olds and eliminate it among VYA 52 , improving menstrual health literacy is a good start.

The need for comprehensive sexuality education, including information about puberty, menstruation and gender is critical in primary school and especially among girls who come from lower income households. Program that improve menstrual health literacy have the potential reduce menstruation-related stress and increase self-efficacy, thereby improving the quality of girls' educational experiences.

Many teachers are unprepared to provide this information and training on these topics is not readily available. As these subject are rarely monitored or assessed, updating education policies to include these topics and monitor their coverage 43 , 84 will be imperative for affecting change at scale.

In Mexico, girls and adolescents have high rates of pregnancy, gender-based violence and young sexual debut, especially among girls who are out of school. Educating VYA and empowering them with this information at earlier ages could have longer term impacts on their future health and education.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. The studies involving human participants were reviewed and approved by Save the Children US Ethics Review Committee. JL provided technical support to the WSE project, including the formative research design used to adapt the Choices materials.

She worked with country staff to design the survey KAP assessment questions and methods and worked on the interpretation of the analysis results for the research paper submitted. JH and JL co-developed the MENSES tool. JH reviewed data analysis and methods for this research study, contributed significantly to the literature review, and developed key conceptual arguments for the manuscript.

PM led data analysis and interpretation for the research study, and has supported the psychometric analysis of the MENSES tool and its improvements over time, providing strategic guidance to evaluation methods for WSE.

SV led the research, design and program operations of We See Equal in Mexico. She headed the Choices adaptation process and was intimately involved in the development of the KAP survey as well as ensuring data quality throughout program implementation. SV provided critical contextual background information, as well as supported in the interpretation of results, future research and programming needs having a perspective most closely tied to the field.

All authors contributed to the article and approved the submitted version. This includes staff time and operational costs of implementation in Mexico.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers.

Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. The We See Equal program and this research could not have been completed without the dedication of several individuals: Lorena Annel Aquino Hernández, Juan Manuel Castro Reyes, Alejando Fernández Monreal, Úrsula Hernández Mellado, Irene Mata Gómez, Miguel Mauricio Santamaría Chale, Eduardo Velasco Gutiérrez, Charles E.

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Caruso B, Fehr A, Inden K, Ellis A, Andes K, Freeman M. WASH in Schools Empowers Girls' Education in Freetown, Sierra Leone: An Assessment of Menstrual Hygiene Management in Schools.

New York, NY: United Nations Childrens Fund Ellis A, Haver J, Villasenor J, Parawan A, Venkatesh M, Freeman MC, et al. WASH challenges to girls' menstrual hygiene management in Metro Manila, Masbate, and South Central Mindanao, Philippines.

Haver J, Caruso BA, Ellis A, Sahin M, Villasenor J, Andes KL, et al. WASH in Schools Empowers Girls' Education in Masbate Province and Metro Manila, Philippines: An Assessment of Menstrual Hygiene Management in Schools. New York, NY: United Nations Children's Fund Long J, Caruso BA, Lopez D, Vancraeynest K, Sahin M, Andes KL, et al.

WASH in Schools Empowers Girls' Education in Rural Cochabamba, Bolivia: An Assessment of Menstrual Hygiene Management in Schools. Mason L, Nyothach E, Alexander K, Odhiambo FO, Eleveld A, Vulule J, et al. We keep it secret so no one should know — a qualitative study to explore young schoolgirls attitudes and experiences with menstruation in rural western Kenya.

PLoS ONE. McMahon SA, Winch PJ, Caruso BA, Obure AF, Ogutu EA, Ochari IA, et al. BMC Int Health Hum Rights. Sommer M. Ideologies of sexuality, menstruation and risk: girls' experiences of puberty and schooling in northern Tanzania.

Katharine is sonographer, hysteroscopist and non medical prescriber and has a specialist interest in menstrual wellbeing and the menopause. She is currently employed by North Bristol NHS Trust and has received hospital charity funding to research the 'Working lives of menopausal women in the NHS'.

