A bleeding shame: Period poverty, stigma and menstrual equity in a regional Australian university setting

Abstract

Background

Period poverty, defined as inadequate access to menstrual products, education and supportive infrastructure, is recognised as a public health, equity and human rights issue in both low- and high-income settings.

Objectives

To examine the extent and impact of period poverty among students at a regional Australian university, explore their lived experiences, coping strategies and the role of menstrual stigma, and evaluate awareness and use of Dignity Vending Machines (DVMs).

Design

Exploratory descriptive mixed-methods study.

Study duration

October 2023 to March 2024.

Methods

A cross-sectional online survey was administered to students at a regional Australian university. Quantitative data were analysed descriptively. Semi-structured interviews and open-ended survey responses were analysed thematically following Braun and Clarke’s framework.

Results

Among survey respondents, 69.2% reported at least occasional difficulty affording menstrual products, with 14.4% reporting frequent or chronic difficulty. This lack of access led to missed classes (55.1%), work absence (31.9%) and avoidance of sporting or leisure activities (72.5%). Coping strategies included switching to cheaper products (75.5%), extending wear time (68.4%) and improvising with other materials (43.9%). Over half of respondents (58.3%) were unaware of DVMs, and operational problems reduced trust and usability. Qualitative analysis identified three themes: financial precarity and undignified coping; the emotional and psychological toll of menstrual stigma; and the imperative for normalisation and educational advocacy.

Conclusion

Period poverty is a complex biopsychosocial issue among regional Australian university students, disrupting education, work and social participation. Free product provision via DVMs is valued but underutilised. Universities should adopt strategies that combine reliable free access to products with menstrual health literacy, stigma reduction, and efforts to address financial hardship and social exclusion.

Background

Period poverty is defined as the inability to afford or access menstrual products due to financial constraints or limited availability. ¹ This phenomenon can lead to a range of adverse health outcomes, psychological impacts such as stress, shame, embarrassment and low self-esteem, and significant social consequences, including absenteeism from school and work.^2–4 Period poverty encompasses a spectrum of experiences, ranging from a complete lack of access to menstrual products to having to choose between purchasing menstrual products and other necessities, such as food or rent, often leading to the use of inadequate or unsanitary alternatives.^5–7

Menstrual management refers to the ability to manage menstrual bleeding safely and with dignity, including access to appropriate products, adequate water and sanitation, privacy for changing, and safe disposal facilities. ¹ An estimated 500 million women of reproductive age worldwide lack access to adequate sanitation for menstrual management. ¹

Menstrual equity positions the responsibility for menstruation as systemic rather than individual, encompassing access to affordable products, along with the provision of accurate education, adequate sanitation, infrastructure and a social environment free from stigma and discrimination.^3,5,8 Applied to institutional settings, this framework draws attention to where policy gaps and a lack of awareness may be compounding disadvantage for those who menstruate.^3,8

In this paper, ‘insufficient infrastructure’ describes settings in which the physical and service-level supports needed for dignified menstrual management are inadequate or unreliable. In a university context, this may include toilets that lack privacy or disposal facilities, free product access points that are poorly stocked or non-functional, limited product variety, and unclear signage directing students to available resources.^4,9,10

Cultural norms, stigmas and taboos surrounding menstruation further exacerbate these challenges. ⁸ These social dimensions shape menstrual experiences in multiple ways: stigma can deter individuals from purchasing products openly or seeking help when in need; restrictive norms may limit open discussion within families, peer groups and educational settings; and the resulting silence can prevent people from recognising when their menstrual experiences warrant medical attention or support.^4,8,10 These factors create barriers that restrict access to products, discourage help-seeking and limit full participation in education, work and social life. Collectively, they work against the achievement of menstrual health, understood here as a state of complete physical, mental and social wellbeing in relation to the menstrual cycle.^8,11

While often associated with developing countries, recent research has revealed the significant prevalence of period poverty in high-income countries, including Australia.^8,12,13 Factors contributing to period poverty include rising living costs, stagnant wages and systemic inequalities that disproportionately affect low-income individuals, students and marginalised communities. ¹⁴ To address this global crisis, the United Nations has emphasised the importance of menstrual hygiene management as part of its Sustainable Development Goals, particularly Goals 3, 4, 5, 6 and 8.^11,15

