Exploring the lived experiences of menstrual hygiene management among in-school visually impaired adolescent girls in Rwanda: A phenomenological study

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Visual impairment further compounds the difficulties faced by in-school adolescent girls, but little is known about its consequences in Rwanda. Objective: To explore the lived experiences of MHM among in-school visually impaired adolescent girls in Rwanda. Design: Descriptive phenomenology. Methods: This study was conducted in four specialized educational institutions for visually impaired students in Rwanda. We conducted four focus group discussions with 25 visually impaired adolescent girls selected purposively. The seven steps Colaizzi's method were used to analyze the data. Results: Some participants reported double stigma due to both gender norms and menstruation as well as being visually impaired. Due to taboos and misconceptions around menstruation, some participants reported not getting accurate information about MHM from their parents or teachers. Some poor practices related to taboos and misconceptions such as drying the reusable clothes out of sight of others were reported. Finally, some participants faced a double burden regarding period poverty. Due to the lack of sanitary pads, some must use reusable clothes, which are challenging to clean and dry. In case of water outages, participantscould not travel to fetch water. Educational materials in three out of four girls' rooms are visual, making it difficult for visuallyimpaired girls to access accurate information. Conclusions: To combat stigma against visually impaired girls who menstruate, it's vital to consider cultural and social contexts. Providing accessible menstrual health management (MHM) education, such as in braille or audio, and ensuring sanitary pad availability is essential. Accessible water stations with tanks should also be constructed to ensure a continuous water supply. Menstruating adolescent girls Menstrual hygiene management Period poverty visually impaired girls Rwanda Menstrual hygiene management among Rwandan adolescent girls with visual impairment in schools. The Sustainable Development Goals (SDGs) emphasize the importance of Menstrual Hygiene Management (MHM) for women's and girls' well-being. However, in low-income countries, many menstruating persons continue to encounter numerous challenges regarding MHM. Visually impaired girls face even more challenges than their counterparts, especially in schools. We explored the lived experiences of in-school visually impaired adolescent girls towards MHM in Rwanda. We invited 25 visually impaired adolescent girls from four specialized educational institutions for visually impaired students in Rwanda to participate in four focus group discussions. Our findings revealed that in-school visually impaired girls continuously faced several challenges when managing their menstruation. These included a double stigma related to gender norms and being visually impaired, taboos and misconceptions that shaped knowledge sharing and menstrual hygiene practices negatively, and lack of tailored resources for MHM. Additionally, double stigma significantly poses challenges and impact on their health, inclusion, and overall quality of life. There is a need to improve education, raise awareness, revise existing policies, and improve infrastructure to ensure that visually impaired girls manage their menstruation health. Introduction Menstrual Hygiene Management (MHM) is an integral component of the Sustainable Development Goals (SDGs), as it directly impacts on women’s and girls' physical and mental well-being 1 . MHM describes the needs experienced by people who menstruate, including but not limited to the availability and accessibility of information, products, and facilities that allow them to manage their periods safely, comfortably, and with dignity 2 . More than 300 million women worldwide menstruate on any given day. It is estimated that 500 million women cannot access adequate facilities for MHM and cannot obtain menstrual products 3 . The World Health Organization (WHO) recommends three actions to ensure menstrual health is viewed, framed and addressed as a health and human rights issue, rather than a hygienic issue 4 . As a first step, menstruation needs to be recognized and framed as a health issue – a health issue that has physical, psychological, and social dimensions, and needs to be addressed from pre-menarche to post-menopause. Secondly, to recognize menstrual health, we must ensure that women and girls who menstruate have access to the necessary products, such as water, sanitation, and disposal facilities, as well as supportive care when needed. Additionally, it is crucial to create an environment where menstruation is viewed positively and considered a health issue rather than a stigma, enabling individuals to participate fully in work and social activities. Thirdly, these activities must be included in sectoral budgets and work plans, and their performance must be monitored regularly 4 . While some progress has been made in various areas, women, girls and other people menstruating such as transgender men and nonbinary individuals still face significant challenges in both developed and developing countries, especially those in schools 5–8 . Improving MHM in schools in low and middle-income countries (LMICs) is hindered by several factors, including the lack of adequate support from teachers, perceived and internalized stigma, the lack of family support, the lack of cultural acceptance for alternative menstrual products, financial constraints in affording supplies, the lack of adequate facilities for water and sanitation and hygiene (WASH), cramps and discomfort during menstruation, and long-distance travel to and from school, which increases leakage and staining 6,9 . It is more difficult for females with disability and that they are often neglected in when it comes to WASH interventions in LMICs 7,8 . In 2020, an estimated 43.3 million people were blind, and 55% were female 10 . Managing menstruation can present unique challenges for visually impaired girls and women due to social norms surrounding gender and menstruation 11 . Many visually impaired women struggle to manage their periods independently, their menstrual hygiene practices are not at a satisfactory level, and almost half of them receive support to manage their menstrual hygiene 12 . Furthermore, evidence from African countries found that adolescents with visual impairment face difficulties maintaining good menstrual hygiene because they cannot detect menstrual blood, fix sanitary pads properly, or wash underwear correctly, and they are anxious and stressed because they don't know if their period has started or not 13,14 . Visually impaired girls attending schools face a double burden of menstruation such as inaccessible water, sanitation and hygiene (WASH), and lack of support. In addition, they lack accurate information on menstrual hygiene practices, lack of sanitary pads, as well as stigma and discrimination 7,15 . A study conducted in Indonesia revealed that visually impaired girls still face psychosocial and physical challenges when managing menstruation, including negative thoughts such as fear and myths and beliefs about menstruation. In the same study, young girls reported their teachers as the main source of menstrual management knowledge 16 . In Rwanda, there are an estimated 400,000 people with visual impairments, most of whom are young people and attending schools 17 . In 2019, the Government of Rwanda has adopted an inclusive and special education policy following the United Nations Convention on the rights of persons with disabilities in 2008 and the 2018 United Kingdom Global Disability Summit 17 . A review conducted by Sommer and colleagues 18 revealed that despite the growing gender-responsiveness of education sector plans and policies in LMICs, they still do not adequately address the inequities caused by inadequate WASH facilities and, more specifically, the specific improvements to school environments for girls that require MHM. Despite the tremendous efforts to establish visually impaired schools in Rwanda, the literature on the challenges of MHM faced by visually impaired menstruators is scarce. This lack of research highlights the critical gap in understanding the lived experiences of visually impaired adolescent girls in Rwanda regarding MHM. As a result, this study aimed to explore the visually impaired adolescent girls’ lived experiences of MHM in Rwanda to inform policies and interventions to promote better MHM practices for this vulnerable population. Methodology T he aim, design and setting of the study The aim of this study was to explore the lived experiences of MHM among menstruating visually impaired adolescent girls in Rwanda. A descriptive phenomenological qualitative design was used to describe and interpret the lived experiences of MHM from the perspective of menstruating visually impaired adolescent girls’ view in Rwanda. Using this design allowed us to directly explore, analyze, and interpret the lived experiences of visually impaired girls’ experiences of MHM to make an objective analysis of the information they provided 19 . This was done to gain insight into the experiences of visually impaired girls in high schools and to transfer the knowledge to others facing similar challenges 20 . It is documented that using a phenomenological approach when studying people with disabilities can help make profound issues visible and enable voices to be heard 21 . The study involved four specialized educational institutions caring for individuals with visual impairments, offering education up to the secondary level and providing Rwanda education program-based study materials. One school is mixed with non-visually impaired students and three exclusively for visually impaired students. Furthermore, two are located in the Eastern province, one in the Northern province, and one in the Southern province. Study population In this study, our target population was visually impaired young girls, involving the entire target population. Participants were included if they (1) had been students in the study settings for at least one year and (2) were capable of providing verbal assent and informed consent. However, unavailable individuals, along with those with mental disorders, deafness, or a lack of willingness to participate, were systematically excluded from the study. Data collection was conducted from January to February, 2023. Recruitment Purposive sampling was employed to select 25 visually impaired young girls, and they were subsequently divided into four Focus Group Discussions (FGDs). In phenomenology, FGDs provide a valuable platform for researchers to gather rich data and gain insights into the collective lived experiences and perceptions of a group of individuals 22–24 . FGDs were composed of five to eight participants. Using smaller FGDs, where participants are homogeneous and emotionally connected to the study topic (i.e., MHM), would be beneficial 25 . Phenomenological scholars used fewer than five study participants in one FGD and produced rich data 26 . Data saturation was achieved after the third FGD. Due to geographical differences, we added another school to gain more insights. However, there was no new information from the fourth group. Data collection procedures and measurements After getting the permission from the school, the research team explained the study to the guardians and study participants. Written informed consent from the legal guardians and oral assent were completed and obtained for the study participants aged 13-24. Before enrolling participants in the study, our research team conducted thorough eligibility screenings. This ensured that only those who met the criteria would participate. Eligible participants expressed their consent verbally. Once selected, participants were allocated FGDs. These discussions were conducted in a private and comfortable setting in schools, ensuring confidentiality and creating an environment conducive to open dialogue. The interview guide included questions and probes designed to explore the challenges faced by visually impaired adolescent girls in managing menstrual hygiene (Supplementary file 1). The guide was initially developed by the research team members in English and translated into Kinyarwanda, the local language, to ensure full understanding and inclusivity. Back translation was done to ensure that it was consistent with the English version To foster a conducive atmosphere of trust and openness among visually impaired young girls, we took into account gender dynamics within our research team. Specifically, three women from our team moderated the discussions, ensuring that participants felt comfortable and encouraged to share their experiences and insights. They are experienced midwives and assistant lecturers at the University of Rwanda with extensive experience in qualitative data collection. One of the data collectors took field notes. In addition to verbal data collection, data were captured using professional recording equipment, guaranteeing the completeness and accuracy of the information gathered. Furthermore, one team member was dedicated to transcribing key responses in real-time using a laptop, ensuring that all necessary information was captured to address the study objectives comprehensively. The average interview length was 47 minutes. Data Analysis The recorded interviews were transcribed verbatim. Dedoose software was used to sort and organize data. Seven steps of Colaizzi's method were used to analyze data 27 . These steps include gaining familiarity with the data, identifying significant statements, establishing meanings, identifying themes, constructing a comprehensive description, developing the fundamental structure, and verifying the fundamental structure. To ensure a thorough understanding of the data, the