As well as a nurse, she is a Certified Coach and supports women particularly around the time of the menopause. Janet Lindsay is Chief Executive of Wellbeing of Women, a charity improving the health and wellbeing of women, girls and babies.

Janet started her career working for a global advertising agency before running her own communications agency. She was the 30th President of the Royal College of Obstetricians and Gynaecologists, only the second woman to ever hold this role and the first in sixty-four years.

Professor Regan is Professor of Obstetrics at Imperial College London and Head of Obstetrics and Gynaecology at St Mary's Hospital; she is also director of Women's Health Research Centre, co-director of the UK Pregnancy Baby Bio Bank and co-Chair of the People and Culture Committee Athena SWAN for the Department of Metabolism, Digestion and Reproduction.

Having graduated from the Royal Free Hospital School of Medicine, London, in Professor Regan pursued her career at Addenbrooke's Hospital, Cambridge, where she first became enthused by clinical and laboratory research, completing an MD on miscarriage.

In she received an Honorary Fellowship of the American College and a Doctorate of Science from University College London for the contribution to women's health.

Dedicated to raising the profile of menstrual health. Mission and Purpose The Menstrual Health Coalition MHC is a coalition of patient and advocate groups, life sciences industry, leading clinicians and individuals who have come together to discuss and make recommendations around menstrual health.

Dr Anne Connolly MBE The Royal College of General Practitioners' Clinical Champion in Women's Health Member of the Menstrual Health Coalition's Steering Committee. dR ANNE CONNOLLY MBE After a two year volunteer posting to a under-resourced mission hospital in rural Zimbabwe Anne returned to General Practice in inner-city Bradford in and is currently working as a GP providing care for asylum seekers, refugees, homeless and sex workers.

Emma Cox CEO of Endometriosis UK Member of the Menstrual Health Coalition's Steering Committee. Emma Cox Emma joined Endometriosis UK as Chief Executive in February , and has overseen a sustained period of growth and development for the organisation, including awareness raising, new campaigns, and building key relationships with healthcare practitioners, researchers and policy influencers.

Although our measures were consistent with previous qualitative and quantitative research, more research is needed to validate our approach.

Future research is also needed with broader populations of menstruators, including transgender and non-binary populations.

These limitations notwithstanding, this study is among the first to quantify period poverty and to examine its association with depression, and has implications for research and programming. Period poverty has not been definitively defined in academic spaces, and thus further scale development research is warranted.

Regarding programming and policy, addressing the mental health issues of college students is of particular concern given the high prevalence of stress, anxiety, and depression experienced by this population [ 9 ].

College administrators are addressing the issue by adding more comprehensive mental health services, but they should also examine the importance of unmet needs.

Specifically, they should assess how period poverty may be contributing to the mental health issues among young women and consider making products more accessible. Some universities have such efforts underway—offering free menstrual products to students—and in some places in conjunction with efforts to reduce food insecurity.

More broadly, city- and state-level policy efforts to reduce the cost of menstrual products and increase their accessibility among vulnerable populations are gaining momentum.

For example, as of New York City provides free menstrual products in public schools, homeless shelters, and prisons [ 23 ].

Similarly, starting in the fall of , Boston began providing free menstrual products in public middle and high schools [ 24 ]. There have been added calls from advocates to remove other structural barriers to accessing menstrual products, such as requiring Medicaid and Supplemental Nutrition Assistance Program to cover menstrual products [ 26 ].

Though preliminary, current study findings suggest that many young women cannot afford menstrual health products to meet their monthly needs, and this may impact their mental well-being.

With additional research to help inform how period poverty impacts college students, there is tremendous opportunity to help address this critical, yet under-addressed issue.

Gundersen C, Ziliak JP. Food insecurity and health outcomes. Health Aff. Article Google Scholar. Singh A, Daniel L, Baker E, Bentley R.

Housing disadvantage and poor mental health: a systematic review. Am J Prev Med. Article PubMed Google Scholar. Whitaker RC, Phillips SM, Orzol SM. Food insecurity and the risks of depression and anxiety in mothers and behavior problems in their preschool-aged children.