The university environment presents a distinct context for examining period poverty due to the typical financial constraints among students and academic pressures that may exacerbate challenges associated with menstruation.^13,16 Munro and colleagues’ systematic review of menstrual experiences among university students globally found that inadequate product access, limited menstrual health knowledge and persistent stigma were common across diverse institutional and national contexts, with negative consequences for academic attendance, concentration and wellbeing. ¹⁷ In the United Kingdom, Ennis and colleagues found that a student-led initiative to provide free menstrual products on campus improved both access and awareness, but that sustained institutional support and visible promotion were critical to uptake. ¹⁸ The 2024 Bloody Big Survey, the largest Australian survey of menstrual experiences to date, confirmed that a substantial proportion of respondents had difficulty affording products, with younger people and those on lower incomes disproportionately affected. ¹² Similarly, Suleman and colleagues reported that among students at an urban American university, many were unaware of free product services on campus, and that financial strain and stigma together reduced students’ willingness to seek support. ¹⁹

Students in regional universities face additional layers of vulnerability. In Australia, regional university students have been reported to experience lower average incomes, higher rates of financial hardship and potential isolation from support services compared with their urban counterparts. ²⁰ These factors can disproportionately affect their ability to afford essential items, including menstrual products. ²¹ Period poverty in regional university settings is not merely a reflection of a national issue; it is likely a magnified problem. ¹³ The intersection of pre-existing socioeconomic disparities and limited access to support services in regional areas suggests that interventions need to be specifically tailored. They must address both the direct financial aspects and the broader context of economic disadvantage and social isolation unique to these student populations. ²²

A ‘regional university’ refers to a university with campuses located outside major metropolitan centres, servicing regional and rural communities. In this study, campus locations are described using the Modified Monash Model (MMM), a seven-level geographic classification used in Australian health workforce planning, where MM1 represents major metropolitan areas, and MM7 represents very remote communities. ²³ The university’s campuses fell within categories MM2 (large regional centres) through MM6 (small rural communities), reflecting a predominantly non-metropolitan footprint.

Addressing the menstrual needs of regional university students is important not only for physical health and wellbeing, but also for reducing the social and stigma-related impacts of period poverty that can limit help-seeking, increase distress, and restrict full participation in study, work and university life.^18,19

Aims

This study aimed to explore the experiences of students facing period poverty at a regional Australian university. Specifically, the study sought to:

• 1. Identify the extent and impact of period poverty on students’ daily lives, including academic, social and professional engagement.

• 2. Describe students’ lived experiences of period poverty and the coping mechanisms they use in the absence of adequate resources.

• 3. Explore how social stigma surrounding menstruation contributes to students’ experiences of period poverty.

• 4. Examine students’ awareness, use and perceptions of Dignity Vending Machines (DVMs) as an intervention strategy.

Findings are intended to inform the development of university policies and programmes that improve access to menstrual products, strengthen menstrual literacy and reduce stigma to support student participation and wellbeing.

Methods

Design

This study used an exploratory descriptive design, integrating quantitative and qualitative methods to address the research questions.

Reporting guidelines

The reporting of the quantitative component conforms to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement, ²⁴ and the qualitative component conforms to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. ²⁵ Completed checklists are provided as supplementary material.

Population

The target population comprised students enrolled at a multi-campus regional university in New South Wales, Australia. The university’s geographical footprint extends across regional NSW, with campuses located in Modified Monash Model (MMM) categories MM2–MM6, indicating predominantly regional and rural locations. ²³

Based on institutional enrolment data for the year of data collection, the university had approximately 10,700 students, of whom about 6,200 were located across the five campus sites where DVMs had been installed. Within these campuses, around 65.9% of students identified as female and a small proportion identified as another gender, yielding an estimated eligible population of approximately 4,100 students who may menstruate and/or use free menstrual product services such as the DVMs. ²⁶

Participants were eligible if they were aged 18 years or older and had ever experienced menstruation, regardless of gender identity. Gender identity was collected via self-report to ensure the study was inclusive of trans, non-binary and gender-diverse individuals who menstruate. Among survey respondents who reported their gender identity (n=106), 97.2% identified as female, 0.94% as transgender, 0.94% as non-binary and 0.94% preferred not to say.

Study duration

Survey recruitment and data collection occurred from October 2023 to January 2024. Semi-structured interviews were conducted in March 2024.

Recruitment

The survey was open to all enrolled students at the university who were aged 18 years or older and had ever experienced menstruation. Recruitment was conducted via electronic and print posters that included a brief study description and a QR code linking to the online survey (Figure 1).

Figure 1.

Survey recruitment poster.