research team members who actively participated in the data collection transcribed and translated the transcripts. They also participated in opening coding. The codebook was used to structure and identify nodes with similarities that were further grouped in the same theme. After having a list of codes, they presented them to the whole research team to ensure a common understanding. The codes were then grouped into categories and subcategories. The team then analyzed the data to identify patterns and themes. Some respondents’ quotes were quoted, matching the original idea of the participants, and were used in the main text to clarify or strengthen a node. At the end of each quote, there was an indicative information explaining which FGD group that participated in the interview from which the quote was extracted. Ethical Considerations Before the study, the principal investigators sought ethical approval from the Institutional Review Board (330/CMHS IRB/2022 on May 31, 2022) at the College of Medicine and Health Sciences at the University of Rwanda. The data collection permission was sought from the study settings and granted. The study participants voluntarily and willingly provided verbal assent and informed consent, and their guardians signed the consent form before participation. To protect respondents’ privacy and safety, data were saved anonymously. The respondent's name was not registered on the mobile data collection forms or recorders. The findings were reported cumulatively, and no individual could be recognized. Results Socio-demographic data The Table 1 presents the socio-demographic characteristics of 25 visual impaired young girls who participated in the FGDs. The majority of participants (76%) were enrolled in specialized schools, while 24% attended mixed schools. Age distribution was relatively balanced, with 48% aged 13 to 17 years and 52% aged 18 to 24 years. Most participants (60%) were in primary education, and a significant portion (68%) resided in rural areas. The data reveal diverse family structures and backgrounds, with 72% belonging to larger families of five or more members. Notably, 44% of participants identified as Catholics, while other religious affiliations included Protestants (32%), Muslims (12%), and Seventh-Day Adventists (12%). In terms of parental status, 60% of participants had both parents alive, while a smaller percentage had only one parent (24% mothers) or none at all (8%). Living arrangements varied, with 36% residing with both parents and other relatives. The educational attainment of parents revealed notable illiteracy rates, particularly among fathers (38%) and mothers (53%), with farming being the predominant occupation for both (60% of fathers and 72% of mothers). Table 1 Socio-demographic characteristics of participants (N = 25) Variable Category Frequency Percent Type of school Specialized schools 19 76.0 Mixed school (integrated) 6 24.0 Age 13 to 17 years 12 48.0 18 to 24 years 13 52.0 Education Primary 15 60.0 Secondary 1–3 6 24.0 Secondary 4–6 4 16.0 Residence Rural 17 68.0 Urban 8 32.0 Family size 2 to 4 persons 7 28.0 5 persons and above 18 72.0 Religion Catholic 11 44.0 Muslim 3 12.0 Protestant 8 32.0 Seventh Day Adventist 3 12.0 Alive parents Both Father and mother 15 60.0 None of them 2 8.0 Only Father 2 8.0 Only Mother 6 24.0 Living with Mother and father 3 12.0 Mother and Relatives 4 16.0 Mother, father and Relatives 9 36.0 Father only 1 4.0 Mother and Relatives 2 8.0 Mother only 1 4.0 Others (non-relatives) 2 8.0 Relatives 3 12.0 Father’s literacy Literate (able to read and write) 8 62.0 Illiterate (cannot read and write) 5 38.0 Mother’s literacy Literate (able to read and write) 9 47.0 Illiterate (cannot read and write) 10 53.0 Father's occupation Salaried employee 2 8.0 Farmer 15 60.0 Deceased 8 32.0 Mother's Occupation Farmer 18 72.0 Business person 2 8.0 Salaried employee 1 4.0 Deceased 4 16.0 Major themes During analysis, three main themes were identified: a) Intersection of menstrual stigma and visual impairment; b) Impact of taboos and misconceptions on access to comprehensive menstrual hygiene information and practice; and c) period poverty. Intersection of menstrual stigma and visual impairment In this study, many participants reported the social stigmas that these young girls face during their menstrual periods, particularly in the context of inadvertent staining of clothes especially in mixed schools. They reflect the embarrassment and lack of support that can arise from peers, who might mock or shame them instead of offering help disregarding the additional challenges posed by their visual impairment. The experience is depicted as isolating, with the affected individual feeling the need to escape the situation rather than confront it due to the absence of understanding and assistance from others. The quotes also convey the heightened sensitivity and discomfort associated with menstruation, exacerbated by the negative reactions of those who are not visually impaired. Hmmm…Like any other girl, it happens that you may stain your skirt with blood while In your period. However, your colleagues embarrass you for not acting like a girl. Sometimes, they tell you, “Behave like a girl." It’s very hard to realize that you stained your clothes. In that case, it's challenging since you feel like no one can help you ... yeah, no support. R1, FGD1 I'd hate to have a dirty seat during my menstrual period! because we have others who are not visually impaired, I hear them murmur and laugh. What a shame for a grown-up girl like you! There's nothing else to do.... hmmm, but run away and find yourself what to do. R1, FGD2 Discussing menstrual hygiene practices is often challenging for visually impaired individuals. They frequently face skepticism and resistance when broaching the topic, with others questioning their knowledge and deeming it culturally inappropriate. This resistance comes from various sources, including family, community members, and peers at school. The skepticism is rooted in the belief that visually impaired individuals lack the authority or experience to discuss such matters. This cultural stigma can lead to conflicts within families, discouraging visually impaired individuals from engaging in these discussions to avoid familial discord. For instance, one participant explained, “Well…it’s challenging… uhmm when discussing this topic [menstrual hygiene practices], sometimes they don't let you speak. Some of them would even question how you knew those practices while you are visually impaired. So, when you initiate that discussion because you heard this from colleagues or at school, they take it as culturally inappropriate … yeah!” R8, FGD3 “Ahhh… We still have people in our communities and families and even here at school who think that you cannot have a say on this topic [menstrual hygiene] when you are visually impaired. It’s better to leave it and don’t talk about it….it can even cause conflicts between you and your parents if you don't listen to them.” R1, FD1 Visually impaired girls often face unique challenges, particularly in familial settings. Some parents may not view or treat them the same as other siblings, which can lead to a lack of essential education and skills. This disparity can result in situations where visually impaired girls might experience significant life events, such as menstruation, without the necessary knowledge and preparedness, often learning about it for the first time at school. “Some parents don't consider us [visually impaired girls] like other siblings. If your parents did not teach you as they do for others, you could get menses without basic knowledge and skills while at school.” R2, FGD3 Impact of taboos and misconceptions on access to comprehensive menstrual hygiene information and practice Participants reported that finding accurate information about menstrual hygiene practices is challenging, with many relying on their parents, who often provide incomplete information due to stigma and taboos. While teachers believe parents are responsible for this education, some students expect comprehensive guidance from teachers, especially for visually impaired girls who lack tailored information. According to the participants, no one provides comprehensive information tailored to the needs of visually impaired girls: “Well…It's not easy to discuss this topic in public, and that's why some parents don't tell you everything. Teachers might assume you know some basics from your parents. Consequently, you do not have accurate information because you arrange to get it from your colleagues, who are sometimes incorrectly informed. As a visually impaired girl, I think I need more information compared to our peers who are not visually impaired… Ah yeah either from our parents or teachers.” R5, FGD1 Some study participants shared challenges related to menstrual hygiene management knowledge and practices. Due to visual impairment, one major issue is the improper use of sanitary pads, such as difficulties in determining the correct side to stick onto underwear. This can result in leakage, leading to stained clothing. Additionally, there's a lack of knowledge on how frequently to change pads and underwear, as well as the proper frequency for cleaning genital areas. These challenges are compounded by insufficient guidance from parents, who might only be familiar with traditional methods like using cloth instead of modern sanitary products or don’t understand that this could be a challenge for visually impaired girls. This lack of education and visibility about menstrual flow further complicates effective menstrual hygiene management. The following quotes evidence this: “One of our common problems is the inappropriate use of cotex [sanitary pads]. Determining which side to manipulate when sticking underwear on is sometimes difficult. Even though we wear underwear, blood sometimes passes through and stains my skirt. This is because my parents could not teach me how to do this properly since they only know to use the pieces of clothes , don’t see how this could be difficult for visually impaired girls .” R5, FGD4 “Hmmm…sometimes, you can't tell if the menses have come out, making it difficult to determine how often to change underwear and pads. It is also challenging to know how often to clean our genital areas. It is either a lack of knowledge, unable to see that cause all of these or even some don’t from our parents regarding taboos.” R7, FGD3 Visually impaired girls face particular challenges with menstrual hygiene, especially when using reusable sanitary pads. The lack of tactile feedback makes it difficult for them to ascertain if their pads have been thoroughly washed and dried in the sun. Without proper guidance, many are unaware of the crucial role sunlight plays in sanitizing their menstrual products and underwear. Cultural taboos and myths surrounding menstruation often compel families to dry these items in concealed, less hygienic locations with inadequate sunlight, increasing the risk of infections due to the potential exposure to unsanitary conditions. “Especially for visually impaired girls who use sanitary pads (pieces of clothing), it can be challenging to determine whether they have been washed and soaked properly in the sun. Due to a lack of instructions, some of us [visually impaired girls] are unaware of the importance of soaking our pads and underwear in the sunlight. Some parents even suggest drying them in hidden areas out of sight of others since it's considered taboo and there are myths about menstruation. There might not be enough sunlight reaching these areas. It might be hung in a dirty place, and you understand you can get infected.” R6, FGD3 “As a matter of fact, even washing sanitary pads and underwear properly can be problematic. If you didn't wash it correctly, you may be unable to tell. If you have the information or someone to guide you, you can wash them thoroughly to ensure there is no blood staining. It can't be washed by anyone else; it's your blood. Without someone to guide you, it isn't easy.” R5, FGD4 Period poverty During the study, the majority of menstruating participants complained of a lack of resources, especially at school. Among these are inaccessible washing stations, a lack of water in schools, dysfunctional girls' rooms, and a lack of basic materials. The accessibility of washing stations in schools varies significantly, with three schools having easily accessible facilities. However, participants at one school report significant challenges for visually impaired girls. These stations are not easily accessible and are sometimes located far away, making them difficult to reach. Participants highlighted the difficulty of collecting water at school, despite the best efforts to assist, resulting in inadequate opportunities for personal hygiene during menstruation due to insufficient water. Additionally, during water outages, visually impaired girls face a lack of first aid measures and struggle to collect water, especially when it requires going outside and there is no one to ask for help. “At school, collecting water is a challenge. It is still very difficult to get there, despite our best efforts. I want to thank our colleagues for helping. As a result, you may not be able to wash yourself as often as you wish during our periods because you will not have enough water to do so.” R3, FGD2 In case of a water outage, visually impaired girls are not provided with first aid measures at school. It can be challenging for us to collect water when others have to walk outside. You don't even have anyone to ask for help. R5, FGD2 Four participants from different groups reported using remedies and medicines to relieve menstrual symptoms such as pain during menstruation. According to them, these simple remedies and pain medicines are unavailable at some schools and sometimes difficult to locate. “We sometimes drink warm water to manage pain or put hot water in a bottle and apply it to our lower abdominals. There