absorbents, is a considerable challenge. 1 countries. Women in Bangladesh. Source: waterdotorg

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1 Julie Hennegan, University of Oxford, United Kingdom Menstruation is a healthy and natural process for women from menarche in adolescence until menopause. Women spend a significant portion of their lives menstruating, though stigma and taboo mean this is rarely discussed openly. In resource poor contexts, menstrual hygiene management (MHM), that is; having access to clean absorbents, facilities to change absorbents as needed, access to soap and water for cleaning the body and Menstrual hygiene management is a challengeabsorbents, and disposal facilities for used for women in many low and middle income absorbents, is a considerable challenge. 1 countries. Women in Bangladesh. Source: waterdotorg Poor MHM is prevalent across low and middle income countries. 2,3 Research has linked poor MHM to negative consequences for women s dignity, health, education, work, and psychosocial wellbeing. Qualitative studies and case reports have documented many of these consequences. 4,5 Quantitative studies, although yet limited, have started to support some of these links. 6,7 This article describes MHM interventions and summarises our recent systematic review of the evidence for their effectiveness for improving education and psychosocial outcomes. Two broad categories of interventions have been proposed to address poor MHM and the associated negative consequences: Global Water Forum 1

2 1.Hardware interventions These types of interventions focus on providing necessary physical resources. Generally, programs have focused on the provision of menstrual absorbents to equip women and girls with clean and reliable ways to absorb menstrual bleeding. Improvements to water, sanitation and hygiene facilities have also been proposed as potential interventions. Women and girls need to be able to wash their body and reusable absorbents to an acceptable standard. They must be able to do so as often as necessary and in privacy, without attracting unwanted attention. This necessitates gender-separate latrines, private spaces at home and in schools to facilitate menstrual absorbent change and cleaning. Toilets with lockable doors may help women and girls safety and privacy whilst managing menstruation. Access to water within latrines or in private spaces to clean the body and absorbents effectively is also an area for improvement and possible intervention. Finally, improved disposal facilities, where open pit toilets often reveal when a woman is menstruating or are not designed to handle the disposal of sanitary products, may be a way to reduce poor MHM, shame and embarrassment Software interventions These focus on the provision of information about menstruation and MHM, and may also target associated taboos and stigma. Many girls are unaware of menstruation prior to menarche, and stigma around the topic has often prevented their access to accurate information to understand menstruation and its management. 2 Improving understanding of menstruation, such as knowledge of cycle length and requirements for hygiene, is Global Water Forum 2

3 hypothesised to improve management practices, self-efficacy, and reduce anxiety and shame. Figure 1. Predictors and consequences of unhygienic and ineffective menstruation management, and proposed interventions Hardware and software interventions hypothesised influences on MHM and associated consequences are summarised in Figure 1. Effectiveness of menstrual hygiene management interventions 8 Our recent systematic review provided a summary and critical appraisal of the available evidence for the effectiveness of MHM for improving women and girls education, work, and psychosocial wellbeing in low and middle income countries. 8 We conducted structured systematic searches in peer-reviewed and grey literature to identify eligible studies. Individual and cluster-randomised controlled trials, or non-randomised trials which included a control group, were eligible. These inclusion criteria maximised the included studies in light of the limited research available, while excluding case studies or pre-post assessments which are open to many additional biases. Eight eligible trials were identified. Six of these tested the effectiveness of software (education) interventions and three the effectiveness of hardware interventions. Hardware interventions all focused on the provision of menstrual absorbents (menstrual cups, disposable sanitary pads, or reusable sanitary pads). Despite extensive searching no eligible trials were found of other hardware interventions such as improvements to water access in latrines or girl friendly environments, focussed on improving MHM and associated consequences. No trials of programs aimed at mature women were identified; all focused on adolescent girls and young women. Studies were heterogeneous in design and context and had considerable risk of bias. Trials of Global Water Forum 3

