The homeless period: a qualitative evidence synthesis

Figures & data

Figure 1. PRISMA flow diagram.

Table 1. Literature review.

Paper	Location	Participant characteristics and data collection methods	Findings
Aparicio et al. 2019)	USA	51 adolescents/young women (14–22 years) experiencing homelessness or at imminent risk of homelessness. Mixed-methods quasi-experimental	Participants shared that the youth drop-in center provided a stable place for people to access menstrual pads.
Boden et al. (2021)	(USA)	32 participants who self-identify as currently or formerly homeless within the past 10 years. 22 homeless adults focus group & survey participants, 10 survey only.	Facilitators and barriers to menstrual hygiene management. Participants had a variety of period product preferences, but their occupational choice was minimized due to limited resources. Discusses unhygienic practices and the health concerns. Stigma and shame prevent seeking or receiving services.
Budhathoki et al. (2018)	Nepal	127 girls and women in the age group of 15–49 years living in temporary shelter. Mixed-method survey and in-depth interviews	Menstrual hygiene was rated as the sixth highest overall need and perceived as an immediate need. Reusable sanitary cloth was used by about 66.7 percent of the respondents before the earthquake and remained a popular method (76.1 percent) post-earthquake. None of the respondents reported receiving menstrual adsorbents as relief materials in the first month following the earthquake.
Ensign (2000)	USA	Clinic-based adolescents living with homelessness, 20 youth (ages 15–23) Interviews and focus groups	They described female-specific health issues of being homeless, such as problems with hygiene, sexual exploitation, survival sex, self-induced abortions through drugs, herbs or physical abuse. They spoke of fertility control practices of young women living on the streets. The women also spoke of the development of self-sufficiency.
Gruer et al. (2021)	USA	15 key informant interviews. 22 interviews with individuals with homeless experience (living on the street and in shelters).	Key themes that emerged included: insufficient and inconsistent access to menstrual products; systemic challenges to providing menstrual products; and creative solutions to promote access to menstrual products.
Haldenby et al.(2007)	Canada	6 female and 7 male youth experiencing homelessness (ages 14–19) Qualitative- semi structured “dialogic” interviews	Their stories revealed that living without a home had a substantial impact on their health and wellness
Myers et al. (2018)	Nepal	Interviews with key informants, and 32 focus groups n = 249 people, 127 men and 122 women, aged 18-49 yrs	Facilitating factors included disaster preparedness; leadership and commitment; resource mobilization; strong national level coordination; existing reproductive and child health services and community outreach programs; and supply chain management. Barriers included inadequate training; weak stakeholder communication; inadequate staffing; under-resourced/fewer facilities in rural areas; limited attention given to local organizations; low availability of clinical management of rape services; and low awareness of gender-based violence services and benefits of timely care.
Sommer et al. (2020)	USA	People experiencing homelessness (n = 22) aged 18+. Key informants (n = 15) In-depth interviews	This paper explores difficulties presented by inadequate access to facilities and stigma. Pressure “to pass,” as someone who was not homeless to access toilets, and as someone who was not menstruating.
Vora (2020)	UK	40 women who were accessing services supporting vulnerable people in precarious housing situations. In-depth interviews	Menstruation is regarded as a negative, emotional, and expensive experience. The participants are conscious of their doubly stigmatized status as homeless and menstruating, and they mobilize strategic rationalities to manage and conceal their menstrual status

Table 2. Coding framework.

