A pilot survey of students’ menstrual attitudes, experiences, and needs on an urban university campus

Abstract

Background:

In the United States, many menstruators face barriers to period management, such as period poverty, or the lack of access to relevant knowledge and affordable menstrual products. Our current understanding of the social, emotional, and physical impacts of period poverty on students in post-secondary institutions is largely limited.

Objectives:

The purpose of this pilot study is to assess period poverty, period-related class disruption, and avoidance of menstrual hygiene management on campus among students and to identify recommendations for action at the University of Illinois Chicago and other urban universities.

Design:

An online cross-sectional study from February to May 2023.

Methods:

Enrolled students who were at least 18 years old completed an anonymous, self-administered online survey. Through descriptive statistics and chi-square tests in SAS version 9.4, we analyzed the sociodemographic, academic, and menstrual characteristics of those who had a period in the past 12 months. We also performed a thematic analysis of students’ open-ended responses regarding their menstrual experiences on campus.

Results:

Of our sample (N = 106), 17.1% of students have faced period poverty, 55.8% experienced period-related class disruption, and 47.5% avoided changing their menstrual products on campus. The relationships between the three menstrual experiences were statistically significant. In the open responses, students reported that their personal experiences with menstruation were largely painful and disruptive. We identified the following themes: (1) inadequate water, sanitation, and hygiene facilities; (2) understocked, empty, or non-existent menstrual product dispensers; (3) a desire for additional resources for menstruation; and (4) the unpredictability of menstruation.

Conclusion:

Our findings indicate that students continue to face obstacles to menstruation management due to inadequate support related to menstrual infrastructure, products, and pain. We outline several recommendations for university/college institutions to prioritize a more inclusive and supportive educational environment for all students.

Plain Language Summary

Students’ experiences of menstrual periods while on an urban university campus

In the United States, many girls, women, and other menstruators encounter challenges while managing their menstrual periods. Such barriers include period poverty, or the inability to afford resources and menstrual products such as tampons or pads. In this study, we explored how period poverty impacts college/university students. We shared an online survey with 106 students who were older than 18 years, had a period in the last 12 months, and attended the University of Illinois Chicago. We asked them about their menstrual, social, and academic experiences. We found that approximately one in six students could not afford menstrual products at some point in their lives, over half missed all or portions of class due to their period, and about one in two students avoided changing their menstrual products on campus. The relationships between these three menstrual experiences were statistically significant. Many students also reported that periods were largely painful, disruptive, and unpredictable and that their campus had few physical resources and more obstacles to managing menstruation. From our findings, we identified several steps that universities and colleges can take to prioritize a more inclusive and supportive educational environment for all students.

Background

In recent years, there has been a notable surge in global initiatives to make menstrual products free in public settings, such as schools, prisons, and homeless shelters, tax-free in stores, and reimbursable through government programs.^{1 –7} These efforts are in part addressing “period poverty,” defined as a lack of financial access to proper menstrual management resources including knowledge and materials.^{1,8 –10} According to the World Bank, period poverty affects more than 500 million women worldwide, including people in the United States.^{9,11 –14} In a recent survey of 1020 teens (ages 13–19 years) and 1050 adults (ages 20–50 years) who menstruate, 23% of teens and 34% of adults could not afford menstrual products. ¹⁵

A growing body of global research has demonstrated that period poverty has several social, emotional, and physical implications.^{1,10 –12,16,17} Peer-reviewed studies have found that menstruators navigate the challenges of menstrual hygiene management (MHM) by often skipping meals to reduce costs, using menstrual materials longer than recommended, or acquiring products through transactional sex, thereby risking infections, such as bacterial vaginosis, toxic shock syndrome (TSS), and other detrimental health impacts.^{10 –12,16,17} Without access to menstrual products, people sometimes miss class, work, or other activities.^12,14,18,19 Period poverty in the United States is under-researched and often focuses on the experiences and impact on secondary school, low income, and homeless populations.^1,20 Our understanding of period poverty among students attending post-secondary institutions is further limited.^1,20

