Estimating the impact of menstrual poverty on adolescents in Nova Scotia

Abstract

Background

Menstrual poverty is defined as the inability of people who menstruate to obtain menstrual products due to financial burden. The impact of menstrual poverty is not well studied in developed countries.

Objectives

This study aims to estimate the impact of menstrual poverty on adolescents who reside in Nova Scotia (NS), Canada.

Methods

A web-based, 25-item questionnaire, the adolescent Menstrual Poverty Questionnaire (aMPQ), was developed and distributed via social media. Adolescents less than 18 years of age, English-speaking and living in NS were eligible to complete the questionnaire. Data were analysed using descriptive analysis.

Results

Four hundred and twenty adolescents completed the questionnaire, with a mean age of 16.1 years (14.4–17.9 years). Results revealed that 65% of respondents do not always have enough money to buy menstrual products. This led to unsafe menstrual hygiene practices including using alternatives for menstrual products (e.g., rags), washing disposable menstrual products, and/or wearing products for longer than intended. Forty percent of respondents reported lack of affordability of menstrual products as a cause for school absenteeism and lack of participation in sport/social activities. Seventy percent of respondents felt embarrassed to ask for products even when they are provided for free, and almost all supported the idea of having freely available menstrual products in public washrooms.

Conclusions

This study determined that menstrual poverty impacts adolescents in Nova Scotia. To address menstrual poverty, menstrual products should be freely available in all public washrooms, as this will provide unrestricted access to menstruators and promote their full participation in society.

Graphical Abstract

Graphical Abstract.

INTRODUCTION

Menstrual poverty is defined as the inability of people who menstruate to obtain menstrual products due to financial burden (1). In 2015, the federal government of Canada vetoed GST on menstrual products after recognition of menstrual products as a necessity rather than a luxury (2). Despite this, in 2020, a survey reported that one-third of women in Canada under 25 years of age struggle to afford menstrual products, whereas 70% report that they have missed school/work or have withdrawn from social activities due to menstrual bleeding (3). School/work absenteeism affects education and economic opportunities for girls and women (4), which further underscores inequities between those who do and those who do not menstruate. Similar to food, water, and shelter, menstrual health must be considered a basic need to ensure the health and well-being of women and girls (5).

Many institutions in multiple countries have made menstrual products available free of charge. Scotland became the first country to make menstrual products free nationwide in 2020 (6). In 2021, New Zealand announced that free menstrual products will be available in schools to ensure that girls do not miss school during their periods (7). In 2019, public schools in Nova Scotia began to provide universal access to menstrual products (8), and the Halifax Regional Municipality (HRM) started to provide free menstrual products in all its facilities (9).

The impact of menstrual poverty on adolescents in Canada is unknown. The primary objective of this study is to estimate the impact of menstrual poverty in adolescent youth less than 18 years of age, who reside in Nova Scotia (NS), Canada.

METHODS

Given the limits on conducting in-person research during the COVID-19 pandemic, we determined an estimate of the impact of menstrual poverty among youth in NS, using a web-based questionnaire that was distributed via social media platforms.

Development of the questionnaire

Authors developed a 25-item questionnaire, the adolescent Menstrual Poverty Questionnaire (aMPQ), after reviewing previously published questionnaires on menstrual health and poverty (10) (Appendix 1).

The aMPQ was developed with questions around four themes of menstrual poverty: affordability of menstrual products, menstrual product availability and alternatives, impact of the cost and/or lack of access to menstrual products on the quality of life of adolescent menstruators, and impact of COVID-19 on the availability and access to menstrual products.

Questions were generated based on a combination of clinical experience and review of previously published questionnaires addressing menstrual poverty and hygiene (10,11). Each question was answered according to a 5-point Likert scale ranging from “yes, always” to “no, never.” The following sociodemographic data were collected: age, grade in school, and the ethnicity with which respondents most identify. The aMPQ contained one open-ended question: “Is there any other place where getting free menstrual products would be helpful?” Participants were able to enter free text as a response.

A web-based questionnaire was developed using OPINIO software (12) and distributed through social media platforms (@for.teens.period) Twitter, TikTok, Facebook, and Instagram for 6 weeks. The questionnaire was also shared via email with stakeholders including local pediatricians and community leaders who were identified via social media pages/websites and/or were personally known to the authors. Community leaders were individuals or groups that were already doing work in menstrual equity, such as the Canadian Hemophilia Society (@chs_national) and Dr. Taq Kaur (@imwithperiods), in order to further disseminate the questionnaire.

