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Cited by 577Menstrual Health and DisordersHypothalamic control of reproductive hormonesAdolescent Sexual and Reproductive Health

Women’s and girls’ experiences of menstruation in low- and middle-income countries: A systematic review and qualitative metasynthesis

Open access
Hennegan, Julie, Shannon, Alexandra K., Rubli, Jennifer, Schwab, Kellogg J., Melendez-Torres, G. J.·2019·PLOS Medicine
DOI 10.1371/journal.pmed.1002803PMC PMC6521998
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Abstract

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.

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review and qualitative metasynthesis of 76 studies from 35 low- and middle-income countries found consistent menstrual stigma, resource limitations, knowledge and support gaps, and negative impacts on health, education, and social participation. It presents an integrated directional model linking sociocultural context and resource limitations to menstrual experience and downstream impacts.

Key findings

  • Of 6,892 citations screened, 76 studies reported in 87 citations were included, capturing over 6,000 participants across 35 countries; most studies were from sub-Saharan Africa (n = 45), followed by South Asia (n = 21), East Asia and the Pacific (n = 8), Latin America and the Caribbean (n = 5), Middle East and North Africa (n = 5), and Europe and Central Asia (n = 1).
  • Study quality was varied: 18 studies were rated high, 35 medium, and 23 low trustworthiness; lower-quality studies were characterised by poor reporting of participant selection and analysis.
  • Synthesis identified antecedents (sociocultural context including menstrual stigma and gender norms; knowledge; social support; behavioural expectations; resource limitations including physical and economic environments), experience components (menstrual practices, perceptions of practices and environments, confidence, shame and distress, containment, and individual menstrual factors), and impacts (physical and psychological health, education/employment, and social participation).
  • The integrated model maps distal and proximal antecedents through menstrual experience to impacts; no single included study reflected the full picture gained through metasynthesis.

Methods

  • Systematic review and qualitative metasynthesis reported according to PRISMA, with protocol registered on PROSPERO (CRD42018089581); searches were undertaken in 11 databases plus grey literature and hand searching, completed in January 2019 with no language or date restrictions.
  • Eligible studies reported qualitative analysis of menstrual experiences of women and girls residing in LMICs; studies exclusively on menstrual suppression, menopause, premenstrual syndrome, polycystic ovary syndrome, premenarche, key informants, or males were excluded, as were studies of menstrual interventions or products retained for analyses reported elsewhere.
  • Analysis used thematic synthesis and thematic networks; quality was appraised with the EPPI-Centre checklist, with one author appraising all studies and 10% independently appraised by a second author with 100% agreement; low-quality studies were checked for fit with the proposed themes and integrated model.

Limitations

  • The paper states that findings are limited by available studies; the majority came from sub-Saharan Africa, no studies were identified from China, Middle East and North African studies were more often urban and highly educated, searching was only undertaken in English, mixed-methods studies may have scored lower on the qualitative appraisal tool, and a different team may have generated different insights.
  • The paper states that adolescent girls were most strongly represented and early saturation was achieved for this group, while adult women and certain geographical areas were under-researched; pain and menstrual disorders were poorly integrated and did not reach saturation.
  • Evident from the text: most studies relied on focus group discussions, often capturing shared school-environment experiences rather than deep individual sociological or psychological insights, and adult women’s workplace experiences were under-researched.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1371/journal.pmed.1002803

Cites

89 of 89 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 193 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Through synthesis, the review identified overarching themes and their relationships to develop a directional model of menstrual experience.

    “Through synthesis, we identified overarching themes and their relationships to develop a directional model of menstrual experience.”
    Quote in the paperSubstantial claim
  • Findingown data

    Included studies captured the experiences of over 6,000 participants from 35 countries.

    “Studies captured the experiences of over 6,000 participants from 35 countries.”
    • Also stated in: § Results · plain
      “Included studies captured experiences from 35 countries and over 6,000 participants.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Included studies were distributed by region: 45 in sub-Saharan Africa, 21 in South Asia, 8 in East Asia and the Pacific, 5 in Latin America and the Caribbean, 5 in Middle East and North Africa, and 1 in Europe and Central Asia.

    “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.”
    • Also stated in: § Results · plain
      “Using World Bank regional groupings [24], most studies were conducted in sub-Saharan Africa (n = 45); this was followed by 21 studies undertaken in South Asia, 8 in East Asia and the Pacific, 5 in Latin America and the Caribbean, 5 in the Middle East and North Africa, and 1 study from Europe and Central Asia (Kyrgyzstan).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [24] 2017, World Bank Country and Lending Groups

      Not checked in the free run.

  • Findingreasoning

    Negative attitudes to menstruation manifested as shame and distress at the potential of having menses exposed.

    “and shame and distress at the potential of having menses exposed”
    Quote in the paperSubstantial claim
  • Findingreasoning

    Some studies did not address the impacts of menstruation on outcomes, exploring only the experience itself.

    “Others did not address the impacts of menstruation on such outcomes, exploring only the experience itself.”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 47
  • May combine two claims. 75
  • The quote only partly states this claim. 1

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Of 6,892 citations screened, 76 studies reported in 87 citations were included.

    “Of 6,892 citations screened, 76 studies reported in 87 citations were included.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Menstrual experience included multiple themes: menstrual practices, perceptions of practices and environments, confidence, shame and distress, and containment of bleeding and odour.

    “Menstrual experience included multiple themes: menstrual practices, perceptions of practices and environments, confidence, shame and distress, and containment of bleeding and odour.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Studies focused on the experiences of adolescent girls were most strongly represented, and early saturation was achieved for this group.