Sommer M, Hirsch JS, Nathanson C, Parker RG. Comfortably, safely, and without shame: defining menstrual hygiene management as a public health issue.

Am J Public Health. Article PubMed PubMed Central Google Scholar. Kuhlmann AS, Bergquist EP, Danjoint D, Wall LL.

Unmet menstrual hygiene needs among low-income women. Obstet Gynecol. The World Bank. Menstrual hygiene management enables women and girls to reach their full potential. Accessed 29 Jan International Centre for Diarrheal Diseases Research, WaterAid Bangladesh.

Bangladesh National Hygiene Baseline Survey: Preliminary Report. Dhaka: International Centre for Diarrheal Diseases Research; Tegegne T, Sisay M.

Menstrual hygiene management and school absenteeism among female adolescent students in Northeast Ethiopia. BMC Public Health. American College Health Association. Spring reference group executive summary. Silver Spring, MD: American College Health Association; Goldrick-Rab S, Baker-Smith C, Coca V, Looker E, Williams T.

College and university basic needs insecurity: a national RealCollege survey report. Philadelphia, PA: The HOPE Center; Richardson LP, McCauley E, Grossman DC, McCarty C, Richards J, Russo JE, et al.

Evaluation of the Patient Health Questionnaire PHQ-9 for detecting major depression among adolescents. National college health assessment. Cataldi EF, Bennet CT, Chen X. Washington, DC: National Center for Education Statistics; Heflin CM, Siefert K, Williams DR. Soc Sci Med. Pryor L, Lioret S, Van der Waerden J, Fombonne É, Falissard B, Melchior M.

Food insecurity and mental health problems among a community sample of young adults. Soc Psychiatry Psychiatr Epidemiol.

McLaughlin KA, Green JG, Alegría M, Costello JE, Gruber MJ, Sampson NA, et al. Food insecurity and mental disorders in a national sample of U.

J Am Acad Child Adolesc Psychiatry. Stahre M, VanEenwyk J, Siegel P, Njai R. Housing insecurity and the association with health outcomes and unhealthy behaviors.

Prev Chronic Dis. Burgard SA, Seefeldt KS, Zelner S. Housing instability and health: findings from the Michigan recession and recovery study. Schooler D, Ward LM, Merriwether A, Caruthers AS. Cycles of shame: menstrual shame, body shame, and sexual decision-making.

J Sex Res. Lee J. Bodies at menarche: stories of shame, concealment, and sexual maturation. Sex Roles. Google Scholar. Laws S. Issues of blood: the politics of menstruation. Basingstoke, Hampshire: Macmillan; Book Google Scholar.

Chaparro PM, Zaghloul SS, Holck P, Dobbs J. Public Health Nutr. The Official Website of the City of New York. Mayor de Blasio signs legislation increasing access to feminine hygiene products for students.

The Boston Globe. Kempe Y. Period Equity. Food or tampons? No one should have to choose. Menstrual Equity for All Act of Download references.

We would also like to acknowledge Jennifer Weiss-Wolf for her helpful insights on current policy efforts to address period poverty. We would like to acknowledge our funders, the Endometriosis Foundation of America EndoFound Grant , PI: Dr.

Jhumka Gupta. EndoFound had no role in study design, analysis, or writing. School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA.

Department of Global and Community Health, College of Health and Human Services, George Mason University, University Dr. Anna M. You can also search for this author in PubMed Google Scholar. LC led the writing of the manuscript, data analysis and conceptualized the study.

AS and AH assisted with writing and interpretation of findings. JG co-led the conceptualization and design of the study. All authors read and approved the final manuscript. Correspondence to Jhumka Gupta. Written informed consent was obtained from all participants.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Period Poverty Questionnaire Items.

This document includes the three questionnaire items related to period poverty that were used to assess period poverty prevalence in our study population.