is no doubt that it works. There is, however, a shortage of hot water at school. It's not easy to get into the kitchen, even though it's prohibited. We have no one nearby who can help us. Therefore, you understand how difficult it is for us.” R5, FGD2 “We all know that you can take medicines during menstruation to reduce pain. There are times, however, when finding these medicines at school can be difficult. Occasionally, you find girls experiencing pain without pills. The number of painkiller tablets should be increased in schools.” R5, FGD1 The participants’ accounts described a situation where a school's designated "girl's room" for is ineffective. The room, though labeled for girls, lacks proper functionality and assistance. A proposed improvement is to establish a separate, specialized room equipped with necessary materials and staffed by someone to aid visually impaired girls, ensuring it meets their needs effectively. Additionally, it highlights that the current room is shared by all girls, suggesting that a dedicated space for visually impaired girls would better address their unique requirements. “Yeah... they [school leaders] say we have a girl’s room, but it doesn’t work; it’s just a name. It would be better to function properly and have someone inside to help visually impaired girls.” R4, FGD2 “One challenge is that this room is common to all girls in the school. Having a special room with all the materials would be better." R3, FGD2 In two FGDs, participants noted that many girls' rooms lack information provided in Braille, making it challenging for those with visual impairments to read independently. Often, they can hear peers discussing the displayed information, highlighting the need for these details to be translated into Braille or presented through audio methods to ensure accessibility for everyone. “Some information in girls’ rooms is not provided in Braille to read independently. You can hear your peers discussing what is displayed in there.” P4, FGD2 “It would be helpful if some information we hear was translated into Braille or audio method.” P2, FGD3 A few study participants reported a lack of basic materials as a challenge during their periods. Due to the high cost of sanitary pads, some participants from all FGDs use clothes that are difficult to wash and dry. For example, “Our families cannot afford sanitary pads (cotex). So, we use these pieces of clothes and cleaning them is also a challenge for us.” R1, FGD3 “Yeah, you can afford that piece of cloth, but lack money to buy soap.” R3, FGD1 Discussion This study aimed to explore the lived experiences of MHM among menstruating visually impaired adolescent girls in Rwanda. Visually impaired girls face unique challenges when managing menstruation in schools due to a combination of gender norms and their disability. They experience a double stigma, as they are affected by societal expectations surrounding menstruation as well as misconceptions about their visual impairment. Accessing accurate and comprehensive menstrual hygiene information is particularly difficult for them, often resulting in inadequate management practices. Additionally, many visually impaired girls face period poverty, which exacerbates their struggles by limiting their access to necessary menstrual hygiene products. These factors collectively create a significant barrier to their comfort, dignity and confidence during menstruation. Our findings revealed that the stigma surrounding menstruation, when intersected with visual impairment, results in significant challenges and heightened discrimination for visually impaired adolescent girls. Families, schools, and communities frequently fail to acknowledge and address the unique needs and experiences of these girls, leading to further marginalization and neglect. These findings are consistent with studies conducted in LMICs, which have shown that women and girls with disabilities often face stigma due to prevailing social norms and attitudes that regard menstruation as filthy and impure 7,15 . The double stigma surrounding menstruation and disability needs to be addressed strategically through education, awareness campaigns, and open dialogue to promote inclusiveness and understanding. According to some study participants, finding accurate information about menstrual hygiene was a significant challenge. This difficulty was compounded by the fact that their only source of information was their parents. However, participants noted that their parents did not provide complete and comprehensive information due to the taboos and misconceptions surrounding menstruation. These findings align with other studies in LMICs, which have shown that taboos and secrecy about menstruation hinder open discussions and prevent the sharing of accurate information, resulting in negative consequences for individuals and communities 28,29 . To address the challenge of finding accurate information about menstrual hygiene for visually impaired girls, it is essential to implement multifaceted educational strategies that extend beyond familial boundaries. For example, comprehensive sexual and reproductive health education should be integrated into school curricula, ensuring that young individuals receive scientifically accurate and culturally sensitive information. Additionally, community-based programs can also play a crucial role by engaging local leaders and health professionals to dispel myths and misconceptions, creating safe spaces for open discussions. In this study, visually impaired adolescent girls did not receive the appropriate guidance and support needed to navigate the changes and challenges of menstruation. This lack of support may stem from teachers' assumptions that these girls obtain basic knowledge from their parents. However, the girls regarded their teachers as their primary source of information due to a lack of adequate information on MHM at home. Similarly, research in other contexts has shown that mothers are often misinformed and tend to pass on this inadequate or incorrect information to their daughters 30 . It is also well documented in other studies that due to the taboo surrounding the menstruation topic, teachers also tend to be reluctant to discuss menstrual hygiene and sometimes may also be as well uninformed of the current information 31,32 . Consequently, students are left with no other option but to learn menstruation in the most effective way they can 31,33 . This can be challenging for visually impaired girls since they need support and guidance to ensure they manage their periods with dignity. Interventions to support and guide parents, especially mothers, of visually adolescent girls regarding MHM are crucial to ensuring their health and well-being. These interventions aim to equip parents with the necessary knowledge and resources to educate their daughters about menstruation effectively 34 . In this study, due to inaccurate knowledge from different sources, participants reported improper body cleaning and washing of their pads for those who used reusable pads. Some of them did not know the importance of soaking their pads and drying them directly in the sun. Others preferred to dry their pads in hidden places away from direct sunlight in order to avoid exposure in form of public views related to taboos and misconceptions around menstruation by their family members, especially their mothers. The findings from this study are consistent with those that point to poor hygienic practices related to body cleaning, washing and drying the reusable cloth, and sanitary pads disposals reported in several LMICs 35 . Also, in these countries, women take careful precautions when washing and drying underwear with menstrual blood and cloth used as an absorbent for menstrual blood out of fear that they will be bewitched 7,8 . Despite the widespread taboos and misconceptions surrounding menstruation in African countries 36,37 , these challenges can be even more daunting for visually impaired girls. For instance, when it comes to drying reusable menstrual clothes out of sight, visually impaired girls may struggle to determine the cleanliness of the area or whether there is adequate sunlight. This makes them more vulnerable to using dirty or contaminated reusable clothes, potentially leading to health issues such as skin infections. The key to overcoming these harmful beliefs lies in breaking the silence, promoting education, and engaging all stakeholders. By doing so, we can empower visually impaired adolescent girls and ensure their access to safe and hygienic menstrual practices. In the present study, menstruating visually impaired adolescent girls reported period poverty as a big challenge during their periods. Period poverty is defined as inadequate access to menstrual hygiene materials, including but not limited to menstrual hygiene products, sanitation facilities, and waste management 5 . Even though the period poverty is a global issue 38 , visually impaired girls in this study experience it in a particular way compared to their peers who are not visually impaired. First, they reported inaccessible washing stations and water outages which adds a burden to their hygienic practices as also reported in other studies 7,39 . This is a serious concern for visually impaired girls since others can reach these stations or be able to fetch water, even though they travel a long distance out of the school. The lack of access to water and sanitation facilities may have serious health consequences, resulting in infections and other health problems. Lack of basic amenities can also negatively affect their academic performance, as they cannot concentrate on their studies. Second, at schools, the visually impaired adolescent girls reported lack of remedies or medicines, commonly used at home, to manage uncomfortable symptoms associated with menstruation. The commonly reported remedies were drinking warm water or tea, getting a rest and apply heat on lower abdomen. In these schools, warm water is available in kitchens that are inaccessible to visually impaired girls due to risks related to burns. During menstruation, the use of traditional medicines and remedies is increasingly reported in various cultures worldwide, these traditional approaches have been used to relieve discomfort during menstruation and promote wellness in general for centuries 35 . Visually impaired adolescent girls seeking relief from menstrual symptoms may find it frustrating to find no remedies during menstruation at school. In order to ensure visually impaired adolescent girls are able to follow their academic activities, schools should avail of over-the-counter pain relievers and alternative remedies in the school clinics or resting areas. These pain relievers should be put in the first aid box carried by the school nurse or a person in charge of the girls’ room. Third, our findings revealed that the existing girls’ rooms, which are equipped with a bed, painkillers, water, sanitary pads, and other necessary materials - dedicated to helping female students during their menstrual periods, are not functioning properly. It is worth noting that most teaching aids to manage periods are visual, and there is a lack of this information in the Braille or audio methods in some schools, which is challenging for visually impaired girls. Studies in SSA countries, including Rwanda, report that the girls' rooms are not functional, although some studies believe they encourage adolescent girls to practice menstrual management 36,37,40,41 . Another study in Nepal shows that the lack of menstruating rooms in schools lead to the increased absenteeism rate 42 . It is important that schools establish menstruation-friendly environments that will cater to the unique needs of visually impaired adolescent girls, i.e., translating the visual teaching aids into Braille methods. This will enable blind and visually impaired students to access the same educational materials as their peers. It will also provide equal access to learning, which can help break down some challenges they have when managing menstruation. Lastly, many visually impaired girls reported additional challenges during menstruation, such as not having access to sanitary pads necessary to maintain proper menstrual hygiene. Although missing basic materials for MHM is a common problem in African settings, including Rwanda 36,37,40,41 , for visually impaired girls, it is a double burden since they cannot take care of their reusable clothes like others who are not visually impaired do. These reusable clothes require deep cleaning and soaking in the sun, which might be challenging for visually impaired girls. These findings were also reported in one setting where study participants reported menstruators should collect their water and wash their reusable menstrual cloth, which is more complicated for visually impaired menstruators 39 . Providing visually impaired girls with sanitary pads is essential to ensuring they have the necessary resources to manage their menstruation hygienically and respectfully. In addition, it reduces the double burden of cleaning and drying out. This helps to reduce the stigma of menstruation and helps these girls feel more confident and secure during this critical time of the month. Generally, in this study, visually impaired girls from schools with a mixed population of visually impaired and non-visually impaired face more challenges than others from other schools which are exclusively for visually impaired students. In addition, our analysis found that in homogeneous schools, there is more support for visually impaired girls during menstruation compared to mixed schools. This could be due to greater understanding within homogeneous schools about the challenges visually impaired girls face during menstruation. Furthermore, the additional support and services provided by homogeneous schools may offer greater comfort for visually impaired girls. As such, our study indicates that homogeneous schools may be