Quantitative phase

A cross-sectional online survey was administered to students enrolled at a multi-campus regional Australian university to assess the prevalence and impact of period poverty, as well as awareness and utilisation of DVMs. The online survey (Supplementary File 1), administered via SurveyMonkey©, included both closed and open-ended questions to allow more detailed responses.

Survey instrument

The survey instrument was developed based on previous research on period poverty ¹ and, with permission, adapted to the specific context of regional university students. It covered topics such as financial strain, access to menstrual products, impact on daily life, awareness and utilisation of DVMs, coping mechanisms and suggestions for improvement. Formal pilot testing of the survey instrument was not undertaken.

Sample size

As this was an exploratory descriptive study, a formal a priori power calculation was not undertaken. The survey was open to all eligible students, and the final sample reflects voluntary participation during the recruitment period.

Qualitative phase

Following survey closure and initial data analysis, semi-structured interviews were conducted online with interested participants via Microsoft Teams©. The interview guide was developed by the research team based on the survey findings and key concepts of period poverty, menstrual equity and DVMs. It comprised open-ended questions covering participants’ experiences of menstrual product access and affordability, the emotional and social impacts of menstruation, coping strategies, awareness and perceptions of campus-based supports, and views on what universities could do to improve menstrual equity. Example questions included: ‘How familiar are you with the concept of period poverty?’, ‘As a student, have you had any concerns or issues managing your period hygiene?’, and ‘How effective do you think the Share the Dignity vending machines are in providing access to menstrual hygiene products for those in need?’

Interview sampling

At survey completion, participants could indicate willingness to be contacted for follow-up interviews. Of 25 survey respondents who indicated interest, 15 provided contact details. All 15 were contacted, and four agreed and completed an interview. Interviews lasted between 30 and 50 minutes. All interviews were audio-recorded and automatically transcribed using Descript transcription software, followed by manual checking and correction. Interviews were scheduled until the available recruitment pool was exhausted.

Data saturation

Four interviews were completed from fifteen expressions of interest. The interviews were supplemented by open-ended survey responses, which generated between 30 and 69 written responses per item, depending on the question. The research team reviewed themes across both the interview transcripts and the survey responses, and, by the end of this process, the same ideas and experiences recurred consistently across both sources, and no new themes emerged.

Data analysis

Quantitative analysis

All quantitative data were de-identified before analysis to ensure participant anonymity. Descriptive statistics, including frequencies and percentages, were used to summarise demographic data and key survey findings. Advice on data preparation was obtained from an internal quantitative consulting unit, and quantitative analysis was supported by the university’s medical school. Because not all items required a response, analyses were conducted using available data at the item level. Denominators (valid N) are reported for each relevant result. No imputation was performed.

Qualitative analysis

Open-ended survey responses and interview transcripts were analysed thematically following Braun and Clarke’s six-phase framework, ²⁷ which involved familiarisation with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and synthesising findings. ²⁷ Elizabeth Smith read through all interview transcripts and open-ended survey responses multiple times, highlighting key ideas and quotes. These were initially sorted using a whiteboard to map out connections between concepts, and then organised into a working document that grouped quotes by topic. Groupings included participants’ understanding of period poverty, their personal experiences, the emotional and social impacts they described, the coping strategies they used and their experiences with DVMs. This produced roughly six broad groupings with sub-categories. Elizabeth Smith discussed these groupings with Tracey Parnell and Jessica Biles during monthly supervision meetings, where the team discussed what the data were showing, questioned whether the groupings made sense, and collaborated to refine them into the final three themes. A concept map was developed to visualise the relationships between themes. Formal inter-coder reliability testing was not conducted, but the documented working sheet of quotes, the concept map, and the regular supervision discussions provided a way to check that the themes were grounded in the data.

Reflexivity and rigour

The research team included a medical student (now Junior Medical Officer; Elizabeth Smith) who conducted all interviews and led data collection, supervised by an Associate Professor in Rural Health (Tracey Parnell) and an Associate Professor in Nursing (Jessica Biles). All three were based at the study university. As a student at the university, Elizabeth Smith had firsthand experience of the campus environment, which helped build rapport with participants, but also meant there was a risk of making assumptions based on personal experience. Elizabeth Smith maintained a research diary throughout the project, recording thoughts, feelings and preliminary interpretations before and after each interview and during data analysis. These reflections were discussed during regular monthly supervision meetings, where Tracey Parnell and Jessica Biles challenged interpretations and offered alternative readings of the data. Participants were also offered the opportunity to review their interview transcripts, providing a form of member checking.

