Table 1.
Final shortlist of indicators for monitoring adolescent girls' menstrual health and hygiene at national and global level
| Domain | Indicator | Evidence and importance | Indicator type |
|---|---|---|---|
| Materials | 1. % of girls who reported having enough menstrual materials during their last period. | A single individual-level indicator was selected to capture girls' access to materials to catch or absorb menses with sufficient clean material, an essential requirement for MHH [33,37]. This indicator was developed based on an item from the Menstrual Practice Needs Scale [48] to provide an assessment of access to sufficient quantities of absorbent. This was prioritized as a basic level of assessment, where use of preferred materials could be considered indicative of greater access. | Individual outcome |
| Materials | 2. % of schools with menstrual materials available to girls in case of an emergency. | The availability of materials in schools in the case of unexpected need was a new indicator developed by the core group adapted from data collected in the Philippines Department of Education monitoring [49]. The indicator reflects policies aimed at supporting consistent access to menstrual materials. It does not require the availability of free products for all of girls' material needs as this approach is pursued in a limited number of countries and may not be feasible or best practice for all. | School output |
| WASH | 3. % of girls who reported changing their menstrual materials during their last menstrual period at school. | MHH requires supportive facilities to care for the body. The experience of these spaces can only be captured among those using them by capturing the proportion of girls who have used school spaces for changing menstrual materials. Indicator 3 provides a denominator for indicator 4, along with context for interpreting indicators 5–7 as the presence and quality of facilities are relevant if they are being used. | Individual outcome |
| WASH | 4. % of girls who changed their menstrual materials at school in a space that was clean, private, and safe during their last menstrual period. | Indicator 4 is an individual-level indicator capturing girls' experience of menstrual-friendly facilities for blood management tasks at school. Nationally representative data on the quality (cleanliness, privacy, safety) of spaces used to change menstrual materials have been collected in PMA [25] and JMP MICS [30] programs, with the shortlisted indicator drawing on advancements in assessing privacy and safety in self-report [29,48,50]. | Individual outcome |
| WASH | 5. % of schools (primary/secondary) with improved sanitation facilities that are single-sex and usable (available, functional, and private) at the time of the survey. | Indicators 5–7 can be assessed at the school level to appraise the quality of facilities provided to girls for menstrual self-care. Increasing criteria are applied, capturing the availability of facilities, menstrual-friendly features, and the availability of resources for washing. Indicators are drawn from monitoring undertaken by the JMP [51] and in two exemplar countries (Bangladesh and the Philippines) [49,52]. The indicator provides direct feedback to government on the condition of supportive WASH facilities in schools for MHH. | School output |
| WASH | 6. % of (primary/secondary) schools with improved sanitation facilities that are single-sex, usable (available, functional, and private), lockable from the inside, have covered disposal bins, and have disposal mechanisms at the time of the survey. | School output | |
| WASH | 7. % of (primary/secondary) schools that have water and soap available in a private space for girls to manage menstruation. | School output | |
| Knowledge | 8. % of students (male/female) who have received education about menstruation in primary and secondary school. | An individual-level outcome monitored in exemplar country, Bangladesh [52], this indicator captures the receipt of menstrual education. The indicator can be captured for male and female students. As a basic level of assessment, the indicator captures the receipt of any education, with additional criteria such as quality or content feasible for higher-level assessments. | Individual outcome |
| Knowledge | 9. % of females who know about menstruation prior to menarche. | Timely menstrual cycle knowledge is essential for MHH. Awareness of menstruation at menarche has been assessed in nationally representative surveys and many smaller data collections [30,44,53]. It was developed as an indicator and recommended by the 2019 Monitoring MHH activities preceding the shortlisting effort [20]. | Individual outcome |
| Knowledge | 10. % of females with correct knowledge of the fertile period during the ovulatory cycle. | Indicator 10 has been routinely captured for women 15–49 in nationally representative Demographic and Health Surveys [45], assessing key knowledge related to the menstrual cycle and its links with reproductive health and fertility [32]. Thus, data are available for older age groups, and the indicator can be incorporated into assessments among adolescent girls to provide a more comprehensive picture of menstrual cycle awareness and education received. | Individual outcome |