better equipped to provide the necessary support for visually impaired girls during menstruation. Strengths and limitations One of this study's strengths lies in its use of a qualitative approach to explore the sensitive topic of menstruation with teenage visually impaired females who have likely never discussed it with anyone, including teachers, parents, relatives, or friends. This approach allows for an in-depth exploration of the personal and private nature of menstruation, which is particularly significant for visually impaired individuals who may have limited access to information and resources regarding this important life stage. Another strength is that female data collectors moderated the discussions to create an environment of trust and openness among visually impaired young girls, ensuring that participants felt safe and encouraged to share their experiences and thoughts. However, when interpreting the findings, a few limitations need to be taken into account. First, only the focus group discussion approach was used to acquire the data, and data triangulation was not used to compare the information produced by other modes. Second, study participants were purposely selected, which might raise the possibility of selection bias. Third, in certain instances, visually impaired girls may be integrated into mixed classrooms with students who are not visually impaired. As a result, they may have distinct experiences compared to schools that exclusively cater to visually impaired girls. Conclusion This study revealed visually impaired adolescent girls face a double stigma within their schools as menstruating young females with a disability. These young girls reported a lack of accurate information about menstrual hygiene practices, which sometimes resulted in poor hygiene practices. One of the key challenges identified was inadequate resources, including inaccessible washing stations, a lack of water in schools, dysfunctional girls' rooms, and a lack of basic materials. Creating a safe and non-judgmental environment where visually impaired adolescent girls can openly discuss their experiences and concerns is crucial. In order to mitigate these barriers and fostering a more supportive community, menstrual health education is imperative. To enhance their knowledge on utilizing Braille or audio resources to ensure that visually impaired girls can access comprehensive and accurate information about MHM is paramount. Recognizing and addressing the unique challenges visually impaired adolescents face by providing adequate resources such as accessible water, hygiene, and sanitation, distributing pads, availing remedies at schools, and reworking girls' rooms and tailoring them to visually impaired adolescent girls' needs is significant. Abbreviations CMHS College of Medicine and Health Sciences at the University of Rwanda FGDs Focus Group Discussions IRB Institutional Review Board LMICs Low- and middle-income countries MHM Menstrual Hygiene Management N Number R Respondent SDGs Sustainable Development Goals UN United Nations WASH Water and sanitation and hygiene WHO World Health Organization Declarations Ethics approval and consent to participate Ethics approval Ethical approval was obtained from the Institutional Review Board (330/CMHS IRB/2022 on May 31, 2022) at the College of Medicine and Health Sciences at the University of Rwanda. Consent for publication Not applicable. Consent to participate Verbal assent was obtained from the study participants under age of 18 and written informed consents from their legal guardians. Participants over the age of 18 provided oral consent since they could not read. We allowed sufficient time for questions to be asked and answered to ensure study participants comprehended the consent information. It was made clear that participation was voluntary. Research conformed to the principles of the Helsinki Declaration. Authors' contributions AN, JB, MLIB, MH, JBHH, YDNU, JM, GK, and DN conceptualized and designed the study. Qualitative fieldwork was carried out by JB, MLIB, JBHH, JM, YDNU, and DN and supervised through intermittent field visits by DM and GK. Data analysis was carried out jointly by AN, JB, MLIB, MH, JBHH, GK, and DM. AN, DM MH, and GK wrote the preliminary manuscript, after which all authors read, contributed to and approved the final manuscript. Acknowledgements We extend our heartfelt thanks to the 25 study participants, legal guardians and the four schools for granting the permission to access the study participants. We also acknowledge the Pre-Publication Support Service (PREPSS) supported the development of this manuscript by providing author training. Funding This work was funded by The Center for International Reproductive Health Training at the University of Michigan (CIRHT-UM). This funding source had no role in the design of this study, analyses, interpretation of the data, and decision to submit results. Competing interests The authors declare no competing interests. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. However, the interview guide is available as supplementary file. References Sommer M, Torondel B, Hennegan J, et al. How addressing menstrual health and hygiene may enable progress across the Sustainable Development Goals. Glob Health Action 2021; 14: 1–10. Sommer BM, Sahin M. 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Research Design: Qualitative, Quantitative and Mixed Methods Approaches . SAGE Publications, 2014. Kumar DN, Tandon M, Dubey SK. a Phenomenological Study of the Experiences of Inclusive Education Students With Disabilities. J Pharm Negat Results 2022; 13: 1400–1404. Bradbury-jones C, Sambrook S, Irvine F. The phenomenological focus group : an oxymoron ? J Adv Nurs 2009; 65: 663–671. Bush EJ, Singh RL, Kooienga S. Lived Experiences of a Community : Merging Interpretive Phenomenology and Community-Based Participatory Research. Int J Qual Methods 2019; 18: 1–12. Ataro G. Methods , methodological challenges and lesson learned from phenomenological study about OSCE experience : Overview of paradigm- driven qualitative approach in medical education. Ann Med Surg 2020; 49: 19–23. Morgan DL. Focus Groups As Qualitative Research . 2ed., https://www.kth.se/social/upload/6566/Morgan.pdf (1997). Love B, Vetere A, Davis P. Should Interpretative Phenomenological Analysis ( IPA ) be Used With Focus Groups ? Navigating the Bumpy Road of “ Iterative Loops ,” Idiographic Journeys , and “ Phenomenological Bridges ”. Int J Qual Methods Vol 2020; 19: 1–17. Denzin NK, Lincoln YS. The SAGE handbook of Qualitative Research . Sage Publications, Inc, 2018. Mohamed Y, Durrant K, Huggett C, et al. A qualitative exploration of menstruation-related restrictive practices in Fiji, Solomon Islands and Papua New Guinea. PLoS One 2018; 13: 1–19. Maulingin-Gumbaketi E, Larkins S, Whittaker M, et al. Socio-cultural implications for women’s menstrual health in the Pacific Island Countries and Territories (PICTs): a scoping review. Reprod Health 2022; 19: 1–20. Chandra-mouli V, Patel SV. Mapping the knowledge and understanding of menarche , menstrual hygiene and menstrual health among adolescent girls in low- and middle-income countries. Reprod Health 2017; 14: 1–16. Swedish International Development Cooperation Agency. Health: Both a prerequisite and an outcome of sustainable development. , http://www.sida.se/contentassets/2d05faf3aebc4092a0ef96439c026262/cceb317a-2662-46cf-9114-8c988b8318a1.pdf (2016, accessed 30 August 2023). Kiribati Ministry of Education. Breaking Down Barriers Coming of Age , Becoming the Change: Case study on the knowledge, attitudes and practices of Menstrual Hygiene Management in Kiribati Schools 2018 , https://pacificwomen.org/wp-content/uploads/2018/06/Menstrual-Health-Management-Report-Kiribati.pdf (2018, accessed 30 August 2023). Shah V, Nabwera HM, Sosseh F, et al. A rite of passage: A mixed methodology study about knowledge, perceptions and practices of menstrual hygiene management in rural Gambia. BMC Public Health 2019; 19: 1–15. Wilbur J, Torondel B, Hameed S, et al. Systematic review of menstrual hygiene management requirements, its barriers and strategies for disabled people. PLoS One 2019; 14: 1–17. Chandra-mouli V, Patel SV. Mapping the Knowledge and Understanding of Menarche , Menstrual Hygiene and Menstrual Health Among Adolescent Girls in Low- and Middle-Income Countries. In: Bobel C, Winkler IT, Fahs B, et al. (eds) The Palgrave Handbook of Critical Menstruation Studies . Palgrave Macmillan Singapore, pp. 609–636. Deriba BS, Garedew G, Gemeda D, et al. Safe menstrual hygiene management practice and associated factors among female adolescent students at high schools in central Ethiopia : A mixed – method study. Front Publlic Heal 2022; 10: 1–12. Betsu BD, Medhanyie AA, Gebrehiwet TG, et al. “ Menstruation is a Fearful Thing ”: A Qualitative Exploration of Menstrual Experiences and Sources of Information About Menstruation Among Adolescent Schoolgirls. Int J Women’s Heal 2023; 15: 881–892. Michel J, Mettler A, Schönenberger S, et al. Period poverty : why it should be everybody ’ s business. J Glob Heal Reports 2022; 6: 1–4. Wilbur J, Morrison C, Iakavai J, et al. “ The weather is not good ” : exploring the menstrual health experiences of menstruators with and without disabilities in Vanuatu. Lancet Reg Heal - West Pacifi 2022; 18: 1–15. Ssemata AS, Ndekezi D, Kansiime C, et al. Understanding the social and physical menstrual health environment of secondary schools in Uganda : A qualitative methods study. PLOS Glob Public Heal 2023; 1: 1–19. Isano S, Iradukunda IG, Ingabire P, et al. Assessing the knowledge and attitude of menstrual hygiene among high school students , and menstrual practices among high school girls in rural Rwanda. Int J Reprod Contraception, Obstet Gynecol 2022; 11: 696–703. Shrestha S, Shrestha S, Ito Y, et al. Situation of menstrual management facilities in schools of peri-urban areas of Nepal : WASH , privacy , and healthcare. J Water, Sanit Hyg Dev 2022; 12: 41–51. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5016676","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":366142073,"identity":"f20bde84-71ca-41eb-aa22-18cd635b97d9","order_by":0,"name":"Marie Laetitia Ishimwe 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08:36:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5016676/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5016676/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12982-025-00519-4","type":"published","date":"2025-04-14T15:56:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":81050585,"identity":"fa0965c6-90cb-49d4-801d-312529810674","added_by":"auto","created_at":"2025-04-21 15:58:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1094340,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5016676/v1/f8ea7f2c-18ba-4c22-8304-5943dc0b2441.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring the lived experiences of menstrual hygiene management among in-school visually impaired adolescent girls in Rwanda: A phenomenological study","fulltext":[{"header":"Menstrual hygiene management among Rwandan adolescent girls with visual impairment in schools.","content":"\u003cp\u003eThe Sustainable Development Goals (SDGs) emphasize the importance of Menstrual Hygiene Management (MHM) for women\u0026apos;s and girls\u0026apos; well-being. However, in low-income countries, many menstruating persons continue to encounter numerous challenges regarding MHM. Visually impaired girls face even more challenges than their counterparts, especially in schools. We explored the lived experiences of in-school visually impaired adolescent girls towards MHM in Rwanda. We invited 25 visually impaired adolescent girls from four specialized educational institutions for visually impaired students in Rwanda to participate in four focus group discussions. Our findings revealed that in-school visually impaired girls continuously faced several challenges when managing their menstruation. These included a double stigma related to gender norms and being visually impaired, taboos and misconceptions that shaped knowledge sharing and menstrual hygiene practices negatively, and lack of tailored resources for MHM. Additionally, double stigma significantly poses challenges and impact on their health, inclusion, and overall quality of life. There is a need to improve education, raise awareness, revise existing policies, and improve infrastructure to ensure that visually impaired girls manage their menstruation health.