Ethics approval

Ethical approval for this study was obtained from the Charles Sturt University Human Research Ethics Committee (approval number H23835, approved 12 October 2023). Written informed consent to participate was obtained from all survey and interview participants before data collection. Full details of ethical procedures, including consent processes and data protection measures, are provided in the Declarations section.

Results

A total of 113 students commenced the online survey. Of these, 107 provided informed consent and completed the initial demographic questions. One respondent who reported being under 18 years of age was excluded as ineligible, giving an analytic sample of 106 for the quantitative component. Because not all survey items required a response, the number of valid responses (N) varies by item and is reported alongside relevant statistics. Four participants completed follow-up semi-structured interviews. To ensure participant confidentiality, all identifying details have been removed, and pseudonyms are used for quoted material.

Quantitative findings

Sample characteristics

The sample was predominantly younger students, with most participants aged 18–24 years (78.3%, n=83) and enrolled in full-time study, and a large proportion working in casual employment or reporting no paid employment, indicating that these students were already under financial pressure (Table 1).

Table 1.

Demographic characteristics of survey respondents.

Characteristic	N	%
Age (N=106)
18–24	83	78.3
25–29	11	10.4
30–34	6	5.7
35–39	5	4.7
40–44	1	0.9
Enrolment status (N=106)
Full-time	90	84.9
Part-time	16	15.1
Employment status (N=105)
Casual	64	61.0
Permanent part-time	16	15.2
Permanent full-time	11	10.5
Not in paid employment	9	8.6
None/other	5	4.8

Percentages are calculated from valid responses for each item.

Demographic characteristics of the four interview participants are presented in Table 2.

Table 2.

Demographic characteristics of interview participants.

Pseudonym	Age	Campus	Degree	Year of study	Employment
Zara	37	Port Macquarie	Social Science	3rd	Disability support worker
Chloe	27	Orange	Dentistry	3rd	Not reported
Isabelle	22	Bathurst	Exercise and Sport Science	3rd (starting Honours)	No paid employment
Marie	29	Albury	Health Sciences	4th	Social worker

Prevalence and financial impact of period poverty

Survey data demonstrated that period poverty is a financially burdensome issue for this regional university cohort. As presented in Table 3, among respondents who answered this item (N=104), 54.8% reported sometimes finding it difficult to afford menstrual products, 10.6% reported difficulty often, and 3.8% reported difficulty always, indicating that 69.2% of respondents experienced at least occasional financial difficulty in purchasing menstrual products.

Table 3.

Prevalence, impact on daily life, coping strategies and DVM awareness.

Question	Response category	N	% of valid responses
Frequency of difficulty affording menstrual products
How often do you find it difficult to afford period products? (N=104)	Never	13	12.5
	Rarely	19	18.3
	Sometimes	57	54.8
	Often	11	10.6
	Always (every month)	4	3.8
Impact of inability to afford or access products
Due to not affording or accessing products, have you… (N=69)	Avoided sporting or leisure activities	50	72.5
	Stayed at home	47	68.1
	Did not attend social activities	45	65.2
	Missed at least one class	38	55.1
	Missed at least one work shift	22	31.9
	None applicable	2	2.9
Coping strategies related to cost
How have you managed when menstrual products were difficult to afford? (N=98)	Changed to cheaper products	74	75.5
	Worn a product for longer than recommended	67	68.4
	Improvised with other materials (e.g. toilet paper, rags, socks)	43	43.9
	Not able to buy product of choice	40	40.8
	Accessed free products	30	30.6
	Asked someone to buy for them	26	26.5
Awareness of Dignity Vending Machines
Are you aware that your university has Dignity Vending Machines? (N=96)	Not aware	56	58.3
	Aware	40	41.7

Percentages are calculated from valid responses for each item. Items on impact and coping allowed multiple responses.

Impact on daily life

This financial strain directly disrupted daily life, interfering with students’ ability to attend classes, work shifts, and participate in social, sporting or leisure activities. Of those who responded to this question (N=69; Table 3), 68.1% reported staying at home, 55.1% reported not attending class, 65.2% did not attend social activities, 72.5% avoided sporting or leisure activities, and 31.9% reported missing work because they could not afford or access menstrual products.

Coping strategies

To manage these pressures (N=98), 75.5% reported changing to cheaper products, 68.4% reported wearing products for longer than recommended, and 43.9% reported improvising with other materials, such as toilet paper, rags or socks (Table 3).

