High uptake of menstrual health information, products and analgesics within an integrated sexual reproductive health service for young people in Zimbabwe

Background Achieving good menstrual health (MH), integral to women’s well-being, remains a challenge. This study examined MH services uptake (including information, analgesics, and a choice of MH products - the menstrual cup and reusable pads) and sustained use of MH products within an integrated sexual and reproductive health intervention for young people in Zimbabwe. Methods This study was embedded within a cluster randomised trial of integrated sexual and reproductive health services (CHIEDZA) in three provinces (Harare, Mashonaland East, and Bulawayo). The study collected qualitative and quantitative data from female clients aged 16–24 years, who accessed CHIEDZA from April 2019 – March 2022. Uptake of MH information, products, and analgesics and other services was tracked for each client. Descriptive statistics and logistic regression were used to investigate MH service uptake and product choice and use over time, and the factors associated with these outcomes. Thematic analysis of focus group discussions and interviews were used to further explore providers’ and participants’ experiences of the MH service and CHIEDZA intervention. Results Overall, 36991 clients accessed CHIEDZA of whom 27725 (75%) were female. Almost all (n = 26448; 95.4%) took up the MH service at least once: 25433 took up an MH product with the majority (23346; 92.8%) choosing reusable pads. The uptake of cups varied across province with Bulawayo province having the highest uptake (13.4%). Clients aged 20–24 years old were more likely to choose cups than reusable pads compared with those aged 16–19 years (9.4% vs 6.0%; p < 0.001). Over the implementation period, 300/1819 (16.5%) of clients swapped from the menstrual cup to reusable pads and 83/23346 (0.4%) swapped from reusable pads to the menstrual cup. Provision of the MH service encouraged uptake of other important SRH services. Qualitative findings highlighted the provision of free integrated SRH and MH services that included a choice of MH products and analgesics in a youth-friendly environment were key to high uptake and overall female engagement with SRH services. Conclusions High uptake demonstrates how the MH service provided much needed access to MH products and information. Integration of MH within an SRH intervention proved central to young women accessing other SRH services.


Introduction
Menstrual health (MH), de ned as having access to the materials, facilities, and support to manage menstruation with privacy and dignity, is integral to women's empowerment, reproductive health, and overall wellbeing (1,2). To effectively manage menstruation, women need to have access to affordable and effective menstrual products, pain management, education and support, and water, sanitation and hygiene (WASH) facilities (1,3). As well as lacking access to these, many women are also affected by both the shame and taboo around menstruation (2,4,5). Lack of access to support and MH products can lead to embarrassment and isolation during menstruation, school drop-out, and transactional sex, which in turn increases the risk of early age at pregnancy and sexually transmitted infections (5)(6)(7)(8)(9)(10)(11).
With a growing understanding of the importance of MH, a variety of interventions have been implemented to mitigate the impact of inadequate MH (12). As of 2022, these include community-based interventions (13), multicomponent interventions (14), and interventions that address the MH needs of those with disabilities (15). However, most of these interventions have 1) framed MH as an isolated issue, 2) targeted school-going girls, and 3) focused on the provision of MH education or products, but rarely both (16).
MH is now widely accepted as a core component of sexual and reproductive health (SRH) (1,17,18). Menstruation is a key feature of women's reproductive years thus making MH a natural entry point and acceptable pathway to understanding and addressing women's reproductive needs (17,19). Integrating MH into SRH service provision can potentially be an effective and acceptable model to maximize use of healthcare resources, provide comprehensive care and increase engagement with critical health services in the community (20). This is important as young women face many barriers when seeking healthcare and are often the most vulnerable to adverse reproductive health outcomes linked to risky sexual practices (21)(22)(23). Despite this, there is limited research work to inform best practices and acceptable and sustainable approaches to integrated service provision approaches for women across the globe (19).
The aim of this study was to investigate the uptake and usage patterns of MH services including analgesics, MH education and a choice of MH products (the menstrual cup or reusable pads) within a comprehensive integrated SRH service.