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eMenstrual Hygiene Management (MHM) is an integral component of the Sustainable Development Goals (SDGs), as it directly impacts on women\u0026rsquo;s and girls\u0026apos; physical and mental well-being \u003csup\u003e1\u003c/sup\u003e. MHM describes the needs experienced by people who menstruate, including but not limited to the availability and accessibility of information, products, and facilities that allow them to manage their periods safely, comfortably, and with dignity \u003csup\u003e2\u003c/sup\u003e. More than 300 million women worldwide menstruate on any given day. It is estimated that 500 million women cannot access adequate facilities for MHM and cannot obtain menstrual products \u003csup\u003e3\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe World Health Organization (WHO) recommends three actions to ensure menstrual health is viewed, framed and addressed as a health and human rights issue, rather than a hygienic issue \u003csup\u003e4\u003c/sup\u003e. As a first step, menstruation needs to be recognized and framed as a health issue \u0026ndash; a health issue that has physical, psychological, and social dimensions, and needs to be addressed from pre-menarche to post-menopause. Secondly, to recognize menstrual health, we must ensure that women and girls who menstruate have access to the necessary products, such as water, sanitation, and disposal facilities, as well as supportive care when needed. Additionally, it is crucial to create an environment where menstruation is viewed positively and considered a health issue rather than a stigma, enabling individuals to participate fully in work and social activities. Thirdly, these activities must be included in sectoral budgets and work plans, and their performance must be monitored regularly \u003csup\u003e4\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile some progress has been made in various areas, women, girls and other people menstruating such as transgender men and nonbinary individuals \u0026nbsp;still face significant challenges in both developed and developing countries, especially those in schools \u003csup\u003e5\u0026ndash;8\u003c/sup\u003e. Improving MHM in schools in low and middle-income countries (LMICs) is hindered by several factors, including the lack of adequate support from teachers, perceived and internalized stigma, the lack of family support, the lack of cultural acceptance for alternative menstrual products, financial constraints in affording supplies, the lack of adequate facilities for water and sanitation and hygiene (WASH), cramps and discomfort during menstruation, and long-distance travel to and from school, which increases leakage and staining \u003csup\u003e6,9\u003c/sup\u003e. It is more difficult for females with disability and that they are often neglected in when it comes to WASH interventions in LMICs \u003csup\u003e7,8\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn 2020, an estimated 43.3 million people were blind, and 55% were female \u003csup\u003e10\u003c/sup\u003e. Managing menstruation can present unique challenges for visually impaired girls and women due to social norms surrounding gender and menstruation \u003csup\u003e11\u003c/sup\u003e. Many visually impaired women struggle to manage their periods independently, their menstrual hygiene practices are not at a satisfactory level, and almost half of them receive support to manage their menstrual hygiene \u003csup\u003e12\u003c/sup\u003e. Furthermore, evidence from African countries found that adolescents with visual impairment face difficulties maintaining good menstrual hygiene because they cannot detect menstrual blood, fix sanitary pads properly, or wash underwear correctly, and they are anxious and stressed because they don\u0026apos;t know if their period has started or not \u003csup\u003e13,14\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eVisually impaired girls attending schools face a double burden of menstruation such as inaccessible water, sanitation and hygiene (WASH), and lack of support. In addition, they lack accurate information on menstrual hygiene practices, lack of sanitary pads, as well as stigma and discrimination \u003csup\u003e7,15\u003c/sup\u003e. A study conducted in Indonesia revealed that visually impaired girls still face psychosocial and physical challenges when managing menstruation, including negative thoughts such as fear and myths and beliefs about menstruation. In the same study, young girls reported their teachers as the main source of menstrual management knowledge \u003csup\u003e16\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn Rwanda, there are an estimated 400,000 people with visual impairments, most of whom are young people and attending schools \u003csup\u003e17\u003c/sup\u003e. In 2019, the Government of Rwanda has adopted an inclusive and special education policy following the United Nations Convention on the rights of persons with disabilities in 2008 and the 2018 United Kingdom Global Disability Summit \u003csup\u003e17\u003c/sup\u003e. A review conducted by Sommer and colleagues \u003csup\u003e18\u003c/sup\u003e revealed that despite the growing gender-responsiveness of education sector plans and policies in LMICs, they still do not adequately address the inequities caused by inadequate WASH facilities and, more specifically, the specific improvements to school environments for girls that require MHM. Despite the tremendous efforts to establish visually impaired schools in Rwanda, the literature on the challenges of MHM faced by visually impaired menstruators is scarce. This lack of research highlights the critical gap in understanding the lived experiences of visually impaired adolescent girls in Rwanda regarding MHM. As a result, this study aimed to explore the visually impaired adolescent girls\u0026rsquo; lived experiences of MHM in Rwanda to inform policies and interventions to promote better MHM practices for this vulnerable population.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cstrong\u003eT\u003c/strong\u003e\u003cstrong\u003ehe aim, design and setting of the study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe aim of this study was to explore the lived experiences of MHM among menstruating visually impaired adolescent girls in Rwanda.\u0026nbsp;A descriptive phenomenological qualitative design was used\u0026nbsp;to describe and interpret the lived experiences of MHM from the perspective of menstruating visually impaired adolescent girls\u0026rsquo; view in Rwanda. Using this design allowed us to directly explore, analyze, and interpret the lived experiences of visually impaired girls\u0026rsquo; experiences of MHM to make an objective analysis of the information they provided \u003csup\u003e19\u003c/sup\u003e. This was done to gain insight into the experiences of visually impaired girls in high schools and to transfer the knowledge to others facing similar challenges \u003csup\u003e20\u003c/sup\u003e. It is documented that using a phenomenological approach when studying people with disabilities can help make profound issues visible and enable voices to be heard \u003csup\u003e21\u003c/sup\u003e. The study involved four specialized educational institutions caring for individuals with visual impairments, offering education up to the secondary level and providing Rwanda education program-based study materials. \u0026nbsp;One school is mixed with non-visually impaired students and three exclusively for visually impaired students. Furthermore, two are located in the Eastern province, one in the Northern province, and one in the Southern province.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, our target population was visually impaired young girls, involving the entire target population. Participants were included if they (1) had been students in the study settings for at least one year and (2) were capable of providing verbal assent and informed consent. However, unavailable individuals, along with those with mental disorders, deafness, or a lack of willingness to participate, were systematically excluded from the study. Data collection was conducted from January to February, 2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePurposive sampling was employed to select 25 visually impaired young girls, and they were subsequently divided into four Focus Group Discussions (FGDs). In phenomenology, FGDs provide a valuable platform for researchers to gather rich data and gain insights into the collective lived experiences and perceptions of a group of individuals \u003csup\u003e22\u0026ndash;24\u003c/sup\u003e. FGDs were composed of five to eight participants. Using smaller FGDs, where participants are homogeneous and emotionally connected to the study topic (i.e., MHM), would be beneficial \u003csup\u003e25\u003c/sup\u003e. Phenomenological scholars used fewer than five study participants in one FGD and produced rich data \u003csup\u003e26\u003c/sup\u003e. Data saturation was achieved after the third FGD. Due to geographical differences, we added another school to gain more insights. However, there was no new information from the fourth group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection procedures and measurements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter getting the permission from the school, the research team explained the study to the guardians and study participants. Written informed consent from the legal guardians and oral assent were completed and obtained for the study participants aged 13-24. Before enrolling participants in the study, our research team conducted thorough eligibility screenings. This ensured that only those who met the criteria would participate. Eligible participants expressed their consent verbally. Once selected, participants were allocated FGDs. These discussions were conducted in a private and comfortable setting in schools, ensuring confidentiality and creating an environment conducive to open dialogue.\u003c/p\u003e\n\u003cp\u003eThe interview guide included questions and probes designed to explore the challenges faced by visually impaired adolescent girls in managing menstrual hygiene (Supplementary file 1). The guide was initially developed by the research team members in English and translated into Kinyarwanda, the local language, to ensure full understanding and inclusivity. Back translation was done to ensure that it was consistent with the English version\u003c/p\u003e\n\u003cp\u003eTo foster a conducive atmosphere of trust and openness among visually impaired young girls, we took into account gender dynamics within our research team. Specifically, three women from our team moderated the discussions, ensuring that participants felt comfortable and encouraged to share their experiences and insights. They are experienced midwives and assistant lecturers at the University of Rwanda with extensive experience in qualitative data collection. One of the data collectors took field notes. In addition to verbal data collection, data were captured using professional recording equipment, guaranteeing the completeness and accuracy of the information gathered. Furthermore, one team member was dedicated to transcribing key responses in real-time using a laptop, ensuring that all necessary information was captured to address the study objectives comprehensively. The average interview length was 47 minutes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe recorded interviews were transcribed verbatim. Dedoose software was used to sort and organize data. Seven steps of Colaizzi\u0026apos;s method were used to analyze data\u0026nbsp;\u003csup\u003e27\u003c/sup\u003e. These steps include gaining familiarity with the data, identifying significant statements, establishing meanings, identifying themes, constructing a comprehensive description, developing the fundamental structure, and verifying the fundamental structure. To ensure a thorough understanding of the data, the research team members who actively participated in the data collection transcribed and translated the transcripts. They also participated in opening coding. The codebook was used to structure and identify nodes with similarities that were further grouped in the same theme. After having a list of codes, they presented them to the whole research team to ensure a common understanding. The codes were then grouped into categories and subcategories. The team then analyzed the data to identify patterns and themes. Some respondents\u0026rsquo; quotes were quoted, matching the original idea of the participants, and were used in the main text to clarify or strengthen a node. At the end of each quote, there was an indicative information explaining which FGD group that participated in the interview from which the quote was extracted.\u003c/p\u003e\n\u003cp\u003eEthical Considerations\u003c/p\u003e\n\u003cp\u003eBefore the study, the principal investigators sought ethical approval from the Institutional Review Board (330/CMHS IRB/2022 on May 31, 2022) at the College of Medicine and Health Sciences at the University of Rwanda. The data collection permission was sought from the study settings and granted. The study participants voluntarily and willingly provided verbal assent and informed consent, and their guardians signed the consent form before participation. To protect respondents\u0026rsquo; privacy and safety, data were saved anonymously. The respondent\u0026apos;s name was not registered on the mobile data collection forms or recorders. The findings were reported cumulatively, and no individual could be recognized.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic data\u003c/h2\u003e \u003cp\u003eThe Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the socio-demographic characteristics of 25 visual impaired young girls who participated in the FGDs. The majority of participants (76%) were enrolled in specialized schools, while 24% attended mixed schools. Age distribution was relatively balanced, with 48% aged 13 to 17 years and 52% aged 18 to 24 years. Most participants (60%) were in primary education, and a significant portion (68%) resided in rural areas. The data reveal diverse family structures and backgrounds, with 72% belonging to larger families of five or more members. Notably, 44% of participants identified as Catholics, while other religious affiliations included Protestants (32%), Muslims (12%), and Seventh-Day Adventists (12%).\u003c/p\u003e \u003cp\u003eIn terms of parental status, 60% of participants had both parents alive, while a smaller percentage had only one parent (24% mothers) or none at all (8%). Living arrangements varied, with 36% residing with both parents and other relatives. The educational attainment of parents revealed notable illiteracy rates, particularly among fathers (38%) and mothers (53%), with farming being the predominant occupation for both (60% of fathers and 72% of mothers).