Recent literature demonstrates the urgent need to address period poverty among this population. A survey commissioned in the United States by an international sexual and reproductive health brand in late 2023 found that 18.7% of 1321 college students felt forced to decide between purchasing menstrual products and managing other basic expenses, such as bills and food. ²¹ Many college students are vulnerable to stress and anxiety which can disrupt their academic performance and attendance; this perceived stress amplifies the effects of chronic financial pressure on college students’ academic, social, and psychological health and well-being long into their adult years.^22,23 The association between period poverty and mental health has also been also examined. In a 2021 study of a national sample of 471 college women aged 18–24 years, 14% of undergraduate women experienced period poverty at least once in the past year, and approximately two-thirds of those who reported monthly period poverty also experienced moderate–severe depression. ¹³ Often, the effects of period poverty are particularly exacerbated for college and university students.^13,24

Addressing university students’ menstrual needs is important for ensuring that students remain engaged while in their program, successfully complete their studies, and experience the lifetime benefits of pursuing higher education, including economic and gender equity.^20,21 The current gap in literature calls for more attention to the role of post-secondary institutions in supporting the menstrual health of their students. In a qualitative study at a public university in the Midwest, students found that their university’s recent program that offered free tampons and pads in campus bathrooms made them feel supported by the university community and helped to normalize menstruation and reduce period taboos. ²⁰ At the same time, many students were unaware of the details and implementation of the period policy, reducing their opportunity to access the free menstrual supplies. ²⁰ Continued assessment of students’ menstrual attitudes and challenges across university settings is needed so that post-secondary institutions, including those that have implemented menstrual product programs, can evaluate the impact of their initiatives and understand what steps are needed to ensure that their campuses support students’ current menstrual needs.

Research questions

To further understand the menstrual attitudes, experiences, needs, and recommendations of students enrolled in post-secondary institutions, we explored the following research questions:

• How prevalent are period poverty and period-related class disruption on campus among students who had a period in the last 12 months?

• Why do students experience period-related class disruption and avoid changing their menstrual products on campus?

• How can a post-secondary institution support its students’ needs surrounding MHM and overall menstrual knowledge?

Methods

Study design

We obtained data from the Assessment of Menstrual Attitudes, Knowledge, Experiences, and Needs of Students at a Post-Secondary Institution, a pilot, cross-sectional observational study that we conducted from February 2023 to May 2023 at the University of Illinois Chicago (UIC). The UIC Institutional Review Board reviewed and approved this study (#2022-1348).

Setting and research team

UIC is a post-secondary Minority-Serving Institution (MSI) in a large, urban city in the Midwest, serving more than 33,000 undergraduate and graduate students. At UIC, the research team were members of a student-led menstrual advocacy initiative, Blood Buds, which has distributed more than 1,000 free menstrual cups to the University of Illinois and local Chicago community since February 2021. During study preparation and data collection, A.S., S.K., D.K., K.N., and M.L.T.N. were all female-identifying students of color pursuing pre-health and health degrees at UIC, including three graduate and two undergraduate students. S.D.M., a female-identifying research faculty member of color, has an extensive research background in sexual, reproductive, and menstrual health.

In August 2021, there were two significant changes at UIC: (1) the university provided approximately 30 bathrooms with dispensers stocked with free menstrual pads and tampons based on the recommendation of Blood Buds and three other student organizations, and after that, (2) the Illinois Governor approved legislation that mandated the supply of free menstrual products at public universities and community colleges to combat period poverty. ²⁵

Sample recruitment

Participants were eligible to complete the survey if they could understand English, were at least 18 years old, and were enrolled at UIC any time within the 2022–2023 academic year (August 2022–July 2023). We identified eligible participants using convenience and snowball sampling methods. We contacted university offices, cultural centers, student-based listservs, and student organizations for approval from appropriate representatives to help promote students’ awareness of the survey. Then we disseminated electronic and physical flyers on campus and via email and social media posts. For the present analysis, we only included students who reported having menstruated in the past 12 months.

Data collection

To develop the survey questions, we adapted questions from previous studies related to period poverty among adolescents and disability.^{8,13,26 –29} The survey instrument was tested by the research team and two other students: a nonbinary undergraduate menstruator and a cis-male graduate student non-menstruator. As the study was conducted online, a student consultant with a vision impairment reviewed the survey for visual accessibility.