Study design and setting
This mixed-methods study was nested within a cluster-randomised trial aimed at investigating the impact of community-based integrated HIV and SRH services for young people in Zimbabwe aged 16-24 years on population-level HIV outcomes. (CHIEDZA trial registration number in clinical trials.gov: NCT03719521) (24). The trial protocol has been described elsewhere (24) but in brief the CHIEDZA intervention included HIV testing and treatment with adherence support, as well as family planning, management of sexually transmitted infections (STIs), condoms, referrals for voluntary medical male circumcision (VMMC), counselling, and MH services (described below), provided free-of-cost in a youthfriendly environment. The intervention was delivered by a multidisciplinary team of trained healthcare providers comprising two youth workers, one counsellor, two nurses, and four community health workers (CHWs). CHIEDZA was conducted in three provinces in Zimbabwe (Harare, Bulawayo, and Mashonaland East) with eight clusters per province (total 24 clusters) randomised 4:4 to the intervention or to existing services (control arm) from April 2019 -March 2022. A cluster was de ned as a geographically de ned area with a community centre from where services were delivered.
Training of providers included comprehensive MH education that addressed puberty and body autonomy, harmful myths and taboos around menstruation, and correct use and maintenance of reusable MH products. Training materials used can be found elsewhere (www.chiedza.com). Providers were also given menstrual cups and reusable pads for their own use.

Menstrual health services
The MH services available to all female CHIEDZA clients included two pairs of underwear, MH education and support, a simple paper-based period-tracking diary, a bar of soap, a choice of analgesics (12 tablets of paracetamol or ibuprofen available on a monthly basis), and a choice between either a menstrual cup (the Butter y Cup that can used for up to ten years) (www.vivalily.com) or a four-pack of reusable pads which included three normal sized pads and one night-time pad (AFRIpads™ that can be used for up to two years) (www.afripads.com). The MH service also included trained menstrual cup ambassadors on site for menstrual cup sensitization and user support over time. All female CHIEDZA clients also had the option to swap their original MH product choice for another after a minimum 3 months of usage.
Quantitative data collection and analysis Every attendance to CHIEDZA was captured using a biometric system (Simprints, Cambridge, UK) (25). At rst visit, a client provided a registration ngerprint which was converted into a unique identi er. Age, sex, and type of service taken up at each visit was documented for each client, linked to their unique ID. No identifying information such as name or address was collected. Clients gave verbal consent for services as need for verbal consent was waived. At subsequent visits, clients provided ngerprints which enabled tracking of services taken up by clients over time.
Data was collected using electronic tablets. All female clients that attended CHIEDZA were eligible to take up the MH service. Uptake of MH information, product, and type and/or analgesics was recorded. If a client's choice of MH product or analgesics was unavailable, this was recorded as a "stock-out" occurrence and clients were advised on when to return to pick up their preferred product and/or analgesics. MH service uptake across all the 12 intervention clusters was calculated as the proportion of women who took up MH services of those who attended CHIEDZA. Logistic regression with a random effect for cluster was used to estimate the association of uptake of MH services and MH product choice with province and age group. Data were analysed using Stata version 17 (StataCorp, Texas, USA).

Qualitative data collection and analysis
We conducted non-participant observations of CHIEDZA sites, and in-depth interviews (IDIs), and focus group discussions (FGDs) with CHIEDZA service providers and clients. Data was collected by three trained qualitative researchers (CVM, RN, PN) who were independent of the implementation team. All interviews were conducted in Shona, English, or Ndebele (as preferred by the participants), lasted between 20-100 minutes, and were conducted in-person or by phone (when COVID-19 restrictions prevented inperson engagement).
Semi-structured topic guides were iteratively informed by preliminary ndings from previously collected data and discussions with the qualitative team. The interviews explored participants' perspectives on CHIEDZA and the overall acceptability and feasibility of the intervention, and speci c services, including MH. Interviews were audio recorded, transcribed verbatim, and then translated into English where necessary. Written informed consent was obtained before the interviews were initiated and pseudonyms were used throughout for con dentiality and anonymity.
For this paper, qualitative data that related speci cally to the acceptability of integrated services and, more speci cally, the MH service were identi ed and selected from a larger qualitative dataset. This included non-participant observation notes, three FGDs with healthcare providers, and three FGDs and ve IDIs with clients. From familiarisation of the data, qualitative analytical discussion between CMY and MT, and discussion of quantitative ndings, themes were identi ed. Data were coded in Nvivo 12.
Analytical memos were written to analyze, and organize emerging ndings, and as a basis for iterative analytical discussion (26). This approach allowed for the generation of unanticipated insights and a nuanced understanding of participants' experiences with CHIEDZA and the MH service within it. Nonparticipant observations of CHIEDZA sites and observations of monthly study team meetings primarily aimed to understand intervention implementation, adaptations, and context.
Other papers detailing qualitative ndings of the CHIEDZA intervention have been published elsewhere (27,28).
Of the remaining 40.1% of female clients, 5353 (19.3%) accessed CHIEDZA services twice, 2254 (8.1%) three times, 1209 (4.4%) four times, and 2039 (8.3%) ve or more times. Overall, MH service uptake was consistently high with over 85% uptake per visit throughout the intervention period. However, there were periods between July -March 2020 that showed a decrease in MH service uptake with 85.8% and 87.3% uptake from July -September 2020 in Harare and Mashonaland East respectively and 85.4% and 79.3% uptake from October -December 2020 uptake from Harare and Mashonaland East respectively.