    “Studies focused on the experiences of adolescent girls were most strongly represented, and we achieved early saturation for this group.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Findings of low-quality studies were assessed for fit with the proposed themes and integrated model; low-quality studies supported the primary analysis, and no new constructs emerged.

    “Findings of low-quality studies were assessed for their fit with the proposed themes and integrated model. Low-quality studies supported the primary analysis, and no new constructs emerged.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingreasoning

    Menstrual stigma made it difficult to access accurate information or seek support.

    “making it difficult to access accurate information or seek support”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Eleven studies reported using participatory activities such as asking groups to design an 'ideal latrine' or rank priorities for improvements.

    “Eleven studies reported using participatory activities such as asking groups to design an ‘ideal latrine’, or rank priorities for improvements to explore experiences and preferences.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Knowledge and cultural practices were important in resource-centric studies but were more often linked with a failure to support effective management practices.

    “Knowledge and cultural practices were important in resource-centric studies but were more often linked with a failure to support effective management practices.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Differences in author orientations across the body of literature were apparent.

    “In identifying themes and mapping the relationships between themes as part of our analysis, differences in author orientations across the body of literature were apparent.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Most studies were situated within a public health discipline and focused on cataloguing antecedents and impacts of menstruation on participants' lives, rather than sociological analysis.

    “Most studies were situated within a public health discipline and focused on cataloguing antecedents and impacts of menstruation on participants’ lives, rather than sociological analysis.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    There was an absence of studies focused on adult women and those from certain geographical areas.

    “Reflecting the focus of menstrual health research globally, there was an absence of studies focused on adult women and those from certain geographical areas.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Studies varied in their coverage of included themes, with none reflecting the full picture gained through metasynthesis.

    “Studies varied in their coverage of included themes, with none reflecting the full picture gained through metasynthesis.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning

    These studies viewed the resources available to women and girls as inadequate to meet their basic biological needs.

    “These studies viewed the resources available to women and girls as inadequate to meet their basic biological needs.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    A total of 55 studies included adolescent girls (school aged), with only 21 studies including exclusively university students or adult women.

    “A total of 55 studies included adolescent girls (school aged), with only 21 studies including exclusively university students or adult women.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Stigma-centric models of menstruation rarely elaborated on physical health consequences; rather, they detailed psychological and educational concerns and consequences for empowerment.

    “Stigma-centric models of menstruation rarely elaborated on physical health consequences; rather, they detailed psychological and educational concerns and consequences for empowerment.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Most studies reported undertaking a thematic approach to analysis.

    “Most studies reported undertaking a thematic approach to analysis.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    India was the country with the highest number of studies (n = 12), followed by Kenya (n = 7) and Uganda (n = 6).

    “India was the country with the highest number of studies (n = 12), followed by Kenya (n = 7) and Uganda (n = 6).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    These studies frequently noted concerns around infection and consequences for school attendance.

    “which frequently noted concerns around infection and consequences for school attendance”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Lower-quality studies were characterised by poor reporting of participant selection and analysis, with many having no defined or described analytic approach.

    “Lower-quality studies were characterised by poor reporting of participant selection and analysis, with many having no defined or described analytic approach.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingreasoning

    Expectations of female propriety and the roles of women and girls over the life course as daughters, wives, and mothers restricted resource access and proscribed care-giving tasks and movement outside the home.

    “Expectations of female propriety and the roles of women and girls over the life course as daughters, wives, and mothers restricted resource access and proscribed care-giving tasks and movement outside the home”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Multiple domains of knowledge were discussed across studies, including the basic biology of menstruation, reproduction and the links between menstruation and pregnancy, practical management of menses and pain, and interpreting the accuracy of local taboos around menstruation.

    “Multiple domains of knowledge were discussed across studies, including the basic biology of menstruation, reproduction and the links between menstruation and pregnancy, practical management of menses and pain, and interpreting the accuracy of local taboos around menstruation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Near universally across studies, women and girls recalled experiences of intense distress and confusion if they were unaware of menstruation at menarche, with many participants reporting they thought they were sick or dying.

    “Near universally across studies, women and girls recalled experiences of intense distress and confusion if they were unaware of menstruation at menarche, with many participants reporting they thought they were sick or dying.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    In some studies, girls' post menarche and older women linked menstruation with reproduction but had other lingering questions such as why menstrual bleeding occurred.

    “In others, girls’ post menarche and older women linked menstruation with reproduction but had other lingering questions such as why menstrual bleeding occurred”
    Quote in the paperNot a substantial claim0 of 5 sources checked
    • cites [11] L Mason, 2013, '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 source

      Not checked in the free run.

    • cites [15] A Parker, 2014, Menstrual management: a neglected aspect of hygiene interventions, Disaster Prevention and Management: An International Journal source

      Not checked in the free run.

    • cites [44] J Chinyama, 2019, Menstrual hygiene management in rural schools of Zambia: a descriptive study of knowledge, experiences and challenges faced by schoolgirls, BMC Public Health source

      Not checked in the free run.

    • cites [72] J Morrison, 2016, Menstrual hygiene management in Udaypur and Sindhuli districts of Nepal

      Not checked in the free run.

    • cites [73] Z Mumtaz, 2016, Formative Menstrual Hygiene Management Research: Adolescent Girls in Baluchistan

      Not checked in the free run.

  • May combine two claims.

    Findingreasoning

    Such beliefs translated into restrictions on women's behaviour, including not interacting or sitting with males; touching or cooking food; having contact with crops, livestock, or farming; or having sex.