| Knowledge | 11. % of schools where education about menstruation is provided for students from age 9. | Indicator 11 captures school-level implementation of menstrual education in curriculum, providing direct feedback where policies or plans incorporate attention to menstruation in curriculum or a baseline where the guidance is absence. The indicator is drawn from monitoring in two exemplar countries (Bangladesh and the Philippines) [49,52]. Education prior to age 9 was selected to target information provision prior to menarche. | School output |
| Knowledge | 12. Existence of preservice or in-service teacher training about menstruation at the primary or secondary level. | The quality of menstrual education provided to girls is shaped by the support and training provided to teachers. Ensuring teacher comfort with menstrual topics also enables a supportive environment for menstruation in schools. Indicators 12 and 13 capture the coverage of training to equip teachers to provide education about menstruation. The indicator is based on current national monitoring in the Philippines [49] and could facilitate country-relevant targets being set, for example, a proportion of teachers beyond “at least one.” |
School output |
| Knowledge | 13. % of schools that have at least one teacher trained to educate primary/secondary students about menstruation. | School output | |
| Knowledge | 14. % of countries where national policy mandates education about menstruation at primary and secondary level. | This indicator is for use in global monitoring and was developed during the shortlisting activities to monitor the status of education mandated for menstruation across countries. | Policy input |
| Discomfort/disorders | 15. % of girls who report that they were able to reduce their menstrual (abdominal/back/cramping) pain when they needed to during their last menstrual period. | Review of current indicators and monitoring indicated gaps in available measures related to pain management or care for menstrual discomforts and disorders. Two individual indicators were developed by the core group. Indicator 15 provides a basic indication of girls' ability to reduce pain, informed by recent measures [54]; it does not provide information on the degree of relief or strategies for pain relief. | Individual outcome |
| Discomfort/disorders | 16. % of girls who would feel comfortable seeking help for menstrual problems from a health-care provider. | Menstrual concerns may require treatment or support from health-care providers. Indicator 16 was also developed by the core group to provide an indication of comfort approaching care providers, as a minimal step required for providing adolescent-friendly care for menstrual health concerns. | Individual outcome |
| Supportive social environment | 17. % of girls who have someone they feel comfortable asking for support (advice, resources, emotional support) regarding menstruation. | MHH requires a supportive environment, and adolescents require access to courses of advice and support. Review of indicators identified a dearth of evidence-based measures capturing psychosocial concepts. Indicator 17 was developed by the core group, drawn from measures used in research studies seeking to capture support for MHH [55,56]. | Individual outcome |
| Menstrual health impacts | 18. % of girls who report a period does not impact their day. | While most indicators capture requirements for supporting menstrual health, two indicators were identified to capture impacts on adolescent girls' lives. Indicator 18 was derived from the Global Early Adolescence Study, and similar measures used in research studies, to assess any overarching impact of menstruation on daily life [[57], [58], [59]]. | Individual impact |
| Menstrual health impacts | 19. % of girls whose class participation was not impacted by their last period. | Indicator 19 was developed based on indicators used in PMA and JMP MICS programs focused on the impacts of MHH on attendance at school or work [26,30]. The indicator was modified to capture the influence on participation, with absenteeism due to menstruation often difficult to capture accurately or sensitive to girls' discomforts or challenges while attending school [60,61]. | Individual impact |
| Policy | 20. % of countries with policies or plans that include menstrual health and hygiene. | Indicators 20 and 21 support global monitoring of progress toward supporting MHH. Informed by the GLAAS survey [62], these indicators capture the presence of policies or plans including MHH, such as those developed in the exemplar country, Kenya [12]. The importance of budget allocation was emphasized by exemplar country experts and is assessed in indicator 21, building on the World Bank SABER School Health Questionnaire [63]. | Policy input |
| Policy | 21. National budget is allocated to menstrual health and hygiene; funds are dispersed to the schools in a timely and efficient manner. | Policy input |
GLAAS, global analysis and assessment of sanitation and drinking-water; JMP = Joint Monitoring Program; MHH = menstrual health and hygiene; MICS = Multiple Indicator Cluster Surveys; SABER, systems approach for better education results; WASH = water, sanitation, and hygiene.