Uptake of menstrual health services
Most CHIEDZA clients (24029; 86.7%) took up MH services at their rst visit. Of those who did not take up MH services at the rst visit, 37.3% took up MH services at the second visit, and 19.1% took up MH services on a subsequent visit, with a similar pattern across the three provinces.
Most participants only took up analgesics at one visit (12011/16475; 79.2%). However, one participant took up analgesics at each visit for up to 24 visits. The median time between any two visits was 80 days (IQR: 52-98 days).
Factors that informed MH service uptake Qualitative ndings from interviews with CHIEDZA providers and clients provided a nuanced understanding of the factors that informed uptake of the MH service. For example, when asked what young people appreciated about CHIEDZA, a client noted that they appreciated the provision of free services, speci cally MH products, that they could no longer afford: "CHIEDZA helped a lot of young people by giving us free services. Condoms are expensive to buy these days, pads are expensive too so these free services were really helpful…" (Client IDI, male, 25 years old).
Clients also appreciated the youth-friendly and non-judgemental service delivery offered at CHIEDZA and many felt very comfortable coming to CHIEDZA to not only receive free MH products, but also to talk about how to use the MH products and about menstruation and SRH more generally: "When I came to CHIEDZA I saw a youth worker who wasn't shy at all. He really explained that a pad works in such and such a manner, condoms are supposed to be worn like this and this and it came to my mind that there really isn't anything embarrassing after all. I… actually realized that there is nothing to be ashamed of." (Client IDI, female, 19 years old).
Qualitative ndings also highlighted the prevalence of MH-related pain and the importance of analgesic provision from CHIEDZA as clients described how menstrual pain limited their mobility and often affected their ability to engage in social and economic activities. When asked if one could go to work or church when experiencing menstrual pain, clients responded: "It is impossible… You will do nothing with that pain," (Client IDI, Female, 22 years old).
"I usually have a massive period pain and so I stay at home most of the times. The fact that I stay at home for two or four days affects my routine and practices because am a dancer I do not practice until I nish," (FGD, Female, 16-19 years old) When discussing how they managed MH-related pain, many clients noted that they used free analgesics from CHIEDZA or bought analgesics from the pharmacy when they can afford them. Other pain management options used included "drinking hot water" or "using heat".
Among the 23 participants who swapped more than once, the median time from the rst product choice to rst swap was 224 days (IQR 140-378, range 7-476) and the median time from then to the second switch was 175 days (IQR 140-413).
After 12 months or more, 2969 and 367 clients swapped their old reusable pads for new reusable pads once or more than once respectively. This was done as old reusable pads were no longer su ciently absorbent. The median time between swapping of old reusables for new ones was 399 days (IQR: 343-490 days).
Interviews with CHIEDZA clients highlighted the factors that informed product choice. Some clients chose the menstrual cups either because they had a heavy ow and felt that the cup would be less likely to leak or because they were uncomfortable with the idea of carrying around a wet reusable pad or washing and drying their used reusable pads: "Well… I took a cup and I am very comfortable with my cup as I hate washing pads with blood. I can wear my tight jeans and there are no markings or signs that I am wearing it unlike when wearing a pad," (Client IDI, Female, 20 years old) "Many indeed are not comfortable with the act of washing a reusable pad… That's why some wanted to adopt the cup. They take the cup because they do not want to look at their blood and worse still wash it," (CHIEDZA service provider IDI, Bulawayo).
However, most clients, particularly younger women, were uncomfortable with the use of insertable MH products such as the menstrual cup. Clients either feared that it would be painful "down there" or believed cup use contradicted longstanding beliefs around "virginity" and the importance of preserving the hymen and keeping it intact before marriage. This barrier to insertable menstrual cups due to "virginity" or fear was highlighted when clients were asked about product choice and swapping: "I chose the pads and if the pads were not there, I was not going to choose the cup because I have never used a cup and I am scared to put things down there." (Client FGD, Female, 16-19 years old).
"When I came [to CHIEDZA] they did not have pads so I took a cup… It was not a comfortable experience for me because I am still young and so I returned it after 3 months…" (Client FGD, Female, 16-19 years old).
"The pads are not di cult to wash and they are also very comfortable… Most people are scared of the cup because they think it will affect their virginity," (Client FGD, Female, 16-19 years old).

