How do women and girls experience menstrual health interventions in low- and middle-income countries? Insights from a systematic review and qualitative metasynthesis

Figures & data

Figure 1. Review flow diagram showing the number of titles, abstracts and full text citations assessed for eligibility and reasons for exclusion.

Table 1. Included study and intervention characteristics and overall trustworthiness rating.

Study ID	Data collection	Country	Sample, N* (method)	Participants (age)	Analysis method	Intervention/product	Time from intervention to data collection	Study research question	Trustworthiness
Averbach et al. (2009)	Oct 2007–Mar 2008	Zimbabwe	43 (4 FGDs)	Sexually active women living in Harare (18–45)	Thematic	Type: Duet menstrual cup A Duet menstrual cup was presented during FGDs.	Immediate	Explore current menstrual practices and the acceptability of the Duet menstrual cup (pg. 464).	Medium
Blake et al. (2018)	Not stated	Ethiopia	75 (open ended written questions)	Girls in rural study schools (10–19)	Thematic	Type: Puberty book The Ethiopia Growth and Changes puberty book was developed for the context and included information on adolescent girls’ puberty development, reproduction and menstrual hygiene.	4 weeks	Assess the impact of the Ethiopia Growth and Changes puberty book as it influences girls’ MHM (pg. 5).	Medium
Chikulo (2015)	Not stated	South Africa	150 (10 FGDs)	Girls in rural government high schools (15–22)	NR	Type: Menstrual cup and education The Teenage Transnet Health Programme (TTHP) was provided in schools and included puberty education, sensitisation of girls to MHM and the promotion of awareness around menstruation to girls and communities.	NR	Assess knowledge, practices, beliefs related to MHM, and use of the menstrual cup among schoolgirls (pg. 1975).	Low
Garikipati and Boudot (2017)	NR	India	150 (IDI)	Women of menstrual age residing in slums (15–49)	NR	Type: Sanitary pads Program engaged small groups of women in door-to-door sales of household products, including sanitary pads, in their community.	NR	Understand current menstrual practices and constraints to adoption of sanitary pads among women slum dwellers (pg. 34).	Low
Hennegan et al. (2017)	Oct 2014	Uganda	27 (IDI)	Girls in rural primary schools (12–17)	Framework	Type: AFRIpad kits and puberty education. Qualitative follow-up to a controlled trial of puberty education and reusable pad provision. Girls were given a pack of reusable cloth pads, underwear, and a small amount of soap. Education covered puberty changes, menstruation and early pregnancy.	24 months	Describe and compare [schoolgirls’] experiences of menstruation at the conclusion of a controlled trial of puberty education and sanitary pad provision (pg. 2).	High
Hyttel et al. (2017)	Jul–Oct 2013	Uganda	36 (12 IDIs; 4 FGDs)	Girls in rural primary schools (13–17)	Thematic	Type: Ruby Cup menstrual cup Qualitative follow-up to a school-based trial that distributed menstrual cups and an information session compared with controls. Prior to cup distribution, girls received training on puberty, the menstrual cycle, reproduction, and hygiene.	3 months	Explore drivers and challenges of acceptability of the menstrual cup following a controlled trial of menstrual cup provision (pg. 110).	High
Mason et al. (2015)	NR	Kenya	101 (10 FGDs)	Girls in rural primary schools (14–16)	Thematic	Type: Mooncup menstrual cup and Always sanitary pads Qualitative follow-up to a cluster randomised trial with three arms: menstrual cups (MoonCup and training by study nurse), sanitary pads (two packs per month), or control. All schoolgirls received education on puberty and hygiene.	6 months	Report on girls’ early experiences using a menstrual cup or commercial sanitary pads versus use of traditional items (pg.16).	High
Rajagopal and Mathur (2017)	Apr–Jun 2016	India	270 (FGDs)	Girls in slums and government schools (10–20)	NR	Type: Sanitary pads Study was conducted with women across 12 slums, and schoolgirls in 5 government schools where the UDAAN scheme (a free sanitary pad distribution scheme launched by the Government of Rajasthan in 2015) was present and pads had been distributed. Girls from government schools and slum areas were provided with a three-month supply of sanitary pads.	2 months	Assess the impact of the government’s UDAAN scheme, and explore the experiences and challenges faced by adolescent girls in managing menstruation at school and at home (pg. 307-8).	Low
Rane (2014)	NR	India	23 (IDIs)	Married, sexually active, office-going women (24–40)	NR	Type: Tampons Market research conducted to assess women’s awareness and acceptance of tampons as a ‘new age’ menstrual product in India.	Immediate	Determine the viability of marketing tampons in urban India with a focus on barriers and facilitators of tampon use (pg. 13).	Low
Shah et al. (2013)	Jan–Jul 2011	India	26 (6 IDIs; 2 FGDs)	Adolescent girls (school-going and non-school-going) in rural project villages (12–22)	NR	Type: Cloth and sanitary pads Falalin cloths (locally constructed cloth pads) were offered first to all girls at a subsidised price. Subsequently, packs of eight sanitary pads called Raasi Napkins were offered to all girls at subsidised prices.	3 months	Describe menstrual health and hygiene practices among adolescent girls, and their experiences using old cloths, a reusable cloth pad and sanitary pads (pg. 206).	Medium
Stopford (2011)	NR	Kenya	42 (6 FGDs)	Girls in primary schools (11–18)	Thematic	Type: Sanitary pads Distributed reusable sanitary pads and hygiene kits to girls in Class 8 followed by distribution of sanitary pads homemade in the U.S. across multiple schools. Study focuses analysis on commercial pads, defined as ‘mass produced and available for purchase in a shop’.	NR	Evaluate the association of commercial sanitary pads with school attendance and symptoms of vaginal infections (pg. 11).	Low
WoMena (2017)	Jan–Jul 2017	Uganda	12 (15 IDIs; 5 FGDs)	Primary schoolgirls and mothers in refugee settlement (mean girls 16, mean mother: 29.5)	Content	Type: Ruby Cup menstrual cup and AFRIpad kits School girls and mothers/guardians were divided into four conditions and received: both menstrual cups and reusable pads; the choice of either a menstrual cup or reusable pads; only a menstrual cup; or only menstrual pads. All participants received training on menstruation and hygiene.	4 months	Assess the acceptability and feasibility and potential health and social impact of introducing menstrual cups and reusable pads as MHM methods to girls and women in a refugee settlement context in Uganda (pg. 12).	Low