    “Such beliefs translated into restrictions on women’s behaviour, including not interacting or sitting with males; touching or cooking food; having contact with crops, livestock, or farming; or having sex.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    In some settings such as Ghana, Malawi, South Africa, and Tanzania, mothers were sometimes considered culturally inappropriate, and other female relatives such as aunts or grandmothers were expected to serve in this role.

    “whereas in others such as Ghana [4], Malawi [79], South Africa [84], and Tanzania [3], they were sometimes considered culturally inappropriate, and other female relatives such as aunts or grandmothers were expected to serve in this role”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [4] CS Dolan, 2014, A Blind Spot in Girls’ Education: Menarche and Its Webs of Exclusion in Ghana, Journal of International Development source

      Not checked in the free run.

    • cites [79] SP Pillitteri, 2011, School menstrual hygiene management in Malawi: More than toilets

      Not checked in the free run.

    • cites [84] F Scorgie, 2016, "Bitten By Shyness": Menstrual Hygiene Management, Sanitation, and the Quest for Privacy in South Africa, Med Anthropol source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Healthcare providers such as nurses or community health workers were mentioned in only a few studies, and always as unsupportive.

    “Healthcare providers such as nurses or community health workers were mentioned in only a few studies, and always as unsupportive”
    Quote in the paperNot a substantial claim0 of 6 sources checked
    • cites [3] M Sommer, 2009, Ideologies of sexuality, menstruation and risk: girls’ experiences of puberty and schooling in northern Tanzania, Cult Health Sex source

      Not checked in the free run.

    • cites [84] F Scorgie, 2016, "Bitten By Shyness": Menstrual Hygiene Management, Sanitation, and the Quest for Privacy in South Africa, Med Anthropol source

      Not checked in the free run.

    • cites [87] M Sommer, 2013, Structural factors influencing menstruating school girls’ health and well-being in Tanzania, Compare: A Journal of Comparative and International Education source

      Not checked in the free run.

    • cites [101] 2009, A comparative study of four schools in different settings in Nepal

      Not checked in the free run.

    • cites [103] L Aziato, 2015, Dysmenorrhea Management and Coping among Students in Ghana: A Qualitative Exploration, J Pediatr Adolesc Gynecol source

      Not checked in the free run.

    • cites [109] LP Wong, 2011, Premenstrual syndrome and dysmenorrhea: urban-rural and multiethnic differences in perception, impacts, and treatment seeking, J Pediatr Adolesc Gynecol source

      Not checked in the free run.

  • May combine two claims.

    Findingreasoning

    Adolescent girls reported distress at these changes to expected behaviour and fears that they would cause harm to themselves or others.

    “Adolescent girls reported distress at these changes to expected behaviour and fears that they would cause harm to themselves or others.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Women and girls took steps to ensure that others could not see or access their disposed menstrual blood such as washing materials prior to disposal, eschewing single-use disposable sanitary pads, or wrapping used absorbents to prevent detection.

    “Women and girls took steps to ensure that others could not see or access their disposed menstrual blood such as washing materials prior to disposal, eschewing single-use disposable sanitary pads, or wrapping used absorbents to prevent detection.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    Externally enforced behavioural expectations included explicit cultural or religious expectations of menstruating women as well as more implicit ideals of propriety and cleanliness placed on menstruating bodies.

    “Externally enforced behavioural expectations included explicit cultural or religious expectations of menstruating women as well as more implicit ideals of propriety and cleanliness placed on menstruating bodies.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given

    Girls often felt more comfortable with female teachers than male teachers, who were viewed as less understanding and presented threats of sexual advances.

    “Girls often felt more comfortable with female teachers than male teachers, who were viewed as less understanding and presented threats of sexual advances.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Deficits in knowledge created confusion around the accuracy of cultural restrictions and taboos, creating distress and impacting confidence.

    “Deficits in knowledge created confusion around the accuracy of cultural restrictions and taboos, creating distress and impacting confidence.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    Partners' perceptions of menses contributed to women's self-conceptualisation, resource availability, and the impact of menses on daily activities.

    “Partners’ perceptions of menses contributed to women’s self-conceptualisation, resource availability, and the impact of menses on daily activities.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Adolescent girls reported great distress at males being aware of their menstrual status and bullying behaviours such as males teasing them if their status was revealed.

    “They reported great distress at males being aware of their menstrual status and bullying behaviours such as males teasing them if their status was revealed.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    Friends and peers were critical: in school settings, they checked for stains, accompanied others to changing facilities, or provided emergency supplies.

    “Friends and peers were critical: in school settings, they checked for stains, accompanied others to changing facilities, or provided emergency supplies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    In many religions, women and girls were banned from touching religious texts, praying, or entering places of worship during menstruation.

    “In many religions, women and girls were banned from touching religious texts, praying, or entering places of worship during menstruation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    Hot or cold foods were feared to influence blood flow or clotting, and foods of various colour or flavour groups were feared to exacerbate menstrual pain, smell, acne, or cause illness.

    “Hot or cold foods were feared to influence blood flow or clotting, and foods of various colour or flavour groups were feared to exacerbate menstrual pain, smell, acne, or cause illness.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    Menstrual symptoms and the presence of abnormalities or disorders moderated individuals' experiences, exacerbating shame and reducing confidence if participants felt that their experience was abnormal and making it more difficult to conceal menses.

    “Menstrual symptoms and the presence of abnormalities or disorders moderated individuals’ experiences, exacerbating shame and reducing confidence if participants felt that their experience was abnormal and making it more difficult to conceal menses.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Two studies from Kenya and one in Ghana noted concerns that girls engaged in transactional sex to meet menstrual and other personal funding needs; authors of a study in Ethiopia noted that this was not reported in their population.