Difficulty maintaining menstrual health related to perceptions of maintaining dignity and embarrassment
1. Menstrual health practices/ Difficulty maintaining menstrual health Menstrual health related to feelings of health	Communal shelter bathrooms are unsanitary
	Culturally appropriate menstrual health supplies
	Douching after menstruation
	Feeling healthy involved having a place to shower
	Gender differences in making use of public facilities for bathing
	Managing menstrual health and stained clothing while homeless
	Not being able to keep clean causes vaginal infections (e.g., thrush)
	Public bathrooms as unsanitary and unkept
	Running out of clean underwear
	Struggling to access showers to wash
	Women need free and accessible bathing and laundering services
2. Embarrassment/maintaining dignity	Male shelter staff handing out menstrual products creating embarrassment
	Embarrassment of leaks intensified due to lack of supplies or access to facilities
	Menstruation leading to isolation through fear of embarrassment
	Menstruation compounding the challenge of maintaining dignity while homeless
	Menstruation making it harder to “pass” as not homeless
	Needing to “pass” as someone who is not homeless to access public facilities
	Having to disclose menstruating status to meet basic needs
Challenges in the logistics of managing menstruation while homeless/all of the additional barriers to menstruation as a women living with homelessness
Lack of privacy/safety	Lack of privacy is difficult when menstruating
	Finding a bathroom to change sanitary products is difficult
	Privacy concerns in shelter bathrooms when bathing
	Uncertain access to safe and clean areas to change menstrual products
Menstruation is expensive	Foregoing food to buy sanitary products
	Having to have money to afford period products
	OTC creams for vaginal infections are too expensive
The logistics of menstruation is harder when homeless Break down into: Lack of/limited facilities Limited access to period products	Lack of sanitary disposal options in shelter bathrooms
	Finding sanitary products is difficult
	Lack of toilet paper in communal bathrooms
	Limited availability of public use toilet facilities in city
	Menstruation is difficult to manage when homeless
	Menstruation more frequent creating bathing and laundering
	Nowhere suitable to dispose of used sanitary products
	Public toilet facilities closing during the night
	Sanitary products aren’t something you think about until you don’t have them when you need them
	Shelter closing during daytime removing access to bathrooms
	Irregular menses are bothersome (more likely to have irregular menses based on health difficulties around homelessness) [PHJ1]
Action theme- what is being done to manage this by women including what services do they have access to?
“Making do”	“Making do” with alternative sanitary products
	Finding cheaper and reusable alternatives to sanitary products
	Using cheap herbal methods to treat vagina infections
	Using female towelettes to wash genitals
	Stealing sanitary products as a last resort
	Having to buy things to get urgent access to public facilities Tension around time spent in communal shelter bathroom stalls
	Drop-in center is helpful because they provide menstrual pads and other basic needs

Table

Population	Girls OR wom*n OR “young wom*n” OR mother* OR menstruation wom*n OR “wom*n of a reproductive age”
AND
Context	Homeless* OR “rough sleep*” OR “street living” OR “homeless person*” OR shelter OR Hostel
AND
Outcome	Mens* OR period* OR “reproductive health” OR “sexual health”OR “mens* health” OR hygiene

Aparicio, E. M., O. N. Kachingwe, D. R. Phillips, J. Fleishman, J. Novick, T. Okimoto, M. K. Cabral, et al. 2019. “Holistic, Trauma-Informed Adolescent Pregnancy Prevention and Sexual Health Promotion for Female Youth Experiencing Homelessness: Initial Outcomes of Wahine Talk.” Children and Youth Services Review 107:104509. https://doi.org/10.1016/j.childyouth.2019.104509.

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Boden, L., A. Wolski, A. S. Rubin, L. Pfaltzgraff Oliveira, and Q. P. Tyminski. 2021. “Exploring the Barriers and Facilitators to Menstrual Hygiene Management for Women Experiencing Homelessness.” Journal of Occupational Science 30 (2): 235–50. https://doi.org/10.1080/14427591.2021.1944897.

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Budhathoki, S. S., M. Bhattachan, E. Castro-Sánchez, R. Agrawal Sagtani, R. Bikram Rayamajhi, P. Rai, and G. Sharma. 2018. “Menstrual Hygiene Management Among Women and Adolescent Girls in the Aftermath of the Earthquake in Nepal.” BMC Women’s Health 18 (1). https://doi.org/10.1186/s12905-018-0527-y.

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Ensign, J. 2000. “Reproductive Health of Homeless Adolescent Women in Seattle, Washington, USA.” Women & Health 31 (2–3): 133–51. https://doi.org/10.1300/j013v31n02_07.

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Gruer, C., K. Hopper, R. Clark Smith, E. Kelly, A. Maroko, and M. Sommer. 2021. “Seeking Menstrual Products: A Qualitative Exploration of the Unmet Menstrual Needs of Individuals Experiencing Homelessness in New York City.” Reproductive Health 18 (1): 1. https://doi.org/10.1186/s12978-021-01133-8.

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Haldenby, A. M., H. Berman, and C. Forchuk. 2007. “Homelessness and Health in Adolescents.” Qualitative Health Research 17 (9): 1232–44. doi:10.1177/1049732307307550.

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Myers, A., S. Sami, M. Adhiambo Onyango, H. Karki, R. Anggraini, and S. Krause. 2018. “Facilitators and Barriers in Implementing the Minimum Initial Services Package (MISP) for Reproductive Health in Nepal Post-Earthquake.” Conflict and Health 12 (1): 1. https://doi.org/10.1186/s13031-018-0170-0.

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Sommer, M., C. Gruer, R. Clark Smith, A. Maroko, and K. Hopper. 2020. “Menstruation and Homelessness: Challenges Faced Living in Shelters and on the Street in New York City.” Health & Place 66:102431. https://doi.org/10.1016/j.healthplace.2020.102431.

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Vora, S. 2020. “The Realities of Period Poverty: How Homelessness Shapes Women’s Lived Experiences of Menstruation.” The Palgrave Handbook of Critical Menstruation Studies 31–47. https://doi.org/10.1007/978-981-15-0614-7_4.

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