4 software interventions were typically of poor quality. Most found positive effects on girls knowledge of menstruation. While knowledge of menstruation is hypothesised to improve girls MHM practices and reduce negative psychosocial consequences such as fear and shame, few studies tested these outcomes. Two studies tested effects on fear and shame; one found improvements for education interventions compared to controls, and one did not. 8 The three trials of hardware interventions tested different types of menstrual absorbents in different settings; Nepal, Kenya and Ghana. For the two studies providing pads, metaanalysis revealed a moderate pooled effect on school attendance, but this was not statistically significant. Both studies were pilots with small numbers. Larger studies are needed to verify these effects. The study of menstrual cup provision in Nepal found no difference in school attendance for those receiving the intervention, however baseline attendance was high leaving little room for improvement. Conclusions MHM Interventions for adolescent girls have attracted investment from a range of funding bodies in the absence of evidence for their effectiveness. Our findings suggest practitioners and policy-makers consider comprehensive evaluations when implementing these programs. We do not yet know if these programs are the most effective use of scarce development funds or have dangerous unintended consequences for those they aim to help. There is a need for more high quality studies of MHM interventions, as well as primary research on MHM. High-quality studies providing data on management practices will be essential for understanding how widespread poor MHM is, attracting attention to the problem, and developing interventions that actually work. We should aim to test and implement interventions or policy changes that efficiently use the limited available resources available in low and middle income countries to improve women s lives. What we need is a situation where all women and girls are able to manage their menstruation with comfort and dignity. Global Water Forum 4

5 As we found in our review, there have been few studies on how to achieve this, and none have looked at potential unintended harms. Those working within in areas of water, sanitation and hygiene, and education, should act with increased awareness of the needs of menstruating women and girls. They should also consider comprehensive evaluation of programs implemented in light of the sparse evidence base. References: 1. Sommer, M., & Sahin, M. (2013). Overcoming the Taboo: Advancing the Global Agenda for Menstrual Hygiene Management for Schoolgirls. American Journal of Public Health, 103(9), van Eijk, A. M., Sivakami, M., Thakkar, M. B., Bauman, A., Laserson, K. F., Coates, S., & Phillips-Howard, P. A. (2016). Menstrual hygiene management among adolescent girls in India: a systematic review and meta-analysis. BMJ Open, 6(3). doi: /bmjopen House, S., Cavill, S., Mahon, T. (2012). Menstrual hygiene matters: A resource for improving menstrual hygiene around the world: WaterAid. Available from cation?id=02309d73-8e41-4d04-b2ef-6641f6616a4f 4. Crichton, J., Okal, J., Kabiru, C. W., & Zulu, E. M. (2012). Emotional and Psychosocial Aspects of Menstrual Poverty in Resource-Poor Settings: A Qualitative Study of the Experiences of Adolescent Girls in an Informal Settlement in Nairobi. Health Care for Women International, 34(10), doi: / Sommer, M., Ackatia-Armah, N., Connolly, S., & Smiles, D. (2015). A comparison of the menstruation and education experiences of girls in Tanzania, Ghana, Cambodia and Ethiopia. Compare: A Journal of Comparative and International Education, 45(4), Sumpter, C., & Torondel, B. (2013). A Systematic Review of the Health and Social Global Water Forum 5

6 7. 8. Effects of Menstrual Hygiene Management. PLOS ONE, 8(4), e Das, P., Baker, K. K., Dutta, A., Swain, T., Sahoo, S., Das, B. S., Bilung, B. (2015). Menstrual Hygiene Practices, WASH Access and the Risk of Urogenital Infection in Women from Odisha, India. PLOS ONE, 10(6), e Hennegan, J., & Montgomery, P. (2016). Do Menstrual Hygiene Management Interventions Improve Education and Psychosocial Outcomes for Women and Girls in Low and Middle Income Countries? A Systematic Review. PLOS ONE, 11(2): e doi: /journal.pone Julie Hennegan is a PhD candidate at the Centre for Evidence-Based Intervention at the University of Oxford. Her work focuses on the impact of menstrual management on women and girls health, education, and psychosocial wellbeing. Julie holds an MSc in Evidence-Based Social Intervention from the University of Oxford and a Bachelors of Psychological Science (Hons) from the University of Queensland, Australia. Her doctoral studies are supported by the Department of Social Policy & Intervention Centenary Scholarship, Fellowships Fund of Graduate Women Queensland Freda Bage Fellowship, and a Rotary Global Grant. The views expressed in this article belong to the individual authors and do not represent the views of the Global Water Forum, the UNESCO Chair in Water Economics and Transboundary Water Governance, UNESCO, the Australian National University, or any of the institutions to which the authors are associated. Please see the Global Water Forum terms and conditions here. Global Water Forum 6