Awareness and use of dignity vending machines

Awareness and use of the existing campus intervention were limited. Among those who responded to this question (N=96), 58.3% were unaware that Dignity Vending Machines (DVMs) were available on university campuses. Among those who had attempted to use them, several reported operational failures, including empty or malfunctioning machines, which one survey participant described as “crushing” when this occurred during a time of need.

Association with employment status

On a five-point ordinal scale (1=never to 5=always), the mean frequency score for difficulty affording menstrual products was 2.75 (median 3.0; N=104). Students not in paid employment reported the highest mean difficulty score (M=3.56), followed by those in permanent part-time employment (M=3.06), permanent full-time employment (M=2.73) and casual employment (M=2.60). Patterns in the frequency of difficulty by employment status are presented in Table 4.

Table 4.

Difficulty affording menstrual products by employment status.

Employment status	N	Never	Rarely	Sometimes	Often	Always	Mean (1–5)
Not in paid employment	9	1	0	4	1	3	3.56
Permanent part-time	16	0	3	10	2	1	3.06
Permanent full-time	11	2	1	6	2	0	2.73
Casual	63	9	13	35	6	0	2.60
None/other	4	1	2	1	0	0	2.00
Total	103	13	19	56	11	4	2.75

Scores: 1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Often, 5 = Always (every month).

Note. One respondent answered the affordability item but did not report employment status.

Qualitative findings

The qualitative data, drawn from semi-structured interviews with four students and open-ended survey responses, provided contextual depth to the quantitative results. Three core, interconnected themes were identified:

• 1. Financial precarity and undignified coping

• 2. The emotional and psychological toll of menstrual stigma

• 3. The imperative for normalisation and educational advocacy

Figure 2 illustrates the relationships between these themes, showing how financial precarity, emotional burden and coping responses combine to shape students’ experiences of period poverty and to generate a perceived need for education and advocacy.

Figure 2.

Thematic relationships underpinning period poverty experiences. The three blue boxes represent interrelated core themes; the white boxes represent associated subthemes.

Financial precarity and undignified coping

Period poverty was experienced by participants as an ongoing financial pressure, where the high and recurrent cost of menstrual products forced students into deliberate coping strategies that often compromised their comfort, hygiene and dignity. Participants consistently defined the phenomenon in terms of both structural access and knowledge. Student Isabelle framed it as involving both “the lack of accessibility to period products” and “a lack of education around periods”.

The lived experience of this financial pressure was characterised by persistent anxiety over expense. For one student, the choice was framed as existential: “I think when people are trying to decide between, you know, milk and bread and pads and tampons yeah… something’s got to give.”

This economic reality gave rise to two distinct coping pathways. Some students initiated proactive, cost-avoidant mitigation, such as Isabelle, who purchased menstrual cups as an “executive decision to avoid having to worry about buying tampons”. Others facing immediate scarcity resorted to rationing. Chloe described her situation as “more like a scarcity thing than to not have access at all”, admitting to actively managing product longevity: she noted there were times she “would have liked to have changed it, but I didn’t just cause I was partitioning it out a little bit more”.

When preventative and rationing strategies failed, participants described resorting to crisis improvisation, using makeshift solutions such as toilet paper, rags and socks. One participant reported relying on “toilet paper (often)… it is accessible, but does not work at all. A sock, a couple of times”, encapsulating both the practicality and inadequacy of these measures. Other participants recounted that they “free bled and stayed home” or “just bled into my underwear because I couldn’t afford pads”. These accounts show how financial constraints pushed students into crisis improvisation and menstrual management practices that compromised both dignity and safety.

The emotional and psychological toll of menstrual stigma

The central psychological consequence identified was the burden of shame and social isolation associated with managing menstruation, which acted as a significant barrier to help-seeking and emotional wellbeing. Participants consistently described feelings of shame and anxiety that functioned as primary barriers to seeking assistance. The data revealed an entrenched “culture of silence and shame” within social environments. Isabelle noted that people “forget that periods are normal and humans get embarrassed by it”.

The persistence of this discomfort was also reflected in generational differences. Zara observed that her father viewed supplying period products as “Mum’s job” and was reluctant to discuss the topic, whereas her partner was more open with their daughters.

This psychological burden was further compounded by the cognitive labour required to manage unpredictable cycles, which rendered cycle irregularity a high-stakes risk-mitigation event. For students lacking a financial safety net, the uncertainty of menstruation necessitated constant, pre-emptive tracking and hyper-awareness of physiological symptoms to avoid crises. Participants described being “always aware” of bodily cues and worried about potential leaks, illustrating the ongoing mental load of menstruating under conditions of scarcity.