We collected data through an anonymous self-administered survey that took 10–30 min to complete on Research Electronic Data Capture (REDCap).^30,31 At the start of the survey, each student provided informed consent electronically and indicated whether they had been enrolled during the 2022–2023 academic year before proceeding. These were the only required questions. Participants could decline participation or withdraw at any time.

Sociodemographic characteristics

Sociodemographic information was requested including age in years, race, ethnicity, gender, and disability status. Disability status (yes versus no) was evaluated with respect to serious difficulty with seeing, hearing, mobility, cognition, self-care, and independence using the same definitions applied in the American Community Survey. ²⁹ Characteristics related to student status were also collected and included educational level (“Undergraduate,” “Graduate,” or “Other”), days per week on campus (“0–1,” “2–3,” or “4 or more days”), and residency (“In-state,” “Out-of-state,” or “International”).

Menstrual experiences

We examined students’ menstrual experience, including primary or secondary school-based menstrual education (yes versus no), number of period-related symptoms (0, ⩽ 5, > 5), and last period product used (pads, tampons, reusable products). Menstrual cups, reusable pads and disks, and period underwear and “Nothing/Free-bleeding” were classified as reusable. Respondents could select multiple symptoms as listed in Supplemental Appendix A. Confidence managing menses on campus and at home was measured through a scale from 1 = “Not confident at all” to 5 = “Completely confident” with respect to the following: “Finding a menstrual product, changing it as much as you need to, and washing/disposing of it after you are finished with it.” For our analyses, we dichotomized confidence to manage menses as “Completely confident” versus “Less than completely confident,” which included responses 1, 2, 3, and 4. Finally, we asked students how comfortable they were discussing their own or others’ periods (“Very uncomfortable,” “Moderately uncomfortable,” “Neutral,” “Moderately comfortable,” or “Very comfortable”). Comfort discussing periods were collapsed into the variables: “Very or moderately comfortable,” “Neutral,” and “Not very or moderately comfortable.”

Period poverty, class disruption, and MHM avoidance

To assess period poverty, participants were asked if they had ever not been able to afford menstrual products (“Yes,” “No,” or “Don’t know”) and the frequency of this experience in the last 12 months (“Always,” “Often,” “Sometimes,” “Rarely,” or “Never”). Students who experienced period poverty or did not know were asked what they did when they did not have enough money to purchase products. They could select as many answers as applied: “Used other materials (e.g. toilet paper, tissues, cloth, rag) as menstrual products”; “Borrowed menstrual products (e.g. from friends, coworkers, strangers)”; “Used a menstrual product longer than advised/preferred”; “Had to go without menstrual products (i.e. free bleed)”; “I have always had enough money to purchase menstrual products”; “Other.”

Participants indicated their experience of period-related class disruption by responding “Yes,” “No,” or “I don’t know” to the questions: “Have you ever missed, had to leave, or arrived late for class for period-related reasons? (select all that apply).” We assessed reasons for class disruption to those who said “Yes” to at least one circumstance. Those who indicated “I don’t know” and no other response related to class disruption were marked missing. Participants chose from six reasons for class disruption: “Did not have the products readily available to manage my menstrual flow”; “Menstrual cramps”; “Headaches”; “Menstrual blood leakage/had to clean a blood stain”; “Needed to change menstrual product”; “Unable to concentrate”; “Other.”

We evaluated whether anyone had ever avoided changing their menstrual product while on campus (yes versus no). Those who had ever avoided changing their product were asked why, and closed-ended responses were provided: “I worry that someone might hear or see me”; “I don’t have another menstrual product available”; “I do not have enough time”; “The toilet facilities are not sanitary”; “There is no place to dispose of/empty my period product”; “I don’t need to change my menstrual product while on campus”; “Other.”

Attitudes and open-ended responses

We asked two questions to understand how student’s attitudes and experiences related to periods. These open-ended questions were “What words would you use to describe periods generally?” and “Final question: Is there anything you wish we knew about your experience with periods while being a student on campus?”

Data analysis

After cleaning the data, we presented descriptive statistics of the sample’s characteristics and prevalence of the primary menstrual experiences (period poverty, class disruption, and MHM avoidance). We performed chi-square tests on our hypothesized, conceptual model of the relationships between period poverty, class disruption, and MHM avoidance (Figure 2). After testing whether the demographic characteristics were associated with the three primary variables, we found that there were no statistical associations and omitted the relationships from our analysis. The level of significance was p ⩽ 0.05, and we conducted the statistical analyses in SAS version 9.4 software.