Stock-outs
MH product stock-outs during the CHIEDZA implementation period occurred mostly between July -December 2020 (data available in supplementary material). Overall, CHIEDZA sites in Bulawayo were particularly affected with 1164 incidences as opposed to 662 and 646 in Harare and Mashonaland East respectively. Interviews with providers highlighted that high stock-outs in Bulawayo were due to logistical delays in getting products from Harare to Bulawayo.
Other services within CHIEDZA Overall, the MH services had the highest uptake at rst visit (95.5%) for female clients. Of these, 1747 clients only took up the MH services at rst visit and the rest took up MH services and other services such as HIV testing (77.8%), SRH sensitization via SMS (56.2%), and contraception (30.3%) (Fig. 3). For female CHIEDZA clients that visited CHIEDZA more than once and were eligible to receive other services at those visits, most took up the MH services, HIV testing, SRH sensitization via SMS, and family planning: "The rst time she visited the site, she self-tested for HIV, received sanitary pads, pants, pain killer tablets for period pains and counselling services on sexual relationship…" (Client, IDI, 18 years old).
The pathways through which the integrated nature of the CHIEDZA intervention positively informed client engagement with MH and other SRH services was especially highlighted during interviews with CHIEDZA service providers and clients. Providers described how both the integration of services in CHIEDZA and the popularity of the MH service among young women in the communities led to clients coming to CHIEDZA for MH products and then being exposed to or taking up more services such as HIV testing: "Initially the client thought that CHIEDZA is a program which offers pads only but when she got there, she was surprised to hear that a range of services are in store," (CHIEDZA service provider IDI, Male).
"She indicated that she was invited by her friend to get pads at CHIEDZA and that is how she later got tested, HIV positive." (Client IDI, Female, 22 years old).
Client interviews also revealed that the popularity of the MH services within CHIEDZA facilitated an outward-facing branding of the intervention that did not focus SRH thus making it easier for young people, particularly young women, to visit CHIEDZA without fear of judgement from peers and the larger community. This feeling of ease and comfort with engaging with CHIEDZA was shown in how young people chose to come with family or groups of friends and did not shy away when they were noticed by other members of the community: "Young people do come to CHIEDZA as groups of friends; two girls walked into the community centre together and noticed their friend… and they all waved to each other in greeting." (Non-participant site observation).