The imperative for normalisation and educational advocacy

Beyond product provision, participants recognised that period poverty is linked to a lack of cultural acceptance and knowledge, pointing to the need to address cultural and educational gaps for systemic change. This conceptual link was reinforced by reflections on social stigma, which participants frequently connected to the absence of open discussion about menstruation during their youth. Marie, who had previously completed a social work degree and was now studying health sciences, recalled that in her late teens and early twenties menstruation was “pretty uncomfortable to talk about”. Working and studying in the health space had since “normalised it a lot for me and broken down the stigma”, and she expressed a desire to “normalise these things so that… people who are struggling or suffering can feel more comfortable to talk about it”. For Marie, education and professional exposure had fundamentally changed how she understood and managed her own menstrual health.

Participants highlighted gaps in menstrual health literacy, including uncertainty about what constitutes a “normal” period, appropriate product use and the availability of support services. Several students described feeling inadequately prepared for menstruation by their school-based education, recalling that information was limited, clinical, or focused narrowly on biology rather than practical management. Isabelle made a similar point. She recalled that her school-based education had left her underprepared: “I knew a little bit about it from health classes, but in the grand scheme of things, I didn’t really know completely what to expect. I knew there could be some pain… I knew of pads and tampons but didn’t know how to use them.” She went on to observe that someone “who didn’t know about their body or what was happening or cheaper ways to deal with periods” and who had not had the chance to educate themselves “wouldn’t be in a place where [they] can look after [themselves]”. This suggests that knowing about one’s body and available options is itself a form of protection against period poverty, and that education matters just as much as product access.

Discussion

The findings of this study demonstrate that period poverty is a common and consequential issue for students attending this regional Australian university, with implications that extend across financial, educational, emotional and social domains. By focusing on a multi-campus regional university, this study extends evidence from metropolitan universities and national samples^12,17–19 and illustrates how regional, financial and service-access constraints can compound the experience and consequences of period poverty for tertiary students.^20–22

Financial precarity, cost of living and undignified coping

The financial strain reported by participants is consistent with national data from the 2024 Bloody Big Survey and with Australian and international studies showing that many people who menstruate cannot reliably purchase adequate menstrual products.^5,12,16,28 These difficulties occur within a broader economic context of rising living costs, insecure and casualised employment and entrenched income inequalities that disproportionately affect students and people from low socioeconomic backgrounds.^14,20,22,29 Participant descriptions of choosing between menstrual products and necessities closely mirror accounts reported elsewhere.^5,12,28,30

The coping strategies reported, including switching to cheaper products, extending wear times and improvising with socks, rags or toilet paper, are consistent with mitigation and rationing strategies reported among university students, low-income women and people experiencing homelessness in other high-income countries.^7,12,28,30 These practices may reduce immediate financial stress. However, they can jeopardise comfort and hygiene and increase the risk of infection, particularly when products are worn for prolonged periods or improvised materials are used without adequate sanitation.^4,9,28,31 They also undermine students’ sense of dignity and control, supporting arguments that period poverty is not only an economic problem but also an infringement of human rights and menstrual justice.^3,5,8,11

The pattern of missed classes, lost work shifts and social withdrawal reported here is consistent with global evidence that difficulties managing menstruation interfere with education, employment and daily life.^10,15,19,28 For regional and low-income students, who already face structural barriers to progression in higher education, the cumulative effect of missed learning and reduced work capacity may contribute to poorer academic outcomes and limited career opportunities.^{16,20,22,28,29} Period poverty for these students was driven by more than individual financial capacity. Regional living costs, insecure and casualised employment, reluctance to discuss menstruation openly, and distance from services all contributed.^3,8,11,14

Emotional and psychosocial impacts

Feelings of shame, embarrassment and reluctance to seek help are consistent with research demonstrating associations between period poverty and symptoms of anxiety, depression, stress and reduced self-esteem among adolescents and university students.^2,6,8,32 Cardoso and colleagues found that college students who had experienced period poverty were significantly more likely to report moderate or severe depression and anxiety, even after adjustment for other forms of financial stress. ⁶ Similar patterns have been documented during the COVID-19 pandemic, in which product shortages and income losses intensified distress among those who menstruate, already facing financial hardship.^30,32,33