Figure 2.

Conceptual model of menstrual experiences of university students on campus.

After familiarization and discussion of responses, we generated a word cloud in Voyant Tools to visualize the frequency of open-text terms used to describe menstruation. ³² We also analyzed students’ open responses on their final thoughts on the campus menstrual experience through conventional qualitative content analysis. We reviewed the data multiple times, assigned codes to repeated phrases or ideas, and then categorized the codes to identify themes.^33,34 We followed the STROBE guidelines for reporting cross-sectional studies during the preparation of the article. ³⁵

Results

Of 151 survey submissions, 118 (78.1%) students provided informed consent and completed the survey. There were 111 (94.1%) students who indicated ever having a menstrual period, of whom 106 (95.5%) experienced it in the past 12 months.

Sociodemographic characteristics

In Table 1, participants were a median age of 24 years, ranging from 18 to 42 years. While most respondents identified as cis-women, there were a few gender-nonbinary students (5.7%). Most participants were White (43.1%), non-Hispanic (84.0%), graduate-level (57.1%), and in-state (76.4%) students who went to campus four or more times per week (50.0%). Approximately one in five students reported a disability (21.2%). The disabilities reported included significant serious difficulties with (1) concentrating, remembering, or making decisions (20.8%); (2) doing errands alone due to a physical, mental, or emotional condition (5.7%); (3) walking or climbing stairs (1.9%); (4) seeing even when wearing glasses (1.9%); and (5) dressing or bathing (0.9%).

Table 1.

Sociodemographic, academic, and menstrual characteristics of university students who had a period in the last 12 months (N = 106).

Characteristic	Frequency	%
Sociodemographic
Median age, years (range) (n = 106)	24 (18–42)
Disability status (n = 106) a
Has a disability	25	21.2
Has no disability	81	68.6
Gender (n = 106) b
Cis woman	100	94.3
Gender nonbinary c	6	5.7
Race (n = 91) d
White	44	43.1
Asian	37	36.3
Black/African American	3	2.9
Middle Eastern and North African	1	1.0
More than one race selected	5	4.9
Other	1	1.0
Ethnicity (n = 106)
Hispanic or Latino	17	16.0
Not Hispanic or Latino	89	84.0
Academic
Educational level (n = 105)
Graduate	60	57.1
Undergraduate	41	39.0
Other	4	3.8
Student residency (n = 106)
In-state	81	76.4
Out-of-state	19	17.9
International	6	5.7
Days on campus (n = 106)
⩾4	53	50.0
2–3	40	37.7
0–1	13	12.3
Menstrual
School-based menstrual education (n = 104)
Yes	80	76.9
No	24	23.1
Menstrual-related symptoms (n = 105)
>5	59	56.2
0–5	46	43.8
Most recent period product used (n = 105)
Pads	53	50.5
Tampons	27	25.7
Reusable products	25	23.8
Confidence to manage period on campus (n = 106)
Completely confident	15	14.1
Not completely confident	91	85.9
Confidence to manage period at home (n = 106)
Completely confident	95	89.6
Not completely confident	11	10.4
Comfort discussing periods (n = 106)
Very or moderately comfortable	70	66.0
Neutral	13	12.3
Not very or moderately comfortable	23	21.7

^aTypes of disability reported overall included (1) concentrating, remembering, or making decisions (20.8%); (2) doing errands alone due to a physical, mental, or emotional condition (5.7%); (3) walking or climbing stairs (1.9%); (4) seeing even when wearing glasses (1.9%); and (5) dressing or bathing (0.9%), but no reported a Hearing Disability.

^bNo student identified as a Trans-man or woman.

^cStudents selected the multiple-choice option “Gender-nonconforming/nonbinary/expansive.”

^dPossibilities for race also included American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander. No student selected Native Hawaiian or Other Pacific Islander.

Menstruation experiences

A majority (56.2%) of students reported having more than five period-related symptoms. The most common symptoms were feeling moody, stressed, or depressed; fatigue; pain and consistent cramping; and food cravings (Figure 1(a)). Pads were the most frequent primary period product used (50.5%), followed by tampons (25.7%), and then reusable products (23.8%) (Table 1). Finally, while most students (89.6%) reported feeling completely confident to manage menses at home, just 14.1% of respondents felt completely confident managing their periods while on campus (Table 1).