    “Two studies from Kenya and one in Ghana noted concerns that girls engaged in transactional sex to meet menstrual and other personal funding needs [4, 11, 64]; authors of a study in Ethiopia noted that this was not reported in their population [100].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [4] CS Dolan, 2014, A Blind Spot in Girls’ Education: Menarche and Its Webs of Exclusion in Ghana, Journal of International Development source

      Not checked in the free run.

    • cites [11] L Mason, 2013, '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 source

      Not checked in the free run.

    • cites [64] S Jewitt, 2014, It’s a girl thing: Menstruation, school attendance, spatial mobility and wider gender inequalities in Kenya, Geoforum source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    For women and girls, the priority was perceived privacy, with concerns that materials would attract pests.

    “For women and girls, the priority was perceived privacy, with concerns that materials would attract pests.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Women and girls internalised menstrual restrictions and stigma and sought to regulate their behaviour accordingly.

    “Women and girls internalised menstrual restrictions and stigma and sought to regulate their behaviour accordingly.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingreasoning

    An absence of sanitation facilities or safe spaces outside the home meant managing menstruation in these locations was more challenging, reducing confidence to travel outside the home and increasing distress and fear of shame.

    “An absence of sanitation facilities or safe spaces outside the home meant managing menstruation in these locations was more challenging, reducing confidence to travel outside the home and increasing distress and fear of shame.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Containment was fundamental to participants across populations and included leakage, keeping materials in place, and minimising detectable odour.

    “Containment was fundamental to participants across populations and included leakage, keeping materials in place, and minimising detectable odour.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given

    Pain directly restricted school, work, and social participation.

    “Pain directly restricted school, work, and social participation.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given

    In schools, gender-separate latrines and locks on doors were frequently discussed as compromising privacy, as was a lack of water to wash hands and remove evidence of menstrual blood from latrines.

    “In schools, gender-separate latrines and locks on doors were frequently discussed as compromising privacy, as was a lack of water to wash hands and remove evidence of menstrual blood from latrines.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    This impacted confidence to engage in other activities during menstruation and added to experiences of shame because a failure to hide menses was viewed as a personal failure to maintain feminine standards or menstrual etiquette.

    “This impacted confidence to engage in other activities during menstruation and added to experiences of shame because a failure to hide menses was viewed as a personal failure to maintain feminine standards or menstrual etiquette.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    Few women accessed healthcare, and the economic environment restricted access to pharmaceutical pain relief.

    “Few women accessed healthcare, and the economic environment restricted access to pharmaceutical pain relief.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Many women and girls struggled to afford their choice of material, some studies noting that the household frequently lacked money for basic necessities and that commercial sanitary pads were considered an unaffordable luxury.

    “Many women and girls struggled to afford their choice of material, some studies noting that the household frequently lacked money for basic necessities and that commercial sanitary pads were considered an unaffordable luxury [5, 10, 15, 41, 43, 51, 64, 68].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [5] SA McMahon, 2011, 'The girl with her period is the one to hang her head’ Reflections on menstrual management among schoolgirls in rural Kenya, BMC International Health And Human Rights source

      Not checked in the free run.

    • cites [10] J Crichton, 2013, 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 Women Int source

      Not checked in the free run.

    • cites [15] A Parker, 2014, Menstrual management: a neglected aspect of hygiene interventions, Disaster Prevention and Management: An International Journal source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Lack of funds to purchase menstrual items or pain relief, and lack of affordable cloth or commercial menstrual products, was a frequent study finding.

    “Lack of funds to purchase menstrual items or pain relief, and lack of affordable cloth or commercial menstrual products, was a frequent study finding.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    In some studies, authors noted that teachers and NGOs provided menstrual materials, but that this was unreliable.

    “In some studies, authors noted that teachers and NGOs provided menstrual materials, but that this was unreliable [44, 58].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [44] J Chinyama, 2019, Menstrual hygiene management in rural schools of Zambia: a descriptive study of knowledge, experiences and challenges faced by schoolgirls, BMC Public Health source

      Not checked in the free run.

    • cites [58] C Girod, 2017, Physical, Social, and Political Inequities Constraining Girls’ Menstrual Management at Schools in Informal Settlements of Nairobi, Kenya, J Urban Health source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Authors noted the erosion of self-esteem due to menstrual experiences, the contribution of stress during menstruation to anxiety, and depression linked to reduced social participation or experiences of stigma.

    “Authors noted the erosion of self-esteem due to menstrual experiences, the contribution of stress during menstruation to anxiety, and depression linked to reduced social participation or experiences of stigma.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Included studies represented a broad range of contexts, although the majority attended to the experiences of school-aged girls.

    “Included studies represented a broad range of contexts, although the majority attended to the experiences of school-aged girls.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Women and girls reported altering movement and participation outside the household during menses, as well as restricting activities such as running or playing sports.

    “Women and girls reported altering movement and participation outside the household during menses, as well as restricting activities such as running or playing sports [9, 14, 15, 35, 36, 38, 41, 43, 44, 47, 51, 59, 62–64, 70, 74, 77, 85, 97, 98, 100, 103–105, 107, 109].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [9] J Long, 2013, WASH in Schools Empowers Girls’ Education in Rural Cochabamba, Bolivia: An Assessment of menstrual hygiene management in schools

      Not checked in the free run.