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic characteristics of participants \u003cem\u003e(N\u0026thinsp;=\u0026thinsp;25)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of school\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpecialized schools\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed school (integrated)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 to 17 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 to 24 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary 1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary 4\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily size\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 to 4 persons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 persons and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCatholic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProtestant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSeventh Day Adventist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlive parents\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBoth Father and mother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone of them\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnly Father\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnly Mother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLiving with\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMother and father\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMother and Relatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMother, father and Relatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFather only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMother and Relatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMother only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers (non-relatives)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFather\u0026rsquo;s literacy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLiterate (able to read and write)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate (cannot read and write)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMother\u0026rsquo;s literacy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLiterate (able to read and write)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate (cannot read and write)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFather's occupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSalaried employee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeceased\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMother's Occupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBusiness person\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSalaried employee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeceased\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMajor themes\u003c/h2\u003e \u003cp\u003eDuring analysis, three main themes were identified: a) Intersection of menstrual stigma and visual impairment; b) Impact of taboos and misconceptions on access to comprehensive menstrual hygiene information and practice; and c) period poverty.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eIntersection of menstrual stigma and visual impairment\u003c/h2\u003e \u003cp\u003eIn this study, many participants reported the social stigmas that these young girls face during their menstrual periods, particularly in the context of inadvertent staining of clothes especially in mixed schools. They reflect the embarrassment and lack of support that can arise from peers, who might mock or shame them instead of offering help disregarding the additional challenges posed by their visual impairment. The experience is depicted as isolating, with the affected individual feeling the need to escape the situation rather than confront it due to the absence of understanding and assistance from others. The quotes also convey the heightened sensitivity and discomfort associated with menstruation, exacerbated by the negative reactions of those who are not visually impaired.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eHmmm\u0026hellip;Like any other girl, it happens that you may stain your skirt with blood while In your period. However, your colleagues embarrass you for not acting like a girl. Sometimes, they tell you, \u0026ldquo;Behave like a girl.\" It\u0026rsquo;s very hard to realize that you stained your clothes. In that case, it's challenging since you feel like no one can help you ... yeah, no support.\u003c/em\u003e \u003cb\u003eR1, FGD1\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003eI'd hate to have a dirty seat during my menstrual period! because we have others who are not visually impaired, I hear them murmur and laugh. What a shame for a grown-up girl like you! There's nothing else to do.... hmmm, but run away and find yourself what to do.\u003c/em\u003e \u003cb\u003eR1, FGD2\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDiscussing menstrual hygiene practices is often challenging for visually impaired individuals. They frequently face skepticism and resistance when broaching the topic, with others questioning their knowledge and deeming it culturally inappropriate. This resistance comes from various sources, including family, community members, and peers at school. The skepticism is rooted in the belief that visually impaired individuals lack the authority or experience to discuss such matters. This cultural stigma can lead to conflicts within families, discouraging visually impaired individuals from engaging in these discussions to avoid familial discord. For instance, one participant explained,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Well\u0026hellip;it\u0026rsquo;s challenging\u0026hellip; uhmm when discussing this topic [menstrual hygiene practices], sometimes they don't let you speak. Some of them would even question how you knew those practices while you are visually impaired. So, when you initiate that discussion because you heard this from colleagues or at school, they take it as culturally inappropriate \u0026hellip; yeah!\u0026rdquo;\u003c/em\u003e\u003cb\u003eR8, FGD3\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Ahhh\u0026hellip; We still have people in our communities and families and even here at school who think that you cannot have a say on this topic [menstrual hygiene] when you are visually impaired. It\u0026rsquo;s better to leave it and don\u0026rsquo;t talk about it\u0026hellip;.it can even cause conflicts between you and your parents if you don't listen to them.\u0026rdquo;\u003c/em\u003e\u003cb\u003eR1, FD1\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eVisually impaired girls often face unique challenges, particularly in familial settings. Some parents may not view or treat them the same as other siblings, which can lead to a lack of essential education and skills. This disparity can result in situations where visually impaired girls might experience significant life events, such as menstruation, without the necessary knowledge and preparedness, often learning about it for the first time at school.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Some parents don't consider us [visually impaired girls] like other siblings. If your parents did not teach you as they do for others, you could get menses without basic knowledge and skills while at school.\u0026rdquo;\u003c/em\u003e\u003cb\u003eR2, FGD3\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eImpact of taboos and misconceptions on access to comprehensive menstrual hygiene information and practice\u003c/h2\u003e \u003cp\u003eParticipants reported that finding accurate information about menstrual hygiene practices is challenging, with many relying on their parents, who often provide incomplete information due to stigma and taboos. While teachers believe parents are responsible for this education, some students expect comprehensive guidance from teachers, especially for visually impaired girls who lack tailored information. According to the participants, no one provides comprehensive information tailored to the needs of visually impaired girls:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Well\u0026hellip;It's not easy to discuss this topic in public, and that's why some parents don't tell you everything. Teachers might assume you know some basics from your parents. Consequently, you do not have accurate information because you arrange to get it from your colleagues, who are sometimes incorrectly informed. As a visually impaired girl, I think I need more information compared to our peers who are not visually impaired\u0026hellip; Ah yeah either from our parents or teachers.\u0026rdquo;\u003c/em\u003e \u003cb\u003eR5, FGD1\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Some study participants shared challenges related to menstrual hygiene management knowledge and practices. Due to visual impairment, one major issue is the improper use of sanitary pads, such as difficulties in determining the correct side to stick onto underwear. This can result in leakage, leading to stained clothing. Additionally, there's a lack of knowledge on how frequently to change pads and underwear, as well as the proper frequency for cleaning genital areas. These challenges are compounded by insufficient guidance from parents, who might only be familiar with traditional methods like using cloth instead of modern sanitary products or don\u0026rsquo;t understand that this could be a challenge for visually impaired girls. This lack of education and visibility about menstrual flow further complicates effective menstrual hygiene management. The following quotes evidence this:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;One of our common problems is the inappropriate use of cotex [sanitary pads]. Determining which side to manipulate when sticking underwear on is sometimes difficult. Even though we wear underwear, blood sometimes passes through and stains my skirt. This is because my parents could not teach me how to do this properly since they only know to use the pieces of clothes\u003c/em\u003e, \u003cem\u003edon\u0026rsquo;t see how this could be difficult for visually impaired girls\u003c/em\u003e.\u0026rdquo; \u003cb\u003eR5, FGD4\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Hmmm\u0026hellip;sometimes, you can't tell if the menses have come out, making it difficult to determine how often to change underwear and pads. It is also challenging to know how often to clean our genital areas. It is either a lack of knowledge, unable to see that cause all of these or even some don\u0026rsquo;t from our parents regarding taboos.\u0026rdquo;\u003c/em\u003e\u003cb\u003eR7, FGD3\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eVisually impaired girls face particular challenges with menstrual hygiene, especially when using reusable sanitary pads. The lack of tactile feedback makes it difficult for them to ascertain if their pads have been thoroughly washed and dried in the sun. Without proper guidance, many are unaware of the crucial role sunlight plays in sanitizing their menstrual products and underwear. Cultural taboos and myths surrounding menstruation often compel families to dry these items in concealed, less hygienic locations with inadequate sunlight, increasing the risk of infections due to the potential exposure to unsanitary conditions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Especially for visually impaired girls who use sanitary pads (pieces of clothing), it can be challenging to determine whether they have been washed and soaked properly in the sun. Due to a lack of instructions, some of us [visually impaired girls] are unaware of the importance of soaking our pads and underwear in the sunlight. Some parents even suggest drying them in hidden areas out of sight of others since it's considered taboo and there are myths about menstruation. There might not be enough sunlight reaching these areas. It might be hung in a dirty place, and you understand you can get infected.\u0026rdquo;\u003c/em\u003e \u003cb\u003eR6, FGD3\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;As a matter of fact, even washing sanitary pads and underwear properly can be problematic. If you didn't wash it correctly, you may be unable to tell. If you have the information or someone to guide you, you can wash them thoroughly to ensure there is no blood staining. It can't be washed by anyone else; it's your blood. Without someone to guide you, it isn't easy.\u0026rdquo;\u003c/em\u003e \u003cb\u003eR5, FGD4\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePeriod poverty\u003c/h2\u003e \u003cp\u003eDuring the study, the majority of menstruating participants complained of a lack of resources, especially at school. Among these are inaccessible washing stations, a lack of water in schools, dysfunctional girls' rooms, and a lack of basic materials.\u003c/p\u003e \u003cp\u003eThe accessibility of washing stations in schools varies significantly, with three schools having easily accessible facilities. However, participants at one school report significant challenges for visually impaired girls. These stations are not easily accessible and are sometimes located far away, making them difficult to reach. Participants highlighted the difficulty of collecting water at school, despite the best efforts to assist, resulting in inadequate opportunities for personal hygiene during menstruation due to insufficient water. Additionally, during water outages, visually impaired girls face a lack of first aid measures and struggle to collect water, especially when it requires going outside and there is no one to ask for help.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;At school, collecting water is a challenge. It is still very difficult to get there, despite our best efforts. I want to thank our colleagues for helping. As a result, you may not be able to wash yourself as often as you wish during our periods because you will not have enough water to do so.\u0026rdquo;\u003c/em\u003e\u003cb\u003eR3, FGD2\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eIn case of a water outage, visually impaired girls are not provided with first aid measures at school. It can be challenging for us to collect water when others have to walk outside. You don't even have anyone to ask for help.\u003c/em\u003e\u003cb\u003eR5, FGD2\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFour participants from different groups reported using remedies and medicines to relieve menstrual symptoms such as pain during menstruation. According to them, these simple remedies and pain medicines are unavailable at some schools and sometimes difficult to locate.