Figure 1.

Four menstruation experiences reported by students: (a) students’ menstrual symptoms (n = 106); (b) actions taken when students could not afford menstrual products, also referred to as period poverty (n = 19); (c) period-related reasons that students missed class, arrived late, and left early (n = 58); and (d) reasons why students avoided changing their menstrual product on campus (n = 48).

As reported in Table 2, 17.1% of participants had ever experienced period poverty, and 61.1% of those students experienced period poverty within the past 12 months (always, often, sometimes, or rarely). In the survey, students reported that they resorted to potentially unsafe practices when they were unable to afford menstrual products, such as using improvised non-menstrual products, extending the use of their products beyond recommended guidelines, and going without any products at all (Figure 1(b)). Half of the respondents who had periods in the past year (55.8%) experienced difficulties attending classes due to period-related reasons (Table 2). Students indicated that the top reasons they missed classes due to menstrual-related issues were menstrual cramps, menstrual blood leakage or stain cleanup, and needing to change their menstrual products (Figure 1(c)). Nearly half of the respondents (47.5%) reported avoiding changing their menstrual products on campus, and the most common reasons were insufficient time, a lack of available menstrual products, inadequate disposal and emptying facilities, and unsanitary toilet facilities (Table 2, Figure 1(d)). Finally, based on the chi-square tests which had a p-value less than 0.02, we identified that period poverty and class disruption, period poverty and MHM avoidance, and class disruption and MHM avoidance were all significantly associated (Table 3).

Table 2.

Prevalence of period poverty, period-related class disruption, and hygiene management avoidance on campus among university students who had a period in the last 12 months (N = 106).

Indicator	Frequency	%
Experienced period poverty ever (n = 105)
Yes	19	17.1
No	86	81.9
Experienced period poverty in past year (n = 19)
Always	1	5.3
Often	1	5.3
Sometimes	7	36.8
Rarely	2	10.5
Never	8	42.1
Missed class, arrived late, or left early (class disruption) for period-related reasons (n = 104)
Yes	58	55.8
No	46	44.2
Avoided changing menstrual products on campus (MHM avoidance) (n = 101)
Yes	48	47.5
No	53	52.5

Table 3.

Association between the primary menstrual experiences (period poverty, period-related class disruption, and avoidance of MHM) based on the conceptual model in Figure 2.

Relationship	N (%)	N (%)	χ² (p)*
(1)	Class disruption 53 (53.0)	No class disruption 47 (47.0)	0.002*
Period poverty	14 (87.5)	2 (12.5)
No period poverty	39 (46.4)	45 (53.6)
(2)	MHM avoidance 47 (48.0)	No MHM avoidance 51 (52.0)	0.017*
Period poverty	12 (85.7)	4 (14.3)
No period poverty	35 (42.7)	47 (57.3)
(3)	MHM avoidance 46 (46.9)	No MHM avoidance 52 (53.1)	<0.001*
Class disruption	33 (63.5)	19 (36.5)
No class disruption	13 (28.3)	33 (71.7)

^*Chi-square test (χ²) with Fisher’s exact test applied in comparisons where there is a cell with n < 5. These p-values less than 0.05 are significant.

Attitudes and perspectives on menstruation

In our qualitative analyses, students (n = 81) provided words and statements to describe their menstruation. Responses described the biological process of menstruation, menstrual period flow (heavy, moderate, light), feelings about the experience of seeing blood itself, and the physical and mental impacts on the body and students’ time. Many also touched on the current stigmatization of menstruation. The most common words students used to describe menstruation were “painful”/“pain” (n = 39), “inconvenient”/“inconvenience” (n = 15), and “discomfort”/“uncomfortable” (n = 11). Some individuals found that menstruation was “rewarding,” “interesting,” “useful,” and “unique” and allowed students to be “introspective” or “aware of my body” (Figure 3).

Figure 3.

Word cloud of key terms from university students’ responses to the survey question: “What words would you use to describe periods generally?” (n = 81).