The aMPQ contained a simplified consent form that explained the study. Respondents were required to review this prior to completing the aMPQ.

Three adolescents were asked to review the aMPQ prior to dissemination, and they unanimously verified its understanding and readability.

The aMPQ was administered to adolescents who were younger than 18 years of age, living in NS, English-speaking or had access to a trained interpreter, and had experienced at least one menstrual period. The questionnaire was developed using conditional branching, such that if a respondent indicated they lived in a province other than Nova Scotia and/or if they were over 18 years of age, they were unable to view or respond to the remaining questions.

Data analysis

Data were analysed using descriptive analysis (mean, ranges) and these were generated by the OPINIO software (Opinio 2021).

Ethics

This study was approved by the IWK Health Centre’s Research Ethics Board (File Number: 1026883). Results were anonymous and contained no identifying information.

RESULTS

There were 510 respondents; however, with the pre-set conditional branching, data were collected from 420. Table 1 summarizes the demographics of these responses.

Table 1.

Demographics of aMPQ respondents

Control group
Number of subjects (n = 420)	420
Age (years)
Mean age	16. 1 (14.4 – 17.9)
School Grade
Mean grade	10. 3 (8.7 – 11.9)
Ethnicity
White/Caucasian (European Heritage)	314 (65.7%)
Black/African Nova Scotian/African Canadian/African/Caribbean	35 (7.3%)
Chinese	26 (5.4%)
Latin American	23 (4.8%)
Pacific Islanders (e.g., Filipino)	20 (4.2%)
Korean	11 (2.3%)
Southeast Asian (including Vietnamese, Cambodian, Laotian, Thai, etc.)	9 (2.0%)
South Asian (e.g., East Indian, Pakistani, Sri Lankan, etc.)	8 (1.87%)
Arab	8 (1.7%)
Japanese	5 (1.0%)
West Asian (e.g., Iranian and Afghan)	3 (0.63%)
Population group was not listed above	8 (1.7%)
Prefer not to answer	9 (1.9%)

Twenty-nine percent of respondents reported that they purchased menstrual products using their own money. Sixty-five percent of respondents reported not always having enough money to buy menstrual products. Furthermore, 73% did not have enough products to change as often as they needed. Seventy percent of respondents reported feeling embarrassed to buy or ask for menstrual products at some point (Figure 1).

Figure 1.

Side by side bar graph showing the survey responses on access and affordability of menstrual products.

Seventy-five percent of the respondents have worried about bleeding through their clothes. As a result of not having the financial means to purchase menstrual products, 37% of the respondents have used rags and/or toilet paper as alternatives and 22% reported washing used disposable menstrual products for reuse. Fifty-two percent reported having to use menstrual products for longer than they should because they did not have any extra (Figure 2).

Figure 2.

Side by side bar graph showing the survey responses on menstrual product usage and alternatives.

Forty percent of the respondents have missed school, sports/gym, and/or social activities while menstruating because they did not have menstrual products (Figure 3).

Figure 3.

Side by side bar graph showing the survey responses on the quality of life impact of menstruation.

Fifty-eight percent of the respondents indicated that COVID-19 has made it harder for them to get menstrual products.

The availability of menstrual products at schools has been helpful to 52% of respondents at some point as they did not have enough money to buy their own. Whilst almost half of the respondents felt comfortable asking for menstrual products at school or at a community/youth centre, 94.6% said it would be helpful to have menstrual products readily available in public bathrooms (Figure 4).

Figure 4.

Side by side bar graph showing the survey responses on the availability of menstrual products.

Below are some of the comments that participants chose to share (Table 2).

Table 2.

Comments received from respondents that were collected with the aMPQ

“Throughout my life there’s been times where I didn’t have money or anybody to ask [for menstrual products]. Mainly myself occasionally my grandma [purchase menstrual products].” – Respondent A “Periods are a normal thing and I feel [menstrual products] should be put as many places as possible! There are so many people who cannot afford menstrual products, so it’s always helpful to have some for free in public.” – Respondent B “I think schools and sports centers and workplaces should all have accessible, free menstrual products.” – Respondent C “School - available in the bathroom, you can get them, but you have to go to the office or the guidance counselor and that takes effort and embarrassment.” – Respondent D “In all bathrooms, not just female as not everybody who menstruates are women.” – Respondent E “School bathrooms (in the actual bathroom, not in classrooms that you have to interrupt the class and ask the teacher for a tampon, [because] that’s not a solution) and public bathrooms. Also, men’s washrooms because not only women menstruate” – Respondent F

DISCUSSION

This study estimates the impact of menstrual poverty on adolescents in NS. The results provide evidence that menstrual poverty affects youth in Nova Scotia, with up to 40% of the respondents reporting lack of affordability of menstrual products as a cause for school absenteeism and lack of participation in sport or social activities. Affordability and access to sufficient menstrual products were a source of worry for more than 50% of the respondents.