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We sometimes drink warm water to manage pain or put hot water in a bottle and apply it to our lower abdominals. There is no doubt that it works. There is, however, a shortage of hot water at school. It's not easy to get into the kitchen, even though it's prohibited. We have no one nearby who can help us. Therefore, you understand how difficult it is for us.\u0026rdquo;\u003c/em\u003e \u003cb\u003eR5, FGD2\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We all know that you can take medicines during menstruation to reduce pain. There are times, however, when finding these medicines at school can be difficult. Occasionally, you find girls experiencing pain without pills. The number of painkiller tablets should be increased in schools.\u0026rdquo;\u003c/em\u003e \u003cb\u003eR5, FGD1\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe participants\u0026rsquo; accounts described a situation where a school's designated \"girl's room\" for is ineffective. The room, though labeled for girls, lacks proper functionality and assistance. A proposed improvement is to establish a separate, specialized room equipped with necessary materials and staffed by someone to aid visually impaired girls, ensuring it meets their needs effectively. Additionally, it highlights that the current room is shared by all girls, suggesting that a dedicated space for visually impaired girls would better address their unique requirements.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Yeah... they [school leaders] say we have a girl\u0026rsquo;s room, but it doesn\u0026rsquo;t work; it\u0026rsquo;s just a name. It would be better to function properly and have someone inside to help visually impaired girls.\u0026rdquo;\u003c/em\u003e \u003cb\u003eR4, FGD2\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;One challenge is that this room is common to all girls in the school. Having a special room with all the materials would be better.\"\u003c/em\u003e \u003cb\u003eR3, FGD2\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn two FGDs, participants noted that many girls' rooms lack information provided in Braille, making it challenging for those with visual impairments to read independently. Often, they can hear peers discussing the displayed information, highlighting the need for these details to be translated into Braille or presented through audio methods to ensure accessibility for everyone.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Some information in girls\u0026rsquo; rooms is not provided in Braille to read independently. You can hear your peers discussing what is displayed in there.\u0026rdquo;\u003c/em\u003e \u003cb\u003eP4, FGD2\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It would be helpful if some information we hear was translated into Braille or audio method.\u0026rdquo;\u003c/em\u003e \u003cb\u003eP2, FGD3\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA few study participants reported a lack of basic materials as a challenge during their periods. Due to the high cost of sanitary pads, some participants from all FGDs use clothes that are difficult to wash and dry. For example,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Our families cannot afford sanitary pads (cotex). So, we use these pieces of clothes and cleaning them is also a challenge for us.\u0026rdquo;\u003c/em\u003e \u003cb\u003eR1, FGD3\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Yeah, you can afford that piece of cloth, but lack money to buy soap.\u0026rdquo;\u003c/em\u003e \u003cb\u003eR3, FGD1\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to explore the lived experiences of MHM among menstruating visually impaired adolescent girls in Rwanda. Visually impaired girls face unique challenges when managing menstruation in schools due to a combination of gender norms and their disability. They experience a double stigma, as they are affected by societal expectations surrounding menstruation as well as misconceptions about their visual impairment. Accessing accurate and comprehensive menstrual hygiene information is particularly difficult for them, often resulting in inadequate management practices. Additionally, many visually impaired girls face period poverty, which exacerbates their struggles by limiting their access to necessary menstrual hygiene products. These factors collectively create a significant barrier to their comfort, dignity and confidence during menstruation.\u003c/p\u003e\n\u003cp\u003eOur findings revealed that the stigma surrounding menstruation, when intersected with visual impairment, results in significant challenges and heightened discrimination for visually impaired adolescent girls. Families, schools, and communities frequently fail to acknowledge and address the unique needs and experiences of these girls, leading to further marginalization and neglect. These findings are consistent with studies conducted in LMICs, which have shown that women and girls with disabilities often face stigma due to prevailing social norms and attitudes that regard menstruation as filthy and impure \u003csup\u003e7,15\u003c/sup\u003e. The double stigma surrounding menstruation and disability needs to be addressed strategically through education, awareness campaigns, and open dialogue to promote inclusiveness and understanding.\u003c/p\u003e\n\u003cp\u003eAccording to some study participants, finding accurate information about menstrual hygiene was a significant challenge. This difficulty was compounded by the fact that their only source of information was their parents. However, participants noted that their parents did not provide complete and comprehensive information due to the taboos and misconceptions surrounding menstruation. These findings align with other studies in LMICs, which have shown that taboos and secrecy about menstruation hinder open discussions and prevent the sharing of accurate information, resulting in negative consequences for individuals and communities \u003csup\u003e28,29\u003c/sup\u003e. To address the challenge of finding accurate information about menstrual hygiene for visually impaired girls, it is essential to implement multifaceted educational strategies that extend beyond familial boundaries. For example, comprehensive sexual and reproductive health education should be integrated into school curricula, ensuring that young individuals receive scientifically accurate and culturally sensitive information. Additionally, community-based programs can also play a crucial role by engaging local leaders and health professionals to dispel myths and misconceptions, creating safe spaces for open discussions.\u003c/p\u003e\n\u003cp\u003eIn this study, visually impaired adolescent girls did not receive the appropriate guidance and support needed to navigate the changes and challenges of menstruation. This lack of support may stem from teachers\u0026apos; assumptions that these girls obtain basic knowledge from their parents. However, the girls regarded their teachers as their primary source of information due to a lack of adequate information on MHM at home. Similarly, research in other contexts has shown that mothers are often misinformed and tend to pass on this inadequate or incorrect information to their daughters \u003csup\u003e30\u003c/sup\u003e. It is also well documented in other studies that due to the taboo surrounding the menstruation topic, teachers also tend to be reluctant to discuss menstrual hygiene and sometimes may also be as well uninformed of the current information \u003csup\u003e31,32\u003c/sup\u003e. Consequently, students are left with no other option but to learn menstruation in the most effective way they can \u003csup\u003e31,33\u003c/sup\u003e. This can be challenging for visually impaired girls since they need support and guidance to ensure they manage their periods with dignity. Interventions to support and guide parents, especially mothers, of visually adolescent girls regarding MHM are crucial to ensuring their health and well-being. These interventions aim to equip parents with the necessary knowledge and resources to educate their daughters about menstruation effectively \u003csup\u003e34\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn this study, due to inaccurate knowledge from different sources, participants reported improper body cleaning and washing of their pads for those who used reusable pads. Some of them did not know the importance of soaking their pads and drying them directly in the sun. Others preferred to dry their pads in hidden places away from direct sunlight in order to avoid exposure in form of public views related to taboos and misconceptions around menstruation by their family members, especially their mothers. The findings from this study are consistent with those that point \u0026nbsp;to poor hygienic practices related to body cleaning, washing and drying the reusable cloth, and sanitary pads disposals reported in several LMICs \u003csup\u003e35\u003c/sup\u003e. Also, in these countries, women take careful precautions when washing and drying underwear with menstrual blood and cloth used as an absorbent for menstrual blood out of fear that they will be bewitched \u003csup\u003e7,8\u003c/sup\u003e. Despite the widespread taboos and misconceptions surrounding menstruation in African countries \u003csup\u003e36,37\u003c/sup\u003e, these challenges can be even more daunting for visually impaired girls. For instance, when it comes to drying reusable menstrual clothes out of sight, visually impaired girls may struggle to determine the cleanliness of the area or whether there is adequate sunlight. This makes them more vulnerable to using dirty or contaminated reusable clothes, potentially leading to health issues such as skin infections. The key to overcoming these harmful beliefs lies in breaking the silence, promoting education, and engaging all stakeholders. By doing so, we can empower visually impaired adolescent girls and ensure their access to safe and hygienic menstrual practices.\u003c/p\u003e\n\u003cp\u003eIn the present study, menstruating visually impaired adolescent girls reported period poverty as a big challenge during their periods. Period poverty is defined as inadequate access to menstrual hygiene materials, including but not limited to menstrual hygiene products, sanitation facilities, and waste management \u003csup\u003e5\u003c/sup\u003e. Even though the period poverty is a global issue \u003csup\u003e38\u003c/sup\u003e, visually impaired girls in this study experience it in a particular way compared to their peers who are not visually impaired. First, they reported inaccessible washing stations and water outages which adds a burden to their hygienic practices as also reported in other studies \u003csup\u003e7,39\u003c/sup\u003e. This is a serious concern for visually impaired girls since others can reach these stations or be able to fetch water, even though they travel a long distance out of the school. The lack of access to water and sanitation facilities may have serious health consequences, resulting in infections and other health problems. Lack of basic amenities can also negatively affect their academic performance, as they cannot concentrate on their studies.\u003c/p\u003e\n\u003cp\u003eSecond, at schools, the visually impaired adolescent girls reported lack of remedies or medicines, commonly used at home, to manage uncomfortable symptoms associated with menstruation. The commonly reported remedies were drinking warm water or tea, getting a rest and apply heat on lower abdomen. In these schools, warm water is available in kitchens that are inaccessible to visually impaired girls due to risks related to burns. During menstruation, the use of traditional medicines and remedies is increasingly reported in various cultures worldwide, these traditional approaches have been used to relieve discomfort during menstruation and promote wellness in general for centuries \u003csup\u003e35\u003c/sup\u003e. Visually impaired adolescent girls seeking relief from menstrual symptoms may find it frustrating to find no remedies during menstruation at school. In order to ensure visually impaired adolescent girls are able to follow their academic activities, schools should avail of over-the-counter pain relievers and alternative remedies in the school clinics or resting areas. These pain relievers should be put in the first aid box carried by the school nurse or a person in charge of the girls\u0026rsquo; room.\u003c/p\u003e\n\u003cp\u003eThird, our findings revealed that the existing girls\u0026rsquo; rooms, which are equipped with a bed, painkillers, water, sanitary pads, and other necessary materials - dedicated to helping female students during their menstrual periods, are not functioning properly. It is worth noting that most teaching aids to manage periods are visual, and there is a lack of this information in the Braille or audio methods in some schools, which is challenging for visually impaired girls. Studies in SSA countries, including Rwanda, report that the girls\u0026apos; rooms are not functional, although some studies believe they encourage adolescent girls to practice menstrual management \u003csup\u003e36,37,40,41\u003c/sup\u003e. Another study in Nepal shows that the lack of menstruating rooms in schools lead to the increased absenteeism rate \u003csup\u003e42\u003c/sup\u003e. It is important that schools establish menstruation-friendly environments that will cater to the unique needs of visually impaired adolescent girls, i.e., translating the visual teaching aids into Braille methods. This will enable blind and visually impaired students to access the same educational materials as their peers. It will also provide equal access to learning, which can help break down some challenges they have when managing menstruation.