Overall, a total of 28,745 articles were screened across the three databases, with 3,427 included as part of the abstract review (11.9%), 371 for full-text eligibility (1.3%), and 84 in the desk review (0.3%).
Based on the quality assessment for the 84 articles, nine articles were coded as “strong” (10.8%), 46 (55.4%) were coded as “moderate,” and 28 (33.7%) were coded as “weak.” The two criteria that had the highest percentages of 0’s were “outlining a conceptual framework” (73.96%) and “justification for analytical method” (60.42%). The two criteria that had the highest number of 3’s were “outlining a research question” (64.58%) and “recommendations” (43.75%). Table 4 includes background information on the 84 articles where over 80% reported cross-sectional data and more than half (54.2%) used quantitative methodologies. The studies were derived from multiple geographical locations. Almost all studies involved adolescent girls.
Table 4: Summary of Articles Included in the Systematic Review (N=84)
Categories
|
N
|
%
|
Methodology
|
|
|
Quantitative
|
46
|
54.2
|
Qualitative
|
17
|
20.5
|
Mixed-methods
|
12
|
14.4
|
Participatory
|
9
|
10.8
|
Cross-sectional
|
69
|
82
|
Geographic Regions
|
|
|
South Asia
|
35
|
42.2
|
Eastern Africa
|
35
|
42.2
|
Southern Africa
|
24
|
28.9
|
West and Central Africa
|
9
|
10.8
|
Middle East and North Africa
|
9
|
10.8
|
East Asia and the Pacific
|
4
|
4.8
|
Americas and the Caribbean
|
1
|
1.2
|
Combination
|
1
|
1.2
|
Targeted Audience
|
|
|
Girls
|
83
|
99
|
School staff and administrators
|
16
|
19.3
|
Community members
|
10
|
12
|
Boys
|
6
|
7.2
|
Parents of girls
|
6
|
7.2
|
Non-governmental organizations and ministries
|
3
|
3.6
|
More than 60% of the articles looked at the relationship of MHHM with health (37.3%) or with WASH (25.3%). The rest looked at the relationship of MHHM with education (13.3%) nutrition (7.2%), and child protection (2.4%). Additionally, 14.4% of the studies examined the relationship between MHHM and two development issues, for example, 7.2% of the articles examined the links between adequate MHHM with WASH and education.
MHHM was defined in only seven (8.4%) articles. None of the definitions matched WHO/JMP’s (2012) definition, which summarizes the sub-constructs of procurement, storage, personal hygiene, privacy, frequency of changing and disposal. All seven definitions outlined personal hygiene, six included procurement of clean absorbent, four included privacy and discreet disposal, and two included frequency of changing the absorbent. None of the definitions specified storage of absorbents.
Only 19 articles referenced theories, with the most commonly used theory being the socioecological model, which represents a social system with every level of the system impacting the individual. Other mentioned theories include the grounded theory, social cognitive theory, the PRECEDE model, MRC framework, and feminist theory.
Access to adequate facilities emerged as a major factor, with ramifications for child protection, WASH, education, and health. A total of 30 articles (34%) outlined the relationship between MHHM and access to facilities. Lack of facilities were also examined in the context of knowledge, restrictions, seeking healthcare, facilities available in school, access to information and support, and not disposing the menstrual absorbent in the toilet or latrine. Limited access to facilities was associated with dirty and constricted water and sanitation facilities within the school and home environment. The cycle of inadequate procurement of clean menstrual absorbents, infrequent changing of absorbents, inadequate drying of absorbents in the sun, and unsafe disposal further led to physical discomfort, inconvenience, embarrassment, and school absenteeism. Seven studies demonstrated that access to facilities (including covered toilets, locked doors, and availability of clean absorbents, water, soap, and dustbins) coupled with education programs was protective for MHHM and school attendance during menstruation (41-47).
Sociodemographic factors that came into play included poverty, social restrictions, secrecy around menstruation within the societies in which the studies took place, lower socio-economic status, and mothers with lower literacy. These factors were also associated with lack of facilities (48, 49).
14 articles outlined the relationship between MHHM with health and nutrition. Some manuscripts focusing on this also tangentially discussed MHHM in the context of educational achievement. One article demonstrated that those with better individual health had better menstrual health (p = 0.001) (50). Most of the studies associated poor MHHM with social secrecy and taboos surrounding menstruation, which led adolescent girls to use unhygienic methods (cloth), stay home from school, not exercise, and be unable to perform daily tasks during menstruation. This in turn led to adolescent girls being significantly more likely to exhibit at least one symptom of a reproductive tract infection (RTI) (OR = 1.046 – 1.94, p < 0.05), vaginal discharge (OR = 1.303, p < 0.001), urinary tract infection (UTI) (OR: 1.38, p<0.05), and sexually transmitted infections (STI), as well as lower likelihood of seeking treatment for any of these health problems (15, 51-56). One article provided contradictory information by showing no association between either washing the cloth with soap and water or not, or drying the cloth in the sun or not and having RTI/ STI symptoms (57). Two articles outlined a negative relationship between adequate MHHM and nutrition. Religion and mothers’ education showed either societal-imposed or self-imposed restrictions, such as avoiding food during menstruation to manage menstrual flow (48, 58).
There were 15 articles (18%) outlining the importance of pre-menarche training and health education that cut across health, education, and WASH issues. (12, 44, 50, 57, 59-69). These programs covered all definitional aspects of MHHM, all of which were operationalized except for the ability to change the absorbent in privacy. Additional MHMM information in these programs included regularity of menstrual cycle, knowledge, health seeking behavior, student’s behavior during first day of menstruation, tendency to stay at home, school absenteeism during menstruation, change in diet during menstruation (restrictions), and methods for managing menstrual problems.
Overall, there was a lack of consistency in the results when it came to pre-menarche training. Those who had prior knowledge on menstruation had better handwashing (69), had a higher proportion reporting no pain during menses (29.3% vs 20.7%, p=0.05), had a higher proportion having no effect on schooling life (33.3% vs 19.8%, p<0.01), had a higher proportion using sanitary pads (75.1% vs 61.7%, p<0.01), and had a higher proportion disposing absorbents by burning (35.5% vs 25.2%, p<0.01) (59). At the same time, pre-menarche training and frequency of changing absorbent were not significantly associated (Aniebue et al., 2009). In one study, those who did not have prior knowledge on menstruation had better disposal practices (69).
Results from studies summarizing health education programs in schools showed that after adjusting for other co-factors, those who had never received health education had a 44% greater probability (p=0.04) of dysmenorrhea than those who had previously received health education (62). Health educational programs had a positive correlation with improved intention to visit the health center at any time, increased knowledge, better attitudes, hygienic choice of absorbent, increased frequency of changing sanitary pads, reusing of cloth after washing, proper cleanliness of genitalia during menstruation, improved self-care behavior, increased bathing during menstruation, increased school attendance, fewer health complications, and seeking treatment for RTI or STI as compared to the control group (12, 44, 50, 57, 60, 61, 64-68). One study demonstrated that, while training by either parents and health trainers was beneficial in comparison to no training, school health trainers elicited better MHHM behaviors (63).