    • cites [14] S Garg, 2001, Socio-cultural aspects of menstruation in an urban slum in Delhi, India, Reproductive Health Matters source

      Not checked in the free run.

    • cites [15] A Parker, 2014, Menstrual management: a neglected aspect of hygiene interventions, Disaster Prevention and Management: An International Journal source

      Not checked in the free run.

  • May combine two claims.

    Findingnone given

    The experience of pain and menstrual disorders was poorly integrated in included studies and did not reach saturation.

    “The experience of pain and menstrual disorders was poorly integrated in included studies and did not reach saturation.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Authors identified health impacts resulting from adherence to taboos such as dietary restrictions on the consumption of common foods, linked to fatigue, or withholding urination for fear of others observing menstrual blood in latrines.

    “Authors identified health impacts resulting from adherence to taboos such as dietary restrictions on the consumption of common foods, linked to fatigue, or withholding urination for fear of others observing menstrual blood in latrines [16, 41, 56, 57].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [16] BA Caruso, 2017, Understanding and defining sanitation insecurity: women’s gendered experiences of urination, defecation and menstruation in rural Odisha, India, BMJ Glob Health source

      Not checked in the free run.

    • cites [41] BA Caruso, 2013, WASH in Schools Empowers Girls’ Education in Freetown, Sierra Leone: An assessment of menstrual hygiene management in schools

      Not checked in the free run.

    • cites [56] A Ellis, 2016, WASH challenges to girls’ menstrual hygiene management in Metro Manila, Masbate, and South Central Mindanao, Philippines, Waterlines source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Despite different settings and populations, the narratives and lived experiences that emerged reflected consistent themes, with manifestations that differed by context.

    “Despite different settings and populations, the narratives and lived experiences that emerged reflected consistent themes, with manifestations that differed by context.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    In many schools, girls reported that they had no adequate location to change absorbents, feared others seeing menstrual blood in latrines, or lacked facilities to dispose or clean absorbents.

    “In many schools, girls reported that they had no adequate location to change absorbents, feared others seeing menstrual blood in latrines, or lacked facilities to dispose or clean absorbents [4, 5, 9, 10, 15, 41, 51, 56–58, 64, 70, 72, 74, 79, 87, 88].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [4] CS Dolan, 2014, A Blind Spot in Girls’ Education: Menarche and Its Webs of Exclusion in Ghana, Journal of International Development source

      Not checked in the free run.

    • cites [5] SA McMahon, 2011, 'The girl with her period is the one to hang her head’ Reflections on menstrual management among schoolgirls in rural Kenya, BMC International Health And Human Rights source

      Not checked in the free run.

    • cites [9] J Long, 2013, WASH in Schools Empowers Girls’ Education in Rural Cochabamba, Bolivia: An Assessment of menstrual hygiene management in schools

      Not checked in the free run.

  • May combine two claims.

    Findingreasoning

    This meant travelling home to change menstrual materials, often resulting in part-day absences.

    “This meant travelling home to change menstrual materials, often resulting in part-day absences.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingnone given

    This review included a large volume of studies.

    “This review included a large volume of studies.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Social support, the physical environment, cultural restrictions, and the perception of menses as dirty and needing to be concealed were all highly salient in included studies.

    “Social support, the physical environment, cultural restrictions, and the perception of menses as dirty and needing to be concealed were all highly salient in included studies, yet these risk factors have received limited attention in interventions.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    These components of menstrual experience were interlinked and contributed to negative impacts on women's and girls' lives.

    “These components of experience were interlinked and contributed to negative impacts on women’s and girls’ lives.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Resource limitations underlay inadequate physical infrastructure to support menstruation and an economic environment restricting access to affordable menstrual materials.

    “Resource limitations underlay inadequate physical infrastructure to support menstruation, as well as an economic environment restricting access to affordable menstrual materials.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The sociocultural context, including menstrual stigma and gender norms, influenced menstrual experiences by limiting knowledge about menstruation, limiting social support, and shaping internalised and externally enforced behavioural expectations.

    “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.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Impacts of menstrual experience included harms to physical and psychological health as well as education and social engagement.

    “Impacts included harms to physical and psychological health as well as education and social engagement.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    The review undertook systematic searching to identify qualitative studies of women's and girls' experiences of menstruation in low- and middle-income countries.

    “We undertook systematic searching to identify qualitative studies of women’s and girls’ experiences of menstruation in low- and middle-income countries (LMICs).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The review is reported according to PRISMA guidance.

    “The review protocol is registered on PROSPERO: CRD42018089581 and is reported according to PRISMA guidance (S1 PRISMA Checklist).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    The review employed a thematic synthesis approach to describe themes as recurrent units of meaning within and across studies.

    “Reflecting the research questions, we employed a thematic synthesis approach [28], or an approach that seeks to describe themes as recurrent ‘units of meaning’ within and across studies, to synthesise insights from individual studies [29, 30].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [28] J Thomas, 2008, Methods for the thematic synthesis of qualitative research in systematic reviews, BMC Med Res Methodol source

      Not checked in the free run.

    • cites [29] J Attride-Stirling, 2001, Thematic networks: an analytic tool for qualitative research, Qualitative Research source

      Not checked in the free run.

    • cites [30] GJ Melendez-Torres, 2015, A systematic review and critical appraisal of qualitative metasynthetic practice in public health to develop a taxonomy of operations of reciprocal translation, Res Synth Methods source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Emergent themes were discussed among the authorship team until consensus was reached on a representation with the greatest explanatory power.

    “Emergent themes were discussed among the authorship team, and multiple mappings of the relationships between themes were generated until authors reached consensus on a representation with the greatest explanatory power.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Analysis was undertaken in four steps, with findings of high- and medium-quality studies thematically coded by the first author.