A small minority of students agreed with the following statements: “The use of insert-type menstrual products (i.e. tampons, menstrual cups) may cause a loss of virginity,” and that “Menstrual cramps are often exaggerated.” Almost all agreed that “Menstruation is a normal and healthy part of life.” There was more variability around sentiments related to menstrual blood being dirty, refraining from religious activities during menses, whether code words should be used when discussing menstruation, whether it is normal to have really painful periods, and whether cloth reusable pads were unsanitary (Figure 4).

Figure 4.

Attitudes of menstruation among students who had a period in the last 12 months (n = 106).

About one-third of students (n = 37; 34.9%), including eight non-responses, provided open-ended responses to the prompt: “Final question: Is there anything you wish we knew about your experience with periods while being a student on campus?” When we analyzed these responses for university-related recommendations, we found that students highlighted (1) a lack of water, sanitation, and hygiene (WASH) facilities; (2) understocked or empty menstrual product dispensers and the need for free menstrual products in more locations across campus; (3) a desire for additional resources for menstruation; and (4) menstruation’s unpredictability (Table 4).

Table 4.

Illustrative quotations from the thematic analysis of students’ recommendations and experiences with menstrual periods while on campus (n = 37).

Themes	Representative Quotes
Inadequate WASH facilities (n = 14)	• “Not all campus bathroom stalls have bins to place disposed-of pads or tampons which is very uncomfortable and unacceptable honestly. having a location to dispose of your period product discreetly, if desired, is essential.”
	• “No, I use a menstrual cup and don’t often need to empty/wash on campus, however, it would be difficult to empty/wash on campus as many bathrooms have multiple stalls with sinks inaccessible from the stall.”
	• “I[t] would be nice if there were sanitizing products (wipes/spray) available in the stall so I could clean my hands and not contaminate all the surfaces for the next person.”
	• “I have avoided using my menstrual cup on campus due to there not being single bathrooms to be able to empty, clean, and re-insert the cup.”
Understocked, empty, or non-existent menstrual product dispensers (n = 9)	• “[Dispensers] are usually understocked or completely empty, which defeats the purpose. I also think dispensers should be outside of bathrooms, so that people who feel more comfortable using the men’s bathroom, but also menstruate can access products!”
	• “Not all bathrooms are always stocked with period products such as pads and tampons.”
	• “I would like to see more stations offering free menstrual products in the bathrooms, especially in SPH.”
	• “I don’t feel like there are enough visible period product dispensers or free products around campus, especially in bathrooms.”
Desire for additional resources for menstruation (n = 6)	• “I wish sometimes that it was easier to find a place to sit/relax while I’m cramping. It can be difficult sometimes to find seating normally but when I’m on my period and cramping, it makes it harder to get around.”
	• “being knowledgeable about periods isn’t enough. access is more than knowledge, but period knowledge should be the starting point. Remote learning would have really helped me out on my bad period days.”
	• “I would love to try period underwear as I feel that is easy to learn. Also, I wish there was more support on how to use some of the reusable products. . . But more info on how to use reusable products etc would be great.”
	• “I think for some women period can be very painful but it shouldn’t be the case so maybe having also painkillers in certain places might help incase a person cannot afford pain killers or forgot their own”
Unpredictability of Menstruation (n = 4)	• I don’t like using something that isn’t sustainable, but my confidence that it will prevent me from being embarrassed by a surprise leak etc - is a primary reason for investing in a less sustainable/more expensive product.
	• it really sucks when your period stains your pants. i had to take a walk of shame to the bookstore to buy pants. i feel awkward leaving to change my pad in the middle of class bc all my period products are in my backpack.”
	• “. . .Having periods on campus can be scary and devastating at the same time. One time, I was coming back from class. By the time I went to the restroom, I pulled down my pants and undies and instantly freaked out. Also, I noticed a red stain.”
	• “Periods are not as predictable as is assumed. Also, many women in Perimenopause experience significant systems and inability to know the timing of periods.”

Four excerpts from responses are shown from each theme. See Appendix B for participants’ full responses.

