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Background: Women worldwide experience challenges managing their periods. Menstrual and genital hygiene behaviours have been linked to negative health outcomes, including urogenital symptoms and confirmed infections. However, evidence testing this association has been limited and mixed. This study aimed to (1) describe the menstrual care practices and prevalence of self-reported urogenital symptoms among working women in Mukono District, Uganda, and (2) test the associations between menstrual and genital care practices, and urogenital symptoms., Methodology: We undertook a cross-sectional survey of women aged 18-45 working in markets, schools, and healthcare facilities in Mukono District, with 499 participants who had menstruated in the past two months included in this analysis. We developed an aggregated measure of menstrual material cleanliness, incorporating material type and laundering practices. Associations with urogenital symptoms were tested using the aggregated material cleanliness measure alongside the frequency of changing materials, handwashing before menstrual tasks, and sanitation practices., Results: Among our sample, 41% experienced urogenital symptoms in the past month. Compared to women exclusively using disposable pads, using appropriately cleaned or non-reused improvised materials (PR = 1.33, 95%CI 1.04-1.71), or inadequately cleaned materials (improvised or commercially produced reusable pads) (PR = 1.84, 95%CI 1.46-3.42) was associated with an increased prevalence of self-reported urogenital symptoms in the last month. There was no difference between those using disposable pads and those using clean reusable pads (PR = 0.98; 95%CI 0.66-1.57). Infrequent handwashing before changing materials (PR 1.18, 95%CI: 0.96-1.47), and delaying urination at work (PR = 1.37, 95%CI: 1.08-1.73) were associated with an increased prevalence of self-reported symptoms., Conclusion: Prevalence of self-reported urogenital symptoms was associated with the type and cleanliness of menstrual material used as well as infrequent handwashing and urinary restriction. There is a need for interventions to enable women to maintain cleanliness of their menstrual materials and meet their menstruation, urination and hand washing needs at home and work., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Borg 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.)

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

Surveys monitoring population health and sanitation are increasingly seeking to monitor menstrual health. In the absence of established indicators, these surveys have most often collected data on the type of menstrual material used. This study investigated whether such data provides a useful indication of women's menstrual material needs being met. Using data from 12 national or state representative surveys from the Performance Monitoring and Accountability 2020 program, we compared self-reported menstrual material use against respondents' reported menstrual material needs (including needing clean materials, money, or access to a vendor). The use of menstrual pads did not indicate that menstrual material needs were met for many respondents. Of those exclusively using pads, a pooled 26.4% (95% Confidence Interval 17.1-38.5) of respondents reported that they had unmet material needs. More disadvantaged groups were particularly misrepresented; of rural women exclusively using pads, a pooled 38.5% (95%CI 27.3-51.1) reported unmet material needs, compared to 17.1% (95%CI 12.4-23.0) of urban women. Similar disparities were observed for levels of education and wealth, with a pooled 45.9% (95%CI 29.2-63.6) of women in the lowest wealth quintile reporting unmet material needs. Findings suggest that caution is needed when using menstrual material use as an indicator for menstrual health.

Objective: This study describes the development and validation of the Menstrual Practice Needs Scale (MPNS-36), which measures the extent to which respondents' menstrual practices and environments meet their needs., Methods: A 54-item pool was developed following systematic review of qualitative and quantitative studies and expert feedback. Item reduction and scale validation were undertaken using a cross-sectional survey of 538 menstruating schoolgirls in Soroti, Uganda. Test-retest reliability was assessed in a subsample of 52 girls 2 weeks after the first administration. Construct validity was tested through relationships with hypothesised correlates: confidence to manage menses, self-reported school absenteeism and mental health symptoms., Results: The MPNS-36 comprises 28 items applicable to all respondents and 8 items capturing washing and drying experiences for those reusing menstrual materials. A four-factor solution for the core 28 items was the best fit for the data (root mean square error of approximation (RMSEA)=0.028-0.029; comparative fit index (CFI)=0.961-0.964; Tucker-Lewis index (TLI)=0.953-0.955), supplemented by two factors for reuse (RMSEA=0.021-0.030; CFI=0.987-0.994; TLI=0.981-0.991). Subscale and total scores were calculated as mean scores to support accessibility for practitioners. The subscales were 'material and home environment needs' (11 items, α ordinal =0.84), 'transport and school environment needs' (5 items, α ordinal =0.73), 'material reliability concerns' (3 items, α ordinal =0.55), 'change and disposal insecurity' (9 items, α ordinal =0.80), 'reuse needs' (5 items, α ordinal =0.76) and 'reuse insecurity' (3 items, α ordinal =0.56). Relationships between subscales and hypothesised correlates supported validity. Home-based and school-based items were more strongly associated with confidence to manage menstruation at home and school, respectively. Higher total scores indicated more positive experiences and were associated with greater odds of not missing school during the last menstrual period (OR=2.62, 95% CI 1.52 to 4.50). Test-retest reliability was moderate (total score: intraclass correlation coefficient, ICC (2,1) =0.69)., Conclusions: The MPNS-36 demonstrated acceptable reliability and validity. It is the first measure to capture perceived menstrual hygiene and may be useful across a range of study designs. Future research should explore the validity and suitability of the measure across contexts and populations., Competing Interests: Competing interests: CS works for Irise International, an organisation dedicated to creating a world where all women and girls can reach their full potential, regardless of their periods. AN and AA work for Irise Institute East Africa, a local implementing partner of Irise International., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Diarrhoeal outcomes in children are often ascertained using caregiver-reported symptoms, which are subject to a variety of biases and methodological challenges. One source of bias is the time window used for reporting diarrhoeal illness and the ability of caregivers to accurately recall episodes in children., Methods: Diarrhoea period prevalence in children under five was determined using two similarly administered, nationally representative household surveys: Performance Monitoring and Accountability 2020 (PMA2020) (1-week recall, N = 14 603) and Demographic and Health Surveys (DHS) (2-week recall, N = 66 717). Countries included in the analysis were the Democratic Republic of the Congo, Ethiopia, Ghana, Kenya and Uganda. Diarrhoea period prevalence estimates were compared and water, sanitation and hygiene risk factors were analysed., Results: Childhood diarrhoea prevalence using 1-week recall (PMA2020) pooled across countries was 21.4% [95% confidence interval (CI): 19.9%, 22.9%] versus 16.0% using 2-week recall (DHS) (95% CI: 15.4%, 16.5%). In stratified analyses for all five countries, the number of diarrhoea cases detected was consistently higher using 1-week recall versus 2-week recall. The key risk factors identified in the PMA2020 data that were not associated with diarrhoeal episodes or were attenuated in the DHS data included: the main sanitation classifications for households, disposal method used for child faeces, number of household members and wealth quintiles., Conclusions: For nationally representative household surveys assessing childhood diarrhoea period prevalence, a 2-week recall period may underestimate diarrhoea prevalence compared with a 1-week period. The household sanitation facility and practices remain key risk factors for diarrhoeal disease in children under five., (© The Author(s) 2019. Published by Oxford University Press on behalf of the International Epidemiological Association.)