    “Analysis was undertaken in 4 steps: The findings of high- and medium-quality studies were thematically coded using NVivo 12 (QSR International; https://www.qsrinternational.com/nvivo/nvivo-products) by the first author.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    One author appraised the quality of all studies; 10% were independently appraised by a second author, with 100% agreement.

    “One author (JH) appraised the quality of all studies; 10% were independently appraised by a second author (GJMT), with 100% agreement.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    The integrated model hypothesises directional pathways that could be tested by future studies and may serve as a framework for program and policy development.

    “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.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Comprehensive grey literature searching and hand searching were undertaken.

    “Comprehensive grey literature searching and hand searching were undertaken.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    All studies were recoded against the consensus themes and integrated model for validation.

    “Using Nvivo 12, all studies were recoded against the consensus themes and integrated model for validation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Through synthesis of extant qualitative studies, the review highlights consistent challenges and developed an integrated model of menstrual experience.

    “Through synthesis of extant qualitative studies of menstrual experience, we highlight consistent challenges and developed an integrated model of menstrual experience.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The use of thematic networks reflected a lines-of-argument approach to meta-ethnography.

    “The use of thematic networks reflected a lines-of-argument approach to meta-ethnography [31]; that is, drawing on the synthesis of qualitative research (meta-ethnography), we sought to go beyond merely describing a phenomenon to interpreting and understanding the social processes underlying it as part of an integrated scheme, such that no one study captures the entirety of the phenomenon (lines of”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [31] G Noblit, 1988, Meta-Ethnography source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Thematic networks were used to facilitate repeated comparison of the relationships between themes.

    “We then used these themes to generate thematic networks to facilitate repeated comparison of the relationships between these themes.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Included studies were appraised using the EPPI-Centre checklist, which assesses methodological quality across sampling, data collection, analysis, interpretation, and privileging of participant perspectives.

    “Included studies were appraised using the EPPI-Centre checklist [25]. This checklist assesses methodological quality across recommended domains: sampling, data collection, analysis, interpretation, and privileging of participant perspectives (see S1 Table) [26, 27].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [25] R Rees, 2009, Children’s views about obesity, body size, shape and weight: a systematic review

      Not checked in the free run.

    • cites [26] J Noyes, 2018, Cochrane Qualitative and Implementation Methods Group guidance series-paper 3: methods for assessing methodological limitations, data extraction and synthesis, and confidence in synthesized qualitative findings, J Clin Epidemiol source

      Not checked in the free run.

    • cites [27] M Santiago-Delefosse, 2016, Quality of qualitative research in the health sciences: Analysis of the common criteria present in 58 assessment guidelines by expert users, Soc Sci Med source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Searches were completed in January 2019 with no language of publication or date restrictions applied.

    “Searches were completed in January 2019 with no language of publication or date restrictions applied.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Two authors independently screened titles and abstracts, followed by full-text screening.

    “Two authors (JH, AS) independently screened titles and abstracts, followed by full-text screening to determine eligibility (JH).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The review protocol was registered on PROSPERO (CRD42018089581).

    “The review protocol registration is PROSPERO: CRD42018089581.”
    • Also stated in: § Methods · plain
      “The review protocol is registered on PROSPERO: CRD42018089581 and is reported according to PRISMA guidance (S1 PRISMA Checklist).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Authors linked these reports to reproductive tract infections, supported by key informants such as healthcare providers.

    “Authors linked these reports to reproductive tract infections, supported by key informants such as healthcare providers.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationnone given

    Internalised menstrual stigma and expectations of silence on the topic resulted in negative attitudes and intense fears of shame should menstrual status be exposed.

    “Internalised menstrual stigma and expectations of silence on the topic resulted in negative attitudes and intense fears of shame should menstrual status be exposed.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    Resource deficits contributed to economic and physical environments that limited women's choices for menstrual practices and shaped their experiences of menstruation.

    “Resource deficits contributed to economic and physical environments that limited women’s choices for menstrual practices and shaped their experiences of menstruation.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationnone given

    The model presented differs from previous nonsystematic summaries that have generated lists of considerations to improve menstrual experience but have not specified directional relationships.

    “The model presented differs from previous nonsystematic summaries that have generated lists of considerations to improve menstrual experience but have not specified directional relationships.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Systematic searching identified a large body of literature, facilitating clarity in the identified themes.

    “Systematic searching identified a large body of literature, facilitating clarity in the identified themes.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Metasynthesis remains an evolving methodology for the review of qualitative literature.

    “Metasynthesis remains an evolving methodology for the review of qualitative literature [30, 110–112].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [30] GJ Melendez-Torres, 2015, A systematic review and critical appraisal of qualitative metasynthetic practice in public health to develop a taxonomy of operations of reciprocal translation, Res Synth Methods source

      Not checked in the free run.

    • cites [110] JL Harris, 2018, Cochrane Qualitative and Implementation Methods Group guidance series-paper 2: methods for question formulation, searching, and protocol development for qualitative evidence synthesis, J Clin Epidemiol source

      Not checked in the free run.

    • cites [111] A Booth, 2019, Formulating questions to explore complex interventions within qualitative evidence synthesis, BMJ Global Health source

      Not checked in the free run.

    • cites [112] E Nye, 2016, Origins, methods and advances in qualitative meta-synthesis, Review of Education source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Study quality was appraised using a tool designed for qualitative studies.