Discussion

In this analysis of students who had a period in the past 12 months, approximately one in six students (17.1%) have faced financial barriers to obtaining menstrual products at some point in their lives, and over half (55.8%) experienced difficulties attending classes due to period-related reasons. Similarly, about one in two students (47.5%) reported avoiding changing their menstrual products on campus. Unfortunately, students who could not afford menstrual products commonly reported that they used menstrual products longer than recommended and improvised with non-menstrual materials such as toilet paper and cloths, which can both contribute to irritation and discomfort.^16,17 In addition, we found that experiencing period poverty had a significantly higher probability of missing class time for period-related reasons and avoiding MHM on campus, and the association between the latter two menstrual experiences (class disruption and MHM avoidance) was also statistically significant.

The present findings are consistent with a mixed-method study of female participants aged 13–24 years at two pediatric and adolescent outpatient clinics in an urban US city (N = 101). ³⁶ Almost one in five participants (18.8%) were not able to afford menstrual products, and nearly half (54.5%) of the participants missed work or school due to menses because of cramps (78.2%), heavy flow (40.0%), lack of menstrual products (7.3%), and other reasons. ³⁶ Class disruption in our study was slightly less prevalent than in another study examining period poverty and absenteeism in St Louis, Missouri (N = 119). Two in three high school students with menstrual periods missed a day in school monthly for at least one period-related reason, including for cramps (78.7%), heavy flow (71.7%), bad odor (41%), and lack of period products (33.6%). ¹⁹ Overall, these experiences can result in stress, anxiety, and social stigma and influence young people to stay home instead of engaging in their academic and extracurricular commitments.^19,26,37

In our qualitative analysis of open-ended responses, we identified that students reported structural difficulties with managing menstruation on campus. The respondents underscored that the bathrooms they sometimes used lacked adequate disposal systems for menstrual products and sinks or other cleaning resources accessible from bathroom stalls. While their personal experiences with menstruation were painful and disruptive, students did not express or endorse negative and stigmatizing views on menstruation. In fact, they overwhelmingly agreed that “menstruation is a normal and healthy part of life” and wished that more effort was done to reduce menstrual stigma around menstruation and menstrual products at the university. Menstrual researchers and advocates have identified that menstrual stigmas can reinforce challenges.^{10,11,38 –40} Within this context, students were overwhelmingly more confident when at home than on campus (89.6% versus 14.2% completely confident, respectively). Our results align with a similar study conducted with university students in Australia, where only 16.2% of students felt completely confident in managing menstruation on campus. ²⁷ The stark contrast in confidence in period management between home and school indicates that barriers to menstrual hygiene and health management on campus still exist. Our findings underscore the urgent need (1) to ensure that all individuals have access to safe and affordable menstrual products along with a safe, convenient, and sanitary environment for students to comfortably manage their menstrual needs and (2) to dismantle the institutional stigma surrounding menstruation.

In proposing strategies to enhance support for menstrual challenges on university campuses, students have suggested increased access to reusable period products. Reusable period products, such as menstrual cups or cloth pads, are often more cost-effective in the long run compared to disposable alternatives. They may significantly reduce the financial burden on students who may be struggling with period poverty. ⁴¹ Despite the benefits, in our study, only 23.8% of students stated that they use reusable products, and in the open-ended response, some participants mentioned that reusable products are often expensive.

Previous studies have found additional barriers to using sustainable period products. These include lack of education on how to use them, unawareness of the existence of these products, and stigmas surrounding these products (e.g. vaginal insertion of menstrual cups is taboo and reusable menstrual items are often seen as dirty).^37,42 A recent qualitative study found that university students are interested in having eco-friendly products available on campus along with more education. ²⁰ In addition to limited knowledge, inadequate privacy restricts menstruators’ ability to change, clean, and store their menstrual cups.^27,41 Similarly, students in our study who used menstrual cups found it difficult to change and clean their cups privately in the current bathroom facilities. With that in mind, implementing broader distributions of sustainable products will require effort to increase knowledge, de-stigmatize reusable menstrual products, and improve WASH facilities on campus.

In recent years, Illinois and other states passed legislation mandating educational institutions to provide access to free menstrual products to their students. The lack of a plan to evaluate the programs’ feasibility and impact is a significant institutional oversight.^25,43 Although students on this campus benefit from the availability of free disposable pads and tampons in specific bathrooms today, students reported that product dispensers were often left empty or did not exist in some university buildings. According to researchers who studied four US universities with free menstrual product initiatives, the success and sustainability of free product distributions depend on stable funding, stocked and maintained dispensers, and continued conversation to expand menstrual product access across campus. ⁴³ Moreover, this assessment at our university highlights the need for accountability to make our current and future solutions to period poverty and class disruption sustainable.