Students also described the cognitive labour of menstruating under conditions of scarcity, including constant monitoring of bodily sensations, planning around unpredictable cycles and worrying about leaks or odour. This ongoing “thought load” reflects broader work on self-care and wellbeing, which shows how managing health needs in the context of limited resources can erode psychological wellbeing and a sense of control.^31,34 Social participation was also affected: over half of respondents who answered this item reported avoiding social activities because they lacked products, aligning with literature describing how menstruation under conditions of scarcity can lead to social withdrawal, isolation and reduced participation in extracurricular and community life.^12,19,28,35 In regional universities, where social connectedness is an essential buffer against isolation and attrition, the social consequences of period poverty are particularly significant.^20,22

Normalisation, education and menstrual health literacy

Participants did not frame period poverty purely as a question of product access; they also linked their experiences to deficits in menstrual health literacy and to enduring cultural discomfort with menstruation. Participants reflected on limited education at school, silence within families and ongoing uncertainty about whether their experiences of menstruation were typical or cause for concern. These accounts resonate with international evidence that inadequate menstrual education, restrictive social norms and taboos contribute to poor menstrual hygiene practices and help sustain period poverty.^4,10,31 Global frameworks position menstrual health as a public health and human rights issue that cuts across Sustainable Development Goals related to health, education, gender equality, water and sanitation and decent work.^10,11,15

Students articulated a clear desire for normalisation and open discussion about menstruation. Several emphasised the importance of “normalising these things” so that people who are struggling feel able to talk about it, echoing calls in the literature for stigma reduction and a rights-based approach to menstrual health.^3,8,11,31 Lack of awareness of available supports, including free products, further constrained students’ ability to manage their menstruation with dignity, a pattern also identified among university students, adolescents and marginalised groups in other settings.^13,17–19 These findings suggest that interventions focused solely on distributing products are unlikely to fully address the burden of period poverty without concurrent efforts to improve menstrual health literacy, challenge stigma and support open dialogue.

Strategies to address period poverty in higher education

In this study, DVMs served as the primary institutional response to period poverty. Students who used the machines appreciated their convenience and discretion, which is consistent with evaluations of similar initiatives in higher education and community settings.^12,19,36,37 Massengale and colleagues reported that access to free products reduced avoidance of social and health care appointments and improved recipients’ feelings of security in the United States. ³⁷ Other case studies of university-based menstrual equity initiatives also suggest that free product provision may reduce absenteeism and help students feel more supported.^18,19,36

The impact of DVMs in this setting was limited by several modifiable barriers. Awareness was low, with over half of the respondents (58.3%) unaware of the machines. Marie was unaware of the machines until she happened to see one in the library bathroom, and noted that students who do not regularly use the library may never encounter them. This finding is in line with work from the United States showing that free-product schemes often remain under-utilised when promotion is minimal or signage is unclear.^19,36 Operational issues, including stockouts, machine faults, restricted placement and limited product variety, were described as particularly distressing when they occurred at moments of need. Similar operational barriers have been observed in other interventions, where inconsistent availability eroded trust in free-product programmes and reduced willingness to rely on them.^12,30,33,36

Stigma also shaped how students interpreted and used the DVMs. Some reported avoiding the machines because they perceived them as resources intended for others who were “more in need”, reinforcing a charitable rather than a rights-based framing. This pattern echoes critiques that narrowly targeted or means-tested approaches can deepen shame and discourage people from seeking support.^3,8,11,38 The findings suggest that while DVMs are an important practical strategy, they need to be embedded in broader institutional commitments to menstrual equity. Such commitments include clear, inclusive messaging that normalises use for anyone who menstruates, reliable maintenance systems, a diverse range of products (including reusable options where appropriate), and parallel efforts to address stigma and improve menstrual literacy.^8,10,36,37

Implications for policy and practice

These findings have practical implications for both universities and policymakers. At the university level, providing free menstrual products should not be treated as a one-off initiative or left to rely on external organisations alone. For the DVMs to work effectively, someone needs to be responsible for keeping them stocked and maintained, students need to know they exist, and the products need to be available in more locations than just the library. Communication should position these resources as available to anyone who menstruates, whether the need arises from cost, convenience, or unexpected bleeding, rather than framing them as a safety net only for those most in need.^3,5,8,11 Universities could build menstrual product access into their existing student wellbeing and equity plans, with dedicated funding and clear responsibility for promotion through channels such as orientation week, student services and campus signage.^3,11,36

Alongside product provision, universities should invest in menstrual health literacy and reducing stigma through student health services, orientation programmes and relevant curricula.^4,10,34 Peer-led education and student-led advocacy can help normalise menstruation and create an environment where students feel able to seek support.^15,19,36