\u003c/p\u003e\n\u003cp\u003eLastly, many visually impaired girls reported additional challenges during menstruation, such as not having access to sanitary pads necessary to maintain proper menstrual hygiene. Although missing basic materials for MHM is a common problem in African settings, including Rwanda \u003csup\u003e36,37,40,41\u003c/sup\u003e, for visually impaired girls, it is a double burden since they cannot take care of their reusable clothes like others who are not visually impaired do. These reusable clothes require deep cleaning and soaking in the sun, which might be challenging for visually impaired girls. These findings were also reported in one setting where study participants reported menstruators should collect their water and wash their reusable menstrual cloth, which is more complicated for visually impaired menstruators \u003csup\u003e39\u003c/sup\u003e. Providing visually impaired girls with sanitary pads is essential to ensuring they have the necessary resources to manage their menstruation hygienically and respectfully. In addition, it reduces the double burden of cleaning and drying out. This helps to reduce the stigma of menstruation and helps these girls feel more confident and secure during this critical time of the month.\u003c/p\u003e\n\u003cp\u003eGenerally, in this study, visually impaired girls from schools with a mixed population of visually impaired and non-visually impaired face more challenges than others from other schools which are exclusively for visually impaired students. In addition, our analysis found that in homogeneous schools, there is more support for visually impaired girls during menstruation compared to mixed schools. This could be due to greater understanding within homogeneous schools about the challenges visually impaired girls face during menstruation. Furthermore, the additional support and services provided by homogeneous schools may offer greater comfort for visually impaired girls. As such, our study indicates that homogeneous schools may be better equipped to provide the necessary support for visually impaired girls during menstruation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrengths and limitations\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne of this study\u0026apos;s strengths lies in its use of a qualitative approach to explore the sensitive topic of menstruation with teenage visually impaired females who have likely never discussed it with anyone, including teachers, parents, relatives, or friends. This approach allows for an in-depth exploration of the personal and private nature of menstruation, which is particularly significant for visually impaired individuals who may have limited access to information and resources regarding this important life stage. Another strength is that female data collectors moderated the discussions to create an environment of trust and openness among visually impaired young girls, ensuring that participants felt safe and encouraged to share their experiences and thoughts. \u0026nbsp;However, when interpreting the findings, a few limitations need to be taken into account. First, only the focus group discussion approach was used to acquire the data, and data triangulation was not used to compare the information produced by other modes. Second, study participants were purposely selected, which might raise the possibility of selection bias. Third, in certain instances, visually impaired girls may be integrated into mixed classrooms with students who are not visually impaired. As a result, they may have distinct experiences compared to schools that exclusively cater to visually impaired girls.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study revealed visually impaired adolescent girls face a double stigma within their schools as menstruating young females with a disability. These young girls reported a lack of accurate information about menstrual hygiene practices, which sometimes resulted in poor hygiene practices. One of the key challenges identified was inadequate resources, including inaccessible washing stations, a lack of water in schools, dysfunctional girls\u0026apos; rooms, and a lack of basic materials. Creating a safe and non-judgmental environment where visually impaired adolescent girls can openly discuss their experiences and concerns is crucial. In order to mitigate these barriers and fostering a more supportive community, menstrual health education is imperative. To enhance their knowledge on utilizing Braille or audio resources to ensure that visually impaired girls can access comprehensive and accurate information about MHM is paramount. \u0026nbsp;Recognizing and addressing the unique challenges visually impaired adolescents face by providing adequate resources such as accessible water, hygiene, and sanitation, distributing pads, availing remedies at schools, and reworking girls\u0026apos; rooms and tailoring them to visually impaired adolescent girls\u0026apos; needs is significant.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCMHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCollege of Medicine and Health Sciences at the University of Rwanda\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFGDs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFocus Group Discussions\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIRB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInstitutional Review Board\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMICs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow- and middle-income countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMHM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMenstrual Hygiene Management\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRespondent\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSDGs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSustainable Development Goals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited Nations\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWASH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWater and sanitation and hygiene\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Institutional Review Board (330/CMHS IRB/2022 on May 31, 2022) at the College of Medicine and Health Sciences at the University of Rwanda.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVerbal assent was obtained from the study participants under age of 18 and written informed consents from their legal guardians. Participants over the age of 18 provided oral consent since they could not read. We allowed sufficient time for questions to be asked and answered to ensure study participants comprehended the consent information. It was made clear that participation was voluntary. Research conformed to the principles of the Helsinki Declaration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAN, JB, MLIB, MH, JBHH, YDNU, JM, GK, and DN\u0026nbsp;conceptualized and designed the study. Qualitative fieldwork was carried out by\u0026nbsp;JB, MLIB, JBHH, JM, YDNU, and DN\u0026nbsp;and supervised through intermittent field visits by DM and GK. Data analysis was carried out jointly by\u0026nbsp;AN, JB, MLIB, MH, JBHH, GK, and DM. AN, DM MH, and GK\u0026nbsp;wrote the preliminary manuscript, after which all authors read, contributed to and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our heartfelt thanks to the 25 study participants, legal guardians and the four schools for granting the permission to access the study participants. We also acknowledge the Pre-Publication Support Service (PREPSS) supported the development of this manuscript by providing author training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was funded by The Center for International Reproductive Health Training at the University of Michigan (CIRHT-UM). This funding source had no role in the design of this study, analyses, interpretation of the data, and decision to submit results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. However, the interview guide is available as supplementary file.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSommer M, Torondel B, Hennegan J, et al. How addressing menstrual health and hygiene may enable progress across the Sustainable Development Goals. \u003cem\u003eGlob Health Action\u003c/em\u003e 2021; 14: 1\u0026ndash;10.\u003c/li\u003e\n\u003cli\u003eSommer BM, Sahin M. 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Safe menstrual hygiene management practice and associated factors among female adolescent students at high schools in central Ethiopia : A mixed \u0026ndash; method study. \u003cem\u003eFront Publlic Heal\u003c/em\u003e 2022; 10: 1\u0026ndash;12.\u003c/li\u003e\n\u003cli\u003eBetsu BD, Medhanyie AA, Gebrehiwet TG, et al. \u0026ldquo; Menstruation is a Fearful Thing \u0026rdquo;: A Qualitative Exploration of Menstrual Experiences and Sources of Information About Menstruation Among Adolescent Schoolgirls. \u003cem\u003eInt J Women\u0026rsquo;s Heal\u003c/em\u003e 2023; 15: 881\u0026ndash;892.\u003c/li\u003e\n\u003cli\u003eMichel J, Mettler A, Sch\u0026ouml;nenberger S, et al. 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Assessing the knowledge and attitude of menstrual hygiene among high school students , and menstrual practices among high school girls in rural Rwanda. \u003cem\u003eInt J Reprod Contraception, Obstet Gynecol\u003c/em\u003e 2022; 11: 696\u0026ndash;703.\u003c/li\u003e\n\u003cli\u003eShrestha S, Shrestha S, Ito Y, et al. Situation of menstrual management facilities in schools of peri-urban areas of Nepal : WASH , privacy , and healthcare. \u003cem\u003eJ Water, Sanit Hyg Dev\u003c/em\u003e 2022; 12: 41\u0026ndash;51.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Menstruating adolescent girls, Menstrual hygiene management, Period poverty, visually impaired girls, Rwanda","lastPublishedDoi":"10.21203/rs.3.rs-5016676/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5016676/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003eIn low-income countries, many menstruating persons continue to face numerous challenges regarding menstrual hygiene management (MHM). Visual impairment further compounds the difficulties faced by in-school adolescent girls, but little is known about its consequences in Rwanda.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To explore the lived experiences of MHM among in-school visually impaired adolescent girls in Rwanda.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Descriptive phenomenology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This study was conducted in four specialized educational institutions for visually impaired students in Rwanda. We conducted four focus group discussions with 25 visually impaired adolescent girls selected purposively. The seven steps Colaizzi's method were used to analyze the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Some participants reported double stigma due to both gender norms and menstruation as well as being visually impaired. Due to taboos and misconceptions around menstruation, some participants reported not getting accurate information about MHM from their parents or teachers. Some poor practices related to taboos and misconceptions such as drying the reusable clothes out of sight of others were reported. Finally, some participants faced a double burden regarding period poverty. Due to the lack of sanitary pads, some must use reusable clothes, which are challenging to clean and dry. In case of water outages, participantscould not travel to fetch water. Educational materials in three out of four girls' rooms are visual, making it difficult for visuallyimpaired girls to access accurate information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e To combat stigma against visually impaired girls who menstruate, it's vital to consider cultural and social contexts. Providing accessible menstrual health management (MHM) education, such as in braille or audio, and ensuring sanitary pad availability is essential. Accessible water stations with tanks should also be constructed to ensure a continuous water supply.\u003c/p\u003e","manuscriptTitle":"Exploring the lived experiences of menstrual hygiene management among in-school visually impaired adolescent girls in Rwanda: A phenomenological study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-31 04:49:38","doi":"10.21203/rs.3.rs-5016676/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-15T07:05:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-14T22:21:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178632046676136698184526502038250502468","date":"2024-10-10T17:56:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-24T16:00:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"199923040598477810376231287709170040569","date":"2024-09-22T06:17:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"125471379713820446044513124904349432780","date":"2024-09-17T08:10:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-17T05:53:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-12T13:36:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-10T03:54:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2024-09-02T08:35:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"24dbfb42-4aba-4008-ab29-5d7c60907197","owner":[],"postedDate":"October 31st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-21T15:58:07+00:00","versionOfRecord":{"articleIdentity":"rs-5016676","link":"https://doi.org/10.1186/s12982-025-00519-4","journal":{"identity":"discover-public-health","isVorOnly":false,"title":"Discover Public Health"},"publishedOn":"2025-04-14 15:56:50","publishedOnDateReadable":"April 14th, 2025"},"versionCreatedAt":"2024-10-31 04:49:38","video":"","vorDoi":"10.1186/s12982-025-00519-4","vorDoiUrl":"https://doi.org/10.1186/s12982-025-00519-4","workflowStages":[]},"version":"v1","identity":"rs-5016676","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5016676","identity":"rs-5016676","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}