Almost one-third of respondents indicated that they purchase their own menstrual products, underscoring that the financial responsibility to purchase adequate products may lie with the adolescent. It is possible there are other factors, such as embarrassment or shyness, that pose a barrier to adolescents requesting money from others to purchase menstrual products. The results provide evidence for the vicious circle of menstrual poverty as depicted in Figure 5: unaffordability and/or lack of access to sufficient menstrual products results in poor menstrual hygiene practices (e.g., using alternatives, prolonged use of products, and re-use of products) and vice versa; this ultimately presents a barrier to learning (school attendance) and participation in sport/social activities. Although having menstrual products available in schools in NS has improved access to products, 70% of respondents still feel embarrassed to ask for products and 43% have been bullied/teased for asking for them. Having products readily available in bathrooms may increase accessibility and aim to break the cycle of menstrual poverty.

Figure 5.

The cycle of menstrual poverty as suggested by responses to the adolescent Menstrual Poverty Questionnaire (aMPQ).

The concept of menstrual poverty was introduced by Crichton et al. in 2013 based on a qualitative study of the experiences of adolescent girls in Nairobi (13). This study found that menstrual poverty has a profound psychosocial impact on girls at home and school, including anxiety, embarrassment, fear of stigma, and low mood. Other studies conducted on menstrual poverty in adolescents include the MENISCUS study (14), which identified poverty as a key factor associated with school attendance and found that lack of effective materials for menstrual hygiene management led to school absenteeism. These studies were conducted in developing and resource-poor countries but support our findings regarding the impact of menstrual poverty on psychosocial health and school attendance.

A qualitative study in Barcelona, Spain describes the experience of menstrual inequity and menstrual health among women, but not specifically adolescents (15). In this study, several participants reported menstrual poverty and identified that their choice of menstrual products was often influenced by price. This study, in addition to our findings, supports that the experience of menstrual poverty is not unique to developing or resource-poor countries.

The COVID-19 pandemic decreased access to menstrual products for around half of the respondents. This may have been due to increased financial burden with decreased income due to unemployment during the pandemic. Another possible explanation may be due to cessation of in-person attendance at school and/or sport activities and, therefore, lack of access to any free products available at these public facilities.

Over 94% of the respondents said that free menstrual products in public washrooms would be useful to be freely available and accessible directly in the bathrooms, in the same manner as toilet paper, instead of them being held behind a desk for people to ask for. Respondents expressed the importance of having menstrual products available in all public washrooms as not every menstruator identifies as female, emphasizing the importance of providing menstrual products in any and all washrooms, not just “women’s” washrooms.

Limitations

The COVID-19 pandemic presents unique challenges in conducting research and recruiting participants. Social media (e.g., TikTok, Facebook, and Instagram) offers novel methods of recruiting participants for adolescents who are typically comfortable engaging with the world through technology (16, 17). The pandemic presented an opportunity for the study to be conducted and disseminated on the internet using different social media and communication platforms while adhering to privacy policies. However, this excluded the population of adolescents who would not have had access to the internet or social media.

The aMPQ has not been validated. Other published questionnaires were reviewed by the authors and felt not to be applicable to the study population and/or study question as they have been designed to assess the impact of menstrual poverty in developing countries (10) and/or assess menstrual health in general without specifically addressing menstrual poverty (11). Future studies validating the aMPQ would be useful.

CONCLUSION

This study determined that menstrual poverty impacts adolescents in Nova Scotia. Adolescents miss school, sports/gym, and social opportunities because they cannot afford menstrual products. Adolescents worry about being able to afford menstrual products and may resort to less sanitary means to manage their menstrual periods. One solution to address menstrual poverty is to provide menstrual products in all public washrooms, as this will provide unrestricted access to menstruators and promote their full participation in society. This will mitigate the impact that menstrual poverty has on quality of life, including psychosocial health.

FUNDING

This study was funded by Imhotep’s Legacy Academy and the Dalhousie Faculty of Medicine.

POTENTIAL CONFLICTS OF INTEREST

MP reports funding from the Canadian Hemophilia Society and DATCH-Menarche outside the submitted work. There are no other disclosures. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.