At the policy level, the results add to growing calls for state and national governments to fund free menstrual products in educational institutions, as has been legislated in Scotland and New Zealand and is being trialled in parts of Australia.^11,14 Collaboration between universities, government agencies, non-government organisations and student associations could support sustainable funding models, particularly in regional and remote areas where cost-of-living pressures and service gaps are pronounced.^12,20,22,33

Limitations

Several limitations of this study are acknowledged. First, this study was conducted at a single regional Australian university with a predominantly female sample. The findings may not reflect the experiences of students at other regional universities or urban universities, those enrolled in other forms of tertiary education, or gender-diverse people who menstruate. Emerging literature indicates that trans, non-binary and gender-diverse menstruators face distinct forms of stigma and access barriers, including discrimination and lack of appropriate facilities.^3,8,11 Future research should purposefully include a broader range of institutions, geographic locations and gender identities to build a more complete picture of period poverty in higher education.

Second, all data were self-reported. Survey and interview responses are susceptible to recall bias and social desirability bias. Given the sensitivity of menstruation and finances, some participants may have under-reported difficulties, while those with particularly strong experiences of period poverty may have been more motivated to participate. Missing data for some survey items limits the precision of prevalence estimates. In particular, the item on impact on daily life had a lower completion rate (N=69) than other items. Respondents who had experienced these impacts may have been more likely to answer, potentially inflating these estimates. Future studies could strengthen validity by triangulating self-report with additional data sources, such as administrative records on class attendance, vending machine usage data, financial stress indicators, or longitudinal tracking of product use.^28,29,36

Third, as an exploratory descriptive study, a formal a priori sample size calculation was not conducted. The analytic sample of 106 respondents with complete demographics represents approximately 2.6% of the estimated eligible population of 4,100 students and may limit the generalisability of prevalence estimates.

Fourth, formal pilot testing of the survey instrument was not undertaken. While the instrument was adapted from a previously used tool, the absence of formal piloting in the study population is a limitation.

Fifth, the qualitative component involved a small number of interview participants (n=4). Although the interviews, supplemented by open-ended survey responses, provided rich accounts, it is unlikely that they capture the full diversity of experiences within the student population. Building on this exploratory work, future qualitative research could expand sampling to include a range of disciplines, age groups, cultural backgrounds, disability status, and caregiving responsibilities, all of which may interact with menstrual health and financial stress.^7,9,20,38 Participatory or co-design approaches, in which students and other stakeholders help develop and test interventions, may also produce solutions that are more responsive to local contexts and sustainable over time.^15,36

Finally, this study did not formally examine the cost-effectiveness or longer-term outcomes of DVMs or other interventions. Longitudinal and implementation-focused research is needed to determine which combinations of strategies, including awareness campaigns, product mix, placement, maintenance processes and policy support, produce the greatest gains in equity and student wellbeing.^{10,11,15,28,33,36,37} Comparative studies across institutions and jurisdictions could explore how state or national policy environments, such as mandates for free period products in schools and universities, shape the success of local initiatives.^11,14,21

Conclusion

This study is one of the first mixed-methods examinations of period poverty in a regional Australian university context. The findings highlight that period poverty is experienced as an interplay of financial constraints, emotional distress and social stigma that disrupts education, work and social participation and, for some students, leads to undignified and potentially unsafe coping strategies. Free-product initiatives such as DVMs offer valued practical support, but their impact is limited by low awareness, operational problems and persistent stigma. By centring the voices of regional university students, this study adds local evidence to international work framing menstrual health as a public health, human rights and equity issue.^1,3,8,11 Responses to period poverty must go beyond the distribution of products to include menstrual health literacy, stigma reduction and broader strategies that address the structural determinants of financial hardship and social exclusion.

ORCID iDs

Elizabeth Smith https://orcid.org/0009-0005-5845-3066

Tracey Parnell https://orcid.org/0000-0002-7434-1268

Ethical considerations

This study was approved by the Charles Sturt University Human Research Ethics Committee (Protocol number: H23835, approved 12 October 2023).

Consent to participate

Written informed consent to participate was obtained from all survey and interview participants before data collection.

Consent for publication

The manuscript does not contain identifiable personal data, images or videos, and pseudonyms have been used.

Data Availability Statement

The data supporting this study’s findings are not publicly available due to ethical and privacy restrictions. De-identified data may be available from the corresponding author on reasonable request and subject to approval from the Charles Sturt University Human Research Ethics Committee.*