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Reprints and permissions. Cardoso, L. et al. Period poverty and mental health implications among college-aged women in the United States. BMC Women's Health 21 , 14 Download citation. Received : 29 July Accepted : 11 December Published : 06 January Anyone you share the following link with will be able to read this content:.

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Download PDF. Research article Open access Published: 06 January Period poverty and mental health implications among college-aged women in the United States Lauren F. Cardoso 1 , Anna M.

Experiencing period poverty every month was also most frequently reported by Latina women past year: One in five first generation college students One in ten non-first generation students experienced past-year 9.

No significant difference was observed for other sociodemographic variables displayed in Table 1 below. Just under half Those who had the lowest self-rated health reported the most severe depression. Among women who reported experiencing period poverty every month, These relationships remained significant in the adjusted analyses.

We conducted additional analysis to examine potential impacts of a prior mental health diagnosis on the association of interest in our study. Specifically, we ran an additional model where we accounted for prior self-reported mental health diagnosis i. Future research is needed to examine any potential role that timing of diagnosis, lack of diagnosis, and medication may have on the association of interest.

In this nationally-drawn sample of college attending women in the United States, This is the first study to quantify unmet menstrual product needs among this population. This study also sought to assess the relationship between period poverty and depression.

Findings revealed that period poverty was significantly associated with depression on a gradient. Compared to those who had never experienced period poverty, women who had experienced period poverty every month reported the most severe depression, followed by those who had ever experienced period poverty in the past year.

To our knowledge, there are no other studies that have examined the mental health impacts of period poverty, thus making comparisons difficult. However, our findings are broadly consistent with other research documenting an association between unmet basic needs and an elevated likelihood of poor mental health.

For example, food insecurity has been found to be associated with depression among adults and depression, suicidal ideation, and anxiety among young adults and adolescents [ 14 , 15 , 16 ]. Similarly, people experiencing housing insecurity are more likely to report depression and anxiety than those who are stably housed [ 17 , 18 ].

Notably, these studies collectively indicate that these unmet needs uniquely contribute to mental health, above and beyond the effects of income or wealth. The same may be true of unmet menstrual health needs, particularly given the shame and stigma associated with menstruation generally [ 19 , 20 , 21 ].

This study has several limitations. Income level is difficult to measure among college students via self-report, as discussed in existing research on food insecurity among university students [ 22 ].

Thus, this was not included as a covariate. Therefore, we could not test if period poverty was associated with depression independent of economic deprivation.

Future research would be strengthened with the inclusion of appropriate economic measures, including food security, for this population. In addition, the sample was not probability-based and we do not have data on those who declined participation.

Responses and findings are only generalizable to the demographics and experiences within this study. Finally, there is no standard way to assess period poverty. Although our measures were consistent with previous qualitative and quantitative research, more research is needed to validate our approach.

Future research is also needed with broader populations of menstruators, including transgender and non-binary populations. These limitations notwithstanding, this study is among the first to quantify period poverty and to examine its association with depression, and has implications for research and programming.

Period poverty has not been definitively defined in academic spaces, and thus further scale development research is warranted. Regarding programming and policy, addressing the mental health issues of college students is of particular concern given the high prevalence of stress, anxiety, and depression experienced by this population [ 9 ].

College administrators are addressing the issue by adding more comprehensive mental health services, but they should also examine the importance of unmet needs.

Specifically, they should assess how period poverty may be contributing to the mental health issues among young women and consider making products more accessible.

Some universities have such efforts underway—offering free menstrual products to students—and in some places in conjunction with efforts to reduce food insecurity. More broadly, city- and state-level policy efforts to reduce the cost of menstrual products and increase their accessibility among vulnerable populations are gaining momentum.

For example, as of New York City provides free menstrual products in public schools, homeless shelters, and prisons [ 23 ]. Similarly, starting in the fall of , Boston began providing free menstrual products in public middle and high schools [ 24 ].

There have been added calls from advocates to remove other structural barriers to accessing menstrual products, such as requiring Medicaid and Supplemental Nutrition Assistance Program to cover menstrual products [ 26 ]. Though preliminary, current study findings suggest that many young women cannot afford menstrual health products to meet their monthly needs, and this may impact their mental well-being.