Strengths and limitations

Our study had several strengths. We sought the inclusion and perspective of people who had periods, recognizing that not all women menstruate, and not all menstruators are women. The online survey design allowed large amounts of information to be gathered. We found that environmental and programmatic sustainability may be important to consider in dialogues and studies related to MHM outcomes for our campus and potentially other university students. Furthermore, this pilot study initiated a campus-wide discussion about the small, yet growing body of research and advocacy surrounding period poverty in high-income countries and among university students.

Although this study aimed to recruit 600 students, only 118 (22.8%) menstruators and non-menstruators completed the survey. Several subgroups of age, gender, race, and ethnicity, and undergraduate students in general, were underrepresented compared to the university’s demographics. ⁴⁴ This limited our power to detect differences between demographic characteristics and our primary outcomes. Overall, this study’s small sample size limits the generalizability of findings and widespread application to other US post-secondary institutions. Future studies may be able to combat recruitment issues by providing incentives for participants’ significant time investment (15–30 min), recruiting at large events, and using community ambassadors to assist with recruitment.

It would have been valuable to include student majors, primary campus, and students’ working status/how they pay for school. Along with their financial status, indicators such as food and housing security are correlated to one’s ability to afford period products and can inform the interventional and basic needs of students.^12,14 Further considerations for future study include assessing comfort with discussing menstruation in professional versus personal contexts and whether students experience the same ease in discussing their periods with friends as they do with professors and university administrators, which can play a role in advocating for one’s health on university campuses. For future research, we hope to incorporate validated measures and resources such as the Beliefs About And Attitudes Toward Menstruation (BATM) instrument. ⁴⁵

Recommendations

Based on these pilot survey findings, post-secondary institutions should consider a multifaceted approach that involves student feedback in the design, execution, and evaluation of menstrual programs. To support students’ menstrual needs and promote menstrual equity, colleges and universities should:

1. Commit to increasing and sustaining the availability of free menstrual products and pain-relief resources on campus.

2. Provide educational resources on menstrual health and hygiene management along with programming on menstrual equity and stigma reduction.

3. Engage university administration in the recruitment and provision of incentives to a more diverse group of students for future evaluations, research, and task forces related to students’ menstrual needs.

Improving menstruation management for students should be done through the lens of intersectionality. In the United States, certain populations are disproportionately affected by period poverty including people who are low income, experiencing homelessness, from underrepresented racial/ethnic groups, and Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, and more identities (LGBTQ+).^{14,46 –49} In other surveys on period poverty among high school and college-age students, Latina and Black women faced a statistically significant increase in period poverty as compared to White women and women of other races.^11,13,50 Gender-nonconforming people, trans-men, and other gender-diverse individuals who menstruate are often overlooked in period poverty interventions and research.^{47,51 –53} They may experience inadequate access to safe and private washroom facilities, gender dysphoria during menstruation, and/or difficulty finding gender-affirming healthcare and period products, and some choose to stay at home.^18,52,53 People with physical, intellectual, mental, and sensory disabilities may face the additional stigmas surrounding disability and reproduction/sexuality and a harmful history of forced sterilization and other medical means to suppress menstruation.^{38,54 –56} The limited research surrounding disability and menstruation highlights systemic barriers to clean and physically accessible bathroom facilities, affordable and needs-appropriate menstrual products, and knowledge for themselves and caretakers about how to manage menstruation.^38,54,57 Given that menstrual disparities persist, an important next step in mitigating further harm to people with periods is studying period poverty and its outcomes on students with an array of marginalized identities.

Menstrual inequity manifests itself in the form of a lack of access to menstrual products, difficulties in managing pain, persistent stigmas and misinformation, and disruptions to academic performance. Our exploratory research underscores the need for universities to prioritize and enhance support for students who struggle to manage their menses. By acknowledging the impact of period poverty and menstrual health on the campus experience, identifying the existing gaps in menstrual support and knowledge, and taking proactive measures to address these issues, institutions can contribute to a more inclusive and supportive educational environment for all students.