    “Study quality was appraised using a tool designed for qualitative studies.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductnone given

    Searching was only undertaken in English and may not have identified all available publications.

    “A small number of studies in languages other than English were included; however, searching was only undertaken in English and may not have identified all available publications.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Study design and conductnone given

    As in all reviews, the findings are limited by available studies.

    “As in all reviews, the findings are limited by available studies.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The large volume of studies presented the opportunity to draw themes and an integrated model across a broad range of contexts and populations.

    “This presented the opportunity to draw themes and an integrated model across a broad range of contexts and populations.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The definition 'menstrual hygiene' outlined in the Introduction fit poorly with the integrated model resulting from this metasynthesis.

    “The definition ‘menstrual hygiene’ outlined in the Introduction fit poorly with the integrated model resulting from this metasynthesis.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Study design and conductnone given

    The focus on consensus themes and auditable methods lends credibility to the results as presented.

    “However, our focus on consensus themes and auditable methods lends credibility to our results as presented.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The use of a qualitative appraisal tool may have resulted in poorer scoring of mixed-methods studies that were considered only based on their qualitative components.

    “This may have resulted in poorer scoring of mixed-methods studies that were considered only based on their qualitative components.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Interventions that focus on products may maintain menstrual stigma and reinforce behavioural expectations that concealing menses is paramount.

    “Interventions that focus on products may maintain menstrual stigma and reinforce behavioural expectations that concealing menses is paramount.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationnone given

    The integrated model presented advances the development of problem theory in menstrual health research and highlights important factors to consider in future research and practice.

    “The integrated model presented advances the development of problem theory in menstrual health research and highlights important factors to consider in future research and practice.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Study design and conductnone given

    As with any systematic review of qualitative research, a different team of researchers may have generated different insights.

    “Finally, as with any systematic review of qualitative research, a different team of researchers may have generated different insights.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    Through synthesis, the review elucidates antecedent pathways and highlights the multiple components of menstrual experience that must be considered for effective interventions and comprehensive quantitative evaluation.

    “Through synthesis, we elucidate antecedent pathways and highlight the multiple components of menstrual experience that must be considered for effective interventions and comprehensive quantitative evaluation.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    As presently defined, 'menstrual hygiene' may reflect an incomplete set of menstrual rights or needs, or it could be amended to capture menstrual practices as have emerged here.

    “As presently defined, ‘menstrual hygiene’ may reflect an incomplete set of menstrual rights or needs, or it could be amended to capture menstrual practices as have emerged here.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    To date, developed interventions have sought to improve menstrual experience by investing in education (to improve knowledge) and menstrual products (to improve the economic environment), two of the core pillars of existing menstrual health frameworks.

    “To date, developed interventions have sought to improve menstrual experience by investing in education (to improve knowledge) and menstrual products (to improve the economic environment), two of the core pillars of existing menstrual health frameworks [19, 113].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [19] J Hennegan, 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 source

      Not checked in the free run.

    • cites [113] C Sumpter, 2013, A systematic review of the health and social effects of menstrual hygiene management, PLoS ONE source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisereasoning

    The definition 'menstrual hygiene' provides an unclear list of menstrual practices, incorporates one mention of perceptions of the menstrual environment but not practices, and refers to physical facilities for disposal only.

    “This definition provides an unclear list of menstrual practices, incorporates one mention of perceptions of the menstrual environment but not practices, and refers to physical facilities for disposal only.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    This work draws on current best practice guidance.

    “This work draws on current best practice guidance [26, 27, 29, 30, 112].”
    Quote in the paperNot a substantial claim0 of 5 sources checked
    • cites [26] J Noyes, 2018, Cochrane Qualitative and Implementation Methods Group guidance series-paper 3: methods for assessing methodological limitations, data extraction and synthesis, and confidence in synthesized qualitative findings, J Clin Epidemiol source

      Not checked in the free run.

    • cites [27] M Santiago-Delefosse, 2016, Quality of qualitative research in the health sciences: Analysis of the common criteria present in 58 assessment guidelines by expert users, Soc Sci Med source

      Not checked in the free run.

    • cites [29] J Attride-Stirling, 2001, Thematic networks: an analytic tool for qualitative research, Qualitative Research source

      Not checked in the free run.

    • cites [30] GJ Melendez-Torres, 2015, A systematic review and critical appraisal of qualitative metasynthetic practice in public health to develop a taxonomy of operations of reciprocal translation, Res Synth Methods source

      Not checked in the free run.

    • cites [112] E Nye, 2016, Origins, methods and advances in qualitative meta-synthesis, Review of Education source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    The integrated model may serve to inform measure development for identified components of menstrual experience, antecedents, and impacts.

    “Furthermore, it may serve to inform measure development for identified components of menstrual experience, antecedents, and impacts.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    The integrated model presented here offers a more nuanced framework to inform theories of change in program development and to assist evaluation strategies.

    “The integrated model presented here offers a more nuanced framework to inform theories of change in program development and to assist evaluation strategies.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    Menstrual experience is characterised not only as the hygiene practices undertaken to manage menstrual bleeding but by women's and girls' perceptions of these practices, their confidence to manage menses and engage in other activities while menstruating, and their experience of shame and containment.

    “Menstrual experience is characterised not only as the hygiene practices undertaken to manage menstrual bleeding but by women’s and girls’ perceptions of these practices, their confidence to manage menses and engage in other activities while menstruating, and their experience of shame and containment.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Findings of this review suggest that terminology and construct definition in menstrual health research may need to be expanded to recognise the many components of menstrual experience and contributing factors.