With additional research to help inform how period poverty impacts college students, there is tremendous opportunity to help address this critical, yet under-addressed issue. Gundersen C, Ziliak JP. Food insecurity and health outcomes. Health Aff. Article Google Scholar. Singh A, Daniel L, Baker E, Bentley R.

Housing disadvantage and poor mental health: a systematic review. Am J Prev Med. Article PubMed Google Scholar. Whitaker RC, Phillips SM, Orzol SM.

Food insecurity and the risks of depression and anxiety in mothers and behavior problems in their preschool-aged children.

Sommer M, Hirsch JS, Nathanson C, Parker RG. Comfortably, safely, and without shame: defining menstrual hygiene management as a public health issue. Am J Public Health. Article PubMed PubMed Central Google Scholar. Kuhlmann AS, Bergquist EP, Danjoint D, Wall LL. Unmet menstrual hygiene needs among low-income women.

Obstet Gynecol. The World Bank. Menstrual hygiene management enables women and girls to reach their full potential. Accessed 29 Jan International Centre for Diarrheal Diseases Research, WaterAid Bangladesh. Bangladesh National Hygiene Baseline Survey: Preliminary Report.

Dhaka: International Centre for Diarrheal Diseases Research; Tegegne T, Sisay M. Menstrual hygiene management and school absenteeism among female adolescent students in Northeast Ethiopia. BMC Public Health. American College Health Association.

Spring reference group executive summary. Silver Spring, MD: American College Health Association; Goldrick-Rab S, Baker-Smith C, Coca V, Looker E, Williams T. College and university basic needs insecurity: a national RealCollege survey report. Philadelphia, PA: The HOPE Center; Richardson LP, McCauley E, Grossman DC, McCarty C, Richards J, Russo JE, et al.

Evaluation of the Patient Health Questionnaire PHQ-9 for detecting major depression among adolescents. National college health assessment. Cataldi EF, Bennet CT, Chen X.

Washington, DC: National Center for Education Statistics; Search UNICEF Fulltext search. Files available for download English PDF, 3 MB. Related topics Water, sanitation and hygiene. More to explore. Footer UNICEF Home What we do Research and reports Stories and features Where we work Press centre Take action.

About us Work for UNICEF Partner with UNICEF UNICEF Executive Board Evaluation Ethics Internal Audit and Investigations Transparency and accountability Sustainable Development Goals Frequently asked questions FAQ. In addition to the 1. While menstruation can be a taboo topic, the importance of menstrual health is increasingly recognized, and advances have been made both in terms of norms and monitoring.

Emerging national data on each of these indicators have been compiled and harmonized across countries and surveys, to the extent possible, to support cross-country comparison.

The data available on the JMP website and progress update are based on the most recent available surveys. The JMP does not currently use a service ladder for menstrual health, as norms and standards relating to menstrual health and associated water, sanitation, and hygiene needs are still evolving.

Further work is needed to refine these indicators and evaluate if others may be more relevant. During , the JMP convened experts to seek technical recommendations on updating the JMP core questions for monitoring menstrual health in household surveys, specifically in the questionnaire for individual women.

The resulting zero draft of ' Proposed questions on menstrual health for inclusion in household survey questionnaires for individual women ' aims to: provide impactful data that can support national policy and programming changes, reflect the new definition of menstrual health, include emerging recommended questions and indicator domains from MH experts , prioritize questions already being used in national surveys and data collection efforts, maintain comparability with previously used questions to support time series data, and optimize the number of questions while ensuring they are clear and simple.

The JMP team is grateful to the following menstrual health experts for their review of the menstrual health chapter in the household report : Therese Mahon WaterAid , Bethany Caruso Emory University , Julie Hennegan Burnet Institute , Janita Bartell UNICEF HQ , Marni Sommer Columbia University , Brooke Yamakoshi UNICEF EAPRO , Sue Cavill consultant.

Menstrual Health.