Discussion
This study shows a very high uptake of MH services offered as part of integrated HIV and SRH services.
The MH services were the most accessed CHIEDZA services among young women across all provinces. This re ects a large unmet need for a choice of MH products, analgesics, and education among young women across Zimbabwe and adds to the evidence base for the need for comprehensive MH interventions in community-based settings (16, 29, 30).
The study demonstrates that the integration of MH in community-based SRH interventions may be an effective implementation pathway to increase female engagement and uptake of other critical SRH services such as HIV testing or family planning. It demonstrates the value of integrated service provision that places MH at the centre of SRH service provision for women (19,30,31). When provided with a range of SRH services within an integrated package, young women, regardless of age or geographical location almost always chose to take up MH services. Given these ndings, it is essential that MH is integrated in SRH interventions for young women. Alongside the MH services, young women took up HIV testing, SRH sensitization, analgesics, and condoms at rst and subsequent visits, suggesting these additional services are important to young women and thus should be prioritized in integrated SRH service provision. Moreover, these MH services may act as "hook"-encouraging the uptake of services such HIV testing and/or contraception that may need more time and understanding before being taken up (28, 32, 33).
Most current MH interventions provide access to either reusable pads or menstrual cups but not both (34,35). Our ndings suggest that factors such as age, geographical location, and sociocultural norms inform MH product choice and use. Women, particularly younger women, in Zimbabwe preferred reusable pads to the menstrual cup and the uptake and acceptability of the cup was low (36). Of the few young women that did opt for menstrual cups, many later swapped out the menstrual cup for reusable pads. However, very few clients chose to swap out the reusable pads for the menstrual cup in the study. In contrast to other studies (37, 38), we found that, given product choice, menstrual cups were not the preferred MH product among young women in Zimbabwe. The reluctance to opt for and/or use the menstrual cup may be due to an unwillingness to try a novel menstrual product or unwillingness to use an insertable product that may affect their "virginity" (35,39,40). These barriers persisted despite MH and menstrual cup sensitization and education provided through group talks, educational materials, and "menstrual cup champions" on site (41).
A closer look at the product choice and patterns of use in Bulawayo also provide insight into the importance of product choice. Bulawayo had the highest menstrual cup uptake and highest product swapping from menstrual cups to reusable pads. We hypothesise that in the absence of product choice (when reusable pads were not available), young women chose to take up the menstrual cup, but when given the opportunity to swap after three months, many opted to swap the menstrual cup for reusable pads once available. While young women Bulawayo were more willing to try novel products such as the menstrual cup, their preference over time was reusable pads. This preference may be informed by user experience or other factors but it is important that interventions address this change by providing informed choice when addressing unmet MH needs (34,42).
The overall low incidence of MH product swapping itself highlights that when given the information and support needed to make an informed decision regarding MH product choice, most young women are happy with their initial choice. Youth-friendly and non-judgemental MH service delivery allows for young women to feel comfortable enough to come back to service for more guidance on MH product use and/or guidance on other options to manage their menstruation.
As well as provision of products, analgesia is a critical component of MH services. There is limited research on MH-related pain among young women, particularly in LMICs (43). Other studies including a systematic review of studies investigating menstrual experiences in high income countries (HICs) (44), show that menstrual pain is associated with lower engagement in work and school. We found high uptake of analgesics with a signi cant proportion of clients returning repeatedly for analgesia, with ibuprofen being the preferred over paracetamol. MH interventions should include pain management through the provision of a choice of analgesics or other methods such as hot water bottles.
As reported in other studies of many health interventions, more females than males engaged with the CHIEDZA service. The high MH service uptake at rst visit and the popularity of the MH service overall suggests that the MH service may have had a particularly strong in uence on bringing young women to CHIEDZA. This nding is further supported by a qualitative study we conducted to explore the acceptability of the MH service within CHIEDZA (41). Here, particularly during the COVID-19 pandemic, when markets were closed, less money was available in the household, and social activities and games within CHIEDZA were suspended, the MH service became the sole "pull factor" framing CHIEDZA as a "women's service" and encouraging young women to visit CHIEDZA (41,45). These ndings are similar to those found in a study looking at MH access through a peer-led SRH service for youth in Zambia before and during the COVID-19 pandemic (13). In the Zambian study, access to MH products and education through community-based SRH service addressed an unmet need for MH support and proved to be essential to young women in the community, particularly during the COVID-19 pandemic (13).
External factors such as supply chains inform service implementation and delivery (46). In our study, dips in MH service uptake coincided with recorded incidences of stock-outs and the COVID-19 restrictions in Zimbabwe in 2020. In March of 2020, the Zimbabwean government announced a mandatory nationwide lockdown (47) and all CHIEDZA service provision was paused for six weeks from March 30th -May 18th, 2020. This lockdown also negatively affected procurement and delivery of MH products to CHIEDZA sites across the country, highlighting the importance of consistent MH product supply in MH and SRH service delivery.
To our knowledge, this is the rst study to investigate provision of MH services in SRH services. Our MH service included education, menstrual products, and analgesics, with choices of products and analgesics provided (19,48). We were able to track MH service uptake as well as uptake of other services at individual level over time (34). The study had a large sample size and was conducted across three provinces in Zimbabwe, including the two main ethnic groups.
Our study also had some limitations. The MH service did not include other forms of MH pain management. However, information on other forms of pain management was disseminated on site. We also did not collect detailed quantitative beyond age, sex, and provincial location but this was done for a MH cohort study detailed elsewhere (49). Additionally, observed uptake of the MH products may not have equated to use over time. However, this was further explored qualitatively in another study that showed high uptake was also linked to high use of MH products, particularly the reusable pads (41).

Conclusion
Overall, the study results showed high uptake of the MH service among young women as part of a multicomponent SRH service package. The provision of MH education, analgesics, and a choice of MH products through comprehensive MH interventions may serve as a pathway to increase female engagement with other important SRH services such as family planning and HIV testing (17,19,41,50).
These study ndings should encourage policymakers to increase their commitment to integrated service SRH provision that sets MH as a key part of reproductive health for young women. Availability of data and materials

Abbreviations
The datasets used and/or analysed during the current study are available from the corresponding author on request.
Authors' contributions MT designed the menstrual health intervention, and collected, analysed, and interpreted the data, and drafted the manuscript. SCF, HAW, and JR contributed to design of the MH intervention and the analysis plan. CMY and HAW were major contributors in writing the manuscript. MT and VS prepared all the gures and tables. VS, HAW, and LL assisted in analysing the quantitative data. TN, PI, NG, RN, PN and SB assisted with qualitative data collection and analysis. TB and NR assisted with quantitative data collection and management. RAF is the Principal Investigator of the CHIEDZA Trial. RAF, CDC, CVM, and ED contributed to the coordination of the study and critical revisions of the manuscript. All authors read and approved the nal manuscript.

Competing interests
No competing interests. MH product choice strati ed by province and age group