    “Findings of this review suggest that terminology and construct definition in menstrual health research may need to be expanded to recognise the many components of menstrual experience and contributing factors.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Despite extensive searching, eligible studies may have been missed.

    “Despite extensive searching, eligible studies may have been missed.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Such interventions may have positive impacts on containment in the short term but risk greater harms if access to more reliable menstrual materials is unsustained.

    “Such interventions may have positive impacts on containment in the short term but risk greater harms if access to more reliable menstrual materials is unsustained.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Recent expansions on the definition of 'menstrual hygiene' to include menstrual knowledge conflate menstrual experience with antecedents.

    “Recent expansions on this definition to include menstrual knowledge conflates menstrual experience with antecedents [115].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [115] M Sommer, 2017, Attention to menstrual hygiene management in schools: An analysis of education policy documents in low-and middle-income countries, International Journal of Educational Development source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    These factors likely represent important covariates that should be considered when not the focus of interventions.

    “Furthermore, these factors likely represent important covariates that should be considered when not the focus of interventions.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Awareness of multiple, interconnected constructs also aids the identification of unanticipated harms.

    “Awareness of multiple, interconnected constructs also aids the identification of unanticipated harms.”
    Quote in the paperNot a substantial claim
108 of 108

  • The paper relies on this without support.

    The use of qualitative evidence in menstrual health programming has been anecdotal and situated, drawing on individual studies that may be restricted in scope and have limited generalizability beyond their context.

    “However, this use of qualitative evidence has been anecdotal and situated, drawing on individual studies that may be restricted in scope and have limited generalizability beyond their context.”

  • The paper relies on this without support.

    Menstrual health research has tended to draw on programmatic models rather than detailed problem theory.

    “Menstrual health research has tended to draw on programmatic models rather than detailed problem theory.”

  • The paper relies on this without support.

    Risk factors such as social support, the physical environment, cultural restrictions, and the perception of menses as dirty and needing to be concealed have received limited attention in interventions.

    “Social support, the physical environment, cultural restrictions, and the perception of menses as dirty and needing to be concealed were all highly salient in included studies, yet these risk factors have received limited attention in interventions.”

  • The paper relies on this without support.

    Models focused exclusively on menstrual practices have assessed only physical harms such as infections.

    “Models focused exclusively on menstrual practices have assessed only physical harms such as infections.”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • With the principal focus of MHM research centered on adolescent girls in school settings, considerably less attention has been given to women's experience of MHM at other life stages.

    “With the principal focus of MHM research centered on adolescent girls in school settings, considerably less attention has been given to women’s experience of MHM at other life stages, outside of a few key papers that focus on menstruation in the workplace and in emergency contexts, along with other types of vaginal bleeding [38–43].”

    From ’It’s like a burden on the head’: Redefining adequate menstrual hygiene management throughout women’s varied life stages in Odisha, India. (2019) · cites this paper as [43]

  • Outside of a few key papers that highlight the menstrual experiences of women in the workplace, emergency context, or vaginal bleeding throughout the life course, experiences of menstruation among adult women and outside of school settings remains underexplored.

    “Outside of a few key papers that highlight the menstrual experiences of women in the workplace, emergency context, or vaginal bleeding throughout the life course, experiences of menstruation among adult women and outside of school settings remains underexplored [38, 39, 43, 70].”

    From ’It’s like a burden on the head’: Redefining adequate menstrual hygiene management throughout women’s varied life stages in Odisha, India. (2019) · cites this paper as [43]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Physical-environment low-trustworthiness count is one short

    Minor

    Table 3 reports three low-trustworthiness studies for this theme but names four.

1 of 1

Cites

Flagged first, then by citations

4 of the 93 references couldn’t be matched to a known paper.

Cited by

Sorted by citations

Related

Authors
Hennegan, J., Shannon, A. K., Rubli, J., Schwab, K. J., & Melendez-Torres, G. J.
Affiliations
Johns Hopkins University (US)
Corresponding author
Hennegan, Julie
ORCID
Venue
PLOS Medicine
Publisher
Public Library of Science (PLoS)
Published
2019-05-16
Volume
16
Issue
5
Pages
e1002803
ISSN
  • 1549-1277 (ISSN-L)
  • 1549-1676
DOI
10.1371/journal.pmed.1002803
PMC
PMC6521998
OpenAlex
W2946739594
Cited by
577
References
93
Citations by year
2026: 123 · 2025: 101 · 2024: 101 · 2023: 69 · 2022: 65 · 2021: 69 · 2020: 39 · 2019: 8 · 2018: 2
FWCI
7.40
Type
journal article
Language
en
Open access
Licence
Locations
  • PLoS Medicine (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • RePEc: Research Papers in Economics (submittedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Figshare (submittedVersion, cc-by)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Menstrual Health and Disorders
  • Health Sciences › Medicine › Reproductive Medicine › Hypothalamic control of reproductive hormones
  • Health Sciences › Health Professions › General Health Professions › Adolescent Sexual and Reproductive Health
Keywords
menstruation, menstrual health, low- and middle-income countries, menstrual stigma, gender norms, menstrual products access, adolescent girls, sociocultural context, gender equality, menstrual health policy, menstrual health services, menstrual health education, sub-Saharan Africa
MeSH terms
Adolescent, Adolescent Behavior, Adult, Child, Child Behavior, Cultural Characteristics, Developing Countries, Female, Humans, Health Knowledge, Attitudes, Practice, Menstruation, Middle Aged, Public Opinion, Social Support, Stereotyping, Women's Health, Access to Information, Young Adult, Social Stigma, Reproductive Health

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-08.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-08.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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