Inadequate menstrual hygiene presents a barrier to women's dignity and health. Recent attention to this marginalised challenge has resulted in the first national assessments of menstrual practices. Intuitively, surveys require women to have had a recent menses to be eligible. This study seeks to determine if there are demographic differences between women who are eligible and ineligible to answer questions about their menstrual hygiene during these assessments. Secondary analyses were undertaken on nationally or state representative data collected by the Performance Monitoring and Accountability 2020 survey programme across eight countries (Burkina Faso, Ethiopia, Ghana, India, Kenya, Niger, Nigeria, and Uganda). Female respondents were included in the study and compared on whether they had a menstrual period within the past three months and thus were eligible to answer questions regarding menstrual practices. On average, 29% of surveyed women across samples were ineligible to be asked menstrual hygiene questions. Higher levels of education, wealth, and urban residence were associated with higher odds of eligibility. Young and unmarried women were also more likely to be eligible. Demographic differences between eligible and ineligible women were consistent across all countries. Wealthy, urban, and educated women are more likely to be eligible to answer survey questions about menstrual hygiene. While population surveys may be representative of menstruating women, proportions of menstrual hygiene practices reported underrepresent the experiences of more vulnerable groups. These groups are likely to have greater struggles with menstrual hygiene when they are menstruating.

Global efforts to improve sanitation have emphasized the needs of women and girls. Managing menstruation is one such need, yet there is scarce research capturing current practices. This study investigated the relationships between household sanitation and women’s experience of menstrual management. Secondary analyses were undertaken on data from 1994 women and girls collected through the Performance Monitoring and Accountability 2020 survey in Kaduna, Nigeria. In multivariable models, women had higher odds of using the main household sanitation facility for menstrual management when they had access to a basic (OR = 1.76 95%CI 1.26⁻2.46) or limited (OR = 1.63 95%CI 1.08⁻2.48) sanitation facility, compared to an unimproved facility. Women with no household sanitation facility had higher odds of using their sleeping area (OR = 3.56 95%CI 2.50⁻5.06) or having no facility for menstrual management (OR = 9.86 95%CI 5.76⁻16.87) than women with an unimproved sanitation facility. Menstrual management locations were associated with ratings of their characteristics. Safely managed or basic sanitation facilities were not rated more favorably than unimproved facilities in privacy (OR = 1.02 95%CI 0.70⁻1.48), safety (OR = 1.45 95%CI 0.98⁻2.15), access to a lock (OR = 0.93 95%CI 0.62⁻1.37), or soap and water (OR = 1.04 95%CI 0.70⁻1.56). Women using their sleeping area had more favorable perceptions of their environment. Findings suggest household sanitation influences women’s choices for menstrual management, but that existing indicators for improvement are not sensitive to menstrual needs.