* Note: The number of FGDs and IDIs reported here represent only the primary population of interest and do not include key informant interviews or quantitative data collection. FGDs, focus group discussions; IDIs, in-depth interviews; MHM, menstrual hygiene management; NR, not reported.

Figure 2. Visual representation of themes and subthemes.

Averbach, S., N. Sahin-Hodoglugil, P. Musara, T. Chipato, and A. van der Straten. 2009. “Duet for Menstrual Protection: A Feasibility Study in Zimbabwe.” Contraception 79 (6): 463–468. doi:10.1016/j.contraception.2008.12.002

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Blake, S., M. Boone, A. Yenew Kassa, and M. Sommer. 2018. “Teaching Girls about Puberty and Menstrual Hygiene Management in Rural Ethiopia.” Journal of Adolescent Research 33 (5): 623–646. doi:10.1177/0743558417701246

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Chikulo, B. C. 2015. “An Exploratory Study into Menstrual Hygiene Management Amongst Rural High School for Girls in the North West Province, South Africa. (Special Issue: Sexual and Reproductive Health Challenges in Sub-Saharan Africa.).” African Population Studies 29 (2): 1971–1987. doi:10.11564/29-2-777

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Garikipati, S., and C. Boudot. 2017. “To Pad or Not to Pad: Towards Better Sanitary Care for Women in Indian Slums.” Journal of International Development 29 (1): 32–51. doi:10.1002/jid.3266

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Hennegan, J., C. Dolan, L. Steinfield, and P. Montgomery. 2017. “A Qualitative Understanding of the Effects of Reusable Sanitary Pads and Puberty Education: Implications for Future Research and Practice.” Reproductive Health 14 (1): 78. doi:10.1186/s12978-017-0339-9

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Hyttel, M., C. F. Thomsen, B. Luff, H. Storrusten, V. N. Nyakato, and M. Tellier. 2017. “Drivers and Challenges to Use of Menstrual Cups among Schoolgirls in Rural Uganda: A Qualitative Study.” Waterlines 36 (2): 109–124. doi:10.3362/1756-3488.16-00013

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Mason, L., K. Laserson, K. Oruko, E. Nyothach, K. Alexander, F. Odhiambo, A. Eleveld, et al. 2015. “Adolescent Schoolgirls’ Experiences of Menstrual Cups and Pads in Rural Western Kenya: A Qualitative Study.” Waterlines 34 (1): 15–30. doi:10.3362/1756-3488.2015.003

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Rajagopal, S., and K. Mathur. 2017. “Breaking the Silence around Menstruation’: Experiences of Adolescent Girls in an Urban Setting in India.” Gender & Development 25 (2): 303–317. doi:10.1080/13552074.2017.1335451

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Rane, R. 2014. “Marketing Tampons in Urban India: A Study of Barriers and Triggers to Purchase.” Degree of PGDM, Mudra Institute of Communications, Ahmedabad. Ann Arbor: ProQuest Dissertations Publishing.

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Shah, S. P., R. Nair, P. P. Shah, D. K. Modi, S. A. Desai, and L. Desai. 2013. “Improving Quality of Life with New Menstrual Hygiene Practices among Adolescent Tribal Girls in Rural Gujarat, India.” Reproductive Health Matters 21 (41): 205–213. doi:10.1016/S0968-8080(13)41691-9

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Stopford, A. L. 2011. “The Effect of Commercial Sanitary Pad Use on School Attendance and Health of Adolescents in Western Kenya.” Master’s Thesis, Duke University. https://hdl.handle.net/10161/5062

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WoMena. 2017. “Pilot Intervention Report: Menstrual Health in Rhino Camp Refugee Settlement West Nile, Uganda.” Uganda: WoMena. http://womena.dk/wp-content/uploads/2017/12/WoMena-ZOA-Rhino-Camp-Refugee-Settlement-MHM-Pilot-Intervention-Report.pdf

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