Poor child gut health, resulting from a lack of access to an improved toilet or clean water, has been proposed as a biological mechanism underlying child stunting and oral vaccine failure. Characteristics related to household sanitation, water use, and hygiene were measured among a birth cohort of 270 children from peri-urban Iquitos Peru. These children had monthly stool samples and urine samples at four time points and serum samples at (2-4) time points analyzed for biomarkers related to intestinal inflammation and permeability. We found that less storage of fecal matter near the household along with a reliable water connection were associated with reduced inflammation, most prominently the fecal biomarker myeloperoxidase (MPO) (no sanitation facility compared with those with an onsite toilet had -0.43 log MPO, 95% confidence interval [CI]: -0.74, -0.13; and households with an intermittent connection versus those with a continuous supply had +0.36 log MPO, 95% CI: 0.08, 0.63). These results provide preliminary evidence for the hypothesis that children less than 24 months of age living in unsanitary conditions will have elevated gut inflammation.

Empiric quantification of environmental fecal contamination is an important step toward understanding the impact that water, sanitation, and hygiene interventions have on reducing enteric infections. There is a need to standardize the methods used for surface sampling in field studies that examine fecal contamination in low-income settings. The dry cloth method presented in this manuscript improves upon the more commonly used swabbing technique that has been shown in the literature to have a low sampling efficiency. The recovery efficiency of a dry electrostatic cloth sampling method was evaluated using Escherichia coli and then applied to household surfaces in Iquitos, Peru, where there is high fecal contamination and enteric infection. Side-by-side measurements were taken from various floor locations within a household at the same time over a three-month period to compare for consistency of quantification of E. coli bacteria. The dry cloth sampling method in the laboratory setting showed 105% (95% Confidence Interval: 98%, 113%) E. coli recovery efficiency off of the cloths. The field application demonstrated strong agreement of side-by-side results (Pearson correlation coefficient for dirt surfaces was 0.83 ( p < 0.0001) and 0.91 ( p < 0.0001) for cement surfaces) and moderate agreement for results between entrance and kitchen samples (Pearson (0.53, p < 0.0001) and weighted Kappa statistic (0.54, p < 0.0001)). Our findings suggest that this method can be utilized in households with high bacterial loads using either continuous (quantitative) or categorical (semi-quantitative) data. The standardization of this low-cost, dry electrostatic cloth sampling method can be used to measure differences between households in intervention and non-intervention arms of randomized trials., Competing Interests: The authors declare no conflict of interest. The founding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results.

Surface-mediated disease transmission is understudied in developing countries, particularly in light of the evidence that surface concentrations of fecal bacteria typically exceed concentrations in developed countries by 10- to 100-fold. In this study, we examined fecal indicator bacterial contamination of dinner plates at 21 households in four peri-urban communities in the Peruvian Amazon. We also used surveys to estimate household use of and demand for surface disinfectants at 280 households. Despite detecting total coliform, enterococci, and Escherichia coli on 86%, 43%, and 24% of plates sampled, respectively, less than one-third of households were regularly using bleach to disinfect surfaces. Among non-users of bleach, only 3.2% of respondents reported a new demand for bleach, defined as a high likelihood of using bleach within the next year. This study highlights the potential for marketing approaches to increase use of and demand for surface disinfectants to improve domestic hygiene.

Innovative solutions are essential to improving global access to potable water for nearly 1 billion people. This study presents an independent investigation of one alternative by examining for-profit water-vending kiosks, WaterHealth Centers (WHCs), in rural Ghana to determine their association with household drinking water quality. WHCs' design includes surface water treatment using filtration and ultraviolet light disinfection along with community-based hygiene education. Analyses of water samples for Escherichia coli and household surveys from 49 households across five villages collected one time per year for 3 years indicate that households using WHCs had improved water quality compared with households using untreated surface water (adjusted incidence rate ratio = 0.07, 95% confidence interval = 0.02, 0.21). However, only 38% of households used WHCs by the third year, and 60% of those households had E. coli in their water. Recontamination during water transport and storage is an obstacle to maintaining WHC-vended water quality.

High-quality evidence is needed to inform policies and programmes aiming to improve menstrual health. Quantitative studies must address the many evidence gaps in this field, and practitioners have increased monitoring and evaluation efforts to track their progress. A significant barrier to improving the rigor of this work is the lack of comprehensive and comparable measures to capture core concepts. The Menstrual Practices Questionnaire (MPQ) is a new tool to support comprehensive and standardised assessment of the activities undertaken in order to collect, contain, and remove menstrual blood from the body in self-report surveys. The questionnaire is freely available online for download and can be adapted for use across contexts and age groups. In this article, we describe the purpose of the MPQ as a best-practice tool to align the description of menstrual practices and provide a foundation for further question refinement. We outline the development of the tool using systematic review of qualitative studies of menstrual experiences, audit of measures used in the study of menstrual health and hygiene, survey of experts, insights from past research, and examples from piloted questions in a survey of adolescent girls in Soroti, Uganda. We describe the identification of menstrual practices as a priority for measurement, coverage of practices included in the MPQ, and justify the inclusion of location-specific questions. For each section of the questionnaire, we outline key reasons for the inclusion of practice items alongside elaboration for users to help inform item selection. Finally, we outline priorities for future research to refine the assessment and reporting of menstrual practices, including the identification of minimum reporting requirements for population characteristics to facilitate comparison across studies, testing the extent to which experiences during the most recent menstrual period reflect those over longer time periods, and further exploration of biases in self-report. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]